Bone grafts and biomaterials substitutes for bone defect repair: A review.

BACKGROUND\nReoperations after intertrochanteric fractures are often necessitated by fracture displacement following mobilization of the patient. The biomechanical complexity of the fracture, the position of the implant, and the patient's characteristics are known to influence postoperative outcome. We investigated the importance of an intact lateral femoral wall as a factor in postoperative fracture displacement after fixation with a sliding compression hip screw.\n\n\nMETHODS\nTwo hundred and fourteen consecutive patients with an intertrochanteric fracture were treated with a 135 degrees sliding compression hip screw with a four-hole side-plate between 2002 and 2004. The fractures were classified on preoperative radiographs according to the AO/OTA classification system. The status of the greater and lesser trochanters, the integrity of the lateral femoral wall, and the position of the implant were assessed postoperatively. Reoperations due to technical failure were recorded for six months postoperatively.\n\n\nRESULTS\nOnly 3% (five) of 168 patients with an intact lateral femoral wall postoperatively underwent a reoperation within six months, whereas 22% (ten) of forty-six patients with a fractured lateral femoral wall were operated on again (p < 0.001). Multivariate logistic regression analyses combining demographic and biomechanical parameters showed a compromised lateral femoral wall to be a significant predictor of a reoperation (p = 0.010). Seventy-four percent (thirty-four) of the forty-six fractures of the lateral femoral wall occurred during the operative procedure itself. A fracture of the lateral femoral wall occurred in only 3% (three) of the 103 patients with an AO/OTA type-31-A1.1, A1.2, A1.3, or A2.1 intertrochanteric fracture compared with 31% (thirty-one) of the ninety-nine with an AO/OTA type 31-A2.2 or A2.3 fracture (p < 0.001).\n\n\nCONCLUSIONS\nA postoperative fracture of the lateral femoral wall was found to be the main predictor for a reoperation after an intertrochanteric fracture. Consequently, we concluded that patients with preoperative or intraoperative fracture of the lateral femoral wall are not treated adequately with a sliding compression hip-screw device, and intertrochanteric fractures should therefore be classified according to the integrity of the lateral femoral wall, especially in randomized trials comparing fracture implants.

Integrity of the Lateral Femoral Wall in Intertrochanteric Hip Fractures : An Important Predictor of a Reoperation. Authors' reply

Bone fracture healing is a complex physiological process relying on numerous cell types and signals. Inflammatory factors secreted by immune cells help to control recruitment, proliferation, differentiation, and activation of hematopoietic and mesenchymal cells. Within this review we will discuss the functional role of immune cells as it pertains to bone fracture healing. In doing so, we will outline the cytokines secreted and their effects within the healing fracture callus. Macrophages have been found to play an important role in fracture healing. These immune cells signal to other cells of the fracture callus, modulating bone healing. Cytokines and cellular signals within fracture healing continue to be studied. The findings from this work have helped to reinforce the importance of osteoimmunity in bone fracture healing. Owing to these efforts, immunomodulation is emerging as a potential therapeutic target to improve bone fracture healing.

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The Role of the Immune Cells in Fracture Healing.

The treatment of large bone defects represents a significant challenge for orthopaedic surgeons. In recent years, biologic agents have also been used to further improve bone healing. Among these, platelet-rich plasma (PRP) is the most exploited strategy. The aim of the present study was to systematically review the available literature to identify: 1) preclinical in-vivo results supporting the rational of PRP use for bone healing; 2) evidence from the clinical practice on the actual clinical benefit of PRP for the treatment of fractures and complications such as delayed unions and non-unions. A systematic review of the literature was performed on the application of PRP in bone healing, using the following inclusion criteria: pre-clinical and clinical reports of any level of evidence, written in English language, published in the last 20 years (1996–2016), on the use of PRP to stimulate long-bone defect treatment, with focus on fracture and delayed/non-unions healing. The search in the Pubmed database identified 64 articles eligible for inclusion: 45 were preclinical in-vivo studies and 19 were clinical studies. Despite the fact that the overall pre-clinical results seem to support the benefit of PRP in 91.1 % of the studies, a more in depth analysis underlined a lower success rate, with a positive outcome of 84.4 % in terms of histological analysis, and even lower values considering radiological and biomechanical results (75.0 % and 72.7 % positive outcome respectively). This was also mirrored in the clinical literature, where the real benefit of PRP use to treat fractures and non-unions is still under debate. Overall, the available literature presents major limitations in terms of low quality and extreme heterogeneity, which hamper the possibility to optimize PRP treatment and translate it into a real clinical benefit despite positive preclinical findings on its biological potential to favour bone healing.

