Management Of Bone Defects Research Articles

One-Step Gas Foaming Strategy for Constructing Strontium Nanoparticle Decorated 3D Scaffolds: a New Platform for Repairing Critical Bone Defects.

The management of critical-sized bone defects poses significant clinical challenges, particularly in the battlefield and trauma-related injuries. However, bone tissue engineering scaffolds that satisfy high porosity and good angiogenic and osteogenic functions are scarce. In this study, 3D nanofiber scaffolds decorated with strontium nanoparticles (3DS-Sr) were fabricated by combining electrospinning and gas foaming. Sodium borohydride (NaBH4) served a dual role as both a reducing and gas-foaming agent, enabling a one-step process for expansion and modification. In vitro experimental results demonstrated that 3DS-Sr possessed an integrated multilayered porous structure. It promoted angiogenesis by upregulating the expression of hypoxia-inducible factor-1α (HIF-1α) protein and phosphorylation of ERK through the sustained release of Sr2+ and created a favorable microenvironment for osteogenesis by activating the Wnt/β-catenin pathway. In vivo experiments indicated that 3DS-Sr promoted cranial bone regeneration by synergistically promoting the effects of vascularization and osteogenesis. In summary, this study proposed a bioactive bone scaffold in a "one stone, two birds" manner, providing a promising strategy for bone defect repair.

Applying 3D-Printed Porous Ti6Al4V Prostheses to Repair Osteomyelitis-Induced Partial Bone Defects of Lower Limbs: Finite Element Analysis and Clinical Outcomes.

The clinical management of partial bone defects in lower limbs, particularly those resulting from osteomyelitis, remains a significant challenge. This study aimed to systematically evaluate the effectiveness of 3D-printed porous Ti6Al4V prostheses in addressing osteomyelitis-induced partial bone defects. We established a comprehensive protocol for utilizing 3D-printed prostheses for bone defect repair, encompassing 3D simulation of prosthesis implantation and internal fixation, finite element analysis (FEA), and clinical implementation. Mimics software facilitated simulation of fixation patterns and screw lengths. FEA modeled bone defects in the distal metaphyseal femur and distal diaphyseal tibia to assess changes in stress conduction pre- and post-prosthesis implantation. The clinical study involved eight patients (average age: 56.3 years) with an average defect length of 14.9 cm. Postoperative outcomes were evaluated using X-rays and the Lower Extremity Functional Scale (LEFS). FEA demonstrated that the implanted prostheses effectively shared stress and reduced the load on residual bone in both models, thus lowering the risk of fractures under external forces. The average follow-up period was 24.5 months, with patients initiating weight-bearing activities on average 7.8 days post-surgery. Serial postoperative X-rays demonstrated long-term stability of the prostheses, with progressive bone regeneration around and integration with the prostheses. While two patients experienced infection recurrence requiring prosthesis removal and debridement, the remaining six showed significant improvement in LEFS scores, increasing from 31.5 preoperatively to 61.0 at the last follow-up. 3D-printed porous Ti6Al4V prostheses effectively restore anatomical integrity and optimize stress conduction in lower limbs, resulting in substantial functional recovery. This innovative approach shows promise for wider clinical adoption and warrants further investigation in medical practice.

Biomimetic mineralization of collagen from fish scale to construct a functionally gradient lamellar bone-like structure for guided bone regeneration

Wide used guided bone regeneration (GBR) membrane materials, such as collagen, Teflon, and other synthesized polymers, present a great challenge in term of integrating the mechanical property and degradation rate when addressing critical bone defects. Therefore, inspired by the distinctive architecture of fish scales, this study utilized epigallocatechin gallate to modify decellularized fish scales following biomimetic mineralization to fabricate a GBR membrane that mimics the structure of lamellar bone. The structure, physical and chemical properties, and biological functions of the novel GBR membrane were evaluated. Results indicate that the decellularized fish scale with 5 remineralization cycles (5R-E-DCFS) exhibited a composite and structure similar to natural bone and had a special functionally gradient mineral contents character, demonstrating excellent mechanical properties, hydrophilicity, and degradation properties. In vitro, the 5R-E-DCFS membrane exhibited excellent cytocompatibility promoting Sprague-Dawley (SD) rat bone marrow mesenchymal stem cell proliferation and differentiation up-regulating the expression of osteogenic-related genes and proteins. Furthermore, in vivo, the 5R-E-DCFS membrane promoted the critical skull bone defects of SD rats repairment and regeneration. Therefore, this innovative biomimetic membrane holds substantial clinical potential as an ideal GBR membrane with mechanical properties for space-making and suitable degradation rate for bone regeneration to manage bone defects.

