Resection of a primary sarcoma of the diaphysis
of a long bone creates a large defect. The biological options for reconstruction
include the use of a vascularised and non-vascularised fibular autograft. The purpose of the present study was to compare these methods
of reconstruction. Between 1985 and 2007, 53 patients (26 male and 27 female) underwent
biological reconstruction of a diaphyseal defect after resection
of a primary sarcoma. Their mean age was 20.7 years (3.6 to 62.4).
Of these, 26 (49 %) had a vascularised and 27 (51 %) a non-vascularised
fibular autograft. Either method could have been used for any patient in
the study. The mean follow-up was 52 months (12 to 259). Oncological,
surgical and functional outcome were evaluated. Kaplan–Meier analysis
was performed for graft survival with major complication as the
end point. At final follow-up, eight patients had died of disease. Primary
union was achieved in 40 patients (75%); 22 (42%) with a vascularised
fibular autograft and 18 (34%) a non-vascularised (p = 0.167). A
total of 32 patients (60%) required revision surgery. Kaplan–Meier
analysis revealed a mean survival without complication of 36 months
(0.06 to 107.3, Both groups seem to be reliable biological methods of reconstructing
a diaphyseal bone defect. Vascularised autografts require more revisions
mainly due to problems with wound healing in distal sites of tumour,
such as the foot. Cite this article:
Pathological fractures in children can occur
as a result of a variety of conditions, ranging from metabolic diseases and
infection to tumours. Fractures through benign and malignant bone
tumours should be recognised and managed appropriately by the treating
orthopaedic surgeon. The most common benign bone tumours that cause pathological
fractures in children are unicameral bone cysts, aneurysmal bone
cysts, non-ossifying fibromas and fibrous dysplasia. Although pathological
fractures through a primary bone malignancy are rare, these should
be recognised quickly in order to achieve better outcomes. A thorough
history, physical examination and review of plain radiographs are
crucial to determine the cause and guide treatment. In most benign
cases the fracture will heal and the lesion can be addressed at
the time of the fracture, or after the fracture is healed. A step-wise
and multidisciplinary approach is necessary in caring for paediatric
patients with malignancies. Pathological fractures do not have to
be treated by amputation; these fractures can heal and limb salvage
can be performed when indicated.
Effects of insulin-like growth factor 1 (IGF1), fibroblast growth
factor 2 (FGF2) and bone morphogenetic protein 2 (BMP2) on the expression
of genes involved in the proliferation and differentiation of osteoblasts
in culture were analysed. The best sequence of growth factor addition
that induces expansion of cells before their differentiation was
sought. Primary human osteoblasts in Objectives
Methods
Non-accidental injury (NAI) in children includes orthopaedic trauma throughout the skeleton. Fractures with soft-tissue injuries constitute the majority of manifestations of physical abuse in children. Fracture and injury patterns vary with age and development, and NAI is intrinsically related to the mobility of the child. No fracture in isolation is pathognomonic of NAI, but specific abuse-related injuries include multiple fractures, particularly at various stages of healing, metaphyseal corner and bucket-handle fractures and fractures of ribs. Isolated or multiple rib fractures, irrespective of location, have the highest specificity for NAI. Other fractures with a high specificity for abuse include those of the scapula, lateral end of the clavicle, vertebrae and complex skull fractures. Injuries caused by NAI constitute a relatively small proportion of childhood fractures. They may be associated with significant physical and psychological morbidity, with wide- ranging effects from deviations in normal developmental progression to death. Orthopaedic surgeons must systematically assess, recognise and act on the indicators for NAI in conjunction with the paediatric multidisciplinary team.
Cubitus varus is the most frequent complication
following the treatment of supracondylar humeral fractures in children.
We investigated data from publications reporting on the surgical
management of cubitus varus found in electronic searches of Ovid/MEDLINE
and Cochrane Library databases. In 894 children from 40 included
studies, the mean age at initial injury was 5.7 years (3 to 8.6)
and 9.8 years (4 to 15.7) at the time of secondary correction. The four
osteotomy techniques were classified as lateral closing wedge, dome,
complex (multiplanar) and distraction osteogenesis. A mean angular
correction of 27.6º (18.5° to 37.0°) was achieved across all classes
of osteotomy. The meta-analytical summary estimate for overall rate
of good to excellent results was 87.8% (95% CI 84.4 to 91.2). No technique
was shown to significantly affect the surgical outcome, and the
risk of complications across all osteotomy classes was 14.5% (95%
CI 10.6 to 18.5). Nerve palsies occurred in 2.53% of cases (95%
CI 1.4 to 3.6), although 78.4% were transient. No one technique
was found to be statistically safer or more effective than any other. Cite this article:
Successful healing of a nine-year tibial nonunion resistant to six previous surgical procedures was achieved by tissue engineering. We used autologous bone marrow stromal cells (BMSCs) expanded to 5 × 106 cells after three weeks’ tissue culture. Calcium sulphate (CaSO4) in pellet form was combined with these cells at operation. The nonunion was clinically and radiologically healed two months after implantation. This is the description of on healing of a long-standing tibial nonunion by tissue engineering. The successful combination of BMSCs and CaSO4 has not to our knowledge been reported in a clinical setting.
