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Sakdejayont S, Chobpenthai T, Suksirivecharuk P, Ninatkiattikul IF, Poosiripinyo T. A Review on Bone Tumor Management: Cutting-Edge Strategies in Bone Grafting, Bone Graft Substitute, and Growth Factors for Defect Reconstruction. Orthop Res Rev 2025; 17:175-188. [PMID: 40357445 PMCID: PMC12067467 DOI: 10.2147/orr.s521832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2025] [Accepted: 04/21/2025] [Indexed: 05/15/2025] Open
Abstract
Bone tumors present complex challenges in orthopaedic oncology, requiring precise management strategies to restore skeletal integrity and function with minimal morbidity. Traditional autologous bone grafting has been the gold standard due to its osteogenic, osteoconductive, and osteoinductive properties. However, limitations such as donor site morbidity and graft availability have prompted the development of alternative approaches.This review evaluates contemporary approaches in bone tumor management, focusing on advancements in bone grafting techniques, bone graft substitutes (eg, ceramics, polymers, bioactive materials), and growth factor-based therapies. The efficacy and safety of these substitutes are compared with autografts, examining their potential benefits and drawbacks.Recent innovations in bone graft substitutes show promise in overcoming autograft limitations. Ceramic, polymer, and bioactive materials offer diverse properties that may enhance bone regeneration. Growth factor-based therapies, including bone morphogenetic proteins (BMPs) and vascular endothelial growth factor (VEGF), have revolutionized bone healing by stimulating osteogenesis and angiogenesis.
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Affiliation(s)
- Siwat Sakdejayont
- Princess Srisavangavadhana Faculty of Medicine, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Thanapon Chobpenthai
- Princess Srisavangavadhana Faculty of Medicine, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Ploy Suksirivecharuk
- Princess Srisavangavadhana Faculty of Medicine, Chulabhorn Royal Academy, Bangkok, Thailand
| | - I-Fan Ninatkiattikul
- Princess Srisavangavadhana Faculty of Medicine, Chulabhorn Royal Academy, Bangkok, Thailand
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Bankhead A, Rabinowitz Y, Khosa H, Le TT, Phero JA. Mandibular Reconstruction Utilizing the Reamer-Irrigator-Aspirator to Obtain Nonvascularized Femur Grafts. J Oral Maxillofac Surg 2025; 83:240-249. [PMID: 39561969 DOI: 10.1016/j.joms.2024.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 10/15/2024] [Accepted: 10/24/2024] [Indexed: 11/21/2024]
Abstract
Between July 2021 and February 2024, 6 patients with biopsy-confirmed benign pathologic lesions had mandibular defects reconstructed using a reamer-irrigator-aspirator at the University of Cincinnati Medical Center. Patients' ages ranged from 34 to 73, 5 of which were males and one female. Primary end points were bony continuity of the mandible, recovery time, and ability of the graft to receive implants. The reamer-irrigator-aspirator obtained 40 to 100 cm3 of uncompressed bone from donor sites. All patients ambulated on the day of surgery or postoperative day one. No neurosensory disturbances were reported at the donor site. Five patients achieved radiographic continuity of the mandible postoperatively. Of the patients with continuity, 4 received implants, and one received a removable prosthesis. The patient without mandibular continuity declined further intervention and received a removable prosthesis. The findings lend support to the possibility of harvesting medullary bone from the femur for mandibular defect reconstruction.
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Affiliation(s)
- Alec Bankhead
- Resident, Division of Oral & Maxillofacial Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Yotom Rabinowitz
- Assistant Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, Virginia Commonwealth University, Richmond, VA
| | - Hether Khosa
- Assistant Professor, Division of Oral & Maxillofacial Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - T Toan Le
- Professor of Surgery, Department of Orthopedic Surgery, University of Cincinnati, Cincinnati, OH
| | - James A Phero
- Resident, Division of Oral & Maxillofacial Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH; Assistant Professor of Surgery, Division of Oral & Maxillofacial Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH.
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Jain A, Rathsam AM, Springer KJ, Perumbala K, Parker A, Burns PR, Manway JM. Morbidity Associated With Distal Tibial Autograft Harvest. J Foot Ankle Surg 2024; 63:345-349. [PMID: 38246336 DOI: 10.1053/j.jfas.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/29/2023] [Accepted: 01/03/2024] [Indexed: 01/23/2024]
Abstract
Distal tibial autograft harvesting has been studied in the past, but morbidity at the level of the donor site is unclear. The purpose of this retrospective review is to assess morbidity in distal tibial autograft harvesting associated with foot and ankle arthrodesis procedures. A retrospective analysis was performed utilizing patients treated in the last 13 years at a large, multicenter, academic, tertiary referral, research institution. Included patients were between the ages of 18 and 80 years old. One-hundred and seven patients (39 male; 68 female) underwent ipsilateral distal tibial bone graft (n = 110) harvesting to augment the index procedure. Patients were followed for an average of 11.2 months after surgery (Range: 1-73 months). The incidence rate of distal tibial stress fractures was 4.5%, with an overall postoperative complication rate of 8.2%. Overall, low complication rates associated with distal tibial autograft harvesting were found, supporting the use of the distal tibia as an appropriate site for autograft harvesting in foot and ankle surgery.
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Affiliation(s)
- Akshay Jain
- University of Pittsburgh Medical Center, Mercy Hospital, Pittsburgh, PA.
| | - Aaron M Rathsam
- University of Pittsburgh Medical Center, Mercy Hospital, Pittsburgh, PA
| | - Katie J Springer
- University of Pittsburgh Medical Center, Mercy Hospital, Pittsburgh, PA
| | | | | | | | - Jeffrey M Manway
- University of Pittsburgh Medical Center, Mercy Hospital, Pittsburgh, PA
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Yamamoto Y, Fukui T, Sawauchi K, Yoshikawa R, Takase K, Kumabe Y, Maruo A, Niikura T, Kuroda R, Oe K. Effects of high antibiotic concentrations applied to continuous local antibiotic perfusion on human bone tissue-derived cells. Bone Joint Res 2024; 13:91-100. [PMID: 38425312 PMCID: PMC10904204 DOI: 10.1302/2046-3758.133.bjr-2023-0198.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
Aims Continuous local antibiotic perfusion (CLAP) has recently attracted attention as a new drug delivery system for orthopaedic infections. CLAP is a direct continuous infusion of high-concentration gentamicin (1,200 μg/ml) into the bone marrow. As it is a new system, its influence on the bone marrow is unknown. This study aimed to examine the effects of high-concentration antibiotics on human bone tissue-derived cells. Methods Cells were isolated from the bone tissue grafts collected from six patients using the Reamer-Irrigator-Aspirator system, and exposed to different gentamicin concentrations. Live cells rate, apoptosis rate, alkaline phosphatase (ALP) activity, expression of osteoblast-related genes, mineralization potential, and restoration of cell viability and ALP activity were examined by in vitro studies. Results The live cells rate (the ratio of total number of cells in the well plate to the absorbance-measured number of live cells) was significantly decreased at ≥ 500 μg/ml of gentamicin on day 14; apoptosis rate was significantly increased at ≥ 750 μg/ml, and ALP activity was significantly decreased at ≥ 750 μg/ml. Real-time reverse transcription-polymerase chain reaction results showed no significant decrease in the ALP and activating transcription factor 4 transcript levels at ≥ 1,000 μg/ml on day 7. Mineralization potential was significantly decreased at all concentrations. Restoration of cell viability was significantly decreased at 750 and 1,000 μg/ml on day 21 and at 500 μg/ml on day 28, and ALP activity was significantly decreased at 500 μg/ml on day 28. Conclusion Our findings suggest that the exposure concentration and duration of antibiotic administration during CLAP could affect cell functions. However, further in vivo studies are needed to determine the optimal dose in a clinical setting.
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Affiliation(s)
- Yuya Yamamoto
- Kobe University Graduate School of Medicine, Department of Orthopaedic Surgery, Kobe, Japan
| | - Tomoaki Fukui
- Kobe University Graduate School of Medicine, Department of Orthopaedic Surgery, Kobe, Japan
| | - Kenichi Sawauchi
- Kobe University Graduate School of Medicine, Department of Orthopaedic Surgery, Kobe, Japan
| | - Ryo Yoshikawa
- Kobe University Graduate School of Medicine, Department of Orthopaedic Surgery, Kobe, Japan
| | - Kyohei Takase
- Kobe University Graduate School of Medicine, Department of Orthopaedic Surgery, Kobe, Japan
| | - Yohei Kumabe
- Kobe University Graduate School of Medicine, Department of Orthopaedic Surgery, Kobe, Japan
| | - Akihiro Maruo
- Hyogo Prefectural Harima-Himeji General Medical Center, Department of Orthopaedic Surgery, Himeji, Japan
| | - Takahiro Niikura
- Kobe University Graduate School of Medicine, Department of Orthopaedic Surgery, Kobe, Japan
- Hyogo Prefectural Nishinomiya Hospital, Department of Orthopaedic Surgery, Nishinomiya, Japan
| | - Ryosuke Kuroda
- Kobe University Graduate School of Medicine, Department of Orthopaedic Surgery, Kobe, Japan
| | - Keisuke Oe
- Kobe University Graduate School of Medicine, Department of Orthopaedic Surgery, Kobe, Japan
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Laubach M, Weimer LP, Bläsius FM, Hildebrand F, Kobbe P, Hutmacher DW. Complications associated using the reamer-irrigator -aspirator (RIA) system: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2023; 143:3823-3843. [PMID: 36114869 PMCID: PMC10293355 DOI: 10.1007/s00402-022-04621-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 09/07/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Complications associated with the application of the Reamer-irrigator-Aspirator (RIA) system are described in the literature. However, to date a systematic review and meta-analysis to assess prevalence of complications associated with the use of the RIA system have not been conducted. MATERIALS AND METHODS The review is registered with PROSPERO (CRD42021269982). MEDLINE, the Web of Science Core Collection, and Embase were searched from the inception to 10 August 2021. The primary objective was to assess complications and blood loss associated with the use of the RIA system. RESULTS Forty-seven studies involving 1834 procedures performed with the RIA system were finally included. A total of 105 complications were reported, with a pooled estimated overall prevalence of 1.7% with a 95% confidence interval (CI) of 0.40 to 3.60, with cortex perforation being the largest reported complication with a total of 34 incidences. A significant subgroup difference was observed (p = 0.02). In subgroup 1 (bone graft harvesting), complication prevalence was 1.4% (95% CI 0.2-3.4); in subgroup 2 (clearance intramedullary canal) it was 0.7% (95% CI 0.00-6.30) and in subgroup 3 (reaming with RIA system prior to nail fixation) 11.9% (95% CI 1.80-26.40). No statistically significant difference for tibia and femur as RIA system application site was observed (CI 0.69-4.19). In studies reporting blood loss, a mean volume of 803.29 ml, a mean drop of hemoglobin of 3.74 g/dl and a necessity of blood transfusion in 9.72% of the patients were observed. CONCLUSIONS The systematic review and meta-analysis demonstrate a low overall prevalence rate of complications associated with the RIA system. However, especially the risk of cortical perforation and the frequently reported relevant intraoperative blood loss are complications that should be anticipated in perioperative management and ultimately considered when using the RIA system.
