It is difficult to predict the future of any major technology. Nanotechnology is a science that deals with the research and development of materials and devices at the atomic or molecular level. Almost every aspect of human life will be influenced by future nanotechnologies. With the advancement in the technology, it is also getting incorporated in various medical fields including dentistry (nanodentistry). Though it is relatively new in dentistry, there is ever growing interest in application of nanodentistry both in the development of materials and devices.
Abstract Introduction Soft/dynamic braces today are used all over the world under the name of SpineCor. The marketing concept is very effective in promoting the soft brace as the first and only ‘dynamic’ brace. A short review has been undertaken, investigating the history of dynamic braces and devices available today. Short communication The use of soft braces to treat scoliosis has been documented by Schanz as early as 1904. In his book, various soft and hard braces with soft addons are described as state of the art in the nineteenth century. Many of these soft braces were developed by Fischer. Today, shortcomings of the dynamic brace have been revealed in literature in comparison with hard braces; however, the concept of improving the quality of life while under brace treatment should be considered further. The purpose of this review is to highlight the history of soft braces and to present recent developments. Conclusion There is more than one soft brace used today and the history of soft bracing is long (over 120 years). Claims made by a company to distribute the first and only soft/dynamic brace may be misleading.
Introduction Non-union of femur fracture is a known complication, managed by various methods, including exchange nailing. Additional bone grafting is known to enhance fracture healing. Percutaneous bone grafting has been reported for tibia and humerus in the literature. The authors report a series of aseptic non-union of the femoral shaft managed by exchange nailing, supplemented with percutaneous reamer debris grafting. Materials and methods Our purpose was to deliver more vital osteoblasts to the fracture gap through a percutaneous route. The reamer debris, which accumulated at the proximal entry point and collected from the reamer flutes, was percuta-neously delivered into the non-union site, after disturbing the fibrous tissue around the fracture. This study analysed the management of aseptic non-union of five cases of aseptic non-union of the femur in adults. Results The fracture was found healed when there was bony continuity in at least three cortices and the patient was able to bear weight without pain. Conclusion We achieved sound union in all five cases of aseptic non-union of the femur with our technique of exchange nailing with percutaneous bone grafting.
Introduction Osteogenesis imperfecta (OI) is a human genetic disorder of increased bone fragility and low bone mass. Severity varies widely, ranging from intrauterine fractures and perinatal lethality to very mild forms without fractures. There is variable association of typical extra skeletal manifestations with the disorder, including blue sclera, dentinogenesis imperfecta, hyperlaxity of ligaments and skin, hearing impairment and the presence of Wormian bones on skull radiography1. The most widely used classification of OI distinguished four clinical types2. The most relevant clinical characteristic of all OI t-ypes is bone fragility, the severity of which increases in the order type I < type IV < type III < type II. It is now w-idely recognized that there may be m-any more types of OI than those class-ified by Sillence et al. Some forms of congenital brittle bones have been considered OI and have been added as types V, VI and VII3–5. There is still no perfect consensus about the definition of OI. Plotkin recently proposed defining OI as syndromes resulting from mutations in either COL1A1 or COL1A2 genes, and to group all other syndromes with congenital brittle bones as ‘syndromes resembling OI (SROI)’, pending the identification of their causal mutations6. In the new Nosology and Classification of the Genetic Skeletal disorders7, OI is declined in several forms depending on the severity of the phenotype, whatever the mode of the transmission or the gene involved. We first review the genetic mutations implicated in the eight different types of OI, then, the craniofacial consequences of OI mutations are summarized. * Corresponding author Email: mgoldberg.goldberg004@gmail.com
Introduction Sickle cell disease is the most common molecular disease. The sickling of the haemoglobin S followed by micro-vascular occlusion leads to complications observable in several tissues. Osteoarticular complications represent the most frequent pattern of hospitalization of children with sickle cell disease. This review discusses osteoarticular complications of sickle cell disease in children. Materials and methods This study is a review concerning children <15 years of age. Phenotypes retained are SS, SC and AS, with or without thalassaemia or foetal haemoglobin. Osteomyelitis, arthritis and osteonecrosis are included. Ficat’s classification was used for osteonecrosis of femoral head. Discussion Osteomyelitis is the most frequent complication. It is classically due mainly to salmonella species, but currently, several studies have found other micro-organisms (Staphylococcus aureus, Streptococcus pneumonia, klebsiella). Multiple sites are affected at the same time. Long bones are the most affected and according to studies, the most frequent are the humerus, the tibia or the femur. Delay to diagnosis often leads to chronic osteomyelitis, with a high risk of orthopaedic sequela. Arthritis can affect all joints. Also due to salmonella and S. aureus, they can have multiple locations. The hip and knee are the favoured sites. Inadequate treatment can result in the destruction of the joints. Avascular osteonecrosis occurs later, after the age of 10. Their evolution is progressive and insidious, explaining the late diagnosis. Osteonecrosis of the femoral head is the most frequent, and poses the problem of hip arthroplasty in children. Conclusion The osteoarticular complications must be hunted in children with sickle cell disease in order to diagnose them early. A quick and efficient treatment enables to avoid serious orthopaedic sequela.
