Surgical treatment outcome after serial debridement of infected nonunion—A retrospective cohort study

Purpose Reported outcome after multiple staged surgical treatment of infected nonunion is scarce. We, therefore, asked: (1) What is the clinical outcome in infected nonunion patients after multiple staged revision surgery? (2) Are different pathogens evidenced after surgical treatment in patients who have undergone more or less surgeries? Methods All enrolled patients were surgically treated for long bone-infected nonunion between January 2010 and March 2018. Besides patients´ demographics outcome in terms of bony consolidation and major complications defined as death during inward treatment, amputation and recurrence of infection during follow-up of at least 12 months were assessed. Microbiological findings were assessed and compared between two groups with less than five versus five or more surgical revisions. Results Bone consolidation was achieved in 86% of the patients while complications such as femoral or transtibial amputation, recurrence of infection or even death during inpatient treatment could be evidenced in six patients (14%). In patients who underwent multiple-stage surgery for five or more times, germ changes and repeated germ detection was more common than in patients with less surgeries. Conclusions Surgical treatment of infected nonunions poses a high burden on the patients with major complications occurring in about 14% of the patients using a multiple staged treatment concept. Future prospective studies comparing outcomes after limited with multiple staged revision surgeries are necessary.

Does Dynamic Anterior Plate Fixation Provide Adequate Stability for Traumatic Subaxial Cervical Spine Fractures at Mid-Term Follow-Up?

Background: It remains questionable if the treatment of cervical fractures with dynamic plates in trauma surgery provides adequate stability for unstable fractures with disco-ligamentous injuries. The primary goal of this study was to assess the radiological and mid-term patient-reported outcome of traumatic subaxial cervical fractures treated with different plate systems. Patients and Methods: Patients, treated with anterior cervical discectomy and fusion (ACDF) between 2001 and 2015, using either a dynamic plate (DP: Mambo™, Ulrich, Germany) or a rigid locking plate (RP: CSLP™, Depuy Synthes, USA), were identified. For radiological evaluation, the sagittal alignment, the sagittal anterior translation and the bony consolidation were evaluated. After at least two years, the patient-reported outcome measures (PROM) were evaluated using the German Short-Form 36 (SF-36), Neck Disability Index (NDI) and the EuroQol in 5 Dimensions (EQ-5D) scores. Results: 33 patients met the inclusion criteria (DP: 13; RP:20). Twenty-six patients suffered from AO Type B or C fractures. Both the sagittal alignment and the sagittal translation could be sufficiently improved in both groups (p ≥ 0.05). No significant loss of reduction could be observed at the follow-up in both groups (p ≥ 0.05). Bony consolidation could be observed in 30 patients (DP: 12/13 (92%); RP: 18/20 (90%); (p ≥ 0.05)). In 20 patients, PROMs could be evaluated (follow-up: 71.2 ± 25.5 months). The whole cohort showed satisfactory PROM results (EQ-5D: 72.0 ± 4.9; SF-36 PCS: 41.9 ± 16.2, MCS: 45.4 ± 14.9; NDI: 11.0 ± 9.1). without significant differences between the DP and RP group (p ≥ 0.05) Conclusion: The dynamic plate concept provides enough stability without a difference in fusion rates in comparison to rigid locking plates in a population that mostly suffered fragile fractures.

Minimally Invasive vs Open Akin Osteotomy

Background: Minimally invasive techniques of Akin osteotomy have grown in popularity, as early results suggest faster recovery, earlier return to work, and minimized wound healing problems. Preserving lateral cortex integrity during first phalanx osteotomy thereby presents a challenge because of the lack of direct visual control. This retrospective comparative study investigated clinical and radiographic outcomes of minimally invasive and open Akin osteotomy with different fixation methods and analyzed whether or not intraoperative violation of the lateral cortex caused loss of correction or delayed bone healing. Methods: One hundred eighty-four patients (210 feet) with symptomatic hallux valgus and pathologic interphalangeal angle (IPA) of at least 10 degrees underwent surgery combined with Akin osteotomy. Minimally invasive Akin osteotomies were fixed in 124 feet with 2 crossing percutaneous K-wires and compared to 86 Akin osteotomies by open technique with double-threaded (head and shank) screw fixation. At 1 day and 6 and 12 weeks postoperatively, IPA and bony consolidation were radiographically and clinically assessed. Results: Mean preoperative IPA was 13.4 ± 3.6 degrees in minimally invasive (MI) and 13.3 ± 3.5 degrees in open surgery (OS) cases ( P > .05). Intraoperative breach of the lateral cortex occurred in 12 (13.9%) in OS and 64 (51.6%) in MI cases. Whereas the breach occurred in open technique mainly during manual correction by applying a medial closing force, it was caused predominantly by the use of the burr in minimally invasive technique. After 12 weeks, the mean IPA was 4.1 ± 1.4 degrees in MI and 4.8 ± 1.2 degrees in OS cases ( P > .05). Bony consolidation was complete after 6 and 12 weeks in OS and MI, respectively. Three deep infections occurred in the OS Group after Lapidus arthrodesis and 2 deep infections were registered in the MI Group after minimally invasive chevron and Akin osteotomy. The infections were not at the site of the Akin osteotomy. Conclusion: Breach of the lateral cortex did not impair bone healing or correction of IPA. Minimally invasive Akin osteotomy with K-wire fixation provided equivalent correction of IPA compared to open surgery with screw fixation. Level of Evidence: Level III, retrospective comparative series.