Knowledge mapping of induced membrane technique: a scientometric study from 2004 to 2023

BackgroundThe induced membrane technique (IMT) is a two-step procedure used for reconstructing segmental bone defects in the limbs. The osteogenic mechanism after bone grafting using IMT remains unclear, and efforts to modify the original techniques are limited to the investigative phase. Therefore, reviewing existing knowledge and identifying hotspots and new trends in IMT is critical.MethodsWe retrieved reviews and articles associated with IMT published between 2004 and 2023 from the Web of Science Core Collection (WoSCC). The keywords included induced membrane technique, guided bone regeneration, bone defect reconstruction, bone graft, stem cells, Masquelet technique, management of bone defects, and scaffold. HistCite, VOSviewer, CiteSpace, and R-bibliometrics were used for scientometric analysis.ResultsA total of 1019 publications from 374 academic journals with 33,995 co-cited references by 2,331 institutions from 65 countries or regions were included. China (n = 235) and the United States (n = 215) were the most productive countries, with Shanghai Jiao Tong University producing the most number of publications (n = 18). Journal Injury [co-citations = 1774; impact factor (IF) 2022 = 2.5] published the most manuscripts, while Masquelet AC and Giannoudis PV published literature with a significant influence on IMT, showing more co-citations (n = 727; n = 355). Two preface hotspots of IMT focused on investigating the microscopic mechanism (such as the membrane supporting graft-to-bone union and the role of inflammatory cells) and developing new techniques to improve IMT (such as bone tissue engineering and new drugs).ConclusionThis study comprehensively reviewed the literature about IMT published in the last 20 years using qualitative and quantitative methods, providing valuable information for researchers investigating IMT.

Application of Mg-MOF-loaded gelatin microspheres with osteogenic, angiogenic, and ROS scavenging capabilities in bone defect repair

The management of bone defects, particularly those with irregular geometries resulting from osteoporotic fractures, remains fraught with challenges. Microspheres have emerged as a promising vehicle for tissue engineering, distinguished by their controlled release, safety, and ease of application. Various bioactive components are integrated into microspheres to improve their performance. Metal-organic frameworks, formed from metal ions interconnected by organic ligands, are increasingly utilized in tissue engineering. Specifically, magnesium-based MOFs are notable for their broad applicability; Mg2+ ions are instrumental in bone reconstruction and repair, facilitating osteogenesis, angiogenesis, antibacterial effects, and anti-inflammatory properties. Mg-MOF was synthesized using magnesium chloride and gallic acid, and it was incorporated into gelatin microspheres to create Gel@Mg-MOF composite microspheres. Leveraging gelatin's biocompatibility, controlled release, and biodegradability, the composites' biocompatibility was evaluated through toxicity and adhesion assays. Moreover, the osteogenic and angiogenic potentials of the Gel@Mg-MOF microspheres were assessed, alongside their capacity for ROS scavenging. Results suggest that controlled Mg2+ release from Gel@Mg-MOF microspheres promotes osteogenic activity in RBMSCs and enhances angiogenic potential in HUVECs. Additionally, the gallic acid-containing composite microspheres exhibited antioxidative properties. Collectively, the findings suggest that Gel@Mg-MOF microspheres could provide effective support for bone defect repair, with potential for clinical deployment.

SCUBE3 promotes osteogenic differentiation and mitophagy in human bone marrow mesenchymal stem cells through the BMP2/TGF-β signaling pathway.

