Nonunion – consensus from the 4th annual meeting of the Danish Orthopaedic Trauma Society

Nonunions are a relevant economic burden affecting about 1.9% of all fractures. Rather than specifying a certain time frame, a nonunion is better defined as a fracture that will not heal without further intervention. Successful fracture healing depends on local biology, biomechanics and a variety of systemic factors. All components can principally be decisive and determine the classification of atrophic, oligotrophic or hypertrophic nonunions. Treatment prioritizes mechanics before biology. The degree of motion between fracture parts is the key for healing and is described by strain theory. If the change of length at a given load is > 10%, fibrous tissue and not bone is formed. Therefore, simple fractures require absolute and complex fractures relative stability. The main characteristics of a nonunion are pain while weight bearing, and persistent fracture lines on X-ray. Treatment concepts such as ‘mechanobiology’ or the ‘diamond concept’ determine the applied osteosynthesis considering soft tissue, local biology and stability. Fine wire circular external fixation is considered the only form of true biologic fixation due to its ability to eliminate parasitic motions while maintaining load-dependent axial stiffness. Nailing provides intramedullary stability and biology via reaming. Plates are successful when complex fractures turn into simple nonunions demanding absolute stability. Despite available alternatives, autograft is the gold standard for providing osteoinductive and osteoconductive stimuli. The infected nonunion remains a challenge. Bacteria, especially staphylococcus species, have developed mechanisms to survive such as biofilm formation, inactive forms and internalization. Therefore, radical debridement and specific antibiotics are necessary prior to reconstruction. Cite this article: EFORT Open Rev 2020;5:46-57. DOI: 10.1302/2058-5241.5.190037

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Mechanical Pressure Driving Proteoglycan Expression in Mammographic Density: a Self-perpetuating Cycle?

Journal of Mammary Gland Biology and Neoplasia ◽

10.1007/s10911-021-09494-3 ◽

2021 ◽

Cited By ~ 1

Author(s):

Gina Reye ◽

Xuan Huang ◽

Larisa M. Haupt ◽

Ryan J. Murphy ◽

Jason J. Northey ◽

...

Keyword(s):

Mammographic Density ◽

Positive Feedback ◽

Weight Bearing ◽

Fibrous Tissue ◽

Feedback Mechanism ◽

Mechanical Force ◽

Mechanical Stiffness ◽

Mechanical Pressure ◽

Fibrous Stroma ◽

High Mammographic Density

AbstractRegions of high mammographic density (MD) in the breast are characterised by a proteoglycan (PG)-rich fibrous stroma, where PGs mediate aligned collagen fibrils to control tissue stiffness and hence the response to mechanical forces. Literature is accumulating to support the notion that mechanical stiffness may drive PG synthesis in the breast contributing to MD. We review emerging patterns in MD and other biological settings, of a positive feedback cycle of force promoting PG synthesis, such as in articular cartilage, due to increased pressure on weight bearing joints. Furthermore, we present evidence to suggest a pro-tumorigenic effect of increased mechanical force on epithelial cells in contexts where PG-mediated, aligned collagen fibrous tissue abounds, with implications for breast cancer development attributable to high MD. Finally, we summarise means through which this positive feedback mechanism of PG synthesis may be intercepted to reduce mechanical force within tissues and thus reduce disease burden.

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Talus Arthritis Pattern in Juvenile Idiopathic Arthritis (JIA)

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00092 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0009

Author(s):

Mohammad Alkhreisat ◽

Jayasree Ramas Ramaskandhan ◽

Malik Siddique

Keyword(s):

