Bone Repair Using the Masquelet Technique Masquelet, Alain; Kanakaris, Nikolaos K; Obert, Laurent ...
Journal of bone and joint surgery. American volume,
2019-June-5, 2019-Jun-05, 2019-6-5, 20190605, Letnik:
101, Številka:
11
Journal Article
Recenzirano
➤ The optimal time for the second stage is between 4 and 8 weeks.
➤ Multiple tissue biopsy specimens must be sent for microbiological analysis during both stages of the procedure.
➤ Recurrence of ...infection requires debridement of the membrane and surrounding soft tissues and reinitiation of the technique (return to first stage).
➤ The bone graft utilized is autologous cancellous pieces or filtered reamer-irrigator-aspirator graft, which can be expanded further with osteoconductive, osteoinductive, and osteogenic material.
➤ Bone healing of the defect is independent of its size.
Abstract Bone grafting is a commonly performed surgical procedure to augment bone regeneration in a variety of cases in orthopaedic and maxillofacial surgery. Autologous bone graft remains to be the ...‘gold standard’ and the iliac crest to be the most common harvesting site. The intramedullary canal of long bones represents another potential site for large volume of autologous bone graft harvesting and is recently being used as an alternative donor site. However, harvesting of autologous bone graft is associated with morbidity and a number of complications. The aim of this systematic review was to collect and summarise the existing data on reported complications after harvesting autologous bone from the iliac crest (anterior and posterior) and the long bone intramedullary canal using the RIA device. We searched the PubMed Medline and Ovid Medline databases, from January 1990 to October 2010, to retrieve all relevant articles. A total of 92 articles (6682 patients) were included in the analysis. Overall, the complication rate following RIA was 6% (14 complications in 233 patients) and 19.37% after iliac crest bone graft harvesting (1249 complications in 6449 patients). The rate of each of the reported complications was assessed and, when the donor site was properly documented, comparison within the anterior and posterior iliac crest donor sites was performed. Although the difference of the overall morbidity rates between the two harvesting sites was not statistically significant ( p = 0.71); the rates of certain complications were found to significantly differ when anterior or posterior iliac crest was used. The rates of infection ( p = 0.016), haematoma formation ( p = 0.002), fracture ( p = 0.017), and hyperthrophic scar ( p = 0.017) were significantly higher when the donor site was the anterior iliac crest compared to the posterior iliac crest; whereas the rates of chronic donor site pain ( p = 0.004) and sensory disturbances ( p = 0.003) were significantly lower. The incidence of bone graft harvesting related complications can be reduced further if certain principles are followed depending on the performed harvesting methods; but overall the use of RIA device as harvesting method seems a promising alternative with a low complication rate.
Abstract This prospective study was undertaken at a regional tertiary referral centre to evaluate the results of treatment of bone defects managed with the induced membrane (IM) technique. Inclusion ...criteria were patients with bone defects secondary to septic non-union, chronic osteomyelitis and acute fracture with bone loss. Pathological fractures with bone loss were excluded. Data collection included patient demographics, pathology, previous surgical intervention, size of bone defect, type of graft implanted, time-to-union and complications/reinterventions. The minimum time of follow up was 12 months. Forty-three patients (32 males) met the inclusion criteria with a mean age of 47.9 years (range 18–80 years). 22 patients had an acute traumatic bone loss associated with open fracture and 21 presented with an infected non-union or underlying osteomyelitis requiring bone excision. The most common microorganisms grown were staphylcoccous aureus and coagulase negative staphylococcous. The mean length of the bone defect area was 4.2 cm (range 2–12 cm). All patients were managed with the two stage technique receiving composited grafting (Autologous bone graft (Iliac crest/RIA), graft expander as required, osteoprogenitor cells, growth factor) during the second stage. There was one failure (humeral infected non-union) in a previous background of bone radiation that necessitated reconstruction with a free fibula vascularized graft. One patient had a fall and sustained implant failure (humeral defect) 3 months after reconstruction and following re-plating progressed to union 4 months later. Two patients required re-grafting due to failure of healing in one of the defect sides. One patient presented with a discharging sinus 2 years after successful healing of a tibial defect that was treated successfully with soft tissue and bone debridement without necessitating further interventions. One patient despite union (distal 1/3 tibia) underwent a below knee amputation due to a dysfunctional ankle/foot (previous foot compartment syndrome-regional pain syndrome). Of those patients, with lower limb injuries, 4 patients had leg length discrepancies of 1 cm, 1.5 cm, 2 cm (two patients) respectively. The mean time to radiological union was 5.4 months (range 2–12 months). The average time of healing of 1 cm bone defect was 1.24 months. Patients with upper limb reconstruction recovered earlier than those with lower limb injuries. At the latest follow up all patients were able to mobilize full weight bearing without residual pain. The induced membrane technique appears to be an alternative good option for the management of large bone defects secondary to acute bone loss or infected non-unions. The incidence of re-interventions was low in this challenging cohort of patients. The technique should be considered in the surgeon's armamentarium as it is effective and is associated with a low rate of complications.
