Publications by authors named "Peter V Giannoudis"

478 Publications

Induced membrane technique for acute bone loss and nonunion management of the tibia.

OTA Int 2022 Apr 18;5(2 Suppl):e170. Epub 2022 Apr 18.

Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds.

Objectives: To report our experience and clinical results of using the Masquelet technique for the treatment of tibial nonunions and acute traumatic tibial bone defects.

Design: Retrospective study of prospectively collected data (Level IV).

Setting: Level I trauma center in the UK.

Patients/participants: Consecutive patients with tibial nonunions and open fractures associated with bone loss.Intervention: Two-stage Masquelet Procedure for the tibia.

Main Outcome Measurements: Clinical and imaging assessment at 6 weeks, 3,6,9,12 months, or until pain-free mobilization and union.

Results: There were 17 eligible patients, with a mean size of bone defect of 6 cm (range, 4-8 cm) and an 88.2% union rate at a mean of 8 months (range 5-18 months). Mean range of motion was 95 degrees of knee flexion (range 80°-130°). All patients but 2 returned to their previous occupation.

Conclusions: The Masquelet technique is simple, effective, and has a high rate of success for the management of a variety of situations including acute bone loss or infected nonunions and is associated with a low incidence of complications.
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http://dx.doi.org/10.1097/OI9.0000000000000170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9359030PMC
April 2022

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 Jul 4;11(13). Epub 2022 Jul 4.

Department of Trauma and Orthopaedics, Patras University Hospital and Medical School, 26504 Patras, Greece.

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 (I = 60%, 95% CI = 1.59 [0.99-2.54], Z =1.93, = 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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http://dx.doi.org/10.3390/jcm11133901DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9267779PMC
July 2022

Letter to the Editor Response: 'Classification of non-union: Need for a new scoring system?'

Injury 2022 Jun 28. Epub 2022 Jun 28.

Academic Department of Trauma and Orthopaedics, Floor D, Clarendon Wing, LGI, University of Leeds, Leeds Teaching Hospitals, Leeds, UK. Electronic address:

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http://dx.doi.org/10.1016/j.injury.2022.05.003DOI Listing
June 2022

Subtrochanteric femoral fractures and intramedullary nailing complications: a comparison of two implants.

J Orthop Traumatol 2022 Jun 28;23(1):27. Epub 2022 Jun 28.

Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level D, Great George Street, Leeds, LS1 3EX, West Yorkshire, UK.

Introduction: Intramedullary (IM) nails are considered the 'gold' standard treatment for subtrochanteric femoral fractures. The incidence and risk factors for re-operation in subtrochanteric fractures remain unclear. Furthermore, no studies have compared the outcomes of different nailing systems used to treat subtrochanteric fractures in the same study population.

Aims/objectives: Our study aimed to (i) investigate the cumulative incidence and factors associated with an increased risk of re-operation in subtrochanteric fractures treated with a long intramedullary (IM) nail, (ii) compare the outcomes of subtrochanteric fractures treated with long Affixus and Gamma nails, and (iii) establish whether the addition of a proximal anti-rotation screw in the Affixus nail confers any clinical benefit.

Methods: A retrospective review of all adult patients admitted to a level 1 trauma centre with a subtrochanteric femur fracture treated with a long cephalomedullary IM nail over an 8-year period was conducted. Exclusion criteria were primary surgery performed at another institution, prophylactic nailing because of tumours, incomplete fractures, and patients who were lost to follow-up or died before fracture healing. Data variables were assessed for normality prior to determining the use of either parametric or non-parametric tests. Logistic regression analysis was performed to identify potential factors associated with re-operation. For the comparison between the two nail types, patients were matched into two groups of 119 each by age (10-year intervals), gender and mechanism of injury (low energy, high energy and pathological fractures). A p-value < 0.05 was considered significant. The Kaplan-Meier nail survival curve was used to demonstrate the survival of each nail. Data were analysed using the statistical package R (R version 3.6.0).

