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Gagnon D, Mouallem M, Leduc S, Rouleau DM, Chapleau J. A systematic scoping review of the latest data on orthobiologics in the surgical treatment of non-union. Orthop Traumatol Surg Res 2024:103896. [PMID: 38663743 DOI: 10.1016/j.otsr.2024.103896] [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: 11/29/2023] [Revised: 04/02/2024] [Accepted: 04/18/2024] [Indexed: 05/03/2024]
Abstract
INTRODUCTION Recent studies have shown a growing concern regarding the cost-effectiveness and the lack of supporting data for the biologic agents that are being increasingly used in the orthopedic field. Our aim was to conduct a systematic scoping review of recent publications (last five years) on the use of orthobiologics to treat fracture non-union and summarize the latest available data. PATIENTS AND METHODS The inclusion criteria for this review were articles published in English, from 2016 to 2022, and focusing on the use of orthobiologics for the surgical treatment of non-union. Searches were conducted in March 2023 using Pubmed/MEDLINE and Embase. Studies on spinal fusion or gene therapy were excluded. Reviews, case reports with five cases or less, conference proceedings, preliminary reports, pediatric or non-human studies were excluded as well. RESULTS The search found 1807 articles, 15 were eligible after PRISMA checklist and exclusions. The evidence was heterogenous and there was only one level II RCT. Recent data suggests that bone morphogenic protein (BMP-2) products could be effective for septic and aseptic tibial non-unions. However, the evidence was not conclusive regarding BMP-7, plasma rich platelets (PRP), stem cells or demineralized bone matrix (DBM). DISCUSSION Every non-union case is different in terms of bone defect, biology, mechanical stability, surgical technique and host factors, which contributes to the conflicting reports on the efficacy of orthobiologics in the literature. We might never see a level 1, high powered and robust study defining the efficacy, safety profile and cost-effectiveness of such products. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- David Gagnon
- Faculty of Medicine, Université de Montréal, 2900 boulevard Edouard-Montpetit, Montreal, QC. H3T 1J4, Canada
| | - Maya Mouallem
- Faculty of Medicine, Université de Montréal, 2900 boulevard Edouard-Montpetit, Montreal, QC. H3T 1J4, Canada
| | - Stéphane Leduc
- Faculty of Medicine, Université de Montréal, 2900 boulevard Edouard-Montpetit, Montreal, QC. H3T 1J4, Canada; Department of orthopedic surgery, CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, C2095-5400 Boul. Gouin O., Montreal, QC. H4J 1C5, Canada
| | - Dominique M Rouleau
- Faculty of Medicine, Université de Montréal, 2900 boulevard Edouard-Montpetit, Montreal, QC. H3T 1J4, Canada; Department of orthopedic surgery, CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, C2095-5400 Boul. Gouin O., Montreal, QC. H4J 1C5, Canada
| | - Julien Chapleau
- Faculty of Medicine, Université de Montréal, 2900 boulevard Edouard-Montpetit, Montreal, QC. H3T 1J4, Canada; Department of orthopedic surgery, CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, C2095-5400 Boul. Gouin O., Montreal, QC. H4J 1C5, Canada.
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Harrison N, Hysong A, Posey S, Yu Z, Chen AT, Pallitto P, Gardner MJ, Dumpe J, Mir H, Babcock S, Natoli RM, Adams JD, Zura RD, Miller AN, Seymour RB, Hsu JR, Obremskey W. Outcomes of Humerus Nonunion Surgery in Patients With Initial Operative Fracture Fixation. J Orthop Trauma 2024; 38:168-175. [PMID: 38158607 DOI: 10.1097/bot.0000000000002740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 12/12/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES To describe outcomes following humerus aseptic nonunion surgery in patients whose initial fracture was treated operatively and to identify risk factors for nonunion surgery failure in the same population. METHODS DESIGN Retrospective case series. SETTING Eight, academic, level 1 trauma centers. PATIENTS SELECTION CRITERIA Patients with aseptic humerus nonunion (OTA/AO 11 and 12) after the initial operative management between 1998 and 2019. OUTCOME MEASURES AND COMPARISONS Success rate of nonunion surgery. RESULTS Ninety patients were included (56% female; median age 50 years; mean follow-up 21.2 months). Of 90 aseptic humerus nonunions, 71 (78.9%) united following nonunion surgery. Thirty patients (33.3%) experienced 1 or more postoperative complications, including infection, failure of fixation, and readmission. Multivariate analysis found that not performing revision internal fixation during nonunion surgery (n = 8; P = 0.002) and postoperative de novo infection (n = 9; P = 0.005) were associated with an increased risk of recalcitrant nonunion. Patient smoking status and the use of bone graft were not associated with differences in the nonunion repair success rate. CONCLUSIONS This series of previously operated aseptic humerus nonunions found that more than 1 in 5 patients failed nonunion repair. De novo postoperative infection and failure to perform revision internal fixation during nonunion surgery were associated with recalcitrant nonunion. Smoking and use of bone graft did not influence the success rate of nonunion surgery. These findings can be used to give patients a realistic expectation of results and complications following humerus nonunion surgery. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Noah Harrison
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Alexander Hysong
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Samuel Posey
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Ziqing Yu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Andrew T Chen
- Department of Orthopaedic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Patrick Pallitto
- Department of Orthopaedic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA
| | - Jarrod Dumpe
- Department of Orthopaedic Surgery, Atrium Health Navicent Medical Center, Macon, GA
| | - Hassan Mir
- Department of Orthopaedic Surgery, Florida Orthopedic Institute, Tampa, FL
| | - Sharon Babcock
- Department of Orthopaedic Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Roman M Natoli
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IU Health Methodist Hospital, Indianapolis, IN
| | - John D Adams
- Department of Orthopaedic Surgery, Prisma Health, Greenville, SC
| | - Robert D Zura
- Department of Orthopaedics, Louisiana State University, New Orleans, LA; and
| | - Anna N Miller
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - William Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
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Hackl S, von Rüden C, Trenkwalder K, Keppler L, Hierholzer C, Perl M. Long-Term Outcomes Following Single-Stage Reamed Intramedullary Exchange Nailing in Apparently Aseptic Femoral Shaft Nonunion with Unsuspected Proof of Bacteria. J Clin Med 2024; 13:1414. [PMID: 38592249 PMCID: PMC10933962 DOI: 10.3390/jcm13051414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 02/25/2024] [Accepted: 02/27/2024] [Indexed: 04/10/2024] Open
Abstract
Background: The aim of this study was to evaluate detection rates and risk factors for unsuspected proof of bacteria, as well as clinical and radiologic outcomes following femoral shaft nonunion without clinical signs of infection treated by a single-stage surgical revision procedure including reamed intramedullary exchange nailing. Methods: A retrospective cohort study was performed in a European level I trauma center between January 2015 and December 2022. Fifty-eight patients were included who underwent reamed intramedullary exchange nailing as a single-step procedure for surgical revision of posttraumatic diaphyseal femoral nonunion without any indications of infection in medical history and without clinical signs of local infection. Clinical details of the patients were analyzed and functional and radiologic long-term outcomes were determined. Results: In all patients, with and without proof of bacteria osseous, healing could be observed. The physical component summary of the SF-12 demonstrated significantly better results at least one year after the final surgical revision in case of a negative bacterial culture during exchange nailing. Conclusions: Clinical long-term outcomes demonstrated a trend towards better results following femoral shaft nonunion revision if there was no evidence for the presence of low-grade infected nonunion. In this case, a single-stage surgical procedure may be recommended.