https://link.springer.com/content/pdf/10.1007%2Fs00264-016-3342-9.pdf

Platelet-rich plasma for the treatment of bone defects: from pre-clinical rational to evidence in the clinical practice. A systematic review

The outcome of THA following acetabular fracture was analyzed on 654 patients with a systematic review approach. An uncemented acetabular and femoral component was used in 80.1% and 59.8% of the cases respectively. The median Harris hip score was 88 points. In the early THA group, Kaplan-Meier survivorship analysis with any loosening, osteolysis or revision as the end point revealed that the 10-year cup survival was 81% whereas in the late THA group was 76% (P=0.287). The 10-year survival was 95% for the early stems and 85% for the late ones (P=0.001). Due to their complexity these fractures should be managed in highly specializing units where the expertise of arthroplasty and trauma reconstruction is available.

Total Hip Arthroplasty after Acetabular Fracture: Incidence of Complications, Reoperation Rates and Functional Outcomes: Evidence Today

Fracture union is a 
complex biological process, which depends upon several systemic and local factors. Disturbance of any of these factors may lead to nonunion of the fracture. These nonunions have a huge impact on quality of life as well as socioeconomical aspects. The platelets on activation release a number of growth factors and differentiation factors, which play important role in fracture healing. This study aimed to look for efficacy of platelet-rich plasma in the treatment of established fracture nonunions of long bones. A total of 94 patients with established nonunion of long bone (35 tibia, 30 femur, 11 humerus, 4 radius, 12 ulna, 2 with both radius and ulna) were included in this study. We injected 15–20 ml of autologous platelet-rich plasma (>2,000,000 platelets/μl) under image intensifier at each nonunion site. The fracture union was evaluated clinically and radiologically regularly at monthly interval till 4 months. Eighty-two patients had their fracture united at the end of 4 months. Thirty-four patients showed bridging trabeculae on X-rays at the end of 2 months, while 41 patients showed bridging trabeculae at the end of third month. Twelve patients did not show any attempt of union at 4 months and were labeled as failure of treatment. There were no complications. Platelet-rich plasma is a safe and effective treatment for the treatment of nonunions. More studies are needed to look into molecular mechanism of this fracture healing acceleration by platelet-rich plasma.

Role of autologous platelet-rich plasma in treatment of long-bone nonunions: a prospective study.

Background In this study we describe the morphology of the posteromedial fragment in pertrochanteric fractures using 3D CT scans and answer two questions 1) Do differences exist between the 3D CT appearances of posteromedial fragments and the depictions made in the AO classification 2) Does the posteromedial fragment affect stability in pertrochanteric fractures, in terms of fracture collapse? Methods Preoperative CT scans of eight 31-A1 and fifty 31-A2 fractures were analysed. The presence of PM fragment, its fragmentation, greater trochanter (GT) involvement, lesser trochanter (LT) fragment size (in terms of its posterior and medial extent as well as LT length), LT fragment displacement (in terms of medial displacement and rotation) were determined. All fractures were treated with a DHS. Fracture collapse was determined on postoperative radiographs. The relationship between fracture collapse and patient factors including age, gender, fracture type (A1 versus A2), characteristics of the posteromedial fragment, and the presence of a lateral wall fracture were determined. Results Three out of eight 31-A1 fractures demonstrated a separate GT fragment (three part fracture). Out of the 50 31-A2 fractures, 12 had a single PM fragment, which included the LT and GT in continuity. The more common four part fractures seem to form by further fragmentation of this basic form. In A2 fractures, the GT was almost always broken and the broken fragment comprised a mean 56% of normal GT. The LT fragment involved an average of 74% of the posterior wall, and an average of 36% of the medial wall of the proximal femur. Larger LT fragments were less displaced as compared to smaller fragments. Univariate regression analyses revealed that fracture collapse was significantly correlated with fracture type (A1 versus A2, p 0.036), GT size (p 0.002) and the presence of a lateral wall fracture (p  Conclusions This study revealed some important differences between the 3D CT appearances and AO classification of pertrochanteric fractures. Further, neither fragmentation of the posteromedial fragment, nor the size of the lesser trochanter fragment was found to predict stability in pertrochanteric fractures. A perioperative lateral wall fracture is the main determinant of stability in these fractures.

