Osteogenic Potential of a Biomaterial Enriched with Osteostatin and Mesenchymal Stem Cells in Osteoporotic Rabbits.

Mesoporous bioactive glasses (MBGs) of the SiO2-CaO-P2O5 system are biocompatible materials with a quick and effective in vitro and in vivo bioactive response. MBGs can be enhanced by including therapeutically active ions in their composition, by hosting osteogenic molecules within their mesopores, or by decorating their surfaces with mesenchymal stem cells (MSCs). In previous studies, our group showed that MBGs, ZnO-enriched and loaded with the osteogenic peptide osteostatin (OST), and MSCs exhibited osteogenic features under in vitro conditions. The aim of the present study was to evaluate bone repair capability after large bone defect treatment in distal femur osteoporotic rabbits using MBGs (76%SiO2-15%CaO-5%P2O5-4%ZnO (mol-%)) before and after loading with OST and MSCs from a donor rabbit. MSCs presence and/or OST in scaffolds significantly improved bone repair capacity at 6 and 12 weeks, as confirmed by variations observed in trabecular and cortical bone parameters obtained by micro-CT as well as histological analysis results. A greater effect was observed when OST and MSCs were combined. These findings may indicate the great potential for treating critical bone defects by combining MBGs with MSCs and osteogenic peptides such as OST, with good prospects for translation to clinical practice.

Association of Instability History and Off-Track Hill-Sachs Lesions in Anterior Shoulder Instability.

Background: The glenoid track concept is now widely accepted, and its evaluation is considered essential for making decisions about surgery. Purpose: To define preoperative descriptive data and clinical and functional features in patients with anterior glenohumeral instability according to glenoid track status and to analyze the influence of off-track Hill-Sachs (HS) lesions on preoperative shoulder function. Study Design: Case-control study; Level of evidence, 3. Methods: Preoperative magnetic resonance imaging or computed tomography scans were used to measure the glenoid track. Descriptive data and preoperative objective and subjective clinical and functional features were compared between patients with on-track HS lesions versus off-track HS lesions. Multivariate regression analysis was conducted to identify potential risk factors for off-track HS lesion development. Results: A total of 235 patients (201 men, 34 women; mean age, 29.6 ± 8.6 years) were included- 134 shoulders (57%) with on-track HS lesions and 101 shoulders (43%) with off-track HS lesions. Age <20 years at first dislocation, number of dislocations, and ≥2 years between first dislocation and surgery were significantly different between the study groups (P = .005, P = .0001, and P = .01, respectively). Regarding these characteristics, the odds ratios for the risk of developing an off-track lesion were 2.67 (95% CI, 1.2-5.99)-1.2 times higher for each additional instability episode (95% CI, 1.025-1.14) and 2.42 times higher (95% CI, 1.176-4.608) for patients whose first dislocation was ≥2 years before surgery, respectively. Patients with off-track HS lesions had a significantly greater degree of instability (P = .04), worse Rowe scores (48.8 ± 15.3 vs 54.8 ± 28.3 for on-track HS lesions; P = .04), and lower Western Ontario Shoulder Instability scores (975 ± 454 vs 1179 ± 428 for on-track HS lesions; P = .01). Conclusion: Characteristics related to a history of instability (age <20 years at first instability episode, larger number of dislocations, ≥2 years between first dislocation and surgery) were found to be risk factors for the development of an off-track HS lesion in this study. Off-track lesions led to a higher degree of instability and worse objective and subjective preoperative shoulder function versus on-track HS lesions.

Does preoperative glenoid bony defect determine final coracoid graft positioning in arthroscopic Latarjet?