In clinical settings, addressing large bone defects remains a significant challenge for orthopedic surgeons. The use of genetically modified bone marrow mesenchymal stem cells (BMSCs) has emerged as a highly promising approach for these treatments. Signal peptide-CUB-EGF domain-containing protein 3 (SCUBE3) is a multifunctional secreted glycoprotein, the role of which remains unclear in human hBMSCs. This study used various experimental methods to elucidate the potential mechanism by which SCUBE3 influences osteogenic differentiation of hBMSCs invitro. Additionally, the therapeutic efficacy of SCUBE3, in conjunction with porous GeLMA microspheres, was evaluated invivo using a mouse bone defect model. Our findings indicate that SCUBE3 levels increase significantly during early osteogenic differentiation of hBMSCs, and that reducing SCUBE3 levels can hinder this differentiation. Overexpressing SCUBE3 elevated osteogenesis gene and protein levels and enhanced calcium deposition. Furthermore, treatment with recombinant human SCUBE3 (rhSCUBE3) protein boosted BMP2 and TGF-β expression, activated mitophagy in hBMSCs, ameliorated oxidative stress, and restored osteogenic function through SMAD phosphorylation. Invivo, GELMA/OE treatment effectively accelerated bone healing in mice. In conclusion, SCUBE3 fosters osteogenic differentiation and mitophagy in hBMSCs by activating the BMP2/TGF-β signaling pathway. When combined with engineered hydrogel cell therapy, it could offer valuable guidance for the clinical management of extensive bone defects.

Management of acetabular bone defect in revision hip arthroplasty

The number of hip revision surgeries is expected to increase in recent years, and reconstruction of acetabular defects is a challenge for joint surgeons. The principle of reconstruction of acetabular defects is to achieve initial and long-term stability between the prosthesis and the host bone. With the development of surgical techniques, prosthetic materials, and revision concepts, there is an urgent need for new acetabular bone defect evaluation systems to meet clinical needs. The uncemented porous hemispherical cup has become the main prosthesis in clinical application, and metal augments are gradually replacing the structural allograft. Modular reconstruction combined cups and augments has shown favorable clinical results, which can be used for large acetabular defects with acetabular distraction technique, such as pelvic discontinuity. The advantages and disadvantages of impaction bone grafting, jumbo cups, metal augments, acetabular reinforcement rings, custom components (including custom triflanged acetabular components), and acetabular distraction technique still need to be observed in long-term follow-up.

Algorithm of surgical treatment for diaphyseal defects of the forearm bones due to gunshot injuries

Introduction In the current system of providing medical aid to wounded servicemen, along with the conservative primary surgical treatment and minimally invasive extrafocal fixation, high-tech surgical interventions of considerable complexity with the use of additive and tissue-engineering technologies have been coming to the forefront. It is necessary to determine their place in the current algorithm of limb bone defect management, which was the substantiation of our study.The purpose of the study was to improve the algorithm for selecting a treatment method for patients with associated gunshot defects of the forearm based on the literature and clinical observations.Materials and Methods We analyzed scientific articles in PubMed and Scientific Electronic Library (eLIBRARY.ru) platforms, published from 2004 to 2024, on the basis of which we could refine the algorithm of treatment method selection for patients with associated gunshot defects of the forearm. The developed algorithm was used to treat 178 patients with gunshot fractures of the forearm.Results The review of the literature established the main provisions and principles that are applied in the reconstruction of the forearm with an associated defect. When choosing the method of bone defect management, a great number of authors tend to build a “reconstructive ladder”, moving from less severe (one bone) and extended defects (small defect up to 2 cm) to more complex (both bones) and massive defect (more than 10 cm). Upon having considered the revealed regularities, we improved the algorithm of surgical treatment of the latter, which is based on two classification principles: defect extention and location. Reconstruction of the forearm as a dynamic system after diaphyseal fractures requires consider the state of the radioulnar joint. The function of the latter depends on the length ratio of the radius and ulna bones. Therefore, we substantiated small (up to 2 cm) forearm bone defects that can be managed by simple surgical methods. Another fundamental addition to the algorithm was the allocation of a patients’ group with a defect of one forearm bone and a fracture of the other bone (defect-fracture); this combination allows avoiding complex surgical methods for reconstruction and use segment shortening.Discussion The treatment of associated forearm defects is challenging, the choice of reconstruction technique remains uncertain, and the required consensus is lacking. Several forearm reconstruction techniques are available, yet there is no reliable evidence of their effectiveness in terms of treatment time, complications, reoperations, and functional recovery.Conclusion The algorithm proposed for the treatment of extensive gunshot-associated defects of the forearm allows us to consider the change in the anatomy, make a surgical plan based on the reconstruction vector, and select optimal surgical techniques.

