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Song JH, Kang C, Park WH, Lee GS, Lee JK, Kim DH, Lee SW. Extended Distal Chevron Osteotomy and Akin Osteotomy Using Bioabsorbable Materials for Treatment of Moderate to Severe Hallux Valgus. J Foot Ankle Surg 2021; 60:1110-1116. [PMID: 34130930 DOI: 10.1053/j.jfas.2021.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 09/28/2020] [Accepted: 01/04/2021] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to investigate the suitability of bioabsorbable materials for fixation of extended distal chevron osteotomy and Akin osteotomy for the treatment of moderate to severe hallux valgus. We performed a retrospective analysis of extended distal chevron osteotomy and Akin osteotomy for the treatment of moderate to severe hallux valgus (33 patients, 42 feet). Fixation of extended distal chevron osteotomy and Akin osteotomy was performed using poly-l-lactic acid pins and polylactic acid/polyglycolic acid copolymer sutures, respectively. The radiological outcomes were evaluated based on the preoperative and 3-year follow-up intermetatarsal angle, hallux valgus angle, and hallux interphalangeal angle. The clinical results were assessed according to 3-year follow-up Manchester-Oxford Foot Questionnaire scores, patient satisfaction, and postoperative complications. All radiological and clinical results were compared with those of a control group treated with metallic implants. The mean 3-year follow-up intermetatarsal angle, hallux valgus angle, and hallux interphalangeal angle were significantly corrected from the preoperative values (all p < .001). The mean 3-year follow-up Manchester-Oxford Foot Questionnaire scores score was significantly improved from the preoperative values (p < .001). Regarding patient satisfaction, 88.1% of the patients reported good to excellent results. A total of seven complications were reported. All radiological and clinical results were comparable with those of control group treated with metallic implant. Based on these results, we recommend using bioabsorbable materials as another reliable device for fixation of extended distal chevron osteotomy and Akin osteotomy even for the treatment of moderate to severe hallux valgus.
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Affiliation(s)
- Jae Hwang Song
- Assistant Professor, Department of Orthopedic Surgery, Konyang University Hospital, Daejeon, South Korea
| | - Chan Kang
- Associate Professor, Department of Orthopedic Surgery, Chungnam National University Hospital, Daejeon, South Korea.
| | - Won Ho Park
- Professor, Department of Advanced Organic Materials and Textile Engineering System, Chungnam National University, Daejeon, South Korea
| | - Gi Soo Lee
- Assistant Professor, Department of Orthopedic Surgery, Chungnam National University Hospital, Daejeon, South Korea
| | - Jeong Kil Lee
- Assistant Professor, Department of Orthopedic Surgery, Chungnam National University Hospital, Daejeon, South Korea
| | - Dong Hwan Kim
- Third Year Resident, Department of Orthopedic Surgery, Chungnam National University Hospital, Daejeon, South Korea
| | - Seok Won Lee
- Third Year Resident, Department of Orthopedic Surgery, Konyang University Hospital, Daejeon, South Korea
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Abstract
Acute and chronic syndesmotic injuries significantly impact athletic function and activities of daily living. Patient history, examination, and judicious use of imaging modalities aid diagnosis. Surgical management should be used when frank diastasis, instability, and/or chronic pain and disability ensue. Screw and suture-button fixation remain the mainstay of treatment of acute injuries, but novel syndesmotic reconstruction techniques hold promise for treatment of acute and chronic injuries, especially for athletes. This article focuses on anatomy, mechanisms of injury, diagnosis, and surgical reduction and stabilization of acute and chronic syndesmotic instability. Fixation methods with a focus on considerations for athletes are discussed.
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Wang JH, Lee ES, Lee BH. Paradoxical tunnel enlargement after ACL reconstruction with hamstring autografts when using β-TCP containing interference screws for tibial aperture fixation- prospectively comparative study. BMC Musculoskelet Disord 2017; 18:398. [PMID: 28915914 PMCID: PMC5602947 DOI: 10.1186/s12891-017-1757-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 09/07/2017] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Tibial aperture fixation with a bioabsorbable interference screw is a popular fixation method in anterior cruciate ligament reconstruction (ACLR). An interference screw containing β-tricalcium phosphate (β-TCP) to improve bony integration and biocompatibility was recently introduced. This study aims to compare the clinical outcomes and radiological results of tunnel enlargement effect between the 2 bioabsorbable fixative devices of pure poly-L-lactic acid (PLLA) interference screws and β-TCP-containing screws, for tibial interference fixation in ACLR using hamstring autografts. METHODS Eighty consecutive patients who had undergone double-bundle ACLR between 2011 to 2012 were prospectively reviewed and randomly divided into two groups based on the type of tibial interference screw: 28 were assigned to the pure PLLA screw group (Group A), while the other 29 were assigned to the β-TCP-containing screw fixation group (Group B). Clinical evaluations and radiological analyses were conducted in both groups with a minimum 2- year follow-up. RESULTS There was no significant difference in subjective or objective clinical outcome between the 2 groups. In radiological analyses, the use of a β-TCP-containing screw reduced tunnel widening in the portion of the tunnel with screw engagement compared to the pure PLLA screw, while the use of a β-TCP-containing screw resulted in greater tunnel enlargement in the proximal portion of the tunnel without screw engagement than use of a pure PLLA screw. CONCLUSION Use of a β-TCP-containing interference screw in tibial aperture fixation reduced tunnel enlargement in the vicinity of the screw, whereas greater enlargement occurred proximal to the screw end relative to use of a pure PLLA interference screw. These paradoxical enlargements in use of β-TCP containing screws suggest that for reducing tunnel enlargement, the length of the interference screw should be as fit as possible with tunnel length in terms of using soft grafts. LEVEL OF EVIDENCE II, Prospectively comparative study. TRIAL REGISTRATION Retrospectively registered with ClinicalTrials.gov. (NCT02754674) , Date of trial registration: February 10, 2016.
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Affiliation(s)
- Joon Ho Wang
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, South Korea.,Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, South Korea.,Department of Medical Device Management and Research, SAIHST, Sungkyunkwan University, Seoul, South Korea
| | - Eun Su Lee
- Department of Orthopaedic Surgery, Dongbu Jaeil Hospital, Seoul, Republic of Korea
| | - Byung Hoon Lee
- Department of Orthopaedic Surgery, Kang-Dong Sacred Heart Hospital, Hallym University Medical Center, Gil-dong, Seoul, 134-701, South Korea.
