General: injerto óseo abundante en el aspirado de médula ósea

Qualitative and quantitative differences between bone graft obtained from the medullary canal (with a Reamer/Irrigator/Aspirator) and the iliac crest of the same patient.
Sagi HC, Young ML, Gerstenfeld L, Einhorn TA, Tornetta P
J Bone Joint Surg Am 2012 Dec 5; 94(23):2128-35.

BACKGROUND

Donor site morbidity and limited volume remain primary drawbacks of using bone graft from the iliac crest and an impetus for finding other sources of autologous bone-graft material. The Synthes Reamer/Irrigator/Aspirator (RIA) has been found to have value as an autologous bone-graft harvesting device. The purpose of this study was to compare the cellular and biochemical characteristics of bone grafts obtained with use of the RIA and from the iliac crest of the same patient.

METHODS

A prospective study was performed on a consecutive series of ten skeletally mature patients presenting for repair of nonunited tibial or femoral fractures. Graft material was harvested from both the iliac crest (in the standard fashion) and the medullary canal of the femur or tibia (with use of the RIA) of each patient. Portions of each autologous graft sample were assessed histologically and by genomewide transcriptional profiling for biochemical markers known to be expressed during fracture-healing.

RESULTS

Principal-component analysis comparing the messenger RNA expression profiles in the RIA and iliac crest samples showed that the expression profile at each harvest site was unique and independent of patient, age, sex, or any identified comorbidity. Transcriptional analysis showed that the RIA samples had greater levels of expression of genes associated with vascular, skeletal, and hematopoietic tissues. Additionally, stem cell markers and growth factors that act early in the osteogenic cascade were more abundant in the RIA samples compared with the iliac crest samples.

CONCLUSIONS

This is the first study to directly compare the histological and molecular profiles of bone grafts from reaming debris and the iliac crest of the same patient. The debris generated during intramedullary reaming, harvested with use of the RIA technique, and the bone graft harvested from the iliac crest possessed a similar transcriptional profile for genes known to act in the early stages of bone repair and formation. This suggests that reaming debris may be a viable alternative to iliac crest bone graft when autologous cancellous graft is needed.

Cadera / Hip: cada milímetro cuenta

Restoration of the Hip Center During THA Performed for Protrusio Acetabuli Is Associated With Better Implant Survival
Yaser M. K. Baghdadi MD, A. Noelle Larson MD, Rafael J. Sierra MD
Clin Orthop Relat Res (2013) 471:3251–3259
DOI 10.1007/s11999-013-3072-x

Abstract

Background
Acetabular protrusio is an uncommon finding in hip arthritis. Several reconstructive approaches have been used; however the best approach remains undefined. Questions/purposes Our purposes in this study were to (1) describe the THA survivorship for protrusio as a function of the acetabular component, (2) evaluate survi- vorship of the cup as a function of restoration of radiographic hip mechanics and offset, and (3) report the long-term clinical results.

Methods
One hundred twenty-seven patients (162 hips) undergoing primary THA with acetabular protrusio were retrospectively reviewed. The mean age of the patients at surgery was 66 ± 13 years, and the mean followup was 10 ± 6 years (range, 2–25 years).The cup fixation was uncemented in 107 (83 with bone graft) and cemented in 55 hips (14 with bone graft). Preoperative and postoperative radiographs were reviewed for restoration of hip mechanics and offset.

Results
The THA survival from aseptic cup revision at 15 years was 89% (95% CI, 75%–96%) for uncemented compared with 85% (95% CI, 68%–94%) for cemented cups. The risk of aseptic cup revision significantly increased by 24% (hazards ratio, 1.24; 95% CI, 1.02–1.5) for every 1 mm medial or lateral distance away from the native hip center of rotation to the prosthetic head center. Harris hip scores were improved by mean of 27 ± 20 points (n = 123) with a higher postoperative score for uncemented bone grafted compared with solely cemented cups (81 ± 16 versus 71 ± 20 points).

Conclusions
Restoring hip center of rotation using an uncemented cup with or without bone graft was associated with increased durability in our series. There was a 24% increase in the risk of aseptic cup revision for every 1 mm medial or lateral distance away from the native hip center to the prosthetic head center.

Level of Evidence
Level III, therapeutic study

Pelvis: menos complicado el injerto autólogo extraído mediante RIA

Complications following autologous bone graft harvesting from the iliac crest and using the RIA [Reamer-Irrigator-Aspirator]: a systematic review.