Does Dynamic Ventral Plate Fixation Provide Adequate Stability for Traumatic Subaxial Cervical Spine Fractures in Mid-term Follow-up?

BackgroundIt remains questionable if the treatment of cervical fractures with dynamic plates in trauma surgery provides adequate stability for fractures with disco-ligamentous injuries. The primary goal of this study was to assess the radiological and mid-term patient-reported outcome of traumatic subaxial cervical fractures treated with a dynamic plate compared to rigid locking plate system.Patients and MethodsPatients, treated with anterior cervical discectomy and fusion (ACDF) between 2001 and 2015, using either a dynamic plate (DP: Mambo™, Ulrich, Germany) or a rigid locking plate (RP: CSLP™, Depuy Synthes, USA), were identified. Only patients with complete radiological follow (pre- and postoperatively and minimum one year after surgery) were included in the study. Next to the sagittal alignment, the sagittal anterior translation and the bony consolidation were evaluated. After at least two years the patient reported outcome measures (PROM) were evaluated using the German Short-Form 36 (SF-36) with the physical components summary (PCS) and mental components summary (MCS), Neck Disability Index (NDI) and the EuroQol in 5 Dimensions (EQ-5D) score.Results33 patients met the in- and exclusion criteria. 26 patients suffered from an AO Type B or C fracture. 13 patients were treated with a dynamic plate and 20 with a rigid locking plate. Both, the sagittal alignment, and the sagittal translation could be sufficiently restored with no differences between the two groups (p ≥ 0.05). No significant loss of reduction could be observed at the follow-up in both groups (p ≥ 0.05). Bony consolidation could be observed in 30 patients (91%) with no significant differences between both groups (DP: 12/13 (92%); RP: 18/20 (90%); (p ≥ 0.05)). In 20 patients PROMs could be evaluated after a mean follow-up of 71.2±25.5 months. No significant differences between DP and RP could be detected in EQ-5D, SF- 36 (PCS and MCS) or NDI (EQ-5D: 72±5; SF-36 PCS 41.9±16.2, MCS 45.4±14.9; NDI: 11±9).ConclusionThe dynamic plate concept provides enough stability without a difference in fusion rates in comparison to rigid locking plates in a population that mostly suffered AO Type B and C fractures.

Minimally Invasive Versus Open Akin Osteotomy: A Comparative Study

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: Minimally invasive techniques of Akin osteotomy grow in popularity in order to minimize wound healing problems. To date it is recommended to keep the lateral corticalis intact during first phalanx osteotomy. The lack of direct visual control makes this a challenging goal in minimally invasive surgery. This retrospective study investigates whether or not the perforation of the lateral corticalis causes clinical or radiological negative effects. The quality of fixation with crossed K-wires and double threaded screws is compared. Methods: 184 patients (210 feet) with symptomatic mild to severe hallux valgus deformity and pathological interphalangeal angle (IPA) of at least 10° underwent surgery combined with Akin osteotomy. 124 minimally invasive Akin osteotomies were fixed with two crossing K-wires and compared to 86 Akin osteotomies in open technique with double threaded screw fixation. After 6 and 12 weeks IPA and bony consolidation were assessed. Results: Preoperative interphalangeal angles were mean 13.4° (+- 3.6°) (minimally invasive group (MI)), or 13.3° (+- 3.5°) (open surgery group (OS)) degrees (p>0.05).Perforation of the lateral corticalis occurred in 12 (13.9%) (OS), or 64 (51.6%) cases (MI), respectively.12 weeks after surgery the mean IPA was 4.1° (+- 1.4°) (MI), or 4.8° (+- 1.2°) in the open surgery group (OS) (p > 0.05).Bony consolidation was noticed after 6 weeks (OS, double threaded screw) or 12 weeks (MI, crossing K-wires).Three deep infections occurred in the OS group after Lapidus arthrodesis and two deep infections were registered in the MI group after MICA. All patients required revision with removal of implants. Pseudarthrosis did not occur in any group. Conclusion: Perforation of the lateral corticalis did not cause negative effects on bone healing or IPA. Minimally invasive Akin osteotomy provides equivalent correction of IPA compared to open surgery with a slightly prolonged radiological bony consolidation. The fixation technique had no influence on IPA correction.