A large number of scientists from a wide range of medical and surgical disciplines have reported on the existence and characteristics of the clinical syndrome of pelvic girdle pain during or after ...pregnancy. This syndrome refers to a musculoskeletal type of persistent pain localised at the anterior and/or posterior aspect of the pelvic ring. The pain may radiate across the hip joint and the thigh bones. The symptoms may begin either during the first trimester of pregnancy, at labour or even during the postpartum period. The physiological processes characterising this clinical entity remain obscure. In this review, the definition and epidemiology, as well as a proposed diagnostic algorithm and treatment options, are presented. Ongoing research is desirable to establish clear management strategies that are based on the pathophysiologic mechanisms responsible for the escalation of the syndrome's symptoms to a fraction of the population of pregnant women.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract The aim of this retrospective study with prospectively documented data was to report the clinical results of treatment of long bone non-unions using the “diamond concept”. Over a 4-year ...period, patients that presented with a long bone non-union and were managed with the diamond conceptual framework of bone repair were evaluated. Exclusion criteria were hypertrophic, pathological, and infected non-unions. Fixation was revised as it was indicated whilst biological enhancement included the implantation of RIA graft, BMP-7 and concentrated bone marrow aspirate. Data recorded included patient demographics, initial fracture pattern and type of stabilisation, number of previous interventions, time to reoperation, time to union and functional outcome. Painless full weight bearing defined clinical union. Radiological union was defined as the presence of mature callous bridging to at least 3 bone cortices. The minimum follow up was 12 months (range 12–32). In total 64 patients (34 males) with a mean age of 45 years (17–83) were evaluated. Anatomical distribution of non-unions included the femur (54.68%), tibia (34.38%), humerus (4.68%), radius (3.13%) and clavicle (3.13%). The median number of previous interventions was 1 (range 1–5). The majority of patients (82.62%) underwent revision of fixation whereas only bone grafting was performed 9.38% of patients. Three patients developed superficial wound infection (one was MRSA), 1 had deep vein thrombosis and 1 developed heterotopic bone formation. Union was successful in 63/64 (98.4%) non-unions at a mean time of 6 months (range 3–12). All patients were mobilising pain free and returned to their daily living activities at the final follow up. The application of the “diamond concept” in this cohort of patients was associated with a high union rate by providing an optimal mechanical and biological environment. Such an approach should be considered in the surgeon's armamentarium particularly in such cases where difficulty of bone repair is foreseen.