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Buijs GJ, Stegenga B, Bos RRM. Efficacy and Safety of Biodegradable Osteofixation Devices in Oral and Maxillofacial Surgery: a Systematic Review. J Dent Res 2016; 85:980-9. [PMID: 17062736 DOI: 10.1177/154405910608501102] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The use of osteofixation devices should be evidence-based if uncomplicated bone healing is to be achieved. Numerous studies describe and claim the advantages of biodegradable over titanium devices as a bone fixation method. Here, we systematically review the available literature to determine the clinical efficacy and safety of biodegradable devices compared with titanium devices in oral and maxillofacial surgery. In addition, related general aspects of bone surgery are discussed. We conducted a highly sensitive search in the databases of MEDLINE (1966–2005), EMBASE (1989–2005), and CENTRAL (1800–2005) to identify eligible studies. Eligible studies were independently evaluated by two assessors using a quality assessment scale. The study selection procedure revealed four methodologically ‘acceptable’ articles. Owing to the different outcome measures used in the studies, it was impossible to perform a meta-analysis. Therefore, the major effects regarding the stability and morbidity of fracture fixation using titanium and biodegradable fixation systems were qualitatively described. Any firm conclusions regarding the fixation of traumatically fractured bone segments cannot be drawn, due to the lack of controlled clinical trials. Regarding the fixation of bone segments in orthognathic surgery, only a few controlled clinical studies are available. There does not appear to be a significant short-term difference between titanium and biodegradable fixation systems regarding stability and morbidity. However, definite conclusions, especially with respect to the long-term performance of biodegradable fixation devices used in maxillofacial surgery, cannot be drawn. Abbreviations: CENTRAL, Cochrane Central Register of Controlled Trials; MeSH, Medical Subject Heading; VAS, Visual Analogue Scale; and W, weight.
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Affiliation(s)
- G J Buijs
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
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Kim JS, Cho HK, Young KW, Lee SY, Kim JS, Lee K. Effectiveness of Headless Bioabsorbable Screws for Fixation of the Scarf Osteotomy. Foot Ankle Int 2016; 37:1189-1196. [PMID: 27672017 DOI: 10.1177/1071100716661826] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Scarf osteotomy has been used in hallux valgus surgery due to its large fixation surface for screws and low postoperative complications. However, screws may cause skin irritation from their head, which may require an additional surgical procedure to remove. METHODS This study included 115 patients (106 females and 9 males, 115 feet) who underwent hallux valgus correction with a scarf osteotomy using bioabsorbable screws between September 2010 and September 2012. Preoperative and postoperative 1-month and 1-year radiographic measurements, including intermetatarsal angle (IMA), hallux valgus angle (HVA), distal metatarsal articular angle (DMAA), proximal phalangeal articular angle (PPAA), and lateral translational distance (LTD), were obtained. American Orthopaedic Foot & Ankle Society (AOFAS) hallux/forefoot scores were used for patient satisfaction. RESULTS Preoperative mean values of HVA, IMA, and PPA of 32.8 degrees, 14.6 degrees, and 7.52 degrees, respectively, improved to 10.7 degrees, 6.0 degrees, and 4.6 degrees, respectively at 1-year follow up (P < .05). The difference in LTD between the 1-month and 1-year follow-up was not statistically significant. AOFAS hallux/forefoot score improved from 69.1 to 96.1 at the 1-year follow up (P < .001). Complete screw absorption was not seen radiographically. Sixteen feet had complications reported. One patient complained of skin irritation over a small protrusion of the screw, and another patient had a foreign body reaction. There were 3 patients with neurologic injury from a popliteal block and 3 patients with dorsal cutaneous nerve symptoms. Four feet had metatarsal fracture during surgery. CONCLUSION We found the scarf osteotomy using bioabsorbable screws to have satisfactory clinical and radiographic results with a low complication rate. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Jin Su Kim
- Surgery of Foot and Ankle, CM chungmu general hospital, Yeongdeuon-po, Seoul, Republic of Korea
| | - Hun Ki Cho
- Surgery of Foot and Ankle, Eulji Medical Center, College of Medicine, Eulji University, Seoul, Republic of Korea
| | - Ki Won Young
- Surgery of Foot and Ankle, Eulji Medical Center, College of Medicine, Eulji University, Seoul, Republic of Korea
| | - Sang Young Lee
- Surgery of Foot and Ankle, Eulji Medical Center, College of Medicine, Eulji University, Seoul, Republic of Korea
| | - Ji Soo Kim
- Surgery of Foot and Ankle, Eulji Medical Center, College of Medicine, Eulji University, Seoul, Republic of Korea
| | - Kyoungtae Lee
- KT Lee's Orthopedic Hospital, Seoul, Republic of Korea
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Nardo T, Chiono V, Gentile P, Tabrizian M, Ciardelli G. Poly(DL-lactide-co-ε-caprolactone) and poly(DL-lactide-co-glycolide) blends for biomedical application: Physical properties, cell compatibility, and in vitro degradation behavior. INT J POLYM MATER PO 2016. [DOI: 10.1080/00914037.2016.1163566] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Tiziana Nardo
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino, Italy
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Valeria Chiono
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino, Italy
| | - Piergiorgio Gentile
- School of Mechanical and Systems Engineering, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Maryam Tabrizian
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Gianluca Ciardelli
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino, Italy
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van Dijk CN, Longo UG, Loppini M, Florio P, Maltese L, Ciuffreda M, Denaro V. Conservative and surgical management of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines. Knee Surg Sports Traumatol Arthrosc 2016; 24:1217-27. [PMID: 26846658 DOI: 10.1007/s00167-016-4017-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 01/20/2016] [Indexed: 12/11/2022]
Abstract
PURPOSE Correct management of syndesmotic injuries is mandatory to avoid scar tissue impingement, chronic instability, heterotopic ossification, or deformity of the ankle. The aim of the present study was to perform a systematic review of the current treatments of these injuries to identify the best non-surgical and surgical management for patients with acute isolated syndesmotic injuries. METHODS A review of the literature was performed according to the PRISMA guidelines. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases was performed using the following keywords: "ankle injury", "syndesmotic injury", "chronic", "acute", "treatment", "conservative", "non-operative" "operative", "fixation", "osteosynthesis", "screw", "synostosis", "ligamentoplasties" over the years 1962-2015. RESULTS The literature search and cross-referencing resulted in a total of 345 references, of which 283 were rejected due to off-topic abstract and/or failure to fulfil the inclusion criteria. After reading the remaining full-text articles, we included four studies, describing non-surgical management, and only two studies investigating surgical management of acute isolated injuries. CONCLUSIONS The ESSKA-AFAS consensus panel provided recommendations to improve the management of patients with isolated acute syndesmotic injury in clinical practice. Non-surgical management is recommended for stable ankle lesions and includes: 3-week non-weight bearing, a below-the-knee cast, rest and ice, followed by proprioceptive exercises. Surgery is recommended for unstable lesions. Syndesmotic screw is recommended to achieve a temporary fixation of the mortise. Suture-button device can be considered a viable alternative to a positioning screw. Partial weight bearing is allowed 6 weeks after surgery. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- C Niek van Dijk
- Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, PO Box 22700, 1100, DE, Amsterdam, The Netherlands
| | - Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy.
