Treatment of Non-Union and Bone Loss of Tibial Pilon

Non-union is a fracture with no healing potential without a further surgical procedure. Diagnosis of non-union can be done in case of healing failure from 6 to 9 months after the first fracture. We consider appropriate to keep the attention of the reader on the relevance that more frequent traumatic mechanisms have in relationship with evolution and eventual failure of healing processes. In literature, non-union mean rate for tibial pilon fractures is around 5% independently from the synthesis technique used; as main causes we can recognize a significant fracture’s comminution ad eventual bone loss, vascular damage, and local infection. Risk factors can be divided into two big groups: factors proper of the patient at the moment of injury (age, diseases, drugs, smoke, etc.) and characteristics of the trauma itself (comminution and dislocation of fragments, involvement of soft tissues, topography, distance between fragments). Tibial pilon fractures are mainly caused by high-energy trauma. This kind of dynamic determines not only more serious damage to the bone, but often cause damage of the surrounding tissues. Following important lesions of the periosteum and of the vascular network and after a suboptimal synthesis caused by comminution and dislocation of fragments is frequent with the evolution toward a bad bone healing process. Bone healing was, in the last 50 years, argument of intense research activity. The incidence of non-union is growing steadily, although principles and materials of synthesys are well standardized. Recently it has been codified the “diamond concept,” which clarified different appliances mechanical and biological, these distinguished between cells, scaffolds, and growth factors. Under the mechanical profile, it must be restored the spectrum of stability that consider the set of bone and synthesis implanted. The spectrum of stability interprets Wolf’s law providing indications on the need to modulate the rigidity of the synthesis in reason of the level of instability of the pseudoarthrosis itself. During the years several kinds of non-union classifications have been proposed. The most widespread until now is the one proposed by Weber–Cech in 1976, which distinguishes vital forms (hypertrophic and oligotrophic) from non-vital forms (atrophic). In 2007 a new score classification system has been processed, which is the “Non-Union Scoring System (NUSS),” which divides patients in four big groups by score awarded based on the real non-healing risk. The NUSS represents an innovative approach to the problem because it understand the multifactorial reasons of failure, explains why in a variable percentage of cases (depending from de district affected), the healing is not obtained, even with a correct treatment and above all make possible the drafting of a therapeutic choice algorithm. Biotechnologies at our disposal are synthetic growth factors, the autologous growth factors and platelet-rich plasma, mesenchymal stem cells, and scaffolds or bone substitute. The biologic chamber represent the ideal site for bone regeneration; it is a bio-reactor in which are present all those elements at the base of the concept of diamond. The chamber needs to be aseptic, vital, mechanically stable, and sealed but selectively permeable. Thanks to the use of megaprosthesis not only in oncologic orthopaedics, but also it is now possible to avoid the amputation or long and often inconclusive treatment of lengthening or ankle arthrodesis. The new frontier in treatment of non-unions will be genetic therapy, that is, the possibility to transport to the patient those genes that con drive to the formation of good bone callus and his maturation toward strong bone

Polytherapy in bone regeneration: clinical applications and preliminary considerations.

Polytherapy, namely the simultaneous application of three fundamental elements necessary for bone regeneration (growth factors, osteogenic cells and osteocnductive scaffolds) seems to lead to a very high success rate in the treatment of complex non-union (NU) cases and critical bone defects. NU are reported in 5–10% of long bone fractures. The use of autologous bone grafts has been long-considered the gold standard for the treatment of these cases. However the harvesting procedure from the iliac crest increases surgery time and presents some donor site complications which may be elevated. In recent years, surgeons have some alternatives to autologous grafting such as: application of organic or synthetic bone substitute, application of mesenchymal stromal cells (MSC) or growth factors (GF). In the literature there are many studies available about their application in monotherapy, but unfortunately the healing rate doesn't exceed 90%. Polytherapy seems to be a logical option to improve the healing rate, nevertheless, there are not still extensive studies that validate this strategy and moreover, some questions are not resolved

7U-Thulium Laser Enucleation of the Prostate (7U-ThuLEP): description of the technique

Objective: To present a modification to the classical ThuLEP technique, called 7U-ThuLEP and to compare its clinical intra- and post-operative outcomes to those of conventional ThuLEP in the treatment of benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS)

