Preliminary outcomes of the combination of demineralized bone matrix and platelet Rich plasma in the treatment of long bone non-unions

Background A variety of bone graft substitutes have been introduced into the treatment of bone non-unions. However, clinical outcomes from current evidences are various and conflicting. This study aimed to present the preliminary outcomes of a treatment protocol in which the combination of demineralized bone matrix (DBM) and platelet rich plasma (PRP) was used as a bone graft substitute for long bone non-unions. Methods Data of this retrospective study were reviewed and collected from a consecutive case series involving 43 patients who presented with a long bone non-union and were treated in our department from October 2018 to May 2019. The combination of DMB and PRP was applied as a bone defect filler in 16 patients, whilst the other 27 patients were treated with iliac bone autografting. Patients’ demographics, postoperative complications and the result of bone union were compared and evaluated. Results The demographic data between the two groups were comparable. No significant difference was found with regard to the incidence of postoperative complications. No graft rejection, heterotopic ossification or other complications were noted. The distribution of bony healing time was rather scattered but did not differ significantly between the groups (7.533 ± 3.357 months vs. 6.625 ± 2.516 months; P=0.341). Union was identified radiographically in 15 of 16 patients in the DBM+PRP group and in 24 of 27 patients in autograft group. Conclusions The present study identified that low incidence of postoperative complications and satisfactory bony healing rate could be achieved in the treatment of long bone non-unions augmented with the combination of DBM and PRP. Although these findings might indicate the promising future of this treatment protocol, larger and higher quality studies should also be executed to assess its routine use.

The acetabular roof reinforcement plate for the treatment of displaced acetabular fractures in the elderly: results in 59 patients

Introduction Open reduction and internal fixation is considered the gold standard of treatment for displaced acetabular fractures in younger patients. For elderly patients with osteoporotic bone quality, however, primary total hip arthroplasty (THA) with the advantage of immediate postoperative mobilization might be an option. The purpose of this study was to evaluate the clinical and radiological outcomes of surgical treatment of displaced osteoporotic acetabular fractures using the acetabular roof reinforcement plate (ARRP) combined with THA. Materials and methods Between 2009 and 2019, 84 patients were operated using the ARRP combined with THA. Inclusion criteria were displaced osteoporotic fractures of the acetabulum with or without previous hemi- or total hip arthroplasty, age above 65 years, and pre-injury ability to walk at least with use of a walking frame. Of the 84 patients, 59 could be followed up after 6 months clinically and radiographically. Forty-nine (83%) were primary fractures and 10 (17%) periprosthetic acetabular fractures. Results The mean age was 80.5 years (range 65–98 years). The average time from injury to surgery was 8.5 days (range 1–28). Mean time of surgery was 167 min (range 100–303 min). Immediate postoperative full weight bearing (FWB) was allowed for 51 patients (86%). At the 6-month follow-up, all 59 patients except one showed bony healing and incorporation of the ARRP. One case developed a non-union of the anterior column. No disruption, breakage or loosening of the ARRP was seen. Additional CT scans performed in 18 patients confirmed bony healing. Twenty-six patients (44%) had regained their pre-injury level of mobility. Complications requiring revision surgery occurred in 8 patients. Five of them were suffering from a prosthetic head dislocation, one from infection, one from hematoma and one from a heterotopic ossification. Conclusions The ARRP has proven to provide sufficient primary stability to allow for immediate FWB in most cases and represents a valuable option for the surgical management of displaced acetabular fractures in this challenging patient group.

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A Retrospective Analysis of Outcomes from Foot and Ankle Arthrodesis and Open Reduction and Internal Fixation using Cellular Bone Allograft Augmentation

