Arthroscopic reduction of adult comminuted tibial eminence avulsion with single tunnel pull-through suture fixation: A case report of technical note.

INTRODUCTION AND IMPORTANCE: Tibial eminence avulsion is an exceptional knee injury in the adult population. The treatment of this injury is generally based on the pattern of the fragment fracture displacement and operative treatment is recommended for comminuted eminence fracture to prevent nonunion and knee instability. CASE PRESENTATION: We reported a 30-years-old female with severe left knee pain after falling from a motorcycle. Physical examination showed moderate left knee effusion with restricted knee joint range of motion from 0 to 90°. Anterior drawer test was positive without opening varus or valgus stress. A preliminary radiograph and CT scan of the left knee denoted displaced and comminuted tibial eminence avulsion. CLINICAL DISCUSSION: Anatomical reduction of the displaced fragment and adequate tension of the ACL bundle are the surgical goal to promote fracture healing, maintain knee stability, and restore range of motion. Various reduction and fixation techniques have been devised for comminuted tibial eminence avulsion ranging from arthroscopic screw to suture fixation. Although arthroscopic reduction and suture fixation become the prominent treatment for this injury, the ideal technique remains unclear. CONCLUSION: We propose a modified arthroscopic reduction and suture fixation technique by using a single tibial tunnel and knotless distal anchoring screw fixation. Despite some limitations, this technique simplifies anatomic reduction and fixation with single tunnel placement which has shown to be effective in reducing surgical time.

Implantation of bovine hydroxyapatite and secretome with different oxygen concentration may improve massive bone defect regeneration: An experimental study on animal model.

The most widely used biomaterials in the treatment of massive bone defects are allograft bone or metal implants. The current problem is that the availability of allographs is limited and metal implants are very expensive. Mass production of secretome can make bone reconstruction of massive bone defects using a scaffold more effective and efficient. This study aims to prove bone regeneration in massive bone defects using bovine hydroxyapatite reconstruction with normoxic and hypoxic secretome conditions using collagen type 1 (COL1), alkaline phosphate (ALP), osteonectin (ON), and osteopontin (OPN) parameters. This is an in vivo study using male New Zealand white rabbits aged 6-9 months. The research was carried out at the Biomaterials Center-Tissue Bank, Dr. Soetomo Hospital for the manufacturer of bovine hydroxyapatite (BHA) and secretome BM-MSC culture under normoxic and hypoxic conditions, and UNAIR Tropical Disease Institute for implantation in experimental animals. Data analysis was carried out with the one-way ANOVA statistical test and continued with the Post Hoc test LSD statistical test to determine whether or not there were significant differences between groups. There were significant differences between hypoxic to normoxic group and hypoxic to BHA group at day-30 observation using ALP, COL 1, ON, and OPN parameters. Meanwhile, there is only osteonectin parameter has significant difference at day-30 observation. At day-60 observation, only OPN parameter has significant differences between hypoxic to normoxic and hypoxic to BHA group. Between day-30 and day-60 observation, BHA and normoxic groups have a significant difference at all parameters, but in hypoxic group, there are only difference at ALP, COL 1, and ON parameters. Hypoxic condition BM-MSC secretome with BHA composite is superior and could be an option for treating bone defect.

Lengthening of Massive Intercalary Cortical Allograft After Successful Graft Incorporation in Skeletally Immature Bone with Critical-Sized Defect: A Case Report with 6-year Follow-up.

Bone allograft serves as an alternative to overcome the limitation of autograft. Some concerns, such as graft rejection, infection, and low union rate, arise from the use of bone allograft since the graft is a non-living and foreign material. We reported a case of critical-sized bone defect in a skeletally immature patient treated with massive intercalary allograft that not only did it show union but also graft incorporation that allowed for subsequent bone lengthening at the site of the incorporated massive allograft. To our knowledge, there has been a report of lengthening of free-vascularized fibular autograft but not the nonvascularized one. Massive intercalary allograft that incorporates well to the host could be an option to treat critical-sized bone defect.

Analysis of prognostic factors in soft tissue sarcoma: Cancer registry from a single tertiary hospital in Indonesia. A retrospective cohort study.

BACKGROUND: Soft tissue sarcoma is one cause of mortality in adult malignancies. This tumor is rare, persistent, and highly-recurrent. Many patients are came in late stage. It is important to identify a prognostic tool that is reliable, easily obtainable, and widely applicable. The aim of this study is to investigate and analyze the prognostic value of clinicopathological and biomarker factors in patients with soft tissue sarcoma. METHODS: This retrospective study extracts data from the musculoskeletal tumor registry from January 2012 to December 2018 in a single tertiary hospital. Eighty patients with diagnosis of soft tissue sarcoma were included. Preoperative modified Glasgow Prognostic Score, Neutrophils/Lymphocytes Ratio, Hemoglobin, serum lactate dehydrogenase data were analyzed along with demographic, clinical, radiological and histopathological data. The relationship between variables on overall survival, distant metastasis, and local recurrence were evaluated using univariate and multivariate Cox regression. RESULTS: On univariate analysis, there was significant relationship between hemoglobin, Neutrophils/Lymphocytes Ratio and modified Glasgow Prognostic Score with overall survival (p = 0.031, HR = 1.99; p = 0.04, HR = 1.129; and p = 0.044, HR = 3.89). A significant relationship was found between age and soft tissue sarcoma stage with distant metastasis (p = 0.046, HR = 1.95; and p = 0.00, HR = 3.22). In addition, we also found significant relationship between surgical margin with local recurrence (p = 0.018, OR = 3.44). However, on multivariate analysis the independent prognostic factor for overall survival was only modified Glasgow Prognostic Score (HR = 2.138; p = 0.011). Stage IIIA (HR = 5.32; p = 0.005) and IIIB (HR = 13.48; p = 0.00) were independent prognostic for distant metastasis. Surgical margin was independently associated with local recurrence (HR = 14.84; p = 0.001). CONCLUSION: Modified Glasgow Prognostic Score can be used as prognostic tool of overall survival in soft tissue sarcoma patients. Moreover, stage of STS and surgical margin can be used as a prognostic factor for distant metastasis and local recurrence of soft tissue sarcoma respectively.