INTRODUCTIONOsteoporotic fractures are a vital public health concern and have created a great economic burden to our society. Therefore, early diagnosis of patients with high risk of osteoporotic fractures is essential. The current gold standard for assessment of fracture risk is the measurement of bone mineral density using dual-energy X-ray absorptiometry. However, such techniques are not very effective in the diagnosis of patients with osteopaenia. Doctors are usually unable to make an informed decision regarding the treatment plan of these patients. In addition to bone mineral density, advanced imaging modalities have been explored in recent years to assess bone quality in other contributing factors, such as microarchitecture of trabecular bone, mineralisation, microdamage and bone remodelling rates. Currently, the microarchitecture of trabecular bone can be evaluated in vivo by high-resolution peripheral quantitative computed tomography techniques, which have a resolution of 80 µm. However, such imaging techniques still remain a high-end research tool rather than a diagnostic tool for clinical applications. Thus, the limited accessibility and affordability of high-resolution peripheral quantitative computed tomography have become major concerns for the general public. Alternatively, combining bone mineral density measurements with stochastic assessments of spatial bone mineral density distribution from dual-energy X-ray absorptiometry images may offer an economic and efficient approach to non-invasively evaluate skeletal integrity and identify the at-risk population for osteoporotic fractures. The aim of this critical review is to assess bone fragility with clinical imaging modalities.CONCLUSIONHigh-resolution quantitative computed tomography imaging technique may provide direct measurements of microarchitectures of trabecular bone in vivo. However, it is an expensive method of imaging modality.
Algorithms for operative treatment of symptomatic chondral lesions vary, but guidelines for choosing between currently available treatments have been offered4,5. These include evaluation and treatment of any associated joint pathologies including systemic disorders, limb malalignment, meniscal deficiency and ligamentous instability. A thorough assessment of the size, thickness and location of the chondral lesion is also required. Based on lesion and patient characteristics, a treatment strategy is chosen. In current practice, this typically includes one of the following options: simple debridement, microfracture, osteochondral autograft or allograft transplantation or cell-based therapy such as autologous chondrocyte implantation (ACI). Each of these strategies has relative merits and limitations, but no currently available technique meets all requirements for an ‘ideal’ treatment option. As described by Gomoll and Farr, an ideal cartilage repair technique would be (1) cost-efficient, (2) easily available or of-the-shelf, (3) implantable through a single-stage, minimally invasive technique, (4) produce physiologically stratified, fully integrated (basilar and marginal) hyaline repair tissue and (5) allow for quick return to activity6. While current options–with varying degrees of efficacy–may ameliorate symptoms, the broader goal of restoring a durable, smooth, hyaline tissue that effectively transmits shear and compressive loads from the cartilage to the bone remains elusive7. A recapitulation of the multilayered nature of hyaline cartilage, including * Corresponding author: Email: David.Flanigan@osumc.edu
Areal bone mineral density is commonly categorised into normal bone mineral density, osteopaenia and osteoporosis on the basis of nominal thresholds recommended by the World Health Organization. However, bone mineral density is a continuous variable and there is a strong association between lower bone mineral density and greater risk for fracture. Fracture risk is not negligible in persons with moderate deficits in bone mineral density. Although absolute fracture risk is greatest for individuals with osteoporosis, more than half of the fractures arise from those with osteopaenia, and even normal bone mineral density, a probable consequence of greater numbers of individuals at risk in these categories. However, areal bone mineral density measurements used commonly in clinical practice do not detect differences in bone tissue properties, geometry and microarchitecture, which contribute to bone strength. Newer technologies such as high-resolution peripheral computed tomography have the advantage of assessing trabecular and cortical components of bone separately, in addition to geometric characteristics of the skeleton. Quantifying these parameters and considering clinical risk factors that affect fracture risk independent of bone quantity and quality, may better discriminate between high- and lowrisk individuals. This would improve the decision-making for targeting appropriate interventions, either lifestyle or medication, to reduce the public health burden of fractures.