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Affiliation(s)
- Simon Hackl
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Christian von Rüden
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
- Department of Trauma Surgery, Orthopedics and Hand Surgery, Weiden Medical Center, 92637 Weiden, Germany
| | - Katharina Trenkwalder
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
- Institute for Biomechanics, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Lena Keppler
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Christian Hierholzer
- Department of Trauma Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Mario Perl
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
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Hackl S, Eijkenboom A, Militz M, von Rüden C. [Diagnostic and therapeutic work-up of infected tibial nonunion]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:96-102. [PMID: 37812233 DOI: 10.1007/s00113-023-01371-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND The failure of bone fracture healing is one of the major complications of fracture treatment, especially of the tibia due to its limited soft tissue coverage and high rate of open injuries. Although implant development is constantly progressing and modern surgical techniques are continuously improving, infected tibial nonunion plays a decisive role in terms of its variable clinical presentation. OBJECTIVE This article provides guidelines for the successful surgical treatment of infected tibial nonunion. MATERIAL AND METHOD Strategies are presented to identify infection as a cause of failure of fracture healing and to achieve infection and bone healing. RESULTS A significant amount of tibial nonunions primarily thought to be aseptic ultimately turn out to be infected nonunions. CONCLUSION The treatment of infected tibial nonunion requires extensive clinical, radiological and laboratory diagnostics as well as a profound biomechanical and biological understanding of the bone situation. This is the only way to achieve rapid osseous healing with as few revision interventions as possible.
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Affiliation(s)
- Simon Hackl
- Abteilung für Septische und Rekonstruktive Chirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland.
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich.
| | - Alexander Eijkenboom
- Abteilung für Septische und Rekonstruktive Chirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - Matthias Militz
- Abteilung für Septische und Rekonstruktive Chirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - Christian von Rüden
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
- Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, Klinikum Weiden, Weiden, Deutschland
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Kuroda R, Niikura T, Matsumoto T, Fukui T, Oe K, Mifune Y, Minami H, Matsuoka H, Yakushijin K, Miyata Y, Kawamoto S, Kagimura T, Fujita Y, Kawamoto A. Phase III clinical trial of autologous CD34 + cell transplantation to accelerate fracture nonunion repair. BMC Med 2023; 21:386. [PMID: 37798633 PMCID: PMC10557317 DOI: 10.1186/s12916-023-03088-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 09/21/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND We previously demonstrated that CD34 + cell transplantation in animals healed intractable fractures via osteogenesis and vasculogenesis; we also demonstrated the safety and efficacy of this cell therapy in an earlier phase I/II clinical trial conducted on seven patients with fracture nonunion. Herein, we present the results of a phase III clinical trial conducted to confirm the results of the previous phase studies using a larger cohort of patients. METHODS CD34 + cells were mobilized via administration of granulocyte colony-stimulating factor, harvested using leukapheresis, and isolated using magnetic cell sorting. Autologous CD34 + cells were transplanted in 15 patients with tibia nonunion and 10 patients with femur nonunion, who were followed up for 52 weeks post transplantation. The main outcome was a reduction in time to heal the tibia in nonunion patients compared with that in historical control patients. We calculated the required number of patients as 15 based on the results of the phase I/II study. An independent data monitoring committee performed the radiographic assessments. Adverse events and medical device failures were recorded. RESULTS All fractures healed during the study period. The time to radiological fracture healing was 2.8 times shorter in patients with CD34 + cell transplantation than in the historical control group (hazard ratio: 2.81 and 95% confidence interval 1.16-6.85); moreover, no safety concerns were observed. CONCLUSIONS Our findings strongly suggest that autologous CD34 + cell transplantation is a novel treatment option for fracture nonunion. TRIAL REGISTRATION UMIN-CTR, UMIN000022814. Registered on 22 June 2016.
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Affiliation(s)
- Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Takahiro Niikura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan.
| | - Tomoyuki Matsumoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Tomoaki Fukui
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Keisuke Oe
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Yutaka Mifune
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Hironobu Minami
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Hospital and Graduate School of Medicine, Chuo-Ku, Kobe, 650-0017, Japan
| | - Hiroshi Matsuoka
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Hospital and Graduate School of Medicine, Chuo-Ku, Kobe, 650-0017, Japan
| | - Kimikazu Yakushijin
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Hospital and Graduate School of Medicine, Chuo-Ku, Kobe, 650-0017, Japan
| | - Yoshiharu Miyata
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Hospital and Graduate School of Medicine, Chuo-Ku, Kobe, 650-0017, Japan
| | - Shinichiro Kawamoto
- Department of Transfusion Medicine and Cell Therapy, Kobe University Hospital, Chuo-Ku, Kobe, 650-0017, Japan
| | - Tatsuo Kagimura
- Translational Research Center for Medical Innovation, Foundation for Biomedical Research and Innovation at Kobe, Chuo-Ku, Kobe, 650-0047, Japan
| | - Yasuyuki Fujita
- Translational Research Center for Medical Innovation, Foundation for Biomedical Research and Innovation at Kobe, Chuo-Ku, Kobe, 650-0047, Japan
| | - Atsuhiko Kawamoto
- Translational Research Center for Medical Innovation, Foundation for Biomedical Research and Innovation at Kobe, Chuo-Ku, Kobe, 650-0047, Japan
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Bégué T, Mouchantaf M, Aurégan JC. Aseptic humeral shaft nonunion. Orthop Traumatol Surg Res 2023; 109:103462. [PMID: 36942794 DOI: 10.1016/j.otsr.2022.103462] [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: 02/14/2022] [Accepted: 05/25/2022] [Indexed: 12/24/2022]
Abstract
Aseptic humeral shaft nonunions are rare lesions, with less than 700 cases per year in France. This low frequency explains why they are difficult to manage. They can be hypertrophic or atrophic, with or without a defect. The diagnosis is made based on radiographs and/or CT scan images. Nonunion is suspected early on when a patient presents with abnormal motion at the fracture site 6 weeks after the initial injury event in the context of conservative treatment or has large residual displacement after initial treatment or an open fracture. The treatment for hypertrophic nonunion consists in applying stable, rigid fixation, most often using a large-fragment plate with 4.5 mm screws, combined with cancellous autograft. When combined with the osteoperiosteal decortication first described by Judet, it produces union in 98% of cases. Intramedullary (IM) nail fixation with an autograft is another possibility. In atrophic nonunions, resecting the ends and ensuring the soft tissues have good vitality will generally lead to fracture union. Nonunions with critical size defects (larger than 5 cm), which have a high risk of infection, are a treatment challenge that requires stable fixation and recourse to more complex treatments like the two-step induced membrane technique or vascularized fibular graft. In all cases, to avoid complex repeat revision, internal fixation with plate or IM nail must be combined with a bone graft in situ to maximize the chances of union.
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Affiliation(s)
- Thierry Bégué
- Service de chirurgie orthopédique et traumatologique, hôpital Antoine Béclère, université Paris-Saclay, AP-HP, 157, rue de la Porte de Trivaux, 92140 Clamart, France.
| | - Mark Mouchantaf
- Service de chirurgie orthopédique et traumatologique, hôpital Antoine Béclère, université Paris-Saclay, AP-HP, 157, rue de la Porte de Trivaux, 92140 Clamart, France
| | - Jean-Charles Aurégan
- Service de chirurgie orthopédique et traumatologique, hôpital Antoine Béclère, université Paris-Saclay, AP-HP, 157, rue de la Porte de Trivaux, 92140 Clamart, France
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Xie C, Wang C, Huang W, Huang Y, Li Q, Yu C, Yin D. Recombinant human bone morphogenetic protein is a valid alternative to autologous bone graft for long bone non-unions: a systematic review and meta-analysis. Surgeon 2023:S1479-666X(22)00134-2. [PMID: 36682906 DOI: 10.1016/j.surge.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 06/23/2022] [Accepted: 11/14/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To compare the efficacy of recombinant human bone morphogenetic proteins (rhBMPs) and autologous bone graft (ABG) on the healing of long bone non-union. METHODS A systematic literature search was conducted on PubMed, Web of Science, Cochrane Library, and CNKI up to December 2021. Two authors independently screened the studies, extracted data, and assessed the quality of the trials. A Meta-analysis was performed using state software (version 12.0). RESULTS A total of 14 studies were included in this meta-analysis. Overall, there was no significant difference between the rhBMPs group and the ABG group in terms of healing rate (RR = 1.04, 95% CI = 0.96-1.12, p = 0.365) and healing time (SMD = -0.31, 95% CI = -0.76-0.14, p = 0.175). Subgroup analysis showed rhBMPs lead to higher healing rates (RR = 1.35, 95% CI = 1.17-1.56, p < 0.001), and shorter healing time (SMD = -0.65, 95% CI = -1.08 to -0.22, p = 0.003) in the subgroup of moderate-quality studies. Sensitivity analysis proved that our conclusions were relatively robust. No significant publication bias was recognized in all studies (Begg's test, p = 0.193; Egger's test, p = 0.307). CONCLUSIONS RhBMPs or combined with allografts bone, inorganic bone was a valid alternative to ABG for the treatment of long bone non-union.
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Affiliation(s)
- Chengxin Xie
- Department of Joint Surgery and Sports Medicine, The People's Hospital of Guangxi Zhuang Autonomous Region & Guangxi Academy of Medical Sciences, 530021 Nanning, China.
| | - Chenglong Wang
- Department of Joint Surgery and Sports Medicine, The People's Hospital of Guangxi Zhuang Autonomous Region & Guangxi Academy of Medical Sciences, 530021 Nanning, China.
| | - Wenwen Huang
- Department of Joint Surgery and Sports Medicine, The People's Hospital of Guangxi Zhuang Autonomous Region & Guangxi Academy of Medical Sciences, 530021 Nanning, China.
| | - Yu Huang
- Department of Traumatic Surgery & Microsurgery & Hand Surgery, The People's Hospital of Guangxi Zhuang Autonomous Region & Guangxi Academy of Medical Sciences, 530021 Nanning, China.
| | - Qinglong Li
- Department of Traumatic Surgery & Microsurgery & Hand Surgery, The People's Hospital of Guangxi Zhuang Autonomous Region & Guangxi Academy of Medical Sciences, 530021 Nanning, China.
| | - Chengqiang Yu
- Department of Spine Surgery, The People's Hospital of Guangxi Zhuang Autonomous Region & Guangxi Academy of Medical Sciences, 530021 Nanning, China.
| | - Dong Yin
- Department of Joint Surgery and Sports Medicine, The People's Hospital of Guangxi Zhuang Autonomous Region & Guangxi Academy of Medical Sciences, 530021 Nanning, China.
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Gao X, Hwang MP, Wright N, Lu A, Ruzbarsky JJ, Huard M, Cheng H, Mullen M, Ravuri S, Wang B, Wang Y, Huard J. The use of heparin/polycation coacervate sustain release system to compare the bone regenerative potentials of 5 BMPs using a critical sized calvarial bone defect model. Biomaterials 2022; 288:121708. [PMID: 36031459 PMCID: PMC10129760 DOI: 10.1016/j.biomaterials.2022.121708] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 07/01/2022] [Accepted: 07/30/2022] [Indexed: 11/18/2022]
Abstract
Nonunion following bone fracture and segmental bone defects are challenging clinical conditions. To combat this clinical dilemma, development of new bone tissue engineering therapies using biocompatible materials to deliver bone growth factors is desirable. This aim of this study is to use a heparin/polycation coacervate sustained-release platform to compare 5 bone morphogenetic proteins (BMPs) for promoting bone defect healing in a critical sized calvarial defect model. The in vitro 3D osteogenic pellet cultures assays demonstrated that BMPs 2, 4, 6, 7 and 9 all enhanced mineralization in vitro compared to the control group. BMP2 resulted in higher mineralized volume than BMP4 and BMP6. All BMPs and the control group activated the pSMAD5 signaling pathway and expressed osterix (OSX). The binding of BMP2 with coacervate significantly increased the coacervate average particle size. BMP2, 4, 6, & 7 bound to coacervate significantly increased the Zeta potential of the coacervate while BMP9 binding showed insignificant increase. Furthermore, using a monolayer culture osteogenic assay, it was found that hMDSCs cultured in the coacervate BMP2 osteogenic medium expressed higher levels of RUNX2, OSX, ALP and COX-2 compared to the control and BMPs 4, 6, 7 & 9. Additionally, the coacervate complex can be loaded with up to 2 μg of BMP proteins for sustained release. In vivo, when BMPs were delivered using the coacervate sustained release system, BMP2 was identified to be the most potent BMP promoting bone regeneration and regenerated 10 times of new bone than BMPs 4, 6 & 9. BMP7 also stimulated robust bone regeneration when compared to BMPs 4, 6 & 9. The quality of the newly regenerated bone by all BMPs delivered by coacervate is equivalent to the host bone consisting of bone matrix and bone marrow with normal bone architecture. Although the defect was not completely healed at 6 weeks, coacervate sustain release BMPs, particularly BMP2 and BMP7, could represent a new strategy for treatment of bone defects and non-unions.