Surgical fixation methods for tibial plateau fractures.

Tibial plateau fractures, which are intra-articular injuries of the knee joint, are often difficult to treat and have a high complication rate, including early-onset osteoarthritis. The most common treatment for complex tibial plateau fractures is surgical fixation. Additionally, orthopaedic surgeons often use bone defect fillers to address bone defects caused by the injury. Currently, there is no consensus on the best method of fixation and on whether bone defect fillers are necessary. To assess the benefits and harms of different surgical interventions and bone defect fillers for treating tibial plateau fractures. We searched CENTRAL, MEDLINE, Embase, and trial registries up to March 2023. We also searched conference proceedings and the grey literature. We included randomised controlled trials (RCTs) and quasi-RCTs comparing surgical interventions for treating tibial plateau fractures and different types of filler for bone defects. Two review authors independently screened search results, selected studies, extracted data, and assessed risk of bias. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, with 95% confidence intervals (CIs). Our primary outcomes (and the specific measures we considered most relevant) were generic quality of life (general health score in the 36-item Short-Form Health Survey (SF-36)), patient-reported lower limb function (Hospital for Special Surgery (HSS) score), and adverse events (frequency of unplanned reoperation). We used GRADE to assess the certainty of evidence. We included 15 trials in the review, with a total of 948 adult participants. Nine trials compared different types of fixation, and six trials evaluated different types of bone graft substitutes. All 15 trials were small and at high risk of bias. We considered most available evidence to be of very low certainty, meaning we have very little confidence in the results. Only limited pooling was possible. One trial compared circular fixation combined with insertion of percutaneous screws (hybrid fixation) versus standard open reduction and internal fixation (ORIF) in 82 people with open or closed Schatzker types V or VI tibial plateau fractures. At 24 months' follow-up, hybrid fixation compared with ORIF may have little or no effect on SF-36 general health score (MD 6 points higher, 95% CI 7.7 points lower to 19.7 points higher; 66 participants), patient-reported lower limb function according to the HSS score (MD 7 points higher, 95% CI 2.4 points lower to 16.4 points higher; 66 participants), or frequency of unplanned reoperation (RR 0.78, 95% CI 0.45 to 1.32; 83 fractures (82 participants)). However, the evidence for all three outcomes is very uncertain. Three trials (with 242 participants) compared single-plating ORIF versus double-plating ORIF. There may be little to know difference in patient-reported lower limb function (HSS score) at 24 months' follow-up in people who undergo single-plating ORIF compared with those who undergo double-plating ORIF (MD 0.2 points higher, 95% CI 2.12 points lower to 2.52 points higher; 1 study, 84 participants), but the evidence is very uncertain. There were no data for quality of life or unplanned reoperation at 24 months' follow-up. Six trials (including 368 participants) compared bone substitute versus autologous bone graft (autograft) for managing bone defects. No trials reported SF-36 general health score, HSS score, or frequency of unplanned reoperation at 24 months' follow-up. There is insufficient evidence to ascertain the best method of fixation or the best method of addressing bone defects during surgery in people with tibial plateau fractures. Further well-designed RCTs with larger sample sizes are warranted.

RECONSTRUCTION OF PAPROSKY TYPE III ACETABULAR BONE DEFECTS IN REVISION HIP ARTHROPLASTY USING A COMBINATION OF CAGE AND MORSELIZED ALLOGRAFTS