Background: It has been demonstrated that the accurate positioning of the graft is key to restoring shoulder stability and preventing future arthrosis development. Preoperative anteroinferior glenoid bone loss is frequently encountered when performing a Latarjet, and it has not been determined yet if the amount of bony defect can influence graft positioning. The aim of the study was to determine if a preoperative glenoid bony defect has an influence on the final coracoid graft position in the arthroscopic Latarjet procedure. Methods: Fifty-five patients who underwent the arthroscopic Latarjet procedure were included, with a minimum follow-up of 2 years. There were 51 men (92.7%). Mean age was 29.1 (SD 7.63). Western Ontario Shoulder Instability Index, Rowe, and Single Assessment Numeric Evaluation scores were fulfilled. All measurements were performed by a musculoskeletal radiologist based on a multiplanar bidimensional CT scan. Dimensions of the glenoid, glenoid defect, and glenoid track were calculated. Position of the graft was evaluated in the axial (distance to glenoid surface, angulation of the graft and screws) and sagittal planes (percentage of the coracoid graft below the equator) as described by Kany et al and Barth et al respectively. Results: There was a glenoid defect in 41 patients (74.5 %). Mean width of the defect was 4.32 mm (SD 3.08) which represented 15.3% of the native glenoid surface (SD 10.8). 78.2% of the patients were offtrack preoperatively, and 11.9% remained offtrack postoperatively. The final glenoid diameter with the graft was 32.1 mm (SD 4.34). Mean distance from the graft to the glenoid at 50% height was 1.1 mm (SD 2.19 mm) and at 25% height was 1.31 mm (SD 2.05). Mean angulation of the superior and inferior screws were 26.9° (SD 8.2°) and 27.1° (SD 7.35°), respectively. In 81.8% of the cases, the graft was deemed to be flush with the glenoid. The percentage of the coracoid graft under the equator of the glenoid was 71.2 % (SD 21.8). There was not a statistically significant difference in screw angulation or graft positioning in the axial plane when comparing patients who had a glenoid defect with those who did not, or depending on the size (P > .05). Percentage of graft below the equator was, however, lower in patients without bony defect (P = .04). Conclusion: This study showed that accurate position of the coracoid graft is achieved in the presence of a glenoid bony defect. In the cases of intact glenoid, the height of the graft should be carefully evaluated.

Comprehensive arthroscopic management without axillary nerve release or subacromial decompression achieves satisfactory and durable results in young patients with glenohumeral osteoarthritis.

PURPOSE: The comprehensive arthroscopic management (CAM) procedure is a useful joint-preserving option for young or active patients with glenohumeral osteoarthritis (GHOA). Our objective was to evaluate the results and prognostic factors of the CAM procedure without direct axillary nerve release or subacromial decompression. METHODS: A retrospective observational study among patients with GHOA who underwent the CAM procedure was conducted. Neither axillary nerve neurolysis nor subacromial decompression was performed. Both primary and secondary GHOA were considered; the latter was defined as a history of shoulder pathology (mainly instability or proximal humerus fracture). The American Shoulder and Elbow Surgeons scale, Simple Shoulder Test, Visual Analogue Scale, activity level, Single Assessment Numeric Evaluation, EuroQol 5 Dimensions 3 Levels, Western Ontario Rotator Cuff Index, and active range of motion (aROM) were analysed. RESULTS: Twenty-five patients who underwent the CAM procedure met the inclusion criteria. After a mean follow-up of 42.4 ± 22.9 months, we found improvement (p < 0.001) in all postoperative values of the different scales. The procedure increased aROM overall. Patients with arthropathy due to instability showed worse results. The rate of CAM failures, defined as conversion to shoulder arthroplasty, was 12%. CONCLUSIONS: This study showed that the CAM procedure without direct axillary nerve neurolysis or subacromial decompression might be a valid alternative in active patients with advanced GHOA to improve shoulder function (aROM and scores), decrease pain, and delay arthroplasty. This technique showed good subjective functional scores, high patient satisfaction, and a low rate of complications. LEVEL OF EVIDENCE: IV.

Clinical Outcomes of Trapeziometacarpal Arthrodesis with a Mean 3-Year Follow-up.

Background This paper's purpose was to analyze clinical results obtained with trapeziometacarpal arthrodesis and complications comparing different osteosynthesis systems. Methods Thirty-seven trapeziometacarpal arthrodesis were performed in our center in a 7-year period, with a mean age of 52 years and 34 months of follow-up. The implants were distributed homogenously into three groups, using bone grafts in 12.5% of them. Results A 75% achieved complete consolidation with a mean postsurgical Visual Analog Scale (VAS) of 2.4, Kapandji Opposition Score (KOS) of 8.1, lateral pinch strength of 12.1 kg, tripod pinch strength of 3.6 kg, and tip-to-tip strength of 1.5 kg. Consolidation was not achieved in nine patients, of which five were asymptomatic, three reoperated on trapeziectomy and tenosuspension, and one rearthrodesis. No statistical association was found between the implant used and pseudoarthrosis ( p = 0.17), VAS ( p = 0.06), or KOS ( p = 0.45). Conclusions Trapeziometacarpal arthrodesis reduces pain for well-chosen patients. Nonunion has low clinical significance in most cases and does not seem to depend on the use of allograft or the type of implant but on an appropriate surgical technique.

