Lukas Ernstbrunner

A systematic review of the clinical applications and complications of bone marrow aspirate concentrate in management of bone defects and nonunions

AbstractPurposeFracture healing encompasses a succession of dynamic multifactorial metabolic events, which ultimately re-establishes the integrity of the biomechanical properties of the bone. Up to 10% of the fractures occurring annually will need additional surgical procedures because of impaired healing. The aim of this article is to review the current literature regarding the use of bone marrow aspirate concentrate (BMAC) and its effectiveness in the management of bone defects.MethodsWe have included all published clinical literature investigating the development, techniques and applications of BMAC. Language, design and risk of bias did not deter the initial inclusion of any study. Our search was exclusively limited to studies involving human subjects. A PRISMA compliant search was carried out as published in 2009. This included the online databases: PubMed, EMBASE, clinical trial.gov and the Cochrane library from 1960 to the end of May 2015. MeSH terms used included: “Bone” AND “Marrow” AND “Aspirate” AND “Concentrate” AND “Bone Defects” AND “NONUNION”. Eligible studies were independently appraised by two authors using the Critical Appraisal Skills Program checklist. For the purpose of narrative review, relevant studies were included irrespective of methodology or level of evidence.ResultsThirty-four of the 103 (48 PubMed and 55 EMBASE) results yielded by the preliminary search were included. Exclusions included three duplicate records, six letters, 17 non-orthopaedics related studies and four records irrelevant to our search topic. The CASP appraisal confirmed a satisfactory standard of 31 studies. They all had clearly defined objectives, were well designed and conducted appropriately to meet them. The published studies reported the use of BMAC in non-union and fracture healing (15 studies), bone defects (nine studies), spine fusion (two studies), distraction osteogensis (two studies) and complications related to the use of BMAC (seven studies).ConclusionsStem cells found in BMAC have the potential to self-renew, undertake clonal expansion and differentiate into different musculoskeletal tissues. The commercial processing of BMAC needs to be optimized in order to achieve a consistent end product, which will provide predicable and translatable results. The future potential of cell characterization in order to determine the optimum cell for repair/regeneration of bone also needs to be explored. Level of Evidence: Systematic Review of minimum level IV studies.

Reverse total shoulder arthroplasty for massive, irreparable rotator cuff tears before the age of 60 years: long-term results

Background: There has been serious concern regarding the longevity and durability of outcomes of reverse total shoulder arthroplasty (RTSA) in younger patients. It was the purpose of this study to analyze long-term outcomes and complications of RTSA for irreparable rotator cuff tears in patients younger than 60 years. Methods: Twenty patients (23 shoulders) with a mean age of 57 years (range, 47 to 59 years) were evaluated at a mean of 11.7 years (range, 8 to 19 years) after RTSA. Fifteen shoulders (65%) had undergone previous non-arthroplasty surgery. Longitudinal clinical and radiographic outcomes were assessed. Results: At the time of final follow-up, the mean absolute and relative preoperative Constant score (CS) (and standard deviation) had improved from 24 ± 9 to 59 ± 19 points (p < 0.001) and from 29% ± 11% to 69% ± 21% (p < 0.001), respectively. The mean Subjective Shoulder Value (SSV) had increased from 20% ± 13% to 71% ± 27% (p < 0.001). There were also significant improvements in the mean active anterior elevation (from 64° to 117°), active abduction (from 58° to 111°), pain scores, and strength (all p ⩽ 0.001). Clinical outcomes did not significantly deteriorate beyond 10 years and the functional results of patients with previous surgical procedures were not significantly inferior to the results of those with primary RTSA. The grade of, and number of patients with, radiographically apparent notching increased over time; the mean relative CS was lower in patients in whom the notching was grade 2 or higher (57%) than it was in those with no or grade-1 notching (81%; p = 0.006). Nine (39%) had ≥1 complication, with 2 failed RTSAs (9%). Conclusions: RTSA in patients younger than 60 years leads to substantial subjective and functional improvement without clinical deterioration beyond 10 years. It is associated with a substantial complication rate, and complications compromise ultimate subjective and objective outcomes. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Biomechanical analysis of the effect of congruence, depth and radius on the stability ratio of a simplistic ‘ball-and-socket’ joint model

