LOQTEQ® VA Periprosthetic Plate-A New Concept for Bicortical Screw Fixation in Periprosthetic Fractures: A Technical Note.

Internal fixation using angle stable plates is the treatment standard in periprosthetic fractures around stable implants. To provide instant postoperative full weight-bearing, bicortical screw fixation is advisable but often surgically demanding. This work presents the first clinical results of the LOQTEQ® VA Periprosthetic Plate (aap Implantate AG, Berlin, Germany), a new plate system to simplify screw placement around implants. This plate system uses insertable hinges that allow for variable angle screw anchorage. Data of 26 patients with a mean age of 80 years and a mean follow-up of 13.9 months were retrospectively collected. Patients were clinically and radiologically examined. Bony union was achieved in 14 out of 15 patients with no signs of non-union or implant loosening. One patient, however, presented with implant failure. Clinical scores demonstrated acceptable results. Since the hinge plates are easy to apply, the first results are promising.

Addition of shock wave therapy to nail dynamization increases the chance of long-bone non-union healing.

BACKGROUND: Long-bone non-unions after intramedullary nailing can be treated by nail dynamization or focused high-energy extracorporal shock wave therapy (fESWT). The objective of this study was to assess the effect of the combination therapy of nail dynamization and fESWT on long-bone non-unions. MATERIALS AND METHODS: 49 patients with long-bone non-unions (femur and tibia) after nailing were treated with nail dynamization (group D, n = 15), fESWT (group S, n = 17) or nail dynamization in addition to fESWT (group DS, n = 17). Patients were followed up for 6 months retrospectively. Furthermore, age, sex, Non-Union Scoring System (NUSS) score, time intervals from primary and last surgery until intervention and smoking status were analysed for their correlations to bone union. RESULTS: Union rates were 60% for group D, 64.7% for group S and 88.2% for group DS, with a significant difference between group D and DS (p = 0.024). Successful treatment was correlated with high age (OR 1.131; 95% CI 1.009-1.268; p = 0.034), female gender (OR 0.009; 95% CI 0.000-0.89; p = 0.039), low NUSS score (OR 0.839; 95% CI 0.717-0.081; p = 0.028) and negative smoking status (OR 86.018; 95% CI 3.051-2425.038; p = 0.009). CONCLUSIONS: Data from the present study indicate that the combination therapy of nail dynamization and fESWT leads to a higher union rate than dynamization or fESWT alone. LEVEL OF EVIDENCE: Level 3.

Antibiofilm efficacy of focused high-energy extracorporeal shockwaves and antibiotics in vitro.

AIMS: Biofilm formation is one of the primary reasons for the difficulty in treating implant-related infections (IRIs). Focused high-energy extracorporeal shockwave therapy (fhESWT), which is a treatment modality for fracture nonunions, has been shown to have a direct antibacterial effect on planktonic bacteria. The goal of the present study was to investigate the effect of fhESWT on Staphylococcus aureus biofilms in vitro in the presence and absence of antibiotic agents. METHODS: S. aureus biofilms were grown on titanium discs (13 mm × 4 mm) in a bioreactor for 48 hours. Shockwaves were applied with either 250, 500, or 1,000 impulses onto the discs surrounded by either phosphate-buffered saline or antibiotic (rifampin alone or in combination with nafcillin). The number of viable bacteria was determined by quantitative culture after sonication. Representative samples were taken for scanning electron microscopy. RESULTS: The application of fhESWT led to a ten-fold reduction in bacterial counts on the metal discs for all impulse numbers compared to the control (p < 0.001). Increasing the number of impulses did not further reduce bacterial counts in the absence of antibiotics (all p > 0.289). Antibiotics alone reduced the number of bacteria on the discs; however, the combined application of the fhESWT and antibiotic administration further reduced the bacterial count compared to the antibiotic treatment only (p = 0.032). CONCLUSION: The use of fhESWT significantly reduced the colony-forming unit (CFU) count of a S. aureus biofilm in our model independently, and in combination with antibiotics. Therefore, the supplementary application of fhESWT could be a helpful tool in the treatment of IFIs in certain cases, including infected nonunions. Cite this article: Bone Joint Res 2021;10(1):77-84.

