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This study evaluates the ability of a Glass Reinforced Hydroxyapatite Composite (GRHC), in a new microporous pellet formulation with autologous bone marrow concentrate (BMC), to enhance bone regeneration and new bone formation. Ninety non-critical sized bone defects were created in the femurs of nine Merino breed sheep and randomly left unfilled (group A), filled with GRHC pellets alone (group B) or filled with GRHC pellets combined with BMC (group C). The sheep were sacrificed at 3 weeks (three sheep), 6 weeks (three sheep) and 12 weeks (three sheep) and histological analysis (Light Microscopy-LM), scanning electron microscopy (SEM) and histomorphometric analysis (HM) were performed. At 3, 6, and 12 weeks, HM revealed an average percentage of new bone of 48, 72, 83%; 25, 73, 80%, and 16, 38, 78% for Groups C, B and A respectively (significantly different only at 3 weeks p < 0.05). LM and SEM evaluation revealed earlier formation of well-organized mature lamellar bone in Group C. This study demonstrates that the addition of a bone marrow concentrate to a glass reinforced hydroxyapatite composite in a pellet formulation promotes early bone healing. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1176-1182, 2017.

Introduction. Intertrochanteric hip fractures occur in the proximal femur. They are very common in the elderly and are responsible for high rates of morbidity and mortality. The authors hypothesized that adding an autologous bone marrow stem cells concentrate (ABMC) to a hydroxyapatite scaffold and placing it in the fracture site would improve the outcome after surgical fixation of intertrochanteric hip fractures.Material and Methods. 30 patients were randomly selected and divided into 2 groups of 15 patients, to receive either the scaffold enriched with the ABMC (Group A) during the surgical procedure, or fracture fixation alone (Group B).Results. There was a statistically significant difference in favor of group A at days 30, 60, and 90 for Harris Hip Scores (HHS), at days 30 and 60 for VAS pain scales, for bedridden period and time taken to start partial and total weight bearing (P<0.05).Discussion. These results show a significant benefit of adding a bone marrow enriched scaffold to surgical fixation in intertrochanteric hip fractures, which can significantly reduce the associated morbidity and mortality rates.Conclusion. Bone marrow stem cells added to a hydroxyapatite scaffold result in better outcomes after surgical treatment of intertrochanteric hip fractures.

Current challenges in the development of scaffolds for bone regeneration include the engineering of materials that can withstand normal dynamic physiological mechanical stresses exerted on the bone and provide a matrix capable of supporting cellmigration and tissue ingrowth. The objective of the present workwas to develop and characterize a hybrid polymer–ceramic injectable systemthat consists of an alginatematrix crosslinked in situ in the presence of strontium(Sr), incorporating a ceramic reinforcement in the form of Sr-richmicrospheres. The incorporation of Sr in the microspheres and in the vehicle relies on the growing evidence that Sr has beneficial effects in bone remodeling and in the treatment of osteopenic disorders and osteoporosis. Sr-rich porous hydroxyapatite microspheres with a uniform size and a mean diameter of 555 μmwere prepared, and their compression strength and friability tested. A 3.5% (w/v) ultrapure sodium alginate solution was used as the vehicle and its in situ gelation was promoted by the addition of calcium (Ca) or Sr carbonate and Glucone-δ-lactone. Gelation times varied with temperature and crosslinking agent, being slower for Sr than for Ca, but adequate for injection in both cases. Injectability was evaluated using a device employed in vertebroplasty surgical procedures, coupled to a texture analyzer in compression mode. Compositions with 35%w ofmicrospheres presented the best compromise between injectability and compression strength of the system, the force required to extrude it being lower than 100 N.Micro CT analysis revealed a homogeneous distribution of themicrospheres inside the vehicle, and a mean inter-microspheres space of 220 μm. DMA results showed that elastic behavior of the hybrid is dominant over the viscous one and that the higher storage modulus was obtained for the 3.5%Alg–35%Sr-HAp-Sr formulation.

The improvement rescue and transport of politrauma patients (PTP) increases the number of patients admitted to the Emergency departments in very severe conditions. The early prediction of later complications and bad outcomes is paramount for a good strategy. The aim of this study was to evaluate the severity of PTP in the Trauma Room (TR) of a Level 1 Hospital, using the ISS, RTS, TRISS scores and define variables associated with bad outcomes, namely ICU admission (ICU), ARDS, MODS and Death.Prospective study with data collection of demographic, clinical, laboratory and imaging parameters of all PTP admitted to the TR. The ISS was calculated by the Abbreviated Injury Scale, RTS and TRISS by Trauma.org site formulas. Statistical analysis was performed in SPSS.278 patients were admitted in TR after Manchester screening during 6 months: 244 (185 men, 59 women) were studied, average age 39,32±19.32 years. Hospital admission- 157 patients (ICU-46, Intermediate Care Unit-29, Surgery Services-82) and 85 discharged. Submitted to Surgery-75. Scores: ISS-13,58±19,32, RTS-7,30±1,01; TRISS-92,42±15,85; Glasgow Coma Score (GCS)-13,00±3,61.Severe complications: ARDS-8%; SIRS-40%; MODS-18%; Death-14%.There is statistical correlation between Surgery Type: ICU and MODS; GCS, ISS, RTS, TRISS: ICU, ARDS, MODS and Death. Multivariate analysis shows that Surgery Type, GCS and TRISS predict ICU admission (ROC-0,884); TRISS predicts ARDS (ROC-0,844); TRISS predicts MODS (ROC-0,876); TRISS and age predicts Death (ROC-0,887).This study confirms scores validity in PTP assessment, as they are able to predict severe complications. TRISS seems to be the best score for prediction of bad outcomes.

Background. This work compares the osteoblastic behaviour of a bone marrow (BM) aspirate and a prepared BM concentrate of nucleated cells associated with a glass reinforced hydroxyapatite composite (GRHC) in a microporous pellet formulation.Methods. BM aspirate (30 mL) was collected during 3 orthopedic surgical procedures, and a concentration system was used to achieve 3 rapid preparations of a concentrate of nucleated cells (3 mL) from the BM aspirates. The BM aspirates (53% cell viability;2.7×106nucleated cell/mL) and the BM concentrates (76% cell viability;2×107nucleated cell/mL) were cultured over glass reinforced hydroxyapatite pellets, at the same volume/mass ratio, for 30 days. Cultures performed in standard tissue culture plates were used as control.Results. The colonized BM concentrate/material constructs exhibited a representative osteoblastic proliferation/differentiation pathway, evidenced by a high alkaline phosphatase (ALP) activity, expression of collagen type 1, ALP, BMP-2, M-CSF, RANKL, and OPG, and formation of a calcium phosphate mineralized matrix. A clear improved behaviour was noticed compared to the BM aspirate/material constructs.Conclusions. The results suggest the benefit of using an autologous BM concentrate/material construct in the clinical setting, in bone regeneration applications.

Synthetic bone grafts provide an alternative to autografts and allografts. Bonelike is a patented synthetic bone graft that mimics the mineral composition of bone. The aim of the present work was to assess the biological behavior of Bonelike graft in humans, before using the material in orthopedic applications of bone regeneration, for example, in opening wedge high tibial osteotomies for medial knee osteoarthritis. Bonelike granules were implanted in cortical bone of 11 patients undergoing osteotomies, and new bone formation, osteoconductive properties, and resorption characteristics of the granules were analyzed. The granules ranged from 500 to 1000 microm and were implanted in the lateral aspect of the tibia. The patients' mean age was 59 years (range 48 to 70 years); there were eight women and three men, all suffering from medial compartment osteoarthritis of the knee. At surgery, a 1 x 1 x 1-cm cortical defect was created 3 cm distal to the entry point of the screws, in line with the long axis of tibia. The implanted Bonelike graft sample was extracted for analysis during removal of the metallic prosthesis after implantation times of 6, 9, and 12 months. Radiological follow-up, scanning electron microscopy, histological analysis, and histomorphometric measurements were conducted on the retrieved samples to assess bone regeneration in the defect area. Osteoconductive capacity was demonstrated by extensive mature bone formation around the implanted granules and high levels of percentage bone-to-graft contact (from 67-84%). Bonelike acted as an excellent bioactive scaffold, allowing the migration, proliferation, and differentiation of bone cells on its surface, and therefore regeneration of the defects was achieved in a rapid, controlled manner. Our results suggest that Bonelike graft is an excellent candidate for orthopedic applications where rapid new bone formation is a fundamental requirement.

Para-articular osteochondroma, a benign osteoarticular tumor which develops near joints, is, unlike classical osteochondroma, extremely rare. We present the case of a 59-year-old woman who developed a calcified mass in the infrapatellar region. The differential diagnosis between chondrosarcoma, synovial chondromatosis, and para-aticular osteochondroma was only possible after resection and pathology examination of the surgical specimen.

