Experimental Evaluation of the Properties of 3D Porous Bone Substitute Based on Calcium Phosphate on the Model of Monocortical Diaphysial Femur Defect in Rats.

A new alloplastic high-permeable material based on tricalcium phosphate with Kelvin architectonics created by stereolithographic 3D-printing was studied in vivo. A monocortical defect of the femur was modeled in rats and the material was implanted into the defect area. In 24 weeks, the animals were euthanized and histological examination of the defect area was performed. One femur fracture with fixator migration was recorded after implantation of the studied material and the reference chronOS synthetic material. The studied material demonstrated better osteoconductive properties then traditional osteoplastic material, which was seen from greater number of bone trabeculae and their area in the defect area.

Corrective Osteotomy of Malunited Diaphyseal Fractures of the Forearm Simplified Using 3-Dimensional CT Data: Proposal of Our Simple Strategy Through Case Presentation.

BACKGROUND: Reconstruction of malunited diaphyseal fractures of the forearm is one of the most difficult treatments due to its complicated structure. Widespread usage of Digital Imaging and Communications in Medicine (DICOM) data of 3-dimensional (3D) computed tomography (CT) and 3D printing can make estimating the true plane of the deformity easy. METHODS: A 21-year-old man with limited supination due to left forearm nonunion deformity initially treated by locking plate fixation was referred to our hospital. We evaluated the deformity by superimposing the mirror image bone model of the contralateral normal bone onto a model of the affected bone and 3D real full-scale bone model. RESULTS: The patient underwent a manual corrective osteotomy according to our planning. He had satisfactory improvement of his symptoms with no complications. CONCLUSIONS: We postulated that our simple preoperative simulation and manual osteotomy with the aid of 3D CT reconstruction and 3D real full-scale bone model fit in the clinical practice as a recent trend.

Morphological features of healing of experimental defect of long bones diaphysis under the conditions of implantation of biphasic osteoplastic material / Características morfológicas del proceso de reparación de un defecto experimental en diáfisis de huesos largos postimplantación de material bifásico osteoplástico

Purpose: to study the healing process of a defect of the compact bone tissue after the implantation of osteoplastic material «easygraft CRYSTAL¼. Methods: the experiment was conducted on 24 Wistar rats. In the middle third of the diaphysis of the femur we created a perforated defect of 2.5 mm diameter in the medullary canal, which was filled with osteoplastic material «easy-graft CRYSTAL¼. Fragments of the injured bones were studied on the 60th and 120th days by light microscopy with morphometry and scanning electron microscopy. Results: it was found that in the area of the defect of the compact bone tissue «easy-graft CRYSTAL¼ shows high biocompatibility, osteoconductive properties and provides stability to the volume of the defect due to good integration with the bone tissue of regenerate and absence of signs of resorption of osteoplastic material throughout the period of experiment. (AU)

Objetivo: estudiar el proceso de reparación de un defecto del tejido óseo compacto después de la implantación de material osteoplástico (easy-graft CRYSTAL). Métodos: el experimento se realizó en 24 ratas Wistar. Se realizó en el tercio medio de la diáfisis del fémur un defecto de 2,5 mm de diámetro en el canal medular que se rellenó de material de osteoplástico (easy-graft CRYSTAL). Los huesos lesionados fueron estudiados en los días 60ª y 120ª mediante microscopía óptica y microscopía electrónica de barrido. Resultados: se encontró que en la zona del defecto del tejido óseo compacto el injerto mostró alta biocompatibilidad y propiedades osteoconductivas y proporcionó estabilidad al volumen del defecto debido a la buena integración con el tejido óseo y ausencia de signos de resorción de material osteoplástico durante todo el período experimental. (AU)

Derotational femoral osteotomy technique with locking nail fixation for adolescent femoral antetorsion: surgical technique and preliminary study.