Dimitriou RMataliotakis GIAngoules AGKanakaris NKGiannoudis PV

Injury 2011 Sep.:S3-15.

Abstract

Bone grafting is a commonly performed surgical procedure to augment bone regeneration in a variety of cases in orthopaedic and maxillofacial surgery. Autologous bone graft remains to be the 'gold standard' and the iliac crest to be the most common harvesting site. The intramedullary canal of long bones represents another potential site for large volume of autologous bone graft harvesting and is recently being used as an alternative donor site. However, harvesting of autologous bone graft is associated with morbidity and a number of complications. The aim of this systematic review was to collect and summarise the existing data on reported complications after harvesting autologous bone from the iliac crest (anterior and posterior) and the long bone intramedullary canal using the RIA device.

We searched the PubMed Medline and Ovid Medline databases, from January 1990 to October 2010, to retrieve all relevant articles. A total of 92 articles (6682 patients) were included in the analysis.

Overall, the complication rate following RIA was 6% (14 complications in 233 patients) and 19.37% after iliac crest bone graft harvesting (1249 complications in 6449 patients). The rate of each of the reported complications was assessed and, when the donor site was properly documented, comparison within the anterior and posterior iliac crest donor sites was performed. Although the difference of the overall morbidity rates between the two harvesting sites was not statistically significant (p=0.71); the rates of certain complications were found to significantly differ when anterior or posterior iliac crest was used. The rates of infection (p=0.016), haematoma formation (p=0.002), fracture (p=0.017), and hyperthrophic scar (p=0.017) were significantly higher when the donor site was the anterior iliac crest compared to the posterior iliac crest; whereas the rates of chronic donor site pain (p=0.004) and sensory disturbances (p=0.003) were significantly lower.

The incidence of bone graft harvesting related complications can be reduced further if certain principles are followed depending on the performed harvesting methods; but overall the use of RIA device as harvesting method seems a promising alternative with a low complication rate.

Rodilla / Knee: difícil aloinjerto para la rotura del mecanismo extensor

Extensor mechanism allograft reconstruction for extensor mechanism failure following total knee arthroplasty.

Brown NM, Murray T, Sporer SM, Wetters N, Berger RA, Della Valle CJ.

J Bone Joint Surg Am. 2015 Feb 18;97(4):279-83. doi: 10.2106/JBJS.N.00759.

Abstract

BACKGROUND: Extensor mechanism disruption following total knee arthroplasty is a rare but devastating complication. The purpose of this study was to report our experience with extensor mechanism allograft reconstruction for chronic extensor mechanism failure.

METHODS: Fifty consecutive extensor mechanism allograft reconstructions were performed in forty-seven patients with a mean age of 67.6 years who were followed for a mean time of 57.6 months (range, twenty-four to 125 months). The operative technique included the use of a fresh-frozen, correctly sized full extensor mechanism allograft that was tensioned tightly in full extension. Patients were evaluated clinically with use of the Knee Society score, and reconstructions were considered failures if the patient had a score of <60 points or a recurrent extensor lag of >30° or if they required revision or removal of the allograft.

RESULTS: Nineteen reconstructions (38%) were considered failures, including four revised to a second extensor mechanism allograft due to failure of the allograft, five for deep infection, and ten considered clinical failures secondary to a Knee Society score of <60 points or an extensor lag of >30°. The mean Knee Society score improved from 33.9 to 75.9 points (p < 0.0001). The estimated Kaplan-Meier survivorship with failure for any reason as the end point was 56.2% (95% confidence interval, 39.4% to 70.1%) at ten years.

CONCLUSIONS: Extensor mechanism disruption following total knee arthroplasty is a difficult complication to treat, with modest outcomes. Extensor mechanism allograft reconstruction is a reasonable option; however, patients must be informed regarding the substantial risk of complications, and although initial extensor mechanism function may be restored, expectations regarding longer-term outcomes are more guarded.

