Surgery for chronic symptoms after whiplash injury: Follow-up of 20 cases

Whereas continuous exposure to PTH results in bone resorption, administration at intermittent doses results in bone formation by increasing osteoblast number and activity. The anabolic action of PTH has also been demonstrated in clinical trials, in which PTH increased the bone mass and reduced fracture rate in patients with osteoporosis. In animal models of fracture healing and fixation of orthopedic implants, PTH increases the bone density in a dose-dependent manner, leading to faster repair and better fixation. The effect appears to be stronger on the new forming bone than on pre-existing bone. Based on these preclinical studies, we suggest that intermittent PTH treatment may also benefit fracture healing and implant fixation in patients.     

Parathyroid hormone--a drug for orthopedic surgery?

Whereas continuous exposure to PTH results in bone resorption, administration at intermittent doses results in bone formation by increasing osteoblast number and activity. The anabolic action of PTH has also been demonstrated in clinical trials, in which PTH increased the bone mass and reduced fracture rate in patients with osteoporosis. In animal models of fracture healing and fixation of orthopedic implants, PTH increases the bone density in a dose-dependent manner, leading to faster repair and better fixation. The effect appears to be stronger on the new forming bone than on pre-existing bone. Based on these preclinical studies, we suggest that intermittent PTH treatment may also benefit fracture healing and implant fixation in patients.     

Infection of orthopedic implants and the use of antibiotic-loaded bone cements: A review

Infections by bacteria are a serious complication following orthopedic implant surgery, that can usually only be cured by removing the implant, since the biofilm mode of growth of infecting bacteria on an implant surface protects the organisms from the host immune system and antibiotic therapy. Over the past few decades, attempts have been made to prevent and cure orthopedic implant infections by incorporating antibiotics in polymethylmethacrylate bone cements, in primary and revision surgery. However, the clinical efficacy of antibiotic-releasing bone cements is not accepted by all and the long-term exposure to low doses from antibiotic-releasing bone cements in patients is strongly related to the emerging threat of antibiotic resistance in medicine today. In this article, we start by reviewing the mechanisms governing the formation of an infectious biofilm on orthopedic implant materials, the release mechanisms and properties of clinically-used, antibiotic-loaded bone cements. The clinical efficacy of antibiotic-loaded bone cements is evaluated analyzing separatedly the prophylactic and therapeutic uses of these products.     

Infection of orthopedic implants and the use of antibiotic-loaded bone cements. A review

Infections by bacteria are a serious complication following orthopedic implant surgery, that can usually only be cured by removing the implant, since the biofilm mode of growth of infecting bacteria on an implant surface protects the organisms from the host immune system and antibiotic therapy. Over the past few decades, attempts have been made to prevent and cure orthopedic implant infections by incorporating antibiotics in polymethylmethacrylate bone cements, in primary and revision surgery. However, the clinical efficacy of antibiotic-releasing bone cements is not accepted by all and the long-term exposure to low doses from antibiotic-releasing bone cements in patients is strongly related to the emerging threat of antibiotic resistance in medicine today. In this article, we start by reviewing the mechanisms governing the formation of an infectious biofilm on orthopedic implant materials, the release mechanisms and properties of clinically-used, antibiotic-loaded bone cements. The clinical efficacy of antibiotic-loaded bone cements is evaluated analyzing separatedly the prophylactic and therapeutic uses of these products.     

Infection of orthopedic implants and the use of antibiotic-loaded bone cements: A review

Infections by bacteria are a serious complication following orthopedic implant surgery, that can usually only be cured by removing the implant, since the biofilm mode of growth of infecting bacteria on an implant surface protects the organisms from the host immune system and antibiotic therapy. Over the past few decades, attempts have been made to prevent and cure orthopedic implant infections by incorporating antibiotics in polymethylmethacrylate bone cements, in primary and revision surgery. However, the clinical efficacy of antibiotic-releasing bone cements is not accepted by all and the long-term exposure to low doses from antibiotic-releasing bone cements in patients is strongly related to the emerging threat of antibiotic resistance in medicine today. In this article, we start by reviewing the mechanisms governing the formation of an infectious biofilm on orthopedic implant materials, the release mechanisms and properties of clinically-used, antibiotic-loaded bone cements. The clinical efficacy of antibiotic-loaded bone cements is evaluated analyzing separatedly the prophylactic and therapeutic uses of these products.     