The management of severe acetabular bone defects poses a complex challenge in revision hip arthroplasty. Although biological fixation materials are currently dominant, cage has played an important role in complex acetabular revision in the past decades, especially when a biological prosthesis is not available. The purpose of this study is to report the long-term clinical and radiographic results of Paprosky type Ⅲ acetabular bone defects revised with cage and morselized allografts.We retrospectively analyzed 45 patients who underwent revision hip arthroplasty with cage and morselized allografts between January 2007 and January 2019. Forty-three patients were followed up. There were 19 Paprosky type IIIA bone defect patients and 24 Paprosky type IIIB bone defect patients and 7 patients of the 24 were also with pelvic discontinuity. Clinical assessment included Harris Hip Score (HHS) and Short Form-12 (SF-12). Radiographic assessment included cage stability, allografts incorporation, and center of rotation.All patients were followed up with a mean follow-up of 10.6 years, HHS and SF-12 improved significantly at last follow-up in comparison to the preoperative. There were 2 re-revisions, one at 5 years after surgery, another at 13.6 years after surgery. Two patients had nonprogressive radiolucency in zone III and the junction of zone II and zone III at the bone implant interface. Allografts of 40 (93%) cases incorporated fully.The combination of cage and morselized allograft is an alternative option for acetabular revision with Paprosky type III bone defects with satisfactory long-term follow-up results.

A photothermal responsive system accelerating nitric oxide release to enhance bone repair by promoting osteogenesis and angiogenesis

Managing bone defects remains a formidable clinical hurdle, primarily attributed to the inadequate orchestration of vascular reconstruction and osteogenic differentiation in both spatial and temporal dimensions. This challenge persists due to the constrained availability of autogenous grafts and the limited regenerative capacity of allogeneic or synthetic bone substitutes, thus necessitating continual exploration and innovation in the realm of functional and bioactive bone graft materials. While synthetic scaffolds have emerged as promising carriers for bone grafts, their efficacy is curtailed by deficiencies in vascularization and osteoinductive potential. Nitric oxide (NO) plays a key role in revascularization and bone tissue regeneration, yet studies related to the use of NO for the treatment of bone defects remain scarce. Herein, we present a pioneering approach leveraging a photothermal-responsive system to augment NO release. This system comprises macromolecular mPEG-P nanoparticles encapsulating indocyanine green (ICG) (NO-NPs@ICG) and a mPEG-PA-PP injectable thermosensitive hydrogel carrier. By harnessing the synergistic photothermal effects of near-infrared radiation and ICG, the system achieves sustained NO release, thereby activating the soluble guanylate cyclase (SGC)-cyclic guanosine monophosphate (cGMP) signaling pathway both in vitro and in vivo. This orchestrated cascade culminates in the facilitation of angiogenesis and osteogenesis, thus expediting the reparative processes in bone defects. In a nutshell, the NO release-responsive system elucidated in this study presents a pioneering avenue for refining the bone tissue microenvironment and fostering enhanced bone regeneration.

The management of critical bone defects: outcomes of a systematic approach

BackgroundThe reconstruction of segmental long bone defects remains one of ‘The holy grails of orthopaedics’. The optimal treatment of which remains a topic of great debate. This study aimed to evaluate the outcomes following the management of critical-sized bone defects using a classification-based treatment algorithm.MethodsA retrospective review of all patients undergoing treatment for segmental diaphyseal defects of long bones at a tertiary-level limb reconstruction unit between January 2016 and December 2021, was performed. The management of the bone defect was standardised as per the classification by Ferreira and Tanwar (2020).ResultsA total of 96 patients (mean age 39.8, SD 15.2) with a minimum six months follow-up were included. Most bone defects were the result of open fractures (75/96) with 67% associated with Gustilo-Anderson IIIB injuries. There was a statistical difference in the likelihood of union between treatment strategies with more than 90% of cases undergoing acute shortening and bone transport achieving union and only 72% of cases undergoing the induced membrane technique consolidating (p = 0.049). Of those defects that consolidated, there was no difference in the time to bone union between strategies (p = 0.308) with an overall median time to union 8.33 months (95% CI 7.4 – 9.2 months). The induced membrane technique was associated with a 40% risk of sepsis.ConclusionThis study reported the outcomes of a standardised approach to the management of critical-sized bone defects. Whilst overall results were supportive of this approach, the outcomes associated with the induced membrane technique require further refinement of its indications in the management of critical-sized bone defects.Level of evidence4.

Bone regeneration driven by a nano-hydroxyapatite/chitosan composite bioaerogel for periodontal regeneration.

