Locking Attachment Plate for the Surgical Treatment of Periprosthetic and Periimplant Fractures: Long-Term Follow-Up.

Objectives: The surgical management of periprosthetic fractures (PPF) and periimplant fractures (PIF) can be challenging. The locking attachment plate (LAP) was proposed in recent years for the osteosynthesis of such fractures. The aim of this study was to assess the experience of a third-level hospital with LAP for the treatment of PPF and PIF, and analyse the clinical outcomes. Methods: Data were prospectively collected and analysed from all patients whose PPF/PIF was treated surgically with LAP in a third-level hospital from June 2018 to June 2022. All fractures were postoperative low-energy femur fractures. The minimum follow-up period was six months. Results: Thirty-eight patients (31 women) met the eligibility criteria. The mean age was 86.3 years. The median time until surgery was 4 days. A mean of 3.61 screws were used for each LAP. The mean femur plate length was 14 holes, and the mean working length 7.1 holes. The median hospital stay was nine days. The mean follow-up was 19.56 months. At one month, 12 patients tolerated partial weight-bearing. Five patients walked independently indoors. One patient had died and seven patients were readmitted. At six months, six more patients had died. Fifteen patients tolerated full weight-bearing (FWB). Nine patients walked independently indoors, six outdoors. Twenty-five patients reached fracture consolidation without malalignment. Nine patients were readmitted. At 12 months, another patient had died. Seventeen patients tolerated FWB. Eleven patients walked independently indoors, six outdoors. Twenty-five patients achieved fracture consolidation without malalignment. Five patients were readmitted. Fourteen patients crossed the two-year postoperative threshold. All achieved fracture consolidation. Two patients passed the 4-year postoperative milestone. Conclusion: The clinical results of patients whose PPF or PIF was treated with the LAP are promising. This fixation method is a viable option to be considered when planning surgery for such fractures.

Traumatic recurrent hip dislocation associated with femoral head fracturere constructed with iliac crest autograft / Luxación recurrente de cadera asociada a fractura de cabeza femoral reconstruida con autoinjerto de cresta iliaca

Hip femoral head fractures are extremely uncommon, but likely associated with traumatic hip dislocations. Both lesions require emergent treatment to avoid further complications.19-year-old male patient was received after a high-energy motor vehicle accident with severe brain and thoraco-abdominal trauma and a displaced femoral head fracture with posterior hip dislocation with no acetabular fracture. An emergent open reduction and internal fixation with 2 headless screws was performed, as well as posterior capsule repair. After 1 month as an inpatient in Intensive Care Unit, he sustained a new episode of posterior hip dislocation. Consequently, a second successful surgical reduction was obtained, and hip stability was achieved by posterior reconstruction with iliac crest autograft fixed with cannulated screw and posterior structure repair. Two years later, he was able to walk independently and he does not present any signs of degenerative joint disease nor avascular necrosis.

Las fracturas de la cabeza femoral son extremadamente raras y están asociadas comúnmente con una luxación de cadera traumática. Ambas lesiones requieren tratamiento urgente con el objetivo de evitar complicaciones posteriores. Un paciente varón de 19 años fue trasladado tras un accidente de tráfico de alta energía en el que sufrió un traumatismo craneoencefálico y toracoabdominal grave, además de una fractura de cabeza femoral desplazada junto a una luxación posterior de cadera sin afectación acetabular. De manera urgente, fue intervenido mediante una reducción abierta y fijación interna de la fractura con dos tornillos canulados sin cabeza y reparación de la cápsula articular posterior. Tras un mes de ingreso en la unidad de cuidados intensivos, sufrió un nuevo episodio de luxación posterior de cadera. Debido a ello, se realiza una segunda intervención quirúrgica con reducción abierta y en la que se obtiene una adecuada estabilidad de la cadera mediante reconstrucción posterior con la adición de autoinjerto tricortical de cresta ilíaca y reparación capsular posterior. Después de dos años de seguimiento, el paciente deambula de manera independiente, sin dolor y sin signos degenerativos ni de necrosis avascular en las pruebas de imagen.

Mortality after distal femur fractures in the elderly.

INTRODUCTION: the frequency of distal femur fractures in the elderly is rapidly increasing. A study of these fractures was conducted in our center in order to evaluate the comorbidities and the mortality associated with this entity. MATERIAL AND METHODS: all the distal femur fractures by low energy in patients over 65 years old at a tertiary center were included, between January 2010 and December 2016. Baseline characteristics, the type of fracture, comorbidities, and functional status before admission, were collected. The relationship of each of these variables to the final functional class, immediate and late complications and mortality during the follow-up. Fifty-nine patients were included, with a median age of 85.3 years (IQR 78.6-91.6). Fifty-one patients were women. In 10 patients, the fractures were atraumatic (postural change mainly in non-walking patients), and in 54 of the cases were treated surgically (6 with retrograde intramedullary nailing and 48 with lateral locking plate). The median time to surgery was 4.5 days (IQR 2-6) and 14 patients were operated within 48 hours. The median follow-up was 26.3 months. RESULTS: fourteen patients died during the first year of follow-up. Factors independently associated with death during the first year after the fracture were: conservative treatment, and the inability to ambulate before the episode. The absence of certain comorbidities, such as chronic heart disease, and cancer, and an age under 80 years, behaved as protective factors. CONCLUSION: low-energy distal femur fractures comprise a severe injury in the elderly and are associated with high mortality. Surgical treatment showed better outcomes in terms of survival, with no significant differences depending on the type of fracture, the type of implant or the median time to surgery.