Introduction Recently, a paper was published containing the long-term results of the first ‘modern’ double rod instrumentation, the Cotrel–Dubousset instrumentation. Results showed an unexpected high rate of reoperation of nearly 50% due to late infections or chronic back pain occurring after surgery. Further research into the longterm complications of spinal fusion surgery in adolescent idiopathic scoliosis (AIS) patients is necessary, with special attention to more recent instrumentations. This critical review discusses risks and long-term complications of AIS surgery versus nonsurgical and natural history outcomes. Materials and methods The previous systematic review on long-term complications, as they might develop over a lifetime, was published in 2008. The first author conducted a PubMed search to locate additional studies related to longterm outcomes of AIS surgical complications published after August 2008. Target publications were prospective or retrospective papers on complications in spinal fusion surgery for AIS with a minimum followup of 10 years and prospective or retrospective papers on reoperation rates in spinal fusion surgery for AIS with a minimum follow-up of 10 years. Results No paper with the topic on complications and a long-term follow-up of at least 10 years was found. Two papers were found with the topic of reoperation rates and a long-term followup of at least 10 years. Reoperation rates were reported between 12.9% and 47.5%. Discussion In the relatively benign population of AIS patients, according to the findings within this review, it may be concluded that the long-term outcome of surgery for AIS is worse than the long-term consequences of the condition itself. Conclusion A medical indication for AIS spinal fusion surgery does not exist, except in extreme cases. The rate of complications of spinal fusion surgery appears to increase with time. The risk/reward relationship of spinal fusion surgery is unfavourable for the AIS patient, except in rare cases. There is no evidence that spinal fusion surgery improves quality of life for AIS patients versus natural history. The risks and long-term costs, in terms of pain and suffering, after spinal fusion surgery exceeds what is reasonable for AIS patients, putting the common practice of surgery in question, except in extreme cases.
Introduction The management of periprosthetic fractures is challenging and is guided by the configuration of the fracture, stability of implants and quality of the patient’s bone. This case report discusses the long-term fate of femoral allograft for periprosthetic fracture around a revision knee arthroplasty. Case report We present the operative technique and long-term fate of a bivalved femoral allograft used for the treatment of a periprosthetic fracture around a stemmed femoral component of a revision total knee arthroplasty (TKA) in a patient with rheumatoid arthritis and osteoporosis. Regular radiographic follow-up confirmed incorporation and docking of the allograft. A subsequent ipsilateral femoral neck fracture 4 years after allograft implantation was treated with routine total hip replacement. Conclusion The use of femoral allograft for augmenting fixation of periprosthetic fractures above a TKA is not widely reported, and, at 11 years, this case represents the longest published follow-up above a revision TKA. Our case supports the use of a bivalved total femoral allograft in the treatment of long-bone periprosthetic fractures with poor bone stock. Introduction Data from joint registries indicate an increase in the number of primary and revision knee arthroplasties being performed each year internationally, and the volume of revision knee arthroplasty being performed in the USA alone is expected to increase by 601% between 2005 and 20301. Periprosthetic supracondylar femoral fractures can occur intraoperatively and postoperatively, with an overall incidence of 0.3–2.5% above primary total knee arthroplasties (TKAs)2–7. Estimates of the incidence after revision knee arthroplasty vary greatly from 1.7% to 38%3,6–8, with most reports quoting closer to 2%. Periprosthetic femoral fractures above TKA and revision TKA have historically been associated with high complication rates when treated nonoperatively or with internal fixation4,5,9. Periprosthetic fractures are more common in the elderly population and in females7. Additional risk factors include rheumatoid arthritis, chronic steroid treatment, reduced bone stock, neurological disorders, revision surgery, notching of the anterior cortex of the femur, and in particular poor bone stock3,9–11. Primary osteopenia or secondary to stress shielding