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Affiliation(s)
- Markus Laubach
- Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD 4000 Australia
- Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Lucas P. Weimer
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands
| | - Felix M. Bläsius
- Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Philipp Kobbe
- Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Dietmar W. Hutmacher
- Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD 4000 Australia
- Australian Research Council (ARC) Training Centre for Cell and Tissue Engineering Technologies, Queensland University of Technology (QUT), Brisbane, QLD 4000 Australia
- Max Planck Queensland Center for the Materials Science of Extracellular Matrices, Queensland University of Technology, Brisbane, QLD 4000 Australia
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Ahmed H, Shakshak M, Trompeter A. A review of the Masquelet technique in the treatment of lower limb critical-size bone defects. Ann R Coll Surg Engl 2023. [PMID: 37367227 DOI: 10.1308/rcsann.2023.0022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
The need for bone tissue to heal effectively is paramount given its role in the mechanical support of tissues. Bone has a very good natural healing potential in comparison with most other tissue types, largely regenerating to its pre-injury state in the vast majority of cases. Certain factors such as high energy trauma, tumour resection, revision surgery, developmental deformities and infection can lead to the formation of bone defects, where the intrinsic healing potential of bone is diminished owing to bone loss. Various approaches to resolving bone defects exist in current practice, each with their respective benefits and drawbacks. These include bone grafting, free tissue transfer, Ilizarov bone transport and the Masquelet induced membrane technique. This review focuses on evaluating the Masquelet technique, discussing its method and underlying mechanisms, the effectiveness of certain modifications, and its potential future directions.
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Affiliation(s)
- H Ahmed
- St George's, University of London, UK
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Marchand LS, Kellam PJ, Dekeyser GJ, Haller JM, Rothberg DL, Higgins TF. Transfusion after harvesting bone graft with RIA: Practice changes reduced transfusion rate by more than half. Injury 2023:S0020-1383(23)00437-0. [PMID: 37169695 DOI: 10.1016/j.injury.2023.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/10/2023] [Accepted: 05/06/2023] [Indexed: 05/13/2023]
Abstract
INTRODUCTION The Reamer Irrigator Aspirator (RIA) is frequently used as a tool for bone graft harvesting procedures. The initial use of this instrument for bone grafting was met with significant blood loss and high transfusion rates. However, the RIA remains an excellent tool to obtain large volumes of viable autologous graft. The aim of this study was to investigate how changes in the technical use of the RIA may affect blood loss. MATERIALS AND METHODS We conducted a retrospective chart review of all patients who underwent RIA bone graft harvest over a 12-year study period. The patients were divided into two cohorts based upon changes in the technique used to obtain autograft harvest with the RIA. The traditional cohort (2008-2012) connected the RIA to dilation and curettage suction and selected reamer size based on radiographic parameters. The modified cohort (2012-2020) connected the RIA to wall suction, used improved techniques for reamer head sizing, and more diligence was paid toward the time the RIA was suctioning in the canal. Demographic information, surgical details, pre- and post-operative hematocrit (HCT), transfusion rate, intra-operative blood loss, reported volume of graft harvested, and iatrogenic fracture were recorded. RESULTS 201 patients were included in the study with 61 patients in the traditional and 140 patients in the modified cohorts respectively. The average age was 51 years (range: 18-97) with 107 (53%) males. There was no difference in the demographic data between the two cohorts. No difference was noted between the traditional and modified cohorts in terms of the amount of average graft harvested (54cc vs 51cc; p = 0.34) or major complications (1 vs 2; p = 0.91). However, when comparing the traditional versus modified cohorts the traditional group demonstrated a larger average blood loss (675cc vs 500cc; p=<0.01) and HCT drop (13.7 vs 9.5; p=<0.01) with a higher transfusion rate (44% vs 19%; p = 0.001). CONCLUSION This series demonstrated a significant improvement in blood loss and transfusion with modified techniques used to obtain autologous bone graft with the RIA. Importantly, these techniques do not appear to limit bone graft harvest yield and can therefore be efficiently implemented without limiting the utility of the RIA.
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Affiliation(s)
- Lucas S Marchand
- University of Utah, Department of Orthopaedic Surgery, Salt Lake City, UT, USA.
| | - Patrick J Kellam
- University of Utah, Department of Orthopaedic Surgery, Salt Lake City, UT, USA
| | - Graham J Dekeyser
- University of Utah, Department of Orthopaedic Surgery, Salt Lake City, UT, USA
| | - Justin M Haller
- University of Utah, Department of Orthopaedic Surgery, Salt Lake City, UT, USA
| | - David L Rothberg
- University of Utah, Department of Orthopaedic Surgery, Salt Lake City, UT, USA
| | - Thomas F Higgins
- University of Utah, Department of Orthopaedic Surgery, Salt Lake City, UT, USA
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Yao X, Liu H, Hu M, Wang C, Liu D, Hu J, Tang J. The application of a hollow trephine in femoral retrograde intramedullary nailing technique. BMC Musculoskelet Disord 2023; 24:245. [PMID: 36997942 PMCID: PMC10061970 DOI: 10.1186/s12891-023-06351-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 03/20/2023] [Indexed: 04/01/2023] Open
Abstract
PURPOSE The purpose of this study was to describe and evaluate the use of a specially designed hollow trephine to create the entry point through the femoral condyle during retrograde interlocking intramedullary nailing for femoral fractures. METHODS From June 2019 to December 2021, we treated 11 patients (5 men, 6 women; mean age, 64 years; age range 40-77 years) with mid-distal femoral fractures by retrograde intramedullary femoral nailing using a self-designed hollow trephine for femoral condyle reaming and cancellous bone harvesting. The mode of all the nails is static. Patients were followed up at 1, 4, 8, and 12 weeks and for at least 6 months after surgery. The healing process and heterotopic ossification were evaluated by imaging. Partial weight bearing was permitted during the recovery period and complete weight bearing was permitted after clinical healing of the fracture displayed by X-ray. RESULTS The operation was successful in all patients. Over mean follow-up of 9.3 months (range, 6.0-12.0 months), all patients achieved clinical healing within three months. There were no complications such as knee joint infection, heterotopic ossification, knee joint adhesion and wedge effect. CONCLUSION The use of the hollow trephine during femoral retrograde intramedullary nailing helps avoid postoperative complications such as heterotopic ossification, knee joint adhesions, and wedge effect. It also facilitates bone graft harvesting.
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Affiliation(s)
- Xiang Yao
- Department of Orthopaedics, The Affiliated People's Hospital of Jiangsu University, Zhenjiang, 212000, Jiangsu, China
| | - Hongyuan Liu
- Department of Orthopaedics, The Affiliated People's Hospital of Jiangsu University, Zhenjiang, 212000, Jiangsu, China
- Jiangsu University, Zhenjiang, 212000, Jiangsu, China
| | - Minjie Hu
- Department of Orthopaedics, The Affiliated People's Hospital of Jiangsu University, Zhenjiang, 212000, Jiangsu, China
- Jiangsu University, Zhenjiang, 212000, Jiangsu, China
| | - Chong Wang
- Department of Orthopaedics, The Affiliated People's Hospital of Jiangsu University, Zhenjiang, 212000, Jiangsu, China
- Jiangsu University, Zhenjiang, 212000, Jiangsu, China
| | - Dejun Liu
- Department of Orthopaedics, Tengzhou Cengde Department of Orthopedics Hospital, Zaozhuang, 277000, Shandong, China.
| | - Jianping Hu
- Department of Orthopaedics, Tengzhou Cengde Department of Orthopedics Hospital, Zaozhuang, 277000, Shandong, China.
| | - Jilei Tang
- Department of Orthopaedics, Qidong Hospital of Traditional Chinese Medicine, Nantong, 226200, Jiangsu, China.
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Improved Bone Regeneration Using Biodegradable Polybutylene Succinate Artificial Scaffold in a Rabbit Model. J Funct Biomater 2022; 14:jfb14010022. [PMID: 36662069 PMCID: PMC9865108 DOI: 10.3390/jfb14010022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/15/2022] [Accepted: 12/24/2022] [Indexed: 01/03/2023] Open
Abstract
The treatment of extensive bone loss represents a great challenge for orthopaedic and reconstructive surgery. Most of the time, those treatments consist of multiple-stage surgeries over a prolonged period, pose significant infectious risks and carry the possibility of rejection. In this study, we investigated if the use of a polybutylene succinate (PBS) micro-fibrillar scaffold may improve bone regeneration in these procedures. In an in vivo rabbit model, the healing of two calvarial bone defects was studied. One defect was left to heal spontaneously while the other was treated with a PBS scaffold. Computed tomography (CT) scans, histological and immunohistochemical analyses were performed at 4, 12 and 24 weeks. CT examination showed a significantly larger area of mineralised tissue in the treated defect. Histological examination confirmed a greater presence of active osteoblasts and mineralised tissue in the scaffold-treated defect, with no evidence of inflammatory infiltrates around it. Immunohistochemical analysis was positive for CD56 at the transition point between healthy bone and the fracture zone. This study demonstrates that the use of a PBS microfibrillar scaffold in critical bone defects on a rabbit model is a potentially effective technique to improve bone regeneration.
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Landrino M, Alberio RL, Clemente A, Grassi FA. The Reamer-Irrigator-Aspirator (RIA) System for the treatment of aseptic femoral nonunions: Report of two cases and literature review. Orthop Rev (Pavia) 2022; 14:37889. [PMID: 36213618 PMCID: PMC9534743 DOI: 10.52965/001c.37889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Femoral shaft nonunions are disabling complications of fractures, with relevant socioeconomic and psychological impact. The incidence of femoral shaft nonunions is not negligible, ranging between 1% and 10% after intramedullary nailing, but can exceed 20% in case of subtrochanteric fractures. Treatment options are influenced by pathomechanical, anatomical, and clinical factors. Hypertrophic nonunions are usually treated by enhancing stability of fixation, while atrophic nonunions require additional biological stimulation to achieve bone union. The Reamer-Irrigator-Aspirator (RIA) System® was developed to reduce intramedullary pressure and heat generation during intramedullary reaming, thus preventing thermal necrosis and decreasing the risk of fat embolism. The RIA System allows to provide large volumes of high-quality morselized autologous bone, that has shown high osteogenetic and osteoinductive properties. Therefore, its use has been expanded as a valuable source of autologous bone graft for the treatment of large bone defects of different nature. In this article, we present two cases of complex femoral nonunions treated with the use of the RIA System. A review of the published literature on the treatment of femoral nonunions with RIA was also performed. Core tip: In case of atrophic nonunions, the RIA System can be used to obtain biologically active tissue to enhance bone healing. Despite the absence of high-quality studies focused on femoral nonunions, the efficacy of RIA is well-known and orthopaedic surgeons should be aware of this powerful tool.
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Affiliation(s)
- Marco Landrino
- Department of Health Sciences, University of East Piedmont, Novara (Italy)
| | | | - Alice Clemente
- Department of Health Sciences, University of East Piedmont, Novara (Italy)
| | - Federico Alberto Grassi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia (Italy); IRCCS Hospital San Matteo, Pavia (Italy)
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Meesters DM, Wijnands KAP, van Eijk HMH, Hofman M, Hildebrand F, Verbruggen JPAM, Brink PRG, Poeze M. Arginine Availability in Reamed Intramedullary Aspirate as Predictor of Outcome in Nonunion Healing. Biomedicines 2022; 10:biomedicines10102474. [PMID: 36289736 PMCID: PMC9598747 DOI: 10.3390/biomedicines10102474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/18/2022] [Accepted: 10/01/2022] [Indexed: 11/16/2022] Open
Abstract
Fracture healing and nonunion development are influenced by a range of biological factors. Adequate amino acid concentrations, especially arginine, are known to be important during normal bone healing. We hypothesize that bone arginine availability in autologous bone marrow grafting, when using the reamer-irrigator-aspirator (RIA) procedure, is a marker of bone healing capacity in patients treated for nonunion. Seventeen patients treated for atrophic long bone nonunion by autologous bone grafting by the RIA procedure were included and divided into two groups, successful treatment of nonunion and unsuccessful, and were compared with control patients after normal fracture healing. Reamed bone marrow aspirate from a site distant to the nonunion was obtained and the amino acids and enzymes relevant to arginine metabolism were measured. Arginine and ornithine concentrations were higher in patients with successful bone healing after RIA in comparison with unsuccessful healing. Ornithine concentrations and arginase-1 expression were lower in all nonunion patients compared to control patients, while citrulline concentrations were increased. Nitric oxide synthase 2 (Nos2) expression was significantly increased in all RIA-treated patients, and higher in patients with a successful outcome when compared with an unsuccessful outcome. The results indicate an influence of the arginine-nitric oxide metabolism in collected bone marrow, on the outcome of nonunion treatment, with indications for a prolonged inflammatory response in patients with unsuccessful bone grafting therapy. The determination of arginine concentrations and Nos2 expression could be used as a predictor for the successful treatment of autologous bone grafting in nonunion treatment.