Rotational femoral osteotomies for excessive femoral antetorsion may be considered only for symptomatic adolescents. Our main objective was to describe our femoral osteotomy technique. Preoperative planning was performed clinically and with the EOS imaging system. Percutaneous osteotomy was performed on distal femoral metaphysis under radioscopic control. Fixation was achieved with an antegrade locking nail. Rotation was checked precisely using a specially designed protractor before distal locking. We carried out a prospective pilot study between 2009 and 2010 on six patients (nine procedures). All the patients included presented a symptomatic femoral antetorsion greater than 20°. Clinical parameters including range of hip mobility and femoral antetorsion were measured every 2 months during the first 6 months, and then every year until skeletal maturation was reached. We obtained orthoroentgenograms using the same technique at each follow-up and torsional analysis by EOS 3D Imaging at 6 months. The average correction of the femoral antetorsion was 19.0 ± 4.0° (range, 13-25°). The average time of union was 3 ± 1.2 months (range, 2-6 months). Patients returned to full weight bearing at an average of 2.6 ± 0.4 months (range, 2-4 months). One patient experienced an early secondary displacement in varus for which a reoperation was required. We believe that this technique can accurately achieve derotational femoral osteotomies. A study is ongoing to evaluate the clinical results of this technique including mechanical and cosmetic advantages.

Single osteotomy at the radial diaphysis for congenital radioulnar synostosis.

PURPOSE: To report the effectiveness of single derotation osteotomy at the radial diaphysis for the treatment of congenital radioulnar (RU) synostosis. METHODS: Since 2000, we performed 35 radial diaphysis osteotomies on 17 boys and 9 girls younger than 9 years old (average, 5 y). The radius was cut at the midshaft and manually rotated to a neutral position. A long-arm cast was applied for 4 to 6 weeks. Complications of surgeries were recorded, and pre- and postoperative forearm position was measured. RESULTS: The average postoperative follow-up was 5 years. The patient age at the final follow-up ranged from 5 to 19 years. There were no major surgery-related complications. The average forearm position was improved from 72° pronation before surgery to neutral after surgery, except 2 forearms. Elbow flexion and extension showed no change. All parents noted that daily activities were improved after surgery, and they found the surgical scar in the midforearm acceptable. CONCLUSIONS: Single osteotomy at the radial diaphysis was effective for correcting pronation deformity in congenital RU synostosis in children younger than 9 years. Complications were few, and the correction was maintained through midterm follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Clinical factors affecting lower limb torsional deformities treatment with the Ilizarov method.

INTRODUCTION: One of the many uses of the Ilizarov fixator is for torsional deformities correction. Rotational and translational bone displacement related to torsional deformities correction includes the additional tension stresses, which affect the biology of the regenerated bone. Understanding the clinical factors will assist in designing the optimal treatment strategy, thus possibly improving the outcomes. PATIENTS AND METHODS: It was case series retrospective study. The study examined 56 patients. The mean follow-up time was 5 years and 6 months. The mean age at the start of treatment was 19 years and 10 months. Patients underwent derotational corticotomies of distal metaphysis of the femur or proximal metaphysis of the tibia using the Ilizarov method. In these patients, following derotational corticotomies with the Ilizarov method, numerous variables were defined and their effect evaluated: the selected treatment strategy, the rate, size, type, and level of derotation on complications, the alignment index, the correction coefficient, the elongation index, and deformation correction factor. RESULTS: The differences in the values of alignment index and deformation correction factor in this study subgroups were not statistically significant. We found differences in the elongation index and correction coefficient in a number of subgroups. DISCUSSION: In the case of correcting torsional deformation without significant elongation, acute correction and with a value of >30° does not significantly affect the results. Treatment strategy, type and level of derotation had no major influence on torsional deformities treatment. LEVEL OF EVIDENCE: Case-control study III.

The early phase influence of bone marrow concentrate on metaphyseal bone healing.

