Josh E. Schroeder

Tissue engineering approaches for bone repair: Concepts and evidence

Over the last decades, the medical world has advanced dramatically in the understanding of fracture repair. The three components needed for fracture healing are osteoconduction, osteoinduction and osteogenesis. With newly designed scaffolds, ex vivo produced growth factors and isolated stem cells, most of the challenges of critical size bone defects have been resolved in vitro, and in some cases in animal models as well. However, there are still challenges needed to be overcome before these technologies can be fully converted from the bench to the bedside. These technological and biological advancements need to be converted to mass production of affordable products that can be used in every part of the world. Vascularity, full substation of scaffolds by native bone, and bio-safety are the three most critical steps to be challenged before reaching the clinical setting.

Stem cell-based therapy for prevention of delayed fracture union: a randomized and prospective preliminary study.

Distal tibial fractures tend towards delayed- or nonunion. The purpose of this study was to evaluate the safety and efficacy of early minimally invasive intervention (MII) in the treatment of these fractures. A total 24 consecutive patients who underwent operative treatment for distal tibial fractures were randomized into a control and an intervention group. MII entailed aspirating iliac crest bone marrow and peripheral blood, yielding mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP) respectively, that were mixed with demineralized bone matrix (DBM) and injected under fluoroscopic control into the fracture site. No complications occurred in either group. The median time to union was 1.5 months in the MII group and 3 months in the control group. MII was found to be a safe and efficient procedure.

The current state in the evaluation and treatment of ARdS and SIRS.

Trauma, the number one cause of death until the fourth decade of life, causes an inflammatory response. This response in its extreme is associated with the development of the systemic inflammatory state, adult respiratory distress syndrome, multi-organ failure, and death. The inflammatory response is mediated via multiple pathways- the inflammatory-cytokine, immunologic, coagulation and endocrine pathways. It is countered by producing antiinflammatory mediators. This reaction is altered in elderly patients. Knowledge of the patients prior medical problems and the differential diagnosis for the possible causes of the current condition should help direct the surgical intervention and supportive care in an attempt to stabilize the patient. With the improvement of monitoring and diagnostic technologies, understanding the significance of the inflammatory pathways in trauma patients will decrease morbidity and mortality in this group of patients.

Israeli medical students’ perceptions of six key medical specialties

BackgroundChoosing a medical specialty requires medical students to match their interests and social-cultural situations with their perceptions of the various specialties.ObjectivesExamine Israeli 6th-year medical students’ perceptions of six key specialties: pediatrics, orthopedic surgery, anesthesiology, obstetrics/gynecology, general surgery and family medicine.MethodsQuestionnaires distributed to 355 6th-year students from three successive classes (2008–2010) of 6th-year students at the Hebrew University – Hadassah School of Medicine, Jerusalem, Israel and the 2010 class of the Ben Gurion University School of Medicine, Be’er Sheva, Israel.ResultsResponses were obtained from 234 students, for a response rate of 66%. Pediatrics and obstetrics/gynecology were the specialties most often under positive career consideration by individual students. Anesthesiology and general surgery were least often under positive career consideration and were viewed as being in a workforce crisis. Pediatrics and family medicine, found to be especially popular among women, were perceived by 58% and 78% of respondents, respectively, as providing reasonable ratios of lifestyle to income. None of the students thought the same about general surgery and only 28% thought so about anesthesiology. Pediatrics and obstetrics/gynecology were reported to afford a controllable lifestyle by 63% and 8%, respectively, With respect to positive career considerations and lifestyle perceptions, there were no differences between the opinions of men and women students. Differences between genders arose in responses to queries of whether a specialty was interesting and challenging. Women were more likely than men to perceive pediatrics and family medicine as interesting and challenging while men were more likely to think that general and orthopedic surgery are interesting and challenging.ConclusionsKnowing the medical students’ perceptions of the various specialties should help in understanding the maldistribution of physicians among the various specialties. Such data can also be an important input into the efforts of the healthcare leadership to promote a specialty distribution that matches the population’s evolving needs.

Benefits of a simple glycaemic protocol in an orthopaedic surgery ward: a randomized prospective study.

Hyperglycaemia and diabetes mellitus are common in patients hospitalized in the orthopaedic surgery ward. However, glycaemic control obtained during hospitalization is often suboptimal. No method for achieving adequate glycaemic control in this population has been validated in an in‐hospital setting.

Reinforcing the role of the conventional C-arm - a novel method for simplified distal interlocking

BackgroundThe common practice for insertion of distal locking screws of intramedullary nails is a freehand technique under fluoroscopic control. The process is technically demanding, time-consuming and afflicted to considerable radiation exposure of the patient and the surgical personnel. A new concept is introduced utilizing information from within conventional radiographic images to help accurately guide the surgeon to place the interlocking bolt into the interlocking hole. The newly developed technique was compared to conventional freehand in an operating room (OR) like setting on human cadaveric lower legs in terms of operating time and radiation exposure.MethodsThe proposed concept (guided freehand), generally based on the freehand gold standard, additionally guides the surgeon by means of visible landmarks projected into the C-arm image. A computer program plans the correct drilling trajectory by processing the lens-shaped hole projections of the interlocking holes from a single image. Holes can be drilled by visually aligning the drill to the planned trajectory. Besides a conventional C-arm, no additional tracking or navigation equipment is required.Ten fresh frozen human below-knee specimens were instrumented with an Expert Tibial Nail (Synthes GmbH, Switzerland). The implants were distally locked by performing the newly proposed technique as well as the conventional freehand technique on each specimen. An orthopedic resident surgeon inserted four distal screws per procedure. Operating time, number of images and radiation time were recorded and statistically compared between interlocking techniques using non-parametric tests.ResultsA 58% reduction in number of taken images per screw was found for the guided freehand technique (7.4 ± 3.4) (mean ± SD) compared to the freehand technique (17.6 ± 10.3) (p < 0.001). Total radiation time (all 4 screws) was 55% lower for the guided freehand technique compared to conventional freehand (p = 0.001). Operating time per screw (from first shot to screw tightened) was on average 22% reduced by guided freehand (p = 0.018).ConclusionsIn an experimental setting, the newly developed guided freehand technique for distal interlocking has proven to markedly reduce radiation exposure when compared to the conventional freehand technique. The method utilizes established clinical workflows and does not require cost intensive add-on devices or extensive training. The underlying principle carries potential to assist implant positioning in numerous other applications within orthopedics and trauma from screw insertions to placement of plates, nails or prostheses.