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Affiliation(s)
- Dennis M. Meesters
- Department of Surgery, Division of Trauma Surgery, Maastricht University Medical Center +, 6200 MD Maastricht, The Netherlands
- NUTRIM School for Nutrition and Translational Research in Metabolism, 6200 MD Maastricht, The Netherlands
- Correspondence: ; Tel.: +31-433-881-891
| | - Karolina A. P. Wijnands
- Department of Surgery, Division of Trauma Surgery, Maastricht University Medical Center +, 6200 MD Maastricht, The Netherlands
- NUTRIM School for Nutrition and Translational Research in Metabolism, 6200 MD Maastricht, The Netherlands
| | - Hans M. H. van Eijk
- Department of Surgery, Division of Trauma Surgery, Maastricht University Medical Center +, 6200 MD Maastricht, The Netherlands
- NUTRIM School for Nutrition and Translational Research in Metabolism, 6200 MD Maastricht, The Netherlands
| | - Martijn Hofman
- Department of Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Frank Hildebrand
- Department of Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Jan P. A. M. Verbruggen
- Department of Surgery, Division of Trauma Surgery, Maastricht University Medical Center +, 6200 MD Maastricht, The Netherlands
| | - Peter R. G. Brink
- Department of Surgery, Division of Trauma Surgery, Maastricht University Medical Center +, 6200 MD Maastricht, The Netherlands
| | - Martijn Poeze
- Department of Surgery, Division of Trauma Surgery, Maastricht University Medical Center +, 6200 MD Maastricht, The Netherlands
- NUTRIM School for Nutrition and Translational Research in Metabolism, 6200 MD Maastricht, The Netherlands
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Elhessy AH, Eltayeby HH, Kane SC, Garonzik IM, Conway JE, Conway JD. Fusion Revision Surgery With Reamer-Irrigator-Aspirator to Harvest Autograft After Spinal Pseudarthrosis. Cureus 2022; 14:e27503. [PMID: 35949743 PMCID: PMC9356659 DOI: 10.7759/cureus.27503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2022] [Indexed: 11/24/2022] Open
Abstract
Background and purpose Spinal pseudarthrosis (SPA) is a common complication after attempted cervical or lumbosacral spinal fusion surgery. Revision surgeries usually necessitate bone graft implementation as an adjunct to hardware revision. Iliac crest bone graft is the gold standard but availability can be limited and usage often leads to persistent postoperative pain at the donor site. There is scant literature regarding the use of reamer-irrigator-aspirator (RIA)-harvested bone graft in lumbar spinal fusion. This is a collaborative study between orthopedic surgery and neurosurgery departments to utilize femur intramedullary autograft harvested using the RIA system as an adjunct graft in SPA revision surgeries. Materials and methods A retrospective review was conducted at a single center between August 2014 and December 2017 of patients aged ≥ 18 years and diagnosed with cervical, thoracic, or lumbar SPA who underwent revision fusion surgery using femur intramedullary autograft harvested using the RIA system. Plain radiographs and CT scans were utilized to confirm successful fusion. Results Eleven patients underwent 12 SPA revision surgeries using the RIA system as a source for bone graft in addition to bone morphogenetic protein 2 (BMP-2) and allograft. The mean amount of graft harvested was 51.3 mL (range: 20-70 mL). Nine patients achieved successful fusion (81.8%). The average time to fusion was 9.1 months. Four patients (36.4%) had postoperative knee pain. Regarding patient position and approach for harvesting, 66.7% (n = 8) of cases were positioned prone and a retrograde approach was utilized in 91.7% (n = 11) of cases. Interpretation This is the first case series in known literature to report the RIA system as a reliably considerable source of autologous bone graft for SPA revision surgeries. It provides a useful adjunct to the known types of bone grafts. Patient positioning and the approach choice for graft harvesting can be adjusted according to the fusion approach and the surgeon’s preference.
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VICENTI G, OTTAVIANI G, BIZZOCA D, CARROZZO M, SIMONE F, GROSSO A, ZAVATTINI G, ELIA R, MARUCCIA M, SOLARINO G, MORETTI B. The management of post-traumatic bone defects: a systematic review. MINERVA ORTHOPEDICS 2022; 73. [DOI: 10.23736/s2784-8469.21.04116-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Sawauchi K, Fukui T, Oe K, Kumabe Y, Oda T, Yoshikawa R, Takase K, Matsushita T, Matsumoto T, Hayashi S, Kuroda R, Niikura T. Low-Intensity Pulsed Ultrasound Promotes Osteogenic Differentiation of Reamer-Irrigator-Aspirator Graft-Derived Cells in Vitro. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:313-322. [PMID: 34785092 DOI: 10.1016/j.ultrasmedbio.2021.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 09/29/2021] [Accepted: 10/04/2021] [Indexed: 06/13/2023]
Abstract
Recently, reamer-irrigator-aspirator (RIA) systems have been increasingly used to harvest autologous bone grafts. RIA graft materials contain bone marrow, which provides a viable source to derive large numbers of mesenchymal stem cells. Low-intensity pulsed ultrasound (LIPUS) significantly accelerates the differentiation of stem cells derived from bone marrow. This in vitro study investigated the effect of LIPUS on the osteogenic activity and differentiation of RIA graft-derived cells. A small amount of RIA graft was obtained from seven patients. After the cells derived from RIA grafts were cultured, they were divided into two groups: the LIPUS and control groups. LIPUS was applied once daily for 20 min (1.5 MHz, pulse duration: 200 µs, pulse repetition rate: 1 kHz, spatial average-temporal average intensity: 30 mW/cm2). Alkaline phosphatase activity (113.4% and 130.1% on days 7 and 14), expression of osteoblast-related genes (ALP, Runx2) and mineralization (135.2% on day 21) of the RIA graft-derived cells were significantly higher in the LIPUS group than in the control group. However, LIPUS did not affect the cell proliferation of RIA graft-derived cells. This study indicates that LIPUS may enhance the healing of non-union and critical bone defects treated by autologous bone grafting using the RIA system.
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Affiliation(s)
- Kenichi Sawauchi
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, 650-0017, Japan
| | - Tomoaki Fukui
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, 650-0017, Japan
| | - Keisuke Oe
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, 650-0017, Japan
| | - Yohei Kumabe
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, 650-0017, Japan
| | - Takahiro Oda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, 650-0017, Japan
| | - Ryo Yoshikawa
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, 650-0017, Japan
| | - Kyohei Takase
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, 650-0017, Japan
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, 650-0017, Japan
| | - Tomoyuki Matsumoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, 650-0017, Japan
| | - Shinya Hayashi
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, 650-0017, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, 650-0017, Japan
| | - Takahiro Niikura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, 650-0017, Japan.
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van de Wall BJM, Beeres FJP, Rompen IF, Link BC, Babst R, Schoeneberg C, Michelitsch C, Nebelung S, Pape HC, Gueorguiev B, Knobe M. RIA versus iliac crest bone graft harvesting: A meta-analysis and systematic review. Injury 2022; 53:286-293. [PMID: 34756411 DOI: 10.1016/j.injury.2021.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 09/30/2021] [Accepted: 10/01/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Reamer-Irrigator-Aspirator (RIA) of long bones is increasingly being used as an alternative to iliac crest harvesting for bone-grafts. This meta-analysis compares both harvesting techniques with regard to donor site morbidity, healing potency and implantation site morbidity. METHODS PubMed/Medline/Embase/CENTRAL/CINAHL were searched for both randomized clinical trials (RCT) and observational studies. Effect estimates were pooled across studies using random effects models and presented as weighted odds ratio (OR) with corresponding 95% confidence interval (95%CI). RESULTS A total of 5 studies were included. RIA carries a lower risk for chronic pain (0% versus 14.2%, OR 0.08, 95% CI 0.02 - 0.35) and infection (1% versus 5.9%, OR 0.29, 95% CI 0.09- 0.9) at the donor site compared to iliac crest harvesting. Iliac crest bone-harvesting has an inherent additional risk of neuropraxia of the lateral femoral cutaneous nerve and numbness of the scar which is not encountered in RIA harvesting. Risk for other reported complications such as hematoma and iatrogenic fractures appear equal in both groups. The clinical healing potential of both bone grafts, in terms of union rate (OR 1.53, 95%CI 0.62 - 3.75) at the implantation site and time-to-union (MD 0.44 months, 95%CI -1.72 - 0.83), seems equal. CONCLUSION The main difference between RIA and iliac crest bone graft harvesting is the considerable higher risk of chronic pain of the pelvic procedure. Although risk for infection was also higher for the iliac crest group, the absolute difference is relatively small. Evidence suggests an equal healing potential of the grafts themselves irrespective of harvesting method.
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Affiliation(s)
- Bryan J M van de Wall
- Lucerne Cantonal Hospital, Department of Orthopedic and Trauma Surgery, Spitalstrasse 16, 6000 Luzern, Switzerland; University of Lucerne, Department of Health Sciences and Medicine, Frohburgstrasse 3, 6002 Luzern, Switzerland.
