Bone Union of Osseous Microvascular Free Tissue Transfer in Mandibular Reconstruction

Objectives Osseous microvascular free tissue transfer (MFTT) is the gold standard for reconstruction for most segmental mandibulectomy defects. The most common osseous MFTT utilized in reconstruction is the fibular, scapular, and osteocutaneous radial forearm (OCRF) free flap. We evaluated postoperative bone union as well as clinical complications following MFTT and the impact of various patient and reconstructive characteristics, including type of osseous MFTT. Study Design Retrospective cohort study. Setting Tertiary care academic hospital. Methods This study examined patients who underwent osseous MFTT for mandibular defects from January 2017 to January 2019. Results An overall 144 osteotomies in 58 patients were evaluated. Of the 144 junctions, 28 (19.4%) showed radiographic nonunion. Patients who underwent preoperative (odds ratio [OR] = 0.30, P = .027) and postoperative (OR = 0.28, P = .003) radiation had a significantly lower bone union score. Time from surgery to postoperative imaging was associated with higher bone union scores (OR = 1.07, P = .024). When bone union scores were compared among types of MFTT, fibular (OR = 5.62, P = .008) and scapular (OR = 4.69, P = .043) MFTT had significantly higher scores than OCRF MFTT. Twelve (20.7%) patients had postoperative complications. There was no statistically significant correlation between clinical complications and various variables, including type of osseous MFTT. Conclusion Pre- and postoperative radiation and time from surgery have an impact on bone union. Regarding the type of MFTT, fibular and scapular MFTT appeared to have higher bone union when compared with OCRF. There was no impact of bone union or type of osseous MFTT on clinical complications.

Acetabular Migration of Lag Screw of Intramedullary Nail Used as Treatment for Intertrochanteric Fracture. Case Study

Most trochanteric fractures of the femur are classified as low-energy fractures as they are seen in people with decreased mechanical properties of bone tissue. The treatment is assumed to provide biomechanical fixation with the possibility of dynamization between bony fragments to stimulate the biological processes of bone union. The aim of the study was to analyze a complication presenting as migration of the cervical screw of an intra­medullary nail towards the hip joint acetabulum and present the therapeutic management of this complication. The case report concerned a 74-year-old patient with an AO/OTA type 31 A2.2 fracture of the trochanteric massif of the right femur treated with the Gamma3 intramedullary nail. An assessment of changes over time of the radiological appearances on A-P images after the surgery showed migration of the cervical screw towards the acetabulum and displacement of the major trochanter fracture. Extensive destruction of the acetabular fossa made biologic restorative treatment impossible. A total hip joint prosthesis with a modular stem and MDM articulation was implan­ted and the trochanter was fixed with a "hook" plate with a "cable system". The postoperative course was uneventful. Failure to perform axial radiographs in the preoperative and postoperative period made it impossible to objectively determine the type of fracture and the quality of screw insertion into the femoral neck, and assessment limited to A-P images turned out to be deceptive. The wandering of the screw towards the acetabulum led to extensive destruction of the acetabular fossa. The decision to stop biological treatment, which, if properly performed, stimulates bone union, and perform the mechanical procedure of endoprosthesoplasty was fully prognostically justified. The early and late postoperative course was not complicated.

Treatment of FRI after intramedullary nailing of tibia fractures: assessment of nail retention and nail removal

