Aims

Continuous local antibiotic perfusion (CLAP) has recently attracted attention as a new drug delivery system for orthopaedic infections. CLAP is a direct continuous infusion of high-concentration gentamicin (1,200 μg/ml) into the bone marrow. As it is a new system, its influence on the bone marrow is unknown. This study aimed to examine the effects of high-concentration antibiotics on human bone tissue-derived cells.

Aims

This study aimed to evaluate the effectiveness of the induced membrane technique for treating infected bone defects, and to explore the factors that might affect patient outcomes.

The need for an artificial scaffold in very large bone defects is clear, not only to limit the risk of graft harvesting, but also to improve clinical success. The use of custom osteoconductive scaffolds made from biodegradable polyester and ceramics can be a valuable patient friendly option, especially in case of a concomitant infection. Multiple types of scaffolds for the Masquelet procedure (MP) are available, however these frequently demonstrate central graft involution when defects exceed a certain size and the complication rates remains high. This paper describes three infected tibial defect nonunions with a segmental defect over ten centimeters long treated with a customized 3D printed polycaprolactone-tricalcium phosphate (PCL-TCP) cage in combination with biological adjuncts. Three male patients, between the age of 37 and 47, were treated for an infected tibial defect nonunion after sustaining Gustilo grade 3 open fractures. All had a segmental midshaft bone defect of more than ten centimeters (range 11–15cm). First stage MPs consisted of extensive debridement, external fixation and placement of anterior lateral thigh flaps (ALT). Positive cultures were obtained from all patients during this first stage, that were treated with specific systemic antibiotics during 12 weeks. The second stage MP was carried out at least two months after the first stage. CT scans were obtained after the first stage to manufacture defect-specific cages. In the final procedure a custom 3D printed PCL-TCP cage (Osteopore, Singapore) was placed in the defect in combination with biological adjuncts (BMAC, RIA derived autograft, iFactor and BioActive Glass). Bridging of the defect, assessed at six months by CT, was achieved in all cases. SPECT-scans 6 months post-operatively demonstrated active bone regeneration, also involving the central part of the scaffold. All three patients regained function and reported less pain with full weight-bearing. This case report shows that 3D printed PCL-TCP cages in combination with biological adjuncts is a novel addition to the surgical treatment of very large bone defects in (infected) posttraumatic nonunion of the tibia. This combination could overcome some of the current drawbacks in this challenging indication

Aims

To clarify the effectiveness of the induced membrane technique (IMT) using beta-tricalcium phosphate (β-TCP) for reconstruction of segmental bone defects by evaluating clinical and radiological outcomes, and the effect of defect size and operated site on surgical outcomes.

Introduction. The BOAST (British Orthopaedic Association Standards for Trauma) guidelines do advise that open pilon fractures amongst other open lower limb fractures need to be treated at a specialist centre with Orthoplastic care. The purpose of this study was to determine clinical outcomes in patients with open pilon fractures treated as per BOAST guidelines including relatively aggressive bone debridement. Methods. A retrospective analysis of a single surgeon series of open pilon fractures treated between 2014 and 2019 was conducted. Injuries were graded according to the Gustillo-Anderson classification and all patients were included for the assessment of the rate of infection and fracture healing. Functional outcome assessment was performed in all patients according to the American Orthopedic Foot and Ankle Score (AOFAS) at 6 months after definitive surgery. Initial wound with bone debridement and application of a spanning external fixator was performed within an average of 13.5 (Range: 3–24) hours. Fixation with FWF (Fine Wire Frame) was performed when the wound was healed, with the mean time from primary surgery to application of FWF being 24.5 (Range: 7–60) days. Results. There was a total of 20 patients including 16 males and 4 females. The mean age was 50.45 (Range: 16–88) years. Follow-up was for an average of 23.2 (Range: 5–51) months. There were 3 patients with Gustilo Type I injuries, 6 with Type II, 4 Type with type IIIa and 7 with Type IIIb injuries. Average time to bone union was 9.3 (Range: 2–18) months. The mean AOFAS score was 66 (Range: 15–97) points. TSF was used on 18 patients, while 2 patients had an Ilizarov frame. A corticotomy was performed on 4 patients with critical bone defect post debridement, while 2 patients had Stimulan beads with antibiotics. There was 1 case (5%) of deep infection and 9 cases (45%) of superficial infection. There were also 2 cases (10%) of non-union which required bone grafting from their femur using a RIA (Reamer Irrigation Aspirator). Other complications included 1 case of acute compartment syndrome, 1 case of pulmonary embolism, 1 case of necrotic skin and 1 case of amputation. Conclusion. Results of our study suggests that the use of staged wound debridement including relatively aggressive bone debridement in conjunction with antibiotics, external fixators and patient tailored conversion from spanning external fixator to fine wire frame achieves low rates of wound infection and complications for patients with open pilon fractures