Bone marrow concentrate (BMC) contains high densities of progenitor cells. Therefore, in critical size defects BMC may have the potency to support bone healing. The aim of this study was to investigate the effect of BMC in combination with calcium phosphate granules (CPG) on bone defect healing in a metaphyseal long bone defect in mini-pigs. A metaphyseal critical-size bone defect at the proximal tibia of 24 mini-pigs was filled with CPG combined with BMC, CPG solely (control group) or with an autograft. Radiological and histomorphometrical evaluations after 6 weeks (42 days) showed significantly more bone formation in the BMC group in the central area of the defect zone and the cortical defect zone compared to the CPG group. At the same time the resorption rate of CPG increased significantly in the BMC group. Nevertheless, compared to the BMC group the autograft group showed a significantly higher new bone formation radiologically and histomorphometrically. In BMC the count of mononuclear cells was significantly higher compared to the bone marrow aspirate (3.5-fold). The mesenchymal progenitor cell characteristics of the cells in BMC were confirmed by flow cytometry. Cells from BMC created significantly larger colonies of alkaline phosphatase-positive colony forming units (CFU-ALP) (4.4-fold) compared to cells from bone marrow aspirate. Nevertheless, even in the BMC group complete osseous bridging was only detectable in isolated instances of the bone defects. Within the limitations of this study the BMC+CPG composite promotes bone regeneration in the early phase of bone healing significantly better than the isolated application of CPG. However, the addition of BMC does not lead to a solid fusion of the defect in the early phase of bone healing an still does not represent an equal alternative to autologous bone.

Changes in bone structure of Corriedale sheep with inherited rickets: a peripheral quantitative computed tomography assessment.

An inherited skeletal disease with gross and microscopic features of rickets has been diagnosed in Corriedale sheep in New Zealand. The aim of this study was to quantify the changes present in tibia from sheep with inherited rickets using peripheral quantitative computed tomography. In affected sheep, scans in the proximal tibia, where metaphysis becomes diaphysis, showed significantly greater trabecular bone mineral content (BMC) and bone mineral density (BMD). The sheep with inherited rickets had significantly greater BMC and bone area in the mid-diaphysis of the proximal tibia compared to control sheep. However, BMD in the mid-diaphysis was significantly less in affected sheep than in controls, due to the greater cortical area and lower voxel density values in affected sheep. From this it was concluded that the increased strain on under-mineralised bone in sheep with inherited rickets led to increased bone mass in an attempt to improve bone strength.

Tratamiento de la pseudoartrosis séptica y recalcitrante de la diáfisis humeral mediante impactación intramedular / Treatment of the septic and recalcitrant humeral shaft nounion by means intramedullary impactation

Se presenta un caso de una fractura de la diáfisis humeral complicada con una pseudoartrosis recalcitrante, infección y parálisis radial. Se propone una alternativa de tratamiento que, por su sencillez y aplicabilidad, puede incluirse en el arsenal terapéutico para solucionar esta grave patología (AU)

We present a case of humeral shaft fracture complicated with recalcitrant nonunion, infection and radial nerve paralisys. A treatment alternative sets out that, by its simplicity and applicability, deserves to have it in account within the therapeutic arsenal which we arrange to the solution of this serious pathology (AU)

A osteotomia em um plano oblíquo por corte único para correção de deformidades complexas diafisárias de ossos longos: um método para sua realização / Single-cut oblique plane osteotomy to correct complex diaphyseal deformities of long bones: a method for its performance