Results: A total of 309 subtrochanteric fractures were treated with a distally locked long IM nail (re-operation rate: 22.33%) over an 8-year period. Logistic regression identified six factors associated with an increased risk of re-operation, including age < 75 years old, use of a long Gamma nail, pre-injury coxa-vara femoral neck shaft angles, an immediate post-operative reduction angle of > 10° varus, deep wound infection and non-union. Following matching, we compared the two long cephalomedullary nailing systems used (Gamma versus Affixus nail). The only differences identified from the unadjusted analysis were a higher overall incidence of nail failure in Gamma nails due to any cause, re-operation, and impingement of the nail tip distally against the anterior femoral cortex. When we corrected for covariates, no significant differences remained evident between the two nails. From the Kaplan-Meier nail survival curves, however, the Affixus nail demonstrated better survivorship up to 5 years post-implantation in terms of nail failure and re-operation for all causes. Finally, the addition of a proximal anti-rotation screw in the Affixus nail did not seem to confer any benefit.

Conclusion: We reported a 22.3% re-operation rate in our cohort of subtrochanteric fractures treated with a long IM nail. We have identified six risk factors associated with re-operation: age < 75 years old, pre-injury femoral neck shaft angle, choice of nail, varus reduction angle, fracture-related infection and non-union. The addition of a proximal anti-rotation screw in the Affixus nail did not confer any benefit.
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http://dx.doi.org/10.1186/s10195-022-00645-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9240121PMC
June 2022

Bone defect treatment: does the type and properties of the spacer affect the induction of Masquelet membrane? Evidence today.

Eur J Trauma Emerg Surg 2022 Jun 21. Epub 2022 Jun 21.

Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals, University of Leeds, Leeds, UK.

Purpose: High clinical success rates have been reported with the Masquelet technique in the treatment of traumatic bone loss. An increasing number of studies suggest that various factors can influence the properties of induced membranes. Goal of this systematic review is to answer the following questions: (1) which are the ideal spacer properties (material, surface topography, antibiotic supplementation) to booster the quality and osteogenic potential of induced membranes? (2) what is the ideal time to perform the second-stage operation?

Methods: A systematic search using the keywords "((Masquelet) OR (Induced Periosteum)) AND ((Spacer) OR (Time))" was performed in PubMed, Embase and Cochrane Library according to PRISMA guidelines. Studies published up to the 23rd of February 2022 were included and assessed independently by two reviewers.

Results: Thirteen animal and 1 clinical studies were identified to address the above questions. Spacer materials used were PMMA, silicone, titanium, polypropylene, PVA, PCL and calcium sulfate. With the exception of PVA sponges, all solid materials could induce membranes. Low union rates have been reported with titanium and rough surfaced spacers. Scraping of the inner surface of the IM also increased bony union rates. In terms of the ideal timing to perform the second-stage evidence suggests that membranes older than 8 weeks continue to have regenerative capacities similar to younger ones.

Conclusion: Membranes induced by smooth PMMA spacers loaded with low concentrations of antibiotics showed powerful osteogenic properties. Other materials such as Polypropylene or Calcium sulfate can also be used with good results. Despite current recommendation to perform the second stage operation in 4-8 weeks, membranes older than 8 weeks seem to have similar regenerative capacities to younger ones.
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http://dx.doi.org/10.1007/s00068-022-02005-xDOI Listing
June 2022

Surgical Treatment of Marginal Impaction Injuries of The Acetabulum Associated with Posterior Wall Fractures.

JBJS Essent Surg Tech 2022 Jan-Mar;12(1). Epub 2022 Mar 3.

Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, United Kingdom.

Posterior-wall acetabular fractures have been reported to be associated with marginal impaction characteristics in approximately 16% to 38% of cases. Early recognition of this special entity of joint impaction is essential for effective preoperative planning, intraoperative execution, and favorable outcomes. The 2-level reconstruction technique is safe and effective in experienced hands.

Description: The procedure is performed with the patient under general anesthesia, placed under traction in either the prone or lateral position with use of a radiolucent flat-top fracture table and fluoroscopic guidance. The Kocher-Langenbeck approach is utilized. The big posterior wall fracture is identified and reflected in order to visualize the joint surface. Subsequently, traction is applied to facilitate visualization of the marginal impaction area(s). With use of an osteotome, the impacted fragments are disimpacted and elevated. The femoral head is utilized as a template for accurate reduction of the impacted fragments to the acetabular joint surface. The resultant subchondral void is assessed and may be grafted with use of a variety of bone graft materials. The 2-level reconstruction technique may also be considered when the surgeon desires to optimize stability of the impacted fragments and maintain anatomical reduction. The big posterior wall fragment is reduced and fixed with use of the standard posterior-wall reconstruction technique. Finally, irrigation and wound closure in layers is performed.