Osseointegration of cobalt-chrome alloy implants

Osseointegration or osteointegration refers to a direct bone-to-metal interface without interposition of non-bone tissue. The long-term clinical success of bone implants is critically related to wide bone-to-implant direct contact. However, only poor bone formation or even host bone resorption have been shown where bone is in tight contact with the implant surface. It has been suggested that an appropriate space between implant and host bone may be useful for early peri-implant bone formation. Additionally, osseointegration depends on the topographical and chemical characteristics of the implant surface. Cobalt-chrome (Co-Cr) is a metal alloy of cobalt and chromium. Because of its high strength, temperature endurance and wear resistance, it is commonly used in dental and orthopedic implants. In orthopedic implants it is usually composed of cobalt with chromium, molybdenum, and traces of other elements. Co-Cr alloys are especially useful where high stiffness or a highly polished and extremely wear-resistant material is required. This article reviews the Co-Cr alloy orthopedic implants in terms of their properties, porous coating, osseointegration, outcome, and failure.     

Moderate heat treatment of bone allografts

Summary The use of bone allografts is often essential in orthopedic surgery. Strict donor screening, including HIV testing 3 months postoperatively, is mandatory before a transplant may be used. Yet these measures do not definitely rule out the possibility of HIV transmission, as there is a window period before infection is revealed by blood testing. Accordingly, there is a need for virus inactivation methods that can be used on bone allografts. As radiation treatment and chemical methods have a number of disadvantages, we chose a moderate heat treatment of 65°C for a series of animal experiments. In 12 rabbit femoral condyles, moderate-heattreated bone allografts were implanted into 6-mm drill holes. Twelve normal allografts and 12 empty drill holes served as controls. Radiologic and histological evaluation up to 12 weeks postoperatively revealed slow spontaneous bone remodeling from the rim to the center of the empty cavities. Normal deep frozen allografts were quickly integrated after a short period of osteoclast reaction around the transplant, with occasional bone bridges between host and allgraft. The examination of heattreated allografts showed no differences to the controls, including morphologic aspects and the time course of osteointegration. Five zones of bone repair and osteointegration were distinguished. We conclude that thermal treatment of bone allografts has no adverse effects on osteointegration in the rabbit femoral condyle. Thus, it may contribute to improving safety in human bone transplantation.     

Implications for Fracture Healing of Current and New Osteoporosis Treatments: An ESCEO Consensus Paper

Osteoporotic fracture healing is critical to clinical outcome in terms of functional recovery, morbidity, and quality of life. Osteoporosis treatments may affect bone repair, so insights into their impact on fracture healing are important. We reviewed the current evidence for an impact of osteoporosis treatments on bone repair. Treatment with bisphosphonate in experimental models is associated with increased callus size and mineralization, reduced callus remodeling, and improved mechanical strength. Local and systemic bisphosphonate treatment may improve implant fixation. No negative impact on fracture healing has been observed, even after major surgery or when administered immediately after fracture. Experimental data for denosumab and raloxifene suggest no negative implications for bone repair. The extensive experimental results for teriparatide indicate increased callus formation, improved biomechanical strength, and greater external callus volume and total bone mineral content and density. Case reports and a randomized trial have produced mixed results but are consistent with a positive impact of teriparatide on clinical fracture healing. Studies with strontium ranelate in models of fracture healing indicate that it is associated with improved bone microstructure, callus volume, and biomechanical properties. Finally, there is experimental evidence for a beneficial effect of some of the agents currently being developed for osteoporosis, notably sclerostin antibody and DKK1 antibody. There is currently no evidence that osteoporosis treatments are detrimental for bone repair and some promising experimental evidence for positive effects on healing, notably for agents with a bone-forming mode of action, which may translate into therapeutic applications.     

Tmem100- and Acta2-Lineage Cells Contribute to Implant Osseointegration in a Mouse Model

Metal implants are commonly used in orthopedic surgery. The mechanical stability and longevity of implants depend on adequate bone deposition along the implant surface. The cellular and molecular mechanisms underlying peri-implant bone formation (ie, osseointegration) are incompletely understood. Herein, our goal was to determine the specific bone marrow stromal cell populations that contribute to bone formation around metal implants. To do this, we utilized a mouse tibial implant model that is clinically representative of human joint replacement procedures. Using a lineage-tracing approach, we found that both Acta2.creERT2 and Tmem100.creERT2 lineage cells are involved in peri-implant bone formation, and Pdgfra- and Ly6a/Sca1-expressing stromal cells (PαS cells) are highly enriched in both lineages. Single-cell RNA-seq analysis indicated that PαS cells are quiescent in uninjured bone tissue; however, they express markers of proliferation and osteogenic differentiation shortly after implantation surgery. Our findings indicate that PαS cells are mobilized to repair bone tissue and participate in implant osseointegration after surgery. Biologic therapies targeting PαS cells might improve osseointegration in patients undergoing orthopedic procedures. © 2021 American Society for Bone and Mineral Research (ASBMR).     