Objectives The bony shoulder stability ratio (BSSR) allows for quantification of the bony stabilisers in vivo. We aimed to biomechanically validate the BSSR, determine whether joint incongruence affects the stability ratio (SR) of a shoulder model, and determine the correct parameters (glenoid concavity versus humeral head radius) for calculation of the BSSR in vivo. Methods Four polyethylene balls (radii: 19.1 mm to 38.1 mm) were used to mould four fitting sockets in four different depths (3.2 mm to 19.1mm). The SR was measured in biomechanical congruent and incongruent experimental series. The experimental SR of a congruent system was compared with the calculated SR based on the BSSR approach. Differences in SR between congruent and incongruent experimental conditions were quantified. Finally, the experimental SR was compared with either calculated SR based on the socket concavity or plastic ball radius. Results The experimental SR is comparable with the calculated SR (mean difference 10%, sd 8%; relative values). The experimental incongruence study observed almost no differences (2%, sd 2%). The calculated SR on the basis of the socket concavity radius is superior in predicting the experimental SR (mean difference 10%, sd 9%) compared with the calculated SR based on the plastic ball radius (mean difference 42%, sd 55%). Conclusion The present biomechanical investigation confirmed the validity of the BSSR. Incongruence has no significant effect on the SR of a shoulder model. In the event of an incongruent system, the calculation of the BSSR on the basis of the glenoid concavity radius is recommended. Cite this article: L. Ernstbrunner, J-D. Werthel, T. Hatta, A. R. Thoreson, H. Resch, K-N. An, P. Moroder. Biomechanical analysis of the effect of congruence, depth and radius on the stability ratio of a simplistic ‘ball-and-socket’ joint model. Bone Joint Res 2016;5:453–460. DOI: 10.1302/2046-3758.510.BJR-2016-0078.R1.

Longitudinal observational study of reverse total shoulder arthroplasty for irreparable rotator cuff dysfunction: results after 15 years

HYPOTHESIS This study investigated the hypothesis that functional outcome remains significantly improved over the preoperative state beyond 15 years of reverse total shoulder arthroplasty (RTSA) for irreparable rotator cuff dysfunction. METHODS Operations were performed on 22 shoulders at a mean age of 68 (range, 54-77) years. The patients could personally be reviewed clinically and radiographically in intervals of 2 to 5 years and with a final follow-up examination at no less than 15 years (mean, 16.1; range, 15-19 years). The RTSA was a primary procedure in 7 procedures, and 15 patients had undergone at least 1 previous nonarthroplasty procedure. RESULTS The mean absolute Constant score (CS) had improved from 23 ± 11 to 58 ± 19 points (P < .001) and the relative CS (rCS) from 30% ± 13% to 73% ± 23% (P < .001) at final follow-up. Significant improvements were seen in mean pain scores (4 to 12 points; P < .001), active anterior elevation (53° to 101°; P = .001), abduction (55° to 86°; P = .005), and Subjective Shoulder Value (27% to 78%; P = .001). The mean rCS and Subjective Shoulder Value did not significantly deteriorate over 15 years, but mean active abduction was significantly reduced over time (P = .018). One or more complications were recorded in 13 patients (59%), with 6 failed RTSAs (27%).The mean rCS of patients with complications (explantations excluded) was not significantly inferior compared with that of patients without complications (62% vs. 81%; P = .090). CONCLUSIONS This early series of RTSA shows a substantial complication and failure rate. If, however, complications can be treated without removal of the implants, outcome is not compromised. Overall shoulder function and subjective outcome remained significantly improved and highly satisfactory during the entire study period.

Long-term results of total elbow arthroplasty in patients with hemophilia

HYPOTHESIS It was hypothesized that the long-term survivorship and clinical outcome are reasonable, justifying total elbow arthroplasty (TEA) in patients with end-stage hemophilic arthropathy. METHODS From 2002 to 2012, 13 primary TEAs (Coonrad-Morrey design) were implanted in 9 consecutive patients with an average age of 55 (range, 39-76) years. Type A hemophilia was diagnosed in 7 patients and type B hemophilia in 2 patients. Clinical and radiographic results of all (11 TEAs) but 1 patient were retrospectively analyzed. RESULTS After a mean of 9.1 (range, 5-14) years, the mean visual analog scale score for pain, total Mayo Elbow Performance Score, and subjective elbow value were significantly improved from 5 (standard deviation, ±3) to 2 (±2; P = .007) points, from 64 (±16) to 89 (±11; P = .008) points, and from 47% (±15%) to 81% (±11%; P < .001), respectively. Whereas the flexion arc remained unchanged (P = .279), mean active pronation improved significantly (P = .024). Postoperative complications were recorded in 8 TEAs (62%), whereas 5 TEAs (38%) underwent partial component exchange after a mean of 7.2 (range, 3-10) years: 2 for periprosthetic infection, 2 for polyethylene wear, and 1 for humeral component loosening. Of the living patients after partial component exchange (n = 3), the mean final total Mayo Elbow Performance Score, flexion and rotation arc, visual analog scale score for pain, and subjective elbow value were comparable with the results of the living patients without revision surgery (n = 8). CONCLUSIONS TEA for patients with advanced hemophilic arthropathy is associated with a substantial complication and revision rate. However, even after revision without implant removal, it provides good functional and subjective long-term results.