In order to ensure safety of the cell-based therapy for bone
regeneration, we examined BM cells obtained from a total of 13 Sprague-Dawley (SD) green
fluorescent protein transgenic (GFP-Tg) rats were culture-expanded
in an osteogenic differentiation medium for three weeks. Osteoblast-like
cells were then locally transplanted with collagen scaffolds to
the rat model of segmental bone defect. Donor cells were also intravenously infused
to the normal Sprague-Dawley (SD) rats for systemic biodistribution.
The flow cytometric and histological analyses were performed for
cellular tracking after transplantation.Objectives
Methods
We report our experience using a biodegradable
calcium sulphate antibiotic carrier containing tobramycin in the surgical
management of patients with chronic osteomyelitis. The patients
were reviewed to determine the rate of recurrent infection, the
filling of bony defects, and any problems with wound healing. A
total of 193 patients (195 cases) with a mean age of 46.1 years
(16.1 to 82.0) underwent surgery. According to the Cierny–Mader
classification of osteomyelitis there were 12 type I, 1 type II,
144 type III and 38 type IV cases. The mean follow-up was 3.7 years (1.3
to 7.1) with recurrent infection occurring in 18 cases (9.2%) at
a mean of 10.3 months post-operatively (1 to 25.0). After further
treatment the infection resolved in 191 cases (97.9%). Prolonged
wound ooze (longer than two weeks post-operatively) occurred in
30 cases (15.4%) in which there were no recurrent infection. Radiographic
assessment at final follow-up showed no filling of the defect with
bone in 67 (36.6%), partial filling in 108 (59.0%) and complete filling
in eight (4.4%). A fracture occurred in nine (4.6%) of the treated
osteomyelitic segments at a mean of 1.9 years (0.4 to 4.9) after
operation. We conclude that Osteoset T is helpful in the management of patients
with chronic osteomyelitis, but the filling of the defect in bone
is variable. Prolonged wound ooze is usually self-limiting and not
associated with recurrent infection. Cite this article:
Resveratrol is a polyphenolic compound commonly found in the
skins of red grapes. Sirtuin 1 (SIRT1) is a human gene that is activated
by resveratrol and has been shown to promote longevity and boost
mitochondrial metabolism. We examined the effect of resveratrol
on normal and osteoarthritic (OA) human chondrocytes. Normal and OA chondrocytes were incubated with various concentrations
of resveratrol (1 µM, 10 µM, 25 µM and 50 µM) and cultured for 24,
48 or 72 hours or for six weeks. Cell proliferation, gene expression,
and senescence were evaluated.Background
Methods
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:
The reduced stability of hydroxyapatite (HA)-coated implants in osteopenic conditions is considered to be a major problem. We therefore developed a model of a boosted cementless implantation in osteopenic rats. Twelve-week-old rats were either ovariectomised (OVX) or sham-operated (SO), and after 24 weeks plain or HA-coated implants were inserted. They were treated with either a prostaglandin EP4 receptor agonist (ONO-4819) or saline for one month. The EP4 agonist considerably improved the osteoporosis in the OVX group. Ultrastructural analysis and mechanical testing showed an improvement in the implant-bone attachment in the HA-coated implants, which was further enhanced by the EP4 agonist. Although the stability of the HA-coated implants in the saline-treated OVX rats was less than in the SO normal rats, the administration of the EP4 agonist significantly compensated for this shortage. Our results showed that the osteogenic effect of the EP4 agonist augmented the osteoconductivity of HA and significantly improved the stability of the implant-bone attachment in the osteoporotic rat model.
Stem cells are a key component of regenerative medicine strategies. Particular areas of musculoskeletal application include cartilage and bone regeneration in arthritis and trauma. There are several types of stem cell and this article will focus on the adult derived cells. The review includes current issues and future developments.