Alternatives: Treatment alternatives include either delayed or acute primary total hip arthroplasty in elderly patients >70 years old.

Rationale: Preoperative identification of the marginal impaction is critical because articular incongruency leads to the development of early posttraumatic osteoarthritis. Achieving joint congruency is especially important in the young population in order to avoid an otherwise unnecessary early total hip arthroplasty.

Expected Outcomes: Expected radiographic outcomes are excellent or good in 82% of cases, as measured with use of the Matta radiographic score. Expected function outcomes are good to excellent in 67.5% of patients, as measured with use of the Modified Merle d'Aubigné system. Total hip arthroplasty has been reported as a secondary procedure within 2 years postoperatively in 7.6% of patients.

Important Tips: Joint irrigation is crucial in order to clarify the details of the fragmentation and facilitate removal of debris. Impacted articular cartilage fragments are often rotated and face away from the femoral head. Utilize osteotomes to elevate the impacted area, taking care to mobilize adequate subchondral bone and the accompanying cartilage in case the 2-level reconstruction technique is needed and can be successfully applied. Utilize the femoral head as a template after traction is released to facilitate anatomical reduction. A 1.6-mm Kirschner wire should be available in case it is needed to temporarily stabilize the impacted fragments. Avoid overstuffing the void with bone graft because this may subsequently hinder successful reduction of the posterior wall fragment.

Acronyms And Abbreviations: CT = computed tomographyAP = anteroposteriorK wire = Kirschner wirePDS = polydioxanone sutureAVN = avascular necrosis.
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http://dx.doi.org/10.2106/JBJS.ST.21.00004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9173561PMC
March 2022

What's new in the management of patella fractures?

Injury 2022 06;53(6):1730-1736

Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom. Electronic address:

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http://dx.doi.org/10.1016/j.injury.2022.03.035DOI Listing
June 2022

No Benefit to Platelet-rich Plasma Over Placebo Injections in Terms of Pain or Function in Patients with Hemophilic Knee Arthritis: A Randomized Trial.

Clin Orthop Relat Res 2022 May 31. Epub 2022 May 31.

Department of Orthopedics and Sports Medicine, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China.

Background: Hemophilic knee arthritis is one of the most common presenting symptoms of hemophilia, and its management continues to be challenging to practitioners. Preliminary research has suggested that platelet-rich plasma (PRP) may have short-term efficacy in the treatment of hemophilic knee arthritis, but evidence for this treatment is limited.

Questions/purposes: What is the effectiveness of PRP compared with placebo in (1) reducing pain and improving knee joint function (as measured by WOMAC, VAS, and Hemophilia Joint Health Score [HJHS]) and (2) improving quality of life (as measured by SF-36 scores) in patients with hemophilic knee arthritis through 24 months of follow-up?

Methods: This was a prospective, parallel-group, double-blinded, single-center, placebo-controlled randomized clinical trial that included participants from a tertiary care center starting January 1, 2019, with follow-up completed on November 30, 2021. Participants were older than 18 years and had hemophilic knee arthritis confirmed by MRI, and they were randomly allocated to interventions in a 1:1 ratio. The investigators were not informed of the randomization sequence generated by the computer. Patient groups were comparable with respect to age, gender, BMI, hemophilia type, and disease severity at baseline. Physicians delivered three sessions (one per week) of a standard intraarticular injection of PRP (n = 95) or placebo (n = 95). The rate of successful blinding was balanced across the groups, which was assessed by asking participants which injection they thought they had received. The primary outcome was the WOMAC score (range 0 to 96; higher scores indicate more pain and worse function; minimum clinically important difference, 6.4 points) over 24 months. Among the 190 patients assigned to PRP or saline injections (mean age 31 ± 7 years), 100% (190) of patients were men). There was no between-group difference in the proportion of patients who completed the trial; 97% (92 of 95) of patients in the PRP group and 94% (89 of 95) of patients in the placebo group completed the trial. The most common adverse events were injection site discomfort 8% (8 of 95) in the PRP group and 4% (4 of 95) in the placebo group. An intention-to-treat analysis was planned, but there was no crossover between groups. All patients were included in the analyses. With 95 patients in each group, the study was powered a priori at 90% to detect a difference in WOMAC score of 6.4 points, which was considered a clinically important difference.