| | - Mattia Loppini
- Department of Orthopaedic and Trauma Surgery, Humanitas Research Hospital, Via Alessandro Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Pino Florio
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy
| | - Ludovica Maltese
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy
| | - Mauro Ciuffreda
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy
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Ezechieli M, Diekmann J, Weizbauer A, Becher C, Willbold E, Helmecke P, Lucas A, Schavan R, Windhagen H. Biodegradation of a magnesium alloy implant in the intercondylar femoral notch showed an appropriate response to the synovial membrane in a rabbit model in vivo. J Biomater Appl 2014; 29:291-302. [DOI: 10.1177/0885328214523322] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Degradable magnesium alloys are promising biomaterials for orthopedic applications. The aim of this study was to evaluate the potential effects on both the synovial membrane (synovialis) and the synovial fluid (synovia) of the degradation products of a MgYREZr-pin implanted in the intercondylar femoral notch in a rabbit model. Thirty-six animals were randomized into two groups (MgYREZr or Ti6Al4V alloy) of 18 animals each. Each group was then divided into three subgroups with implantation periods of 1, 4, and 12 weeks, with six animals in each subgroup. The initial inflammatory reaction caused by the surgical trauma declined after 12 weeks of implantation, and elucidated a progressive recovery of the synovial membrane. Compared with control Ti6Al4V pins, there were no significant differences between the groups. However, after 12 weeks, recovery of the synovial membrane was more advanced in the titanium group, in which 92% showed no signs of synovitis, than in the magnesium group. A cytotoxicity test with L929 cells and human osteoblasts (HOB) was also conducted, according to EN ISO 10993-5/12, and no toxic leachable products were observed after 24 h of incubation. In conclusion, the MgYREZr alloy seems to be a suitable material for intra-articular degradable implants.
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Affiliation(s)
- Marco Ezechieli
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
| | - Julia Diekmann
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
- CrossBIT, Center for Biocompatibility and Implant-Immunology, Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
| | - Andreas Weizbauer
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
- CrossBIT, Center for Biocompatibility and Implant-Immunology, Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
| | - Christoph Becher
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
| | - Elmar Willbold
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
| | - Patrick Helmecke
- Institute of Production Engineering and Machine Tools (IFW), Leibniz Universität Hannover, Garbsen, Germany
| | - Arne Lucas
- Syntellix AG, Schiffgraben 11, Hannover, Germany
| | | | - Henning Windhagen
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
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Abstract
This article reviews the basics and evidence base thus far on syndesmosis injuries, focusing on its management in the elite sporting population. A syndesmosis injury or "high ankle sprain" is a significant injury, especially in the elite athlete. Among all ankle sprains, the syndesmotic injury is most predictive of persistent symptoms in the athletic population. Late diagnosis of unstable syndesmosis injuries leads to a poor outcome and delayed return to sports. A high index of suspicion and an understanding of the mechanism of injury is required to ensure an early diagnosis. Incomplete/inaccurate reduction leads to a poor outcome.
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Affiliation(s)
- May Fong Mak
- Department of Orthopaedics, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Republic of Singapore
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Sarraf KM, Shearman AD, Houlihan-Burne D, Thevendran G. Management of adult ankle fractures. Br J Hosp Med (Lond) 2013; 74:C41-4. [PMID: 23717848 DOI: 10.12968/hmed.2013.74.sup3.c41] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Clanton TO, Betech AA, Bott AM, Matheny LM, Hartline B, Hanson TW, McGarvey WC. Complications after tendon transfers in the foot and ankle using bioabsorbable screws. Foot Ankle Int 2013; 34:486-90. [PMID: 23399887 DOI: 10.1177/1071100713477625] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tendon transfers are commonly used for correction of pathology or deformity of the foot and ankle. Bioabsorbable implants have been developed as an alternative to metal interference screws. The purpose of this study was to document complications following tendon transfers of the foot and ankle using bioabsorbable poly-L-lactide interference screws. METHODS A retrospective chart review was used to identify patients in whom either of the 2 senior authors had performed a tendon transfer of the foot and ankle using a bioabsorbable interference screw between 1999 and 2005. A minimum of 6 months of follow-up was required for inclusion in the study. In all, 31 patients were identified who met the inclusion criteria with an average follow-up of 75 weeks. All screws were made of poly-L-lactide (PLLA). RESULTS Complications were identified in 12 (39%) of patients. All of the complications reported were known complications of the tendon transfer procedure itself, and were not directly related to the bioabsorbable screw. CONCLUSIONS Based on these early results, PLLA implants appear safe and effective for tendon transfers of the foot and ankle. However, until long-term outcomes are available, judicious use of these implants is recommended.
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Pina S, Ferreira J. Bioresorbable Plates and Screws for Clinical Applications: A Review. JOURNAL OF HEALTHCARE ENGINEERING 2012. [DOI: 10.1260/2040-2295.3.2.243] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Emond CE, Woelber EB, Kurd SK, Ciccotti MG, Cohen SB. A comparison of the results of anterior cruciate ligament reconstruction using bioabsorbable versus metal interference screws: a meta-analysis. J Bone Joint Surg Am 2011; 93:572-80. [PMID: 21411708 DOI: 10.2106/jbjs.j.00269] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Graft fixation during anterior cruciate ligament (ACL) reconstruction can be achieved with use of either bioabsorbable screws or metal screws. Although bioabsorbable screws and metal screws have similar fixation strengths, bioabsorbable screws eliminate the need for removal. In addition, postoperative imaging is easier to interpret when bioabsorbable screws are used. Bioabsorbable screws may be associated with an increased inflammatory response, an increased risk of screw breakage, incomplete screw absorption, or tunnel widening. We investigated the outcomes associated with the use of bioabsorbable screws as compared with metal screws for ACL reconstruction. Our hypothesis was that there is no significant difference in outcomes between these screw types for ACL reconstruction. METHODS We systematically searched electronic databases to identify randomized controlled trials in which bioabsorbable screws were compared with metal screws for ACL reconstruction. Therapeutic studies with a minimum twelve-month mean follow-up were considered for inclusion. Clinical outcomes (International Knee Documentation Committee [IKDC], Lysholm, Tegner activity scores), laxity testing, and reported complications were evaluated in the meta-analysis. Additionally, imaging assessment of tunnel widening was evaluated. RESULTS Eight studies matched the inclusion criteria. These studies comprised a total of 745 patients undergoing ACL reconstruction (including 378 patients managed with bioabsorbable screws and 367 patients managed with metal screws). No significant differences were identified between the two screw types with respect to IKDC, Lysholm, or Tegner activity scores or with respect to the results of laxity testing with arthrometry. The complication rates were also statistically similar in the two groups. The variability in imaging assessment of tunnel widening among the studies precluded meta-analysis. CONCLUSIONS The clinical results associated with bioabsorbable screws and metal screws are statistically similar. Laxity evaluation demonstrated no significant differences between bioabsorbable screws and metal screws. The complication rates associated with bioabsorbable screws and metal screws were also similar. The results of this meta-analysis support the hypothesis that there are no significant differences in the outcomes associated with bioabsorbable screws as compared with metal screws for ACL reconstruction. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.
