Different coupling mechanisms for a novel modular plate in acetabular fractures-a comparison using a laparoscopic model.

Introduction: Acetabular fractures are among the most challenging injuries in traumatology. The complex anatomy usually requires extensive surgical approaches baring the risk for iatrogenic damage to surrounding neurovascular structures. As a viable alternative, minimally invasive endoscopic techniques have emerged during the recent years. This paper reports on the feasibility of different coupling mechanisms for a novel suprapectineal plate especially designed for minimally invasive acetabular surgery. Methods: A total number of 34 participants contributed to the present study, who differed in their arthroscopic and surgical experience. A laparoscopic model was used to compare four different coupling mechanisms by the number of failed attempts, the time required for plate fixation, the influence of surgical experience as well as the learning success for each individual coupling mechanism. Moreover, the feasibility of each mechanism was evaluated by a questionnaire. Results: The results demonstrate that plates employing grooved and pressure-sliding coupling mechanisms exhibit fewer failed attempts and reduce trial times, especially in contrast to sole sliding mechanisms. Furthermore, our study revealed that proficiency in endoscopic procedures significantly influenced the outcome. Notably, the subjective evaluation of the participants show that the pressure base and pressure-slide base plate designs are the most supportive and feasible designs. Conclusions: In summary, the present study evaluates for the first-time different plate and coupling designs for minimal-invasive surgery, indicating a superior feasibility for plates with a grooved and pressure-sliding mechanism.

[Primary joint replacement for the treatment of acetabular fractures]. / Primär endoprothetische Versorgung von Acetabulumfrakturen.

Open reduction and internal fixation are the gold standard for the treatment of dislocated acetabular fractures. A primary joint replacement is only justified in isolated cases. The indications are merely non-reconstructable acetabular fractures, accompanying displaced fractures of the femoral neck and non-reconstructable fractures of the femoral head.Because of the difficulties in achieving sufficient cup stability, joint replacement for the treatment of acetabular fractures regularly requires implants designed for revision arthroplasty. The Kocher-Langenbeck approach provides the most versatile options, as it enables simultaneous stabilization of the dorsal acetabular structures, which are essential for the stability of the cup.For primary joint replacement as a treatment of acetabular fractures, survival of the prosthetic cup is markedly worse when compared to elective primary joint replacement. Particularly in younger patients but also in aged patients, every effort should be made to achieve a press fit of the cup. In most cases, this will include reduction and fixation of the fracture for stabilization of the acetabulum prior to joint replacement. A staged approach with an early secondary replacement intervention seems to provide better overall results than simultaneous fracture fixation and joint replacement.

Clinical Experience with the New EASY (Endoscopic Approach to the Symphysis) Preparation Technique for Injuries of the Anterior Pelvic Ring.

BACKGROUND: High-energy injuries of the anterior pelvic ring and especially disruptions of the pubic symphysis usually require surgical stabilization. There is a conflict between biomechanical stability and size in the surgical approach. We have previously presented a minimally invasive approach for symphyseal plating. METHODS: Our current endoscopic surgical technique is presented step-by-step and is illustrated in a video. The results and courses of the first seven patients treated with the EASY preparation are presented. RESULTS: In all seven patients, the EASY preparation was successful. In four of the seven patients with an anterior pelvic ring injury, we performed a complete endoscopic plate osteosynthesis of the pubic symphysis. One patient gave consent only for endoscopic preparation, in one patient, we converted to open plate due to ventilation problems, and in one patient, the superior pubic rami fracture was stable. There were no surgical complications. CONCLUSION: The EASY is a feasible minimally invasive preparation technique to stabilize anterior pelvic ring injuries in the most biomechanically stable manner by performing plate osteosynthesis. However, further scientific monitoring is necessary to improve the technique and validate our data.

"Floating Hip": Epidemiology and Quality of Care. / "Floating Hip": Epidemiologie und Qualität der Versorgung.

