Critical-sized bone defects are defined as those that will not heal spontaneously within a patient’s lifetime. Current treatment options include vascularized bone grafts, distraction osteogenesis, ...and the induced membrane technique. The induced membrane technique is an increasingly utilized method with favorable results including high rates of union. Tissue engineering holds promise in the treatment of large bone defects due to advancement of stem cell biology, novel biomaterials, and 3D bioprinting. In this review, we provide an overview of the current operative treatment strategies of critical-sized bone defects as well as the current state of tissue engineering for such defects.
Purpose of Review
This review evaluates current clinical literature on the use of platelet-rich plasma (PRP), including leukocyte-rich PRP (LR-PRP) and leukocyte-poor PRP (LP-PRP), in order to ...develop evidence-based recommendations for various musculoskeletal indications.
Recent Findings
Abundant high-quality evidence supports the use of LR-PRP injection for lateral epicondylitis and LP-PRP for osteoarthritis of the knee. Moderate high-quality evidence supports the use of LR-PRP injection for patellar tendinopathy and of PRP injection for plantar fasciitis and donor site pain in patellar tendon graft BTB ACL reconstruction. There is insufficient evidence to routinely recommend PRP for rotator cuff tendinopathy, osteoarthritis of the hip, or high ankle sprains. Current evidence demonstrates a lack of efficacy of PRP for Achilles tendinopathy, muscle injuries, acute fracture or nonunion, surgical augmentation in rotator cuff repair, Achilles tendon repair, and ACL reconstruction.
Summary
PRP is a promising treatment for some musculoskeletal diseases; however, evidence of its efficacy has been highly variable depending on the specific indication. Additional high-quality clinical trials with longer follow-up will be critical in shaping our perspective of this treatment option.
The number of Mesenchymal Stem/Stromal Cells (MSCs) in the human bone marrow (BM) is small compared to other cell types. BM aspirate concentration (BMAC) may be used to increase numbers of MSCs, but ...the composition of MSC subpopulations and growth factors after processing are unknown. The purpose of this study was to assess the enrichment of stem/progenitor cells and growth factors in BM aspirate by two different commercial concentration devices versus standard BM aspiration.
120 mL of BM was aspirated from the iliac crest of 10 male donors. Each sample was processed simultaneously by either Emcyte GenesisCS
(Emcyte) or Harvest SmartPReP2 BMAC (Harvest) devices and compared to untreated BM aspirate. Samples were analyzed with multicolor flow cytometry for cellular viability and expression of stem/progenitor cells markers. Stem/progenitor cell content was verified by quantification of colony forming unit-fibroblasts (CFU-F). Platelet, red blood cell and total nucleated cell (TNC) content were determined using an automated hematology analyzer. Growth factors contents were analyzed with protein quantification assays. Statistical analyses were performed by ANOVA analysis of variance followed by Tukey's multiple comparison test or Wilcoxon matched-pairs signed rank test with p < 0.05 for significance.
Cell viability after processing was approximately 90% in all groups. Compared to control, both devices significantly enriched TNCs and platelets, as well as the CD45-CD73+ and CD45-CD73+CD90+ cell populations. Further, Harvest significantly concentrated CD45-CD10+, CD45-CD29+, CD45-CD90+, CD45-CD105+, CD45-CD119+ cells, and CD45dimCD90+CD271+ MSCs, whereas Emcyte significantly enriched CD45dimCD44+CD271+ MSCs. BM concentration also increased the numbers of CFU-F, platelet-derived growth factor, vascular endothelial growth factor, macrophage colony-stimulating factor, interleukin-1b, VCAM-1 and total protein. Neither system concentrated red blood cells, hematopoietic stem cells or bone morphogenetic proteins.
This data could contribute to the development of BMAC quality control assays as both BMAC systems concentrated platelets, growth factors and non-hematopoietic stem cell subpopulations with distinct phenotypes without loss of cell viability when compared to unprocessed BM.