Aims

The purpose of this study was to: review the efficacy of the induced membrane technique (IMT), also known as the Masquelet technique; and investigate the relationship between patient factors and technique variations on the outcomes of the IMT.

Aims

This study reviews the use of a titanium mesh cage (TMC) as an adjunct to intramedullary nail or plate reconstruction of an extra-articular segmental long bone defect.

Despite its intrinsic ability to regenerate form and function after injury, bone tissue can be challenged by a multitude of pathological conditions. While innovative approaches have helped to unravel the cascades of bone healing, this knowledge has so far not improved the clinical outcomes of bone defect treatment. Recent findings have allowed us to gain in-depth knowledge about the physiological conditions and biological principles of bone regeneration. Now it is time to transfer the lessons learned from bone healing to the challenging scenarios in defects and employ innovative technologies to enable biomaterial-based strategies for bone defect healing. This review aims to provide an overview on endogenous cascades of bone material formation and how these are transferred to new perspectives in biomaterial-driven approaches in bone regeneration.

Cite this article: T. Winkler, F. A. Sass, G. N. Duda, K. Schmidt-Bleek. A review of biomaterials in bone defect healing, remaining shortcomings and future opportunities for bone tissue engineering: The unsolved challenge. Bone Joint Res 2018;7:232–243. DOI: 10.1302/2046-3758.73.BJR-2017-0270.R1.

Aims

This study describes the use of the Masquelet technique to treat segmental tibial bone loss in 12 patients.

Objectives

Induced membrane technique is a relatively new technique in the reconstruction of large bone defects. It involves the implantation of polymethylmethacrylate (PMMA) cement in the bone defects to induce the formation of membranes after radical debridement and reconstruction of bone defects using an autologous cancellous bone graft in a span of four to eight weeks. The purpose of this study was to explore the clinical outcomes of the induced membrane technique for the treatment of post-traumatic osteomyelitis in 32 patients.

Methods

Between 2005 and 2012, 50 patients (23 female, 27 male) with nonunion of the humeral shaft were included in this retrospective study. The mean age was 51.3 years (14 to 88). The patients had a mean of 1.5 prior operations (sd 1.2;1 to 8).

All patients were assessed according to a specific risk score in order to devise an optimal and individual therapy plan consistent with the Diamond Concept. In 32 cases (64%), a change in the osteosynthesis to an angular stable locking compression plate was performed. According to the individual risk an additional bone graft and/or bone morphogenetic protein-7 (BMP-7) were applied.

Septic complications of long bone fracture are still a significant clinical problem. Although inflammatory process after intramedullary nailing is a rare complication, its treatment is complex. The aim of this study is to analyze the effectiveness of the treatment of septic complications of the long bone union with use of Reamer–Irrigator–Aspirator (RIA) technique and intramedullary antibiotic-coated PMMA nailing. An analysis of the effectiveness of treatment of 49 patients with septic non-union of long bones (12 femur, 37 tibia), in which the RIA method was applied with antibiotic cement impregnated intramedullary nailing. Treatment consisted of reaming of long bone canal using the RIA technique and the intramedullary cement coated nail with the targeted antibiotic. Treatment required second stage with nail exchange and PMMA removal after 6 weeks to prevent the resitant strains selection. In a group of patients treated with use of above-mentioned method the remission of inflammatory process was achieved in all cases. 32 (67%) patients developed bone union, 24 patients with tibial and 8 patients with femoral septic bone union disorders. The average duration of bone union obtainment with intramedullary nailing was 37 weeks. The most common inconveniences that occurred during treatment was prolonged wound discharge and pain. Inflammatory complications of fractures in our material involved extensive injuries, usually high-energetic. Stabilization with intramedullary locked nail coated with antibiotic cement after debridement with RIA method is a convincing treatment. An essential element of biological bone union is to provide a good cover of the bone tissue with a soft tissue envelope and sequestrectomy. The success of the treatment of infected pseudoarthrosis may be obtained under condition of: radical removal of inflammation tissue, convincing biomechanical dynamized stabilization and antibiotic therapy