INTRODUCTION: The "floating hip" is a rare and complex fracture involving the pelvis and the ipsilateral femur and is therefore difficult to treat. Data and studies on this topic are still scarce. The optimal strategy for surgical treatment and thus the resulting quality of treatment are still being debated; a femur-first strategy is often the preferred treatment. METHODS: Retrospectively, patients with a pelvic fracture treated at the Level I Trauma Centre of the University of Tübingen between 2003 and 2017 were identified. Patients with an additional ipsilateral femur fracture were identified in this collective. We compared the quality of treatment of pelvic fractures between floating and non-floating hip injuries. RESULTS: Proximal femur fractures were more common with pelvic ring fractures (n = 16) than with acetabular fractures (n = 1). Floating hip injuries occur more frequently in younger polytraumatised male patients. Pelvic fractures in floating hip injuries are operated more frequently (62.8% vs. 39.1%; p = 0.003) and the clinical course is significantly longer (27.8 ± 19.3 vs. 19.9 ± 23.1 days; p < 0.001). However, the quality of treatment of pelvic fracture, exemplified by morbidity (18.6% vs. 14.6%; p = 0.610) and mortality (7.0% vs. 2.6%; p = 0.108), shows no differences. CONCLUSION: Injury severity and complexity of pelvic fracture is significantly higher in floating hip injuries, but without affecting the resulting quality of treatment. A "femur first" treatment strategy is preferable. Algorithms for emergency treatment and definitive care are proposed in a flowchart.

Deep Learning in the Detection of Rare Fractures - Development of a "Deep Learning Convolutional Network" Model for Detecting Acetabular Fractures. / Deep Learning in der Erkennung seltener Frakturen ­ Entwicklung eines "Deep Convolutional Neural Network" (DCNN) am Beispiel der Azetabulumfraktur.

BACKGROUND: Fracture detection by artificial intelligence and especially Deep Convolutional Neural Networks (DCNN) is a topic of growing interest in current orthopaedic and radiological research. As learning a DCNN usually needs a large amount of training data, mostly frequent fractures as well as conventional X-ray are used. Therefore, less common fractures like acetabular fractures (AF) are underrepresented in the literature. The aim of this pilot study was to establish a DCNN for detection of AF using computer tomography (CT) scans. METHODS: Patients with an acetabular fracture were identified from the monocentric consecutive pelvic injury registry at the BG Trauma Center XXX from 01/2003 - 12/2019. All patients with unilateral AF and CT scans available in DICOM-format were included for further processing. All datasets were automatically anonymised and digitally post-processed. Extraction of the relevant region of interests was performed and the technique of data augmentation (DA) was implemented to artificially increase the number of training samples. A DCNN based on Med3D was used for autonomous fracture detection, using global average pooling (GAP) to reduce overfitting. RESULTS: From a total of 2,340 patients with a pelvic fracture, 654 patients suffered from an AF. After screening and post-processing of the datasets, a total of 159 datasets were enrolled for training of the algorithm. A random assignment into training datasets (80%) and test datasets (20%) was performed. The technique of bone area extraction, DA and GAP increased the accuracy of fracture detection from 58.8% (native DCNN) up to an accuracy of 82.8% despite the low number of datasets. CONCLUSION: The accuracy of fracture detection of our trained DCNN is comparable to published values despite the low number of training datasets. The techniques of bone extraction, DA and GAP are useful for increasing the detection rates of rare fractures by a DCNN. Based on the used DCNN in combination with the described techniques from this pilot study, the possibility of an automatic fracture classification of AF is under investigation in a multicentre study.

[Cement augmentation in pelvic ring fractures]. / Zementaugmentation bei Beckenringfrakturen.

Cement augmentation of sacroiliac (SI) screws in the posterior pelvic ring has been shown to provide greater biomechanical stability in cadaveric studies. Pelvic ring fractures are relatively rare compared to the total number of fractures. Nevertheless, the 1­year mortality rate of up to 27% is very high, especially for geriatric pelvic ring fractures and is also largely associated with reduced mobility due to the fracture. The primary goal of treatment is therefore the restoration of patient mobility. This requires the achievement of sufficient stability of the pelvic ring. As osteoporosis is often a causative factor for the pelvic ring fracture, a more stable anchoring of the implants in the osteoporotic bone can be achieved by cement augmentation. This article presents the possibilities of cement augmentation of the pelvic ring and describes the technique of cement-augmented SI screws.

Patients with combined pelvic and spinal injuries have worse clinical and operative outcomes than patients with isolated pelvic injuries analysis of the German Pelvic Registry.