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Affiliation(s)
- Xueqin Gao
- Linda and Mitch Hart Center for Regenerative and Personalized Medicine, Steadman Philippon Research Institute, Vail, CO, 81657, USA
| | - Mintai P Hwang
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY, 14853, USA
| | - Nathaniel Wright
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY, 14853, USA
| | - Aiping Lu
- Linda and Mitch Hart Center for Regenerative and Personalized Medicine, Steadman Philippon Research Institute, Vail, CO, 81657, USA
| | - Joseph J Ruzbarsky
- Linda and Mitch Hart Center for Regenerative and Personalized Medicine, Steadman Philippon Research Institute, Vail, CO, 81657, USA
| | - Matthieu Huard
- Linda and Mitch Hart Center for Regenerative and Personalized Medicine, Steadman Philippon Research Institute, Vail, CO, 81657, USA
| | - Haizi Cheng
- Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, USA
| | - Michael Mullen
- Linda and Mitch Hart Center for Regenerative and Personalized Medicine, Steadman Philippon Research Institute, Vail, CO, 81657, USA
| | - Sudheer Ravuri
- Linda and Mitch Hart Center for Regenerative and Personalized Medicine, Steadman Philippon Research Institute, Vail, CO, 81657, USA
| | - Bing Wang
- Department of Orthopaedic Surgery, University of Pittsburgh, USA
| | - Yadong Wang
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY, 14853, USA.
| | - Johnny Huard
- Linda and Mitch Hart Center for Regenerative and Personalized Medicine, Steadman Philippon Research Institute, Vail, CO, 81657, USA.
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Hackl S, Trenkwalder K, Militz M, Augat P, Stuby FM, von Rüden C. [Infected nonunion: diagnostic and therapeutic work-up]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2022; 125:602-610. [PMID: 35750886 DOI: 10.1007/s00113-022-01204-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/02/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Septic nonunion is one of the major complications in fracture healing. The challenge is to identify the infection as the cause of nonunion first and then to achieve healing of the infection and the bone. OBJECTIVE Because of the more heterogeneous appearance of an infected nonunion, the prevalence of germ detection in surgical nonunion revision is often underestimated. MATERIAL AND METHODS In a retrospective study between 2010 and 2017, 86 patients with radiologically confirmed femoral shaft nonunion without clinical evidence and unremarkable medical history of a florid infection as the cause of nonunion, who had undergone primary single-stage surgical nonunion revision were analyzed. At least four intraoperatively obtained samples were evaluated for microbiological diagnosis. A distinction was made between tissue samples with subsequent 48‑h short-term incubation and tissue samples with 14-day long-term cultivation. The finding "germ detection" was made if at least two of the samples demonstrated bacterial growth. RESULTS In 18 of 86 patients with a nonunion preoperatively judged to be aseptic, positive bacterial evidence was obtained after short-term incubation. After long-term cultivation, positive bacterial detection was possible in 38 of 86 patients with a femoral shaft nonunion initially classified as aseptic. Regarding potential risk factors, the two groups demonstrated no relevant differences. In 29 patients, 1 pathogen was isolated from the obtained samples, whereas in the remaining 9 patients, a mixed culture with an average of 2.9 ± 0.5 different bacteria was detected. Identification revealed mainly low-virulence bacteria, most commonly Staphylococcus epidermidis. CONCLUSION If the preoperative diagnostics including clinical, laboratory and radiological examination as well as a careful anamnesis reveal indications of a possible infectious event, the surgical nonunion revision should be performed in two stages with specimen collection before definitive nonunion revision. For microbiological diagnosis, several representative tissue samples should independently be obtained from the nonunion site and incubated for 14 days. Only in the absence of evidence of septic nonunion is a single-stage procedure suggested.
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Affiliation(s)
- Simon Hackl
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland.
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich.
| | - Katharina Trenkwalder
- Institut für Biomechanik, BG Unfallklinik Murnau, Murnau, Deutschland
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
| | - Matthias Militz
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - Peter Augat
- Institut für Biomechanik, BG Unfallklinik Murnau, Murnau, Deutschland
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
| | - Fabian M Stuby
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - Christian von Rüden
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland.
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich.
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10
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Kaspiris A, Hadjimichael AC, Vasiliadis ES, Papachristou DJ, Giannoudis PV, Panagiotopoulos EC. Therapeutic Efficacy and Safety of Osteoinductive Factors and Cellular Therapies for Long Bone Fractures and Non-Unions: A Meta-Analysis and Systematic Review. J Clin Med 2022; 11:3901. [PMID: 35807186 PMCID: PMC9267779 DOI: 10.3390/jcm11133901] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/18/2022] [Accepted: 06/21/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Long bone fractures display significant non-union rates, but the exact biological mechanisms implicated in this devastating complication remain unclear. The combination of osteogenetic and angiogenetic factors at the fracture site is an essential prerequisite for successful bone regeneration. The aim of this study is to investigate the results of the clinical implantation of growth factors for intraoperative enhancement of osteogenesis for the treatment of long bone fractures and non-unions. METHODS A systematic literature review search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in the PubMed and Web of Science databases from the date of inception of each database through to 10 January 2022. Specific inclusion and exclusion criteria were applied in order to identify relevant studies reporting on the treatment of upper and lower limb long bone non-unions treated with osteoinductive or cellular factors. RESULTS Overall, 18 studies met the inclusion criteria and examined the effectiveness of the application of Bone Morphogenetic Proteins-2 and -7 (BMPs), platelet rich plasma (PRP) and mesenchymal stem cells (MSCs). Despite the existence of limitations in the studies analysed (containing mixed groups of open and close fractures, different types of fractures, variability of treatment protocols, different selection criteria and follow-up periods amongst others), their overall effectiveness was found significantly increased in patients who received them compared with the controls (I2 = 60%, 95% CI = 1.59 [0.99-2.54], Z =1.93, p = 0.05). CONCLUSION Administration of BMP-2 and -7, PRP and MSCs were considered effective and safe methods in fracture treatment, increasing bone consolidation, reducing time to repair and being linked to satisfactory postoperative functional scores.