We carried out a retrospective study to assess the clinical results of lengthening the fourth metatarsal in brachymetatarsia in 153 feet of 106 patients (100 female, six males) using three different surgical techniques. In one group lengthening was performed by one-stage intercalary bone grafting secured by an intramedullary Kirschner-wire (45 feet, 35 patients). In the second group lengthening was obtained gradually using a mini-external fixator after performing an osteotomy with a saw (59 feet, 39 patients) and in the third group lengthening was achieved in a gradual manner using a mini-external fixator after undertaking an osteotomy using osteotome through pre-drilled holes (49 feet, 32 patients). The mean age of the patients was 26.3 years (13 to 48). Pre-operatively, the fourth ray of the bone-graft group was longer than that of other two groups (p <
0.000). The clinical outcome was compared in the three groups. The mean follow-up was 22 months (7 to 55). At final follow-up, the mean lengthening in the bone-graft group was 13.9 mm (3.5 to 23.0, 27.1%) which was less than that obtained in the saw group with a mean of 17.8 mm (7.0 to 33.0, 29.9%) and in the pre-drilled osteotome group with a mean of 16.8 mm (6.5 to 28.0, 29.4%, p = 0.001). However, the mean time required for retention of the fixation in the bone-graft group was the shortest of the three groups. Patients were dissatisfied with the result for five feet (11.1%) in the bone-graft group, eight (13.6%) in the saw group and none in the pre-drilled osteotomy group (p <
0.000). The saw group included eight feet with failure of bone formation after surgery. Additional operations were performed in 20 feet because of stiffness (n = 7, all groups), failure of bone formation (n = 4, saw group), skin maceration (n = 4, bone-graft group), malunion (n = 4, bone-graft and saw groups) and breakage of the external fixator (n = 1, saw group). We conclude that the gradual lengthening by distraction osteogenesis after osteotomy using an osteotome produces the most reliable results for the treatment of fourth brachymetatarsia.
An 81-year-old woman presented with a fracture
in the left femur. She had well-fixed bilateral hip replacements
and had received long-term bisphosphonate treatment. Prolonged bisphosphonate
use has been recently linked with atypical subtrochanteric and diaphyseal
femoral fractures. While the current definition of an atypical fracture
of the femur excludes peri-prosthetic fractures, this case suggests
that they do occur and should be considered in patients with severe
osteopenia. Union of the fracture followed cessation of bisphosphonates
and treatment with teriparatide. Thus, this case calls into question
whether prophylactic intramedullary nailing is sufficient alone
to treat early or completed atypical femoral fractures.
Neurogenic heterotopic ossification (NHO) is
a disorder of aberrant bone formation affecting one in five patients sustaining
a spinal cord injury or traumatic brain injury. Ectopic bone forms
around joints in characteristic patterns, causing pain and limiting
movement especially around the hip and elbow. Clinical sequelae
of neurogenic heterotopic ossification include urinary tract infection,
pressure injuries, pneumonia and poor hygiene, making early diagnosis
and treatment clinically compelling. However, diagnosis remains
difficult with more investigation needed. Our pathophysiological
understanding stems from mechanisms of basic bone formation enhanced
by evidence of systemic influences from circulating humor factors
and perhaps neurological ones. This increasing understanding guides
our implementation of current prophylaxis and treatment including
the use of non-steroidal anti-inflammatory drugs, bisphosphonates,
radiation therapy and surgery and, importantly, should direct future, more
effective ones.
Early total hip replacement (THR) for acetabular
fractures offers accelerated rehabilitation, but a high risk of heterotopic
ossification (HO) has been reported. The purpose of this study was
to evaluate the incidence of HO, its associated risk factors and
functional impact. A total of 40 patients with acetabular fractures
treated with a THR weres retrospectively reviewed. The incidence
and severity of HO were evaluated using the modified Brooker classification,
and the functional outcome assessed. The overall incidence of HO
was 38%
(n = 15), with nine severe grade III cases. Patients who underwent
surgery early after injury had a fourfold increased chance of developing
HO. The mean blood loss and operating time were more than twice
that of those whose surgery was delayed (p = 0.002 and p <
0.001,
respectively). In those undergoing early THR, the incidence of grade
III HO was eight times higher than in those in whom THR was delayed
(p = 0.01). Only three of the seven patients with severe HO showed
good or excellent Harris hip scores compared with eight of nine
with class 0, I or II HO (p = 0.049). Associated musculoskeletal
injuries, high-energy trauma and head injuries were associated with
the development of grade III HO. The incidence of HO was significantly higher in patients with
a displaced acetabular fracture undergoing THR early compared with
those undergoing THR later and this had an adverse effect on the
functional outcome. Cite this article: