Is open bone graft always necessary when treating aseptic subtrochanteric nonunion with a reamed intramedullary nail?

Background This study aimed to compare the radiological results between closed nailing without bone graft (BG) and open nailing with BG for aseptic subtrochanteric nonunion and to determine when an open procedure with BG should be considered. Methods In this retrospective study, we investigated patients who underwent surgical intervention for subtrochanteric nonunion between January 2008 and March 2018 in two institutions. Patients with infection, large bone defect, pathologic fracture, open fracture, previous surgery using plate, and follow-up of less than 1 year were excluded. We compared the demographic details and radiological results between patients who underwent the open procedure with BG (BG group) and the closed procedure without BG (non-BG group) as a historical control, and risk factors for the failure of revision surgery were evaluated. Results Thirty-seven patients met the criteria and were divided into the following two groups: the BG group (n=19) who underwent open nailing with BG and the non-BG group (n=18) who underwent closed reamed nailing without BG. The mean degrees of correction of varus and flexion deformity were significantly different (p=0.001, respectively), 6.2° and 2.9° in the BG group and 4.1° and 0.6° in the non-BG group, respectively. Bony union was observed in 17 cases (89.5%) in an average of 7.4 months in the BG group and in 16 cases (88.9%) in 7.6 months in the non-BG group, with no significant differences. The factors that were significantly associated with failure of revision were atypical fracture, two or more previous surgeries, and varus and sagittal anterior angulation. Conclusions The radiological results of closed reamed nailing without BG for subtrochanteric nonunion were satisfactory. In the effort of percutaneous realignment, gap reduction, and intramedullary reaming, the radiological results of closed nailing without BG were not different from those of open nailing with BG; therefore, closed procedure without BG may be an acceptable option in appropriately selected patients.

Intensive Care Management of Complicated Case of Fat Embolism Secondary to Femur Fracture

Fat embolism syndrome (FES) is an inflammatory cascade, affecting multi-organs, potentially leading to serious complications in orthopedic patients, especially after femur fractures. It includes hypoxia due to pulmonary dysfunction, neurological and psychiatric changes, fever, tachycardia, petechial hemorrhages, thrombocytopenia, and anemia. Due to advancement in intensive care and supportive management and surgical techniques, like intramedullary reaming, the incidence of fat embolism syndrome has become only 0.5 percent. This report presents case of a 22-year-old male with femur fracture due to road traffic accident, with diagnosis of fat embolism syndrome, wound infection, pneumonia and deep venous thrombosis which was managed successfully.

A Biomechanical Evaluation of the Tibia after Retrograde Intramedullary Reaming

Category: Hindfoot; Ankle; Ankle Arthritis; Basic Sciences/Biologics; Trauma Introduction/Purpose: Autologous bone graft is an important tool in the foot and ankle surgeon’s arsenal, and remains the gold standard despite the release of new biologics. The Reamer-Irrigator-Aspirator (RIA) system has become an option for local intramedullary bone graft harvest. Evidence supports the quality of graft and safety of RIA in the femur, and some series have demonstrated its value in tibial reaming for hindfoot fusion. However, there has been no analysis of the mechanical effects of the system on the tibia. The purpose of this study is to investigate the effect of retrograde intramedullary reaming on the mechanical properties of cadaveric tibias, with the hypothesis that this will produce no significant difference in torsional strength between groups. Methods: Intact, fresh frozen tibias were obtained for testing, totaling 11 matched pairs. One tibia was chosen for reaming from each pair with pre-test randomization. The selected tibia was reamed in a retrograde fashion over a guidewire to 12mm, which is the smallest diameter RIA device available. Each tibia was potted and mounted in a custom jig for testing on a servohydraulic test frame. Each specimen was first tested non-destructively for compressive properties using standardized loading rates. Each specimen was then loaded in torsion under constant angular velocity of 9˚/second until failure or the limit of the load cell was reached. Mechanical properties were determined from the load-displacement curve and compared between reamed and unreamed matched pairs using paired samples statistics, with statistical significance set at p=0.05. Results: Specimens were of mean age 56 (range 39-67) years, with 55% being female. The mean compressive stiffness of reamed (560.4 +- 111.7 N/mm) and unreamed (628.2 +- 117.2 N/mm) tibias were not statistically different (p = 0.167). Nine of the reamed specimens and 10 of the unreamed specimens fractured during torsional testing. Torsional testing for stiffness (178.4 Nm/rad +- 59.4 vs 168.1 +- 40.8, p=0.370), rigidity (50.4 Nm2/rad +- 19.1 vs 47.0 +- 13.7, p=0.331), and ultimate load capacity (71.2 Nm +- 24.3 vs 71.9 +- 20.5, p=0.880) showed minimal differences between reamed and unreamed specimens, respectively. Conclusion: Mechanical testing identified no statistically significant differences in torsional or compressive properties of our cadaveric tibias after intramedullary reaming. There was a trend towards decreased compressive stiffness, but this is not a common mechanism of fracture. Our findings suggest that the use of the smallest size RIA system in the tibia does not drastically alter the mechanical properties or require prophylactic fixation. The RIA can be used safely as a method of bone graft harvest or intramedullary debridement in the tibia, as long as appropriate technique is used to avoid eccentric reaming or excessive blood loss.

Transient Existence of Circulating Mesenchymal Stem Cells in the Deep Veins in Humans Following Long Bone Intramedullary Reaming

The biology of mesenchymal stem cells (MSCs) in humans is incompletely understood and a possible role of systemically circulating cells in health and autoimmune disease remains controversial. Physiological movement of bone marrow MSCs to sites of injury would support the rationale for intravenous administration for relocation to damaged organs. We hypothesized that biophysical skeletal trauma rather than molecular cues may explain reported MSC circulation phenomena. Deep-femoral vein (FV) and matched peripheral vein blood samples (PVBs) were collected from patients undergoing lower-limb orthopaedic procedures during surgery (tibia using conventional sequential reaming, n = 9, femur using reamer/irrigator/aspirator (RIA), n = 15). PVBs were also taken from early (n = 15) and established (n = 12) rheumatoid arthritis (RA) patients and healthy donors (n = 12). Colony-forming unit-fibroblasts (CFU-Fs) were found in 17/36 FVBs but only 7/74 PVBs (mostly from femoral RIA); highly proliferative clonogenic cells were not generated. Only one colony was found in control/RA samples (n = 28). The rare CFU-Fs’ MSC nature was confirmed by phenotypic: CD105+/CD73+/CD90+ and CD19−/CD31−/CD33−/CD34−/CD45−/CD61−, and molecular profiles with 39/80 genes (including osteo-, chondro-, adipo-genic and immaturity markers) similar across multiple MSC tissue controls, but not dermal fibroblasts. Analysis of FVB-MSCs suggested that their likely origin was bone marrow as only two differences were observed between FVB-MSCs and IC-BM-MSCs (ACVR2A, p = 0.032 and MSX1, p = 0.003). Stromal cells with the phenotype and molecular profile of MSCs were scarcely found in the circulation, supporting the hypothesis that their very rare presence is likely linked to biophysical micro-damage caused by skeletal trauma (here orthopaedic manipulation) rather than specific molecular cues to a circulatory pool of MSCs capable of repair of remote organs or tissues. These findings support the use of organ resident cells or MSCs placed in situ to repair tissues rather than systemic administration.

Intramedullary reaming modality for management of postoperative long bone infection: a prospective randomized controlled trial in 44 patients

Background Studies addressing the management of intramedullary infection are mainly retrospective and with a limited number of cases. Reaming can be performed using either conventional reaming or using the reamer/irrigator/aspirator (RIA) system. Until now there have been no comparative prospective studies between these two methods. We aimed to compare the efficacy of RIA with conventional reaming followed by insertion of antibiotic-loaded cement, for the treatment of intramedullary nail infection of long bones. We assessed the rate of remission between groups after two-year follow-up and identified microorganisms using tissue cultures and sonication of explanted intramedullary nail (IMN). Methods A noninferiority, randomized clinical trial was carried out between August 2013 and August 2015 involving 44 patients of whom a locked IMN implant of the femur and/or tibia was retrieved and who all met the clinical and radiological criteria for IMN-associated osteomyelitis. Patients were randomized into two groups: RIA alone versus conventional reaming followed by antibiotic-loaded cement insertion. Both groups also underwent six-weeks of antibiotic treatment according to the results of the antibiogram. Patients were evaluated after 1, 3, 6, 12 and 24 months for radiological and clinical follow-up. Results After 24 months, the rate of infection remission was similar between the two groups, 87% in the RIA group and 95.5% in the conventional reaming group (p = 0.60). Among four patients who had recurrence of infection, the time to reappearance of symptoms varied from 20 days to twenty-two months. Staphylococcus aureus and coagulase-negative Staphylococci were isolated in 23 (40.4%) and 13 (22.9%) patients, respectively. Interestingly, we identified 20% (9/45) of polymicrobial infection. Conclusion This study concludes that the RIA system alone, is noninferior to conventional reaming followed by antibiotic cement spacer in the treatment of IMN infection. However, RIA shows greater efficacy in the collection of infected medullary bone tissue, mainly in cases of infected retrograde nail of the femur. Trial registration ISRCTN82233198. Retroactively registered on July 29, 2019.