Objectives: Fracture related infection (FRI) is a severe, potentially limb-threatening complication after fracture fixation. Dilemma exists with regard to removing or retaining implants while treating the infection. The purpose of this study was to compare primary bone union and infection clearance in patients who had an infection following intramedullary nailing of the tibia treated either by retaining the implant or by removing the implant. Methods: Patients from two level-I trauma centers were identified through billing registries and retrospectively reviewed between January 2013 and December 2020. We identified 44 patients who had a diagnosis of FRI within 90 days of their initial fixation and returned to the OR for operative treatment of the infection. The incidences of both primary union and infection clearance were calculated for both groups and multiple parameters that may be associated with success or failure were assessed. Results: Four patients did not have complete records and were excluded. Of the remaining patients, 20 (50%) achieved infection clearance. Twenty-three (59%) patients achieved primary union whereas 16 (41%) had a primary outcome of either delayed union, nonunion, or amputation (one additional patient excluded as healing status unknown). Further analysis showed no significant difference (X2 (39) = 1.13, p < .29) in infection clearance between patients treated with nail retention (64%) versus nail removal (68%). No significant difference was seen in primary bone union (X2 (39) = 3.24, p < .07) with 36% of patients treated with nail retention and 68% of patients treated with nail removal reaching primary union; however, this does trend toward an association. Fewer surgeries performed for infection and complication after initial fixation was positively associated with infection clearance (p < .04, M=4.6, SD=2.13, df=39) and primary union (p < .001, M=4, SD=2, df=38). Conclusion: Infection clearance seems similarly possible with both nail retention and nail removal strategies, with fewer number of surgeries performed for infection and complication improving the likelihood of infection clearance and bone union. This may suggest that more severe FRI’s are less likely to unite and clear infection. Nail removal may play a role in increasing primary bone union; however, a larger sample size is needed for more definitive assessment.

3D printing in orthopaedic surgery: a scoping review of randomized controlled trials

Aims The use of 3D printing has become increasingly popular and has been widely used in orthopaedic surgery. There has been a trend towards an increasing number of publications in this field, but existing literature incorporates limited high-quality studies, and there is a lack of reports on outcomes. The aim of this study was to perform a scoping review with Level I evidence on the application and effectiveness of 3D printing. Methods A literature search was performed in PubMed, Embase, and Web of Science databases. The keywords used for the search criteria were ((3d print*) OR (rapid prototyp*) OR (additive manufactur*)) AND (orthopaedic). The inclusion criteria were: 1) use of 3D printing in orthopaedics, 2) randomized controlled trials, and 3) studies with participants/patients. Risk of bias was assessed with Cochrane Collaboration Tool and PEDro Score. Pooled analysis was performed. Results Overall, 21 studies were included in our study with a pooled total of 932 participants. Pooled analysis showed that operating time (p < 0.001), blood loss (p < 0.001), fluoroscopy times (p < 0.001), bone union time (p < 0.001), pain (p = 0.040), accuracy (p < 0.001), and functional scores (p < 0.001) were significantly improved with 3D printing compared to the control group. There were no significant differences in complications. Conclusion 3D printing is a rapidly developing field in orthopaedics. Our findings show that 3D printing is advantageous in terms of operating time, blood loss, fluoroscopy times, bone union time, pain, accuracy, and function. The use of 3D printing did not increase the risk of complications. Cite this article: Bone Joint Res 2021;10(12):807–819.

Screw Fixation Method through Temporary Kirschner Wire Hole for Coronal Hamate Fracture

Purpose: Hamate coronal body fracture is a rare injury and often associated with dislocation of the carpometacarpal joint. For preserving the carpometacarpal joint, open reduction and rigid internal fixation is needed to displaced fracture. The purpose of this study was to evaluate the outcome of treating hamate coronal fracture with the screw fixation method through a temporary Kirschner wire (K-wire) fixation hole.Methods: From August 2016 to January 2021, eight patients who had displaced coronal hamate body fractures were enrolled. All patients were performed open reduction and multiple K-wires fixations. After that, the cortical screws were then inserted directly into the holes made by removing the K-wires one by one. The outcome measures were Disabilities of the Arm, Shoulder and Hand (DASH) scores and visual analogue scale (VAS) scores.Results: The average follow-up period was 11.5 months (range, 5–8 months) after surgery, and the bone union was observed at the 8 weeks after surgery. We confirmed that bone union had been completed for all the patients, and functional tests showed that the average DASH score was 3.95 (range, 0–8.3) and VAS score was 0.8 (range, 0–3).Conclusion: In coronal hamate body fractures, open reduction and screw fixation method through temporary K-wire fixation hole is simple and effective treatment technique.