S100B serum protein cannot predict secondary intracranial haemorrhage after mild head injury in patients with low-dose acetylsalicylic acid prophylaxis

Abstract Introduction: The goal of this study was to investigate if S100B serum protein could predict secondary intracranial haemorrhagic events (SIHEs) after mild head injury (mHI) in patients taking low-dose acetylsalicylic acid (LDA), making routinely repeated head computed tomography (RRHCT) scans unnecessary. Methods: Three hundred and eight-two patients with mHI, older than 60 years and taking LDA prophylaxis were enrolled. Primary head CT and RRHCT scans within 3 and 48 hours to trauma were performed. Additionally, S100B serum protein levels were evaluated at admission and predictive power for SIHEs was analysed. Results: Fifty-nine per cent were female and the mean age of all included patients was 81.8 ± 8.9 years. In four patients SIHEs were diagnosed. Sensitivity and the negative predictive value of S100B serum protein (cut-off value 0.10 µg l−1) were 75.0% and 98.6%, respectively. Specificity was 19.0% and the positive predictive value 1.0% (306 false positive values). In patients without bleeding, the median S100B value was 0.18 (IQR = 0.12–0.34) and in the ones with SIHEs, the median was 0.11 (IQR = 0.10–1.16) (p > 0.05). The discriminatory power of S100B in the ROC analysis was 0.399 (95% CI = 0.079–0.720; p > 0.05). Conclusion: S100B cannot be considered as an effective diagnostic tool in the prediction or exclusion of SIHE in older patients with mHIs taking LDA prophylaxis.

Glenoid bone grafting in primary reverse total shoulder arthroplasty

BACKGROUND Severe glenoid bone loss remains a challenge in patients requiring shoulder arthroplasty and may necessitate glenoid bone grafting. The purpose of this study was to determine results, complications, and rates of failure of glenoid bone grafting in primary reverse shoulder arthroplasty. METHODS Forty-one shoulders that underwent primary reverse arthroplasty between 2006 and 2013 with a minimum follow-up of 2 years (mean, 2.8 years; range, 2-6 years) were reviewed. Thirty-four (83%) received corticocancellous grafts and 7 (17%) structural grafts. RESULTS Active range of motion and pain levels were significantly improved (P < .001), with mean American Shoulder and Elbow Surgeons score of 77, Simple Shoulder Test score of 9, and patient satisfaction of 93% at the most recent follow-up. Preoperative severe glenoid erosion and increasing body mass index were significantly associated with worse American Shoulder and Elbow Surgeons scores (P = .04). On radiographic evaluation, 7 patients (18%) had grade 1 or grade 2 glenoid lucency. Glenoid bone graft incorporation was observed in 31 patients (78%). Twelve patients (30%) suffered from grade 1 or grade 2 scapular notching. All of the patients with structural grafts showed graft incorporation and no signs of glenoid lucency. CONCLUSION Although glenoid lucency, glenoid graft resorption, and scapular notching were present at short-term to midterm follow-up, none of the patients needed revision surgery. Primary reverse shoulder arthroplasty with glenoid reconstruction using bone graft relieved pain and restored shoulder function and stability.

A prospective analysis of injury rates, patterns and causes in Cliff and Splash Diving

INTRODUCTION Information about injuries and its differences in Cliff Diving (CD) and Splash Diving (SD) are unknown. It was the aim to analyse (1) injury rates, patterns and causes; (2) differences (in injuries) between both disciplines; and to (3) identify targets for future injury prevention interventions. METHODS From April to November 2013, 81 cliff and 51 splash divers were prospectively surveyed with an encrypted, monthly e-mail-based questionnaire. RESULTS During a total of 7857h diving with an average diving height of 13 (±7)m, an overall injury rate of 7.9 injuries/1000h of sport exposure was reported. Cliff divers most commonly suffered from injuries of the foot and ankle (18%; n=24) and neck and cervical spine (14%; n=19). In SD, the lower limb (52%; n=43) and lower back (23%; n=19) were most frequently involved. In 79% (n=49) of the cases, the injury happened while entering the water. Cliff divers were in 52% (n=15) of the injuries in a feet-first and in 14% (n=4) in a head-first position. Splash divers were in 45% (n=9) of the injuries in a back- or buttocks-first position. Most of the injuries were bruises (47%; n=104) and muscle strains (13%; n=28). The injury risk during practice was significantly higher than in competition (11.3 vs. 4.5 injuries/1000h; OR 2.5; p=0.001). The injury risk of experts (15.4/1000h exposure) was significantly higher than in professionals (6.3/1000h exposure; OR 2.4; 95% CI, 3.3-1.9; p<0.001), although the average diving height was significantly higher in professionals (19m±8 vs. 12m±6; p<0.001). Significantly more professionals performed dryland training compared to experts (p=0.006). CONCLUSION Most of the injuries are related to the water entry. The entry position plays a key role in injury patterns with pursuant differences comparing CD with SD. Although most of the injuries involved soft-tissue only, severe injuries have been reported. Targets for future injury prevention strategies include protection for the increased impaction at entry; adaption of the diving conditions in practice to those in competition; dryland training courses; and instruction of non-professional divers to teach appropriate diving techniques.

