Bone regeneration: current concepts and future directions

Bone regeneration is a complex, well-orchestrated physiological process of bone formation, which can be seen during normal fracture healing, and is involved in continuous remodelling throughout adult life. However, there are complex clinical conditions in which bone regeneration is required in large quantity, such as for skeletal reconstruction of large bone defects created by trauma, infection, tumour resection and skeletal abnormalities, or cases in which the regenerative process is compromised, including avascular necrosis, atrophic non-unions and osteoporosis. Currently, there is a plethora of different strategies to augment the impaired or 'insufficient' bone-regeneration process, including the 'gold standard' autologous bone graft, free fibula vascularised graft, allograft implantation, and use of growth factors, osteoconductive scaffolds, osteoprogenitor cells and distraction osteogenesis. Improved 'local' strategies in terms of tissue engineering and gene therapy, or even 'systemic' enhancement of bone repair, are under intense investigation, in an effort to overcome the limitations of the current methods, to produce bone-graft substitutes with biomechanical properties that are as identical to normal bone as possible, to accelerate the overall regeneration process, or even to address systemic conditions, such as skeletal disorders and osteoporosis

Acute non-traumatic marrow edema syndrome in the knee: MRI findings at presentation, correlation with spinal DEXA and outcome

Purpose: The aim of the study was to present the MRI findings of non-traumatic edema-like lesions presented acutely in the adult knee and to correlate them with the 3-year outcome and the bone mineral density (BMD) in the spine. Materials and methods: Ninety-eight patients (40 men, 58 women, mean age 60.1 +/- 11 years, age range 27-82 years), were followed up clinically as well as with MR imaging, when indicated, for at least 3 years. Patients were classified according to presentation in 3 groups (A: bone marrow edema (BME), B: BME and subchondral fracture, C: BME and articular collapse) and according to outcome in 2 groups (A: reversible BME, B: articular collapse). BMD measurements of the spine were carried out in males over 70 and females over 60 years old using DEXA. Results: The isolated BME pattern was observed in 64.3% (Group A), subchondral fractures without articular collapse in 11.2% (Group B) and articular collapse in 24.5% (Group C). Significant differences were found among the 3 groups at presentation, regarding the age, sex, BMD, affected area and duration of symptoms prior to imaging (p < 0.05). Localization of the lesions in the weight-bearing areas of the knee was shown in 100% of C, in 90.9% of B and in 50.8% of A. The duration of symptoms prior to imaging was longer in C (7.6 +/- 2.8 m) than in A (2.5 +/- 1.7 m) and B (4.0 +/- 3.2 m) (p < 0.05). Group B progressed to articular collapse in 45.5%, the rest demonstrating a favourable outcome. Group C showed clinical improvement in 75% and persistent symptoms that required knee arthroplasty in 25% of cases. Articular collapse was the final outcome in 29.6% and transient BME in 70.4% of patients. These two groups showed significant differences regarding the age (p similar to 0), sex (p=0.002), low BMD (p=0.004), affected area (p similar to 0), presence of subchondral sparing (p similar to 0), duration of symptoms prior to imaging (p similar to 0), time from onset of symptoms to the final outcome (p similar to 0) and need for arthroplasty (p=0.001). None of the patients with transient BME syndrome eventually progressed to articular collapse. Conclusion: In the context of acute non-traumatic knee BME, the age and sex of the patient, the duration of symptoms before imaging, the pattern of BME, and the BMD appear to correlate with the final outcome. (c) 2008 Elsevier Ireland Ltd. All rights reserved

Residual malformations and leg length discrepancy after treatment of fibular hemimelia

Abstract Background Fibular hemimelia has been reported as the most common congenital longitudinal deficiency of the long bones. Previous studies have focused on the best treatment options for this congenital condition. There is very little to our knowledge in the literature focused on residual persisting malformations and leg length discrepancy after treatment. Methods Seven patients presenting fibular hemimelia in eight fibulae received treatment between years 1988 and 2001. Pre-treatment average leg length discrepancy was 5.3 cm. All patients presented associated congenital deformities of the ipsilateral leg. Six patients received surgical treatment. Average post-treatment follow up was 9.7 years. Residual malformations and leg length discrepancy were recorded for all patients. It is a retrospective case series study at one institution by two of the presenting authors as senior surgeons. Results Average leg length gained after successful bone lengthening in six patients was 5.06 cm. Although there was a significant functional improvement, a number of residual malformations and leg length inequality was recorded. Residual average leg length discrepancy of 3.1 cm was observed in five patients who completed surgical treatment. Five patients presented a limp. Residual anterior-medial bowing of the tibia was observed in four patients. Calf atrophy was present in all seven patients. Valgus deformity of the ankle was remained in two patients. Conclusions Treatment of fibular hemimelia, even in cases graded as successful, showed to be accompanied by a number of persisting residual deformities and recurrent leg length inequality. Although the number of patients is limited, the high rate of this phenomenon is indicative of the significance of the report. The family and the patients themselves should have the right expectations and will be more co-operative when well informed about this instance. A report of common post-treatment residual deformities should be valuable in best possible treatment planning of fibular hemimelia.</p

The mangled extremity and attempt for limb salvage

<p>Abstract</p> <p>Background</p> <p>The decision, whether to amputate or reconstruct a mangled extremity remains the subject of extensive debate since multiple factors influence the decision.</p> <p>Methods</p> <p>Sixty three patients with high energy extremity trauma and attempts at limb salvage were retrospectively reviewed. We analyzed 10 cases of massive extremity trauma where there was made an attempt to salvage limbs, although there was a controversy between salvage and amputation.</p> <p>Results</p> <p>All of the patients except one had major vascular injury and ischemia requiring repair. Three patients died. All of the remaining patients were amputated within 15 days after the salvage procedure, mainly because of extremity sepsis. Seven patients required treatment at the intensive care unit. All patients had at least 2 reconstruction procedures and multiple surgical debridements.</p> <p>Conclusion</p> <p>The functional outcome should be considered realistically before a salvage decision making for extremities with indeterminate prognosis.</p

Decompressive surgery for degenerative lumbar spinal stenosis: long-term results

We report the outcome of 50 patients with degenerative lumbar spinal stenosis who were treated surgically by spinal decompression between 1984 and 1995. Their mean age at the time of surgery was 59.9 (45–77) years and the mean follow-up was 11.6 (6.1–17.2) years. Five patients had a concomitant spinal fusion. The preoperative data were collected retrospectively from the patients’ charts. The follow-up data were obtained from a clinical examination and questionnaire including overall pain, ability to work, walking ability, use of analgesics and satisfaction with surgery. The outcome was rated as excellent in 23 patients, good in 13 patients, fair in 9 patients and poor in 5 patients. Patients with concomitant fusion had good to excellent results and were more satisfied, whereas patients with long-standing preoperative symptoms had poor to fair result and were less satisfied