Kivanc Atesok

osteoid Osteoma and Osteoblastoma

&NA; Osteoid osteoma and osteoblastoma are commonly seen benign osteogenic bone neoplasms. Both tumors are typically seen in the second decade of life, with a notable predilection in males. Histologically, these tumors resemble each other, with characteristically increased osteoid tissue formation surrounded by vascular fibrous stroma and perilesional sclerosis. However, osteoblastomas are larger than osteoid osteomas, and they exhibit greater osteoid production and vascularity. Clinically, osteoid osteoma most commonly occurs in the long bones (eg, femur, tibia). The lesions cause night pain that is relieved with nonsteroidal anti‐inflammatory drugs (NSAIDs). Osteoblastoma is most frequently located in the axial skeleton, and the pain is usually not worse at night and is less likely to be relieved with NSAIDs. Osteoblastoma can be locally aggressive; osteoid osteoma lacks growth potential. Osteoid osteoma may be managed nonsurgically with NSAIDs. When surgery is required, minimally invasive methods (eg, CT‐guided excision, radiofrequency ablation) are preferred. Osteoblastoma has a higher rate of recurrence than does osteoid osteoma, and patients must be treated surgically with intralesional curettage or en bloc resection.

Surgical Simulation in Orthopaedic Skills Training

Mastering rapidly evolving orthopaedic surgical techniques requires a lengthy period of training. Current work-hour restrictions and cost pressures force trainees to face the challenge of acquiring more complex surgical skills in a shorter amount of time. As a result, alternative methods to improve the surgical skills of orthopaedic trainees outside the operating room have been developed. These methods include hands-on training in a laboratory setting using synthetic bones or cadaver models as well as software tools and computerized simulators that enable trainees to plan and simulate orthopaedic operations in a three-dimensional virtual environment. Laboratory-based training offers potential benefits in the development of basic surgical skills, such as using surgical tools and implants appropriately, achieving competency in procedures that have a steep learning curve, and assessing already acquired skills while minimizing concerns for patient safety, operating room time, and financial constraints. Current evidence supporting the educational advantages of surgical simulation in orthopaedic skills training is limited. Despite this, positive effects on the overall education of orthopaedic residents, and on maintaining the proficiency of practicing orthopaedic surgeons, are anticipated.

Endothelial progenitor cells promote fracture healing in a segmental bone defect model

The objective of this study was to evaluate the effects of local endothelial progenitor cell (EPC) therapy on bone regeneration in a rat model. A segmental bone defect (5 mm) was created in the femur and fixed with a mini‐plate. There were two groups: EPC‐treated (N = 28) and control (N = 28). Seven animals were sacrificed from each group at 1, 2, 3, and 10 weeks postoperatively. Healing of the defect was evaluated with radiographic, histological, and quantitative micro‐computed tomography (micro‐CT) scans. Radiographically, mean scores of the EPC and control groups were, respectively, 1.16–0.61 (p < 0.05) at 1 week, 2.53–1.54 (p < 0.05) at 2 weeks, and 4.58–2.35 at 3 weeks (p < 0.05). At 10 weeks, all the animals in the EPC‐treated group had complete union (7/7), but in the control group none achieved union (0/7). Histological evaluation revealed that specimens from EPC‐treated animals had abundant new bone and vessel formation compared to that in controls. Micro‐CT assessment of the samples from the animals sacrificed at 10 weeks (N = 14) showed significantly improved parameters of bone volume (36.58–10.57, p = 0.000), bone volume density (0.26–0.17, p = 0.000), model index −2.22–2.79, p = 0.000), trabecular number (1.28–0.91, p = 0.063), trabecular thickness (0.21–0.15, p = 0.001), trabecular spacing (0.63–1.07, p = 0.022), bone surface (353.75–152.08, p = 0.000), and bone surface to bone volume ratio (9.54–14.24, p = 0.004) for the EPC group compared to control, respectively. In conclusion, local EPC therapy significantly enhanced bone regeneration in a segmental defect model in rat femur diaphysis.

Arthroscopy-assisted fracture fixation.