The most recent progress in reconstructive therapy for the management of periodontitis and peri-implantitis bone defects has relied on the development of highly porous biodegradable bioaerogels for guided bone regeneration. The objective of this work was to evaluate in vitro the osteoinduction of periodontal-originating cells (human dental follicle mesenchymal cells, DFMSCs) promoted by a nano-hydroxyapatite/chitosan (nHAp/CS) bioaerogel, which was purified and sterilized by a sustainable technique (supercritical CO2). Moreover, the in vivo bone regeneration capacity of the nHAp/CS bioaerogel was preliminarily assessed as a proof-of-concept on a rat calvaria bone defect model. The quantification of DNA content of DFMSCs seeded upon nHAp/CS and CS scaffolds (control material) showed a significant increase from the 14th to the 21st day of culture. These results were corroborated through confocal laser scanning microscopy analysis (CLSM). Furthermore, the alkaline phosphatase (ALP) activity increased significantly on the 21st day, similarly for both materials. Moreover, the presence of nHAp promoted a significantly higher expression of osteogenic genes after 21days when compared to CS scaffolds and control. CLSM images of 21days of culture also showed an increased deposition of OPN over the nHAp/CS surface. The in vivo bone formation was assessed by microCT and histological analysis. The in vivo evaluation showed a significant increase in bone volume in the nHAp/CS test group when compared to CS and the empty control, as well as higher new bone formation and calcium deposition within the nHAp/CS structure. Overall, the present study showed that the nHAp/CS bioaerogel could offer a potential solution for periodontal and peri-implant bone regeneration treatments since the in vitro results demonstrated that it provided favorable conditions for DFMSC proliferation and osteogenic differentiation, while the in vivo outcomes confirmed that it promoted higher bone ingrowth.

Natural Affinity Driven Modification by Silicene to Construct a "Thermal Switch" for Tumorous Bone Loss.

Tumorous bone defects present significant challenges for surgical bio-reconstruction due to the dual pathological conditions of residual tumor presence and extensive bone loss following excision surgery. To address this challenge, a "thermal switch" smart bone scaffold based on the silicene nanosheet-modified decalcified bone matrix (SNS@DBM) is developed by leveraging the natural affinity between collagen and silicene, which is elucidated by molecular dynamics simulations. Benefitting from its exceptional photothermal ability, biodegradability, and bioactivity, the SNS@DBM "thermal switch" provides an integrated postoperative sequential thermotherapy for tumorous bone loss by exerting three levels of photothermal stimulation (i.e., strong, moderate, and nonstimulation). During the different phases of postoperative bioconstruction, the SNS@DBM scaffold realizes simultaneous residual tumor ablation, tumor recurrence prevention, and bone tissue regeneration. These biological effects are verified in the tumor-bearing nude mice of patient-derived tissue xenografts and critical cranium defect rats. Mechanism research prompts moderate heat stimulus generated by and coordinating with SNSs can upregulate osteogenic genes, promote macrophages M2 polarization, and intensify angiogenesis of H-type vessels. This study introduces a versatile approach to the management of tumorous bone defects.

Management of infected bone defects of the femoral shaft by Masquelet technique: sequential internal fixation and nail with plate augmentation

BackgroundTo evaluate the effectiveness of a sequential internal fixation strategy and intramedullary nailing with plate augmentation (IMN/PA) for bone reconstruction in the management of infected femoral shaft defects using the Masquelet technique.MethodsWe performed a retrospective descriptive cohort study of 21 patients (mean age, 36.4 years) with infected bone defects of the femoral shaft treated by the Masquelet technique with a minimum follow-up of 18 months after second stage. After aggressive debridement, temporary stabilisation (T1) was achieved by an antibiotic-loaded bone cement spacer and internal fixation with a bone cement–coated locking plate. At second stage (T2), the spacer and the locking plate were removed following re-debridement, and IMN/PA was used as definitive fixation together with bone grafting. We evaluated the following clinical outcomes: infection recurrence, bone union time, complications, and the affected limb’s knee joint function.ResultsThe median and quartiles of bone defect length was 7 (4.75–9.5) cm. Four patients required iterative debridement for infection recurrence after T1. The median of interval between T1 and T2 was 10 (9–19) weeks. At a median follow-up of 22 (20–27.5) months, none of the patients experienced recurrence of infection. Bone union was achieved at 7 (6–8.5) months in all patients, with one patient experiencing delayed union at the distal end of bone defect due to screws loosening. At the last follow-up, the median of flexion ROM of the knee joint was 120 (105–120.0)°.ConclusionsFor infected femoral shaft bone defects treated by the Masquelet technique, sequential internal fixation and IMN/PA for the reconstruction can provide excellent mechanical stability, which is beneficial for early functional exercise and bone union, and does not increase the rate of infection recurrence.