The aim of this paper is to describe the technique and evaluate the effectiveness of the RIA system in the first cases of bone loss treated by the authors with this technique. Between January 2010 and January 2011, ten patients were treated with an average age of fourty six years, with infected bone loss as a result of open fractures in various bone segments, with multiple failed treatment attempts, including three humeri, four femurs and three tibiae. The average size of the initial bone loss was 4 cm, varying from 1 to 8 cm. In 4 patients it was used simultaneously a Ilizarov apparatus with acute compression of the focus, in two patients a Ender pin and monolateral external fixator, three other cases with a SAFE nail with core with antibiotics and in one case an osteosynthesis with a plate and screws. The RIA was introduced with a percutaneous technique with a one pass drilling. The graft thus collected was mixed with appropriate antibiotics and aplied at the defect. The volume of the harvested graft, complications of the donor and recipient and the final results was recorded. The review showed that the average volume of graft was 60 cc, from 20 to 90 cc. In two female patients older than 70 years with osteoporosis, insufficient bone of poor quality was obtained. Problems included a case of iatrogenic fracture of the donor site, due to poor surgical technique and a case of relapse of the nonunion. Regarding the effectiveness of grafts extracted with the RIA system, 90% of the cases achieved consolidation in average of 5 months after grafting, range 3–9 months. This short experience with the RIA system showed that it is an attractive method allowing a rapid removal of a large volume of bone graft with a minimally invasive approach and a short learning curve. It is not indicated in elderly patients with osteoporosis and those with a narrow medullar canal less than 11 mm. Special attention must be done to the need to choose a drill no larger than 1 mm of the diameter of the isthmus, to do a single entry point and with only one drill passage to prevent the weakening of the donor site

The August 2014 Foot & Ankle Roundup360 looks at: calcaneotibial nail in ankle fractures; reamer irrigator aspirator for ankle fusion; periprosthetic bone infection; infection in ankle fixation; cheap and cheerful OK in MTP fusion plates; sliding fibular graft for peroneal tendon pathology and fusion for failed ankle replacement.

Intramedullary infection in long bones represents a complex clinical challenge, with an increasing incidence due to the increasing use of intramedullary fixation. We report a prospective case series using an intramedullary reaming device, the Reamer–Irrigator–Aspirator (RIA) system, in association with antibiotic cement rods for the treatment of lower limb long bone infections. A total of 24 such patients, 16 men and eight women, with a mean age of 44.5 years (17 to 75), 14 with femoral and 10 with tibial infection, were treated in a staged manner over a period of 2.5 years in a single referral centre. Of these, 21 patients had had previous surgery, usually for fixation of a fracture (seven had sustained an open fracture originally and one had undergone fasciotomies). According to the Cierny–Mader classification system, 18 patients were classified as type 1A, four as 3A (discharging sinus tract), one as type 4A and one as type 1B. Staphylococcus species were isolated in 20 patients (83.3%). Local antibiotic delivery was used in the form of impregnated cement rods in 23 patients. These were removed at a mean of 2.6 months (1 to 5). Pathogen-specific antibiotics were administered systemically for a mean of six weeks (3 to 18). At a mean follow-up of 21 months (8 to 36), 23 patients (96%) had no evidence of recurrent infection. One underwent a planned trans-tibial amputation two weeks post-operatively due to peripheral vascular disease and chronic recalcitrant osteomyelitis of the tibia and foot. The combination of RIA reaming, the administration of systemic pathogen-specific antibiotics and local delivery using impregnated cement rods proved to be a safe and efficient form of treatment in these patients. Cite this article: Bone Joint J 2014; 96-B:783–8