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Affiliation(s)
- Christopher E Emond
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Ahmad J, Raikin SM, Pour AE, Haytmanek C. Bioabsorbable screw fixation of the syndesmosis in unstable ankle injuries. Foot Ankle Int 2009; 30:99-105. [PMID: 19254501 DOI: 10.3113/fai-2009-0099] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE The purpose of this study was to retrospectively evaluate the clinical and radiographic outcomes of the medium and long-term results of Bionx bioabsorbable screw fixation of the ankle syndesmosis in unstable ankle injuries. MATERIALS AND MATERIALS Between May 2001 and July 2006, 75 patients underwent syndesmotic fixation with a bioabsorbable screw. All patients had closed primary ankle fractures or dislocations with syndesmotic instability. Open reduction and internal fixation of the ankle fracture was performed using current standard orthopaedic technique. Patients were followed clinically and radiographically from 12 to 74 months with the mean being 32.5 months. RESULTS Seventy of 75 patients (93%) returned for the final evaluation. Mean AOFAS Ankle-Hindfoot score was 90 of 100 and mean VAS for pain was 1.8 out of 10 at the time of final followup. No patients in this population showed radiographic syndesmotic instability, loss of mortise congruency, or post-traumatic arthritis in the sigmoid notch area at final followup. No patients required revision surgical fixation of the syndesmosis. CONCLUSION This study demonstrates that the use of bioabsorbable screw for syndesmotic fixation is associated with satisfactory restoration of ankle function and syndesmotic stability.
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Affiliation(s)
- Jamal Ahmad
- Department of Orthopedic Surgery, Rothman Institute, Philadelphia, PA 19107, USA
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Comparison of bioabsorbable versus metallic implant fixation for physeal and epiphyseal fractures of the distal tibia. J Pediatr Orthop 2008; 28:859-63. [PMID: 19034179 DOI: 10.1097/bpo.0b013e31818e19d7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Transepiphyseal screw fixation of displaced distal tibial epiphyseal fractures is the most common method of treatment for these intraarticular injuries. Recent literature indicates that retained transepiphyseal metallic screws cause an increase in ankle joint contact pressure, thus favoring screw removal. Our hypothesis is that bioabsorbable screw fixation is an alternative to metallic fixation, which offers similar results without the need for screw removal. METHODS This is a retrospective review of distal tibial epiphyseal ankle fractures treated with screw fixation. Two groups, those treated with bioabsorbable screw fixation (group B, n = 24) and those with metallic screw fixation (group M, n = 26), were compared (t test) for differences in clinical and radiographic outcomes. RESULTS Analysis of demographic data revealed no significant differences between groups for sex, ethnicity, age, and height. Group B was significantly heavier than group M (67.4 vs 55.6 kg; P = 0.0496). Each group had a similar number of Salter-Harris types III and IV medial malleolus fractures and transitional fracture types. There was no significant difference between groups in the time from injury to fixation or in operative time. Radiographically, there were no nonunions in either group, and at final follow-up, 1 patient in group B had distal tibial joint line irregularity versus 3 in group M. Clinically, there were no significant differences between groups in time to full weight bearing or time to full activities.There were fewer complications in group B. A single case of loss of reduction requiring revision fixation occurred in each group. There was one documented growth arrest in group M and 2 suspected growth arrests in each group. Two patients in group M were successfully treated for a superficial wound infection with oral antibiotics. Fourteen patients in group M underwent planned screw removal. CONCLUSIONS Bioabsorbable screw fixation can be used for distal tibial epiphyseal fractures with no increase in operative time, nonunion rate, number of unplanned secondary surgeries, or other complications. The use of bioabsorbable screws eliminates the need for epiphyseal screw removal. A prospective randomized study is planned to eliminate the potential selection bias and to standardize clinical and radiographic follow-up. LEVEL OF EVIDENCE Level III, case-control study.
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Dattani R, Patnaik S, Kantak A, Srikanth B, Selvan TP. Injuries to the tibiofibular syndesmosis. ACTA ACUST UNITED AC 2008; 90:405-10. [PMID: 18378910 DOI: 10.1302/0301-620x.90b4.19750] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The management of injury to the distal tibiofibular syndesmosis remains controversial in the treatment of ankle fractures. Operative fixation usually involves the insertion of a metallic diastasis screw. There are a variety of options for the position and characterisation of the screw, the type of cortical fixation, and whether the screw should be removed prior to weight-bearing. This paper reviews the relevant anatomy, the clinical and radiological diagnosis and the mechanism of trauma and alternative methods of treatment for injuries to the syndesmosis.
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Affiliation(s)
- R Dattani
- East Surrey Hospital, Canada Avenue, Redhill RH1 5RH, UK.
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Hunt JA, Callaghan JT. Polymer-hydroxyapatite composite versus polymer interference screws in anterior cruciate ligament reconstruction in a large animal model. Knee Surg Sports Traumatol Arthrosc 2008; 16:655-60. [PMID: 18418577 DOI: 10.1007/s00167-008-0528-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2007] [Accepted: 03/10/2008] [Indexed: 10/22/2022]
Abstract
The aim of the study was to assess the hard tissue response of a composite hydroxyapatite/poly L-lactic acid (HA/PLLA) interference screw for anterior cruciate ligament (ACL) reconstruction compared to a standard PLLA screw. Twelve skeletally mature rams underwent unilateral ACL reconstruction using an autologous bone-patellar tendon graft. Each animal received either two test HA/PLLA interference screws or two control PLLA interference screws. Animals were sacrificed at 6 and 12 months post-implantation and the operated knees excised. Undecalcified sections of the screw and surrounding tissues were cut from resin embedded samples and stained; sections were approximately parallel to the longitudinal axis of the screws. A quantitative assessment of bone formation between each screw type (PLLA vs. HA/PLLA) and adjacent tissue in both the tibia and femur was undertaken using automated image analysis (KS400, Zeiss, UK). The inflammatory response of each screw type was assessed by histological evaluation. New bone formation along the perimeter of the screw threads was statistically significantly higher with the HA/PLLA than the PLLA alone. The inflammatory response as assessed semi-quantitatively by histologically determining the number of inflammatory cells present in the tissue adjacent to the implant, was higher for PLLA than HA/PLLA. Significantly increased new bone formation and decreased inflammatory cells were observed in vivo with the composite screw in comparison with the standard polymer. A novel HA/PLLA composite biomaterial in the form of an interference screw demonstrated an improved hard-tissue response compared to PLLA in a large animal ACL reconstruction. This study determined the differences in the tissue response between PLLA and a composite material of HA/PLLA. The improved tissue related outcomes observed in vivo, may be of benefit clinically in ACL reconstruction.
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Affiliation(s)
- John A Hunt
- UK Centre for Tissue Engineering, School of Clinical Sciences, University of Liverpool, Duncan Building, Daulby Street, Liverpool, L69 3GA, UK.