OBJECTIVE: To report the difficulties in managing a case of os odontoideum. METHODS: Female patient, 12 years old who developed a quadiparesis after minor cervical trauma in October 2005. In the emergency department a congenital cervical anomaly was identified. The patient was placed in a Stryker® frame and, few days later, in a halo bracing. After 3 months, an infection around the pins emerged and the halo vest had to be removed. A severe C1-2 instability persisted and a C1-C2 Gallie procedure was attempted. In the following weeks the bone disappeared and another procedure was attempted in June 2006 - C1 laminectomy and occiput-C3 fusion. In the following months the neurological status of the patient improved and a complete mass of occiput-C3 fusion was observed. RESULTS: We choose a posterior cervical arthrodesis of C1-C2 using the Gallie technique. Since the condition was not resolved we performed a second surgery, C1 laminectomy (determined by SAC of 8, 3 mm in MRI) followed by posterior occiput-C3 fusion. In our case, until now, there is no evidence of axial decompensation, but a more prolonged follow-up is needed. CONCLUSIONS: The treatment of os odontoideum has many considerations but the essential that in the presence of instability and neurological deficit a solid fusion is achieved. In case of failure of posterior atlantoaxial wiring, the occiput-C2 or C3 fusion with rods seems to be an excellent option with a high rate of success, avoiding the need for additional support.

The objectives were to analyze one-year survival and mortality predictors in patients with fracture of the proximal femur (low/moderate trauma). A prospective cohort was formed by inviting all patients hospitalized in the Orthopedic Ward of the second largest hospital in Portugal (May 2008-April 2009). Survival was assessed at 3, 6, 9, and 12 months after fracture and related to demographic factors, lifestyle, and clinical history, as well as to data from medical records (fracture type, surgery date, surgical treatment, and preoperative risk). Of the 340 patients hospitalized, 252 were included (78.9% women). Mortality at 3, 6, 9, and 12 months was 21.2%, 25%, 28.8%, and 34.6% for men and 7.8%, 13.5%, 19.2%, and 21.4% for women, respectively. Predictors of death were male gender (HR = 2.54; 95%CI: 1.40-4.58), ASA score III/IV vs. I/II (HR = 1.95; 95%CI: 1.10-3.47), age (HR = 1.06; 95%CI: 1.03-1.10), and delay in days to surgery (HR = 1.07; 95%CI: 1.03-1.12). Factors related to death were mainly related to patients’ characteristics at admission.

Intertrochanteric fractures incidence has been increasing over the past few years and therefore so have all the problems associated with it. It is important to search for possible ways to reduce comorbidities as well as postoperative mortality. We decided to assess the impact of some routine pre-operative analytical values on post-operative mortality of patients with inter-trochanteric fractures 65 years or older.From all intertrochanteric fracture admissions between January 2007 and May 2012, 160 patients were included in this study. The variables studied were age, gender, length of hospital stay, and analytical data such as hemoglobin, total leucocyte count, platelets, urea, creatinin and plasma sodium. Follow-up data on mortality were obtained from the civil registry and, considering 6 months as the cut-off point, patients were divided into 2 groups based on their survival. Mann-Whitney and Chi square statistics were used to study the association between our variables and patients survival.Our population showed a median age of 82 years old and a majority of women (79.4%). Within the first 6 months after surgery, 27 patients of the initial 160 (16.1%) died. Mortality was associated with low hemoglobin, high platelets, high creatinin and low plasma sodium.Postoperative mortality of hip surgery is high. Our findings could be used to reduce this rate by correcting some analytical values preoperatively.Introdução: A incidência das fraturas intertrocantéricas tem aumentado ao longo dos últimos anos, bem como todos os problemas a elas associados. É importante pesquisar possíveis formas de reduzir quer co-morbilidades, quer a mortalidade pós-operatória. Decidimos avaliar o impacto de alguns valores analíticos pré-operatórios na mortalidade pós-operatória de doentes com fractura intertrocantérica, com idade igual ou superior a 65 anos.Material e Métodos: De todas as fracturas intertrocantéricas admitidas entre Janeiro de 2007 e Maio 2012, 160 doentes foram incluídos no estudo. As variáveis estudadas foram idade, género, tempo de internamento, e dados analíticos, como hemoglobina, contagem de leucócitos e plaquetas, níveis de ureia e creatinina e concentração de sódio plasmática. Informação relativa à mortalidade foi obtida através do registo civil e, considerando um ponto de corte de seis meses após a cirurgia, os doentes foram divididos em dois grupos de acordo com a sua sobrevida. Os testes de Mann-Whitney e Chi-quadrado foram utilizados para estudar a associação entre as nossas variáveis e a sobrevida dos doentes.Resultados: A nossa população apresentava uma idade mediana de 82 anos de idade e uma maioria de mulheres (79,4%). Nos primeiros 6 meses após a cirurgia, 27 doentes dos iniciais 160 (16,1%) faleceram. A mortalidade estava relacionada com valores baixos de hemoglobina, elevados de plaquetas, elevados de creatinina e baixa concentração de sódio plasmático.Conclusão: A taxa de mortalidade pos-operatória da cirurgia da anca é elevada. Os nossos resultados podem ser utilizados parareduzir esta taxa, corrigindo valores analíticos pré-operatórios.