We hypothesised that cells obtained via a Reamer–Irrigator–Aspirator (RIA) system retain substantial osteogenic potential and are at least equivalent to graft harvested from the iliac crest. Graft was harvested using the RIA in 25 patients (mean age 37.6 years (18 to 68)) and from the iliac crest in 21 patients (mean age 44.6 years (24 to 78)), after which ≥ 1 g of bony particulate graft material was processed from each. Initial cell viability was assessed using Trypan blue exclusion, and initial fluorescence-activated cell sorting (FACS) analysis for cell lineage was performed. After culturing the cells, repeat FACS analysis for cell lineage was performed and enzyme-linked immunosorbent assay (ELISA) for osteocalcin, and Alizarin red staining to determine osteogenic potential. Cells obtained via RIA or from the iliac crest were viable and matured into mesenchymal stem cells, as shown by staining for the specific mesenchymal antigens CD90 and CD105. For samples from both RIA and the iliac crest there was a statistically significant increase in bone production (both p < 0.001), as demonstrated by osteocalcin production after induction. . Medullary autograft cells harvested using RIA are viable and osteogenic. Cell viability and osteogenic potential were similar between bone grafts obtained from both the RIA system and the iliac crest. Cite this article: Bone Joint J 2013;95-B:1269–74

Introduction:. Open bone graft harvesting continues to be recognized as the gold standard of obtaining autograft in patients needing bone graft. Conventional bone graft harvesting using the iliac crest is often cited as having significant donor site morbidity and complications. Intramedullary harvesting, using a reamer irrigation aspiration system (RIA) has recently become available. Method:. We performed a retrospective case series on 16 patients, where this system was used. A single pass reaming technique to harvest autograft from the femoral canal was performed. Fluoroscopy was used to size the canal and to confirm placement of a guide wire. Bone harvest volumes, complications encountered and donor site satisfaction post operatively was assessed. Patient satisfaction was determined via telephonic interviews at regular intervals with follow-up times up to 2 years. Results:. The study group consisted of 16 patients with an average age of 31 years. The mean post-operative follow up period was 18.8 months. The average amount of bone harvested was 39.6 cc. Although two technical complications were encountered intra-operatively, there were no systemic effects due to reaming. Most of the patients reported mild to severe pain immediately post operatively with an average pain score of 6.5 (1–10). Only seven patients reported minor pain at the donor site with the last interview bringing the average pain score down to 1.2. All pain scores reduced to zero after 21 months. Conclusion:. RIA was found to be a safe technique with reliable volumes of autograft obtained. Patients recovered quickly with no wound complications reported and minimal donor site morbidity at early follow-up. This new technique seems to be a viable option as an alternative to conventional bone graft harvesting

Background. Chronic osteomyelitis with intramedullary sequestrum resulting in persistent infection is a challenging orthopaedic problem that often involves multiple surgical operations and unfortunately has a significant recurrence rate. Reasons for this may include difficulty in eradicating all intramedullary microsequestra making subsequent prolonged antibiotic therapy less effective. Use of the Reamer-Irrigator-Aspirator (RIA) has many advantages for management of intramedullary infections in chronic osteomyelitis. The RIA technique allows irrigation of sterile large quantities of saline with simultaneous bony debridement with very sharp reamers that are specially designed to allow simultaneous fluid aspiration. Purpose. We will illustrate the pearls and pitfalls associated with the RIA technique, based on our experience so far. Method. We retrospectively reviewed a number of 6 (six) patients with chronic osteomyelitis of tibia (n=2) and femur (n=4). In an average follow up of 9.6 months post treatment (range 3–18 months) using a protocol including treatment with RIA we noticed immediate control of infection. Complications. Include pin tract infection, pin site pain and fungal infection (due to prolonged use of antibiotics). Conclusion. Based on our patient series so far, the encouraging results we have seen with regard to eradication of infection lead us to believe that RIA has a valuable role to play in the treatment of chronic osteomyelitis