Morphology of the posteromedial fragment in pertrochanteric fractures: A three-dimensional computed tomography analysis

Patients older than 55 years presenting with acetabular fractures fulfilling the criteria for acute total hip arthroplasty (THA) were included. Cementless THA was done using the Octopus System and autologous bone grafting. 15 patients were available for latest follow up. The average follow-up was 81.5 months (62–122 months). Mean Harris Hip Score was 91.1. 10 patients were walking without any support while 5 were using a cane. There were no cases of acetabular or femoral component loosening. This method of treatment is promising in the older population as there is deficiency of bone stock which may lead to fixation failures. It is, therefore, worthwhile to recommend primary THA using the Octopus system in the successful management of selected types of acetabular fractures in the elderly.

Acute total hip arthroplasty in acetabular fractures in the elderly using the Octopus System: mid term to long term follow-up.

Purpose To define the unique radiographic features, operative treatment, and complications of pertrochanteric fractures (AO/OTA 31-A1 and A2) which are not amenable to the usual closed reduction manoeuvres. Methods During a 2-year period (from August 2011 until December 2013), 212 patients with pertrochanteric fractures were treated at our level I trauma centre. A retrospective review was undertaken to determine which of these fractures were not reducible via the routine closed reduction manoeuvres and required some form of open reduction. These fractures were assessed for radiographic markers of irreducibility, surgical findings, reduction techniques, and perioperative complications. Results Twenty-four patients had fractures, which were not amenable to closed reduction and underwent open reduction. These fractures could be grouped into four patterns. A preoperative CT scan was available for at least two cases of each pattern, which provided further insights into the cause of irreducibility by closed means. These included a variant where the proximal fragment is locked underneath the shaft fragment (3 cases), bisected lesser trochanter with a locked proximal fragment (3 cases), irreducibility due to entrapped posteromedial fragment at the fracture site (6 cases) and a variant where the proximal fragment is flexed passively by the underlying lesser trochanter (12 cases). Conclusions Pertrochanteric fractures, which are not amenable to closed reduction, are uncommon, but are heralded by unique radiographic features. These patients warrant special consideration in terms of recognition and management. The specific radiographic markers should alert the surgeon to this injury pattern and its related difficulty encountered during closed reduction. Once reduction is achieved, however, these fractures follow an uneventful course.

Pertrochanteric fractures (AO/OTA 31-A1 and A2) not amenable to closed reduction: causes of irreducibility.

False aneurysm of the femoral artery is a rare complication of intertrochanteric fracture. Most of these situations are due to iatrogenic trauma or the trauma itself and are rarely caused by dislocated bone fragments. Here we report a case of a 72-year-old man who presented acutely with a pseudoaneurysm of the superficial femoral artery from the spike of a lesser trochanter fragment. Percutaneous endovascular treatment of the pseudoaneurysm with a covered stent was undertaken on an urgent basis. Five days later, the patient was operated upon and the lesser trochanter fragment was excised through an anterior incision and the intertrochanteric fracture was fixed using dynamic hip screws. The fracture was united at 10 weeks. At one-year’s follow-up, there were no graft-related complications. This case illustrates that an intertrochanteric fracture with a displaced lesser trochanter fragment can present acutely with bleeding and a pseudoaneurysm of the femoral artery.

R. A. Singh

Papers

Role of autologous platelet-rich plasma in treatment of long-bone nonunions: a prospective study.

Morphology of the posteromedial fragment in pertrochanteric fractures: A three-dimensional computed tomography analysis

Acute total hip arthroplasty in acetabular fractures in the elderly using the Octopus System: mid term to long term follow-up.

Pertrochanteric fractures (AO/OTA 31-A1 and A2) not amenable to closed reduction: causes of irreducibility.

Acute femoral artery pseudoaneurysm due to lesser trochanter fragment: an unusual complication of an intertrochanteric fracture