Cellular therapies for bone repair: current insights.

Mesenchymal stem cells are core to bone homeostasis and repair. They both provide the progenitor cells from which bone cells are formed and regulate the local cytokine environment to create a pro-osteogenic environment. Dysregulation of these cells is often seen in orthopaedic pathology and can be manipulated by the physician treating the patient. This narrative review aims to describe the common applications of cell therapies to bone healing whilst also suggesting the future direction of these techniques.

Severely injured patients: modern management strategies.

Management of severely injured patients remains a challenge, characterised by a number of advances in clinical practice over the last decades. This evolution refers to all different phases of patient treatment from prehospital to the long-term rehabilitation of the survivors. The spectrum of injuries and their severity is quite extensive, which dictates a clear understanding of the existing nomenclature. What is defined nowadays as polytrauma or major trauma, together with other essential terms used in the orthopaedic trauma literature, is described in this instructional review. Furthermore, an analysis of contemporary management strategies (early total care (ETG), damage control orthopaedics (DCO), early appropriate care (EAC), safe definitive surgery (SDS), prompt individualised safe management (PRISM) and musculoskeletal temporary surgery (MuST)) advocated over the last two decades is presented. A focused description of new methods and techniques that have been introduced in clinical practice recently in all different phases of trauma management will also be presented. As the understanding of trauma pathophysiology and subsequently the clinical practice continuously evolves, as the means of scientific interaction and exchange of knowledge improves dramatically, observing different standards between different healthcare systems and geographic regions remains problematic. Positive impact on the survivorship rates and decrease in disability can only be achieved with teamwork training on technical and non-technical skills, as well as with efficient use of the available resources.

Biological aspects to enhance fracture healing.

The ability to enhance fracture healing is paramount in modern orthopaedic trauma, particularly in the management of challenging cases including peri-prosthetic fractures, non-union and acute bone loss. Materials utilised in enhancing fracture healing should ideally be osteogenic, osteoinductive, osteoconductive, and facilitate vascular in-growth. Autologous bone graft remains the gold standard, providing all of these qualities. Limitations to this technique include low graft volume and donor site morbidity, with alternative techniques including the use of allograft or xenograft. Artificial scaffolds can provide an osteoconductive construct, however fail to provide an osteoinductive stimulus, and frequently have poor mechanical properties. Recombinant bone morphogenetic proteins can provide an osteoinductive stimulus; however, their licencing is limited and larger studies are required to clarify their role. For recalcitricant non-unions or high-risk cases, the use of composite graft combining the above techniques provides the highest chances of successfully achieving bony union.

New Versus Old-How Reliable Is the New OTA/AO Classification for Trochanteric Hip Fractures?

OBJECTIVE: To evaluate the intraobserver and interobserver reliability of the 2018 OTA/AO trochanteric hip fracture (THF) classification compared with the 1983 OTA/AO Muller classification system. To further delineate the reliability of classifying stable and unstable THF using the 2 classification systems. DESIGN: Radiographic observational study. SETTING: Multicenter, one Level 1 and one Level 2 trauma centers. PARTICIPANTS/PATIENTS: Seventy-three radiographic series of patients treated operatively for THF were evaluated by 6 orthopaedic surgeons. INTERVENTION: The OTA/AO THF classification system was applied by each surgeon to 73 cases in 2 independent assessments performed 4 weeks apart: once by the old classification followed by the new 2018 OTA/AO classification. Each radiographic series included lateral hip and anteroposterior initial radiographs. Eight random cases were duplicated in each of the surveys to evaluate the intraobserver reliability. MAIN OUTCOME MEASUREMENTS: Intraobserver and interobserver of the group, subgroup and fracture stability classification determined by the interclass coefficient (ICC) and Cohen kappa values. RESULTS: The interobserver reliability for the group classification (31A1/A2/A3) was moderate using the new classification, whereas substantial agreement was shown using the old classification (0.49 and 0.69, respectively). The reliability of the fracture stability classification was higher using the old classification (0.70 vs. 0.52). Subgroup classifications interobserver agreement was fair for both classification systems, although lower reliability was shown in the old classification (0.34 vs. 0.31). CONCLUSIONS: The new OTA/AO classification has a lower interobserver reliability for THF classification when compared with the old one.

Patient perspective on the use of carbon fibre plates for extremity fracture fixation.