Early efficacy evaluation of mesenchymal stromal cells (MSC) combined to biomaterials to treat long bone non-unions.

BACKGROUND AND STUDY AIM: Advanced therapy medicinal products (ATMP) frequently lack of clinical data on efficacy to substantiate a future clinical use. This study aims to evaluate the efficacy to heal long bone delayed unions and non-unions, as secondary objective of the EudraCT 2011-005441-13 clinical trial, through clinical and radiological bone consolidation at 3, 6 and 12 months of follow-up, with subgroup analysis of affected bone, gender, tobacco use, and time since the original fracture. PATIENTS AND METHODS: Twenty-eight patients were recruited and surgically treated with autologous bone marrow derived mesenchymal stromal cells expanded under Good Manufacturing Practices, combined to bioceramics in the surgical room before implantation. Mean age was 39 ± 13 years, 57% were males, and mean Body Mass Index 27 ± 7. Thirteen (46%) were active smokers. There were 11 femoral, 4 humeral, and 13 tibial non-unions. Initial fracture occurred at a mean ± SD of 27.9 ± 31.2 months before recruitment. Efficacy results were expressed by clinical consolidation (no or mild pain if values under 30 in VAS scale), and by radiological consolidation with a REBORNE score over 11/16 points (value of or above 0.6875). Means were statistically compared and mixed models for repeated measurements estimated the mean and confidence intervals (95%) of the REBORNE Bone Healing scale. Clinical and radiological consolidation were analyzed in the subgroups with Spearman correlation tests (adjusted by Bonferroni). RESULTS: Clinical consolidation was earlier confirmed, while radiological consolidation at 3 months was 25.0% (7/28 cases), at 6 months 67.8% (19/28 cases), and at 12 months, 92.8% (26/28 cases including the drop-out extrapolation of two failures). Bone biopsies confirmed bone formation surrounding the bioceramic granules. All locations showed similar consolidation, although this was delayed in tibial non-unions. No significant gender difference was found in 12-month consolidation (95% confidence). Higher consolidation scale values were seen in non-smoking patients at 6 (p = 0.012, t-test) and 12 months (p = 0.011, t-test). Longer time elapsed after the initial fracture did not preclude the occurrence of consolidation. CONCLUSION: Bone consolidation was efficaciously obtained with the studied expanded hBM-MSCs combined to biomaterials, by clinical and radiological evaluation, and confirmed by bone biopsies, with lower consolidation scores in smokers.

Development of trauma systems in Europe-reports from England, Germany, the Netherlands, and Spain.

Major trauma systems have evolved in many European countries and have resulted in improved care in terms of mortality and morbidity. Many of the systems have similar history, with reports of either poor services, or a single disaster, driving change of policy and set up. We report on 4 European systems, looking at the background, set up and some of the results. Similar issues are identified including the importance of triage, the concentration of specialist skills which require patients to bypass hospitals, and the standardization of treatment protocols. The issues of rehabilitation and the increasing importance of measuring outcome with patient reported metrics are discussed.

Feasibility and safety of treating non-unions in tibia, femur and humerus with autologous, expanded, bone marrow-derived mesenchymal stromal cells associated with biphasic calcium phosphate biomaterials in a multicentric, non-comparative trial.

BACKGROUND: ORTHO-1 is a European, multicentric, first in human clinical trial to prove safety and feasibility after surgical implantation of commercially available biphasic calcium phosphate bioceramic granules associated during surgery with autologous mesenchymal stromal cells expanded from bone marrow (BM-hMSC) under good manufacturing practices, in patients with long bone pseudarthrosis. METHODS: Twenty-eight patients with femur, tibia or humerus diaphyseal or metaphyso-diaphyseal non-unions were recruited and surgically treated in France, Germany, Italy and Spain with 100 or 200 million BM-hMSC/mL associated with 5-10 cc of bioceramic granules. Patients were followed up during one year. The investigational advanced therapy medicinal product (ATMP) was expanded under the same protocol in all four countries, and approved by each National Competent Authority. FINDINGS: With safety as primary end-point, no severe adverse event was reported as related to the BM-hMSC. With feasibility as secondary end-point, the participating production centres manufactured the BM-hMSC as planned. The ATMP combined to the bioceramic was surgically delivered to the non-unions, and 26/28 treated patients were found radiologically healed at one year (3 out of 4 cortices with bone bridging). INTERPRETATION: Safety and feasibility were clinically proven for surgical implantation of expanded autologous BM-hMSC with bioceramic. FUNDING: EU-FP7-HEALTH-2009, REBORNE Project (GA: 241876).