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Affiliation(s)
- Angelos Kaspiris
- Laboratory of Molecular Pharmacology, Department of Pharmacy, School of Health Sciences, University of Patras, 26504 Patras, Greece
| | - Argyris C. Hadjimichael
- Department of Orthopaedics, St. Mary’s Hospital, Imperial College Healthcare NHS Trust, Praed Street, London W2 1NY, UK;
| | - Elias S. Vasiliadis
- Third Department of Orthopaedic Surgery, School of Medicine, “KAT” General Hospital, National and Kapodistrian University of Athens, 2 Nikis Street, 14561 Athens, Greece;
| | - Dionysios J. Papachristou
- Laboratory of Bone and Soft Tissue Studies, Department of Anatomy-Histology-Embryology, University Patras Medical School, 26504 Patras, Greece;
| | - Peter V. Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds LS7 4SA, UK;
- NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds LS7 4SA, UK
| | - Elias C. Panagiotopoulos
- Department of Trauma and Orthopaedics, Patras University Hospital and Medical School, 26504 Patras, Greece;
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11
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Xie C, Wang C, Huang Y, Li Q, Tian X, Huang W, Yin D. Therapeutic effect of autologous bone grafting with adjuvant bone morphogenetic protein on long bone nonunion: a systematic review and meta-analysis. J Orthop Surg Res 2022; 17:298. [PMID: 35659033 PMCID: PMC9166588 DOI: 10.1186/s13018-022-03185-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 05/18/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The recombinant human bone morphogenetic protein (rhBMP) is a common graft substitute for treating cases of long bone nonunion. However, the feasibility of combining an autologous bone graft (ABG) with rhBMPs remains uncertain. Thus, this systematic review and meta-analysis aimed to evaluate the synergistic effect of ABG and rhBMPs on the healing of long bone nonunion. METHODS A systematic literature search was performed on PubMed, Web of Science, Cochrane Library, and China National Knowledge Infrastructure. Two authors independently screened the studies, extracted data, and assessed the quality of the trials. Statistical analyses were performed using Stata 12.0. RESULTS Of the 202 citations, five studies involving a total of 394 cases met the eligibility criteria; thus, they were included in this study. The pooled data revealed no significant differences among the groups in terms of postoperative healing rate (risk ratio [RR] = 1.01, 95% confidence interval [CI] = 0.96-1.06, P = 0.744), healing time (standardised mean difference = - 0.20, 95% CI = - 0.95-0.56, P = 0.610), and pain (RR = 1.44, 95% CI = 0.25-8.29, P = 0.681). The combination of ABG and rhBMPs resulted in good limb function (RR = 1.31, 95% CI = 1.04-1.66, P = 0.023). CONCLUSIONS The combination of ABG and rhBMPs did not result in the healing of long bone nonunion and pain reduction. Nevertheless, it conferred good limb function. Thus, the findings in this study are insufficient to support the use of rhBMPs as an adjuvant to ABG.
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Affiliation(s)
- Chengxin Xie
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province & Taizhou Hospital Affiliated to Wenzhou Medical University, No.150 Ximen Road, Linhai, 317000, Zhejiang Province, China.
| | - Chenglong Wang
- Department of Joint Surgery and Sports Medicine, Guangxi Academy of Medical Sciences & The People's Hospital of Guangxi Zhuang Autonomous Region, No.6 Taoyuan Road, Nanning, 530001, Guangxi Zhuang Autonomous Region, China
| | - Yu Huang
- Department of Traumatic Surgery & Microsurgery & Hand Surgery, Guangxi Academy of Medical Sciences & The People's Hospital of Guangxi Zhuang Autonomous Region, No.6 Taoyuan Road, Nanning, 530001, Guangxi Zhuang Autonomous Region, China
| | - Qinglong Li
- Department of Traumatic Surgery & Microsurgery & Hand Surgery, Guangxi Academy of Medical Sciences & The People's Hospital of Guangxi Zhuang Autonomous Region, No.6 Taoyuan Road, Nanning, 530001, Guangxi Zhuang Autonomous Region, China
| | - Xin Tian
- Department of Joint Surgery and Sports Medicine, Guangxi Academy of Medical Sciences & The People's Hospital of Guangxi Zhuang Autonomous Region, No.6 Taoyuan Road, Nanning, 530001, Guangxi Zhuang Autonomous Region, China
| | - Wenwen Huang
- Department of Joint Surgery and Sports Medicine, Guangxi Academy of Medical Sciences & The People's Hospital of Guangxi Zhuang Autonomous Region, No.6 Taoyuan Road, Nanning, 530001, Guangxi Zhuang Autonomous Region, China.
| | - Dong Yin
- Department of Joint Surgery and Sports Medicine, Guangxi Academy of Medical Sciences & The People's Hospital of Guangxi Zhuang Autonomous Region, No.6 Taoyuan Road, Nanning, 530001, Guangxi Zhuang Autonomous Region, China.
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12
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Zhu L, Liu Y, Wang A, Zhu Z, Li Y, Zhu C, Che Z, Liu T, Liu H, Huang L. Application of BMP in Bone Tissue Engineering. Front Bioeng Biotechnol 2022; 10:810880. [PMID: 35433652 PMCID: PMC9008764 DOI: 10.3389/fbioe.2022.810880] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/01/2022] [Indexed: 01/15/2023] Open
Abstract
At present, bone nonunion and delayed union are still difficult problems in orthopaedics. Since the discovery of bone morphogenetic protein (BMP), it has been widely used in various studies due to its powerful role in promoting osteogenesis and chondrogenesis. Current results show that BMPs can promote healing of bone defects and reduce the occurrence of complications. However, the mechanism of BMP in vivo still needs to be explored, and application of BMP alone to a bone defect site cannot achieve good therapeutic effects. It is particularly important to modify implants to carry BMP to achieve slow and sustained release effects by taking advantage of the nature of the implant. This review aims to explain the mechanism of BMP action in vivo, its biological function, and how BMP can be applied to orthopaedic implants to effectively stimulate bone healing in the long term. Notably, implantation of a system that allows sustained release of BMP can provide an effective method to treat bone nonunion and delayed bone healing in the clinic.
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Affiliation(s)
- Liwei Zhu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
- Orthopaedic Research Institute of Jilin Province, Changchun, China
| | - Yuzhe Liu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Ao Wang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Zhengqing Zhu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Youbin Li
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Chenyi Zhu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Zhenjia Che
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Tengyue Liu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - He Liu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
- Orthopaedic Research Institute of Jilin Province, Changchun, China
- *Correspondence: He Liu, ; Lanfeng Huang,
| | - Lanfeng Huang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
- *Correspondence: He Liu, ; Lanfeng Huang,
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13
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DeRogatis MJ, Kanakamedala AC, Egol KA. Management of Subtrochanteric Femoral Fracture Nonunions. JBJS Rev 2021; 8:e1900143. [PMID: 33006463 DOI: 10.2106/jbjs.rvw.19.00143] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Compared with other proximal femoral fractures, subtrochanteric fractures are at a higher risk for nonunion because of the high deforming forces in this region, the associated increased risk of malreduction, and the risk of poor bone healing secondary to bisphosphonate use frequently associated with these fractures. Further understanding of nonunion of subtrochanteric fractures is of increasing importance given the rise in incidence of subtrochanteric hip fractures. Surgeons should be aware of risk factors for nonunion and techniques for prevention as well as surgical management and complications associated with surgical implantation devices. Surgeons should also consider using adjuncts including bone-grafting and biologic agents.