Background:
Female collegiate athletes with serum relaxin concentrations above 6.0 pg/mL have been shown to have more than 4 times increased risk for anterior cruciate ligament (ACL) tears. However, ...the intracellular effect of relaxin on ACL cells has not been elucidated.
Hypotheses:
The hypotheses were that relaxin binding to receptors on female ACL cells will result in (1) an increase in matrix metalloproteinase (MMP) and decrease in tissue inhibitor of metalloproteinase (TIMP) gene expression, (2) a decrease in collagen and alpha smooth muscle actin (αSMA) expression, (3) inhibition of transforming growth factor β1 (TGFβ1)–induced fibrosis, and (4) an increase in cyclic adenosine 3′,5′-monophosphate (cAMP) production and that these changes will not be observed in male ACL cells.
Study Design:
Controlled laboratory study.
Methods:
Ligament cells from ACL tissue were isolated from 7 male and 7 female human donors and expanded in vitro. The cells were incubated with escalating concentrations of relaxin-2, as well as with TGFβ1 or 17β-estradiol in certain groups. Cells were then lysed and analyzed for MMP1 (collagenase-1), MMP3 (stromelysin-1), MMP13 (collagenase-3), TIMP1, type I collagen, type III collagen, and/or αSMA mRNA expression using quantitative real-time polymerase chain reaction. Intracellular cAMP levels were assessed via an enzyme-linked immunoassay.
Results:
ACL cells primed with estrogen and treated with 10 ng/mL and 100 ng/mL relaxin illustrated increased MMP1 expression (P = .012 and .006, respectively) and MMP3 expression (P = .005 and .001, respectively). Treatment with 100 ng/mL relaxin decreased αSMA expression (P = .001). When ACL tissue isolated from female donors with a history of oral contraceptive use was excluded from the analysis, 100 ng/mL of relaxin decreased type I collagen (P = .005) and type III collagen (P = .028) expression in cells primed with estrogen. Relaxin exhibited no significant effect on male-derived ACL cells.
Conclusion:
Relaxin-2 significantly upregulated intracellular processes in human female ACL cells, but no effect was observed in male cells. Relaxin increased MMP (MMP1 and MMP3) and decreased αSMA and type I and III collagen expression, which may act to alter the structural integrity of the ACL tissue over time.
Clinical Relevance:
Female athletes with higher circulating relaxin levels may be more susceptible to ACL injury.
Platelet-Rich Plasma Le, Adrian D K; Enweze, Lawrence; DeBaun, Malcolm R ...
Clinics in sports medicine
38, Številka:
1
Journal Article
Recenzirano
Platelet-rich plasma (PRP) is a promising treatment for musculoskeletal maladies and clinical data to date have shown that PRP is safe. However, evidence of its efficacy has been mixed and highly ...variable depending on the specific indication. Additional future high-quality large clinical trials will be critical in shaping our perspective of this treatment option. The heterogeneity of PRP preparations, both presently and historically, leads sweeping recommendations about its utility impossible to make. This heterogeneity has also made interpreting existing literature more complicated.
Modern blocking techniques are useful to achieve anatomic alignment and stable fixation during end-segment nailing. Whether with screws or drill bits, blocking implants can correct both angular and ...translational deformities. Understanding the biomechanics of blocking implants allows the surgeon to properly plan their placement based on principles rather than dogma. We use case examples to highlight updates in blocking techniques during acute surgical fixation and chronic deformity correction.
