Arash Moghaddam

Allograft bone matrix versus synthetic bone graft substitutes.

Autologous bone is used very often in the treatment of fresh fractures, delayed unions and non-unions. Alternatives have included allografts and in recent years also demineralized bone matrix. The growing availability of good synthetic bone grafts and their advantages in safety and avoiding donor-site morbidity are the reasons that these products are being used more and more. There are on the market a wide variety of substitutes with different capabilities. Nevertheless autologous bone graft is still considered as the gold standard and will be discussed here in that context. Osteoconductive, osteogenic and osteoinductive products will also be classified and their advantages and disadvantages described.

Cigarette smoking influences the clinical and occupational outcome of patients with tibial shaft fractures.

Tibial shaft fracture is one of the most common types of bone fracture in young patients. In this prospective clinical cohort study, we investigated the effects of cigarette smoking on the clinical, functional, psychosocial and occupational outcomes after isolated lower-leg fracture. We examined 85 patients, including 61 men and 24 women, with a collective mean age of 46 years (range: 18-84 years). Thirty-nine patients had never smoked (G1) and 45 patients were current or previous smokers (G2). The G2 group displayed a significantly increased risk for delayed union or nonunion (G1=3 patients, G2=18 patients; P=0.0007) and increased time required for fracture healing (mean times: G1=11.9 weeks, G2=17.4 weeks; p=0.003) and a markedly increased time out of work (mean times: G1=16.1 weeks, G2=21.5 weeks; p=0.1177 (not significant)). The 18 negatively affected patients in G2 displayed a significant increase in the time required for fracture healing and time out of work (26 weeks (p=0.02) and 31 weeks (p=0.03), respectively). G2 group members had a 3- to 18-fold higher risk of impaired bone healing. The mean Short Form 36 (SF-36) was similar in both groups. The physical-function scores were G1=49.6 and G2=48.6; the mental scores were G1=52.7 and G2=52.8. These findings indicate that smoking significantly increases the risk of impaired fracture healing, which has clinical and occupational consequences for the affected patients. Based on our data, we developed a score to estimate the individual risk of impaired fracture healing. These types of patients must be informed and closely monitored to determine the need for timely re-intervention with additional therapy, such as BMP s or ultrasound.

Cigarette smoking decreases TGF-β1 serum concentrations after long bone fracture

TGF-b1 serum concentrations are considered to be one of the most promising markers of fracture healing. Previously, we demonstrated significant differences in the post-traumatic time courses of patients with timely and delayed fracture healing. The aim of this study was to evaluate possible differences in the serum concentrations of TGF-b1 in cigarette-smoking vs. non-smoking patients with timely and delayed fracture healing in order to understand pathophysiological pathways through which smoking impairs fracture healing.Serum samples were collected from 248 patients undergoing surgical treatment for long bone fractures within 1 year of surgery. Samples from 14 patients with atrophic-type delayed fracture healing were compared with 14 matched patients with normal bone healing. Each group included seven smokers and seven non-smokers. Post-operative serum concentrations were analysed at 1, 2, 4, 8, and 12 weeks as well as 1 year after surgery. The patients were monitored both clinically and radiologically for the entire duration of the study.All patients increased TGF-b1 serum concentrations after surgery. In patients with normal fracture healing, significantly higher TGF-b1 levels were observed in non-smokers (70 ng/ml) than in smokers(50 ng/ml) at the 4th week after surgery (p = 0.007). Also at the 4th week, in patients with delayed healing, significantly lower TGF-b1 levels were observed in smokers than in non-smokers (38 ng/ml vs.47 ng/ml, p = 0.021). However, no significant differences between non-smokers with delayed healing and smokers with normal healing (p = 0.151) were observed at the 4th week after surgery. TGF-b1 serum concentrations reached a plateau in all groups from the 6th to the 12th week after surgery, with a slight decrease observed in the final measurement taken 1 year after surgery.This study demonstrates that, after fracture, TGF-b1 serum concentrations are reduced by smoking,and this reduction is statistically significant during the 4th week after surgery. Our findings may help reveal the mechanism by which smoking impairs fracture healing. Furthermore, these results may help to establish a serological marker that predicts impaired fracture healing soon after the injury. Surgeons will not only be able to monitor the bone healing, but they will also be able to monitor the success of additional treatments such as ultrasound and bone morphologic proteins (BMPs).