| | - Frank J P Beeres
- Lucerne Cantonal Hospital, Department of Orthopedic and Trauma Surgery, Spitalstrasse 16, 6000 Luzern, Switzerland
| | - Ingmar F Rompen
- Lucerne Cantonal Hospital, Department of Orthopedic and Trauma Surgery, Spitalstrasse 16, 6000 Luzern, Switzerland
| | - Björn C Link
- Lucerne Cantonal Hospital, Department of Orthopedic and Trauma Surgery, Spitalstrasse 16, 6000 Luzern, Switzerland
| | - Reto Babst
- University of Lucerne, Department of Health Sciences and Medicine, Frohburgstrasse 3, 6002 Luzern, Switzerland
| | - Carsten Schoeneberg
- Alfried Krupp Hospital, Department of Orthopedic and Trauma Surgery, Alfried-Krupp-Strasse 21, 45131 Essen, Germany
| | - Christian Michelitsch
- Kantonsspital Graubünden, Department of Trauma Surgery, Loëstrasse 170, 7000 Chur, Switzerland
| | - Sven Nebelung
- RWTH Aachen University Hospital, Department of Radiology, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Rämistrasse 100, 8006 Zürich, Switzerland
| | - Boyko Gueorguiev
- AO Research Institute Davos Clavadelerstrasse 8, 7270 Davos, Switzerland
| | - Matthias Knobe
- Lucerne Cantonal Hospital, Department of Orthopedic and Trauma Surgery, Spitalstrasse 16, 6000 Luzern, Switzerland
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Bidolegui F, Pereira S, Irigoyen C, Pires RE. Safety and efficacy of a novel retrograde route for femoral bone graft harvesting by Reamer-Irrigator-Aspirator: a pilot study on 24 patients. Patient Saf Surg 2022; 16:2. [PMID: 34996503 PMCID: PMC8742408 DOI: 10.1186/s13037-021-00315-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 12/14/2021] [Indexed: 11/18/2022] Open
Abstract
Background The Reamer–Irrigator–Aspirator system was initially developed to reduce fat embolism and thermic necrosis during reamed intramedullary nail fixation of femoral shaft fractures. Currently, this system is used in extended applications including accessing large volume of autologous bone graft, as alternative for iliac crest harvesting. Antegrade femoral bone graft harvesting using the Reamer-Irrigator-Aspirator system is considered the standard technique. The aim of our study is to evaluate the efficacy (bone graft volume) and the complications (blood loss, postoperative pain, and incidence of iatrogenic fractures) of the Reamer–Irrigator–Aspirator system through the retrograde femoral route in a series of patients with post-traumatic bone defects or nonunions. Methods A non-controlled single center retrospective observational cohort study was conducted in a level1 trauma center to evaluate all patients who were treated using the RIA system. Between November 2015 and May 2019, 24 patients (8 women and 16 men; mean age: 41 years [range 27–55 years]) with bone defects or nonunions underwent bone graft harvesting using the Reamer–Irrigator–Aspirator system through retrograde femoral route. Postoperative pain, complications, and bone graft volume were analyzed. Inclusion criteria was patients older than 18 years with a diagnosis of post-traumatic bone defect or associated tibial or femoral nonunion, with minimum 6-months follow, treated using the RIA. We hypothesized that the retrograde route of the RIA system is a safe and efficacious method for bone harvesting. Results The average volume of collected graft was 45 cc (range 30–60 cc). In 83% of the cases, bone grafting was sufficient, while in 17% it was necessary to add iliac crest bone graft to completely fill the bone defect. A mean drop in postoperative hemoglobin of 4.1 g / dL (range 0.5–6.0 g / dL) was evidenced. In 4 cases (33%), a unit of packed red blood cells was required. Regarding postoperative pain, visual analogue scale after 3 months postoperatively was 1.6 in average. After 6 months, the value has decreased to 0.4. There were no perioperative or postoperative complications at 6-month follow-up. Conclusion In this limited case series, large volumes of bone graft were harvested using the retrograde route of the RIA system and there were no intra-/ postoperative complications observed at 6-month follow-up. Therefore this novel technique appears safe and efficacious. However, it’s important to highlight that future prospective controlled studies are necessary to validate the insights from this pilot study.
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Affiliation(s)
- Fernando Bidolegui
- Servicio de Ortopedia Y Traumatología, Hospital Sirio-Libanes, ECICARO, Ciudad Autónoma de Buenos Aires, Argentina
| | - Sebastián Pereira
- Servicio de Ortopedia Y Traumatología, Hospital Sirio-Libanes, ECICARO, Ciudad Autónoma de Buenos Aires, Argentina
| | - Cristina Irigoyen
- Servicio de Ortopedia Y Traumatología, Hospital Sirio-Libanes, ECICARO, Ciudad Autónoma de Buenos Aires, Argentina
| | - Robinson Esteves Pires
- Departamento Do Aparelho Locomotor, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil. .,Serviço de Ortopedia E Traumatologia, Instituto Orizonti, Belo Horizonte, MG, Brazil.
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Oliva F, Migliorini F, Cuozzo F, Torsiello E, Hildebrand F, Maffulli N. Outcomes and complications of the reamer irrigator aspirator versus traditional iliac crest bone graft harvesting: a systematic review and meta-analysis. J Orthop Traumatol 2021; 22:50. [PMID: 34851462 PMCID: PMC8636545 DOI: 10.1186/s10195-021-00612-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 11/17/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The reamer irrigator aspirator (RIA) is a relatively recent device that is placed in the medullary canal of long bones to harvest a large volume of bone marrow, which is collected in a filtered canister. This study compares outcomes and complications of the RIA versus a traditional iliac crest bone graft (ICBG) for the treatment of bone defects. METHODS This meta-analysis was conducted according to the PRISMA guidelines. The Embase, Google Scholar, PubMed, and Scopus databases were accessed in June 2021. All clinical trials comparing the RIA and ICBG with a minimum of 6 months follow-up were included. RESULTS Data from 4819 patients were collected. The RIA group demonstrated lower site pain (P < 0.0001), fewer infections (P = 0.001), and a lower rate of adverse events (P < 0.0001). The ICBG group demonstrated a greater rate of bone union (P < 0.0001). There was no difference between groups in VAS (P = 0.09) and mean time to union (P = 0.06). CONCLUSION The current evidence supports the use of the RIA, given its low morbidity and short learning curve.
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Affiliation(s)
- Francesco Oliva
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy.,Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi d'Aragona, 84131, Salerno, Italy
| | - Filippo Migliorini
- Department of Orthopaedic and Trauma Surgery, RWTH University Hospital Aachen, Pauwelsstraße 31, 52074, Aachen, Germany.
| | - Francesco Cuozzo
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy
| | - Ernesto Torsiello
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy
| | - Frank Hildebrand
- Department of Orthopaedic and Trauma Surgery, RWTH University Hospital Aachen, Pauwelsstraße 31, 52074, Aachen, Germany
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy.,Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England.,School of Pharmacy and Biotechnology, Keele University School of Medicine, Thornburrow Drive, Stoke-on-Trent, England
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Migliorini F, Cuozzo F, Torsiello E, Spiezia F, Oliva F, Maffulli N. Autologous Bone Grafting in Trauma and Orthopaedic Surgery: An Evidence-Based Narrative Review. J Clin Med 2021; 10:jcm10194347. [PMID: 34640364 PMCID: PMC8509778 DOI: 10.3390/jcm10194347] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/19/2021] [Accepted: 09/23/2021] [Indexed: 12/11/2022] Open
Abstract
Autologous bone grafting is common in trauma and orthopaedic surgery. Both the Reamer Irrigator Aspirator (RIA) and Iliac Crest Bone Graft (ICBG) aim to obtain autologous bone graft. Although the process of harvesting a bone graft is considered simple, complications may occur. This study examined morbidity and pain at the donor site, blood loss, and iatrogenic fractures, comparing RIA and ICBG. The source of the autologous bone graft, the alternative graft sites, and the storage modalities of the harvested bone marrow were also evaluated. In May 2021, PubMed, Embase, Scopus, and Google Scholar were accessed, with no time constraints. RIA may produce greater blood loss, but with less morbidity and complications, making it a potential alternative source of bone grafting.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, 52074 Aachen, Germany
- Correspondence: ; Tel.: +49-0241-80-35529
| | - Francesco Cuozzo
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Salerno, Italy; (F.C.); (E.T.); (F.O.); (N.M.)
| | - Ernesto Torsiello
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Salerno, Italy; (F.C.); (E.T.); (F.O.); (N.M.)
| | - Filippo Spiezia
- Ospedale San Carlo Potenza, Via Potito Petrone, 85100 Potenza, Italy;
| | - Francesco Oliva
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Salerno, Italy; (F.C.); (E.T.); (F.O.); (N.M.)
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Salerno, Italy; (F.C.); (E.T.); (F.O.); (N.M.)
- School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Thornburrow Drive, Stoke on Trent ST4 7QB, UK
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, London E1 4DG, UK
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Abstract
The reamer-irrigator-aspirator (RIA) technique allows to collect large bone graft amounts without the drawbacks of iliac crest harvesting. Nevertheless, clinical cases with occurrence of femur fractures have been reported. Therefore, this study aimed to systematically investigate the three-dimensional geometry of the reamed bone as a function of the reaming diameter and its influence on the associated potential fracture pattern. Forty-five intact fresh-frozen human cadaveric femora underwent computed tomography (CT). They were randomized to three groups (n = 15) for reaming at a diameter of either 1.5 mm (Group 1), 2.5 mm (Group 2) or 4.0 mm (Group 3) larger than their isthmus using RIA. Reaming was followed by a second CT scan, biomechanical testing until failure and a third CT scan. All CT scans of each femur were aligned via rigid registration, and fracture lines were visualized. Subsequently, a decrease in wall thickness, cross-sectional area, and harvested bone volume have been evaluated. The total volume of the bone graft was significantly higher for Group 3 (7.8 ± 2.9 ml) compared to Group 1 (2.9 ± 1.1 ml) and Group 2 (3.0 ± 1.1 ml). The maximal relative decrease of the wall thickness was located medially (72.7%) in the third (61.4%), fourth (18.2%) and second (9.1%) eighth for all groups. As the diameter of the reaming increased, an overlap of the fracture line with the maximal relative decrease in wall thickness and a maximal average relative decrease of the cross-sectional area became more frequent. This suggests that a reaming-associated fracture is most likely to occur in this region.
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Yin TJ, Jeyapalina S, Naleway SE. Characterization of porous fluorohydroxyapatite bone-scaffolds fabricated using freeze casting. J Mech Behav Biomed Mater 2021; 123:104717. [PMID: 34352488 DOI: 10.1016/j.jmbbm.2021.104717] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/09/2021] [Accepted: 07/13/2021] [Indexed: 12/01/2022]
Abstract
With the increasing demand for orthopedic and dental reconstruction surgeries, there comes a shortage of viable bone substitutes. This study was therefore designed to assess the efficacy of porous fluorohydroxyapatite (FHA) as a potential bone substitute. For this, porous FHA scaffolds were fabricated using the freeze casting technique. They were then sintered at 1250, 1350 and, 1450 °C, and microstructural, mechanical, and in vitro properties were analyzed. The microstructure analyses revealed the porosity remained constant within the temperature range. However, the pore size decreased with increasing sintering temperature. The greatest compressive strength and elastic modulus were obtained at 1450 °C, which were 13.5 ± 4.0 MPa and 379 ± 182 MPa, respectively. These are comparable values to human trabecular bone and other porous scaffolds made using hydroxyapatite. This analysis has thus helped to attain an understanding of the mechanical and material properties of freeze-cast FHA scaffolds that have not been presented before. In vitro studies revealed an increasing rate of human osteoblast cell proliferation on freeze-cast FHA scaffolds with increasing sintering temperature, suggesting improved osteogenic properties. Additionally, osteoblasts cells were also shown to proliferate into the interior pores of all freeze-cast FHA scaffolds. These results indicate the potential of porous FHA scaffolds fabricated using the freeze-casting technique to be utilized clinically as bone substitutes.
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Affiliation(s)
- Tony J Yin
- Department of Mechanical Engineering, University of Utah, USA
| | - Sujee Jeyapalina
- Division of Plastic Surgery, Department of Surgery, University of Utah Health, USA; Research, Department of Veterans Affairs Salt Lake City Health Care System, USA
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Johnson J, Gupton M, Schneider J, Deivaraju C. Symptomatic Nonunion After a Tibial-Sided Posterior Cruciate Ligament Avulsion Fracture Treated with Open Repair: A Case Report. JBJS Case Connect 2021; 11:01709767-202109000-00044. [PMID: 34319933 DOI: 10.2106/jbjs.cc.20.00618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 30-year-old man was in a motorcycle accident resulting in an avulsion fracture of the tibial insertion of the posterior cruciate ligament (PCL). After 19 months of nonoperative treatment, the patient presented with a nonunion and symptoms of pain and instability. He was treated with an open repair with screw fixation through a posterior approach. Six months postoperatively, the patient returned to his work as a heavy laborer with full range of motion and no instability. CONCLUSION PCL avulsion fracture nonunion results in symptoms of swelling, pain, and instability. These symptoms can be treated with screw fixation through a posterior approach.