around a stemmed revision femoral component further increases the difficulty of achieving good fracture fixation by traditional methods. Whilst the introduction of locked plate technology has revolutionized surgery in the presence of osteoporotic bone12, the use of a combination of cortical femoral allograft and compression plate13 or a bivalved total femoral allograft5,14 may be indicated when a periprosthetic fracture around a well-fixed implant is complicated by deficient bone stock or significant comminution. Unfortunately, there remains insufficient evidence to strongly support the use of a single method of surgical treatment in this complex fracture group. In this case report, we aim to provide further evidence that a bivalved total femoral allograft can be successfully used in the treatment of periprosthetic femoral fractures above/around a well-fixed stemmed revision TKA and that incorporation of the graft with the host femur is possible thereby increasing the patient’s bone stock. This technique can provide a reliable long-term solution in this complex fracture group. Case report One month after primary TKA for valgus arthritis, a 60-year-old lady with polyarticular rheumatoid arthritis and severe osteoporosis re-presented with a sintering fracture of the lateral femoral condyle after a simple stumble. The femoral component was revised to an uncemented stemmed implant, and the lateral femoral condyle was reconstructed with femoral head structural allograft. Three months after discharge, she fell and sustained a spiral periprosthetic fracture around the femoral stem (Figure 1). * Corresponding author Email: gavin.macpherson@nhs.net 1 Department of Orthopaedic Surgery, The Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK 2 Stiftung Orthopadische Universitatsklinik, Schlierbacher Landstrase 200a, 69118 Heidelberg, Germany 3 Orthopadischen Klinik Paulinenhilfe, Diakonie Klinikum Stuttgart, Rosenbergstrasse 38, D-70176 Stuttgart, Germany 4 Endoklinik Hamburg, Holstenstr. 2, 22767 Hamburg, Germany
Introduction Treatment of musculoskeletal injuries is still demanding, because most of these tissues have low healing capability and are under different forces during healing and regeneration. Tissue engineering is one of the new approaches aimed to solve these difficulties. Simply, tissue engineering could be divided into three parts: scaffolds, healing promotive factors and stem cells. Healing promotive factors such as growth factors and a wide variety of glycosaminoglycans have major roles in the healing process of connective tissues; however, most of the tissue-engineered products are expensive and may not be available at the time of treatment. Synovial fluid is an available option, and it contains different healing promotive factors mainly glycosaminoglycans and lubricin. The major glycosaminoglycans that have been found in synovial fluid of different species are hyaluronic acid and chondroitin sulphate that have been shown to be effective in reducing peritendinous adhesion and inflammation. They also can modulate different stages of wound healing by motivating the healing cells to deposit more matrix and collagen fibres and have some antioxidant and protective effects, which promote efficient wound healing. This review has focused on the roles of these glycosaminoglycans on different musculoskeletal injuries in vitro, in vivo and in clinical situations. Due to the availability of hyaluronic acid and chondroitin sulphate in normal synovial fluid, it is reasonable to suggest the synovial fluid as a new treatment strategy in musculoskeletal medicine and surgery. Synovial fluid can be obtained from auto-, allo- and xenogeneic bases. The xenogeneicbased synovial fluid is more available than the other two forms. It is recommended to make some processing such as acellularization, sterilization and purification before application of the synovial fluid. Based on this evidence, it seems the exogenous synovial fluid could be considered as a popular therapeutic agent in the near future. The aim of this review was to discuss exogenous synovial fluid as a new option in tissue engineering. Conclusion Glycosaminoglycans such as hyaluronic acid and chondroitin sulphate make up the synovial fluid. Hyaluronic acid is beneficial in reducing peritendinous adhesion and signs of osteoarthrosis and in improving bone tunnel healing, tendon and bone regeneration. Exogenous synovial fluid looks to be a good method of providing glycosaminoglycans to the site of injury. We call on further studies to increase our understanding of synovial fluid and the effectiveness of its compounds in different injured tissues.