BACKGROUND: Pelvic fractures are often associated with spine injury in polytrauma patients. This study aimed to determine whether concomitant spine injury influence the surgical outcome of pelvic fracture. METHODS: We performed a retrospective analysis of data of patients registered in the German Pelvic Registry between January 2003 and December 2017. Clinical characteristics, surgical parameters, and outcomes were compared between patients with isolated pelvic fracture (group A) and patients with pelvic fracture plus spine injury (group B). We also compared apart patients with isolated acetabular fracture (group C) versus patients with acetabular fracture plus spine injury (group D). RESULTS: Surgery for pelvic fracture was significantly more common in group B than in group A (38.3% vs. 36.6%; p = 0.0002), as also emergency pelvic stabilizations (9.5% vs. 6.7%; p < 0.0001). The mean time to emergency stabilization was longer in group B (137 ± 106 min vs. 113 ± 97 min; p < 0.0001), as well as the mean time until definitive stabilization of the pelvic fracture (7.3 ± 4 days vs. 5.4 ± 8.0 days; p = 0.147). The mean duration of treatment and the morbidity and mortality rates were all significantly higher in group B (p < 0.0001). Operation time was significantly shorter in group C than in group D (176 ± 81 min vs. 203 ± 119 min, p < 0.0001). Intraoperative blood loss was not significantly different between the two groups with acetabular injuries. Although preoperative acetabular fracture dislocation was slightly less common in group D, postoperative fracture dislocation was slightly more common. The distribution of Matta grades was significantly different between the two groups. Patients with isolated acetabular injuries were significantly less likely to have neurological deficit at discharge (94.5%; p < 0.0001). In-hospital complications were more common in patients with combined spine plus pelvic injuries (groups B and D) than in patients with isolated pelvic and acetabular injury (groups A and C). CONCLUSIONS: Delaying definitive surgical treatment of pelvic fractures due to spinal cord injury appears to have a negative impact on the outcome of pelvic fractures, especially on the quality of reduction of acetabular fractures.

Pararectus approach vs. Stoppa approach for the treatment of acetabular fractures - a comparison of approach-related complications and operative outcome parameters from the German Pelvic Registry.

PURPOSE: The Pararectus approach has been introduced as an alternative anterior approach to the Stoppa approach in acetabular surgery. There is no evidence which approach should be preferred, especially regarding approach-related complications. Therefore, aim of this registry study was to compare the Pararectus approach to the Stoppa approach regarding complications and quality of reduction. METHODS: Patients from the German Pelvic Registry with a surgically treated acetabular fracture, either through the Pararectus approach or the Stoppa approach, were analyzed or compared regarding demographic, clinical and operative parameters. RESULTS: In total, 384 patients with an acetabular fracture received a surgical procedure with either the Pararectus approach (n=120) or the Stoppa approach (n=264). There were no differences between the two groups regarding demographic parameters and fracture pattern. The overall complication rate (35.0% vs. 31.4%), the mortality rate (5.0% vs. 3.0%) and the osteosynthesis-associated complication rate (5.8% vs. 4.2%) tended to be higher in the Pararectus group with no statistical significance. There were significantly more anatomical reductions in the Pararectus group (56% vs. 43%; p=0.01). However, operation time was significantly longer in the Pararectus group (255±125 vs. 205±103 minutes; p<0.001). CONCLUSION: Despite a longer operation time, the Pararectus approach and the Stoppa approach are equivalently applicable for the treatment of acetabular fractures regarding complication rates and quality of reduction. LEVEL OF EVIDENCE: III, retrospective comparative study.

Robotic-assisted plate osteosynthesis of the anterior pelvic ring and acetabulum: an anatomical feasibility study.

Pelvic ring injuries or acetabular fractures present a challenge to trauma surgeons. Recently, endoscopic dissection techniques for visualization of the anterior pelvic ring and acetabulum have been presented. Robotic-assisted surgical systems offer advantages in terms of improved visualization and easier instrument handling. The aim of this pilot anatomic study was to verify the feasibility of robotic-assisted plate osteosynthesis on the anterior pelvic ring and acetabulum. The experiment was performed on a human whole body specimen. The DaVinci system with standard instruments as used in RARP was used. After docking the system, the anterior pelvic ring was first prepared as previously described for the endoscopic techniques. This was followed by dissection of both acetabula analogous to pelvic lymphadenectomy as performed during RARP. After the dissection was performed along the pelvic brim up to the iliosacral joint, the complete anterior column of the acetabulum including quadrilateral surface and incisura ischiadica major could be visualized. Finally, robotic-assisted endoscopic plate osteosynthesis was performed on the symphysis and anterior acetabular column as previously described in the endoscopic techniques. Robotic-assisted plate osteosynthesis of the anterior pelvic ring and acetabulum is feasible with the available robotic-assisted systems. Due to the excellent freedom of movement of the robotic arms, combined with the magnifying 3D visualization of the system, highly accurate preparation of the situs in preparation for plate osteosynthesis can be performed. The question of reduction of dislocated fractures remains open and is the subject of further investigation. Compared with conventional laparoscopy, robotic-assisted preparation nevertheless appears to offer an advantage in view of the complexity of the operation.

Evaluation of decision-making in the treatment of acetabular fractures.

Treatment of acetabular fractures is challenging and risky, especially when surgery is performed. Yet, stability and congruity of the hip joint need to be achieved to ensure early mobilization, painlessness, and good function. Therefore, coming up with an accurate decision, whether surgical treatment is indicated or not, is the key to successful therapy. Data from the German pelvic Trauma Registry (n = 4213) was evaluated retrospectively, especially regarding predictors for surgery. Furthermore, a logistic regression model with surgical treatment as the dependent variable was established. In total, 25.8% of all registered patients suffered from an acetabular fracture and 61.9% of them underwent surgery. The fracture classification is important for the indication of surgical therapy. Anterior wall fractures were treated surgically in 10.2%, and posterior column plus posterior wall fractures were operated on in 90.2%. Also, larger fracture gaps were treated surgically more often than fractures with smaller gaps (>3 mm 84.4%, <1 mm 20%). In total, 51.4% of women and 66.0% of men underwent surgery. Apart from the injury severity score (ISS), factors that characterize the overall picture of the injury were of no importance for the indication of a surgical therapy (isolated pelvic fracture: 62.0%, polytrauma: 58.8%). The most frequent reason for non-operative treatment was 'minimal displacement' in 42.2%. Besides fracture classification and fracture characteristics, no factors characterizing the overall injury, except for the ISS, and unexpectedly gender, are important for making a treatment decision. Further studies are needed to determine the relevance of these factors, and whether they should be used for the decision-making process, in particular surgeons with less experience in pelvic surgery, can orient themselves to.

Fractures of the femoral head: a narrative review.

Fractures of the femoral head are rare injuries, which typically occur after posterior hip dislocation.The Pipkin classification, developed in 1957, is the most commonly used classification scheme to date.The injury is mostly caused by high-energy trauma, such as motor vehicle accidents or falls from a significant height.Emergency treatment consists of urgent closed reduction of the hip joint, followed by non-operative or operative treatment of the femoral head fracture and any associated injuries.There is an ongoing controversy about the suitable surgical approach (anterior vs. posterior) for addressing fractures of the femoral head. Fracture location, degree of displacement, joint congruity and the presence of loose fragments, as well as concomitant injuries are crucial factors in choosing the adequate surgical approach.Long-term complications such as osteonecrosis of the femoral head, posttraumatic osteoarthritis and heterotopic ossification can lead to a relatively poor functional outcome. Cite this article: EFORT Open Rev 2021;6:1122-1131. DOI: 10.1302/2058-5241.6.210034.

Endoscopically assisted implant removal of a symphyseal pelvic plate - A case report.

INTRODUCTION: The approach-related morbidity rate in the care of pelvic fractures is still high. Endoscopic procedures are known to significantly reduce access-related complications. Recently, a new endoscopically assisted implantation technique for plate osteosynthesis on the anterior pelvic ring has been described as the "Endoscopic Approach to the Symphysis". CASE REPORT: We present a case of a 29-year old male with a pelvic injury (AO type 61B2.3a) initially treated with a supraacetabular external fixator. After one week the definitive stabilization was performed by an endoscopically assisted symphyseal plating as well as a percutaneous iliosacral screw on the right side. One year after primary surgery, we performed an endoscopically assisted removal of the symphyseal plate using standard laparoscopic instruments. RESULTS: We demonstrate the feasibility of an endoscopically assisted implant removal at the anterior pelvic ring. No complications occurred during the procedure. The patient was discharged after a regular time of surveillance and with an adequate decline of pain. DISCUSSION: While we were able to show that the endoscopically assisted implantation as well as the removal of a plate osteosynthesis on the anterior pelvic ring is possible, there is still further research necessary, especially regarding the development of specific endoscopic instruments. This should enable operating times similar to the standard open procedures.