Chronic Isolated Dorsal Dislocation of the Lunate. A Rare Presentation of Carpal Instability.

Isolated dorsal lunate dislocation is a rare injury. Only one case has been reported previously in which the treatment was performed in the chronic stage. In this report, we present the case of a 49-year-old handworker male who presented a dorsal dislocation of the lunate after a traffic accident. He was referred to our clinic 2.5 months later due to an initial misdiagnosis. Surgical treatment was performed and consisted of an open reduction using a nerve-sparing dorsal approach. A complete rupture of the perilunate ligaments and a marked instability of the lunate were detected. Stabilisation of the scapholunate, lunotriquetral and scaphocapitate spaces with a compression screw and Kirschner wires, respectively, was performed. The persistence of pain and functional limitation after the surgery along with an insufficient reduction of the scapholunate space on the X-ray and the development of a fistula on the ulnar edge of the carpus prompted reintervention. A hardware-free total wrist arthrodesis was preferred over other procedures, such as proximal row carpectomy, owing to the important articular damage. At the 3-month follow-up, he was clinically stable, consolidation of arthrodesis was documented and he had returned to his previous activities. Isolated dorsal dislocation of the lunate is a rare lesion. There is no consensus on the management of isolated chronic dislocations of the lunate. The frequent delay in the diagnosis compromises the final outcome of reconstructive techniques and introduces the risk of residual instability, increasing the incidence of chronic pain associated with post-traumatic osteoarthritis. In the case of chronic lesions, treatment with palliative techniques, such as proximal carpectomy or joint arthrodesis, should be considered. How to cite this article: Alonso-Tejero D, Luengo-Alonso G, Jiménez-Díaz V, et al. Chronic Isolated Dorsal Dislocation of the Lunate. A Rare Presentation of Carpal Instability. Strategies Trauma Limb Reconstr 2022;17(1):59-62.

Long term results of lower limb posttraumatic acute bone defects treated with masquelet technique.

INTRODUCTION: Several alternatives are now available when treating posttraumatic acute bone defects. Masquelet's technique represents a safe procedure to treat lower limb open fractures associated with significant bone defects and allows surgeons to try to reduce complications incidence. MATERIAL AND METHODS: Retrospective study based on patients´ record files and images (2015-2017). Twelve patients suffering acute bone defect, treated using Masquelet technique, were evaluated. A total of ten patients were finally included after exclusion criteria were applied. RESULTS: Average time from injury to first stage surgery was 11 days. Free flaps were required in three cases (two latissimus dorsi and one anterolateral thigh flap). Time to second stage surgery was 115 days on average. As bone graft, reaming irrigation-aspiration system was associated to this technique. Consolidation was achieved in all patients but one after an average time of 8.4 months. There was only one case of limb shortening of 20 mm. There was no case of nonunion or infection, and patients could perform daily basic activities independently. VAS mean score was one point one year after final surgery. CONCLUSIONS: Masquelet's technique achieves encouraging results when treating lower limb acute bone defects. Using this technique, surgeons could decrease infection incidence in open fractures with severe bone loss. On the other hand, it is a two-stage surgery process, which makes the process longer.

Predictor variables in acetabular fractures surgically treated.

INTRODUCTION: Up to 25% of acetabular fractures have poor functional outcomes in short-term follow-up. The aim of our study is to analyze predictors related to poor outcome in surgically treated acetabular fractures. Damage to the femoral head cartilage and poor fracture reduction has been reported as predictors to total hip arthroplasty (THA). MATERIAL AND METHODS: retrospective study of 207 consecutive patients with acetabular fractures, over a fourteen-year period. Demographic data, fracture pattern according to AO/OTA, complications related to surgery and predictor variables were analyzed. RESULTS: Analyzing predictor variables, we observed seagull sign, femoral head dislocation, femoral osteochondral damage, acetabular marginal impaction, poor acetabular roof congruency after surgery (p < 0.001) and postoperative fracture congruence (>3mm) (p < 0.023) statistically related to the need of a THA during follow-up. Age (p = 0,98), Sex(p = 0,27), AO-OTA classification (p = 0,10), type of dislocation (p = 0,25), surgical approach (p = 0,57), time to surgery (p = 0,66) and posterior wall involvement (p = 0,06) were not related to THA. Most frequent complication was nerve injury, affecting 22 patients (20.18%). Only seventeen patients (15.6%) needed a THA at an average time of 6 years after initial open reduction and internal fixation. CONCLUSION: Femoral head damage and dislocation, fracture reduction, and seagull sign were the strongest predictors related to THA after surgical treatment of acetabular fractures.