INTRODUCTION: Carbon fibre-reinforced polyetheretherketone (CFR-PEEK) plates represent an exciting development within trauma and orthopaedic surgery, offering advantages including radiolucency, material properties similar to bone, and lack of localised tissue reaction. As more call for trials examining their use, there is no data available as to the acceptability of these implants to patients. This study aimed to therefore examine the acceptability of CFR-PEEK plates to patients undergoing fracture surgery. METHODS: This was a prospective cross-sectional survey of patients undergoing surgery for a fracture of the ankle, distal femur, distal radius, or proximal humerus. Once a decision had been made to pursue operative fixation with a plate, patients were provided with descriptions of both CFR-PEEK and stainless steel and titanium metal implants alongside the current clinical evidence. All patients undertook a questionnaire examining their views as to the advantages and disadvantages of CFR-PEEK plates, and whether they would be happy to participate in a trial comparing both. RESULTS: Ninety-nine patients were happy to participate (64 females, mean age 50). Eighty-seven patients reported that they would want a CFR-PEEK implant for their fracture, and 76 reported that they would be willing to participate in an RCT comparing their use. Commonly reported advantages included radiolucency, low weight and biocompatibility. Disadvantages reported included cost and concerns regarding durability. CONCLUSIONS: This study demonstrates that CFR-PEEK implants would be acceptable to patients undergoing fracture surgery, with high numbers of patients stating that they would be willing to participate in a randomised study examining their use.

Long-term outcomes of lower limb post-traumatic osteomyelitis.

PURPOSE: Whilst recurrence and amputation rates in post-traumatic osteomyelitis (PTOM) are described, limb specific functional outcomes are not, leading to a knowledge gap when counselling patients prior to management. We aim to investigate the patient reported outcomes (PROMS) of this patient group to provide reference for discussions with patients prior to embarking on treatment. METHODS: Single institution cross-sectional retrospective study of all patients presenting with PTOM of the tibia/femur over a 7-year period. Alongside recurrence and amputation rates, patient reported outcomes were recorded including the lower extremity functional scale (LEFS), EQ-5D-3L and EQ-VAS. RESULTS: Seventy-two patients (59 male; median age 46 years) were identified. Treatment was principle-based and included debridement (with Reamer-Irrigator-Aspirator (RIA) in 31/72), local antibiotics (52/72), soft tissue reconstruction (21/72) and systemic antibiotic therapy in all cases. PROMS were collected in 84% of all eligible patients at a median of 112-month post-treatment. Twelve patients experienced recurrence, whilst nine underwent amputation. The median LEFS was 60, the EQ-5D-3L index score was 0.760, and the EQ-VAS was 80. These scores are substantially lower than those seen in the general population (77, 0.856 and 82.2, respectively). LEFS was significantly higher, where RIA was utilised (69.6 vs 52.8; p = 0.02), and in those classified as BACH uncomplicated (74.4 vs 58.4; p = 0.02). EQ-5D-3L was also higher when RIA was utilised (0.883 vs 0.604; p = 0.04), with no difference in EQ-VAS scores. CONCLUSIONS: Patients with PTOM report functional outcomes below that of the general population, even when in remission. Improved outcomes were associated with uncomplicated disease and the use of RIA.

Lower limb post-traumatic osteomyelitis: a systematic review of clinical outcomes.

PURPOSE: The aim of this study was to examine the patient-reported outcomes of patients presenting with post-traumatic osteomyelitis (PTOM) of the lower limb over the past 15 years. This period was chosen to reflect modern treatment principles and increased centralisation of care. METHODS: An electronic literature search of the relevant databases (PubMed, Ovid Medline, Embase, and the Cochrane library) was conducted to identify studies published between January 2006 and July 2021 reporting series of greater than 10 patients with PTOM of the tibia or femur at the site of a previous fracture. Studies reporting septic non-union were excluded. RESULTS: Sixteen eligible studies were identified and included in the final report. Remission of infection was achieved in 93.2% of cases (range 70-100%), whilst amputation was reported in 1-7% of cases. A variety of patient-reported outcome measures were utilised including the lower extremity functional scale, short musculoskeletal functional assessment, Enneking score, and EQ-5D-3L. Limb-specific functional outcomes returned to levels similar to that of the general population although poorer outcomes were noted in specific cohorts including those with complex anatomic disease and active medical comorbidities. CONCLUSION: Infection following fracture fixation remains a difficult problem to treat. Regardless, using modern treatments and techniques patients can have comparable functional outcomes to that of the general population. High-quality studies are required to advance our knowledge into which types of treatments offer a benefit and how to further improve outcomes.