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Affiliation(s)
- Jordan Johnson
- Department of Orthopaedic Surgery, MountainView Regional Medical Center, Las Cruces, New Mexico
| | - Marco Gupton
- Department of Orthopaedic Surgery, MountainView Regional Medical Center, Las Cruces, New Mexico
| | - Jonathan Schneider
- Department of Orthopaedic Surgery, Larkin Community Hospital, South Miami, Florida
| | - Chenthuran Deivaraju
- Department of Orthopaedic Surgery, MountainView Regional Medical Center, Las Cruces, New Mexico
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Autologous bone graft: Is it still the gold standard? Injury 2021; 52 Suppl 2:S18-S22. [PMID: 33563416 DOI: 10.1016/j.injury.2021.01.043] [Citation(s) in RCA: 247] [Impact Index Per Article: 61.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/26/2021] [Accepted: 01/29/2021] [Indexed: 02/02/2023]
Abstract
Bone grafting has over 100 years of successful clinical use. Despite the successes of autograft bone transplantation, complications of bone grafting are significant, mostly at the donor site. This article reviews the biology of fracture healing, the properties of bone grafts, and reviews the specific advantages and problems associated with autograft bone. Recent techniques such as the Reamer Irrigator Aspirator are described, which has dramatically reduced complications of bone autograft harvesting.
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Evaluation and management of atypical femoral fractures: an update of current knowledge. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:825-840. [PMID: 33590316 DOI: 10.1007/s00590-021-02896-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 01/29/2021] [Indexed: 12/12/2022]
Abstract
Atypical femoral fractures are often attributed to the use of anti-resorptive medications such as bisphosphonates (BP). Whilst they have proven effects on fragility fracture prevention, clinical and laboratory evidence is evolving linking BP-related suppression of bone remodelling to the development of atypical stress-related sub-trochanteric fractures (Shane et al. in JBMR 29:1-23, 2014; Odvina et al. in JCEM 90:1294-301, 2005; Durchschlag et al. in JBMR 21(10):1581-1590, 2006; Donnelly et al. in JBMR 27:672-678, 2012; Mashiba et al. in Bone 28(5):524-531, 2001; Dell et al. in JBMR 27(12):2544-2550, 2012; Black et al. in Lancet 348:1535-1541, 1996; Black et al. in NEJM 356:1809-1822, 2007; Black et al. in JAMA 296:2927-2938, 2006; Schwartz et al. in JBMR 25:976-82, 2010). Injuries may present asymptomatically or with prodromal thigh pain and most can be successfully managed with cephalomedullary nailing and discontinuation of BP therapy. Such injuries exhibit a prolonged time to fracture union with high rates of non-union and metal-work failure when compared to typical subtrochanteric osteoporotic femoral fractures. Despite emerging literature on AFFs, their management continues to pose a challenge to the orthopaedic and extended multi-disciplinary team. The purpose of this review includes evaluation of the current evidence supporting the management of AFFs, clinical and radiological features associated with their presentation and a review of reported surgical strategies to treat and prevent these devastating injures.
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Biomechanical Consequences of Nail Insertion Point and Anterior Cortical Perforation for Antegrade Femoral Nailing. BIOMED RESEARCH INTERNATIONAL 2020; 2020:5878607. [PMID: 33426057 PMCID: PMC7772046 DOI: 10.1155/2020/5878607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/19/2020] [Accepted: 12/04/2020] [Indexed: 11/17/2022]
Abstract
This biomechanical study assessed the influence of changing antegrade cephalomedullary nail insertion point from anterior to neutral to posterior locations relative to the tip of the greater trochanter with or without anterior cortical perforation in the distal femur. Artificial osteoporotic femurs and cephalomedullary nails were used to create 5 test groups each with 8 specimens: intact femur without a nail or perforation, anterior nail insertion point without perforation, neutral nail insertion point without perforation, posterior nail insertion point without perforation, and posterior nail insertion point with perforation. Nondestructive biomechanical tests were done at 250 N in axial, coronal 3-point bending, sagittal 3-point bending, and torsional loading in order to measure overall stiffness and bone stress. The intact femur group vs. all femur/nail groups had lower stiffness in all loading modes (p ≤ 0.018), as well as higher bone stress in the proximal femur (p ≤ 0.027) but not in the distal femur above the perforation (p = 0.096). Compared to each other, femur/nail groups only showed differences in sagittal 3-point bending stiffness for anterior and neutral vs. posterior nail insertion points without (p ≤ 0.025) and with perforation (p ≤ 0.047). Although it did not achieve statistical significance (p ≥ 0.096), moving the nail insertion point from anterior to neutral to posterior to posterior with perforation did gradually increase bone stress by 45% (proximal femur) and 46% (distal femur). No femur or hardware failures occurred. Moving the nail insertion point and the presence of a perforation had little effect on stiffness, but the increased bone stress may be important as a predictor of fracture. Based on current bone stress results, surgeons should use anterior or neutral nail insertion points to reduce the risk of anterior cortical perforation.
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Schmitz N, Gehweiler D, Wähnert D, Zderic I, Grünwald L, Richards G, Gueorguiev B, Raschke M. Influence of the Reamer-Irrigator-Aspirator diameter on femoral bone strength and amount of harvested bone graft - a biomechanical cadaveric study. Injury 2020; 51:2846-2850. [PMID: 33051075 DOI: 10.1016/j.injury.2020.09.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/26/2020] [Accepted: 09/26/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Treatment of large bone defects is still related to unsolved problems in orthopaedic trauma surgery. Minimally invasive intramedullary reaming with the use of the Reamer-Irrigator-Aspirator (RIA) device allows autograft harvesting of large bone graft amounts from the medullary canal of the femur. The aim of this study was to investigate the influence of RIA diameter on femoral bone strength and amount of harvested bone graft in a human cadaveric model. METHODS Forty-five pairs human cadaveric femora were randomized to 3 paired groups with 15 pairs each. One femur of each pair was reamed with RIA at a diameter of either 1.5 mm (group 1), 2.5 mm (group 2) or 4.0 mm (group 3) larger than its isthmus, whereas its contralateral femur was left intact without reaming. The amount of harvested bone graft was determined for each specimen and all femora were destructively tested in internal rotation under 750 N axial compression to calculate their torsional stiffness and torque at failure. RESULTS Significant reduction in torsional stiffness was detected after reaming in group 3 (p = 0.03) in contrast to groups 1 and 2 where no such significant reduction was observed (p ≥ 0.34). Torque at failure was significantly reduced after reaming in all 3 groups (p ≤ 0.04). Collected bone graft amount in group 3 was significantly bigger compared to groups 1 and 2 (p ≤ 0.04). CONCLUSIONS Reaming with RIA diameter of 4.0 mm larger than the isthmus of the femur seems to influence considerably its torsional stiffness, however, it allows harvesting of a significantly bigger bone graft amount.
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Affiliation(s)
- Nina Schmitz
- AO Research Institute Davos, Clavadelerstrasse 8, Davos, Switzerland; University Hospital Muenster, Department of Trauma, Hand and Reconstructive Surgery, Albert-Schweitzer-Campus 1, Building W1, 48149 Muenster, Germany.
| | - Dominic Gehweiler
- AO Research Institute Davos, Clavadelerstrasse 8, Davos, Switzerland
| | - Dirk Wähnert
- Protestant Hospital of Bethel Foundation, Department of Orthopaedic and Trauma Surgery, Burgsteig 13, 33617 Bielefeld, Germany
| | - Ivan Zderic
- AO Research Institute Davos, Clavadelerstrasse 8, Davos, Switzerland
| | - Leonard Grünwald
- AO Research Institute Davos, Clavadelerstrasse 8, Davos, Switzerland; BG Clinic Tuebingen, Schnarrenbergstraße 95, 72076 Tuebingen, Germany
| | - Geoff Richards
- AO Research Institute Davos, Clavadelerstrasse 8, Davos, Switzerland
| | - Boyko Gueorguiev
- AO Research Institute Davos, Clavadelerstrasse 8, Davos, Switzerland
| | - Michael Raschke
- University Hospital Muenster, Department of Trauma, Hand and Reconstructive Surgery, Albert-Schweitzer-Campus 1, Building W1, 48149 Muenster, Germany
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A case report of extensive segmental defect of the humerus treated with Masquelet technique. J Shoulder Elbow Surg 2020; 29:1368-1374. [PMID: 32553437 DOI: 10.1016/j.jse.2020.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/16/2020] [Accepted: 03/20/2020] [Indexed: 02/01/2023]
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Marongiu G, Contini A, Cozzi Lepri A, Donadu M, Verona M, Capone A. The Treatment of Acute Diaphyseal Long-bones Fractures with Orthobiologics and Pharmacological Interventions for Bone Healing Enhancement: A Systematic Review of Clinical Evidence. Bioengineering (Basel) 2020; 7:bioengineering7010022. [PMID: 32102398 PMCID: PMC7148449 DOI: 10.3390/bioengineering7010022] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 02/17/2020] [Accepted: 02/20/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The healing of long bones diaphyseal fractures can be often impaired and eventually end into delayed union and non-union. A number of therapeutic strategies have been proposed in combination with surgical treatment in order to enhance the healing process, such as scaffolds, growth factors, cell therapies and systemic pharmacological treatments. Our aim was to investigate the current evidence of bone healing enhancement of acute long bone diaphyseal fractures. METHODS A systematic review was conducted by using Pubmed/MEDLINE; Embase and Ovid databases. The combination of the search terms "long-bones; diaphyseal fracture; bone healing; growth factors; cell therapies; scaffolds; graft; bone substitutes; orthobiologics; teriparatide". RESULTS The initial search resulted in 4156 articles of which 37 papers fulfilled the inclusion criteria and were the subject of this review. The studies included 1350 patients (837 males and 513 females) with a mean age of 65.3 years old. CONCLUSIONS General lack of high-quality studies exists on the use of adjuvant strategies for bone healing enhancement in acute shaft fractures. Strong evidence supports the use of bone grafts, while only moderate evidence demineralized bone matrix and synthetic ceramics. Conflicting results partially supported the use of growth factors and cell therapies in acute fractures. Teriparatide showed promising results, particularly for atypical femoral fractures and periprosthetic femoral fractures.
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Affiliation(s)
- Giuseppe Marongiu
- Orthopaedic and Trauma Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (A.C.); (M.V.); (A.C.)
- Correspondence: or ; Tel.: +39-070-6094368
| | - Andrea Contini
- Orthopaedic and Trauma Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (A.C.); (M.V.); (A.C.)
| | - Andrea Cozzi Lepri
- Orthopaedic Traumatologic Center, University of Florence, 50121 Florence, Italy;
| | - Matthew Donadu
- Dipartimento di Chimica e Farmacia, University of Sassari, 07100 Sassari, Italy;
| | - Marco Verona
- Orthopaedic and Trauma Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (A.C.); (M.V.); (A.C.)
| | - Antonio Capone
- Orthopaedic and Trauma Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (A.C.); (M.V.); (A.C.)
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A review of materials for managing bone loss in revision total knee arthroplasty. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2019; 104:109941. [PMID: 31500053 DOI: 10.1016/j.msec.2019.109941] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 06/14/2019] [Accepted: 07/02/2019] [Indexed: 12/25/2022]
Abstract
In 2014-2015, 61,421 total knee arthroplasties (TKAs) were performed in Canada; an increase of about 20% over 2000-2001. Revision total knee arthroplasties (rTKAs) accounted for 6.8% of TKAs performed between 2014 and 2015, and this is estimated to grow another 12% by 2025. rTKAs are typically more complicated than primary TKAs due to the significant loss of femoral and tibial bone stock. The escalating demand and limitations associated with total knee arthroplasty and their revision drives the development of novel treatments. A variety of materials have been utilized to facilitate regeneration of healthy bone around the site of a knee arthroplasty. The selection of these materials is based on the bone defect size and includes bone grafts, graft substitutes and cements. However, all these materials have certain disadvantages such as blood loss, disease transmission (bone grafts), inflammatory response, insufficient mechanical properties (bone graft substitutes) thermal necrosis and stress shielding (bone cement). Recently, the use of metal augments for large bone defects has attracted attention, however they can undergo fretting, corrosion, and stress shielding. All things considered, this review indicates the necessity of developing augments that have structural integrities and biodegradation rates similar to that of human bone. Therefore, the future of bone loss management may lie in fabricating novel bioactive glass augments as they can promote bone healing and implant stability and can degrade with time.