A 47-year-old female of African origin, presented with history of a growing lump on the sole of her right foot. She normally lives in the UK, but has been visiting an African country in the last few years. Physical examination showed an isolated nodular lesion on the sole of her right foot, at the instep with intact skin, and no sinus formation. The working diagnosis was a plantar fibroma. The patient was otherwise fit and well and was not on steroids or other medications. Physical examination revealed an isolated lump on the sole of her foot, with no other findings. Differential diagnoses considered include plantar fibroma, inter-metatarsal neuroma, subcutaneous lipoma, plantar fasciitis, aspergillosis, ganglion and warts among others. She had Ultrasound and later excision biopsy followed by histology which confirmed fungal Mycetoma. She made a recovery without any additional treatment and had no recurrence after two years of follow-up.
Introduction The subacromial impingement syndrome is a common cause of shoulder pain; it involves the soft tissue compromising the subacromial space. Impingement arises from mechanical compression of the rotator cuff centred primarily on the supraspinatus tendon insertion onto the greater tuberosity against the undersurface of the anterior edge of the acromion. The aetiology of this condition has been debated over the last few decades. Nevertheless, nowadays, many authors consider that this condition is multifactorial. Management includes physical therapy, injections and surgery in some selected patients. This article aims to provide an overview of the nature and pathogenesis of subacromial impingement syndromes, the widely accepted management modalities and the efficiency of the surgical intervention based on other studies. Conclusion We recommend arthroscopic subacromial decompression as it has less surgical morbidities and it allows direct evaluation of the glenohumeral joint and the integrity of the rotator cuff. Subacromial impingement syndrome: review article
Introduction In fractures, electrical properties are generated by the piezoelectric effect and cellular activity, initiate and augment healing. Monitoring these can result in the development a diagnostic tool for diagnosing delayed and early non-union of bones and may enable the clinician to change the line of treatment for decreasing the suffering time of the patient. This article summarizes 12 studies related to the electrical properties of bones for the monitoring of fracture healing. Materials and methods This experience has been used to develop a methodology comprising insulated fixators and measurement of electrical properties by an LCR (inductance, resistance and capacitance) meter at King George’s Medical University (KGMU). Inductance, conductance and impedance of the fractured and normal segments of fractured human tibia were monitored. Results Prospective data analysis was performed; this showed large variances. The patients were then stratified into two groups: (i) delayed union and (ii) normal union in a blinded manner. Analysis of data ensuring blinding was done separately. Conclusion Electrical properties are highly dependent on bone mineral density, temperature, structure and cross-sectional area of the bone. Skin and soft tissue are responsible for masking the electrical signals from bones measured in vivo. Therefore, at KGMU, insulated fixators were designed to prevent short circuit by rods and enable measurement from nothing else but the bone. Electrical properties of bones, can be used as a biomarker for monitoring fracture healing.
Introduction Epidemiological studies have shown that the incidence of fragility fractures of the pelvis in the elderly population is increasing due to ageing. These fractures are often classified as stable and managed predominantly by medical teams. Aggressive surgical management of the neck of femur fractures has resulted in reduced morbidity and mortality in patients. There are no evidence-based guidelines for managing fragility fractures of the pelvis. Our aim was to review the literature and compare operative versus non-operative management of fragility fractures of the pelvis. Materials and Methods Based on the published results, we question whether these fractures have a significant morbidity and mortality to warrant a change in management. We questioned whether the posterior ring should be routinely imaged, which patient groups may benefit from operative intervention, what techniques are available to provide pain relief and to enable full weight bearing to support early mobilisation versus an aesthetic risk and complications of surgery. Results Differences in healthcare systems, rehabilitative provision and social support among hospitals make comparisons between retrospective studies difficult. Conclusion Performing randomised controlled trials to develop evidence-based protocols can reduce the morbidity and mortality in the elderly with fragility fractures of the pelvis. Introduction An increase in the elderly population has resulted in an increased prevalence of fragility fractures of the pelvis1–3. An epidemiological study has found that in the past 12 years, the number of predominantly low energy pelvic fracture admissions in patients aged over 50 years has increased by 58.4% and 