No difference in mid-term outcome after superior vs. anteroinferior plate position for displaced midshaft clavicle fractures

To compare outcomes, complications, revisions, and rates of implant removal of superior compared to anteroinferior plating in displaced midshaft clavicle fractures at mid-term follow-up. We retrospectively reviewed 79 patients who underwent operative treatment for displaced midshaft clavicle fractures (Group A: 28 patients with superior plating; Group B: 51 patients with anteroinferior plating) that were at least 2 years postoperatively. Adjusted Constant Score (aCS), Visual Analog Scale (VAS), and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score were compared. Bone union, implant removal, complications and revision surgeries were assessed. Group A had a significantly higher aCS compared to group B (90, IQR: 85.0–91.0 vs. 91, IQR: 90.0–93.0; P = 0.037). No significant differences between groups were seen in VAS (P = 0.283) and QuickDASH (P = 0.384). Bone union was achieved in 76 patients (96.2%) with no significant differences between groups (Group A: 96.4% vs. Group B: 96.1%; P > 0.999). There were no significant differences in implant removal rates (Group A: 60.7% vs. Group B: 66.7%; P = 0.630), complications (Group A: 46.4% vs. Group B: 31.4%; P = 0.226) and revisions (Group A: 25% vs. Group B: 9.8%; P = 0.102). Superior and anteroinferior plating result in high bone union rates and good clinical outcomes with similar rates of plate removal.

Masquelet Technique Combined with Tissue Flap Transplantation in The Treatment of Infectious Complex Tissue Defect: A Clinical Analysis

Background: Infectious complex tissue defects have been described as injuries with composite infectious bone defects and extensive soft tissue damage, which are still austere challenges for orthopedists all around the world. The study retrospectively evaluated the Masquelet technique combined with the tissue flap transplantation for the treatment of infectious complex tissue defects and assess key factors of success in this technique.Methods: From December 2016 to December 2019, 22 patients of infectious complex tissue defects were recruited for the study. All the cases experienced a two-stages treatment. Thorough debridement, stabilization of fracture by external fixation and implantation of a cement spacer mixed with antibiotics in the first stage. Simultaneously, suitable tissue flaps were designed and transplanted for the soft tissue defect. 6-8 weeks later, after the elimination of the infection, the cement spacer was removed carefully from the induced membrane and cancellous bone was grafted into the site of bone defect. The average duration of follow-up was 21 months.Results: Infection was eliminated after the first stage intervention without recurrence. All the transplanted tissue flaps were survived. Bone union was achieved in all patients in a period of 16-31 weeks following the second stage surgery. According to the Paley fracture healing score, 17 patients showed excellent results and 5 patients displayed good results regarding bone outcomes. When considering functional outcomes, 14 patients exhibited excellent results and 8 patients displayed good results.Conclusions: This study showed evidences that Masquelet technique combined with tissue flap transplantation was an effective method to repair the infectious complex tissue defects. We also demonstrate that a complete soft-tissue envelope plays an important role in the formation of the induced membrane which promote bone union and in the anti-infection treatment.

Shaft Fractures in Patients Requiring Primary or Revision Total Knee Arthroplasty Can Be Successfully Treated with Long-Stemmed Implants without Additional Fixation

The aim of this study was to evaluate the bone union, complication rate, clinical and functional outcomes of long-stemmed total knee arthroplasty (TKA) in patients with periprosthetic femoral or tibial shaft fractures and in patients with femoral or tibial shaft fractures with coexisting advanced knee osteoarthritis (OA). This retrospective study comprised 25 patients who underwent surgery due to tibial or femoral shaft fractures: (1) with coexisting severe knee OA or (2) with a periprosthetic fracture requiring implant exchange. In all cases, fracture stabilization was performed intramedullary with the use of long-stemmed implants without the use of additional fixation material (plates, screws, or cerclage). Bone union was achieved in 22/25 patients (88%). One patient required revision with additional plate stabilization due to non-union, and asymptomatic partial bone union was observed in two cases. The group with periprosthetic fractures demonstrated good clinical (mean 73.1 ± 13.3) and moderate functional (mean 59.2 ± 18.8) outcomes in the Knee Society Scoring system (KSS). In the group with shaft fracture and coexisting OA significantly higher clinical (excellent results, mean 84.1 ± 11; p = 0.03) and functional (good results, mean 76.2 ± 20.6; p = 0.04) results were noted. There were no statistically significant differences in terms of range of motion (ROM) or complication rate between these two groups. One-stage TKA with a long-stemmed implant without the use of additional fixation material is an effective method for the treatment of femoral or tibial shaft fractures in patients who require joint replacement. Despite being technically demanding, the approach yields bone union and moderate to excellent clinical and functional outcomes with a relatively low complication rate.