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O'Callaghan PK, Matthews JH, Kirn PT, Angermeier EW, Kokko KP. Bone Grafting in Total Wrist Arthrodesis With Large Bone Defects Using the Reamer-Irrigator-Aspirator: A Case Study of 2 Patients. J Hand Surg Am 2019; 44:620.e1-620.e7. [PMID: 31280820 DOI: 10.1016/j.jhsa.2018.08.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 08/31/2018] [Indexed: 02/02/2023]
Abstract
Total wrist arthrodesis, fusion of the carpus to the radius, is a well-established and commonly performed procedure for the management of pancarpal degenerative arthritis, trauma, and other severe diseases of the wrist. A well-known complication of this is radiocarpal nonunion, with a rate of 4.4%. Commonly, bone grafting is done at the time of the surgery using local bone, iliac crest bone graft, or cancellous allograft bone. The Synthes Reamer-Irrigator-Aspirator (RIA) is a flexible reamer originally designed as a single-pass intramedullary reamer that can be used in reaming of long bone fractures prior to insertion of an intramedullary nail. Recently, its use has been expanding to the harvesting of bone graft. We present a case study of 2 patients who had total wrist arthrodesis after severe trauma to the wrist resulting in severe bone loss, in whom we used an RIA to obtain bone graft, and both patients went on to union. The first patient is a 17-year-old male who sustained a blast injury from a firework resulting in a mangling injury to the wrist with soft tissue and severe bone loss of his carpus. After being treated with multiple debridements with an external fixator, he was definitively treated with a wrist fusion with RIA bone graft. He went on to osseous union by his 4-month follow-up. Our second patient is a 53-year-old woman who sustained a gunshot wound to the wrist resulting in massive bone loss of the distal radius. After being initially treated with multiple debridements and external fixation, she was treated with a wrist fusion with RIA bone graft and went on to osseous fusion by her 3-month follow-up. Neither patient had complications from the RIA procedure.
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Affiliation(s)
| | - J Hunter Matthews
- Medical University of South Carolina College of Medicine, Charleston, SC
| | - Phil T Kirn
- Department of Orthopaedics, Medical University of South Carolina, Charleston, SC
| | - Eric W Angermeier
- Department of Orthopaedics, Medical University of South Carolina, Charleston, SC
| | - Kyle P Kokko
- Department of Orthopaedics, Medical University of South Carolina, Charleston, SC.
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Le Baron M, Vivona JP, Maman P, Volpi R, Flecher X. Can the Reamer/Irrigator/Aspirator System replace anterior iliac crest grafting when treating long bone nonunion? Orthop Traumatol Surg Res 2019; 105:529-533. [PMID: 30885818 DOI: 10.1016/j.otsr.2018.12.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 10/05/2018] [Accepted: 12/11/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Autologous bone graft is the gold standard for filling bone defects associated with diaphyseal nonunions. It is typically harvested from the anterior iliac crest (AIC) despite the high complication rate. The Reamer/Irrigator/Aspirator System (RIA) was developed to recover the reaming aspirate and use it as autograft. Initially described for harvesting bone from the femur, the bone volume available is similar to the AIC site; however, its use directly at nonunion sites has been studied very little. HYPOTHESES Compared to AIC harvesting, RIA at a non-union site will result in (1) sufficient bone volume, (2) similar time to union and union rate, (3) lower morbidity. RESULTS Two groups of patients received an autograft for aseptic nonunion of the tibia or femur for a bone defect up to 2cm: the RIA group (n=30) was followed prospectively and received an autograft by RIA while the AIC group (n=29) was reviewed retrospectively and received an autograft by AIC. We compared the time to union and union rate, operative time, intake of analgesics, duration of hospital stay and complication rate between groups. The RIA provided sufficient bone, 60cm3 on average in a reliable manner. The union rate was similar between groups: 90% (RIA) and 89.7% (CIA) (p=0.965), while the time to union was shorter in the RIA group (8.63±1.47months vs. 10.08±1.7 months) (p=0.006). The operative time (p<0.0001), analgesic intake (p=0.013), length of stay (p<0.0001) and immediate complication rate (p=0.0195) were higher in the AIC group. DISCUSSION For the treatment of aseptic long bone nonunion, autograft harvested by the RIA from the nonunion site results in similar union rate and time to union as AIC grafts without additional complications. LEVEL OF EVIDENCE IV, comparative retrospective study.
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Affiliation(s)
- Marie Le Baron
- Institut du mouvement et de l'appareil locomoteur, CHU Marseille Nord, chemin des Bourrely, 13015 Marseille, France.
| | - Jean-Philippe Vivona
- Polyclinique du Parc-Rambot - Provençale, 67, cours Gambetta, 13100 Aix-en-Provence, France
| | - Pascal Maman
- Institut du mouvement et de l'appareil locomoteur, CHU Marseille Nord, chemin des Bourrely, 13015 Marseille, France
| | - Richard Volpi
- Institut du mouvement et de l'appareil locomoteur, CHU Marseille Nord, chemin des Bourrely, 13015 Marseille, France
| | - Xavier Flecher
- Institut du mouvement et de l'appareil locomoteur, CHU Marseille Nord, chemin des Bourrely, 13015 Marseille, France
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Autograft, Allograft, and Bone Graft Substitutes: Clinical Evidence and Indications for Use in the Setting of Orthopaedic Trauma Surgery. J Orthop Trauma 2019; 33:203-213. [PMID: 30633080 DOI: 10.1097/bot.0000000000001420] [Citation(s) in RCA: 391] [Impact Index Per Article: 65.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Bone grafts are the second most common tissue transplanted in the United States, and they are an essential treatment tool in the field of acute and reconstructive traumatic orthopaedic surgery. Available in cancellous, cortical, or bone marrow aspirate form, autogenous bone graft is regarded as the gold standard in the treatment of posttraumatic conditions such as fracture, delayed union, and nonunion. However, drawbacks including donor-site morbidity and limited quantity of graft available for harvest make autograft a less-than-ideal option for certain patient populations. Advancements in allograft and bone graft substitutes in the past decade have created viable alternatives that circumvent some of the weak points of autografts. Allograft is a favorable alternative for its convenience, abundance, and lack of procurement-related patient morbidity. Options include structural, particulate, and demineralized bone matrix form. Commonly used bone graft substitutes include calcium phosphate and calcium sulfate synthetics-these grafts provide their own benefits in structural support and availability. In addition, different growth factors including bone morphogenic proteins can augment the healing process of bony defects treated with grafts. Autograft, allograft, and bone graft substitutes all possess their own varying degrees of osteogenic, osteoconductive, and osteoinductive properties that make them better suited for different procedures. It is the purpose of this review to characterize these properties and present clinical evidence supporting their indications for use in the hopes of better elucidating treatment options for patients requiring bone grafting in an orthopaedic trauma setting.
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Kim SW, Seo DK, Lee CC, Kim H, Hwang IY. Successful Limb Salvage Using Bone Transport for Complete Loss of Distal Tibia and Talus: A Case Report. J Foot Ankle Surg 2019; 58:195-199. [PMID: 30583779 DOI: 10.1053/j.jfas.2018.08.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Indexed: 02/03/2023]
Abstract
Complex comminuted fractures involving the distal tibia, ankle joint, and talus are often accompanied by bone loss and are highly prone to complications such as soft tissue infection, fixation failure, and posttraumatic arthrosis, with joint reconstruction being difficult in cases with severe joint destruction or bone loss. In this case, bone transport and fusion procedures were performed to treat a patient with an open fracture involving total talar dislocation, talar bone loss, and distal tibial bone loss. Just as in this case, where the surrounding soft tissues remain healthy, limb salvage via segmental bone transport may be a reasonable option in fractures with massive bone loss that include joints.
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Affiliation(s)
- Sang Woo Kim
- Associate Professor, Department of Orthopedic Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Dong-Kyo Seo
- Assistant Professor, Department of Orthopedic Surgery, GangNeung Asan Hospital, University of Ulsan College of Medicine, Gangwon, Rebulic of Korea
| | - Chae-Chil Lee
- Associate Professor, Department of Orthopedic Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Hanwook Kim
- Senior Resident, Department of Orthopedic Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Il-Yeong Hwang
- Assistant Professor, Department of Orthopedic Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea.
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Voskuil RT, Viscomi B, Holt GE, Bruce J. Reamer-Irrigator-Aspirator Multiuse Application in the Treatment of Chronic Osteomyelitis. J Orthop Case Rep 2019; 9:47-50. [PMID: 32548003 PMCID: PMC7276632 DOI: 10.13107/jocr.2250-0685.1528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction The treatment of chronic intramedullary infection of the long bones relies on microbe-specific antibiotics in conjunction with surgical removal of infected necrotic material. We discuss the use of reamer–irrigator–aspirator(RIA) for debridement of the intramedullary canal instead of conventional reaming techniques. This is the first case report to explore the use of RIA for osteomyelitis. Case Report We discuss the use of the RIA in treatment of a 26-year-old female presenting with chronic osteomyelitis of the left distal femoral shaft. She had normalization of infection laboratories at 6 weeks and complete resolution of symptoms at 3 months and was released at 6 months. Conclusion Recent exploration of the RIA system’s (Synthes®, Inc. West Chester, Philadelphia) multipurpose applications has indicated use in long bone debridement. While further exploration and high-quality studies are needed to make robust claims of efficacy, we believe that the use of RIA in the context of chronic osteomyelitis is a superior alternative to conventional reaming techniques.
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Affiliation(s)
- Ryan T Voskuil
- Department of Orthopaedic Surgery, University of Tennessee College of Medicine, Tennessee 975 E. Third Street, Hospital Box 260,Chattanooga, TN 37403, United States
| | - Brian Viscomi
- Department of Orthopaedic Surgery, East Tennessee State University Quillen School of Medicine, 1276 Gilbreath Dr, Johnson City, TN 37614, United States
| | - Ginger E Holt
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, 1211 Medical Center Drive, Nashville, TN 37232, United States
| | - Jeremy Bruce
- Department of Orthopaedic Surgery, University of Tennessee College of Medicine, Tennessee 975 E. Third Street, Hospital Box 260,Chattanooga, TN 37403, United States
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Morelli I, Drago L, George DA, Romanò D, Romanò CL. Managing large bone defects in children: a systematic review of the 'induced membrane technique'. J Pediatr Orthop B 2018; 27:443-455. [PMID: 28368930 DOI: 10.1097/bpb.0000000000000456] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Thirty years after its description by Masquelet in 1986, this is the first systematic review aiming to critically evaluate the 'induced membrane technique' effectiveness in achieving bone union in children. Only six papers fulfilled our inclusion criteria (54 patients). The relatively small number of reported cases did not allow a formal meta-analysis. The tibia was the most involved bone. Most frequent aetiologies were congenital pseudoarthrosis and tumour resections. Although effective in achieving bone healing in ∼91% of the patients (bone defects ≤24 cm long), the induced membrane technique was associated with a high rate of complications (54% of patients). LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Ilaria Morelli
- Department of Reconstructive Surgery and Osteo-articular Infections C.R.I.O. Unit, I.R.C.C.S. Galeazzi Orthopaedic Institute
- University of Milan, Milan, Italy
| | - Lorenzo Drago
- Laboratory of Clinical Chemistry and Microbiology, I.R.C.C.S. Galeazzi Orthopaedic Institute
- University of Milan, Milan, Italy
| | - David A George
- Department of Trauma and Orthopaedics, University College London Hospitals, London, UK
| | - Delia Romanò
- Department of Reconstructive Surgery and Osteo-articular Infections C.R.I.O. Unit, I.R.C.C.S. Galeazzi Orthopaedic Institute
| | - Carlo L Romanò
- Department of Reconstructive Surgery and Osteo-articular Infections C.R.I.O. Unit, I.R.C.C.S. Galeazzi Orthopaedic Institute
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Basic Science and Clinical Application of Reamed Sources for Autogenous Bone Graft Harvest. J Am Acad Orthop Surg 2018; 26:420-428. [PMID: 29781821 DOI: 10.5435/jaaos-d-16-00512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Autologous bone graft remains the only clinically available source of graft material with osteogenic, osteoinductive, and osteoconductive properties. Although iliac crest autologous bone graft has long served as the benchmark, reamed autogenous bone graft offers several advantages. Reamed autograft has a biochemical and cellular profile that is at least equivalent, and perhaps superior, to that of iliac crest autograft. In addition, larger volumes of reamed autograft can be obtained via less-invasive techniques, giving surgeons an accessible source of mesenchymal stem cells that can be reliably and repeatedly harvested. Early clinical experience involving reamed autogenous bone graft in the management of nonunion, bone defects, and arthrodesis has been encouraging and has demonstrated the necessary properties to warrant regular consideration of reamed graft for these applications.