110.8% in males and females, respectively4. In past, majority of the patients with fragility pelvic fractures were conservatively managed, often by medical teams, as their immobility resulted in medical complications such as pressure sores, chest infections, urinary tract infections and venous thromboembolism5,6. There have been many studies demonstrating a lower mortality and morbidity with early aggressive surgical management of neck of femur fractures when compared with delayed or conservative management7,8. Treatment facilitating pain relief, early unrestricted mobilisation and an aim of returning patients to pre-injury level of care also has implications in reducing the burden on limited healthcare resources. The British Orthopaedic Association and British Geriatric Society published the Blue Book9 in 2007 to guide the management of these patients and emphasising the role of the Orthogeriatric team. This has been coupled with financial incentives from the best practice tariff10 and monitoring via the National Hip Fracture Database11. Despite the similarities with neck of femur fractures, there are no guidelines regarding the management of fragility fractures of the pelvis. Our aim was to review the literature and compare the morbidity and mortality of operative fixation versus non-operative management of fragility fractures of the pelvis. We investigated the functional outcomes and complications. Using the published results, we questioned whether early aggressive management of pelvic fractures could reduce the mortality and morbidity in elderly patients? Is there evidence to suggest which patient groups may benefit from operative intervention and what techniques are available? Materials and Methods MEDLINE and EMBASE databases were searched on 2nd January 2013 using the following search terms: ‘pelvic fracture’, ‘elderly’, ‘pubic rami’, ‘sacral insufficiency’, ‘fragility’, ‘fall’ and ‘low velocity’. References from the literature, including all relevant studies, were screened to find other studies for inclusion in this review. Biomechanical studies, cadaveric studies, literature reviews, letters to the editor, radiological studies, those not pertaining to management of fractures and studies pertaining to patients under the age of 65 years were excluded. All details including mechanism and velocity of injury, age, treatment, complications, duration of follow-up and outcomes were recorded. Results In literature, two prospective case series have been reported; the evidence is otherwise limited to retrospective case series. Overall, the level of evidence is weak with no randomised controlled trials comparing operative with non-operative management. * Corresponding authors Emails: ben_quansah@yahoo.co.uk john.stammers@nhs.net 1 Royal London Pelvic Unit, Royal London Hospital, United Kingdom 2 Care of the Elderly Department, Royal London Hospital, United Kingdom Tr au m a & Or th op ae di cs
resolution (~0.100–0.200 mm) have been developed that can capture some aspects of bone micro-architecture. Alternatively 3D models created using clinical-CT and MRI can be used to virtually simulate loading on a computer and calculate bone mechanical properties. Analysed together these morphological and mechanical data sets might allow clinicians to provide screening programmes for osteoporosis and calculate individual fracture risk. Especially if applied as part of a holistic approach utilising patient meta-data on risk factors for metabolic bone disease (e.g. FRAX). As well as improve primary and secondary care by setting treat to target criteria for pharmacological therapies and planning surgical interventions or following up treatment outcomes. Conclusion In the short to mid term the expense of 3D imaging and (in the case of CT) the risks associated with ionising radiation are going to restrict image resolution. Therefore, in order to achieve the goal of bringing bone quality from bench to bedside, future research needs to be directed towards better analysis of 3D bone geometry at sub-optimal resolution.
exist. This review suggests that the positive effects of platelet-rich plasma were less significant in clinical trials compared with the in vitro and in vivo experimental studies; therefore, it should be highlighted that platelet-rich plasma should not be considered as the first line of treatment in clinics because there is still a lack of evidence demonstrating that the administration of plateletrich plasma is an effective method to restore the quality and integrity of the injured tissues. Conclusion Platelet-rich plasma has some beneficial effects, especially at preclinical level. Most in vitro and in vivo animal studies used allologous forms of platelet-rich plasma, and the results confirmed the efficacy of platelet-rich plasma in soft and hard connective tissue healing in different animal species. In general, platelet-rich plasma is an effective conservative treatment without the complications and cost of surgery, and with moderate success of resolving various musculoskeletal conditions; however, it should not be placed in the first line of treatment modality because it is almost effective in the short term. Future clinical trial studies should be designed to test the real efficacy of platelet-rich plasma in a more standard manner.
