High slew rate pulsed electromagnetic field enhances bone consolidation and shortens daily treatment duration in distraction osteogenesis

Aims Distraction osteogenesis (DO) is a useful orthopaedic procedure employed to lengthen and reshape bones by stimulating bone formation through controlled slow stretching force. Despite its promising applications, difficulties are still encountered. Our previous study demonstrated that pulsed electromagnetic field (PEMF) treatment significantly enhances bone mineralization and neovascularization, suggesting its potential application. The current study compared a new, high slew rate (HSR) PEMF signal, with different treatment durations, with the standard Food and Drug Administration (FDA)-approved signal, to determine if HSR PEMF is a better alternative for bone formation augmentation. Methods The effects of a HSR PEMF signal with three daily treatment durations (0.5, one, and three hours/day) were investigated in an established rat DO model with comparison of an FDA-approved classic signal (three hrs/day). PEMF treatments were applied to the rats daily for 35 days, starting from the distraction phase until termination. Radiography, micro-CT (μCT), biomechanical tests, and histological examinations were employed to evaluate the quality of bone formation. Results All rats tolerated the treatment well and no obvious adverse effects were found. By comparison, the HSR signal (three hrs/day) treatment group achieved the best healing outcome, in that endochondral ossification and bone consolidation were enhanced. In addition, HSR signal treatment (one one hr/day) had similar effects to treatment using the classic signal (three three hrs/day), indicating that treatment duration could be significantly shortened with the HSR signal. Conclusion HSR signal may significantly enhance bone formation and shorten daily treatment duration in DO, making it a potential candidate for a new clinical protocol for patients undergoing DO treatments. Cite this article: Bone Joint Res 2021;10(12):767–779.

Treatment of severely open tibial fractures, non-unions, and fracture-related infections with a gentamicin-coated tibial nail—clinical outcomes including quality of life analysis and psychological ICD-10-based symptom rating

Background Implant-associated infections depict a major challenge in orthopedics and trauma surgery putting a high burden on the patients and health care systems, strongly requiring improvement of infection prevention and of clinical outcomes. One strategy includes the usage of antimicrobial-coated implants. We evaluated outcomes after surgical treatment using a gentamicin-coated nail on (i) treatment success in terms of bone consolidation, (ii) absence of infection, and (iii) patient-reported quality of life in a patient cohort with high risk of infection/reinfection and treatment failure. Methods Thirteen patients with open tibia fractures (n = 4), non-unions (n = 2), and fracture-related infection (n = 7) treated with a gentamicin-coated intramedullary nail (ETN ProtectTM) were retrospectively reviewed. Quality of life was evaluated with the EQ-5D, SF-36, and with an ICD-10-based symptom rating (ISR). Results At a mean follow-up of 2.8 years, 11 of the 13 patients (84.6%) achieved bone consolidation without any additional surgical intervention, whereas two patients required a revision surgery due to infection and removal of the implant. No specific implant-related side effects were noted. Quality of life scores were significantly lower compared to a German age-matched reference population. The mean ISR scores revealed mild psychological symptom burden on the scale depression. Conclusion The use of a gentamicin-coated intramedullary nail seems to be reasonable in open fractures and revision surgery for aseptic non-union or established fracture-related infection to avoid infection complications and to achieve bony union. Despite successful treatment of challenging cases with the gentamicin-treated implant, significantly reduced quality of life after treatment underlines the need of further efforts to improve surgical treatment strategies and psychological support.

Comparative analysis between locking compression plate and Joshi's external stabilization system in the management of proximal tibial fractures

<p><strong>Background:</strong> Proximal tibial fractures present with a variety of patterns. They are mostly treated using plate osteosynthesis or Joshi's external stabilization system (JESS) depending upon the injury configuration and surgeon preference. We have compared the efficacy of plate fixation to JESS in the treatment of complex proximal tibial fractures.<strong></strong></p><p><strong>Methods</strong>: 36 patients of proximal tibial fractures with a mean age of 47 years were included in the study, 20 were treated using plate osteosynthesis while the other 16 were treated using JESS, they were followed up at regular intervals till 24 weeks and the progress was recorded in accordance with the knee society score (KSS) parameters<strong></strong></p><p><strong>Results</strong>: 20 patients were treated using plate osteosynthesis, 18 of them had excellent KSS scores, 2 patients recorded good scores, average range of flexion was 126^o, no incidences of superficial or deep infections were seen in any of them. Bone consolidation was achieved around 12 weeks in plate fixation group of the16 patients treated using JESS, 12 had excellent scores, 4 recorded a good score, average range of flexion was 118^o, superficial infection was seen in 2 patients, with no incidence of deep infection. Bone consolidation was achieved around 16 weeks in JESS group.</p><p><strong>Conclusions</strong>: Both open reduction internal fixation (ORIF) with plating and JESS appear to be adequate fixation methods for complex proximal tibial fractures, but as per our study plate fixation resulted in earlier bone consolidation and gave a slightly better functional outcome compared to JESS.</p>