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Affiliation(s)
- Michael J DeRogatis
- 1Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
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14
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Wang Z, Lu Y, Huang Q, Xue H, Ran C, Wang Q, Ma T, Zhang K, Li Z, Sun L. Efficacy and Safety of Long-Term Intravenous Tranexamic Acid Administration for Blood Management in Revision Surgery for Femoral Shaft Nonunion: A Retrospective Case-Control Study. Clin Appl Thromb Hemost 2021; 27:10760296211002277. [PMID: 33845609 PMCID: PMC8047849 DOI: 10.1177/10760296211002277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Femoral shaft nonunion is a complication that seriously affects physiological functions. We aimed to assess the effectiveness and safety of short- and long-term intravenous tranexamic acid (TXA) administration in the perioperative period of revision surgery for femoral shaft nonunion. In this retrospective study, 53 patients undergoing double-locking plates with channel bone grafting technology for the treatment of femoral shaft nonunion were divided into 3 groups: the patients in group A without use TXA during hospitalization, the patients in group B received intravenous (IV) 1-g TXA at 30 min before the surgery and deep soaked 1-g TXA for 5 min before closing the incision, and then 1-g TXA IV again 6 h after surgery, and the patients in group C received 1-g TXA IV before the operation, 1-g TXA topically during the operation, and subsequent long-term 1-g TXA IV until discharged. The primary outcomes were total blood loss (TBL) and hidden blood loss (HBL). The secondary outcomes included actual hemoglobin (Hb) loss values, transfusion requirement, number of units transfused, postoperative laboratory values (Hb, hematocrit, fibrinogen, and D-dimer), visual analogue scale (VAS) scores, and hospitalization time. The mean TBL was lower in group C than in group A (1168 mL vs. 2714 mL, P < 0.001) and group B (1168 mL vs. 1557 mL, P = 0.008). The differences in HBL volumes were also significant between groups A and C (P < 0.001) and between groups A and B (P < 0.01). The actual Hb loss in the 3 groups showed a consistent trend with TBL, but no significant differences between groups B and C (P = 0.23). On postoperative day (POD) 3, the Hb level was higher in group C than in group A (111.1 g/L vs. 94.6 g/L, P = 0.02). No significant differences were found in VAS, hospital stay, thromboembolic complications, incision-related complications, and TXA adverse reactions among groups. Long-term intravenous TXA during hospitalization can effectively reduce perioperative blood loss, Hb drop, and postoperative hyperfibrinolysis, but is associated with an increased incidence of adverse reactions.
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Affiliation(s)
- Zhimeng Wang
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, People's Republic of China
| | - Yao Lu
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, People's Republic of China.,The Key Laboratory of Biomedical Information Engineering of Ministry of Education, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, People's Republic of China.,Bioinspired Engineering and Biomechanics Center (BEBC), Xi'an Jiaotong University, Xi'an, People's Republic of China
| | - Qiang Huang
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, People's Republic of China
| | - Hanzhong Xue
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, People's Republic of China
| | - Cheng Ran
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, People's Republic of China
| | - Qian Wang
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, People's Republic of China
| | - Teng Ma
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, People's Republic of China
| | - Kun Zhang
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, People's Republic of China
| | - Zhong Li
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, People's Republic of China
| | - Liang Sun
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, People's Republic of China
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15
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Chiari C, Grgurevic L, Bordukalo-Niksic T, Oppermann H, Valentinitsch A, Nemecek E, Staats K, Schreiner M, Trost C, Kolb A, Kainberger F, Pehar S, Milosevic M, Martinovic S, Peric M, Sampath TK, Vukicevic S, Windhager R. Recombinant Human BMP6 Applied Within Autologous Blood Coagulum Accelerates Bone Healing: Randomized Controlled Trial in High Tibial Osteotomy Patients. J Bone Miner Res 2020; 35:1893-1903. [PMID: 32543706 PMCID: PMC7689741 DOI: 10.1002/jbmr.4107] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 06/02/2020] [Accepted: 06/07/2020] [Indexed: 12/11/2022]
Abstract
Bone morphogenetic proteins (BMPs) are potent osteogenic proteins that induce new bone formation in vivo. However, their effect on bone healing in the trabecular bone surfaces remains challenging. We evaluated the safety and efficacy of recombinant human BMP6 (rhBMP6) applied within an autologous blood coagulum (ABC) in a surgically created wedge defect of the proximal tibia in patients undergoing high tibial osteotomy (HTO) for varus deformity and medial osteoarthritis of the knee. We enrolled 20 HTO patients in a randomized, placebo-controlled, double-blinded phase I/II clinical trial. RhBMP6/ABC (1.0 mg/10 mL ABC prepared from peripheral blood) or placebo (10 mL ABC containing excipients) was administered into the tibial wedge defects. Patients were followed for 0 to 24 months by clinical examination (safety) and computed tomography (CT) and serial radiographic analyses (efficacy). The results show that there were no detectable anti-rhBMP6 antibodies in the blood of any of the 20 patients at 14 weeks after implantation. During the 24 months of follow-up, there were no serious adverse reactions recorded. The CT scans from defects of patients treated with rhBMP6/ABC showed an accelerated bone healing compared with placebo at 9 weeks (47.8 ± 24.1 versus 22.2 ± 12.3 mg/cm3 ; p = 0.008) and at 14 weeks (89.7 ± 29.1 versus 53.6 ± 21.9 mg/cm3 ; p = 0.006) follow-up. Radiographic analyses at weeks 6 and 24 and months 12 and 24 suggested the advanced bone formation and remodeling in rhBMP6/ABC-treated patients. In conclusion, we show that rhBMP6/ABC at a dose of 100 μg/mL accelerated bone healing in patients undergoing HTO without serious adverse events and with a good tolerability compared with placebo alone. Overall, for the first time, a BMP-based osteogenic implant was examined against a placebo for bone healing efficacy in the trabecular bone surface, using an objective bone mineral density measurement system. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.