Metallic Biomaterials in Skeletal Repair

Abstract Metallic biomaterials are becoming increasingly important in skeletal repair. The goal of this review article is to present an overview of metallic implant materials currently used in trauma and orthopedic surgery. Further, new research trends and future clinical concepts are described and discussed. Titanium, titanium alloys, stainless steels and CoCr alloys are used as bone implants in orthopedic and trauma surgery. Especially titanium and its alloys currently constitute the most highly favoured implant materials for joint replacement and osteosynthesis. In comparison to other metallic implant materials, titanium is characterized by a high biocompatibility, a good workability and corrosion resistance with suitable mechanical properties (low Young’s modulus—high strength). To improve orthopedic implants, there is a trend in current research towards the development of new titanium alloys with improved biological and biomechanical properties. To achieve a fast and safe bone fixation of the implants, optimized surface characteristics and surface structures are applied. Biomimetic coatings with and without the ability to release growth factors and cell coatings even including the development of stem-cell-coated titanium implants for the partial surface replacement of joints are under investigation.     

Nichtsteroidale Antirheumatika (NSAR) in der perioperativen Phase in Traumatologie und Orthopädie

OBJECTIVE: To achieve analgesic, anti-inflammatory and antipyretic effects in traumatology and orthopedic surgery without side effects or with the least possible side effects, with special emphasis on bone healing. INDICATIONS: Acute and chronic inflammatory conditions, e. g., rheumatoid arthritis, ankylosing spondylitis. Degenerative joint disease. Posttraumatic and postoperative pain, edema, or fever. Prevention of heterotopic bone formation. CONTRAINDICATIONS: Hypersensitivity. Gastrointestinal ulceration or bleeding. Severe hepatic or renal impairment. RESULTS: Nonsteroidal anti-inflammatory drugs (NSAIDs) are invaluable in treating a variety of musculoskeletal conditions. As well as their excellent analgesic potency their anti-inflammatory effects are beneficial in treating posttraumatic and postoperative edema. In addition, NSAIDs inhibit heterotopic bone formation after hip arthroplasty. Animal studies, however, have demonstrated that they cause delayed fracture healing. Although clinical studies have not yet supplied unequivocal evidence of this effect in human subjects, the authors recommend that in the presence of other risk factors which may adversely affect fracture healing, such as smoking, diabetes mellitus or peripheral arterial occlusive disease, the indication of NSAID use for analgesia should be strictly limited. Therapeutic alternatives such as centrally acting agents (e. g., weak opioids) should be considered in these patients.     

Significance of osteoporosis in craniomaxillofacial surgery: A review of the literature

Osteoporosis is a common problem in orthopedic surgery. The purpose of this review of the literature was to examine whether osteoporosis is also an important factor in patient treatment in the field of craniomaxillofacial surgery. Emphasis was given to the consequences of osteoporosis for the maxilla and mandible, the influence of osteoporosis on fracture treatment, the use of dental implants, the importance of soft tissues and the effect of osteoporosis therapies. It was found that osteoporosis does affect the bones of the skull. The effect of osteoporosis on treatment, however, is controversial and necessitates better ways of quantifying bone loss. Large inter-individual and site-specific differences in bone density, as well as other effects such as removal of teeth, periodontitis, implant insertion, augmentation procedures and altered loading with dystrophic consequences need to be considered in future studies. Special attention should be given to osteoporosis during fracture treatment.     

Rapid resorption of calcium sulfate and hardware failure following corrective radius osteotomy: 2 case reports

Bone substitutes are being increasingly used and may avert the need for autogenous bone graft in orthopedic surgery. Thus it is important to note complications that occur with them to better understand the limitations. We report on early mechanical failure of injectable calcium sulfate leading to implant failure in 2 elderly patients who had corrective osteotomies for malunited distal radius fractures. We hypothesize that these occurred because there was inadequate new bone formation to replace the resorbing bone substitute. We advise caution when using bone substitutes in patients with expected delayed fracture healing.     