[Improvement in breathing mechanics by plate osteosynthesis of the ribs after cardiac massage : Case report and review of the literature]. / Verbesserung der Atemmechanik durch Plattenosteosynthese der Rippen nach Herzdruckmassage : Fallbericht und Literaturübersicht.

This article reports the case of a 69-year-old patient with multiple rib fractures and sternal fracture after repetitive cardiopulmonary resuscitation (CPR). Because of secondary respiratory failure due to an unstable thorax, rib fixation was performed 10 days after CPR. Subsequently, ventilation improved resulting in successful extubation 4 days after rib plating. A review of the literature revealed only five documented cases of rib osteosynthesis after CPR. Although flail chest occurs in up to 15% of patients after CPR, there is little evidence of the effect of rib fixation. The benefit of this procedure after chest trauma is reduced pain, shortened intensive care unit stay, lower rates of ventilation-associated pneumonia and lower costs for the healthcare system. Further clinical research is needed and interdisciplinary treatment should be kept in mind when dealing with patients resuscitated with prolonged mechanical ventilation.

Extracorporal shock wave therapy for the treatment of arthrodesis non-unions.

INTRODUCTION: Non-union is a regular complication of arthrodeses. Standard treatment includes revision surgery with frequent need for re-revision due to persistent non-union. Particularly patients with concomitant diseases are at risk of secondary complications. There is a need for evaluation of alternative treatment options. The aim of this study is to provide first evidence on union-rate and pain course after focussed extracorporeal shock-wave therapy of arthrodesis non-unions. PATIENTS AND METHODS: In a retrospective single-centre study, 25 patients with non-union following arthrodesis received one session of focussed extracorporeal shock-wave therapy (energy flux density 0.36 mJ/mm2, 3000 impulses, 23 kV, 4 Hz). Radiographic and clinical results were recorded 6, 12 and 24 weeks after treatment. RESULTS: 24 patients were followed-up. After 24 weeks arthrodeses of the hand healed in 80%, of the upper ankle in 50%, of subtalar joint in 27.2% and of the midfoot in 0% of the cases. Pain decreased from 4.8 (± 2.8) points on the visual analogue scale to 3.4 (± 2.3), 2.9 (± 2.5) and 2.4 (± 2.8) points after 6, 12 and 24 weeks, respectively (p < 0.0001). CONCLUSION: Our data indicate that the effect of focussed, high-energy shock wave therapy depends on body region and is effective for the treatment of non-unions of the hand as well as for pain relief. LEVEL OF EVIDENCE: Level IV.

Correction to: Ex situ reconstruction of comminuted radial head fractures: is it truly worth a try?

The original version of this article unfortunately contained a mistake.

Focused high-energy extracorporeal shockwaves as supplemental treatment in a rabbit model of fracture-related infection.

Focused high-energy extracorporeal shockwave therapy (fhESWT) is used to improve fracture healing in cases of nonunion. In addition, it has been shown to have direct antibacterial effects. We evaluated fhESWT as an adjunct to conventional treatment in a clinically relevant rabbit model of fracture-related infection (FRI). A humeral osteotomy in 31 rabbits was fixed with a seven-hole locking compression plate. FRI was established with a clinical Staphylococcus aureus isolate. After 2 weeks, a revision surgery was performed with debridement, irrigation, and implant retention. Rabbits then received: no further treatment (controls); shockwaves (4000 impulses with 23 kV at days 2 and 6 after revision); systemic antibiotics (rifampin and nafcillin); or the combination of antibiotics and shockwaves. Treatments were applied over 1 week. Blood cultures were taken before and after shockwave sessions. After another week without treatment, rabbits were euthanized and quantitative bacteriology was performed on implants and tissues to determine infection burden. Indicator organs (brain, heart, liver, lungs, kidneys, and spleen) were cultured to assess possible bacteremia. All the rabbits were infected at revision surgery as determined by the bacteriological culture of debrided materials. fhESWT in combination with antibiotic treatment lowered the bacterial burden 100-fold compared with antibiotic treatment alone in all samples (P = .38). This effect was most prevalent for the implant sample (P = .08). No significant effect was seen for fhESWT alone compared with untreated controls. No signs of bacteremia occurred in blood cultures and organs. fhESWT appears safe and could be a helpful adjunct to conventional treatment in certain difficult-to-treat FRIs.