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Affiliation(s)
- Catharina Chiari
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Lovorka Grgurevic
- Laboratory for Mineralized Tissues, Centre for Translational and Clinical Research, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Tatjana Bordukalo-Niksic
- Laboratory for Mineralized Tissues, Centre for Translational and Clinical Research, University of Zagreb School of Medicine, Zagreb, Croatia
| | | | | | - Elena Nemecek
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Kevin Staats
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Markus Schreiner
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Carmen Trost
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Alexander Kolb
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Franz Kainberger
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Sanja Pehar
- Laboratory for Mineralized Tissues, Centre for Translational and Clinical Research, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Milan Milosevic
- Department of Environmental and Occupational Health and Sports, School of Public Health, "Andrija Stampar,", University of Zagreb School of Medicine, Zagreb, Croatia
| | | | - Mihaela Peric
- Department for Intracellular Communication, Centre for Translational and Clinical Research, University of Zagreb School of Medicine, Zagreb, Croatia
| | | | - Slobodan Vukicevic
- Laboratory for Mineralized Tissues, Centre for Translational and Clinical Research, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Reinhard Windhager
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
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16
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Zhou YQ, Tu HL, Duan YJ, Chen X. Comparison of bone morphogenetic protein and autologous grafting in the treatment of limb long bone nonunion: a systematic review and meta-analysis. J Orthop Surg Res 2020; 15:288. [PMID: 32727538 PMCID: PMC7391588 DOI: 10.1186/s13018-020-01805-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/16/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Bone morphogenetic proteins (BMPs) have strong bone induction properties and can promote healing of fractures and other defects. However, BMP treatment efficacy for long bone nonunion remains controversial. The aim of this meta-analysis was to synthetically evaluate the advantages and disadvantages of BMP plus bone grafting (observation group) versus autologous bone grafting (control group) for limb long bone nonunion. METHODS PubMed, Embase, Web of Science, Cochrane Library, OVID, CNKI, Weipu Journal, Chinese Biomedical Literature, and WanFang were searched for randomized and non-randomized controlled trials published before November 2019. A meta-analysis of outcome indicators was performed using RevMan 5.3 and Stata 12.0. RESULTS Five randomized and four non-randomized controlled trials involving 30-124 cases were included, with a total of 655 nonunion cases. There were no significant group differences in postoperative healing rate, infection, and secondary operation rates (P > 0.05), but the study group demonstrated significantly shorter mean healing time (WMD = - 1.27, 95%CI - 1.67 to - 0.88, P < 0.00001), a greater frequency of excellent/good post-treatment limb function (RR = 1.18, 95%CI 1.01-1.39, P = 0.04), and lower intraoperative blood loss (P < 0.05). Alternatively, the hospitalization cost was significantly higher in the study group (P < 0.01). CONCLUSIONS Bone morphogenetic protein is a viable alternative to autologous bone grafting, with potential advantages of accelerated fracture healing and improved postoperative function.
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Affiliation(s)
- Yong-Qiang Zhou
- The Department of Orthopedic Surgery, The First People's Hospital of Neijiang, Neijiang, 641000, Sichuan, China.,The Department of Neonatology, The First People's Hospital of Neijiang, Neijiang, 641000, Sichuan, China
| | - Hong-Liang Tu
- The Department of Orthopedic Surgery, The First People's Hospital of Neijiang, Neijiang, 641000, Sichuan, China.,The Department of Neonatology, The First People's Hospital of Neijiang, Neijiang, 641000, Sichuan, China
| | - Yan-Ji Duan
- The Department of Orthopedic Surgery, The First People's Hospital of Neijiang, Neijiang, 641000, Sichuan, China.,The Department of Neonatology, The First People's Hospital of Neijiang, Neijiang, 641000, Sichuan, China
| | - Xiao Chen
- The Department of Orthopedic Surgery, The First People's Hospital of Neijiang, Neijiang, 641000, Sichuan, China. .,The Department of Neonatology, The First People's Hospital of Neijiang, Neijiang, 641000, Sichuan, China.
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17
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Borzunov DY, Kolchin SN, Malkova TA. Role of the Ilizarov non-free bone plasty in the management of long bone defects and nonunion: Problems solved and unsolved. World J Orthop 2020; 11:304-318. [PMID: 32572367 PMCID: PMC7298454 DOI: 10.5312/wjo.v11.i6.304] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/06/2020] [Accepted: 05/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ilizarov non-free bone plasty is a method of distraction osteogenesis using the Ilizarov apparatus for external fixation which originated in Russia and was disseminated across the world. It has been used in long bone defect and nonunion management along with free vascularized grafting and induced membrane technique. However, the shortcomings and problems of these methods still remain the issues which restrict their overall use. AIM To study the recent available literature on the role of Ilizarov non-free bone plasty in long bone defect and nonunion management, its problems and the solutions to these problems in order to achieve better treatment outcomes. METHODS Three databases (PubMed, Scopus, and Web of Science) were searched for literature sources on distraction osteogenesis, free vascularized grafting and induced membrane technique used in long bone defect and nonunion treatment within a five-year period (2015-2019). Full-text clinical articles in the English language were selected for analysis only if they contained treatment results, complications and described large patient samples (not less than ten cases for congenital, post-tumor resection cases or rare conditions, and more than 20 cases for the rest). Case reports were excluded. RESULTS Fifty full-text articles and reviews on distraction osteogenesis were chosen. Thirty-five clinical studies containing large series of patients treated with this method and problems with its outcome were analyzed. It was found that distraction osteogenesis techniques provide treatment for segmental bone defects and nonunion of the lower extremity in many clinical situations, especially in complex problems. The Ilizarov techniques treat the triad of problems simultaneously (bone loss, soft-tissue loss and infection). Management of tibial defects mostly utilizes the Ilizarov circular fixator. Monolateral fixators are preferable in the femur. The use of a ring fixator is recommended in patients with an infected tibial bone gap of more than 6 cm. High rates of successful treatment were reported by the authors that ranged from 77% to 100% and depended on the pathology and the type of Ilizarov technique used. Hybrid fixation and autogenous grafting are the most applicable solutions to avoid after-frame regenerate fracture or deformity and docking site nonunion. CONCLUSION The role of Ilizarov non-free bone plasty has not lost its significance in the treatment of segmental bone defects despite the shortcomings and treatment problems encountered.
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Affiliation(s)
- Dmitry Y Borzunov
- Department of Traumatology and Orthopedics, Ural State Medical University, Ekaterinburg 620109, Russia
| | - Sergei N Kolchin
- Orthopaedic Department 4, Ilizarov National Medical Research Centre for Traumatology and Orthopaedics, Kurgan 640014, Russia
| | - Tatiana A Malkova
- Department for Medical Information and Analysis, Ilizarov National Medical Research Centre for Traumatology and Orthopaedics, Kurgan 640014, Russia
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Zhang W, Zhang Z, Chen H. [Research progress of augmentation plate for femoral shaft nonunion after intramedullary nail fixation]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:1467-1473. [PMID: 31823542 PMCID: PMC8355795 DOI: 10.7507/1002-1892.201903073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 09/23/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To review the history, current situation, and progress of augmentation plate (AP) for femoral shaft nonunion after intramedullary nail fixation. METHODS The results of the clinical studies about the AP in treatment of femoral shaft nonunion after intramedullary nail fixation in recent years were widely reviewed and analyzed. RESULTS The AP has been successfully applied to femoral shaft nonunion after intramedullary nail fixation since 1997. According to breakage of the previous nailing, AP is divided into two categories: AP with retaining the previous intramedullary nail and AP with exchanging intramedullary nail. AP is not only suitable for simple nonunion, but also for complex nonunion with severe deformity. Compared with exchanging intramedullary nail, lateral plate, and dual plate, AP has less surgical trauma, shorter healing time, higher healing rate, and faster returning to society. However, there are still some problems with the revision method, including difficulty in bicortical screw fixation, lack of anatomic plate suitable for femoral shaft nonunion, and lack of postoperative function and quality of life assessment. CONCLUSION Compared with other revision methods, AP could achieve higher fracture healing rate and better clinical prognosis for patients with femoral shaft nonunion. However, whether patients benefit from AP in terms of function and quality of life remain uncertain. Furthermore, high-quality randomized controlled clinical studies are needed to further confirm that AP are superior to the other revision fixations.