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Haubruck P, Ober J, Heller R, Miska M, Schmidmaier G, Tanner MC. Complications and risk management in the use of the reaming-irrigator-aspirator (RIA) system: RIA is a safe and reliable method in harvesting autologous bone graft. PLoS One 2018; 13:e0196051. [PMID: 29698513 PMCID: PMC5919622 DOI: 10.1371/journal.pone.0196051] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 03/18/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Autologous bone grafting (ABG) remains the gold standard for augmentation of bone defects. The RIA system has become more prevalent, but evidence regarding risk management and complications remain scarce. This study presents the risk management and complications associated with RIA in the largest single-center case series to date. METHODS All records, operative notes, lab data and radiographs of patients receiving a RIA procedure at Heidelberg´s University Hospital between 01/01/2010 and 31/12/2016 were reviewed. Multivariate logistic regression models adjusting for clinically relevant covariates were used to examine the respective relevance regarding the presence and absence of prolonged postoperative pain (PPP). RESULTS A total of 341 RIA procedures on 306 patients were performed at our level-1 trauma center. The femur was the main donor site (98.53%; N = 336) whereas only in 1.47% (N = 5) the tibia was utilized. A total of 11 patients showed a relevant loss of hemoglobin requiring blood transfusion. A total of 22 patients suffered from PPP directly associated with the RIA procedure resulting in prevalence of 6.45%. The 6 major complications in our study were of diverse origin and all intraoperative complications took place in the early phase of the RIA procedure in our center (2010-2013). Our data revealed influence of sex (p = 0.0459) and age (p = 0.0596) on the criterion PPP. The favored model including sex and age resulted in an AUC of 66.2% (CI: 55.5%-76.9%). CONCLUSION Perioperative blood loss remains a prevalent complication during RIA reaming. In addition, PPP occurs with a prevalence of 6.45%. This study showed a complication rate of 1.76%, emphasizing RIA´s overall safety and furthermore highlighting the need for vigilance in its application and prior extensive hands-on training of surgeons. Level of Evidence: II.
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Affiliation(s)
- Patrick Haubruck
- HTRG–Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Heidelberg, Germany
- * E-mail:
| | - Julian Ober
- HTRG–Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Raban Heller
- HTRG–Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias Miska
- HTRG–Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Gerhard Schmidmaier
- HTRG–Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Michael C. Tanner
- HTRG–Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Heidelberg, Germany
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Wang W, Yeung KWK. Bone grafts and biomaterials substitutes for bone defect repair: A review. Bioact Mater 2017; 2:224-247. [PMID: 29744432 PMCID: PMC5935655 DOI: 10.1016/j.bioactmat.2017.05.007] [Citation(s) in RCA: 956] [Impact Index Per Article: 119.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 05/19/2017] [Accepted: 05/19/2017] [Indexed: 02/08/2023] Open
Abstract
Bone grafts have been predominated used to treat bone defects, delayed union or non-union, and spinal fusion in orthopaedic clinically for a period of time, despite the emergency of synthetic bone graft substitutes. Nevertheless, the integration of allogeneic grafts and synthetic substitutes with host bone was found jeopardized in long-term follow-up studies. Hence, the enhancement of osteointegration of these grafts and substitutes with host bone is considerably important. To address this problem, addition of various growth factors, such as bone morphogenetic proteins (BMPs), parathyroid hormone (PTH) and platelet rich plasma (PRP), into structural allografts and synthetic substitutes have been considered. Although clinical applications of these factors have exhibited good bone formation, their further application was limited due to high cost and potential adverse side effects. Alternatively, bioinorganic ions such as magnesium, strontium and zinc are considered as alternative of osteogenic biological factors. Hence, this paper aims to review the currently available bone grafts and bone substitutes as well as the biological and bio-inorganic factors for the treatments of bone defect.
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Affiliation(s)
- Wenhao Wang
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, China
- Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, The University of Hong Kong Shenzhen Hospital, 1 Haiyuan 1st Road, Futian District, Shenzhen, China
| | - Kelvin W K Yeung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, China
- Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, The University of Hong Kong Shenzhen Hospital, 1 Haiyuan 1st Road, Futian District, Shenzhen, China
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Schwartz AM, Schenker ML, Ahn J, Willett NJ. Building better bone: The weaving of biologic and engineering strategies for managing bone loss. J Orthop Res 2017; 35:1855-1864. [PMID: 28467648 DOI: 10.1002/jor.23592] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 04/24/2017] [Indexed: 02/04/2023]
Abstract
Segmental bone loss remains a challenging clinical problem for orthopaedic trauma surgeons. In addition to the missing bone itself, the local tissues (soft tissue, vascular) are often highly traumatized as well, resulting in a less than ideal environment for bone regeneration. As a result, attempts at limb salvage become a highly expensive endeavor, often requiring multiple operations and necessitating the use of every available strategy (autograft, allograft, bone graft substitution, Masquelet, bone transport, etc.) to achieve bony union. A cost-sensitive, functionally appropriate, and volumetrically adequate engineered substitute would be practice-changing for orthopaedic trauma surgeons and these patients with difficult clinical problems. In tissue engineering and bone regeneration fields, numerous research efforts continue to make progress toward new therapeutic interventions for segmental bone loss, including novel biomaterial development as well as cell-based strategies. Despite an ever-evolving literature base of these new therapeutic and engineered options, there remains a disconnect with the clinical practice, with very few translating into clinical use. A symposium entitled "Building better bone: The weaving of biologic and engineering strategies for managing bone loss," was presented at the 2016 Orthopaedic Research Society Conference to further explore this engineering-clinical disconnect, by surveying basic, translational, and clinical researchers along with orthopaedic surgeons and proposing ideas for pushing the bar forward in the field of segmental bone loss. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1855-1864, 2017.
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Affiliation(s)
| | - Mara L Schenker
- Department of Orthopaedics, Emory University, Decatur, Georgia
| | - Jaimo Ahn
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nick J Willett
- Department of Orthopaedics, Emory University, Decatur, Georgia.,Atlanta Veteran's Affairs Medical Center, Decatur, Georgia.,Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, Georgia.,Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia
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Bioreactor as a New Resource of Autologous Bone Graft to Overcome Bone Defect In Vivo. Clin Rev Bone Miner Metab 2017. [DOI: 10.1007/s12018-017-9237-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Long bone mesenchymal stem cells (Lb-MSCs): clinically reliable cells for osteo-diseases. Cell Tissue Bank 2017; 18:489-500. [DOI: 10.1007/s10561-017-9652-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Accepted: 08/08/2017] [Indexed: 01/24/2023]
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Schardosim M, Soulié J, Poquillon D, Cazalbou S, Duployer B, Tenailleau C, Rey C, Hübler R, Combes C. Freeze-casting for PLGA/carbonated apatite composite scaffolds: Structure and properties. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2017; 77:731-738. [DOI: 10.1016/j.msec.2017.03.302] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/28/2017] [Accepted: 03/31/2017] [Indexed: 12/21/2022]
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Abstract
While the RIA system was initially designed for reaming and clearing the femoral canal contents in preparation for femoral nailing, it has since been used in various other applications in the field of orthopaedic surgery. The RIA is an ideal device for accessing large quantities of autogenous bone graft, to be used in the treatment of nonunions, segmental bone loss, or arthrodesis. The RIA has also been used for treatment of intramedullary infections and osteomyelitis, as well as intramedullary nailing of long bones with metastatic lesions, as it allows for clearing the canal of infectious/tumour burden, and lowers the risk of dissemination into the soft tissues and systemic circulation. There is also some limited evidence that the RIA may be used for clearing the femoral/tibial canal of cement debris. Despite multiple applications, the use of RIA has a risk of eccentric reaming and iatrogenic fractures. RIA is also a costly procedure, and its routine use may not be advantageous in the setting of limited health care resources.
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Morris R, Hossain M, Evans A, Pallister I. Induced membrane technique for treating tibial defects gives mixed results. Bone Joint J 2017; 99-B:680-685. [PMID: 28455479 DOI: 10.1302/0301-620x.99b5.bjj-2016-0694.r2] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 12/29/2016] [Indexed: 02/07/2023]
Abstract
Aims This study describes the use of the Masquelet technique to treat segmental tibial bone loss in 12 patients. Patients and Methods This retrospective case series reviewed 12 patients treated between 2010 and 2015 to determine their clinical outcome. Patients were mostly male with a mean age of 36 years (16 to 62). The outcomes recorded included union, infection and amputation. The mean follow-up was 675 days (403 to 952). Results The mean tibial defect measured 5.8 cm (2 to 15) in length. Of the 12 patients, 11 had an open fracture. Eight underwent fixation with an intramedullary nail, three with plates and one with a Taylor Spatial Frame. The mean interval between stages was 57 days (35 to 89). Bony union was achieved in only five patients. Five patients experienced infective complications during treatment, with two requiring amputation because of severe infection. Conclusion The Masquelet technique was relatively ineffective in achieving union in this series, and was associated with a high rate of infection. Cite this article: Bone Joint J 2017;99-B:680–5.
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Affiliation(s)
- R. Morris
- University Hospital of Wales, Heath
Park, Cardiff, CF14 4XW, UK
| | - M. Hossain
- Princess Royal University Hospital, King’s
College Hospital NHS Foundation Trust, BR6
8ND, UK
| | - A. Evans
- West Wales General Hospital, Dolgwili
Road, Carmarthen, SA31
2AF, UK
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Kusnezov N, Prabhakar G, Dallo M, Thabet AM, Abdelgawad AA. Bone grafting via reamer-irrigator-aspirator for nonunion of open Gustilo-Anderson type III tibial fractures treated with multiplanar external fixator. SICOT J 2017; 3:30. [PMID: 28387196 PMCID: PMC5384319 DOI: 10.1051/sicotj/2017002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 12/27/2016] [Indexed: 11/30/2022] Open
Abstract
Introduction: The purpose of this investigation was to evaluate the outcomes following reamer-irrigator-aspirator (RIA) autogenous bone grafting (ABG) of high-grade open tibia fracture nonunions stabilized via multiplanar external fixation. Methods: We retrospectively reviewed all patients with Gustilo-Anderson type III open tibia fractures treated with multiplanar external fixation and who underwent RIA ABG for nonunion at our institutional Level 1 Trauma Center between 2008 and 2015. All patients between 15 and 65 years of age with a minimum of six-month follow-up were included. The primary outcomes of interest were achievement of union, time to union, and incidence of revision surgery. Complications and all-cause reoperation were recorded as secondary endpoints. Results: Fifteen patients met the inclusion criteria with a mean age of 41.1 ± 14.0 years. RIA ABG was harvested from the femur in all cases, with a mean volume of 34 ± 15 mL. At an average follow-up of 13.3 ± 6.8 months, all patients achieved union, including two who required repeat RIA ABG. One patient experienced a femoral shaft fracture four months following RIA that required intramedullary fixation. The average time to union was 6.0 ± 6.3 months. Twelve patients (80%) went on to union within six months and 13 (86.7%) within one year. Five patients experienced a total of six post-operative complications including three deep infections, one refracture through the nonunion site, and one gradual varus deformity. Two patients in this series required a subsequent RIA autografting procedure secondary to persistent nonunion despite initial RIA. Conclusion: We found that RIA ABG offered a reliable solution to nonunion of Gustilo-Anderson type III open tibial fractures treated with multiplanar external fixation, circumventing the need to change the method of fixation.