Results: There were no clinically important differences in the mean WOMAC, VAS pain, HJHS, SF-36, and MRI scores between groups at any timepoint. Intraarticular PRP did not ameliorate function, symptoms, and quality of life in patients with hemophilic knee arthritis. At 24 months of follow-up, the mean difference between the PRP and placebo groups in the WOMAC score was -1 (95% CI -5 to 2; p = 0.42). The mean difference in the VAS pain score was -0.3 (95% CI -0.8 to 0.2; p = 0.19), in the HJHS was -0.6 (95% CI -1.4 to 0.1; p = 0.10), in the SF-36 physical component summary was 0 (95% CI -2 to 3; p = 0.87), and in the SF-36 mental component summary was -1 (95% CI -3 to 2; p = 0.64). The mean differences in the MRI scores of soft tissue and osteochondral subscore were 0.1 (95% CI -0.3 to 0.5; p = 0.59) and -0.3 (95% CI -0.7 to 0.1; p = 0.19), respectively.

Conclusion: Among patients with hemophilic knee arthritis, three intraarticular PRP injections, compared with placebo injections, did not improve hemophilic knee symptoms, function, and quality of life over 24 months. The results of this study do not support the use of PRP injections in patients who have hemophilic knee arthritis.

Level Of Evidence: Level I, therapeutic study.
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http://dx.doi.org/10.1097/CORR.0000000000002264DOI Listing
May 2022

Proximal femur fractures in patients taking anti-coagulants: has anything changed?

EFORT Open Rev 2022 May 31;7(6):356-364. Epub 2022 May 31.

Academic Department of Trauma and Orthopaedics, Floor D, Clarendon Wing, LGI, University of Leeds, Leeds, UK.

With an ever-ageing population, the incidence of hip fractures is increasing worldwide. Increasing age is not just associated with increasing fractures but also increasing comorbidities and polypharmacy. Consequently, a large proportion of patients requiring hip fracture surgery (HFS) are also prescribed antiplatelet and anti-coagulant medication. There remains a clinical conundrum with regards to how such medications should affect surgery, namely with regards to anaesthetic options, timing of surgery, stopping and starting the medication as well as the need for reversal agents. Herein, we present the up-to-date evidence on HFS management in patients taking blood-thinning agents and provide a summary of recommendations based on the existing literature.
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http://dx.doi.org/10.1530/EOR-22-0028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9257726PMC
May 2022

Management and Outcomes of Bilateral Acetabular Fractures: A Critical Review of the Literature.

Indian J Orthop 2022 May 8;56(5):752-761. Epub 2022 Jan 8.

Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Floor D, Great George Street, Leeds, LS1 3EX UK.

Background: Bilateral acetabular fractures constitute a rare entity, and their optimal management is unknown.

Materials And Methods: A systematic literature search was conducted in PubMed, Embase and Cochrane Library between 1995 and 2020. Inclusion criteria were studies presenting cases of bilateral acetabular fractures and reporting outcomes. Extracted data included patient demographics, injury mechanism, fracture classification, associated injuries, management and outcomes.

Results: Thirty-seven studies (47 cases; 35 males vs 12 females) were included. Mean age was 46 years old (range 13-84) and mean follow-up was 19.8 months (range 1.5-56). High-energy injuries (49%) and seizures (45%) were the most common injury mechanisms. Fracture type distribution differed according to injury mechanism. Treatment was surgical in 70% of cases (75% open reduction and internal fixation vs 25% acute total hip arthroplasty). Outcomes were excellent/good in 58% of patients. Complications included heterotopic ossification (11%), nerve injury (11%), degenerative arthritis (6%), DVT (6%), and infection (3%).

Conclusions: Bilateral acetabular fractures most commonly occur either after trauma or seizures and are commonly managed operatively. They are not devoid of complications, however, more than half (58%) achieve complete functional recovery.
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http://dx.doi.org/10.1007/s43465-021-00593-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9043046PMC
May 2022

Neck of femur fractures treated with the femoral neck system: outcomes of one hundred and two patients and literature review.

Int Orthop 2022 Sep 11;46(9):2105-2115. Epub 2022 May 11.

Academic Department of Trauma and Orthopaedic Surgery, School of Medicine, University of Leeds, Leeds, UK.

Introduction: The recently developed femoral neck system (FNS) for treatment of femoral neck fractures (FNF), comprises theoretical biomechanical advantages compared to other implants. The aim of this study was to validate the safety and to report outcomes of patients treated with the FNS.