Abstract The aim of the present study was to comparatively analyse certain outcome measures of open tibial fractures, stratified per grade of open injury and method of treatment. For this purpose, a ...systematic review of the English literature from 1990 until 2010 was undertaken, comprising 32 eligible articles reporting on 3060 open tibial fractures. Outcome measures included rates of union progress (early union, delayed union, late union and non-union rates) and certain complication rates (deep infection, compartment syndrome and amputation rates). Statistical heterogeneity across component studies was detected with the use of Cochran chi-square and I2 tests. In the absence of significant statistical heterogeneity a pooled estimate of effect size for each outcome/complication of interest was produced. All component studies were assigned on average a moderate quality score. Reamed tibial nails (RTNs) were associated with significantly higher odds of early union compared with unreamed tibial nails (UTNs) in IIIB open fractures (odds ratio: 12, 95% CI: 2.4–61). Comparing RTN and UTN modes of treatment, no significant differences were documented per grade of open fractures with respect to both delayed and late union rates. Surprisingly, nonunion rates in IIIB open fractures treated with either RTNs or UTNs were lower than IIIA or II open fractures, although the differences were not statistically significant. Significantly increased deep infection rates of IIIB open fractures compared with all other grades were documented for both modes of treatment (RTN, UTN). However, lower deep infection rates for IIIA open fractures treated with RTNs were recorded compared with grades I and II. Interestingly, grade II open tibial fractures, treated with UTN, presented significantly greater odds for developing compartment syndrome than when treated with RTNs. Our cumulative analysis, providing for each grade of open injury and each particular method of treatment a summarised estimate of effect size for the most important outcome measures of open tibial fractures, constitutes a useful tool of the practicing surgeon for optimal decision making when operative treatment of such fractures is contemplated.
•Adequate resuscitation, blood transfusion, treatment of associated injuries, application of damage control orthopaedics (pelvic ring external fixation +/- C clamp) and soft tissue management are ...essential in their early management of open pelvic fractures for improved outcomes.•A colostomy and cystostomy should be performed in the presence of anorectal and urogenital injuries.•Selection of pelvic fixation depends on the type of fracture sustained and the state of the soft tissues.•The use of negative pressure drainage is recommended if primary closure of the soft tissue wound is not feasible.
Open pelvic fractures remain challenging in terms of their management. The purpose of this narrative review was to evaluate the latest advances made in the management of these injuries and report on their clinical outcome.
A literature review was undertaken focusing on studies that have been published on the management of open pelvic fractures between January 2005 and November 2019. Information extracted from each article include demographics, mechanism of injury, injury severity score (ISS), classification of pelvic ring fracture, classification of open soft tissue, specific injury zone classification, number of cases with hemodynamic instability, number of cases that received blood transfusions, amount of packed red blood cells transfused during the first 24 h, number of cases with anorectal trauma, urogenital injury, number of fecal diversional colostomies and laparotomies, angiographies and embolization, preperitoneal pelvic packings, length of stay in intensive care unit (ICU) and in hospital, and mortality.
Fifteen articles with 646 cases formed the basis of this review. The majority of patients were male adults (74.9%). The mean age was 35.1 years. The main mechanism of injury was road traffic accidents, accounting for 67.1% of the injuries. The mean ISS was 26.8. A mean of 13.5 units of PRBCs were administered the first 24 h. During the whole hospital stay, 79.3% of the patients required blood transfusions. Angiography and pelvic packing were performed in a range of 3%-44% and 13.3%-100% respectively. Unstable types of pelvic injuries were the majority (72%), whilst 32.7% of the cases were associated with anorectal trauma, and 32.6% presented with urogenital injuries. Bladder ruptures were the most reported urogenital injury. Fecal diversional colostomy was performed in 37.4% of the cases. The mean length of ICU stay was 12.5 days and the mean length of hospital stay was 53.0 days. The mean mortality rate was 23.7%.
Mortality following open pelvic fracture remains high despite the evolution of trauma management the last 2 decades. Sufficient blood transfusion, bleeding control, treatments of associated injuries, fracture fixation and soft tissue management remain essential for the reduction of mortality and improved outcomes.
