Three dimensional imaging tool for early detection and follow up of the osteolytic cysts is needed. The conventional CT incorporates streak artifacts around metallic implants that make the interpretation of the images extremely unreliable. We report our preliminary experience with new 16-slice CT techniques that improve the diagnosis of osteolysis.
The infection rate for the entire group was 12%. Non-union occurred in 8%. Secondary amputation rate was 4%
With obesity on the rise in Israel, most of the medical staff will probably encounter the unique challenges that result from the pathophysiological changes in this population. Morbid obesity is a chronic disease manifesting itself in a steady and slow-progressive increase in body weight. Currently, BMI is considered the best score for morbid obesity definition and it is calculated by dividing the body weight (kgs) in body surface area (m2). The score for morbid obesity is above 40 kg/m2 and has many systemic implications such as hypertension, diabetes, cardiovascular changes, especially it effects the musculoskeletal system. Complex multiple trauma in morbid obesity patients present a challenge throughout all stages of treatment: assessment of injury, preliminary care, and definitive surgical approach. In the last two years five morbid obese patients (all weighted more than 150 kgs) sustained various degrees of high-energy multiple-trauma and were operated on in our institution. The patient presented with the following injuries:
Femoral fracture. Femoral fractures and contralateral tibial fracture. Neck of femur fracture, comminuted forearm fracture and ARDS. Pelvic fracture and ARDS. Pelvic fracture and bilateral segmental fractures of femora, bilateral patellar fractures and ARDS. The preoperative, operative and post-operative care presented special curative dilemma and pitfalls which required modifications in regular treatment modalities such as improvisation in special equipment and surgical techniques. The operating tables had to be changed so they could sustain the increased patient’s weight and allow, in the same time, modified percutaneous surgical approaches to overcome the anatomical problems. In all patients we were able to achieve the main goal of trauma treatment, i.e. stable fixation of fractures and mobilization. The experience we have gained in managing and overcoming these obstacles may serve as a basis for devising guidelines for the comprehensive treatment of these patients.
During a period of six months, 31 patients underwent different surgical procedures in which a guided wire was used for: percutaneous fixation of unstable pelvis and hip fractures (13 patients), inserting and locking of an intrameduallry nail (12 patients), inserting pedicular screws (2 patients), or removing foreign-bodies or internal fixations (4 patients). In all cases the placement of the hardware was approved by conventional fluoroscopy as well.
Severe bone loss in weight bearing bones is one of the main causes for morbidity in trauma victims. The use of guided bone regeneration in the treatment of such large defects has not yet been studied extensively. The aim of this study was to establish an accurate evaluation system, which will enable quantifying the compatibility of membranes to provide bone regeneration in a large middiaphyseal bone defect. In our longitudinal study on 16 rabbits we examined the new bone formation obtained in the vicinity of critical segmental defects (2.5 times the diameter of the bone) covered with tubular ethyl cellulose membranes. The contralateral limbs with the same bone defect served as the control group which was not treated by membranes. The healing process was followed up for eight weeks. Bone analysis of the implanted and non-implanted bone defects and adjacent tissues was performed in order to evaluate the total area and the density of the regenerated new bone at the gap area. Computerized X-ray study showed newly formed bone as early as 14 days after membrane implantation within and around the radial defect compared with a typical creation of non-union in the contra-lateral non-implanted defects. The bone formation across the gap progressed until reconstruction of the defect occurred after 6–8 weeks. A slowdown in new bone formation was evident after 6 weeks according to the measurements of area size and density of the formed bone. A parallel longitudinal histomorphological assessment of the process in the treated and non-treated bone defects was conducted. A characteristic process of osteogenic activity and new bone formation takes place inside the confined space and within the tissues around it. A typical modeling process with lytic changes in the different osteogenic fronts takes place from the second week post-implantation. These histological findings, corresponding with the radiological assessment, were summarized according to a scoring system which was constructed by the authors. The scoring was related to eight different zones which were defined within and around the osteotomy site. This rabbit model clarifies the mechanism and provides quantification of guided bone regeneration. It can serve as a means to study the accelerated bone formation using different membranes in large segmental weight bearing bone defects.
The morphological structure of the collagen, namely, the architectural structure of the material and single fibers, as shown by the SEM in various magnifications (100, 1200, 2500 and 5000), was much more similar when comparing between the control group and the microwave group than in the autoclave processed group.