Method: A retrospective multicentric analysis of patients treated by FNS with a minimum of three months of follow-up. Details analysed from three medical centres were operative duration, estimated blood loss, initial hospitalisation duration, fixation quality as well as complications and reoperation rate. Patients who had revision surgery were compared to all other patients to identify risk factors for failure. In addition, a literature review was performed to analyse data on FNS clinical implementation and patient's outcomes. The two data sets were combined and analysed.

Results: One-hundred and two patients were included in this study cohort with an average follow-up of seven months (range 3-27). Ten papers were included in the literature review, reporting data on 278 patients. Overall, 380 patients were analysed. Average age was 62.6 years, 52% of the fractures were classified as Gardens 1-2. Overall, the revision rate was 9.2% (14 patients diagnosed with cut-out of implant, 10 with AVN, 8 with non-union and 8 with hardware removal). For the 102 patients in the cohort risk factors for reoperation included patients age, surgeon seniority and inadequate placement of the implant.

Conclusion: This study shows that FNS is a safe treatment option for FNF. Intra-operative parameters and failure rates are comparable to previously reported rates for this implant and other frequently used implants.
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http://dx.doi.org/10.1007/s00264-022-05414-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9372123PMC
September 2022

Has anything changed in Evidence-Based Medicine?

Injury 2022 Apr 20. Epub 2022 Apr 20.

Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, LS1 3EX, Leeds, United Kingdom; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom.

The Evidence-Based Medicine (EBM) movement, undoubtably one of the most successful movements in medicine, questions dogma and "clinical authority" and combines the "best available evidence" with clinical expertise and patient values in order to provide the best care for the individual patient. Although since its inception in the 1990s its strong theoretical foundations remain unaltered, a lot has changed in its practical implementation due to the electronic explosion of information and the unprecedented COVID-19 crisis. The purpose of this article is to succinctly provide the reader with an update on the major changes in EBM, including the important most recent ones that were "fast-tracked" due to the COVID-19 challenge.
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http://dx.doi.org/10.1016/j.injury.2022.04.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9020495PMC
April 2022

Combination of a free vascularised fibula and the Masquelet technique for long bone ulna defect reconstruction: A case report.

Trauma Case Rep 2022 Jun 7;39:100619. Epub 2022 Feb 7.

Academic Department of Trauma and Orthopaedic Surgery, University of Leeds, Leeds, UK.

We present a case of spontaneous osteomyelitis of the left ulna in a 25-year-old man. There was no history of trauma or haematogenous source identified. Bone biopsy found on culture, sensitive to flucloxacillin, but antibiotic treatment was unsuccessful. He underwent excision of the osteomyelitic ulna and a vascularised free fibula graft (VFF graft) reconstruction of the bony defect (18 cm in length), using the ulnar artery at the wrist as recipient vessel. Six months later he was found to have radiological evidence of bony resorption at the proximal fibula-ulnar junction. He underwent resection of a 5 cm segment of the fibula flap and insertion of an antibiotic-impregnated cement spacer in preparation for the placement of bone graft as per Masquelet technique. Following bone graft placement, he united 4 months later. This case demonstrates that the Masquelet technique can be used successfully as an adjunct to VFF graft when reconstructing very long bony defects.
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http://dx.doi.org/10.1016/j.tcr.2022.100619DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8924682PMC
June 2022

Ectopic bone formation causing chronic pubis symphysis pain: successful management with resection and pubic fusion.

BMJ Case Rep 2022 Mar 9;15(3). Epub 2022 Mar 9.

Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK

Chronic musculoskeletal anterior pelvic pain may originate from a variety of different sources making the diagnosis difficult. Ectopic bone formation on the pubic symphysis is extremely rare and may cause significant disability. Reported herein is the case of a very active patient with symphysis pubis ectopic bone formation causing disability for more than 10 years. Resection of the ectopic bone combined with pubis symphysis fusion led to a successful outcome allowing the patient to return to his previous recreational activities.
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http://dx.doi.org/10.1136/bcr-2021-248350DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8915318PMC
March 2022

Extra-articular Olecranon Osteotomy for Reconstruction of Distal Humerus Fractures: Technique and Clinical Results.

Orthopedics 2022 Jul-Aug;45(4):e220-e225. Epub 2022 Mar 4.