Innovations in orthopaedic trauma: Top advancements of the past two decades and predictions for the next two.

The first Trauma and Orthopaedic unit dates back to 1780, originally dedicated to the treatment of children's deformities. The specialty has subsequently become multifaceted, with a plethora of subspecialty areas of which orthopaedic trauma is the most commonly practiced. Recently there has been a significant demand for an evidence base with more than 130,000 of the 162,000 publications in the last century occurring within the past 20 years. This narrative review will summarise some of the more landmark changes within orthopaedic trauma that have been made within the past 20 years, whilst also attempting to predict where the specialty will continue to develop as we move forward.

Acute Limb Ischaemia and a Disguised Pseudoaneurysm: A Rare Presentation of a Femoral Osteochondroma.

INTRODUCTION: Vascular complications occurring secondary to osteochondroma are a rare phenomenona. They typically present insidiously with claudication, however, uncommonly may present with acute limb ischaemia. We present a case of a young boy who presented with acute limb ischaemia secondary to osteochondroma with an intraoperative diagnosis of popliteal pseudoaneurysm. CASE REPORT: A 15-year-old male presented with an acutely ischaemic limb. A computed tomography CT angiogram was performed which demonstrated complete occlusion of his popliteal artery secondary to a tumour of the distal femur. The patient underwent an open biopsy of the tumour followed by thrombectomy which failed to resolve the ischaemia. After further unsuccessful attempts at thrombectomy, angiography was performed which revealed a pseudoaneurysm. . The patient underwent a successful popliteal exclusion bypass using ipsilateral reversed long saphenous vein. The lesion was subsequently identified as an osteochondroma. The patient made a good recovery and at his latest follow-up is ambulant, free from claudication, and demonstrates good flow through the bypass on duplex ultrasonography. CONCLUSION: Acute limb ischaemia is a rare occurrence within the adolescent population and will, therefore, frequently be secondary to an uncommon aetiology. Whilst While osteochondroma are is a common cause of vascular complications in this population, the onset of symptoms is usually more insidious. The acute onset, in this case, therefore, raised uncertainty as to the potential for malignancy. The management of these patients should involve a combination of both vascular and orthopaedic surgery in order to return perfusion whilest also ensuring the offending lesion is managed appropriately. In patients where initial measures do not restore perfusion, then the potential for further complications such as pseudoaneurysm should be considered and managed promptly.

Asynchronous Unsupervised Video-Enhanced Feedback As Effective As Direct Expert Feedback in the Long-Term Retention of Practical Clinical Skills: Randomised Trial Comparing 2 Feedback Methods in a Cohort of Novice Medical Students.

OBJECTIVES: To determine the degree of practical clinical skills' retention over a 7-week period after receiving either video-enhanced direct expert feedback (DEF) or asynchronous unsupervised video-enhanced feedback (UVF). DESIGN: A prospective single-blinded randomized trial was conducted over a 7-week period with novice medical students. Following a generic introduction, PowerPoint presentation and live demonstration of intravenous cannulation was given by an expert, and candidates performed the same task in isolation while being recorded and were randomized to receive either DEF or UVF. Further, 20 students were randomized to receive UVF and 22 to receive DEF. Candidates returned to repeat the video-recorded task at week 1, 4, and 7, with no further feedback provision on these occasions. Performances were fully anonymized and independently marked by 2 expert assessors. SETTING: Newcastle University, Medical School, England, United Kingdom. PARTICIPANTS: A total of 42 novice medical students from the preclinical years were selected, with no prior experience of intravenous cannulation. RESULTS: No significant difference existed between demographics of either cohort. Good between-assessor score correlation was noted, with an intraclass correlation coefficient (ICC) of 0.89. The DEF arm significantly improved from their prefeedback performance at Day 1 on repeating the skill a week later (p < 0.0001); this improved score was maintained throughout the duration of the study. The UVF arm showed a nonsignificant improvement; however, there was no significant difference in the scores between the UVF and the DEF groups at any point in the trial. CONCLUSIONS: Video-technology may play a significant role in the provision of feedback for practical skills. The ability for experts to provide remotely delivered but individualized feedback can be an efficient use of valuable resources, while students being able to self-assess their own performance alongside an expert video have the potential to provide students with an excellent opportunity to learn clinical skills without requiring intensive educator involvement.