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Abstract
Ankle sprains are among the most common athletic injuries and represent a significant source of persistent pain and disability. Despite the high incidence of ankle sprains in athletes, syndesmosis injuries have historically been underdiagnosed, and assessment in terms of severity and optimal treatment has not been determined. More recently, a heightened awareness in sports medicine has resulted in more frequent diagnoses of syndesmosis injuries. However, there is a low level of evidence and a paucity of literature on this topic compared with lateral ankle sprains. As a result, no clear guidelines are available to help the clinician assess the severity of injury, choose an imaging modality to visualize the injury, make a decision in terms of operative versus nonoperative treatment, or decide when the athlete may return to play. Increased knowledge and understanding of these injuries by clinicians and researchers are essential to improve the prevention, diagnosis, and treatment of this significant condition. This review will discuss the anatomy, mechanism of injury, diagnosis, and treatment of syndesmosis sprains of the ankle while identifying controversies in management and topics for future research.
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Affiliation(s)
- Glenn N Williams
- Graduate Program in Physical Therapy and Rehabilitation Science, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA
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Joukainen A, Partio EK, Waris P, Joukainen J, Kröger H, Törmälä P, Rokkanen P. Bioabsorbable screw fixation for the treatment of ankle fractures. J Orthop Sci 2007; 12:28-34. [PMID: 17260114 DOI: 10.1007/s00776-006-1077-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2006] [Accepted: 09/11/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND Self-reinforced poly(L/dL)lactide 70:30 (SR-PLA70) retains its strength in bone for 24 weeks, whereas self-reinforced poly-L-lactide (SR-PLLA) retains its strength for over 36 weeks. In this prospective randomized study, bioabsorbable 4.5-mm SR-PLA70 screws were compared with SR-PLLA screws in the treatment of displaced ankle fractures in adults. METHODS Sixty-two patients with ankle fractures needing operative treatment were randomized into two groups. Comminuted fractures needing plating were excluded. In total 54 of 62 patients were followed up for 1 year by clinical evaluation, radiographs, and Olerud-Molander score. RESULTS The study groups differed significantly only in the mean duration of sick leave (SR-PLA70, 60 days; SR-PLLA, 65 days; P = 0.02). At the 1-year follow-up, syndesmotic ossification was more common in the SR-PLA70 group (5 versus 1 patient, not significant). Radiologically, the screw channel had not disappeared in any of the patients by the 1-year follow-up. CONCLUSIONS Both implant types proved to have good biocompatibility. SR-PLA70 and SR-PLLA screws are suitable in selected cases for the fixation of ankle fractures, but the mechanical stability of the fixation has to be carefully monitored perioperatively.
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Affiliation(s)
- Antti Joukainen
- Department of Orthopaedics and Traumatology, Kuopio University Hospital, P.O. Box 1777, FIN-70211, Kuopio, Finland
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Abstract
Absorbable implants have become the hottest implant material, overtaking titanium as the future. Absorbable devices have moved beyond orthopedics and maxillofacial surgery to spine, vascular, plastics and general surgery. This chapter outlines the experiences of many specialties.
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Affiliation(s)
- A Douglas Spitalny
- St. Mary's Medical Center, Duluth Clinic Orthopedics, 400 East 3rd Street, Duluth, MN 55803, USA
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Kaukonen JP, Lamberg T, Korkala O, Pajarinen J. Fixation of syndesmotic ruptures in 38 patients with a malleolar fracture: a randomized study comparing a metallic and a bioabsorbable screw. J Orthop Trauma 2005; 19:392-5. [PMID: 16003198 DOI: 10.1097/01.bot.0000155313.50627.f6] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare the performance of a metallic and a biodegradable screw in the fixation of tibia-fibula syndesmotic ruptures. DESIGN A randomized, prospective, and blinded study. SETTING Central hospital, Department of Surgery. PATIENTS Forty consecutive patients with a clinically verified syndesmotic rupture in association with a malleolar fracture, of whom 38 completed the study. INTERVENTION After syndesmosis rupture was diagnosed, implant selection was performed intraoperatively by a strict randomization with sealed envelopes. Eighteen patients were treated with a metallic screw, and 20 with a bioabsorbable polylevolactic acid screw. The metallic screws were removed in a second operation at 8 weeks postoperatively. All patients had a treatment-blinded clinical and radiographic control after a mean follow-up of 35 (range 17-51) months. MAIN OUTCOME MEASURES Return to previous physical activity level, evaluation of ankle stability, range of motion, circumference of the ankle, and a radiographic evaluation of both ankles including a measure of the talocrural, medial joint, and syndesmotic space widths. RESULTS More patients with a polylevolactic acid screw returned to their previous activity level, and there was less swelling in the ankles of these patients, but joint motion was similar between the groups. The mean values of syndesmotic and medial joint spaces were significantly higher in the radiographs of the operated ankles when compared to the uninjured ankle, but there was not a correlation to the type of screw used. CONCLUSIONS Polylevolactic acid screws worked as well, or slightly better than, metallic ones in syndesmosis fixation in patients with an ankle fracture.
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Cox S, Mukherjee DP, Ogden AL, Mayuex RH, Sadasivan KK, Albright JA, Pietrzak WS. Distal tibiofibular syndesmosis fixation: a cadaveric, simulated fracture stabilization study comparing bioabsorbable and metallic single screw fixation. J Foot Ankle Surg 2005; 44:144-51. [PMID: 15768364 DOI: 10.1053/j.jfas.2005.01.010] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Metal screws that are used for ruptured tibiofibular syndesmosis repair are often removed within 3 months of placement, suggesting the utility of bioabsorbable screws. A biomechanical study was performed to compare fixation of a simulated syndesmosis separation with a 5-mm oriented copolymer bioabsorbable (82:18 poly-L-lactic acid/poly-glycolic acid) versus a stainless steel screw. Eight pairs of cadaveric lower-leg specimens were cleaned and a pronation external rotation-type injury was created in each. The syndesmosis was fixed with a single, tricortical bioabsorbable screw in 1 ankle and a metal screw in the contralateral ankle (matched pairs). Sequential testing of the specimens showed that torsional stiffness of the fixed, relative to intact, specimens was nearly equivalent (0.730 +/- 0.260 for copolymer, 0.770 +/- 0.300 for stainless steel; P = .401). Application of 1000 cycles of axial load (90 to 900 N) resulted in a significant decrease ( P < .0001) in axial stiffness for each fixation method, but the relative decrease was equivalent for both ( P = .211). Failure torque (17.8 +/- 8.3 N.m copolymer, 21.0 +/- 11.5 N.m stainless steel; P = .238) and angle of rotation at failure (47.9 +/- 13.6 degrees copolymer, 42.0 +/- 11.5 degrees stainless steel; P = .199) were also nearly equivalent. It appears that the 5.0-mm diameter copolymer screw is biomechanically equivalent to the 5.0-mm diameter stainless steel screw for repair of syndesmosis disruption.