Articular fractures of the distal humerus in adults are challenging fractures requiring adequate surgical exposure for optimum reconstruction. Most commonly, an articular osteotomy of the olecranon is performed, but complications have been reported related to both creating and repairing the articular osteotomy. We describe the use of an extra-articular olecranon osteotomy for approaching articular fractures of the distal humerus. We highlight the surgical steps required to obtain adequate exposure facilitating anatomical reduction, stable fixation, and early range of motion of the elbow joint. This technique can be added to the surgeon's armamentarium for the management of these complex injuries. [. 2022;45(4):e220-e225.].
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http://dx.doi.org/10.3928/01477447-20220225-14DOI Listing
July 2022

Sciatic nerve injury after acetabular fractures: a meta-analysis of incidence and outcomes.

Eur J Trauma Emerg Surg 2022 Aug 16;48(4):2639-2654. Epub 2022 Feb 16.

Department of Orthopaedic Surgery, University Hospital of Heraklion, Crete, Greece.

Purpose: To investigate the incidence and the outcome of post-traumatic and iatrogenic sciatic nerve palsy (SNP) associated with fractures of the acetabulum. The results of sciatic nerve grafting for treatment were also investigated.

Methods: PUBMED, SCOPUS and COCHRANE databases were searched for longitudinal observational studies reporting sciatic nerve palsy related to acetabular fractures in adult patients over the last 20 years. Data regarding patients demographics, type of acetabular fracture, rate of post traumatic and iatrogenic sciatic nerve palsies as well as recovery rate are reported. Studies were assessed for their quality. Random effects meta-analyses were carried out to pool overall proportions of SNP incidence and complete recovery. Variations in SNP incidence by main study characteristics were assessed by subgroup analysis and meta-regression. A narrative review of sciatic nerve grafting was also conducted.

Results: Twenty studies reporting 44 post-operative and 18 iatrogenic SNPs in 651 patients were reviewed. The pooled incidence of posttraumatic SNP was 5.1% (95% CI 2.7-8.2%). The pooled incidence of iatrogenic SNP was 1.4% (95% CI 0.3-2.9%). Complete recovery of post-traumatic and iatrogenic SNP occurred in 64.7% (95% CI 41.7-85.4%) and 74.1% (95% CI 31.5-100%), respectively.

Conclusion: A favorable outcome of both post-traumatic and iatrogenic SNP related to acetabular fractures has been found. Due to the poor results of sciatic nerve grafting, a "wait and see" approach may be the best option, in cases of a contused but anatomically intact sciatic nerve.
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http://dx.doi.org/10.1007/s00068-022-01896-0DOI Listing
August 2022

Clinical and Radiological Outcome of Vancouver B2 Fracture Treated With Open Reduction and Internal Fixation. A Multicenter Cohort Analysis.

J Orthop Trauma 2022 Aug 11;36(8):e306-e311. Epub 2022 Feb 11.

Trauma Related Services, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom; and.

Objectives: To determine whether open reduction and internal fixation (ORIF) of periprosthetic Vancouver B2 fractures can lead to successful fracture healing in selected patients, when attention is given to the surgical exposure and the creation of a balanced extramedullary construct.

Design: Retrospective.

Setting: Two Level-1 trauma centers in Germany and United Kingdom.

Methods: Patients with a B2 fracture receiving solely ORIF using a polyaxial locking plate were included for analysis. Patients with other fracture types, or treated with other methods, or with follow-up less than 12 months were excluded. Clinical characteristics, including the Charlson index, the American Society for Anesthesiologists score, and their preinjury functional levels, were recorded. Main outcome measures were 1-year mortality, revision rate, and radiological healing according to the Beals-Tower criteria.

Results: A total of 32 patients (mean age ,79 ± 12 years) were enrolled. Six patients died within the first year (1-year mortality: 19%), and 5 were unavailable for follow-up studies. The remaining 21 patients had a mean follow-up of 30 months. Of 21, 20 had an excellent/good result using the criteria of Beals-Tower. One patient required revision surgery due to loosening and secondary subsidence of the stem.

Conclusion: ORIF can be offered to selected patients suffering from B2 fractures, especially if their functional demand is limited, and perioperative risk high for revision arthroplasty. In this challenging cohort of patients, ORIF was a safe and effective therapeutic option.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002354DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9249072PMC
August 2022

A technical note: How to extract broken Reamer-Irrigator-Aspirator (RIA) metal intramedullary debris.

