Rozalia Dimitriou

Masquelet technique for the treatment of bone defects: Tips-tricks and future directions

Reconstruction of diaphyseal bone defects still represents a major clinical challenge. Several approaches are used with the common objective to regenerate bone loss and restore function. The methods most commonly used are the vascularised fibula autograft and the Ilizarov bone transfer technique. Recently, Masquelet proposed a procedure combining induced membranes and cancellous autografts. The aim of this article was to briefly describe the technique, to review the current evidence and to discuss the tips and tricks that could help the surgeons to improve outcome. Future directions to increase its effectiveness and expand its application are also being discussed. However, predicting the outcome of reconstruction of bone defects remains difficult; and the patient should always be informed that, although potential complications are mostly predictable, in most of the cases the reconstruction process is long and difficult.

The synergistic effect of autograft and BMP-7 in the treatment of atrophic nonunions.

AbstractCombining autologous bone graft and recombinant human bone morphogenetic protein-7 (BMP-7) to treat long-bone fracture aseptic atrophic nonunions theoretically could promote bone healing at higher rates than each of these grafting agents separately. We retrospectively reviewed prospectively collected data on patient general characteristics, clinical outcomes, and complications over 3xa0years to determine the healing rates and the incidence of complications and adverse events of this “graft expansion rationale.” There were 45 patients (32 male) with a median age of 43xa0years (range, 19–76xa0years). Minimum followup was 12xa0months (mean, 24.5xa0months; range, 12–65xa0months). There were seven humeral, 19 femoral, and 19 tibial nonunions. The median number of prior operations was two (range, 1–7). All fractures united. Clinical and radiographic union occurred within a median of 5xa0months (range, 3–14xa0months) and 6xa0months (range, 4–16xa0months), respectively. Thirty-nine (87%) patients returned to their preinjury occupation at a mean of 4.2xa0months (range, 3–6xa0months). The median visual analog scale pain score was 0.9 (range, 0–2.8; maximum 10), and the median functional score was 86 (range, 67–95; maximum 100) at the final followup. BMP-7 as a bone-stimulating agent combined with conventional autograft resulted in a nonunion healing rate of 100% in these 45 patients.n Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

RETRACTED: Bone graft substitutes: What are the options?

Currently, a number of bone grafting materials are available in the clinical setting to enhance bone regeneration, varying from autologous bone to several bone graft substitutes. Although autologous bone remains the gold standard for stimulating bone repair and regeneration, the morbidity from its harvesting and its restricted availability generated the need for the development of other materials or strategies either to substitute autologous bone graft or expand its limited supply. Bone graft substitutes can possess one or more components: an osteoconductive matrix, acting as a scaffold; osteoinductive proteins and other growth factors to induce differentiation and proliferation of bone-forming cells; and osteogenic cells for bone formation. Based on their distinct properties, all these bone grafting alternatives have specific indications, and can be used either alone or in combination. In this review, we summarise the available bone grafting materials, focussing mainly on the various bone substitutes and their characteristics, in an effort to specify the indications for their use.

The role of arterial embolization in controlling pelvic fracture haemorrhage: A systematic review of the literature

OBJECTIVEnTo evaluate the efficacy of emergency transcatheter arterial embolization (TAE) in controlling retroperitoneal arterial haemorrhage associated with unstable pelvic fractures.nnnMETHODSnA systematic review of the English literature yielded 21 eligible studies published from 1979 to 2010. Evaluation of clinical and methodological heterogeneity was based on recording certain descriptive characteristics in the component studies. Statistical heterogeneity was detected using Cochran chi-square and I square tests and, when absent, a pooled estimate of effect size for each outcome of interest was calculated. The principal outcomes of interest were efficacy rate of TAE to control intrapelvic bleeding, mortality rates and frequency of associated complications.nnnRESULTSnAll component studies were assigned a low to moderate quality score. Methodological and clinical heterogeneity was evident across component studies, but not strongly associated with the observed results. The efficacy rate of TAE ranged from 81 to 100%, while the frequency of repeat TAE for effective control of haemorrhage was 10% (95% CI: 7-13%, range: 0-19%). TAE was associated with an overall mortality ranging from 7 to 47%, and a 0-25% mortality due to intrapelvic bleeding (pooled estimate of effect size: 6%, 95% CI: 4-8%). A very low rate of associated complications were recorded in the component studies (pooled estimate of effect size: 1.1%, 95% CI: 0.1-2.1%).nnnCONCLUSIONnTAE is an efficient acute intervention for controlling severe arterial bleeding related to pelvic trauma with a low complication rate. Repeat of the procedure is occasionally necessary before the effective haemorrhage control.

The use of bone graft substitutes in large cancellous voids: any specific needs?

Bone graft is the second most common transplantation tissue, with blood being by far the commonest. Autograft is considered ideal for grafting procedures, providing osteoinductive growth factors, osteogenic cells and an osteoconductive scaffold. Limitations, however, exist regarding donor site morbidity and graft availability. Allograft on the other hand poses the risk of disease transmission. Synthetic graft substitutes lack osteoinductive or osteogenic properties. Composite grafts combine scaffolding properties with biological elements to stimulate cell proliferation and differentiation and eventually osteogenesis. We present here an overview of bone graft substitutes available for clinical application in large cancellous voids.