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Affiliation(s)
- Stephen Cox
- LSU Health Sciences Center, Shreveport, LA, USA
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Bioresorbable Screw Fixation in Proximal Metatarsal Osteotomies for Hallux Valgus. TECHNIQUES IN FOOT AND ANKLE SURGERY 2004. [DOI: 10.1097/01.btf.0000126169.80323.7a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Lippman CR, Hajjar M, Abshire B, Martin G, Engelman RW, Cahill DW. Cervical spine fusion with bioabsorbable cages. Neurosurg Focus 2004; 16:E4. [PMID: 15198492 DOI: 10.3171/foc.2004.16.3.5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ObjectAlthough it improves rates of fusion in surgical arthrodesis, conventional spinal instrumentation is associated with several risks, including hardware extrusion that injures adjacent anatomical structures, and disuse osteopenia as a result of stress shielding. The long-term effects of indwelling spinal instrumentation, although incompletely documented, may be detrimental. One way to avoid such problems would be to use bioabsorbable implantation devices. In this pilot study, performed in 1998 and 1999, the authors evaluated the use of a bioabsorbable interbody fusion device in a goat cervical spine model.MethodsForty-two goats underwent two-level anterior cervical discectomy and fusion: eight received iliac crest autograft; 16 received a cage implant composed of 70:30 poly(L-lactide-co-D,L-lactide)/polyglycolic acid (70:30 PLDLLA/PGA) filled with either autograft or recombinant human bone morphogenetic protein–2 (rhBMP-2); and 18 received a cage implant composed of 85:15 PLDLLA/PGA filled with either autograft or rhBMP-2. Animals were killed at 3, 6, and 12 months postsurgery, and their cervical spines were evaluated histologically, radiographically, and physically for fusion.A primarily fibrous union was demonstrated in all animals killed at 3 months. At 6 months, bone trabeculae had become more prominent and the fibrous response less so in all cohorts. This occurred most frequently in the animals that underwent fusion with the 70:30 PLDLLA/PGA cages filled with rhBMP-2, in which 63% attained a histologically confirmed union that contained quantitatively more bone and less fibrous tissue than in the other cohorts; 63% of the unions in the aforementioned cohort were graded quantitatively as being stable.ConclusionsIn this study the authors have established that the 85:15 PLDLLA/PGA cages are absorbed too quickly to be functionally useful in this model. The 70:30 PLDLLA/PGA cages worked as well as tricortical autograft when filled with cancellous autograft, and better when filled with rhBMP-2. At 6- and 12-month follow-up review, the 70:30 PLDLLA/PGA cages had not yet begun to be absorbed. There was little if any inflammatory response to these cages at 6 months. Future studies should include biomechanical and microradiographic testing, and a longer follow-up period is necessary in this model to determine when the 70:30 PLDLLA/PGA cages are absorbed.
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Affiliation(s)
- Caleb R Lippman
- Department of Neurosurgery, College of Medicine, University of South Florida, Tampa, Florida, USA.
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Abstract
Ankle fractures are among the most common skeletal injuries; selection of an optimal management method depends on ankle stability. Stable fractures (eg, isolated lateral malleolar) generally are managed nonsurgically; unstable fractures (eg, bimalleolar, bimalleolar equivalent) usually are managed with open reduction and internal fixation. Stress radiographs may aid in the management of incomplete deltoid injury in which there is medial swelling and tenderness without radiographic talar shift. A posterior malleolar fracture should be reduced and stabilized if it comprises >30% of the articular surface and remains displaced after fibular stabilization. Ankle fractures with syndesmotic injury have additional tibiofibular instability that can be controlled by screw fixation. However, the choice between metal and bioabsorbable screws, screw size, number of cortices fixed, and indications for screw removal remain controversial. Conditions such as diabetes or advanced age are no longer contraindications to usual management recommendations.
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Affiliation(s)
- James D Michelson
- Orthopaedic Surgery, and Director, Clinical Informatics, George Washington University Hospital, George Washington University Hospital Medical Center Medical Education and Simulation Center, Washington, DC 20037, USA
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Sayegh S, Bernard L, Stern R, Pache JC, Szalay I, Hoffmeyer P. Suture granuloma mimicking infection following total hip arthroplasty. A report of three cases. J Bone Joint Surg Am 2003; 85:2006-9. [PMID: 14563812 DOI: 10.2106/00004623-200310000-00023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Morgan CD, Gehrmann RM, Jayo MJ, Johnson CS. Histologic findings with a bioabsorbable anterior cruciate ligament interference screw explant after 2.5 years in vivo. Arthroscopy 2002; 18:E47. [PMID: 12426556 DOI: 10.1053/jars.2002.36466] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We retrieved a high-molecular-weight poly-L-lactic) (PLLA) anterior cruciate ligament (ACL) interference screw (Arthrex, Naples, FL) after 30 months in vivo during revision ACL surgery. Gross, histologic, histomorphometric, and molecular weight measurements were carried out on the implant and the surrounding bone. These studies showed a 75% decrease in the molecular weight of the screw, with implant fragmentation and new bone formation adjacent to the screw and graft. Healing of the graft within the bony tunnel with no significant inflammatory reaction had occurred. The clinical implications of these findings are that this implant dissolves slowly, and it was physically present at 30 months in vivo. It is a safe, nonreactive alternative to traditional metal interference screws used for ACL graft fixation. It will eventually be substituted by bone and will eliminate some of the problems associated with metallic devices.
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Affiliation(s)
- Craig D Morgan
- Penn Orthopaedics, Philadelphia, Pennsylvania 19107, USA
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Abstract
The use of absorbable implants has been studied extensively in the clinic and the laboratory. The limitations of absorbable implants are now well-known and include a finite life span and strength profile, the possible development of an inflammatory response, and their limitation to use in fractures that do not require traditional compression techniques. Advantages of these implants include the lack of necessity for removal at a later date, which has cost savings potential, their ease of use, and their strength, which may be sufficient for healing in certain situations. The most likely scenarios for the use of these implants in fracture management of the foot and ankle include syndesmotic disruptions, dislocations about the midfoot, and fractures of the medial malleolus.
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Affiliation(s)
- C Christopher Stroud
- Department of Orthopaedic Surgery, Union Memorial Hospital, 3333 North Calvert Street, Baltimore, MD 21218, USA.
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Abstract
Unrecognized and inappropriately managed foot and ankle injuries can lead to significant long-term functional disability. As many of the above injuries are frequently diagnosed late or not even considered because of the benign appearance of the foot or radiograph, it behooves the sports medicine physician to carefully assess the foot and obtain appropriate radiographs, including stress views as needed. Although quick return to athletic play is among the goals of treatment for the elite athlete, this must be tempered by the fact that certain injuries require significantly greater time for complete recovery. A functional rehabilitation program is the best means to rapidly return the player to competition and while prolonging the athletic career.
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Affiliation(s)
- Craig I Title
- Department of Orthopedics, Lenox Hill Hospital, 130 East 77th Street, New York, NY 10021, USA.