Juvenile Idiopathic Arthritis ◽

Growth Plate ◽

Demographic Data ◽

Weight Bearing ◽

Joint Destruction ◽

Time Frame ◽

Valgus Deformity ◽

X Rays ◽

Number Of Patients ◽

Tibial Growth Plate

Category: Ankle Arthritis Introduction/Purpose: Juvenile idiopathic arthritis is a broad term that describes a clinically heterogeneous group of arthritides of unknown cause, which begin before 16 years of age persist for more than 6 weeks. It is one of the main diseases affecting Paediatric age group Joints in a form of a chronic, long standing and debilitating disease. It is estimated that 1 in 1000 children present with JIA in the UK alone. Radiographic progression of the disease occurs early, and if not addressed may result in permanent joint destruction and poor functional outcomes. The ankle is frequently involved, but it is unclear whether this is due to synovitis, tenosynovitis. To date, no evidence of combined therapies or integrated care for juvenile idiopathic arthritis patients with F&A problems exists. Methods: JIA patients with ankle involvement presented to orthopedic foot and ankle services between 2012-2017 were include. All patients had weight bearing x-rays ankle measuring Tibio talar angle, also underwent Ankle MRI following standard hospital MRI protocols. The MRI scans were used to measure the affected areas in talus. Talus was divided into 4 anatomical regions (Anterio-medial, Anterio-lateral, posterior-medial, posterolateral). lesion involving wider areas were recorded as two or more regions accordingly, i.e.: AM and PM involvement at the same time were given yes for area of involvement in both region and recorded separately. Bilateral Ankles involvement were also recorded. Tibial growth plate involvement in these patients on the MRI scan was recorded. Demographic data was collected along with side, disease pattern, age at diagnosis and age at presentation to F&A speciality and patients requiring surgical intervention. Measurements were carried out by two in dependent orthopaedics F&A surgeons. Results: 14 patients were included in this study with a total of 17 ankles. 12 were females (N=12, 85.7%). Mean age was between 8-21 years (15.0 ± 4.08, M±SD). Time to presentation was 2.9 to 8.4 years (5.1 ± 1.4 years). 5 had Oligo-articular involvement (37.5%),9 patients had polyA (64.2%). 11/17 Right Ankles (64.7%), 3 left (21.4%). 3 bilateral (21.4%). 11/17 Ankles in Varus (64.7%), 1/17 valgus (5.8%), 5/17 neutral (29.4%). Mean Tibiotalar angle was 80° ± 13.5° (Range 49° - 100°). 12/17(70.5%) had involvement of the antero-medial part of the talus,1/17(5.8%)antero-lateral, 8/17 postero-medial(47.06%), 3/17(17.6%) postero-lateral . All the patients with postero-lateral involvement, they also had postero-medial involvement. (p=0.043). 13/17 ankles (76.4%) had tibial growth plate involvement. 5 patients (35.7%) had subsequent operations. Conclusion: This study shows a pattern of involvement in the talus and the effect this disease has on Tibiotalar alignment. This needs to be confirmed on a larger number of patients. And highlights the need for an earlier presentation of these patients to F&A surgeon to prevent the disease sequela. Further research is required to study the tibial growth plate involvement for its contribution to the varus / valgus deformity in a chronological method. Further research is also required to quantify the time frame for disease and deformity progression in the Tibiotalar Joint.

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Rheumatic Diseases and Obesity: Adipocytokines as Potential Comorbidity Biomarkers for Cardiovascular Diseases

Mediators of Inflammation ◽

10.1155/2013/808125 ◽

2013 ◽

Vol 2013 ◽

pp. 1-14 ◽

Cited By ~ 13

Author(s):

Rossana Scrivo ◽

Massimiliano Vasile ◽

Ulf Müller-Ladner ◽

Elena Neumann ◽

Guido Valesini

Keyword(s):