PurposeThe purpose of this article was to systematically analyze the results of published studies in the literature which evaluated the use of arthroscopically assisted techniques in intra-articular fracture fixation.MethodsPublished investigations to date were analyzed by classifying them according to joints that were involved with intra-articular fractures including: knee, ankle, hip, shoulder, elbow, and wrist joints. The results were studied to assess the feasibility, efficiency, and outcomes of arthroscopy-assisted fracture fixation.ResultsArthroscopy-assisted techniques have been used successfully for the treatment of fractures of the tibial plateau, tibial eminence, malleoli, pilon, calcaneus, femoral head, glenoid, greater tuberosity, distal clavicle, radial head, coronoid, distal radius, and scaphoid. The major advantages of arthroscopic fracture fixation over open methods are direct visualization of the intra-articular space, decreased invasiveness, and the possibility for multitask interventions through which fixation of the fracture, and repair of the soft tissues and the cartilage can be performed simultaneously. The time-consuming and technically demanding nature of the procedures with a prolonged learning curve and limited fixation alternatives are the main disadvantages of this technique.ConclusionArthroscopic fixation is increasingly utilized for certain intra-articular fracture types due to the minimally invasive nature of the procedures and high accuracy. Randomized controlled trials are needed to justify wider use of arthroscopy-assisted techniques for treatment of intra-articular fractures.

Computer-assisted trauma surgery.

&NA; Computer‐assisted orthopaedic surgery (CAOS) is performed by digitizing the patients anatomy, combining the images in a computerized system, and integrating the surgical instruments into the digitized image background. This allows the surgeon to navigate the surgical instruments and the bone in an improved, virtual visual environment. CAOS in traumatology is performed with images obtained by fluoroscopy, CT, or three‐dimensional fluoroscopy. CAOS is used in basic trauma procedures for preoperative planning, fracture reduction, intramedullary nailing, percutaneous screw or plate fixation, and hardware or shrapnel removal. Potential benefits of CAOS include minimal invasiveness, increased accuracy, and decreased radiation exposure. Limitations include a significant learning curve, increased surgical time, requirements for special setup and equipment handling in the operating room, specialized technical support, and cost. Current evidence shows no advantage with CAOS in trauma cases compared with conventional methods. Prospective randomized trials and clinical outcomes are lacking.

Augmentation of tendon-to-bone healing.

Tendon-to-bone healing is vital to the ultimate success of the various surgical procedures performed to repair injured tendons. Achieving tendon-to-bone healing that is functionally and biologically similar to native anatomy can be challenging because of the limited regeneration capacity of the tendon-bone interface. Orthopaedic basic-science research strategies aiming to augment tendon-to-bone healing include the use of osteoinductive growth factors, platelet-rich plasma, gene therapy, enveloping the grafts with periosteum, osteoconductive materials, cell-based therapies, biodegradable scaffolds, and biomimetic patches. Low-intensity pulsed ultrasound and extracorporeal shockwave treatment may affect tendon-to-bone healing by means of mechanical forces that stimulate biological cascades at the insertion site. Application of various loading methods and immobilization times influence the stress forces acting on the recently repaired tendon-to-bone attachment, which eventually may change the biological dynamics of the interface. Other approaches, such as the use of coated sutures and interference screws, aim to deliver biological factors while achieving mechanical stability by means of various fixators. Controlled Level-I human trials are required to confirm the promising results from in vitro or animal research studies elucidating the mechanisms underlying tendon-to-bone healing and to translate these results into clinical practice.

Symptomatic bipartite patella: treatment alternatives.

Abstract Bipartite patella is usually an asymptomatic, incidental finding. However, in adolescents, it may be a cause of anterior knee pain following trauma or a result of overuse or strenuous sports activity. Most patients improve with nonsurgical treatment. Surgery is considered when nonsurgical treatment fails. Excision of the fragment is the most popular surgical option, with good results. However, when the fragment is large and has an articular surface, excision may lead to patellofemoral incongruity. Lateral retinacular release and detachment of the vastus lateralis muscle insertion are other surgical options and are reported to produce good pain relief and union in some patients. These procedures reduce the traction force of the vastus lateralis on the loose fragment. Internal fixation of the separated fragment has limited support in the literature. Understanding the possible consequences of different treatment approaches to painful bipartite patella is necessary to preserve quadriceps muscle strength and patellofemoral joint function.

Endothelial progenitor cells for fracture healing: a microcomputed tomography and biomechanical analysis.

Purpose: Local treatment of segmental bone defects with ex vivo expanded endothelial progenitor cells (EPCs) has been shown to increase osteogenesis and callus formation in rat femur diaphyseal defects. The purpose of this study was to evaluate the effects of local EPC therapy on the microarchitecture and biomechanical properties of a segmental bone defect in a rat model. Methods: Five-millimeter segmental defects were created in the femora of 14 Fisher 344 rats and stabilized with miniplates. The treatment group (n = 7) received 1 × 106 EPCs, seeded on a Gelfoam scaffold, locally at the site of the bone defect, and control animals (n = 7) received Gelfoam and saline only. Animals were euthanized 10 weeks after the procedure and new bone formation was assessed with radiographs, microcomputed tomography and biomechanical testing. Results: Radiographically, all the animals in the EPC-treated group healed with bridging callus formation, whereas animals in the control group developed nonunion of the defect. Microcomputed tomography assessment demonstrated significantly superior bone formation in the EPC-treated group versus the control group for all parameters tested (P = 0.013-0.000). Biomechanical testing revealed that the EPC-treated group had significantly higher torsional strength (P = 0.000) and stiffness (P = 0.000) when compared with the control group. Conclusion: The results of this study suggest that local EPC therapy significantly enhances fracture healing in a segmental defect model in a rat femur. EPC therapy results in superior radiographic bone formation and healing when compared with appropriate controls.