Impact of Sars-Cov-2 pandemic on hip fractures: Clinical and radiographic outcomes.

Introduction: Hip fractures affecting older people are at a higher risk of complications during the SARS-CoV-2 pandemic. The aim of this study is to provide data about proximal femoral fractures management and early outcomes during COVID-19 pandemic compared to the same period in 2019. Material and Methods: Retrospective and comparative study performed in two different periods were analyzed: from March 15, 2020, to April 30, 2020 (the first six weeks of Spain´s current confinement) and the same period in 2019. Data regarding demographics (age and sex, housing), type of fracture, surgical performance, early outcomes (at 30 days), and at 1-year follow-up were collected. A total of 146 patients were evaluated, 89 in 2019 and 57 in 2020. Results: Despite the drop ∼35.6% in hip fractures during SARS-CoV-2 period, distribution (age (P = 0.985), sex (P = 0.43), housing (P = 0.61), type of fracture (P = 0.41)) and Charlson comorbidity index (P = 0.12) were similar to a 2019 period. Surgical performance did not worsen in spite of the tough situation and the use of personal protective equipment, improving in some radiological variables (tip-to-apex and calcar reduction). In terms of postoperative outcomes, although there is a tendency to a short-term mortality increase (from 3.4% to 5.2%, P = 0.22), there were no differences at 1-year follow-up (20.2% in 2019 and 20.4% in 2020, P=0.587). In the same line, although in both groups the patients lost functionality at 1 year, there were no significant differences (P = 0.42). Conclusion: Even in challenging times, protocols and adequate organization ensure proper outcomes, reaching satisfying clinical and surgical outcomes during the COVID-19 pandemic, despite an increasing trend in short term mortality not seen at 1-year follow-up.

Arthroscopic Circumferential Release for Stiff Reverse Total Shoulder Arthroplasty.

Stiffness is a well-known complication after reverse shoulder arthroplasty. Although multiple factors may be involved, the main cause for stiffness is rarely identified. Imaging studies frequently are inconclusive in ruling out mechanical or biological causes. Periprosthetic infection should be always suspected, but the absence of major clinical signs and accurate diagnostic tests is frequent. A lack of objective criteria establishing a diagnosis and when to proceed with revision surgery is often present in such cases. Moreover, additional surgical procedures should be carefully evaluated, as they can represent a point of no return. Shoulder arthroscopy plays an increasingly important role in these cases, either as a diagnostic or therapeutic tool. There are no reports about arthroscopy on stiffness after reverse shoulder arthroplasty. In this Technical Note, we describe an arthroscopic technique aimed to identify potential causes of reverse shoulder arthroplasty stiffness. Subsequent circumferential release is described and discussed.

Critical adjustments in a department of orthopaedics through the COVID-19 pandemic.

PURPOSE: SARS-CoV-2's new scenario has forced health systems to work under extreme stress urging to perform a complete reorganization of the way our means and activities were organized. The orthopaedic and trauma units have rescheduled their activities to help SARS-CoV-2 units, but trauma patients require also treatment, and no standardized protocols have been established. METHODS: A single-centre cross-sectional study was performed in a tertiary hospital. Two different periods of time were analyzed: a two week period of time in March 2019 (pre-SARS-CoV-2) and the same period in March 2020 (SARS-CoV-2 pandemic time). Outpatient's data, emergency activity, surgical procedures, and admissions were evaluated. Surgeons' and patient's opinion was also evaluated using a survey. RESULTS: A total of ~ 16k (15,953) patients were evaluated. Scheduled clinical appointments decreased by ~ 22%. Urgent consultations and discharge from clinics also descended (~ 37% and ~ 20% respectively). Telemedicine was used in 90% of outpatient clinical evaluations. No elective surgical procedures during SARS-CoV-2 time were scheduled, and subtracting the effect of elective surgeries, there was a reduction of inpatient surgeries, from ~ 85% to ~ 59%. Patients delayed trauma assistance more than 48 hours in 13 cases (35%). Pre-operative admission for hip fractures decreased in ten hours on average. Finally, surveys stated that patients were more in favour than surgeons were to this new way to evaluate orthopaedic and trauma patients based strongly on telemedicine. CONCLUSION: Detailed protocols should be standardized for surgical departments during the pandemic. This paper offers a general view in how this virus affects an orthopaedic unit and could serve as a protocol and example for orthopaedic and trauma units. Even in the worst scenario, an orthopaedic and trauma unit could offer an effective, efficient, and quality service. SARS-CoV-2 will set up a new paradigm for health care in orthopaedics and trauma.