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Hovis WD, Kaiser BW, Watson JT, Bucholz RW. Treatment of syndesmotic disruptions of the ankle with bioabsorbable screw fixation. J Bone Joint Surg Am 2002; 84:26-31. [PMID: 11792776 DOI: 10.2106/00004623-200201000-00005] [Citation(s) in RCA: 129] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Bioabsorbable implants have restricted indications because of their unique biochemical properties and their inferior biomechanical properties compared with those of conventional metallic implants. The purpose of this prospective study was to assess the efficacy of screws made of polylevolactic acid (PLLA) in the treatment of syndesmotic disruptions associated with ankle fractures and fracture-dislocations. METHODS Thirty-three consecutive patients with a syndesmotic disruption were managed with standard metallic plate-and-screw fixation of the malleolar fracture and with 4.5-mm polylevolactic acid screws, with purchase in four cortices, for fixation of the syndesmosis. Intraoperative radiographs confirmed reduction of the syndesmosis, and all of the patients were managed with a non-weight-bearing plaster splint or brace for six weeks. Clinical and radiographic assessment and functional evaluation with use of the Olerud-Molander scoring system were performed at the time of follow-up. RESULTS Ten patients were lost to follow-up prior to the twenty-four-month evaluation, leaving twenty-three patients with an average duration of follow-up of thirty-four months (range, twenty-four to forty-three months). All of the malleolar fractures healed in an anatomical position at an average of three months, and no postoperative displacement of the syndesmosis or widening of the medial clear space was detectable on radiographs. No episodes of osteolysis or late inflammation secondary to the hydrolyzed polylactide occurred. Nineteen patients (83%) had an excellent result, and four patients (17%) had a good result. All twenty-three patients returned to their preinjury level of work and activities of daily living. No patient had malunion, nonunion, loss of reduction, or complications attributable to the biomechanical or biochemical properties of the implants. CONCLUSIONS Polylevolactic acid screws are effective in stabilizing disruption of the syndesmosis during healing of unstable ankle fractures. In this small series, the bioabsorbable screw was well tolerated, and there was no need for a second operation to remove it.
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Lajtai G, Schmiedhuber G, Unger F, Aitzetmüller G, Klein M, Noszian I, Orthner E. Bone tunnel remodeling at the site of biodegradable interference screws used for anterior cruciate ligament reconstruction: 5-year follow-up. Arthroscopy 2001; 17:597-602. [PMID: 11447546 DOI: 10.1053/jars.2001.21535] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this prospective study was to review, using expanded clinical-assessment tools, the long-term results of the local effects of a bioabsorbable interference screw (copolymer 85/15 D,L lactide/glycolide) in anterior cruciate ligament (ACL) reconstruction. TYPE OF STUDY This prospective study was initiated in May 1993. The inclusion criteria for patient selection included rupture of the ACL in athletic patients without involvement of the collateral ligaments, arthroscopic ACL reconstruction using middle third of the ligamentum patella, and magnetic resonance imaging (MRI) and plain radiographic examinations of the knee joint during follow-up. MATERIALS Between May 1993 and October 1994, 32 patients were enlisted in the study; 48 patients did not fit the inclusion criteria. There were 25 men 7 women. The average age was 29.1 years (range, 19 to 50 years). There were 21 right knees and 11 left knees. The follow-up examinations were performed by an independent examiner. There were 28 patients available for follow-up at a medium of 5.2 years (range, 4.1 to 6.4 years). The evaluation included various testing systems (i.e., OAK, IKDC, Lysholm) as well as MRI and plain radiographic studies to investigate the longevity of the implant and potential adverse effects of this new bioabsorbable material. RESULTS The clinical results were good. The OAK score (Orthopädische Arbeitsgruppe Knie) showed 93% excellent and good results, and 7% fair results. The IKDC and Lysholm scores were 92% and 96% good and excellent results, respectively. MRI showed bone remodeling and new bone formations at the site of the implant in the femoral as well as in the tibial bone tunnel at follow-up. No cystic or osteolytic changes where seen on MRI or plain radiographs. CONCLUSIONS This study showed the correlation between histology and MRI: there was minimal surgical-site edema, minimal reaction to this material, and complete replacement by new bone formation of the previous site of this implant. At 5 years, this bioabsorbable interference screw appeared clinically safe and effective for fixation of bone blocks during ACL reconstruction and MRI showed complete absorption and replacement with new bone.
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Affiliation(s)
- G Lajtai
- Departments of Traumatology and Radiology, AKH-Wels, Wels, Austria.
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Bozic KJ, Perez LE, Wilson DR, Fitzgibbons PG, Jupiter JB. Mechanical testing of bioresorbable implants for use in metacarpal fracture fixation. J Hand Surg Am 2001; 26:755-61. [PMID: 11466654 DOI: 10.1053/jhsu.2001.24145] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The purpose of this study was to evaluate the mechanical properties of a bioresorbable plate and screw system that was developed for the treatment of unstable metacarpal fractures and to compare the strength and stiffness of this system with those of conventional titanium plates and screws. Using a 4-point bending test, we measured the strength and stiffness of these implants over a 12-week period of in vitro degradation. Our data suggest that these implants provide stable bending strength and stiffness for 8 weeks and gradually lose their strength over a period of 12 weeks. Further research is necessary to determine whether this level of fixation is adequate to stabilize unstable metacarpal fractures.
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Affiliation(s)
- K J Bozic
- Orthopaedic Biomechanics Laboratory, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Mosier-Laclair S, Pike H, Pomeroy G. Intraosseous bioabsorbable poly-L-lactic acid screw presenting as a late foreign-body reaction: a case report. Foot Ankle Int 2001; 22:247-51. [PMID: 11310868 DOI: 10.1177/107110070102200313] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
A 17-year-old woman complained of a localized painful swelling in her foot 30 months after internal fixation of a closed tarsometatarsal joint fracture with interfragmentary poly-L-lactic acid screws. Aspiration revealed a sterile abscess. Radiographs displayed an osteolytic lesion corresponding to a screw track in the first tarsometarsal joint. Formation of a draining sinus tract required surgical excision of a small granulomatous lesion. Histologic analysis found deposits of birefringent polymeric particles surrounded by a nonspecific foreign-body type reaction. This represents the first reported case of a draining sinus tract secondary to the use of polylactic acid screw fixation.
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Böstman O, Pihlajamäki H. Clinical biocompatibility of biodegradable orthopaedic implants for internal fixation: a review. Biomaterials 2000; 21:2615-21. [PMID: 11071611 DOI: 10.1016/s0142-9612(00)00129-0] [Citation(s) in RCA: 277] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
When the polymeric material reaches the final stages of its degradation process, biodegradable orthopaedic fixation devices elicit a local foreign-body reaction. In most cases, the symptoms of this tissue response are subclinical and pass unnoticed, but in some patients a clinically manifest inflammatory foreign-body reaction ensues. Mild clinical reactions consist of a painful erythematous papule, those of medium severity show a sinus discharging polymeric debris for up to 6 months, and in the patients affected by a severe reaction, extensive osteolytic lesions may develop at the implant tracks. The histopathologic picture is that of a non-specific foreign-body reaction. For implants made of polyglycolide, the average incidence of the manifest reactions is 5%. When slow-degrading polymers are used, the incidence is lower. The tissue responses to polyglycolide manifest themselves 11 weeks after surgery, on an average, whereas foreign-body reactions to devices made of poly-L-lactide can emerge as late as 4 or 5 yr after the original fracture fixation operation. A poorly vascularized bone section, use of a quinone dye as an additive in the polymer, and an implant geometry with large surface area each seems to be associated with an increased risk of the occurrence of a foreign-body reaction. Yet in majority of the patients affected, no known individual marker of high risk is present. Some recent laboratory experiments indicate that it may be possible to diminish the risk of an adverse tissue response by incorporating alkaline salts or antibodies to inflammatory mediators in the implants. The results of in vitro and animal experiments, however, cannot always be directly extrapolated to humans. Only large-scale long-term clinical research will ultimately show which physico-chemical characteristics of a biodegradable orthopaedic implant provide the optimal clinical biocompatibility.