Cardiovascular Risk ◽

Current Knowledge ◽

Weight Bearing ◽

Joint Damage ◽

Positive Association ◽

Experimental Models ◽

Low Grade ◽

Multifactorial Diseases ◽

Systemic Factors ◽

Low Grade Inflammation

Inflammation has been recognized as a common trait in the pathogenesis of multifactorial diseases including obesity, where a low-grade inflammation has been established and may be responsible for the cardiovascular risk related to the disease. Obesity has also been associated with the increased incidence and a worse outcome of rheumatoid arthritis (RA) and osteoarthritis (OA). RA is characterized by systemic inflammation, which is thought to play a key role in accelerated atherosclerosis and in the increased incidence of cardiovascular disease, an important comorbidity in patients with RA. The inflammatory process underlying the cardiovascular risk both in obesity and RA may be mediated by adipocytokines, a heterogeneous group of soluble proteins mainly secreted by the adipocytes. Many adipocytokines are mainly produced by white adipose tissue. Adipocytokines may also be involved in the pathogenesis of OA since a positive association with obesity has been found for weight-bearing and nonweight-bearing joints, suggesting that, in addition to local overload, systemic factors may contribute to joint damage. In this review we summarize the current knowledge on experimental models and clinical studies in which adipocytokines were examined in obesity, RA, and OA and discuss the potential of adipocytokines as comorbidity biomarkers for cardiovascular risk.

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Do Systemic Factors Influence the Fate of Nonunions to Become Atrophic? A Retrospective Analysis of 162 Cases

BioMed Research International ◽

10.1155/2019/6407098 ◽

2019 ◽

Vol 2019 ◽

pp. 1-12 ◽

Cited By ~ 1

Author(s):

Markus Rupp ◽

Stefanie Kern ◽

Thaqif El Khassawna ◽

Abdullah Ismat ◽

Deeksha Malhan ◽

...

Keyword(s):

Mechanical Stability ◽

Scientific Evidence ◽

Fibrous Tissue ◽

Patient Characteristics ◽

The Elderly ◽

Long Bone ◽

Osteogenic Potential ◽

Accompanying Injuries ◽

Systemic Factors ◽

Atrophic Nonunion

Introduction. Nonunions are a challenge for orthopedic surgeons. In hypertrophic nonunions, improvement of mechanical stability usually is the satisfactory treatment, whereas in atrophic nonunions improvement of the biological environment is most important. However, scientific evidence revealed that “avital” nonunions are not avascular and fibrous tissue contains cells with osteogenic potential. To find out if systemic factors suppress this intrinsic potential in atrophic nonunions, this study compares characteristics of hypertrophic with atrophic nonunion patients. Methods. We analyzed medical records of 162 surgically treated patients suffering from aseptic long bone nonunions. Atrophic and hypertrophic nonunions were distinguished by absence or presence of callus and calcification in the fracture gap. Mechanical implant loosening and patient characteristics such as age, gender, and body mass index were assessed. Fracture classification according to AO/OTA, open and closed fractures, and osteosynthesis were recorded. In addition, comorbidities and allergies between both groups were compared. Results. A higher number of hypertrophic nonunion patients were male with often allergies. Hypertrophic nonunion occurred more often after intramedullary nailing compared to atrophic nonunions. Atrophic nonunion patients being nonallergic were significantly older than nonallergic patients suffering from hypertrophic nonunions. In both atrophic and hypertrophic nonunion patients, age was lower in patients with accompanying injuries compared with age of patients with isolated fractures. Conclusion. Systemic factors influence development of nonunion types. In nonallergic patients, atrophic nonunions occur more often in the elderly. This manuscript is a first step to identify different factors which might influence the nature of nonunion. To enable nonunion treatment which is tailored to individual patient characteristics, further prospective studies with more sophisticated research methods are necessary.

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A New Method in the Design of a Dynamic Pedorthosis for Children With Residual Clubfoot

Journal of Medical Devices ◽

10.1115/1.4001814 ◽

2010 ◽

Vol 4 (2) ◽

Cited By ~ 3

Author(s):

Robert Rizza ◽

XueCheng Liu ◽

John Thometz ◽

Roger Lyon ◽

Channing Tassone

Keyword(s):