LEVEL OF EVIDENCE: Therapeutic Level IV

Rodilla / Knee: impresoras 3D para regenerar meniscos

Protein-releasing polymeric scaffolds induce fibrochondrocytic differentiation of endogenous cells for knee meniscus regeneration in sheep
Chang H. Lee, Scott A. Rodeo, Lisa Ann Fortier, Chuanyong Lu, Cevat Erisken, Jeremy J. Mao
Sci Transl Med 10 December 2014: Vol. 6, Issue 266, p. 266-271
DOI: 10.1126/scitranslmed.3009696

Abstract

Regeneration of complex tissues, such as kidney, liver, and cartilage, continues to be a scientific and translational challenge. Survival of ex vivo cultured, transplanted cells in tissue grafts is among one of the key barriers. Meniscus is a complex tissue consisting of collagen fibers and proteoglycans with gradient phenotypes of fibrocartilage and functions to provide congruence of the knee joint, without which the patient is likely to develop arthritis.

Endogenous stem/progenitor cells regenerated the knee meniscus upon spatially released human connective tissue growth factor (CTGF) and transforming growth factor–β3 (TGFβ3) from a three-dimensional (3D)–printed biomaterial, enabling functional knee recovery. Sequentially applied CTGF and TGFβ3 were necessary and sufficient to propel mesenchymal stem/progenitor cells, as a heterogeneous population or as single-cell progenies, into fibrochondrocytes that concurrently synthesized procollagens I and IIα. When released from microchannels of 3D-printed, human meniscus scaffolds, CTGF and TGFβ3 induced endogenous stem/progenitor cells to differentiate and synthesize zone-specific type I and II collagens. We then replaced sheep meniscus with anatomically correct, 3D-printed scaffolds that incorporated spatially delivered CTGF and TGFβ3.

Endogenous cells regenerated the meniscus with zone-specific matrix phenotypes: primarily type I collagen in the outer zone, and type II collagen in the inner zone, reminiscent of the native meniscus. Spatiotemporally delivered CTGF and TGFβ3 also restored inhomogeneous mechanical properties in the regenerated sheep meniscus.

Survival and directed differentiation of endogenous cells in a tissue defect may have implications in the regeneration of complex (heterogeneous) tissues and organs.

Cadera / Hip: Menos complicaciones en la PTC bajo anestesia regional

Effects of regional versus general anesthesia on outcomes after total hip arthroplasty: a retrospective propensity-matched cohort study.

Helwani MA, Avidan MS, Ben Abdallah A, Kaiser DJ, Clohisy JC, Hall BL, Kaiser HA

J Bone Joint Surg Am. 2015 Feb 4;97(3):186-93

doi: 10.2106/JBJS.N.00612.

Abstract

BACKGROUND: 

Many orthopaedic surgical procedures can be performed with either regional or general anesthesia. We hypothesized that total hip arthroplasty with regional anesthesia is associated with less postoperative morbidity and mortality than total hip arthroplasty with general anesthesia.

METHODS: 

This retrospective propensity-matched cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database included patients who had undergone total hip arthroplasty from 2007 through 2011. After matching, logistic regression was used to determine the association between the type of anesthesia and deep surgical site infections, hospital length of stay, thirty-day mortality, and cardiovascular and pulmonary complications.

RESULTS: 

Of 12,929 surgical procedures, 5103 (39.5%) were performed with regional anesthesia. The adjusted odds for deep surgical site infections were significantly lower in the regional anesthesia group than in the general anesthesia group (odds ratio [OR] = 0.38; 95% confidence interval [CI] = 0.20 to 0.72; p < 0.01). The hospital length of stay (geometric mean) was decreased by 5% (95% CI = 3% to 7%; p < 0.001) with regional anesthesia, which translates to 0.17 day for each total hip arthroplasty. Regional anesthesia was also associated with a 27% decrease in the odds of prolonged hospitalization (OR = 0.73; 95% CI = 0.68 to 0.89; p < 0.001). The mortality rate was not significantly lower with regional anesthesia (OR = 0.78; 95% CI = 0.43 to 1.42; p > 0.05). The adjusted odds for cardiovascular complications (OR = 0.61; 95% CI = 0.44 to 0.85) and respiratory complications (OR = 0.51; 95% CI = 0.33 to 0.81) were all lower in the regional anesthesia group.

CONCLUSIONS: 

Compared with general anesthesia, regional anesthesia for total hip arthroplasty was associated with a reduction in deep surgical site infection rates, hospital length of stay, and rates of postoperative cardiovascular and pulmonary complications. These findings could have an important medical and economic impact on health-care practice

LEVEL OF EVIDENCE: Therapeutic Level III