Treatment of tibial shaft non-unions: bone morphogenetic proteins versus autologous bone graft

Fractures of the tibial shaft are likely to result in delayed union or non-union; 10-30% of these fractures will not heal properly and are commonly treated with autologous bone grafting. BMP-7 is a recombinant bone growth factor that can be applied locally as an alternative or in addition to autologous bone grafting, and this study aimed to compare the efficiency of the two procedures. From January 1995 to December 2002, 82 people with delayed union of a tibial fracture at least 4 months after primary stabilisation underwent autologous bone grafting. Successful healing was defined as radiological bony consolidation. Between May 2002 and June 2005, 26 similar cases were treated after the failure of the graft with local implantation of BMP-7, and were followed up for at least 1 year. Of the 82 people receiving autologous bone grafts only, 24 (28%) still had no signs of consolidation after 4 months and required revision surgery. Of the 26 people with BMP-7 implantation after failed graft, bony consolidation was seen after 4 months in 24 cases and only 2 (8%) required revision surgery. The BMP-7 group, although including more complicated cases, showed a significantly higher (p = 0.025) success rate compared with the group that did not receive BMP-7.

TRACP 5b and CTX as osteological markers of delayed fracture healing

Radiological studies are the standard method to monitor fracture healing but they do not allow a timely assessment of bone healing. Biochemical markers react rapidly to changes in bone metabolism during fracture healing and could be an additional tool to monitor this process. The goal of this study was to observe changes in serum biomarkers and evaluate the possible differences in the serum levels of tartrate-resistant acid phosphatase 5b (TRACP 5b), total N-terminal propeptide of type I collagen (PINP), bone-specific alkaline phosphatase (BAP), and C-terminal cross-linking telopeptide of type I collagen (CTX) in patients with normal and delayed fracture healing. Several serum samples were collected for one year after the surgical treatment of long bone fractures in 248 patients. From this large pool, 15 patients with atrophic nonunion were matched to 15 patients with normal bone healing. Post-operative changes in osteological markers were monitored during the 1st, 2nd, 4th, 8th, 12th and 52nd weeks. The patients were followed both clinically and radiologically for the entire one-year duration of the study. In the first week, the absolute values of CTX decreased significantly (p=0.0164) in cases of delayed fracture healing. The relative values of TRACP 5b were significantly decreased at weeks 4 (p=0.0066) and 8 (p=0.0043). BAP and PINP levels decreased in the first week followed by an increase, but there were no significant differences in the absolute or relative values during the healing process in both patient groups. For the first time, we have demonstrated changes in serum concentrations of TRACP 5b, PINP, BAP, and CTX during normal and delayed fracture healing. Characteristic changes in systemic TRACP 5b and CTX levels could reflect the initial process of successful fracture healing and may be used in clinical practice to monitor the healing process. Furthermore, it could be very important for determining the beneficial effects of additional treatments such as ultrasound or BMPs in clinical trials.

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.

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.

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.

Endoprothesenversorgung nach Radiusköpfchentrümmerfrakturen

BACKGROUND For many years, resection was the only therapy used for comminuted fractures of the radial head. When associated with an injury of the collateral ligament, the outcome was often unsatisfactory. Implantation of the modern radial head prosthesis promises a better outcome. METHODS Between June 2001 and January 2005, 30 patients were treated with a modular metallic radial head arthroplasty; 28 patients were available for follow-up. Their mean age was 49 years. The patients were followed for an average of 29 months. The outcomes were assessed on the basis of pain, motion, radiographic findings, and grip strength as measured with the Jamar Dynamometer. The overall outcome was rated using a pain visual analog scale, and the scoring systems described by Radin and Riseborough and by Broberg and Morrey. RESULTS 19 patients achieved excellent or good results, 8 had fair results, and 1 had a poor result as based on the Morrey score. 22 patients showed periprosthetic osteolysis on radiologic examination. CONCLUSION Arthroplasty with a modular metallic radial head combined with ligament reconstruction is an effective alternative to radial head resection. Compared with resection, the results using the EVOLVE prosthesis demonstrate definite advantages with regard to clinical outcome.

Three-dimensional polymer coated 45S5-type bioactive glass scaffolds seeded with human mesenchymal stem cells show bone formation in vivo

Abstract45S5-type bioactive glasses are a promising alternative to established substitutes for the treatment of bone defects. Because the three-dimensional (3D) structure of bone substitutes is crucial for bone ingrowth and formation, we evaluated the osteoinductive properties of different polymer coated 3D-45S5 bioactive glass (BG) scaffolds seeded with human mesenchymal stem cells (hMSC) in vivo. BG scaffolds coated with gelatin, cross-linked gelatin, and poly(3-hydroxybutyrate-co-3-hydroxyvalerate) were seeded with hMSC prior to implantation into severe combined immunodeficiency mice. Newly formed bone was evaluated with histomorphometry and micro-computed tomography. Bone formation was detectable in all groups, whereas the gelatin-coated BG scaffolds showed the best results and should be considered in further studies.Graphical Abstract