Pressure Distribution ◽

Computer Aided Design ◽

Center Of Pressure ◽

Weight Bearing ◽

Selective Laser Sintering ◽

Time Frame ◽

Plantar Pressure Distribution ◽

Treatment Trends ◽

Aided Design ◽

Night Splints

Clubfoot is a common pediatric orthopaedic deformity. Despite the popularity of Ponseti’s method and night splints such as the Denis–Browne method, there is still an 11–47% rate of deformity relapse reported in the literature. The technique to make traditional orthotics is dependent on a nonweight-bearing casting or foot imprint. These splints outdate clinical treatment trends and only apply to patients who are of nonwalking age. This study shows that a new procedure utilizing computer aided design and the finite element method can be employed to develop a customized weight-bearing dynamic orthotic. In addition, the plantar pressure distribution and the trajectory of the center of this pressure distribution are used to design the orthotic. It is shown that the trajectory of the center of pressure, traditionally used in gait analysis, can be used not only to quantify the severity of the foot deformity but to design a custom orthotic as well. Also, the new procedure allows the custom orthotic to be designed and analyzed within a day. The new orthotic design is composed of soft foam interior layers and a polymer supportive exterior layer. It is proved that rapid prototyping technologies employing selective laser sintering can be used to construct these layers to produce a custom orthotic within a 24 h time frame.

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An innovate strategy to treat large metaphyseal segmental femoral bone defect using customized design and 3D printed micro-porous prosthesis: a prospective clinical study

10.21203/rs.2.24245/v1 ◽

2020 ◽

Author(s):

Guojin Hou ◽

Bingchuan Liu ◽

Yun Tian ◽

Zhongjun Liu ◽

Fang Zhou ◽

...

Keyword(s):

Bone Defect ◽

Weight Bearing ◽

Fibrous Tissue ◽

Radiographic Evaluation ◽

Full Weight Bearing ◽

Prospective Clinical Study ◽

Femoral Bone ◽

3D Printed ◽

Partial Weight

Abstract Background Large segmental bone defect at the metaphyseal area is still difficult to treat, nowadays, there is a tremendous level of interest in uses of 3D printing technology in orthopaedic surgery. This study was introduced to prospectively confirm the safety and effectiveness of 3D printed micro-porous prosthesis in clinical bone defect reconstruction application. Methods Patients with segmental irregular-shaped bone defect of the femur were recruited from 2017.12 to 2018.11. The first stage of the treatment involves radical debridement of all infected or non-viable bone and interposed fibrous tissue, and temporary fixation. Once the culture and biopsy results were negative, the PMMA spacer should remain in the defect approximately 6-8 weeks. This period is for the membrane formation, virtual surgery (computed tomography (CT) scan of the lesion area and the contra-lateral parts of the femur, and then design of the implant). The second stage involves reconstruction the defects with the 3D printed micro-porous prosthesis combined with intra-medullar nailwithout bone graft.Routine clinical follow-up and radiographic evaluation were done to assess bone incorporation and complications of internal fixation. The weight-bearing time and the joint function were recorded. Result 5 consecutive patients were included in the study. They were followed up for an average of 16.4 months. The average length of bone defect and the distal residual bone was 12 cm and 6.5 cm. The average time of partial weight-bearing and full weight-bearing was 12.7 days and 2.6 months. X-ray demonstrated good osseous integration of the implant/bone interface. No complications occurred such as implant loosening, subsidence, loss of correctionand infection. At the last follow-up, Harris score of hip joint was excellent in 2 cases, good in 2 cases, fair in 1 case; HSS score of knee joint was good in 4 cases, middle in 1 case. Conclusion Meticulous customized design 3D printed micro-porous prosthesis combined with intramedullary fixation may be a cost-effective and an alternative strategy to treat metaphyseal segmental irregular-shaped femoral bone defect without bone graft, especially for cases with massive juxta-articular bone loss.

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Management of infected non-unions of long bones using limb reconstruction system (LRS) fixator

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20170540 ◽

2017 ◽

Vol 3 (2) ◽

pp. 213 ◽

Cited By ~ 1

Author(s):

Satya Ranjan Patra ◽

Dasarath Kisan ◽

Divya Madharia ◽

Naresh Kumar Panigrahi ◽

Saswat Samant ◽

...