The role of peptides in bone healing and regeneration: A systematic review

Background: Bone tissue engineering and the research surrounding peptides has expanded significantly over the last few decades. Several peptides have been shown to support and stimulate the bone healing response and have been proposed as therapeutic vehicles for clinical use. The aim of this comprehensive review is to present the clinical and experimental studies analysing the potential role of peptides for bone healing and bone regeneration. Methods: A systematic review according to PRISMA guidelines was conducted. Articles presenting peptides capable of exerting an upregulatory effect on osteoprogenitor cells and bone healing were included in the study. Results: Based on the available literature, a significant amount of experimental in vitro and in vivo evidence exists. Several peptides were found to upregulate the bone healing response in experimental models and could act as potential candidates for future clinical applications. However, from the available peptides that reached the level of clinical trials, the presented results are limited. Conclusion: Further research is desirable to shed more light into the processes governing the osteoprogenitor cellular responses. With further advances in the field of biomimetic materials and scaffolds, new treatment modalities for bone repair will emerge

Long endomedullary nail in proximal third humeral shaft fractures

Proximal humeral fractures with a spiral line of fracture extending from the humeral head to the diaphyseal region are increasing. Treatment for these fractures is comparable to that for shaft fractures. The purpose of this study was to evaluate the use of a new "Long" humeral nail for this type of lesion and identify the best distal locking

Preliminary experience with Piccolo Composite™, a radiolucent distal fibula plate, in ankle fractures

The radiolucent plate has many advantageous properties in the treatment of complex ankle fractures, particularly trimalleolar fractures. Surgeons may sometimes have difficulty observing the posterior malleolus after synthesis of lateral malleolus with a traditional plate because common materials of conventional plates are not radiolucent. In this study, the authors highlight the importance of the radiolucent property in the treatment of ankle fractures and describe their preliminary experience with a carbon fibre-reinforced polyetheretherketone distal fibula plate, with good results at 4 months' follow-up and no signs of tissue inflammatory reaction

PEEK radiolucent plate for distal radius fractures: multicentre clinical results at 12 months follow up

Introduction Open reduction and internal fixation (ORIF) with plate and screws represents the recommended treatment for unstable intra-articular distal radius fractures. Although significant progresses in surgical technique have been made, anatomical reconstruction of radio-carpal articular surface still represent a difficult task, especially in multifragmentary fractures. Available PEEK reinforced-carbon fiber composite radiolucent devices allow both an easier and more careful assessment of intra-operative reduction of the articular surface of distal radius and prompt correction of any residual step deformity. Materials and Methods We retrospectively reviewed clinical and radiological multicentre results of 71 consecutive AO B and C fracture pattern of distal radius treated using the same PEEK reinforced-carbon fiber composite radiolucent plate. Results Three patients lost at final follow up and 4 cases with incomplete radiological documentations were excluded from the study. 64 patients (38 females, 26 males) were available and formed the basis of this report. Fracture types included 9 patients with 23-B, 13 patients 23-B2,15 patients with 23-B3,10 patients with 23-C1, 7 patients with 23-C2 and 10 patients with 23-C3. Mean Modified Mayo wrist Score was on average 38.11 (SD 10.1; range 24â\u80\u9375, 95%CI 34.7â\u80\u9341.4), 67.22 (SD 9.6, range 50â\u80\u9390, 95%CI 64â\u80\u9370.4), 90.54 (SD 6.3, range 75â\u80\u93100, 95%CI 88.4â\u80\u9392.6) at one, two and twelve months of follow-up, respectively. A statistically significant difference was found between mean scores at different follow-up periods (p = 0.001). We noted 1 case of distal screw fixation aseptic loosening at 5 months post surgical intervention. Conclusions PEEK reinforced-carbon fiber composite radiolucent plate represents a useful device for treatment of complex distal radius fractures in the adult population. It possesses unique biomechanical properties and allows for an easier anatomical reduction during surgical intervention

A prospective multicenter randomized comparison between Holmium Laser Enucleation of the Prostate (HoLEP) and Thulium Laser Enucleation of the Prostate (ThuLEP)

To compare intra and perioperative parameters between HoLEP and ThuLEP in the treatment of benign prostatic hyperplasia and to evaluate clinical and functional outcomes of the two procedures with a 12-month follow-up