OBJETIVO: a mielopatia cervical espondilótica (MEC) é uma causa frequente de disfunção da medula espinhal na população adulta. O tratamento implica em descompressão cirúrgica precoce. O objetivo foi apresentar um estudo retrospectivo da descompressão anterior e artrodese para MEC com um seguimento mínimo de dez anos. MÉTODOS: pacientes operados entre Janeiro de 1990 e Dezembro de 1994 foram avaliados por sexo, idade, número de níveis operados, avaliação funcional pela escala de Nurick pré-operatória um ano após cirurgia e após a revisão final que ocorreu em 2004, evidência de consolidação e complicações. RESULTADOS: foram avaliados 91 pacientes, 69 do sexo masculino, 22 do sexo feminino, com uma média de idade de 56,6 anos (42-86) e um seguimento médio de 11,9 anos. Ocorreram cinco óbitos: três pacientes no pós-operatório imediato, um no primeiro ano e um durante o restante período. Em média, foram operados 2,7±1,0 níveis por paciente (1-4). O valor médio de Nurick pré-operatório foi de 3,8±0,9. Houve uma melhoria significativa do estado neurológico um ano após a cirurgia (2,2±1,1; p

We report a case of an unrecognized Jeffery Type 2 lesion in a child complicated by a complete reversal of the radial head during closed manipulation.

The degenerative disc disease (DDD) is a chronic and multifactorial condition of the intervertebral disc that can manifest itself by axial pain, radiculopathy, myelopathy and spinal stenosis. It constitutes an increasing cause of lumbar pain and morbidity in Western Societies, with important socio-economic implications. The available treatment options do not modify the intervertebral disc degeneration process and they are not always capable of relieving symptoms. The loss of proteoglycan content of nucleus pulposus appears to be the main event on DDD pathophysiology. The balance between synthesis and catabolism of the extracellular matrix can be altered by the use of several proteins, including growth factors. The transfer of genes encoding these proteins is an attractive treatment option and has been successfully achieved in animal models. Moreover, the transfer of steam cells in order to repopulate the degenerated disc and to revert the pathologic process might be another promissory strategy. The authors describe the actual knowledge about DDD and the investigation that has been made in gene therapy for DDD. The comprehension of the biological mechanisms of degeneration, as well as genetic manipulation and transfer of steam cells could be decisive and revolutionary in the understanding and treatment of this epidemic condition.

The aim of this study was to evaluate the biological behaviour of porous scaffold structures of Bonelike® which is suitable for either direct clinical use or tissue engineering applications. Porous cylindrical specimens 8 × 10 mm were implanted in the lateral aspect of the tibia of 13 patients (mean age 54 years), during osteotomy surgery for the treatment of medial compartment osteoarthritis of the knee. Implanted cylinders were retrieved at the same time as the removal of the blade plates at 3, 6, 9 and 12 months. Scanning electron microscopy and histological evaluations were performed to observe the biological responses of human bone tissue to porous Bonelike®. The penetration depth was determined for all implantation periods, and after 6 months it was already possible to see new bone in the centre of the implanted cylinders, which gives 100% of penetration depth for all implantations periods except for 3 months when bone could only be seen in the peripherical region. Regarding the percentage of the area covered by new bone calculated from two-dimensional histological sections, values of 53 ± 15, 76 ± 12 and 88 ± 9% were achieved for 6, 9 and 12 months, respectively. Due to its structural features porous Bonelike® permitted effective vascularization and bone ingrowth, and therefore was fully osteointegrated as shown in the histological surveys. A slow biomaterial degradation with implantation time is envisaged since the material has displayed surface degradation. Bonelike® scaffolds show potential for complete ingrowth of osseous tissue and restoration of vascularization throughout the defected site.

Two synthetic calcium phosphates in porous wedge shape, Bonelike and a commercial HA/beta-TCP biphasic material, were used as an alternative to bone autografts and allografts in the treatment of medial compartment osteoarthritis of varus knees. The structure of Bonelike has a 3D architecture that is computer controlled, and a composition that mimics the mineral composition of natural bone. The HA/beta-TCP biphasic material used as a control material in this study was prepared using conventional foaming based methods. No signs of inflammatory reactions were observed post-operatively for both materials. After 4 months signs of fusion at the osteotomy site and good integration of the implanted wedges were observed, showing good mechanical resistance. Concerning the final correction attained, the left knee revealed a satisfactory valgus of 10 degrees , but the right one only had a final value of 6 degrees . The clinical evaluation using International Knee Score (IKS) showed good outcome in all parameters with complete range of motion in both knees and climbing stairs without crutches with only slight pain.