Evaluation of Secondary and Late Secondary Alveolar Bone Grafting on 66 Unilateral Cleft Lip and Palate Patients

Objective: The aim of this retrospective study was to evaluate the outcomes of secondary alveolar bone grafting and late secondary alveolar bone grafting in 66 unilateral cleft lip and palate patients. Materials and Methods: The total patients were 66 unilateral cleft lip and palate patients, out of which 19 patients underwent secondary alveolar bone grafting and 47 patients underwent late secondary alveolar bone grafting. Autogenous anterior iliac crest cancellous bone graft was harvested and used for grafting the alveolar clefts. Radiographic assessment based on Enemark’s scoring according to the marginal bone levels was done on the intraoral periapical radiographs taken 6 months after performing the surgery. Results: Twelve (63%) out of the 19 patients on whom secondary alveolar bone grafting was done achieved score 1 (optimal marginal bone levels), whereas only 12 (25%) out of the 47 patients achieved score 1 amongst the late secondary alveolar bone graftings. Overall results showed, probability, P = .034 (statistically significant). Conclusion: This study reaffirmed the fact that alveolar bone grafting when done in preadolescent age group (secondary alveolar bone grafting) gives better results in terms of marginal bony consolidation and maintaining the continuity of the alveolar arch, but the late presentation (late secondary alveolar bone grafting) should not be the refusal criteria for performing the alveolar bone grafting. Although the latter patients may not be rewarded in terms of bony consolidation as much as the preadolescent patients the potential of successful surgery in them still exists in terms of providing a platform for the dental implant placement, improvement in the soft tissue symmetry and aesthetics of the face.

Cementless Titanium Mesh Fixation of Osteoporotic Burst Fractures of the Lumbar Spine Leads to Bony Healing: Results of an Experimental Sheep Model

Introduction. Current treatment strategies for osteoporotic vertebral compression fractures (VCFs) focus on cement-associated solutions. Complications associated with cement application are leakage, embolism, adjacent fractures, and compromise in bony healing. This study comprises a validated VCF model in osteoporotic sheep in order to (1) evaluate a new cementless fracture fixation technique using titanium mesh implants (TMIs) and (2) demonstrate the healing capabilities in osteoporotic VCFs.Methods. Twelve 5-year-old Merino sheep received ovariectomy, corticosteroid injections, and a calcium/phosphorus/vitamin D-deficient diet for osteoporosis induction. Standardized VCFs (type AO A3.1) were created, reduced, and fixed using intravertebral TMIs. Randomly additional autologous spongiosa grafting (G1) or no augmentation was performed (G2,n=6each). Two months postoperatively, macroscopic, micro-CT and biomechanical evaluation assessed bony consolidation.Results. Fracture reduction succeeded in all cases without intraoperative complications. Bony consolidation was proven for all cases with increased amounts of callus development for G2 (58.3%). Micro-CT revealed cage integration. Neither group showed improved results with biomechanical testing.Conclusions. Fracture reduction/fixation using TMIs without cement in osteoporotic sheep lumbar VCF resulted in bony fracture healing. Intravertebral application of autologous spongiosa showed no beneficial effects. The technique is now available for clinical use; thus, it offers an opportunity to abandon cement-associated complications.

Regenerate augmentation with bone marrow concentrate after traumatic bone loss

Distraction osteogenesis after post-traumatic segmental bone loss of the tibia is a complex and time-consuming procedure that is often complicated due to prolonged consolidation or complete insufficiency of the regenerate. The aim of this feasibility study was to investigate the potential of bone marrow aspiration concentrate (BMAC) for percutaneous regenerate augmentation to accelerate bony consolidation of the regenerate. Eight patients (age 22-64) with an average posttraumatic bone defect of 82.4 mm and concomitant risk factors (nicotine abuse, soft-tissue defects, obesity and/or circulatory disorders) were treated with a modified Ilizarov external frame using an intramedullary cable transportation system. At the end of the distraction phase, each patient was treated with a percutaneously injection of autologous BMAC into the centre of the regenerate. The concentration factor was analysed using flow cytometry. The mean follow up after frame removal was 10 (4-15) months. With a mean healing index (HI) of 36.9 d/cm, bony consolidation of the regenerate was achieved in all eight cases. The mean concentration factor of the bone marrow aspirate was 4.6 (SD 1.23). No further operations concerning the regenerate were needed and no adverse effects were observed with the BMAC procedure. This procedure can be used for augmentation of the regenerate in cases of segmental bone transport. Further studies with a larger number of patients and control groups are needed to evaluate a possible higher success rate and accelerating effects on regenerate healing.

Distraction Osteogenesis in the Pediatric Population

OBJECTIVES: Distraction osteogenesis has been described routinely in the mandible for the advancement of bony segments. Complications, though infrequent, may include postoperative infection, implant extrusion, nonunion of the bony segments, device malfunction, cranial nerve paresis, and premature consolidation. METHODS: Seventy-eight distractions of the mandible were performed over 10 years. The technique in placement of these internal microdistraction devices involves making intraoral and extraoral incisions and beginning distraction after a latency period of 3 days. Following this latency period, distraction occurs at 1 mm/day. RESULTS: In this series of patients, distraction was accomplished successfully. There was a 2.6% rate of wound infection in this series; 2.6% also had bony nonunion; 3.8% had premature bony consolidation; and 3.8% had facial nerve complications. In the three patients with facial nerve paresis, we followed the facial nerve clinically and each paresis resolved within 6 months. CONCLUSIONS: Distraction of the mandible may be accomplished in the pediatric population. As with any intervention, inherent perioperative complications may still arise.