Biomechanical Comparison of Sacral Fixation Characteristics of Standard S1-Pedicle Screw Fixation versus a Novel Constrained S1-Dual-Screw Anchorage in the S1-Pedicle and S1-Alar Bone.

Study Design. Biomechanical Laboratory Study. Objective. Analysis of the biomechanical characteristics of a novel sacral constrained dual-screw fixation device (S1-PALA), combining a S1-pedicle screw and a S1-ala screw, compared to a standard bicortical S1-pedicle screw (S1-PS) fixation. Summary of Background Data. Instrumented fusions to the sacrum are biomechanically challenging and plagued by a high risk of nonunion when S1-PS is used as the sole means of fixation. Thus, lumbopelvic fixation is increasingly selected instead, although associated with a reasonable number of instrumentation-related complications. Methods. Around 30 fresh-frozen human sacral bones were harvested and embedded after CT scans. Instrumentation was conducted in alternating order with bicortical 7.0 mm S1-PS and with the S1-PALA including a S1-PS screw and a S1-ala screw, of 7.0 and 6.0 mm diameter, respectively. Specimens were subjected to cyclic loading with increasing loads (25–250 N) until a maximum of 2000 cycles or displacement >2 mm occurred. All implant sacral units (ISUs) were subject to coaxial pullout tests. Failure load, number of ISUs surpassing 2000 cycles, number of cycles, and loads at failure were recorded and compared. Results. Donors’ age averaged 77 ± 14.2 years, and BMD was 115 ± 64.8 mgCA-HA/ml. Total working length of screws implanted was 90 ± 8.6 mm in the S1-PALA group and 46 ± 5 mm in the S1-PS group (P = 0.0002). In the S1-PALA group, displacement >2 mm occurred after 845 ± 325 cycles at 149 ± 41 N compared to 512 ± 281 cycles at 106 ± 36 N in the S1-PS group (P = 0.004; P = 0.002). In coaxial pull-out testing, failure load was 2118.1 ± 1166 N at a displacement of 2.5 ± 1 mm in the S1-PALA group compared to 1375.6 ± 750.1 N at a displacement of 1.6 ± 0.5 mm in the S1-PS group (P = 0.0007; P = 0.0003). Conclusion. The novel sacral constrained dual-screw anchorage (S1-PALA) significantly improved holding strength after cyclic loading compared to S1-PS. The S1-PALA demonstrated mechanical potential as a useful adjunct in the armamentarium of lumbosacral fixations indicated in cases that need advanced construct stability, but where instrumentation to the ilium or distal dissection to S2 should be avoided. Level of Evidence: N/A

A prospective injury surveillance study in canyoning

INTRODUCTION Little is known about injuries in canyoning. It was the purpose of this study to determine injury rates, patterns, causes and risk factors in canyoning; and to identify targets for future injury prevention strategies. METHODS From May to October 2015, 109 participants from 17 different countries were prospectively followed via a monthly e-mail-based questionnaire. RESULTS During 13,690 h of canyoning, 57 injury-events occurred. The overall injury-rate was 4.2 injuries/1000 h of canyoning. The hand (23%) and lower leg and foot (25%) were most frequently involved. Most of the injuries were mild (n = 27, 49%) and limited to the soft-tissue. There were seven severe injuries (12%) with two lateral malleolar fractures, both necessitating surgery. The majority of injuries were due to material failure (44%) and significantly more injury-events were reported when the tour included rappelling (p = 0.037). Canyoning guides suffered from significantly less injuries compared to beginners and advanced canyoneers (p < 0.001). CONCLUSIONS The majority of canyoning injuries are mild. On the other side, roughly one-tenth suffered from severe injury. Canyoning guides are less prone to injury-events and beginners should consider performing tours with experienced guides. Notwithstanding, rappelling was the most common activity associated with an injury and the material used was deemed causative for an injury-event in almost half of all cases. Further improvement in canyoning equipment, frequent equipment service, and instructional courses to ensure adequate employment of equipment might minimize the risk of getting injured.