Individualised Expert Feedback is Not Essential for Improving Basic Clinical Skills Performance in Novice Learners: A Randomized Trial.

OBJECTIVE: To determine whether unsupervised video feedback (UVF) is as effective as direct expert feedback (DEF) in improving clinical skills performance for medical students learning basic surgical skills-intravenous cannulation, catheterization, and suturing. BACKGROUND: Feedback is a vital component of the learning process, yet great variation persists in its quality, quantity, and methods of delivery. The use of video technology to assist in the provision of feedback has been adopted increasingly. METHODS: A prospective, blinded randomized trial comparing DEF, an expert reviewing students' performances with subsequent improvement suggestions, and UVF, students reviewing their own performance with an expert teaching video, was carried out. Medical students received an initial teaching lecture on intravenous cannulation, catheterization, and suturing and were then recorded performing the task. They subsequently received either DEF or UVF before reperforming the task. Students' recordings were additionally scored by 2 blinded experts using a validated proforma. RESULTS: A total of 71 medical students were recruited. Cannulation scores improved 4.3% with DEF and 9.5% with UVF (p = 0.044), catheterization scores improved 8.7% with DEF and 8.9% with UVF (p = 0.96), and suturing improved 15.6% with DEF and 13.2% with UVF (p = 0.54). Improvement from baseline scores was significant in all cases (p < 0.05). CONCLUSION: Video-assisted feedback allows a significant improvement in clinical skills for novices. No significant additional benefit was demonstrated from DEF, and a similar improvement can be obtained using a generic expert video and allowing students to review their own performance. This could have significant implications for the design and delivery of such training.

Does minimally invasive oesophagectomy provide a benefit in hospital length of stay when compared with open oesophagectomy?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: 'in patients undergoing oesophagectomy, does a minimally invasive approach convey a benefit in hospital length of stay (LOS), when compared to an open approach?' A total of 647 papers were identified, using an a priori defined search strategy; 24 papers represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group, study type, relevant outcomes and key results are tabulated. Of the studies identified, data from two randomized controlled trials were available. The first randomized study compared the use of open thoracotomy and laparotomy versus thoracoscopy and laparoscopy. Those undergoing minimally invasive oesophagectomy (MIO) left hospital on average 3 days earlier than those treated with the open oesophagectomy (OO) technique (P = 0.044). The other randomized trial, which compared thoracotomy with thoracoscopy and laparoscopy, demonstrated a reduction of 1.8 days in the LOS when employing the MIO technique (P < 0.001). With the addition of the remaining 22 non-randomized studies, comprising 3 prospective and 19 retrospective cohort studies, which are heterogeneous with regard to their design, study populations and outcomes; data are available representing 3173 MIO and 25 691 OO procedures. In total, 13 studies (including the randomized trials) demonstrate a significant reduction in hospital LOS associated with MIO; 10 suggest no significant difference between techniques; and only 1 suggests a significantly greater length of stay associated with MIO. The only two randomized trials comparing MIO and OO demonstrated a reduction in length of stay in the MIO group, without compromising survival or increasing complication rates. All bar one of the non-randomized studies demonstrated either a significant reduction in length of stay with MIO or no difference. The benefit in reduced length of stay was not at the cost of worsened survival or increased complications, and conversion rates in all studies were low.

Biomechanical rationale for implant choices in femoral neck fracture fixation in the non-elderly.

Femoral neck fractures represent a relatively uncommon injury in the non-elderly population often resulting from high-energy trauma. The cornerstone of their management is anatomic reduction and stable internal fixation of the femoral neck in an attempt to salvage the femoral head. Complications including avascular necrosis of the femoral head, non-union and post-traumatic osteoarthritis are not uncommon. The clinical outcomes of these patients can be improved with good pre-operative planning, optimization of surgical procedures and introduction of new improved implants and techniques. In the herein study, we attempt to describe the biomechanical properties of the hip and compare the performance of the most commonly used devices. Experimental evidence suggests that in Pauwels type III fracture patterns a cephalomedullary nail was significantly stronger in axial loading. Moreover, in unstable basicervical patterns cannulated screws (triangular configuration) demonstrated a lower ultimate load to failure, whereas in subcapital or transervical patterns both the cannulated screws (triangular configuration) and the sliding hip screw demonstrated no compromise in fixation strength. The fracture pattern appears to be the major determinant of the ideal type of implant to be selected. For a successful outcome each patient needs to be considered on an individual basis taking into account all patient and implant related factors.