Keyword(s):

Weight Bearing ◽

Limb Lengthening ◽

High Energy ◽

Bone Transport ◽

Functional Score ◽

Infected Nonunion ◽

Limb Reconstruction ◽

Erroneous Decision ◽

Pin Tract Infection ◽

Flap Cover

Background: Due to increasing number of high-energy traumatic events, the incidence of complex and compound fractures are also in the rise. Such fractures are often exposed to various environmental contaminants, inadequate debridement and sometimes erroneous decision making leading to cases of infected nonunions. Eradication of infection in such cases and achieving union may sometimes pose serious challenge to orthopaedic surgeons. Presence of comminution, bone gap or deformity can seriously complicate the situation. No definite surgical technique has been found to be full proof in dealing with these infected nonunion cases. In this scenario the limb reconstruction system (LRS) fixator is emerging as a useful option for infected nonunions with deformity or gap nonunion.Methods: Twenty seven cases of infected nonunions involving tibia (n=19), femur (n=7) and humerus (n=1) were treated by LRS fixators after debridement of the infected nonunion site. Flap cover procedure was done as per necessity. Bone gaps and limb length discrepancies were dealt with bone transport or limb lengthening by the LRS instrument. Weight-bearing and removal of fixator was decided according to the radiological evidence of healing.Results: All the nonunions and the regeneration sites healed uneventfully, although the union time was varied (range, 21-52 weeks). Commonest complication was pin-tract infection and pain. The mean lower extremity functional score (LEFS) was 60.3 out of 80. Conclusions: LRS fixator is an excellent tool for management of infected nonunions which is easy to apply, comfortable for the patient with minimum complications and predictable as well as reproducible outcomes.

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Effect of Woven Fabric Biodegradable Polyglycolic Acid on Joint Resurfacing with Fresh Chondrocytes in a Rabbit Model

Key Engineering Materials ◽

10.4028/www.scientific.net/kem.330-332.1197 ◽

2007 ◽

Vol 330-332 ◽

pp. 1197-1200

Author(s):

Zhong Li Shi ◽

Wei Qi Yan ◽

Jie Feng ◽

Bing Gang Guan ◽

Yang Bo Liu ◽

...

Keyword(s):

Weight Bearing ◽

Fibrous Tissue ◽

Rabbit Model ◽

Polyglycolic Acid ◽

Woven Fabric ◽

Histological Evaluation ◽

Cell Group ◽

Cartilage Defects ◽

Control Group

To evaluate the effectiveness of the cell-material in situ on joint resurfacing, a woven fabric polyglycolic acid (PGA) treated with fresh chondrocytes was used for repairing cartilage defects. Full-thickness defects were created in the weight-bearing surfaces of the femoral intercondylar fossa in a rabbit model. The defect was filled with and without PGA under surgical condition. Before implantation, chondrocytes were co-cultured with PGA for one day. The animals were sacrificed at eight weeks after implantation and evaluated grossly and histological score. Morphological examination showed that for PGA/chondrocytes group, the repaired tissue appeared similar in color and texture to the surrounding articular surface. While for the untreated control, no cartilage-like tissue was observed at all defects, but connective fibrous tissue. Histological analysis revealed neochondrogenesis and clusters of cartilage matrix with specific safranin-O staining for the PGA/cell group. The Gross and histological evaluation indicated a significantly higher score for PGA/cell group than for PGA and control group. These results suggest that the woven fabric PGA may facilitate the formation of cartilage tissues by providing a biodegradable and good-handle vehicle for the delivery to and retention of organized cell matrix constructs in vivo site. It might therefore enhance neochondrogenesis because of the superior biodegradable and biocompatible of PGA scaffold sheet, while the more suitable biological environment might sustain cell growth and in situ cell function, suggesting a promising candidate for functional tissue engineering of clinical environment.