Macroscopic and histologic evaluation of cartilage regeneration treated using xenogenic biodegradable porous sponge cartilage scaffold composite supplemented with allogenic adipose derived mesenchymal stem cells (ASCs) and secretome: An in vivo experimental study.

INTRODUCTION: Articular cartilage is an avascular, alymphatic, and anisotropic tissue, these characteristics cause significant healing problems to injuries to the cartilage tissue. To overcome this problem, various techniques have been developed and widely used, but the cost-effectiveness and resulting tissue regeneration have never achieved hyaline-like cartilage that has the best biomechanical properties. The idea of this experiment is to use a Biodegradable Porous Sponge Cartilage (BPSC) Scaffold to enhance the regeneration of hyaline-like cartilage combined with microfracture technique and Adipose Derived Stem Cells (ASCs) or secretome on an animal model. METHODS: A model defect was made on the femoral trochlea of a New Zealand white rabbit. Four groups were made to compare different treatment methods for osteochondral defects. The groups were: (1) Control group; (2) Scaffold Group; (3) Scaffold + ASCs Group; (4) Scaffold + Secretome Group. After 12 weeks, we terminate the animal models, then a macroscopic evaluation using the International Cartilage Research Society (ICRS) scoring system and Oswestry Arthroscopy Score (OAS) was done, followed by sectioning the specimen for microscopic evaluation using the O'Driscoll scoring system. RESULTS: The mean score for all treatment group were better compared to the control group grossly and histologically. The best mean score for macroscopic and microscopic evaluation was the group given Scaffold + ASCs. CONCLUSION: The application of BPSC scaffold enhances cartilage regeneration in larger osteochondral defects. Furthermore, the addition of ASCs or secretome along with the scaffold implantation further enhances the cartilage regeneration, in which ASCs shows better results.

Combination of bone marrow aspirate, cancellous bone allograft, and platelet-rich plasma as an alternative solution to critical-sized diaphyseal bone defect: A case series.

INTRODUCTION: Nonunion due to a critical-sized bone defect is a complicated problem. The healing process must fulfill three mandatory elements of osteogenesis, osteoinduction, and osteoconduction. One ideal source to provide an abundant number of osteogenic cells is from the process of the culture of bone marrow stem cells which demands the availability of processing facility. Unfortunately, this sophisticated option is not always feasible in every hospital in low-income to middle-income countries. We tried to fulfill the requirement of osteogenic cells by using simple and cost-effective bone marrow aspirate. We presented two cases of critical-sized diaphyseal bone defect treated with the combination of bone marrow aspirate, cancellous bone allograft, and platelet-rich plasma (PRP). Presentation of cases: The defect sizes were five and six centimeters in humerus and tibia respectively. We applied a combination of bone marrow aspirate, cancellous bone allograft, and PRP to promote bone healing in the defect sites. Both patients have achieved the good clinical and radiological outcome. DISCUSSION: Critical-sized bone defects require the application of tissue engineering. Aspirated bone marrow can be used as a more affordable option to provide the element of osteogenic cells in bone healing. Combined with cancellous bone allograft and PRP, they fulfill the required ingredients to promote bone regeneration. CONCLUSION: Bone defects remain one of the most challenging conditions to treat in orthopedic. There are many options to treat the defect but the fundamental prerequisites of cells, scaffolds and growth factors for healing have developed into the concept of tissue engineering: osteogenesis, osteoinduction, and osteoconduction.

Correction of severe valgus deformity of knee osteoarthritis with non-constrained total knee arthroplasty implant: A case report.

INTRODUCTION: Knee osteoarthritis with valgus deformity presents a surgical challenge that must be solved during total knee arthroplasty (TKA). In some case whereby ligament imbalance is found, constrained implant should be used. Unfortunately, the implant is not always readily accessible in some developing countries. The objective of this paper is to provide alternative solution to such case. PRESENTATION OF CASE: We reported a 71-year-old female patient with a painful and fixed valgus deformity of her right knee. Preoperatively, the patient's right knee range of motion (ROM) was 10-145° of flexion with a 32° fixed valgus deformity. A constrained implant was not accessible. To balance the ligament, Medial Collateral Ligament (MCL) origin was shifted to superior and anterior. A non-constrained implant was used. The valgus deformity was corrected intraoperatively and ROM achieved 0-140° of flexion. DISCUSSION: It is crucial that attention is given not only to the restoration of proper bony alignment but even more importantly to soft tissue balancing. By using the non-constrained implant, the cost can also be reduced and suitable for developing countries with limited coverage of state insurance. CONCLUSION: Three months after the surgery, the patient achieved stable and painless knee with 10-90° of flexion and complete correction of her valgus deformity.