What is the effect of compartment syndrome and fasciotomies on fracture healing in tibial fractures

Acute compartment syndrome (ACS) in tibial diaphyseal fractures has been associated with such complications as infection, delayed fracture healing or non-union, sensory and motor deficits, deformities, and poor functional outcome. Essential condition of an uncomplicated recovery is early diagnosis with prompt decompression. A comprehensive review of the literature was performed to evaluate the impact of compartment syndrome and leg fasciotomies on the time to fracture union and the incidence of delayed union and non-union in tibial diaphyseal fractures. A total of 16 articles, which included 245 tibial fractures complicated with compartment syndrome were analysed. There were statistically significant differences in the time to healing, being longer by 4.90 weeks (p<0.001), and in the rates of delayed union or non-union (55% versus 17.8%) (p<0.001) when these fractures were compared to tibial fractures without compartment syndrome. Patients with ACS of the tibia undergoing leg fasciotomies should be informed about the increased risk of impaired fracture healing and longer time to union.

Genetic predisposition to non-union: Evidence today

Atrophic non-union represents a complex clinical condition and research is ongoing in an effort to elucidate its pathophysiology and to offer new and more efficient treatment modalities. Differences seen in fracture healing responses and final outcome may be attributed among other factors to biological variations between patients resulting in a disturbed signalling pathway and an inert or deficient local biology with reduced potentials for bone regeneration. The genetic contribution with or without the interaction of other exogenous factors in cases of impaired fracture healing, is yet to be elucidated. However, preliminary animal and human studies demonstrate the molecular basis of fracture non-unions and correlate genetic variants of the molecules regulating fracture healing and their expression patterns with impaired bone healing and fracture non-union. Further research is needed to clarify the genetic component and its role and interaction with other risk factors that may result in increased susceptibility of a patient to develop this complication.

Second hit phenomenon: Existing evidence of clinical implications

The last two decades extensive research evidence has been accumulated regarding the pathophysiology of trauma and the sequelae of interventions that follow. Aim of this analysis has been to collect and categorise the existing data on the so-called second hit phenomenon that includes the biochemical and physiologic alterations occurring in patients having surgery after major trauma. Articles were extracted from the PubMed database and the retrieved reports were included in the study only if pre-specified eligibility criteria were fulfilled. Moreover, a constructed questionnaire was utilised for quality assessment of the outcomes. Twenty-six articles were eligible for the final analysis, referring to a total of 8262 patients that underwent surgery after major trauma. Sixteen retrospective clinical studies including 7322 patients and 10 prospective ones, including 940 patients were evaluated. Several variables able to reproduce a post-operative second hit were identified; mostly related to pulmonary dysfunction, coagulopathy, fat or pulmonary embolism, and the inflammatory immune system. Indicative conclusions were extracted, as well as the need for further prospective randomised trials. Suggestions on the content and the rationale of future studies are provided.

“Internal fixation of proximal humeral fractures using the Polarus intramedullary nail: our institutional experience and review of the literature”

BackgroundThe purpose of this study is to evaluate the functional outcome, union and complication rates after surgical treatment of unstable or displaced proximal humeral fractures using the Polarus intramedullary nail, by reviewing our institutional experience and the relevant current literature.MethodsTwenty-seven patients were treated operatively for proximal humeral fracture using the Polarus nail. Fractures were classified according to Neer’s classification. A number of parameters including patient demographics, mechanism of injury, operative time, time to union and complications were recorded. Functional outcome was evaluated using the Constant Shoulder Score. A comparison among functional outcomes in patients >60u2009years in relation to the younger ones was performed. Moreover, a review of the literature was carried out to evaluate the overall union and complication rates.ResultsTwo patients lost to follow-up were excluded from the analysis. For the twenty-five patients (mean age: 61u2009years), the mean follow-up was 36u2009months. There were 7 complications (28%), including one fixation failure, four protruded screws, one superficial infection and one case of impingement. The union rate was 96% (mean time to union: 4.2u2009months). The mean Constant score was 74.5 (range: 48–89). Patients under the age of 60 had a better functional outcome compared to patients >60u2009years of age (p<0.05). From the literature review and from a total of 215 patients treated with a Polarus nail, the mean union rate was 95.8%, the overall reported complication rate, including both minor and major complications, ranged widely from 9.3% up to 70%.ConclusionsThe Polarus nail was found to be an effective implant for stabilisation of proximal humeral fractures. Functional outcome is for the vast majority of the cases excellent or good, but in elderly patients a lower Constant score can be expected.

Implant Longevity, Complications and Functional Outcome Following Proximal Femoral Arthroplasty for Musculoskeletal Tumors: A Systematic Review

A systematic review of the literature was undertaken to evaluate the outcomes and complications following proximal femoral arthroplasty for primary or metastatic tumors affecting the proximal femur. Six hundred sixty-eight patients were available for review. The length of resection ranged from 92 to 212 mm. Limb salvage rate reached over 90%. At 5 years the implant survival rate was 84% and at 10 years, it was 70%. The overall revision rate was 11.1%. Prevalence of venous thrombo-embolic (VTE) events was 8.5%, dislocation rate was 5.8%, infection was 5.2%, local tumor reoccurrence was 4.7%, perioperative mortality was 1.5%, and periprosthetic fracture was 0.6%. Where it was provided the Musculoskeletal Tumour Score was 70.8%. The implants tend to outlive patients with metastatic disease and high-grade localized disease, providing them with a relatively pain-free limb with good mobility and quality of life.