Induction of periosteal bone formation by intraosseous BMP-2 injection in a mouse model of osteogenesis imperfecta

Purpose Surgical interventions are routinely performed on children with osteogenesis imperfecta (OI) to stabilize long bones, often post fracture. We speculated that a combination of intramedullary reaming and intraosseous injection of recombinant bone morphogenetic protein-2 (BMP-2) could enhance periosteal ossification and ultimately cortical thickness and strength. This approach was conceptually tested in a preclinical model of genetic bone fragility. Methods Six experimental groups were tested including no treatment, intramedullary reaming, and reaming with 5 µg BMP-2 injection performed in the tibiae of both wild type (WT) and Col1a2G610C/+ (OI, Amish mutation) mice. Bone formation was examined at a two-week time point in ex vivo specimens by micro-computed tomography (microCT) analysis and histomorphometry with a dynamic bone label. Results MicroCT data illustrated increases in tibial cortical thickness with intramedullary reaming alone (Saline) and reaming plus BMP-2 injection (BMP-2) compared to no intervention controls. In the OI mice, the periosteal bone increase was not statistically significant with Saline but there was an increase of +192% (p = 0.053) with BMP-2 injection. Dynamic histomorphometry on calcein label was used to quantify new woven bone formation; while BMP-2 induced greater bone formation than Saline, the anabolic response was blunted overall in the OI groups. Conclusions These data indicate that targeting the intramedullary compartment via reaming and intraosseous BMP-2 delivery can lead to gains in cortical bone parameters. It is suggested that the next step is to validate safety and functional improvements in a clinical OI setting.

Ribbing disease: a systematic review

Background Ribbing disease, or multiple diaphyseal sclerosis, is a rare benign bone dysplasia. Purpose To systematically review the literature to determine the clinical and radiological presentation of patients with Ribbing disease as well as the effects of attempted treatments. Material and Methods We considered individual patient data of patients diagnosed with Ribbing disease derived from patient reports and patient series. All stages of the review were performed by two reviewers independently. Standard descriptive statistics were used for quantitative analyses and mixed model analyses were used when appropriate Results The literature search yielded 420 unique hits of which 23 studies were included, covering a total of 40 patients of whom 29 had bilateral involvement. The mean age at diagnosis was 35 years and the mean time between diagnosis and onset of symptoms, mostly pain, was five years (range = 1–16 years). The tibial diaphysis was the most commonly involved bone in 35 of 36 patients. Non-surgical treatment consisted of non-steroidal anti-inflammatory drugs (NSAIDs), prednisone, and bisphophonates with mixed results. Surgical treatment consisted of intramedullary reaming and fenestration and was very effective to reduce pain. Conclusion The clinical presentation and imaging findings of patients with Ribbing disease are becoming more apparent. However, there is paucity of evidence on the natural disease progression and effectiveness of treatment modalities.

Diagnostic use of intramedullary reaming biopsy in metastatic long bone disease

INTRODUCTION Bone is the third most common site of metastasis. A histological diagnosis is important in guiding therapy and prognosis. In up to 15% of cases of metastatic disease, the primary tumour remains unknown. This emphasises the importance of adequate, reliable and accurate sampling when performing any type of biopsy. Reaming biopsy is commonly performed during intramedullary nailing of metastatic long-bone disease but there is little published evidence on the diagnostic use and reliability of this technique. AIMS AND METHODS We reviewed 49 cases of confirmed metastatic bone disease to determine adequacy for analysis, diagnostic accuracy and factors affecting reliability. RESULTS Adequate tissue for histopathological analysis was obtained in 96% of cases but metastasis was confirmed in only 51% of cases. The presence of a pathological fracture had no effect on accuracy of the results but metastasis was more likely to be missed in the presence of tissue crushing and or necrosis (P = 0.015). DISCUSSION This study determines the use and accuracy of bone reaming biopsy in metastatic disease and, to the best of our knowledge, is the only study determining the effect of additional factors such as the presence of a pathological fracture and tissue necrosis or crushing on the diagnostic accuracy of this technique. CONCLUSIONS In spite of adequate tissue sampling, the diagnostic accuracy and, hence, reliability of intramedullary reaming biopsy in metastatic bone disease is less than optimal. A reaming histopathology report suggesting no evident metastasis should always be taken in clinical context.