Bone Transport through Induced Membrane Technique versus Conventional Bone Transport Technique in Management of Bone Defects of Lower Limbs

Abstract Objectives To assess whether Bone transport through induced membrane (BTM) has better outcomes regarding docking site union and infection recurrence than conventional bone transport (BT) or not in the treatment of infected lower limb long bones defects. Methods A prospective randomized controlled study in a single institution was conducted. A total of 30 patients with infected non united fractures of long bones of lower limbs were divided into 15 patients (10 femurs, 5 tibias) treated by BTM and 15 patients (3 femurs,12 tibias) treated by BT. The outcome measures includes external fixation time (EFT), external fixation index (EFI), docking time (DT), bone and functional outcomes evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system, postoperative complications evaluated by Paley classification and number of additional operations. Results The mean docking time (DT) was significantly lower in BTM group in comparison to BT group (3.67 ± 0.82 months vs 4.80 ± 0.86 months respectively) (p value 0.001). Docking site nonunion and infection recurrence were significantly lower in BTM group in comparison to BT group (0% vs 40% respectively) (p value 0.02) and (0% vs 33.3% respectively) (p value 0.04). Mean number of additional operations per patient was significantly lower in BTM group in comparison to BT group (0 vs 0.80 ± 1.08 operations respectively) (p value 0.01) Conclusion Both BTM and BT achieved satisfactory postoperative bone and functional outcomes in patients with infected long bones defects of lower limbs, while BTM had significantly faster docking site union, lower incidence of postoperative complications including docking site nonunion and infection recurrence rates and lower number of additional operations needed at the expense of 2 staged procedure in comparison to BT.

Promising short-term outcomes of free-hand burring technique to implant second-generation metaphyseal cone in Asian knees – a case series

BackgroundThe second-generation metaphyseal cone was useful in managing bone defects in revision knee arthroplasty. However, due to the anatomical constraints in Asian osteometry, the authors utilized a novel free-hand burring technique instead of cannulated reaming for bone preparation. We reported the short-term outcomes of our surgical techniques specific to Asian osteometry.MethodsWe conducted a case series by consecutively recruiting 13 female and 12 male patients (involving 25 knees), with a mean age of 71 years (range, 54–88 years). The patients underwent revision total knee arthroplasty during the period from April 2017 to June 2022. Twenty-three tibial cones and 4 femoral cones using free-hand burring technique were implanted. The mean follow-up duration was 51 months (range 18–80 months). Due to the relatively small bone size and meta-diaphyseal center mismatch in the Asian knees, the free-hand burring technique instead of the cannulated reaming technique was adopted in preparing for cone implantation. The clinical outcomes were knee ranges of motion, the Knee Society Knee scores (KSS), end-of-stem pain, infection, and the need for revision surgery. The radiological outcomes included osteointegration, fracture, and loosening.ResultsMean knee range of motion improved from 83 degrees (range 0°–120°) preoperatively to 106 degrees (range 60°–125°) postoperatively (P < 0.001). Mean KSS improved significantly from 29 (range 0–70) to 69 (range 5–100) (P < 0.001). All cones were osteointegrated. One case had transient end-of-stem pain, two developed intraoperative minor femoral fractures and one suffered from recurrent infection that did not require cone revision. Cone revision-free survivorship was 100%. There was no aseptic loosening.ConclusionsThe second-generation cone implanted with free-hand burring bone preparation yielded promising short-term outcomes in Asian knees.