Expression of VEGF gene isoforms in a rat segmental bone defect model treated with EPCs

Objectives: Angiogenesis and osteogenesis are essential for bone growth, fracture repair, and bone remodeling. Vascular endothelial growth factor (VEGF) has an important role in bone repair by promoting angiogenesis and osteogenesis. In our previous study, endothelial progenitor cells (EPCs) promoted bone healing in a rat segmental bone defect as confirmed by radiological, histological, biomechanical, and micro-CT evaluations. Although EPCs have demonstrated effectiveness in animal models of fracture healing, the mechanism by which EPCs enhance fracture healing remains unclear. We hypothesized a possible paracrine mechanism of action, where the secretion of growth factors critical to the processes of fracture healing (such as VEGF), is responsible for the positive effects of EPC therapy. The purpose of this study was to evaluate VEGF gene expression after local EPC therapy for a rat segmental bone defect. Methods: Rat bone marrow–derived EPCs were isolated by the Ficoll-paque gradient centrifuge technique. The EPCs were cultured for 7–10 days in endothelial cell growth medium with supplements and collected for treatment of the rat segmental bone defect. EPCs were identified by immunocytochemistry staining with primary antibodies for CD34, CD133, fetal liver kinase-1, and Von Willebrand factor. A total of 56 rats were studied. A 5-mL segmental bone defect was created in the middle one-third of each femur followed by miniplate fixation. The treatment group received 1 × 106 EPCs locally at the bone defect on a gelfoam scaffold and control animals received the gelfoam scaffold only. Seven control and 7 EPC-treated rats were included in each group at 1, 2, 3, and 10 weeks. The animals were sacrificed at the end of the treatment period, and specimens from the fracture gap area were collected and immediately frozen. Rat VEGF mRNA was measured by reverse-transcriptase-polymerase chain reaction and quantified by VisionWorksLS. All measurements were performed in triplicate. Results: Cultured EPCs at 1 week showed positive staining for CD34, CD133, fetal liver kinase-1, and Von Willebrand factor markers. The EPC group had a greater VEGF expression than the control group at weeks 1, 2, and 3, but not at week 10. Three VEGF isoforms were detected in this rat model: VEGF120, VEGF164, and VEGF188. VEGF120 and VEGF164 levels peaked at 2 weeks, whereas VEGF188 levels peaked at 3 weeks. All 3 VEGF isoform levels were low at 10 weeks. Discussion and Conclusions: EPC-based therapy for a segmental bone defect results in increased VEGF expression during the early period of fracture repair. In addition, the specific VEGF isoform may be a key regulator of the bone healing process. These findings demonstrate that EPCs may promote fracture healing by increasing VEGF levels and thus stimulating angiogenesis, a process that is essential for early callus formation and bone regeneration.

Perspective: Integrating research into surgical residency education: Lessons learned from orthopaedic surgery

Orthopaedic research has advanced tremendously in parallel with accelerated progress in medical science. Possession of a fundamental understanding of basic and clinical science has become more essential than previously for orthopaedic surgeons to be able to translate advances in research into clinical practice. The number of medical graduates with prior education in scientific research who choose to pursue careers in orthopaedic surgery is small. Therefore, it is important that a core of research education be included during residency training to ensure the continued advancement of the clinical practice of orthopaedics. The authors examine some of the challenges to a comprehensive research experience during residency, including deficient priority, inadequate institutional infrastructure, financial strain on residency budgets, restricted time, and an insufficient number of mentors to encourage and guide residents to become clinician-scientists. They also present some strategies to overcome these challenges, including development and expansion of residency programs with clinician-scientist pathways, promotion of financial sources, and enhancement of opportunities for residents to interact with mentors who can serve as role models. Successful integration of research education into residency programs will stimulate future orthopaedic surgeons to develop the critical skills to lead musculoskeletal research, comprehend related discoveries, and translate them into patient care. Lessons learned from incorporating research training within orthopaedic residency programs will have broad application across medical specialties-in both primary and subspecialty patient care.