Mentored undergraduate operating room teaching during the orthopedic trauma curriculum-No evidence of gender differences.

BACKGROUND: In many surgical disciplines, the interest among medical students to pursue a surgical career decreases during their medical studies. The same goes for students after graduation. The aim of our cohort study was to evaluate the operating room (OR) experiences of medical students during our curriculum. MATERIALS AND METHODS: Over the course of one year 217 senior year medical students were included in our study. All of them took part in our training program for senior year medical students, which consisted of a 1-week clinical rotation including visits to the OR. We developed a Likert-scaled questionnaire, which was evaluated anonymously; free text answers were also possible. RESULTS: Prior to the analysis of the sex and age differences, we confirmed that the evaluation scale provided a coherent measure of the OR evaluation. As a first proxy, we conducted a series of Spearman correlations which revealed high intercorrelations between all of the six items of the questionnaire, r(154) = 0.53 to r(154) = 0.94, all p < 0.001. These high intercorrelations transferred into a very high consistency of the six questions that evaluate the OR teaching; Cronbach's α = 0.95. There was no main effect of sex, F (1,146) = 2.19, p = 0.141. However, there was a main effect of age, F (2,146) = 3.75, p = 0.026, indicating that older participants evaluated the OR teaching more positively. Finally, there was no correlation between sex and age group, F (2,146) < 1, indicating that the effect of age on the evaluation score was equally pronounced for female and male participants. DISCUSSION: The aim of this study was to answer the question how mentored OR teaching during the orthopedic trauma curriculum is evaluated by medical students, and whether there are gender-specific differences. For this purpose we prospectively evaluated senior year medical students over a period of 12 months during the orthopedic trauma curriculum with questionnaires. The medical students rated the mentored OR visits mainly positive. CONCLUSION: Previously published literature as well as our presented data indicate that the interest of medical students in starting a surgical career can only be increased if negative influencing factors are reduced. This includes especially positive communication with medical students and in daily professional interaction.

Laparoscopic Acetabular Surgery (LASY) - vision or illusion?

Displaced acetabular fractures usually require open surgical approaches. Aim of this cadaver study was to evaluate a laparoscopic approach to prepare the anterior acetabular column and the quadrilateral plate in analogy to the laparoscopic pelvic lymphadenectomy. The laparoscopic preparation and anatomy is presented and illustrated step by step in a human cadaver followed by a modular plate osteosynthesis of the anterior column involving the quadrilateral plate is performed via a minimally invasive approach using standard laparoscopic instruments. In conclusion we could demonstrate that the laparoscopic preperitoneal preparation of the acetabulum according to the laparoscopic pelvic lymphadenectomy provides more free range for the surgical instruments compared to a previously described total extraperitoneal approach. The development of specific reduction tools and implants is under investigation. Until then, at least the laparoscopic preparation could be introduced in the clinical setting in the near future. TYPE OF STUDY: Technical note - Cadaver study.

Comparison of pelvic C-clamp and pelvic binder for emergency stabilization and bleeding control in type-C pelvic ring fractures.

Severe bleeding is the major cause of death in unstable pelvic ring fractures. Therefore, a quick and efficient emergency stabilization and bleeding control is inevitable. C-clamp and pelvic binder are efficient tools for temporary bleeding control, especially from the posterior pelvic ring. Yet the C-clamp requires more user knowledge, training and equipment. However, whether this makes up for a more efficient bleeding control, is still under debate. Patients with a type-C pelvic ring fracture were identified from the German Pelvic Registry (GPR) and divided into three groups of 40 patients (1. no emergency stabilization, 2. pelvic binder, 3. C-clamp). The matching occurred according to the parameters age, gender, initial RR and initial HB. Complication-and mortality rates were compared especially regarding bleeding control. Regarding ISS and fracture dislocation there was no difference. The use of the C-clamp resulted in more complications, a higher mortality rate due to severe bleeding and more blood transfusions were admitted. Moreover the pelvic binder was established noticeably faster. However, the C-clamp was more often rated as effective. There is no evidence of advantage comparing the C-clamp to the pelvic binder, regarding bleeding control in type-C pelvic ring fractures. In fact, using the pelvic binder even showed better results, as the time until established bleeding control was significantly shorter. Therefore, the pelvic binder should be the first choice. The C-clamp should remain a measure for selected cases only, if an adequate bleeding control cannot be achieved by the pelvic binder.