Complications included 3 early and one late dislocations – one patient required an early cup revision, one patient suffered a fracture of the femur during stem insertion, and 3 patients (4%) had deep vein thrombosis. There was one case of a femoral vein injury and one resolving superficial infection. No deep infections were noted. 13 patients had undergone cup revision due to severe polyethylene wear and periacetabular osteolysis. Of them 5 were diagnosed during this retrospective study and 8 were referred for revision due to clinical symptoms. Thus the revision rate of the entire operated population is 13/162 = 8.0% and 13/75 = 17.3% of the studied patients. The true loosening rate should be between these 2 figures. In 2 patients the entire cups were removed and revised due to loosening. In 11 patients following the removal of the polyethylene inserts the metal back proved to be stable. In these cases the bone defects were filled-up with bone graft substitute, and a highly cross-linked polyethylene (22 mm head) were cemented into the metal shell. No stems needed revision.
Mesenchymal Stem Cells (MSCs) are key regulators in senile osteoporosis and in bone formation and regeneration. MSCs are therefore suitable candidates for stem cells mediated gene therapy of bone. Recombinant human Bone Morphogenetic Protein-2 (rhBMP-2) is a highly osteoinductive cytokine, promoting osteogenic differentiation of MSCs. We hypothesized that genetically engineered MSCs, expressing rhBMP2, can be utilized for targeted cell mediated gene therapy for local and systemic bone disorders and for bone/cartilage tissue engineering. Engineered MSCs expressing rhBMP-2 have both autocrine and paracrine effects enabling the engineered cells to actively participate in bone formation. We conditionally expressed rhBMP2 (tet-controlled gene expression, tet-off system) in mouse and human mesenchymal stem cells. RhBMP2 expressing clones (tet-off and adeno-BMP2 infected MSCs), spontaneously differentiated into osteogenic cells in vitro and in vivo. Engineered MSCs were transplanted locally and tracked in vivo in radial segmental defects (regenerating site) and in ectopic muscular and subcutaneous sites (non-regenerating sites). In vitro and in vivo analysis revealed rhBMP2 expression and function, confirmed by RT-PCR, ELISA, western blot, immunohistochemistry and bioassays. Secretion of rhBMP2 in vitro was controlled by tetracycline and resulted in secretion of 1231 ng/24 hours/106 cells. Quantitative Micro-CT 3-Dimentional reconstruction revealed complete bone regeneration regulated by tetracycline in vivo, indicating the potential of this platform for bone and cartilage tissue engineering. Angiogenesis, a crucial element in tissue engineering, was increased by 10-folds in transplants of rhBMP2 expressing MSCs (tet-off), shown by histomorphometry and MRI analysis (p<
0.05). In order to establish a gene therapy platform for systemic bone disorders, MSCs with tet-controlled rhBMP-2 expression, were injected systemically (iv). These engineered MSCs were genetically modified in order to achieve homing to the bone marrow. Systemic non invasive tracking of engineered MSCs was achieved by recording topographical bioluminescence derived from luciferase expression detected by a coupled charged CCD imaging camera. For clinical situations that require immuno-isolation of transplanted cells, we developed an additional platform utilizing cell encapsulation technique. Immuno-isolated engineered MSCs, with tet-controlled rhBMP-2 expression, encapsulated with sodium alginate induced bone formation by paracrine effect of secreted rhBMP-2. Finally, we have characterized a novel tissue-engineering platform composed of engineered MSCs and biodegradable polymeric scaffolds, creating a 3D bone tissue in rotating Bioreactors. Our results indicate that engineered MSCs and polymeric scaffolds can be utilized for ex vivo bone tissue engineering. We therefore conclude that genetically engineered MSCs expressing rhBMP-2 under tetracycline control are applicable for: a) local and systemic gene therapy to bone, and b) bone tissue engineering. Our studies should lead to the creation of gene therapy platforms for systemic and local bone diseases in humans and bone/cartilage tissue engineering.
During a period of six months, 31 patients underwent different surgical procedures in which a guided wire was used for: percutaneous fixation of unstable pelvis and hip fractures (13 patients), inserting and locking of an intrameduallry nail (12 patients), inserting pedicular screws (2 patients), or removing foreign-bodies or internal fixations (4 patients). In all cases the placement of the hardware was approved by conventional fluoroscopy as well.