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Affiliation(s)
- Wei Zhang
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, 100853, P.R.China
| | - Zhuo Zhang
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, 100853, P.R.China
| | - Hua Chen
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, 100853,
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19
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Qasim M, Chae DS, Lee NY. Bioengineering strategies for bone and cartilage tissue regeneration using growth factors and stem cells. J Biomed Mater Res A 2019; 108:394-411. [PMID: 31618509 DOI: 10.1002/jbm.a.36817] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 10/03/2019] [Accepted: 10/10/2019] [Indexed: 12/14/2022]
Abstract
Bone and cartilage tissue engineering is an integrative approach that is inspired by the phenomena associated with wound healing. In this respect, growth factors have emerged as important moieties for the control and regulation of this process. Growth factors act as mediators and control the important physiological functions of bone regeneration. Herein, we discuss the importance of growth factors in bone and cartilage tissue engineering, their loading and delivery strategies, release kinetics, and their integration with biomaterials and stem cells to heal bone fractures. We also highlighted the role of growth factors in the determination of the bone tissue microenvironment based on the reciprocal signaling with cells and biomaterial scaffolds on which future bone and cartilage tissue engineering technologies and medical devices will be based upon.
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Affiliation(s)
- Muhammad Qasim
- Department of BioNano Technology, Gachon University, Seongnam-si, Republic of Korea
| | - Dong Sik Chae
- Department of Orthopedic Surgery, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Republic of Korea
| | - Nae Yoon Lee
- Department of BioNano Technology, Gachon University, Seongnam-si, Republic of Korea
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20
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Hierholzer C, Friederichs J, Augat P, Woltmann A, Trapp O, Bühren V, von Rüden C. [Evolution and principles of intramedullary locked nailing]. Unfallchirurg 2019; 121:239-255. [PMID: 29464295 DOI: 10.1007/s00113-018-0461-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Key factors for successful osteosynthetic fracture stabilization are anatomical fracture reduction, restoration of axis and torsion alignment as well as tissue-preserving operative techniques. In long bone fractures, the use of intramedullary long bridging nailing offers ideal conditions for bone healing, as axial and rotational stability is provided by canal-filling nails and locking screws. In addition, the tissue in the fracture region is protected as the intramedullary nail insertion is distant from the fracture. The indication spectrum for modern intramedullary locked nailing includes diaphyseal fractures of long bones, metaphyseal fractures and reconstructions, as well as treatment of nonunion, osteotomy and arthrodesis of the lower extremities. Continuous improvements in nail design and instrumentation as well as the introduction of anatomical reconstruction nails will optimize the spectrum and effectiveness of intramedullary osteosynthesis even further.
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Affiliation(s)
- C Hierholzer
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
- Klinik für Traumatologie, Universitätsspital Zürich, Zürich, Schweiz
| | - J Friederichs
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - P Augat
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
- Institut für Biomechanik, BG Unfallklinik Murnau, Murnau, Deutschland
| | - A Woltmann
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - O Trapp
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - V Bühren
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - C von Rüden
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland.
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich.
- Institut für Biomechanik, BG Unfallklinik Murnau, Murnau, Deutschland.
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Reible B, Schmidmaier G, Moghaddam A, Westhauser F. Insulin-Like Growth Factor-1 as a Possible Alternative to Bone Morphogenetic Protein-7 to Induce Osteogenic Differentiation of Human Mesenchymal Stem Cells in Vitro. Int J Mol Sci 2018; 19:ijms19061674. [PMID: 29874864 PMCID: PMC6032281 DOI: 10.3390/ijms19061674] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 06/01/2018] [Accepted: 06/02/2018] [Indexed: 12/28/2022] Open
Abstract
Growth factors and mesenchymal stem cells (MSC) support consolidation of bone defects. Bone Morphogenetic Protein-7 (BMP-7) has been used clinically and experimentally, but the outcomes remain controversial. Increased systemic expression of Insulin-like Growth Factor-1 (IGF-1) significantly correlates with successful regeneration of bone healing disorders, making IGF-1 a promising alternative to BMP-7. There is no experimental data comparing the osteoinductive potential of IGF-1 and BMP-7. Therefore, in this study, the influence of IGF-1 and BMP-7 in different concentrations on the osteogenic differentiation of two human MSC-subtypes, isolated from reaming debris (RMSC) and iliac crest bone marrow (BMSC) has been assessed. A more sensitive reaction of BMSC towards stimulation with IGF-1 in concentrations of 400–800 ng/mL was found, leading to a significantly higher degree of osteogenic differentiation compared to stimulation with BMP-7. RMSC react more sensitively to stimulation with BMP-7 compared to BMSC. Lower concentrations of IGF-1 were necessary to significantly increase osteogenic differentiation of RMSC and BMSC compared to BMP-7. Therefore, IGF-1 should be considered as a valuable option to improve osteogenic differentiation of MSC and merits further experimental consideration. The MSC subtype and method of differentiation factor application also have to be considered, as they affect the outcome of osteogenic differentiation.
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Affiliation(s)
- Bruno Reible
- HTRG-Heidelberg Trauma Research Group, Center of Orthopedics, Traumatology, and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany.
| | - Gerhard Schmidmaier
- HTRG-Heidelberg Trauma Research Group, Center of Orthopedics, Traumatology, and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany.
| | - Arash Moghaddam
- HTRG-Heidelberg Trauma Research Group, Center of Orthopedics, Traumatology, and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany.
- ATORG-Aschaffenburg Trauma and Orthopedic Research Group, Center for Trauma Surgery, Orthopedics, and Sports Medicine, Klinikum Aschaffenburg-Alzenau, Am Hasenkopf 1, 63739 Aschaffenburg, Germany.
| | - Fabian Westhauser
- HTRG-Heidelberg Trauma Research Group, Center of Orthopedics, Traumatology, and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany.
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