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A Novel External Fixator to Facilitate Accurate and Efficient Fracture Treatment

10.21203/rs.3.rs-138024/v1 ◽

2021 ◽

Author(s):

Mingkui Shen ◽

Zizheng Ai ◽

Jingna Li ◽

Huaping Liang ◽

Xieping Dong

Keyword(s):

External Fixator ◽

Biomechanical Testing ◽

Torsional Stiffness ◽

Axial Stiffness ◽

External Fixators ◽

Therapeutic Effects ◽

Fracture Treatment ◽

Universal Joint ◽

Efficient Treatment ◽

Complex Fractures

Abstract Background: The rapid popularization and application of bone external fixation technology has led to external fixators emerging as remarkable methods to treat various complex fractures. Because of their instability, assembly complexity and poor controllability, however, new external fixators are challenging to design in terms of facilitating accurate and efficient fracture treatment.Methods: We designed a novel external fixator that could feasibly treat clinical complex fractures. A prospective study was conducted on patients with various complex fractures from September 2017 to September 2019. During this period, we treated 24 patients with a universal joint external fixator and then evaluated its therapeutic effects. In this study, adult cadaver femur fracture fixations were modelled by using universal joint (UJ) and AO external fixators, and the mechanical stability was assessed by applying a biomechanical testing device.Results: The designed device not only fits the repair site but could also be conveniently installed and implanted. All patients achieved good fixation and fracture healing with the universal joint fracture external fixators. In in vitro biomechanical testing, constructs were loaded under axial compression, lateral compression and torsion. Overall axial stiffness showed no significant differences between the two groups. The lateral stiffness was 1.554 ± 0.017 mm for the UJ group and 1.342 ± 0.020 mm for the AO group (p<0.001) under a 600 N load, while the torsional stiffness was 15.727 ± 0.141° for the UJ group and 14.472 ± 0.292° for the AO group under a 40 Nm load.Conclusion: In this small and preliminary study, the universal joint external fixator, which achieved a stable mechanical structure, was capable of intensive and efficient treatment for comprehensive fractures. If these findings can be confirmed in a larger study, this external fixator may be widely used in certain situations where traditional external fixators are not a convenient option.

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ILIZAROV TECHNIQUES

The Professional Medical Journal ◽

10.29309/tpmj/2016.23.06.1619 ◽

2016 ◽

Vol 23 (06) ◽

Author(s):

Mohammad Haroon Chohan ◽

Krishan Lal ◽

Muhammad Bux Chachar ◽

M Akhter Baig ◽

Sunil Kumar ◽

...

Keyword(s):

Weight Bearing ◽

Case Series ◽

Full Weight Bearing ◽

Soft Tissue Coverage ◽

Necrotic Bone ◽

Infected Nonunion ◽

Ring Fixator ◽

Ilizarov Ring Fixator ◽

Radical Debridement ◽

K Wires

Objectives: 1. To assess the results of infected nonunion of tibia by Ilizarovtechniques. 2. To ascertain the incidence of complications and advise methods to prevent them.3. To determine various risk factors which contribute to these complications. Study Design: Thisdescriptive case series. Setting: Department of Orthopaedic Surgery, Dow University of HealthSciences/ Civil Hospital Karachi. Period: 1st March 2010 to 28th Feb. 2013. Methods: A total of 30patients with infected nonunion of tibia with or without shortening and bone loss was includedin the study. Patients lying in supine position, after spinal anesthesia, radical debridement weredone and all previous infected implants and necrotic bone removed, pre-assembled ilizarovframe was applied with the help of four or five rings, each ring was fixed with k-wires andschanz pins. Olive wires were used where interfragmentary compression, correction of axialdeviation of fragment, in osteoporotic bones, transport of fibular fragment or more stability wasrequired. Results: Results were divided into bony and functional parts by ASAMI. We achieveexcellent to good bony result in 86.66% (26/30) of cases and excellent to good functional resultin 76.66% (23/30) of cases. Conclusion: It is concluded that bony and functional outcome ofinfected nonunion of tibia treated with ilizarov ring fixator is satisfactory. Although its applicationis lengthy but once applied patients get benefits, they can start walking with full weight bearing,limb length equality and soft tissue coverage achieved, so we recommend its applications insuch type of cases.

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