Denosumab treatment for giant-cell tumor of bone: a systematic review of the literature.

BACKGROUND: Denosumab is a human monoclonal antibody (mAb) that specifically inhibits tumor-associated bone lysis through the RANKL pathway and has been used as neoadjuvant therapy for giant-cell tumor of bone (GCTB) in surgical as well as non-surgical cases. The purpose of this systematic review of the literature, therefore, is to investigate: (1) demographic characteristics of patients affected by GCTBs treated with denosumab and the clinical impact, as well as, possible complications associated with its use (2) oncological outcomes in terms of local recurrence rate (LRR) and development of lung metastasis, and (3) characteristics of its treatment effect in terms of clinical, radiological, and histological response. METHODS: A systematic review of the literature was conducted using PubMed, EMBASE, and COCHRANE search including the following terms and Boolean operators: "Denosumab" AND "primary bone tumor", "denosumab" AND "giant cell tumor", "denosumab" AND "treatment", and finally, "denosumab" AND "giant cell tumor" AND "treatment" since 2000. After applying inclusion and exclusion criteria, a total of 19 articles were included. The quality of the included studies was assessed using STROBE for the assessment of observational studies. RESULTS: A total of 1095 patients were included across all 19 studies. Across all the studies included, there were 615 females and 480 males. The mean patient age was 33.7 ± 8.3 years when starting the denosumab treatment. The pooled weighted local recurrence rate was 9% (95% CI 6-12%) and the pooled weighted metastases rate was 3% (95% CI 1-7%). The most common adverse event was fatigue and muscular pain. Radiologic response was estimated to occur in 66-100% of the patients. A significant reduction in pain under denosumab treatment was reported in seven studies and additional improvement in function and mobility was reported by several authors. Only two studies reported musculoskeletal tumor society (MSTS) scores which were better after denosumab treatment. CONCLUSIONS: The use of denosumab as an adjuvant treatment of GCTB has shown a positive but variable histological response with consistent radiological changes and several types of adverse effects. There is a positive clinical response in terms of pain relief with decrease on the morbidity of surgical procedures to be performed. Finally, oncological outcomes are disparate with neither effect on metastatic disease nor local recurrence rates. LEVEL OF EVIDENCE: IV.

Skeletal muscle metastasis from the most common carcinomas orthopedic surgeons deal with. A systematic review of the literature.

INTRODUCTION: There is scarce information in the literature dealing with the clinical presentation, management and oncologic outcomes of skeletal muscle metastases (SMM). We sought to perform a systematic review of the literature to investigate: (1) tumor characteristics of SMM, (2) therapeutic approach, and (3) oncological outcomes. METHODS: A systematic review of the literature was performed using PubMed and EMBASE search engines. A total of 3231 references were reviewed and 49 studies were included. Demographic data, presentation characteristics, and oncological outcomes were recorded. Statistical analysis was performed using SPSS 22.0 software (IBM; Armonk, New York) and Comprehensive Meta-Analysis software version 3 (Biostat, Inc.), with p < 0.05 as statistically significant. RESULTS: A total of 231 patients were included. These tumors presented more commonly on males 58.4% (135/231), with a mean age of 60.08 ± 10.6 years, and in the axial area 39.6% (88/222). The most common carcinoma type was lung 41.1% (95/231). Resection of a single metastases did not change survival significantly (p = 0.992). LRR was higher within the group of patients that underwent WLE compared with non-WLE [31.3% (23/74) vs. 8.7% (2/23), p ≤ 0.001]. Kaplan-Meier survival analysis for the entire cohort showed an estimate of 15.3 months [95% confidence interval (CI) 11.6-19; standard error (SE) 0.432], with lung carcinoma carrying the worst prognosis 6.7 months (95% CI 5.4-8.07; SE 0.68). Patients with a single SMM showed a worse estimate mean survival time compared to patients with multiple metastases limited to muscles [8.6 months (95% CI 4.7-12.5; SE 2.0) vs 25.4 months (95% CI 19.8-31.05; SE 2.8; p ≤ 0.001)]. CONCLUSIONS: Overall survival is poor and is driven mainly by the type of carcinoma. An Increased LRR might be present due to the systemic nature of the condition, and degree of control of the primary carcinoma.