Asymptomatic and Unnoticed Intra-articular Screw Over 18 Years after Fracture of the Posterior Wall of the Acetabulum - a Question of Stability? / Asymptomatische und unbemerkte intraartikuläre Schraubenlage über 18 Jahre nach Wandfraktur des hinteren Azetabulums ­ eine Frage der Stabilität?

Fractures of the posterior wall of the acetabulum occur in a frequency of 25 - 30%. Multifragmentary fractures involving 40 - 50% of the acetabular surface, the quality of reduction as well as involvement of cartilage and acetabular labrum are considered to have an impact on the development of a reduced posterior stability of the hip joint. This results in a shift of the main weight bearing area with development of a posttraumatic osteoarthritis. In the presented case, a 42-year old male patient was operated on 18 years ago due to a posterior acetabular wall fracture. Retrospectively, one of the screws was located partially intraarticular. However, the patient was asymptomatic over the 18-year period. The first consultation was due to unspecific symptoms of osteoarthritis of the right hip joint especially during flexion and external rotation. Due to only mild radiological signs of osteoarthritis, we indicated only the removal of the intraarticular screw. The symptoms postoperatively switched to a feeling of instability, so a total hip arthroplasty was performed. Since the operation, the patient is asymptomatic regarding the hip joint. The intraarticular screw seemed to stabilize the hip joint. This case demonstrates the importance of a good posterior guidance for the stability of the hip joint on one hand. On the other hand, it demonstrates the minor stress load of the posterior acetabular region, especially after fracture of the posterior wall. Therefore, a good posterior guidance should be one major aim of treatment of posterior acetabular wall fractures.

Risks and Strategies to Avoid Approach-Related Complications During Operative Treatment of Pelvic Ring or Acetabular Fractures. / Risiken und Komplikationsvermeidungsstrategien bei der chirurgischen Zugangspräparation zur operativen Stabilisierung von Beckenringverletzungen und Azetabulumfrakturen.

Injuries of the pelvic ring or the acetabulum are either to be found in young patients with high energy trauma mechanisms or in geriatric patients after simple falls with very low impact energy. The indication for surgical stabilization is given by the grade of instability. Exact knowledge of the different possible surgical approaches is essential for the planning of the surgical treatment. Both, knowledge of reachable anatomical structures and possible risks of the different approaches are important. In this review, we summarize the standard surgical approaches to the pelvic ring and to the acetabulum. We describe the reachable anatomical structures for each approach, approach-related pitfalls, and we focus on strategies to reduce approach-related complications.

Material-Dependent Formation and Degradation of Bone Matrix-Comparison of Two Cryogels.

Cryogels represent ideal carriers for bone tissue engineering. We recently described the osteogenic potential of cryogels with different protein additives, e.g., platelet-rich plasma (PRP). However, these scaffolds raised concerns as different toxic substances are required for their preparation. Therefore, we developed another gelatin (GEL)-based cryogel. This study aimed to compare the two scaffolds regarding their physical characteristics and their influence on osteogenic and osteoclastic cells. Compared to the PRP scaffolds, GEL scaffolds had both larger pores and thicker walls, resulting in a lower connective density. PRP scaffolds, with crystalized calcium phosphates on the surface, were significantly stiffer but less mineralized than GEL scaffolds with hydroxyapatite incorporated within the matrix. The GEL scaffolds favored adherence and proliferation of the osteogenic SCP-1 and SaOS-2 cells. Macrophage colony-stimulating factor (M-CSF) and osteoprotegerin (OPG) levels seemed to be induced by GEL scaffolds. Levels of other osteoblast and osteoclast markers were comparable between the two scaffolds. After 14 days, mineral content and stiffness of the cryogels were increased by SCP-1 and SaOS-2 cells, especially of PRP scaffolds. THP-1 cell-derived osteoclastic cells only reduced mineral content and stiffness of PRP cryogels. In summary, both scaffolds present powerful advantages; however, the possibility to altered mineral content and stiffness may be decisive when it comes to using PRP or GEL scaffolds for bone tissue engineering.