BACKGROUNDThe purpose of this study was to perform a meta-analysis of randomized controlled trials (RCTs) to compare outcomes following intramedullary nailing (IMN) vs. open reduction-internal ...fixation (ORIF) for humeral shaft fractures.METHODSA literature search of 3 databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. RCTs comparing IMN and ORIF for humeral shaft fractures were included. Clinical outcomes were compared using RevMan. P < .05 was considered statistically significant.RESULTSTen RCTs with 512 patients were included. Overall, 8.4% of patients treated with IMN and 6.4% of patients treated with ORIF had nonunion (P = .57, I2 = 0%), with a significantly faster time to union with IMN (10 weeks vs. 11.9 weeks, P < .05). There was no significant difference in the rate of reoperation (11.6% in IMN group vs. 7.6% in ORIF group, P = .26) or radial nerve palsy (2.8% in IMN group vs. 4.2% in ORIF group, P = .58). A lower rate of infection was noted with IMN (1.2% vs. 5.3%, P < .05). Additionally, there was a lower operative time with IMN (61 minutes vs. 88 minutes, P < .05).CONCLUSIONSThe Level I evidence in the literature does not show a significant difference in rates of union, reoperation, or radial nerve palsy between IMN and ORIF for humeral shaft fractures. Overall, treatment with IMN results in a lower infection rate, less operative time, and a modestly quicker time to union. The optimal treatment strategy for humeral shaft fractures may be best informed by fracture pattern and surgeon preference.
To determine the short-term results of surgical treatment with dual posterolateral and posteromedial approaches for fractures of the entire posterior tibial plafond and secondarily to identify common ...fracture characteristics.
Retrospective.
Single academic Level 1 trauma center.
Thirty-five patients with posterior pilon fractures followed until fracture union (minimum 3 months).
Surgical treatment using simultaneous combined posterolateral and posteromedial exposures for fracture reduction and internal fixation.
(1) Surgical outcomes including rate of wound complications and accuracy of the articular reduction. (2) Fracture characteristics including the incidence of articular impaction, comminution interfering with reduction, syndesmosis injury, and the type of fibula fracture.
The rate of wound problems was low (6%), and 94% of patients had an articular reduction with less than 1 mm of step or gap. There were high rates of articular comminution (83%) and posteromedial articular impaction (63%) and a 17% rate of syndesmosis injury requiring repair.
Surgical fixation using simultaneous, combined posterolateral and posteromedial approaches for posterior pilon fractures had a low rate of wound complications and was an effective strategy for obtaining an accurate reduction. The rate of syndesmotic instability requiring fixation was lower than previous work reporting on fixation using a single approach. This may be a useful technique for surgeons who treat these injuries. Careful assessment of the preoperative imaging is required in patients with posterior pilon fractures.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Background:
Supination-adduction (SAD) type II ankle fractures can have medial tibial plafond and talar body impaction. Factors associated with the development of posttraumatic arthritis can be ...intrinsic to the injury pattern or mitigated by the surgeon. We hypothesize that plafond malreducton and talar body impaction is associated with early posttraumatic arthrosis.
Methods:
A retrospective cohort of skeletally mature patients with SAD ankle fractures at 2 level 1 academic trauma centers who underwent operative fixation were identified. Patients with a minimum of 1-year follow-up were included. The presence of articular impaction identified on CT scan was recorded and the quality of reduction on final intraoperative radiographs was assessed. The primary outcome was radiographic ankle arthrosis (Kellgren-Lawrence 3 or 4), and postoperative complications were documented.
Results:
A total of 175 SAD ankle fractures were identified during a 10-year period; 79 patients with 1-year follow-up met inclusion criteria. The majority of injuries resulted from a high-energy mechanism. Articular impaction was present in 73% of injuries, and 23% of all patients had radiographic arthrosis (Kellgren-Lawrence 3 or 4) at final follow-up. Articular malreduction, defined by either a gap or step >2 mm, was significantly associated with development of arthrosis. Early treatment failure, infection, and nonunion was rare in this series.
Conclusion:
Malreduction of articular impaction in SAD ankle fractures is associated with early posttraumatic arthrosis. Recognition and anatomic restoration with stable fixation of articular impaction appears to mitigate risk of posttraumatic arthrosis. Investigations correlating postoperative and long-term radiographic findings to patient-reported outcomes after operative treatment of SAD ankle fractures are warranted.
Level of Evidence:
Level IV, retrospective case series.
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