A custom coupling device of total knee and ipsilateral total hip arthroplasties after distal femoral fracture

The treatment of periprosthetic femoral fractures around long-stemmed hip implants is an orthopedic challenge, which may be complicated by the presence or need for a total knee arthroplasty. Treatment of this fracture when the proximal implant is well fixed and a distal implant is required poses ongoing challenges. Traditional plating and allograft struts have produced variable results, particularly in osteoporotic bone, where incidence of nonunion is greater. Thus, we report a custom interlocking device, which couples the stem of the fixed proximal implant to a new stemmed total knee prosthesis, resulting in the expedited restoration of functionality and fracture union.     

Osteoporotic Vertebral Fractures

Abstract Due to a demographic increase in patients with osteoporosis the epidemiology of vertebral fractures changes. Osteoporosis is characterized by low bone density, microarchitectural deterioration of bone tissue and impaired bone strength, which leads to an increased bone fragility and susceptibility to fracture. Asymptomatic vertebral deformity was found to be associated with subsequent risk of symptomatic fractures, particularly vertebral fracture, and increased risk of mortality after a fracture. After the first osteoporotic fracture at any site the risk for further fractures increases dramatically. Osteoporosis represents, besides the origin of such vertebral fractures and impaired bone healing, a problem in osteofixation and implant stability in fracture treatment in orthopedic surgery. Two new treatment strategies of percutaneous vertebro- and kyphoplasty have gained worldwide attention in the treatment of osteoporotic vertebral fracture and short-term observational studies and case-control studies indicate that the results are favorable, regarding both pain relief and functional status. Actually, it cannot be decided whether the internal application of bone cement to the vertebral body is effective in the long run. Special attention has to be given to the underlying osteoporosis in order to reduce the incidence of further fractures in the patients at risk. Diagnosis and treatment of osteoporosis have to be part of the treatment concept of osteoporotic vertebral fractures. Thus, it is important that orthopedic surgeons identify, assess and treat patients with fragility fractures for osteoporosis according to the currently available treatment protocols.     

Nanocrystalline hydroxyapatite facilitates bone apposition to polymethylmethacrylate: Histological investigation using a sheep model

Polymethylmethacrylate (PMMA) is the most commonly used bone void filler for vertebral augmentation in osteoporotic fracture. It provides mechanical stability and immediate pain relief; however, PMMA is not osteointegrated and is separated from the surrounding bone tissue by a thin fibrous layer. The aim of this study was to investigate the effect of nanocrystalline hydroxyapatite (HA) on osteointegration of PMMA in a sheep model. A composite material, consisting of PMMA and nanocrystalline HA (70:30, v/v), was implanted in one distal femur, with pure PMMA in the other femur as a control. Three and 6 months after implantation, the distal femora were histologically investigated. All composite implants exhibited a tight junction to the surrounding bone tissue, with minimal bone ingrowth into the outer surface of the implant. In comparison, with use of the control implants, we observed an overall bone resorption around pure PMMA, with fibrous connective tissue encapsulating the implant. These results suggest that nanocrystalline HA enables osteointegration of PMMA in bone tissue, which might alter the biomechanical characteristics of the osteoporotic vertebral body after augmentation. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 30:1290–1295, 2012     

数字化骨科手术新方法的建立及其临床广泛应用

目的研究出独特的数字化骨科手术新方法 ,广泛应用于脊柱外科手术、骨关节创伤治疗、韧带重建修复、骨肿瘤切除重建、骨关节严重畸形矫正等骨科各分支领域,探讨数字化骨科手术的特点和临床效果,以期运用现代计算机辅助技术和图像分析处理技术提高骨科疾患诊治水平。方法按反求工程的基本原理,通过CT/MRI扫描获取患者骨骼的二维图像资料,采用计算机辅助三维重建技术建立骨关节解剖模型,将骨关节解剖模型输入计算机辅助设计(computer assisted design,CAD)软件进行精确分析,进一步采用先进制造技术——快速成型(rapid prototyping,RP)技术制作骨关节原型并进行实物原型分析,而后将骨关节解剖模型输入计算机进行外科手术过程的设计和预演,合适内固定材料的选择以及基于CAD-RP技术外科手术辅助模板、个性化植入物的制作等,最后精确实施骨科手术。结果采用该方法治疗123例骨科疾患,在以下临床数字骨科学领域获得成熟经验:(1)计算机辅助骨关节畸形精确数字化矫形;(2)计算机辅助设计个性化假体:如全膝、全髋、半骨盆等;(3)计算机辅助前、后交叉韧带重建;(4)计算机辅助特殊疑难假体置换:如发育不良性髋脱位假体置换及翻修手术、髋臼发育不良并骨性关节炎全髋置换手术等;(5)计算机辅助特殊疑难骨折、关节内骨折以及陈旧性骨折的复位固定等;(6)骨肿瘤个性化切除的设计、结构与功能重建;(7)脊柱侧弯的个性化矫形设计与精确实施;(8)脊柱后凸的个性化矫形设计与精确实施;(9)计算机辅助齿状突骨折复位固定;(10)计算机辅助寰枢椎后路内固定的手术设计和精确置钉技术;(11)计算机辅助颈椎椎弓根的形态分析、测量与精确置钉技术。结论借助现代计算机技术和先进制造技术,术者可以通过CAD、骨关节原型制作、计算机辅助手术设计和预演、个性化辅助手术模板及个性化骨缺损修复植入物制作等手段精确实施骨科手术,实现骨科手术的数字化、个性化和精确化,从而进一步提高手术安全性,改善临床效果。     