Ex situ reconstruction of comminuted radial head fractures: is it truly worth a try?

INTRODUCTION: Complex radial head fractures are difficult to treat. In cases where stable fixation cannot be achieved, radial head resection or primary arthroplasty are frequently performed. Ex situ reconstruction of comminuted fractures may also be an option. This technique has widely been neglected in the literature, and only two small case series report satisfactory results. The aim of the present case series was to determine the functional and radiological outcomes of ex situ reconstructed Mason III and Mason IV fractures. We expect that the on-table reconstruction of comminuted radial head fractures will lead to bony union with no avascular necrosis in the postoperative course, which will demonstrate that this operative procedure is a reasonable option. PATIENTS AND METHODS: Two Mason type III and seven Mason type IV fractures (including four Monteggia-like lesions) were reconstructed ex situ. The mean age of the patients was 47 years (range 22-64). The clinical examination included RoM tests, elbow stability tests, and a neurological examination. The functional outcome was assessed with the MEPS and DASH score. The radiographic examination included a.p. and lateral views of the elbow to detect non-unions, inadequacy or loss of reduction, radial head necrosis, heterotopic ossifications and signs of posttraumatic arthritis. RESULTS: The mean follow-up time was 39 months (range 11-64). The mean MEPS was 82 points (range 15-100), and the mean DASH score was 20 points (range 0-85). All ex situ-reconstructed radial heads survived, and no signs of avascular necrosis were observed. Bony union was achieved in all but one patient who presented with an asymptomatic non-union. Signs of posttraumatic arthritis were found in all patients. With regard to the radial head, neither secondary resection nor arthroplasty had to be performed. All patients returned to their pre-injury occupations. CONCLUSION: Ex situ radial head reconstruction can be a reliable option in the surgical treatment of complex radial head fractures associated with severe elbow trauma. Even in the midterm follow-up, no signs of avascular necrosis were observed. Modern implants may even extend the indications for reconstruction in such cases. LEVEL OF EVIDENCE: Level IV-retrospective cohort study.

Age-related bone deterioration is diminished by disrupted collagen sensing in integrin α2ß1 deficient mice.

Collagen binding integrins are of essential importance in the crosstalk between cells and the extracellular matrix. Integrin α2ß1 is a major receptor for collagen I, the most abundant protein in bone. In this study we show for the first time that integrin α2 deficiency is linked to collagen type I expression in bone. Investigating the femurs of wild type and integrin α2ß1 deficient mice, we found that loss of integrin α2 results in altered bone properties. Histomorphometric analysis of integrin α2 long bones displayed more trabecular network compared to wild type bones. During age related bone loss the integrin α2ß1 deficient bones retain trabecular structure even at old age. These findings were supported by functional, biomechanical testing, wherein the bones of integrin α2ß1 deficient mice do not undergo age-related alteration of biomechanical properties. These results might be explained by the increased presence of collagen in integrin α2ß1 deficient bone. Collagen type I could be detected in higher quantities in the integrin α2ß1 deficient bones, forming abnormal, amorphous fibrils. This was linked to higher expression levels of collagen type I and other bone formation related proteins as alkaline phosphatase of integrin α2ß1 deficient osteoblasts. Osteoclasts of integrin α2ß1 deficient mice did not show any differences. Consequently these results indicate that the absence of integrin α2ß1 alleviates the effects of age related bone degradation through over-expression of collagen type I and demonstrate a molecular mechanism how collagen binding integrins might directly impact bone aging.