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Affiliation(s)
- Nicholas Kusnezov
- Department of Orthopaedic Surgery and Rehabilitation, Texas Tech University Health Sciences Center, El Paso, TX 79905, USA
| | - Gautham Prabhakar
- Department of Orthopaedic Surgery and Rehabilitation, Texas Tech University Health Sciences Center, El Paso, TX 79905, USA
| | - Matthew Dallo
- Department of Orthopaedic Surgery and Rehabilitation, Texas Tech University Health Sciences Center, El Paso, TX 79905, USA
| | - Ahmed M Thabet
- Department of Orthopaedic Surgery and Rehabilitation, Texas Tech University Health Sciences Center, El Paso, TX 79905, USA
| | - Amr A Abdelgawad
- Department of Orthopaedic Surgery and Rehabilitation, Texas Tech University Health Sciences Center, El Paso, TX 79905, USA
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Marchand LS, Rothberg DL, Kubiak EN, Higgins TF. Is This Autograft Worth It?: The Blood Loss and Transfusion Rates Associated With Reamer Irrigator Aspirator Bone Graft Harvest. J Orthop Trauma 2017; 31:205-209. [PMID: 28166173 DOI: 10.1097/bot.0000000000000811] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To investigate the blood loss and transfusion rate associated with the use of reamer irrigator aspirator (RIA). DESIGN Retrospective review. SETTING Academic Level-I trauma hospital. PATIENTS One hundred eight patients requiring bone graft harvest for surgical reconstruction of nonunion or failed arthrodesis. INTERVENTION Bone graft harvest preformed via RIA or iliac crest bone graft (ICBG). MAIN OUTCOME MEASURE Blood loss as measured by a change in preoperative and postoperative hematocrit (Hct). In addition, postoperative transfusion reported intraoperative blood loss, volume of graft harvested, and major complications. RESULTS The average Hct drop was found to be 13.7 (4.1-27.4) in the RIA cohort of 61 patients and 7.36 (1.2-14.5) in the ICBG cohort of 47 patients (P = 0.013). Operative reports documented an average estimated blood loss of 674 mL (100-2000 mL) in the RIA cohort compared with 255 mL (50-1000 mL) in the ICBG cohort (P < 0.001). Twenty-seven patients (44%) required blood transfusion after RIA, whereas 10 patients (21%) required blood transfusion after ICBG (odds ratio 5.32, 95% confidence interval 2.2-6.3, P < 0.001). RIA procedures collected an average 53 mL (20-100 mL) of bone graft compared with 27 mL (15-50 mL) with ICBG. There was no significant difference between groups regarding age, sex, medical comorbidities, or postoperative major complications. CONCLUSIONS This series demonstrated that 44% of patients undergoing RIA bone graft harvest required transfusion, with a mean Hct drop of 13.7 across all subjects, which is significantly greater than that associated with ICBG. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lucas S Marchand
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
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Abstract
Bone graft is a common adjunct procedure in orthopedic surgery used for fusions, fracture repair, and the reconstruction of skeletal defects in the foot and ankle. Autologous graft, or autograft, involves the transport of bone from a donor site to another location in the same patient. It is considered by many to be the gold standard of bone grafting, as it is provides all biologic factors required for functional graft. Further, autograft is 100% histocompatible with no risk of disease transmission.
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Morelli I, Drago L, George DA, Gallazzi E, Scarponi S, Romanò CL. Masquelet technique: myth or reality? A systematic review and meta-analysis. Injury 2016; 47 Suppl 6:S68-S76. [PMID: 28040090 DOI: 10.1016/s0020-1383(16)30842-7] [Citation(s) in RCA: 180] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The induced membrane technique (IMT) or Masquelet technique, is a two-step surgical procedure used to treat pseudoarthroses and bony defects. Many authors have introduced variants to the technique. This study aims to compare the surgical variants of IMT and to evaluate its efficacy in achieving infection eradication and bone union. METHODS A systematic review was carried out following the PRISMA guidelines. PubMed and other medical databases were explored using keywords "Masquelet technique" and "induced membrane technique". Articles were included if written in English, French or Italian, dealing with IMT employed to long bones in adults, reporting at least 5 cases with a 12 months-mean follow-up. Patients' clinical features, bone defect features, aetiologies, surgical data, complications, reinterventions, union rates and infection eradication rates were searched. Fischer's exact test, chi-square test and unpaired t-test were used for the statistical analysis on the individual patient's data. RESULTS Seventeen papers met the inclusion criteria (427 patients). Among these, only 10 studies reported individual patient's data (137 cases). The union rate was 89.7% and the infections rectified in 91.1% of cases. The bone defect length ranged from 0.6 to 26 cm. The main complications were superficial (21; 4.9%) and deep surgical site infections (19; 4.4%), failure of one of the IMT steps (persistence of infections or non unions, 77, 18%), with subsequent requirement for further surgery. The surgical variants included the use of antibiotic-coated spacers, internal fixation during the first step, use of Reamer-Irrigator-Aspirator technique, iliac crest grafting, bone substitutes and growth factors. However, univariate analysis only showed a positive correlation of the need for reinterventions with poorer bone union rates (p = 0.005) and complications (p <0.001), while patients undergoing IMT because of bone infections had a higher risk of surgical complications (p <0.001). DISCUSSION IMT aims to achieve bone union and infection eradication, but persistence of infection or non-union was noted in 18% of cases necessitating re-interventions. This may be related to the different anatomical sites that the technique has been applied and different local and patient related conditions. We believe the choice of a surgical technique to achieve union should be tailored to the individual patient's needs. This systematic review was limited by the few studies meeting our inclusion criteria, and their high variability in data reporting, making it impossible to undertake a meta-analysis. CONCLUSION Further studies are needed to demonstrate the role the patients' clinical features and IMT variants have upon achieving bone union and infection eradication.
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Affiliation(s)
- Ilaria Morelli
- Department of Reconstructive Surgery and Osteo-articular Infections C.R.I.O. Unit, I.R.C.C.S. Galeazzi Orthopaedic Institute, Via R. Galeazzi 4, 20161, Milan, Italy; Università degli Studi di Milano, via Festa del Perdono 7, 20122 Milano, Italy.
| | - Lorenzo Drago
- Laboratory of Clinical Chemistry and Microbiology, I.R.C.C.S. Galeazzi Orthopaedic Institute, Via R. Galeazzi 4, 20161, Milan, Italy
| | - David A George
- Department of Trauma and Orthopaedics, University College London Hospitals, London, UK
| | - Enrico Gallazzi
- Department of Reconstructive Surgery and Osteo-articular Infections C.R.I.O. Unit, I.R.C.C.S. Galeazzi Orthopaedic Institute, Via R. Galeazzi 4, 20161, Milan, Italy; Università degli Studi di Milano, via Festa del Perdono 7, 20122 Milano, Italy
| | - Sara Scarponi
- Department of Reconstructive Surgery and Osteo-articular Infections C.R.I.O. Unit, I.R.C.C.S. Galeazzi Orthopaedic Institute, Via R. Galeazzi 4, 20161, Milan, Italy
| | - Carlo L Romanò
- Department of Reconstructive Surgery and Osteo-articular Infections C.R.I.O. Unit, I.R.C.C.S. Galeazzi Orthopaedic Institute, Via R. Galeazzi 4, 20161, Milan, Italy; Università degli Studi di Milano, via Festa del Perdono 7, 20122 Milano, Italy
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Liu X, Li M, Zhu Y, Yeung KWK, Chu PK, Wu S. The modulation of stem cell behaviors by functionalized nanoceramic coatings on Ti-based implants. Bioact Mater 2016; 1:65-76. [PMID: 29744396 PMCID: PMC5883996 DOI: 10.1016/j.bioactmat.2016.09.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 09/01/2016] [Accepted: 09/01/2016] [Indexed: 12/25/2022] Open
Abstract
Nanoceramic coating on the surface of Ti-based metallic implants is a clinical potential option in orthopedic surgery. Stem cells have been found to have osteogenic capabilities. It is necessary to study the influences of functionalized nanoceramic coatings on the differentiation and proliferation of stem cells in vitro or in vivo. In this paper, we summarized the recent advance on the modulation of stem cells behaviors through controlling the properties of nanoceramic coatings, including surface chemistry, surface roughness and microporosity. In addition, mechanotransduction pathways have also been discussed to reveal the interaction mechanisms between the stem cells and ceramic coatings on Ti-based metals. In the final part, the osteoinduction and osteoconduction of ceramic coating have been also presented when it was used as carrier of BMPs in new bone formation.
The effects of basic physical properties like roughness, topography and porous stucture of ceramic coatings on the stem cells behaviors on Ti-based alloys have been reviewed together. The chemical way to modulate the cell behaviors is also discussed in this review paper; and the related mechanotransduction pathways have been described in this paper.
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Affiliation(s)
- Xiangmei Liu
- Hubei Collaborative Innovation Center for Advanced Organic Chemical Materials, Ministry-of-Education Key Laboratory for the Green Preparation and Application of Functional Materials, Hubei Key Laboratory of Polymer Materials, Faculty of Materials Science & Engineering, Hubei University, Wuhan 430062, China
| | - Man Li
- Hubei Collaborative Innovation Center for Advanced Organic Chemical Materials, Ministry-of-Education Key Laboratory for the Green Preparation and Application of Functional Materials, Hubei Key Laboratory of Polymer Materials, Faculty of Materials Science & Engineering, Hubei University, Wuhan 430062, China
| | - Yizhou Zhu
- Hubei Collaborative Innovation Center for Advanced Organic Chemical Materials, Ministry-of-Education Key Laboratory for the Green Preparation and Application of Functional Materials, Hubei Key Laboratory of Polymer Materials, Faculty of Materials Science & Engineering, Hubei University, Wuhan 430062, China
| | - K W K Yeung
- Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, The University of Hong Kong Shenzhen Hospital, 1 Haiyuan 1st Road, Futian District, Shenzhen, China.,Division of Spine Surgery, Department of Orthopaedics & Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong, China
| | - Paul K Chu
- Department of Physics & Materials Science, City University of Hong Kong, Tat Chee Avenue, Kowloon, Hong Kong, China
| | - Shuilin Wu
- Hubei Collaborative Innovation Center for Advanced Organic Chemical Materials, Ministry-of-Education Key Laboratory for the Green Preparation and Application of Functional Materials, Hubei Key Laboratory of Polymer Materials, Faculty of Materials Science & Engineering, Hubei University, Wuhan 430062, China
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Reamer-irrigator-aspirator for autologous bone graft in spinal fusion: an alternative to conventional bone graft substitutes. CURRENT ORTHOPAEDIC PRACTICE 2016. [DOI: 10.1097/bco.0000000000000413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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