A correção das deformidades complexas, aquelas simultaneamente com desvios angular e torcional, é possível por osteogênese e por osteotomias. O presente estudo foi realizado para desenvolver e aplicar um método para a técnica da osteotomia em um plano oblíquo por um único corte, para a correção de deformidades diafisárias complexas em ossos longos (fêmur ou tíbia) e verificar a sua aplicabilidade. MÉTODOS: Este estudo prospectivo envolveu 10 pacientes de ambos os sexos, com idades, entre 17 e 62 anos, que apresentavam deformidades complexas de ossos longos (quatro no fêmur e seis na tíbia) tratados cirurgicamente com osteotomia corretiva pela técnica de corte único em um plano oblíquo. Os pacientes foram avaliados comparativamente no pré e pós-operatório, para a mensuração das deformidades angulares verdadeiras através do método gráfico, a partir de medições nas radiografias do osso deformado, e clinicalmente para deformidade torcional e do comprimento. Também foram observados o tempo de consolidação e as complicações. O planejamento pré-operatório determinou o cálculo do ângulo do corte do osso. Foram confeccionados para cada paciente um modelo artificial em plástico do osso deformado e nele simulada a correção. Foram realizados desenhos do osso com anotação dos principais passos cirúrgicos e a escolha do local e do tamanho do material de síntese. O planejamento pré-operatório orientou a cirurgia. No pré-operatório, os pacientes apresentavam deformidades com valores médios de: deformidade angular verdadeira de 19º; torção de 12º; encurtamento de 1,3cm. RESULTADOS: Após correção, as medidas mostraram um valor médio de: deformidade angular verdadeira de 4º (p = 0,005); torção de 1º (p = 0,005) e encurtamento de 0,6cm (p = 0,027). Três pacientes apresentaram complicações, sendo dois com retarde de consolidação e outro com infecção profunda tardia e retarde de consolidação. CONCLUSÃO: O presente estudo mostrou ser possível estabelecer um...

Correction of complex deformities, those with concomitant angular and torsional deviations, can be done by osteogenesis and by osteotomies. This study was performed to develop and apply a method of single-cut oblique plane osteotomy to correct complex diaphyseal deformities in long bones (femur or tibia) and to check its applicability. METHODS: This prospective study involved 10 patients of both genders, ages ranging from 17 to 62, who presented with complex deformities of long bones (four in the femur, six in the tibia) and were surgically treated by corrective osteotomy using the single-cut oblique plane technique. The patients were evaluated comparatively before and after surgery to measure the true angular deformities by a graphic method based on radiographic measurements of the deformed bone, and clinically for the torsional deformity and extension. Time till union and complications were also observed. Pre-operative planning determined the calculation of the bone-cutting angle. For each patient, an artificial model was made of the deformed bone, and the correction was simulated in such model. Drawings of the bone with annotations of the major surgical steps and the choice of the site and size of the synthesis material were made. The pre-operative planning guided the surgery. In the pre-operative stage, the patients had deformities with the following mean values: true angular deformity of 19º; torsion of 12º; shortening of 1.3 cm. RESULTS: After correction, the measurements showed the following mean values: true angular deformity of de 4º (p = 0.005); torsion of 1º (p = 0.005), and shortening of 0.6 cm (p = 0.027). Three patients had complications, two with delayed union, and one with late deep infection and delayed union. CONCLUSION: This study showed that it is possible to set up a reliable and reproducible method for the single-cut oblique plane osteotomy technique to correct complex diaphyseal deformities of long bones.

Cytogenetic and molecular characterization of a de-novo t(2p;7p) translocation involving TNS3 and EXOC6B genes in a boy with a complex syndromic phenotype.