The Vancouver classification is still a useful tool of communication and stratification of periprosthetic fractures, but besides the three parameters it considers, clinicians should also assess ...additional factors.Combined advanced trauma and arthroplasty skills must be available in departments managing these complex injuries.Preoperative confirmation of the THA (total hip arthroplasty) stability is sometimes challenging. The most reliable method remains intraoperative assessment during surgical exploration of the hip joint.Certain B1 fractures will benefit from revision surgery, whilst some B2 fractures can be effectively managed with osteosynthesis, especially in frail patients.Less invasive osteosynthesis, balanced plate-bone constructs, composite implant solutions, together with an appropriate reduction of the limb axis, rotation and length are critical for a successful fixation and uneventful fracture healing. Cite this article:
2021;6:75-92. DOI: 10.1302/2058-5241.6.200050.
Objectives:
The purpose of this study was to investigate the safety and early clinical results from the use of a novel, noble metal-coated titanium tibial nail for the definite stabilization of ...tibial shaft fractures at risk of developing complications.
Design:
This is a retrospective case series with prospectively collected data.
Setting:
Level I Trauma Centre in the United Kingdom.
Patients and Intervention:
Thirty-one patients who were managed with the Bactiguard-coated Natural Nail and achieved a minimum of a 12-month follow-up.
Main Outcome Measurements:
The main outcomes of this study were the incidence of adverse events (related to implant safety), complications (particularly infection), and reinterventions.
Results:
Thirty-one patients with a mean age of 41.6 years were included in this study. Active heavy smokers or intravenous drug users were 25.8% and 9.7% of them were diabetic. Five fractures were open while 13 had concomitant soft-tissue involvement (Tscherne grade 1 or 2). Twenty-seven patients healed with no further intervention in a mean time of 3.3 months. Three patients developed nonunion and required further intervention. The overall union rate was 96.7%. One patient developed deep infection after union (infection incidence 3.2%). Six patients (6/31; 19.3%) required reinterventions 2 for the treatment of nonunion, 3 for removal of screws soft-tissue irritation, and 1 for the management of infection).
Conclusions:
The management of tibial shaft fractures with a noble metal-coated titanium tibial nail demonstrates encouraging outcomes. Further studies are desirable to gather more evidence in the performance of this innovative implant.
Level of Evidence:
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Lately, the care of severely injured patients in the United Kingdom has undergone a significant transformation. The establishment of regional trauma networks (RTN) with designated Major Trauma ...Centers (MTCs) and satellite hospitals called Trauma Units (TUs) has centralized the care of severely injured patients in the MTCs.
Pelvic fractures are notoriously linked with hypovolemic shock or even death from excessive blood loss. The aim of this prospective cohort study is to compare the profile of severely injured patients with combined pelvic fractures and their mortality between two different distinct eras of an advanced healthcare system. Anonymized consecutive patient records submitted to TARN UK between 2002 and 2017 by NHS England hospitals were analyzed. Records of patients without a pelvic fracture, or with isolated pelvic fractures (no other serious injury with abbreviated injury scale AIS >2) were excluded.
All patients with known outcomes were included and were divided into 2 distinct periods (pre-RTN era: between January 2002 and March 2008 (control group); and RTN era April 2013 to June 2017 (study group)). Data from the transition period from April 2008 to March 2013 were excluded to minimize the effect of variations between the developing networks and MTCs during that era. Overall, the study group included 10,641 patients, whereas the control group was 3152 patients, with a median age of 52.4 and 35.1 years and an ISS of 24 and 27 respectively. A systolic blood pressure below 90mmHg was observed in 7.2% of patients in the study group and 10.4% in the control group. A significant increase of the median time to death (from 8hrs to 188hrs) was observed between the two eras. The cumulative mortality of severely injured patients with pelvic fractures decreased significantly from 17.8% to 12.4% (p<0.0001).
The recorded improvement of survivorship in the subgroup of severely injured patients with a pelvic fracture (32% lower in the post-RTN than in the pre-RTN period: OR 1.32 (95% CI 1.21 – 1.44), following the first 5 years of established regional trauma networks in NHS England, is encouraging, and should be attributed to a wide range of factors that translate to all levels of trauma care.
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