High-purity magnesium pin enhances bone consolidation in distraction osteogenesis model through activation of the VHL/HIF-1α/VEGF signaling

Distraction osteogenesis has widespread clinical use in the treatment of large bone defects. Nonetheless, the prolonged consolidation period carries the risk of complications. Magnesium-based materials have been shown to promote bone regeneration in fracture healing both in vitro and in vivo. Here, we investigated whether high-purity magnesium could enhance bone formation in distraction osteogenesis. High-purity magnesium pins were placed into the medullary cavity in the rat distraction osteogenesis model. Results showed that the bone volume/total tissue volume, bone mineral density, and mechanical properties of new callus were significantly higher in the high-purity magnesium group compared to stainless steel and control group (p < 0.01). Histological analyses confirmed improved bone consolidation and vascularization in high-purity magnesium group. Further, polymerase chain reaction-array investigation, Western blot, and immunohistochemical results found that vascular endothelial growth factor and hypoxia inducible factor-1α were highly expressed in the high-purity magnesium group, while Von Hippel–Lindau protein was the opposite (p < 0.01). In conclusion, high-purity magnesium implants have the potential to enhance angiogenesis and bone consolidation in the distraction osteogenesis application, and this process might be via the regulation of Von Hippel–Lindau/hypoxia inducible factor-1α/vascular endothelial growth factor signaling.

Arthroscopic Treatment of Scaphoid Pseudoarthrosis without Bone Graft: Is it Really Feasible?

Introduction The current management of scaphoid pseudoarthrosis remains controversial, with a failure rate of up to 40% and no “gold standard” treatment. Based on innovative concepts about the osteogenic potential of cells from scaphoid pseudoarthrosis, encouraging results from increased vascularization by radial and ulnar metaphyseal decompression for Kienböck disease therapy and the advantages of minimal surgical trauma provided by percutaneous and arthroscopic techniques, we analyzed prospective outcomes from scaphoid pseudoarthrosis arthroscopic treatment with no bone graft (ATSPsWBG) to determine its feasibility. Materials and Methods Eighty-four non-union scaphoid prospectively treated for ATSPsWBG were evaluated. Patients had, on average, 32.42 years old. The dominant limb was affected in 77.5% of the cases (65 patients). Mean time from injury to surgical intervention was 20.57 months. Twenty-three fractures were initially treated conservatively with orthopedic cast for an average period of 6.3 weeks, including 17 already immobilized at the time of the visit. All patients were grouped according to the classification proposed by the authors (MC & DF), which is based on perioperative studies. Results Bone consolidation was obtained in 77 cases (91.66%) and documented by computed tomography (CT) scans. Seven cases presented no bone consolidation 9 months after the procedure, and four cases required a new surgery. In cystic pseudoarthrosis, the bone defect was filled with a new bone growth even when the cyst exceeded 10 mm. Single photon emission computerized tomography (SPECT) scans revealed an unique pattern, documenting the biological effect of metaphyseal decompression, which is characterized by increased nonspecific irrigation of the radial column. Average postoperative pain assessed using the visual analog scale was 1.04 (range, 0 to 2). Average postoperative functional range was 65.3° for extension (range, 46° to 88°), 69.2° for flexion (range, 55° to 88°), 10.7° for radial deviation (range, 5° to 20°) and 26° for ulnar deviation (range, 20° to 37°). Average Mayo Clinic score was 95. Conclusion The arthroscopic treatment of scaphoid pseudoarthrosis with no bone graft is recommended in young to middle-aged, non-smokers patients with no scaphoid consolidation, with hemorrhagic peteqchiae (arthroscopic Green’s Sign) at the arthroscopic evaluation and in which a CT scan excluded the presence of an excessive sclerosis focus or revealed a very small proximal bone fragment not suitable for screw placement for stable internal fixation. Our experience proved that this is a reproducible and feasible technique. Level of Evidence IV