Use of Fibrin Glue as a Surgical Adjunct in Bone Grafting of Fracture Non-unions.

Non-union of long bones is a common challenge in the treatment of fractures. Bone grafting is commonly used to treat atrophic non-union, but mechanical displacement of the graft may occur, resulting in delay or failure of treatment. Fibrin glue has demonstrated positive results in management of bone defects in neurosurgery and oromaxillary facial surgery, however, there has yet to be any study on its use in long bone fractures. We conducted a prospective randomised controlled trial at a single tertiary centre involving adult patients with long bone fractures that had undergone non-union and requiring bone grafting only. Autologous iliac crest bone graft was applied to the debrided non-union site, with additional fibrin glue applied for the intervention arm. Patients were followed-up with serial radiographs until clinical and radiographical union. Ten patients (3 male, 7 female), of mean age 41.7 (19 - 63) were recruited over five years, with one drop out. Eight out of nine fractures united after treatment. One patient underwent hypertrophic non-union requiring re-fixation and bone grafting. There was no difference in the time to union for patients in the fibrin glue group (19.5 weeks) versus the control group (18.75 weeks) (p=0.86). There were no complications sustained from usage of fibrin glue. Fibrin glue appears to be a safe adjunct for treatment of non-union of long bone fractures across varying fracture sites by holding the bone graft in place despite not demonstrating a faster time to union.

Role of Sticky Bone in the Management of Various Alveolar Bone Defects: A Systematic Review.

This systematic review aimed to evaluate the effectiveness of sticky bone in managing various alveolar bone defects, examining both its benefits and drawbacks. The review adhered to PRISMA guidelines and employed a thorough search strategy using major databases, medical subject headings (MeSH) keywords, and Boolean operators. As a result, the systematic review identified 12 studies focusing on the efficacy of sticky bone in treating alveolar bone defects. Inclusion criteria consisted of randomized controlled trials and case series reporting on the outcomes of sticky bone use for bone defect treatment. Two examiners meticulously performed screening, data extraction, and bias assessment, with the risk of bias evaluated using the Cochrane tool. The findings indicated significant improvements in bone quality, width, height, and volume, with enhanced predictability in socket preservation and implant placement. Sticky bone was particularly effective in ridge augmentation, guided bone regeneration, and filling periodontal defects, often outperforming alternatives like concentrated growth factors (CGFs) and autologous fibrin glue (AFG). It simplified procedures and reduced resorption during healing, underscoring its value as a versatile adjunct in bone reconstruction surgery. Sticky bone demonstrated exceptional results in various oral surgeries, effectively addressing issues such as furcation defects, bone loss, and ridge augmentation, with significant clinical and radiographic improvements. Further research is needed to explore its full potential and refine protocols for broader oral surgery and periodontics applications.

Concerting magnesium implant degradation facilitates local chemotherapy in tumor-associated bone defect

Effective management of malignant tumor-induced bone defects remains challenging due to severe systemic side effects, substantial tumor recurrence, and long-lasting bone reconstruction post tumor resection. Magnesium and its alloys have recently emerged in clinics as orthopedics implantable metals but mostly restricted to mechanical devices. Here, by deposition of calcium-based bilayer coating on the surface, a Mg-based composite implant platform is developed with tailored degradation characteristics, simultaneously integrated with chemotherapeutic (Taxol) loading capacity. The delicate modulation of Mg degradation occurring in aqueous environment is observed to play dual roles, not only in eliciting desirable osteoinductivity, but allows for modification of tumor microenvironment (TME) owing to the continuous release of degradation products. Specifically, the sustainable H2 evolution and Ca2+ from the implant is distinguished to cooperate with local Taxol delivery to achieve superior antineoplastic activity through activating Cyt-c pathway to induce mitochondrial dysfunction, which in turn leads to significant tumor-growth inhibition in vivo. In addition, the local chemotherapeutic delivery of the implant minimizes toxicity and side effects, but markedly fosters osteogenesis and bone repair with appropriate structure degradation in rat femoral defect model. Taken together, a promising intraosseous administration strategy with biodegradable Mg-based implants to facilitate tumor-associated bone defect is proposed.