Category: Other; Ankle; Basic Sciences/Biologics; Hindfoot; Midfoot/Forefoot Introduction/Purpose: Surgical arthrodesis of joints in the foot and ankle is common in patients who have failed nonoperative management for a variety of conditions. ViviGen is an allogeneic cellular bone matrix product that contains lineage-committed bone cells, and can be used as an alternative to autograft bone or other augments in order to aid in arthrodesis or to enhance bony healing in open reduction and internal fixation (ORIF) procedures. However, compared with autograft bone, ViviGen does not introduce potential for donor site morbidity. Due to the lack of studies examining outcomes following foot and ankle surgeries in which ViviGen is utilized, further investigation is required to determine its efficacy and safety for use in foot and ankle joint arthrodesis and skeletal fracture fixation. Methods: This study included 153 consecutive patients undergoing ankle, midfoot or hindfoot arthrodesis or ORIF procedures in which ViviGen was used as an augment. Pediatric patients and cases involving structural allografts or metal wedges were excluded. Patients were not excluded based on the amount of ViviGen used, type of instrumentation or implants used, or due to comorbidity. This series included revision as well as primary arthrodesis procedures and included various fixation types. Retrospective chart review was used to identify patient demographic factors and medical comorbidities, as well as to evaluate clinical and radiographic data to determine outcome. Results: 135 patients were available for analysis at final evaluation. 113 patients underwent arthrodesis (mean age of 56.29 years, mean body mass index of 32.19). 22 patients underwent an ORIF procedure (mean age of 36.35 years, mean body mass index of 32.79). The fusion rate for the arthrodesis cohort was 97/113 (85.8%). Table 1 demonstrates the fusion rate stratified by region of the foot. Smokers had significantly lower rates of fusion compared to nonsmokers (p=0.01). There was not a statistically significant difference in the rate of fusion between primary and revision arthrodesis (p=0.8650). The rate of fusion was significantly lower in patients with Charcot foot in comparison to patients without Charcot foot (p=0.0076). The bony healing rate for the ORIF cohort was 19/22 (86.4%). Conclusion: This large case series of patients undergoing a wide variety of procedures about the ankle, hindfoot, and midfoot with ViviGen bone graft augmentation demonstrates satisfactory outcomes with regard to fusion rate and successful union, as well as minimal complications. To date, this is the largest case series in the literature of patients undergoing foot and ankle procedures with an allogenic cellular bone matrix product that contains lineage-committed bone cells. Our findings help to introduce ViviGen as a safe and efficacious alternative to other forms of augmentation for fusion and ORIF procedures about the foot and ankle. [Table: see text]

A Retrospective Analysis of Outcomes From Foot and Ankle Arthrodesis and Open Reduction and Internal Fixation Using Cellular Bone Allograft Augmentation

Background ViviGen is an allogeneic cellular bone matrix product containing lineage-committed bone cells, and can be used as an alternative to autograft bone or other augments to aid in arthrodesis or to enhance bony healing in open reduction and internal fixation (ORIF) procedures. Methods This study included 153 consecutive patients undergoing ankle, midfoot, or hindfoot arthrodesis or ORIF procedures from January 2017 to October 2018, in which an allogeneic cellular bone matrix product was used to aid in bony healing. Retrospective chart review identified patient demographic factors and medical comorbidities and evaluated clinical and radiographic data to determine fusion/union rate and complications. Results The overall fusion rate for the arthrodesis cohort was 97/113 (85.8%). The overall complication rate in this cohort was 22/113 (19.5%). Smokers had significantly lower rates of fusion compared with nonsmokers ( P = .01). The observed bony healing rate for the ORIF cohort was 19/22 (86.4%), with a complication rate of 3/22 (13.6%). Conclusion With satisfactory fusion rates and relatively few complications, our findings suggest that ViviGen is a safe and efficacious alternative to other forms of bone graft augmentation for fusion and ORIF procedures about the foot and ankle. Further study is needed to compare the efficacy of ViviGen with autograft bone and other augments. Levels of Evidence: Level IV: Case series

Mid-term Results of an Anterior Plating Via Combined Anterior Approach for complex Acetabular Fractures: A Retrospective Cohort Study

Background: Solely anterior plating via the modified Stoppa approach might yield satisfactory outcomes for selected cases of complex acetabular fractures, however, its indications are not practically clear. Methods: Patients with complex acetabular fractures treated with solely anterior plating via the modified Stoppa approach with or without a lateral window at our trauma center between January 2013 and December 2019 were retrospectively reviewed. Fracture type was identified according the newly established three-column classification of acetabular fracture. Perioperative information was recorded, and fracture reduction was evaluated radiographically at 3 days postoperatively. Postoperative hip function was assessed at least 1 year postoperatively. Results: Twenty patients were included with an average 17 months (range, 13-28) follow-up. According to the three-column classification, 2 cases were classified as type B2.2, 8 cases as type B2.3, 3 cases as type C1, and 7 cases as type C3. The mean time from injury and surgery was 7.0 days (range, 3-13 days), operative time was 2.0 hours (range, 1.4-3.2 hours), and intraoperative blood loss was 320 ml (range, 220-450 ml). Fracture reduction was excellent in 15 cases (75%), good in 3 cases (15%), fair in 1 case (5%), and poor in 1 case (5%). Final hip function was excellent in 13 cases (68%), good in 3 cases (16%), fair in 2 cases (11%), and poor in 1 case (5%). Bony healing was achieved in all cases and few complications were reported including recoverable obturator nerve injuries in 2 patients (10%) and controllable osteoarthritis in 1 patient (5%). Conclusions: Solely anterior plating via the combined anterior approach achieved satisfactory mid-term outcomes for complex acetabular fractures with posterior column detachments. Based on the newly established three-column classification of complex acetabular fracture, the type B, C1, and C3 fractures are possibly the appropriate indications for such a simplified procedure.Trial registration informationThe trial was retrospectively registered in https://www.researchregistry.com (No. Researchregistry4862) on July 04, 2019. The first participant was enrolled on March 06, 2017.