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Affiliation(s)
- O Böstman
- Department of Orthopaedic and Trauma Surgery, Helsinki University Hospital, Finland.
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Fink C, Benedetto KP, Hackl W, Hoser C, Freund MC, Rieger M. Bioabsorbable polyglyconate interference screw fixation in anterior cruciate ligament reconstruction: a prospective computed tomography-controlled study. Arthroscopy 2000; 16:491-8. [PMID: 10882444 DOI: 10.1053/jars.2000.4633] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE It was the purpose of the study to evaluate a new polyglyconate bioabsorbable interference screw for graft fixation in anterior cruciate ligament (ACL) reconstruction. TYPE OF STUDY Prospective randomized. MATERIALS AND METHODS Forty patients who underwent endoscopic ACL reconstruction were included in the study and randomized intraoperatively. Group A consisted of 20 patients (6 women, 14 men; mean age, 29.6 years) who had femoral bone block fixation with a bioabsorbable interference screw and tibial fixation with a titanium interference screw. Group B included 20 patients (5 women, 15 men; mean age 29.6 years) who had fixation of both femoral and tibial bone blocks with titanium interference screws. There was no significant difference between the groups with regard to age, gender, height, weight, time from injury to surgery, activity level, and concomitant injuries. RESULTS Clinical results (using IKDC, Lysholm, Tegner scores) of the 2 groups as well as instrumented laxity measurements (KT-1000) did not show significant (P >.05) differences at any stage of follow-up. No complications with respect to graft fixation could be found. Computed tomography scans, performed within the first postoperative week, at 6 weeks, and at 3, 6, 12, and 24 months postoperatively revealed a uniform picture for all patients within the groups, showing completed screw degradation at 12 months in group A. CONCLUSION Polyglyconate interference screw fixation for patellar tendon grafts has not been found to be associated with increased clinical complications or significant osteolysis. It provided equivalent fixation and clinical results compared with titanium screws. However, replacement of the screw with bone did not take place for up to 3 years postoperatively.
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Affiliation(s)
- C Fink
- University Hospital for Traumatology, Innsbruck, Austria.
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Warme WJ, Arciero RA, Savoie FH, Uhorchak JM, Walton M. Nonabsorbable versus absorbable suture anchors for open Bankart repair. A prospective, randomized comparison. Am J Sports Med 1999; 27:742-6. [PMID: 10569360 DOI: 10.1177/03635465990270061001] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Suture anchors facilitate the surgical repair of capsuloligamentous structures to bone. Bioabsorbable suture anchors, which obviate potential pitfalls in the periarticular use of permanent implants, have recently become available. We randomly assigned 40 patients to undergo modified Bankart shoulder repairs with either nonabsorbable or absorbable suture anchors. The patients had a history of recurrent traumatic anterior instability that had not improved with nonoperative management. The average patient age was 22 years (range, 17 to 46), and the average preoperative Rowe score was 47 points in the nonabsorbable anchor group and 47 points in the absorbable anchor group. Average postoperative Rowe scores were 96 and 93 points, respectively. There was one failed result in the nonabsorbable anchor group and two in the absorbable anchor group. No statistically significant subjective or objective differences were found at an average of 25 months postoperatively. Our results reveal that, in this application, bioabsorbable suture anchors are a viable option for the repair of soft tissue to bone.
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Affiliation(s)
- W J Warme
- Keller Army Community Hospital, West Point, New York, USA
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McGuire DA, Barber FA, Elrod BF, Paulos LE. Bioabsorbable interference screws for graft fixation in anterior cruciate ligament reconstruction. Arthroscopy 1999; 15:463-73. [PMID: 10424549 DOI: 10.1053/ar.1999.v15.015046001] [Citation(s) in RCA: 142] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The central one third of the patellar tendon autograft is popular because the bone-tendon-bone (BTB) construct provides several graft fixation options, robust graft incorporation, and a mechanically sufficient substitute. Interference screw fixation is one method used to secure the graft. Bioabsorbable interference screws may offer advantages over metal interference screws. Bioabsorbable screws are made from poly L-lactic acid (PLLA) and are absorbed by the body. This prospective, randomized study compared the safety and efficacy of the PLLA screw with that of the metal cannulated interference screw for anterior cruciate ligament reconstruction. There were 204 patients randomly assigned to the Bioscrew (Linvatec, Largo, FL) (n = 103) or the metal interference screw (n = 101) groups at four sites. The mean age was 30 years. There were 66 women and 138 men. Mean follow-up was 30 months for Bioscrews and 28 months for metal screws; the average follow-up interval was 2.4 years. The Lysholm mean scores at 4 years for the 32 patients seen at this interval were 95.0 and 97.2 for the Bioscrew and metal screw group, respectively. Ligament laxity comparisons made with an instrumented arthrometer at manual maximum force resulted in side-to-side mean score differences of B = 1.8mm and M = 1.6mm. The Tegner activity level score means were B = 6.1 and M = 5.8. Other variables examined included pain, thigh size, meniscal tests, Lachman's test, range of motion, anterior drawer, pivot shift, patellofemoral crepitus and tenderness, and joint effusion. None of these variables showed a statistically significant difference between groups. No radiographic evidence of osteolytic change or bone resorption around the Bioscrews was observed. There were no complications related to loss of fixation, toxicity, allergenicity, or other evidence of osteolytic or inflammatory reaction. In every assessment between groups there was no difference found. There were 12 PLLA screws that broke during insertion without any adverse effects. The PLLA headless cannulated interference fit screws produce equal results to similarly designed metal screws.
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Affiliation(s)
- D A McGuire
- Southern Sports Medicine and Orthopaedic Center, Nashville, Tennessee, USA
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Böstman OM, Pihlajamäki HK. Late foreign-body reaction to an intraosseous bioabsorbable polylactic acid screw. A case report. J Bone Joint Surg Am 1998; 80:1791-4. [PMID: 9875938 DOI: 10.2106/00004623-199812000-00010] [Citation(s) in RCA: 104] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- O M Böstman
- Department of Orthopaedic and Trauma Surgery, Helsinki University Hospital, Finland.
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