We describe a premature newborn child with left renal agenesis, right low functional kidney, altered chemical-clinical parameters, neutropenia, recurrent pulmonary infections, long bone diaphysis broadening, growth and developmental delay. Postnatal cytogenetic analysis revealed a 46,XY,t(2;7)(p13;p12) de-novo karyotype. The chromosome breakpoints were defined by FISH using BAC probes and initially restricted to about 123,000bp in 2p13 and delimited to 84,600bp in 7p12. Bioinformatic analysis of these genomic regions showed two genes that are involved in the rearrangement: exocyst C6B (EXOC6B) for chromosome 2 breakpoint and tensin3 (TNS3) for chromosome 7 breakpoint. A EXOC6B-TNS3 fusion transcript together with a reciprocal TNS3-EXOC6B chimeric RNA have been detected by RT-PCR performed on skin fibroblasts RNA of the proband. These data localize the chromosome 2 breakpoint within the first intron of EXOC6B, while the translocation event on chromosome 7 occurred in intron 15 of TNS3. We hypothesize that the phenotype observed in the patient results from one or several mechanisms including: haploinsufficiency of EXOC6B and TNS3 genes; a dominant negative effect exerted by the chimeric transcripts; a disregulation in the expression of other genes adjacent the breakpoints. Although no clear evidences exist supporting a role of any of the above mentioned mechanisms in the pathogenesis of the complex phenotype, immunofluorescence analysis of tensin1 in the patient's fibroblasts suggests that the TNS3 gene haploinsufficiency results in a reduced expression of tensin1. These cells may be therefore a model for understanding the role and the organization of the tensin protein family.

The S-ROM modular stem for femoral deformities.

Many conditions produce femoral deformities that complicate primary total hip arthroplasty (THA). In each patient, treatment must be individualized to address the level of the deformity, the type of deformity, and bone quality, as well as surgeon preference. The S-ROM femoral component (DePuy Orthopaedics, Warsaw, Ind) is useful for many deformities from the level of the greater trochanter to the diaphysis. The S-ROM stem optimizes proximal and distal implant stability, allows maximal torsional stability during osteotomies, and permits easy adjustments to anteversion, offset, and leg length to provide optimal biomechanical reconstruction of the deformed femur in THA. Clinical results with few complications are achievable when using the S-ROM stem in complex deformities.

Resultados de la fijación intramedular con clavo colchero a cielo abierto con bloqueo y fresado del canal en fractura de fémur en el servicio de Ortopedia Hospital Roberto Calderón G diciembre 2000 a enero 2003 / Results of the fixing intramedular with nail colchero to sky opened with blockade and fresado of the channel in femur fracture in the Orthopedics service Hospital Roberto Calderón G December 2000 to January 2003

Estudio observacional, ambilectivo transversal, cuyo objetivo fue evaluar las fracturas de la diafisis femoral, tratadas con clavo endomedular colchero, en el servicio de Ortopedia y Traumatología, Hospital Roberto Calderón, durante el periodo Diciembre 2000 a Enero 2003. El seguimiento promedio fue de 24 meses. Sin embargo, para valorar resultados y complicaciones se estableció 24 semanas como rango desde que el paciente fue intervenido hasta su alta de consulta externa, ya que posterior a las 16 o 20 semanas se espera un pobre resultado y por ende complicaciones derivadas del procedimiento. En este periodo se manejaron 15 pacientes, de los cuales el 80 porciento pertenecieron al sexo masculino, y un 20 porciento al sexo femenino. El sistema de clasificación., utilizado (Winquist), tomó en cuenta el grado de conminución y porcentaje de cortical femoral afectada, siendo la tipo IV la que se encontró con mayor frecuencia ( 53.3 porciento). Se valoró resultados tomando en cuenta parámetros clínicos y radiológicos en escala nominal, siendo en un 26.7 porciento resultados excelentes, 46.7 porciento buenos, 26.7 porciento entre regulares y malos.Llama la atención el alto índice de población joven afectada 31 años como promedio económicamente activa.Consideramos que los parámetros de evaluación, utilizados en el análisis del paciente, fractura y tratamiento, tienen una correlación directa sobre los resultados y complicaciones...

Total hip arthroplasty in patients with proximal femoral deformity.