Lag-Screw Osteosynthesis in Thoracolumbar Pincer Fractures

Study Design: Biomechanical. Objective: This study evaluates the biomechanical properties of lag-screws used in vertebral pincer fractures at the thoracolumbar junction. Methods: Pincer fractures were created in 18 bisegmental human specimens. The specimens were assigned to three groups depending on their treatment perspective, either bolted, with the thread positioned in the cortical or cancellous bone, or control. The specimens were mounted in a servo-hydraulic testing machine and loaded with a 500 N follower load. They were consecutively tested in 3 different conditions: intact, fractured, and bolted/control. For each condition 10 cycles in extension/flexion, torsion, and lateral bending were applied. After each tested condition, a computed tomography (CT) scan was performed. Finally, an extension/flexion fatigue loading was applied to all specimens. Results: Biomechanical results revealed a nonsignificant increase in stiffness in extension/flexion of the fractured specimens compared with the intact ones. For lateral bending and torsion, the stiffness was significantly lower. Compared with the fractured specimens, no changes in stiffness due to bolting were discovered. CT scans showed an increasing fracture gap during axial loading both in extension/flexion, torsion, and lateral bending in the control specimens. In bolted specimens, the anterior fragment was approximated, and the fracture gap nullified. This refers to both the cortical and the cancellous thread positions. Conclusion: The results of this study concerning the effect of lag-screws on pincer fractures appear promising. Though there was little effect on stiffness, CT scans reveal a bony contact in the bolted specimens, which is a requirement for bony healing.

Osteosynthesis of a Multifragment Femoral Shaft Fracture and Peri-Implant Refracture in an 83-Year-Old Patient with Osteogenesis Imperfecta

Introduction. Osteogenesis imperfecta (OI) is the term for a heterogenic group of conatal diseases that affect the bone formation. Eight different OI types are known. Patients with types III and IV frequently suffer from fractures without adequate trauma. The literature gives plenty advice for fracture treatment in pediatric OI patients, but there is less for adults, and no recommendations can be found for geriatric OI patients. Case Presentation. We report on an 83-year-old male who suffered from OI type IV. He was able to walk with an individually adapted gait orthosis. In an accident, the patient sustained a distal, multifragment, femoral shaft fracture. The fracture was openly reduced and fixated with a retrograde inserted elastic stable intramedullary nail (ESIN). Three months later, the patient was capable of walking without crutches. Due to another accident, he sustained a peri-implant refracture without failure of the ESIN. We immobilized the leg, and it achieved bony healing without reosteosynthesis. Eleven weeks later, he was again able to mobilize himself with full weight bearing. Discussion. We present a unique case of osteosynthesis in a distal, multifragment, femoral shaft fracture in a geriatric OI patient. No recommendations for the treatment of mature patients with OI can be found in the literature. We present our treatment concept and technique of osteosynthesis with an ESIN. Despite another accident with a peri-implant refracture, sufficient bony healing occurred, which allowed the patient to freely mobilize himself again.

Mid-term results of an anterior plating via combined anterior approach for complex acetabular fractures: a retrospective cohort study

Background: Solely anterior plating via the modified Stoppa approach might yield satisfactory outcomes for selected cases of complex acetabular fractures, however, its indications are not practically clear. Methods: Patients with complex acetabular fractures treated with solely anterior plating via the modified Stoppa approach with or without a lateral window at our trauma center between January 2013 and December 2019 were retrospectively reviewed. Fracture type was identified according the newly established three-column classification of acetabular fracture. Perioperative information was recorded, and fracture reduction was evaluated radiographically at 3 days postoperatively. Postoperative hip function was assessed at least 1 year postoperatively. Results: Twenty patients were included with an average 17 months (range, 13-28) follow-up. According to the three-column classification, 2 cases were classified as type B2.2, 8 cases as type B2.3, 3 cases as type C1, and 7 cases as type C3. The mean time from injury and surgery was 7.0 days (range, 3-13 days), operative time was 2.0 hours (range, 1.4-3.2 hours), and intraoperative blood loss was 320 ml (range, 220-450 ml). Fracture reduction was excellent in 15 cases (75%), good in 3 cases (15%), fair in 1 case (5%), and poor in 1 case (5%). Final hip function was excellent in 13 cases (68%), good in 3 cases (16%), fair in 2 cases (11%), and poor in 1 case (5%). Bony healing was achieved in all cases and few complications were reported including recoverable obturator nerve injuries in 2 patients (10%) and controllable osteoarthritis in 1 patient (5%). Conclusions: Solely anterior plating via the combined anterior approach achieved satisfactory mid-term outcomes for complex acetabular fractures with posterior column detachments. Based on the newly established three-column classification of complex acetabular fracture, the type B, C1, and C3 fractures are possibly the appropriate indications for such a simplified procedure.