Bisphosphonates in orthopedic applications

Bisphosphonates (BPs) exert potent effects on the skeleton. As such, there are important questions relating to how treatment with BPs for metabolic disorders might affect outcomes of orthopedic problems. A further question is what role, if any, might BPs play as adjunctive therapeutics for orthopedic problems. This article outlines the research thus far in the application of BPs to the management of osteonecrosis, bone repair, and joint arthroplasty. Many animal studies show a benefit to decreasing bone resorption in models of osteonecrosis. These include studies in both small and large animals, backed up by limited human data. Further clinical trials are underway for this indication. In bone repair, again, multiple studies exist. There are concerns that BPs could interfere with the normal processes of healing. Some of the controversy about benefits or adverse effects of BPs in this context can be distilled down to effects of dosing and administration. With some exceptions, longer intervals between dosing seem to be more beneficial while not producing adverse healing effects in animal studies. In joint arthroplasty, animal studies suggest a role for topical or systemic BPs for enhancing bone on-growth to implant surfaces and strength of mechanical fixation, although these are yet to be confirmed in clinical studies. Clinical studies show that BPs inhibit periprosthetic bone loss due to strain-adaptive remodeling and after impaction bone grafting, although an efficacy in inhibiting inflammatory bone loss due to wear particle-induced osteolysis has not been confirmed. Lastly, as anabolic drugs have become available, there is increasing interest in their combined use with BPs. From experimental data, manipulation of both the anabolic and catabolic responses is a powerful approach in models of bone repair.     

骨微损伤形成与修复机制的研究进展

骨微损伤是在光学显微镜下能够观察到的骨基质损害,骨微损伤的产生、发展与疲劳载荷有关,骨微损伤能够启动骨重建来进行修复,但不同微损伤类型对骨重建的影响不同。骨微损伤有五种类型,目前研究多集中在线性微裂纹与弥散性微损伤,它们具有完全不同的形态特征和修复方式。本文通过对骨微损伤的分类、检测方法、形成及修复机制进行综述,深入研究神经肽对骨重建的作用,旨在进一步探讨骨微损伤的修复机制,为骨质疏松性骨折的防治奠定基础。     

Teriparatide (rh [1-34] PTH) improved osteointegration of a hemiarthroplasty with signs of aseptic loosening

Incidences of osteoporosis and fragility fractures are constantly increasing, which are associated with increased morbidity and mortality. When these patients undergo surgery, a higher number of postoperative complications may be expected because of poor bone quality and delayed healing. As a result, poorer primary stability of the implant, initial loosening, and impaired fixation strength in different regions may be seen. In these patients, we can choose the most advanced implants, but it is necessary to stimulate bone biology to increase the stability of the implant. This article reports the result obtained in a patient diagnosed with osteoporosis with aseptic loosening of a hip hemiarthroplasty after treatment with teriparatide (rh [1-34] PTH). This drug is indicated for the treatment of osteoporosis in men and postmenopausal women with high fracture risk and glucocorticoid-induced osteoporosis, and is administered subcutaneously for 2 years. It has an anabolic effect through stimulation of the osteoblast population that increases trabecular connectivity, cortical thickness, and bone mineral content. In animal models, teriparatide improved implant fixation 2 to 4 weeks after administration, resulting in the thickening of bone trabeculae and increased bone mass in the peri-implant area. In this retrospective analysis of clinical data and radiographic and scintigraphic images, after 24 months of treatment, the patient experienced clinical improvement associated with the disappearance of radiographic signs of loosening and a decrease in pathological radiotracer uptake in the bone scan, which are signs of osteointegration after treatment with teriparatide.