Most proximal femoral deformities encountered during hip arthroplasty are secondary to developmental processes, previous osteotomy, or fracture. A classification method is proposed in which deformities are categorized anatomically by level. Anatomic deformity levels include: greater trochanteric deformities, femoral neck deformities, metaphyseal level deformities, and diaphyseal level deformities. Deformities at each level may be angular, rotational or translational, abnormal bone size, or a combination thereof. Treatment is individualized according to patient needs and the anatomy of the deformity. Careful preoperative planning helps predict prosthesis requirements and technical challenges. If cemented implants are used, care must be taken to obtain reasonable alignment and a continuous cement mantle. For uncemented implants, obtaining a good fit is challenging and there is a risk of intraoperative fracture. Access to a wide range of implants helps the surgeon treat unique femoral geometries. Implants fixed in the diaphysis allow some proximal femoral deformities to be bypassed. Modular or custom implants simplify treatment of certain deformities. For patients with severe deformities, femoral osteotomy may be required. Successful osteotomy requires correcting the deformity, maintaining vascular supply of fragments, obtaining fixation of osteotomy fragments (with the implant or adjunctive fixation), and obtaining implant stability. Although most deformities can be treated during hip arthroplasty, occasionally there is a role for two-stage treatment: deformity correction followed later by arthroplasty.

Tibioperoneal diaphyseal toxopachyosteosis or Weismann-Netter-Stuhl syndrome: difficulties encountered in classifying this syndrome and differentiation from rickets.

Using two new cases and 70 case reports in the literature as a starting point, the authors focus on the Weismann-Netter-Stuhl syndrome. Weismann-Netter and Stuhl reported the first cases of tibioperoneal diaphyseal toxopachyosteosis in 1954. This syndrome is defined as an anomaly of the diaphyseal part of both tibiae and fibulae with posterior cortical thickening and anterior-posterior bowing. This anomaly is usually bilateral and symmetrical, and patients are therefore short in stature. The thickening of the fibula is true "tibialisation" and "is the main feature and the only feature confirming diagnosis". Routine laboratory investigations showed no abnormalities in the two new cases. The authors specify the limits encountered in classifying this anomaly and discuss the degree to which this anomaly is an entity unto itself when compared with rickets sequelae.

Identification and classification of tibioperoneal diaphyseal toxopachyosteosis (Weismann-Netter-Stuhl syndrome): based on two new cases and a review of the literature.

Using two new cases and 70 case reports in the literature as a starting point, the authors focus on the Weismann-Netter-Stuhl syndrome. Weismann-Netter and Stuhl reported the first cases of tibioperoneal diaphyseal toxopachyosteosis in 1954. This syndrome is defined as an anomaly of the diaphyseal part of both tibiae and fibulae with posterior cortical thickening and anterior-posterior bowing. This anomaly is usually bilateral and symmetrical and patients are short. The thickening of the fibula is true tibialisation and is the main feature and the only feature confirming diagnosis. Routine laboratory investigations showed no abnormalities. The authors specify the limits encountered in classifying this anomaly and discuss the degree to which this anomaly is an entity unto itself when compared with rickets sequelae.

TGF-beta 1 forms functionally normal bone in a segmental sheep tibial diaphyseal defect.

OBJECTIVE: Transforming growth factor-beta 1 (TGF-beta 1) is a polyfunctional regulatory cytokine that has been shown to have roles in extracellular matrix interactions, soft tissue healing, and osteogenesis. This study was undertaken to determine the efficacy of TGF-beta 1 in the formation of functionally normal bone in tibial-diaphyseal defects. METHOD: Seven hundred fifty micrograms of recombinant human TGF-beta 1 was added to a guanidine-extracted demineralised bone matrix (Gu-DBM) carrier and the implants were used to fill a 2.5 cm tibial diaphyseal defect in skeletally mature female sheep. The defects were allowed to heal over a 12-week period. After sacrifice, they were analyzed using four-point bending mechanical testing. RESULTS: Implants with TGF-beta 1 showed complete bony bridging of the defect and stress-strain curves similar to the normal contralateral limb, while implants with the carrier alone failed to bridge the gap. CONCLUSIONS: These results demonstrate the ability of TGF-beta 1 to induce new bone which has structural and functional characteristics similar to normal bone.