Disc degeneration after disc herniation: are we accelerating the process?

Study design: Systematic review. Study rationale: Disc degeneration is a common process starting early in life. Often disc herniation is an early step in disc degeneration, which may cause pain or stenosis. How quickly this subsequent disc degeneration occurs following a disc herniation and subsequent surgical treatment and whether certain spinal procedures increase the rate of degeneration remain unclear. Objectives: To investigate the risk of subsequent radiographic disc degeneration following discectomy, discography, and conservative care in patients with a first-time diagnosed herniated nucleus pulpous (HNP) and to ascertain whether this risk in these defined groups changes over time. Methods: A systematic review of pertinent articles published up to June 2012. Key articles were searched to identify studies evaluating the risk of subsequent radiographic disc degeneration following treatment for HNP. Studies that included patients undergoing secondary surgery for disc herniation or that did not use a validated classification system to measure the severity of disc degeneration were excluded. Two independent reviewers assessed the strength of evidence using the GRADE criteria and disagreements were resolved by consensus. Results: From a total of 147 possible citations, three cohort studies (class of evidence III) met our inclusion criteria and form the basis for this report. The risk of subsequent lumbar disc degeneration following standard discectomy was significantly greater compared with both microdiscectomy (48.7% vs 9.1%) and asymptomatic controls (90% vs 68%) in two studies with mean follow-ups of 5.5 and 25.3 years, respectively. Following conservative care for first-time HNP in the third study, the risk of progression of lumbar disc degeneration was 47.6% over the first 2 years of follow-up and 95.2% over the next 6 years of follow-up. In the same study, the risk of lumbar disc degeneration was shown to increase incrementally over the course of the 8-year follow-up, with all patients showing signs of degeneration at final examination. Conclusion: Standard discectomy in first-time lumbar HNP may increase the risk of subsequent same-level lumbar disc degeneration compared with microdiscectomy as seen in one low-quality study. However, disc degeneration is likely a natural, temporal consequence following HNP, as demonstrated in a second low-quality study. The overall strength of evidence for the conclusions is very low.

Using marketing research concepts to investigate specialty selection by medical students

Medical Education 2012: 46: 974–982

Thermal tibial osteonecrosis: A diagnostic challenge and review of the literature

Intramedullary nail (IMN) is a common treatment for tibial shaft fractures. It has been shown that reamed intramedullary nails are advantageous over non-reamed nails in reducing the number of non-union and hardware breakdown. However, soft tissue damage as well as bone injury may occur during the reaming process. These include deep infection, patellar tendon injury and damage to intra-articular structures. In addition, reaming has been associated with increase in the core temperature of the tibial shaft. This may lead to alter the endosteal architecture and eventually can result in thermal necrosis. Ultimately, this complication may lead to devastating clinical results such as recalcitrant non-union and hardware failure. Despite our understanding of the mechanism leading to this devastating complication only a few case reports dealing with this entity were described in the literature mainly dealing with combined soft and osseous tissue complication. We present here a case of an isolated thermal osteonecrosis of the tibia.

Are they too old? Surgical treatment for metastatic epidural spinal cord compression in patients aged 65 years and older.

Abstract Objectives: We aimed to assess the efficacy of surgical decompression of metastatic epidural spinal cord compression (MESCC) in patients ≧65 years and review our multidisciplinary surgical decision-making process. Methods: We identified all patients operated for MESCC from August 2008 to June 2012. Patients ≧65 years, with a single area of cord compression, back/radicular pain, neurological signs of cord compression, surgery within 48 hours after onset of MESCC-related paraplegia, and follow-up for ≧1 year or until death were included. Files were reviewed retrospectively. The requirement for informed consent was waived. Neurological status was assessed with the American Spinal Injury Association (ASIA) Impairment Scale (AIS). Duration of ambulation and survival were assessed with Kaplan–Meier and Cox regression analysis. Results: Twenty-one patients met inclusion criteria (11 women/10 men; mean age 73 years, range 65–87). All presented with debilitating back/neck pain. Ten patients (48%) were not ambulatory before surgery and four suffered urinary incontinence/constipation (19%). Preoperative AIS was E in 5 patients (24%), D in 11 (62%), and C in 5 (24%). Motor symptoms had been present for a mean of 3·8 days (range 1–14). All patients regained ambulation. Overall, mean survival was 320 days (range 19–798) and mean ambulation was 302 days (range 18–747). On 31 March 2013, 7 patients (33%) were alive and ambulatory at a mean of 459 days (range 302–747); 14 patients had died (67%) at a mean of 251 days (range 19–798), with a mean ambulation of 223 days (range 18–730). Discussion: With careful patient selection, surgery may achieve long duration of ambulation in patients ≧65 years with MESCC.