Injury 2022 Apr 25;53(4):1568-1571. Epub 2022 Jan 25.

Academic Department of Trauma and Orthopaedic Surgery, School of Medicine, University of Leeds, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, Leeds LS1 3EX, United Kingdom; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom. Electronic address:

The Reamer-Irrigator-Aspirator (RIA-2) system has been established as a safe and reliable device to harvest large amounts of autograft. Nevertheless, hardware complications may occur. Breakage of the reamer head from the drive shaft with intramedullary retention of small metal debris has never been dealt with. The authors provide a technical trick as a bailout in this difficult situation.
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http://dx.doi.org/10.1016/j.injury.2022.01.039DOI Listing
April 2022

Fifth metatarsal fractures: an update on management, complications, and outcomes.

EFORT Open Rev 2022 Jan 11;7(1):13-25. Epub 2022 Jan 11.

Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK.

Even though fifth metatarsal fractures represent one of the most common injuries of the lower limb, there is no consensus regarding their classification and treatment, while the term 'Jones' fracture has been used inconsistently in the literature. In the vast majority of patients, Zone 1 fractures are treated non-operatively with good outcomes. Treatment of Zone 2 and 3 fractures remains controversial and should be individualized according to the patient's needs and the 'personality' of the fracture. If treated operatively, anatomic reduction and intramedullary fixation with a single screw, with or without biologic augmentation, remains the 'gold standard' of management; recent reports however report good outcomes with open reduction and internal fixation with specifically designed plating systems. Common surgical complications include hardware failure or irritation of the soft tissues, refracture, non-union, sural nerve injury, and chronic pain. Patients should be informed of the different treatment options and be part of the decision process, especially where time for recovery and returning to previous activities is of essence, such as in the case of high-performance, elite athletes.
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http://dx.doi.org/10.1530/EOR-21-0025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8788151PMC
January 2022

Evaluation of Human Bone Marrow Mesenchymal Stromal Cell (MSC) Functions on a Biomorphic Rattan-Wood-Derived Scaffold: A Comparison between Cultured and Uncultured MSCs.

Bioengineering (Basel) 2021 Dec 21;9(1). Epub 2021 Dec 21.

Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds LS9 7TF, UK.

The reconstruction of large bone defects requires the use of biocompatible osteoconductive scaffolds. These scaffolds are often loaded with the patient's own bone marrow (BM) cells to facilitate osteoinductivity and biological potency. Scaffolds that are naturally sourced and fabricated through biomorphic transitions of rattan wood (B-HA scaffolds) offer a unique advantage of higher mechanical strength and bioactivity. In this study, we investigated the ability of a biomorphic B-HA scaffold (B-HA) to support the attachment, survival and gene expression profile of human uncultured BM-derived mesenchymal stromal cells (BMSCs, = 6) and culture expanded MSCs (cMSCs, = 7) in comparison to a sintered, porous HA scaffold (S-HA). B-HA scaffolds supported BMSC attachment (average 98%) and their survival up to 4 weeks in culture. Flow cytometry confirmed the phenotype of cMSCs on the scaffolds. Gene expression indicated clear segregation between cMSCs and BMSCs with MSC osteogenesis- and adipogenesis-related genes including and being higher expressed in BMSCs. These data indicated a unique transcriptional signature of BMSCs that was distinct from that of cMSCs regardless of the type of scaffold or time in culture. There was no statistical difference in the expression of osteogenic genes in BMSCs or cMSCs in B-HA compared to S-HA. VEGF release from cMSCs co-cultured with human endothelial cells ( = 4) on B-HA scaffolds suggested significantly higher supernatant concentration with endothelial cells on day 14. This indicated a potential mechanism for providing vasculature to the repair area when such scaffolds are used for treating large bone defects.
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http://dx.doi.org/10.3390/bioengineering9010001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8773042PMC
December 2021

Biological and molecular profile of fracture non-union tissue: A systematic review and an update on current insights.

J Cell Mol Med 2022 02 4;26(3):601-623. Epub 2022 Jan 4.

Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds, UK.

Fracture non-union represents a common complication, seen in 5%-10% of all acute fractures. Despite the enhancement in scientific understanding and treatment methods, rates of fracture non-union remain largely unchanged over the years. This systematic review investigates the biological, molecular and genetic profiles of both (i) non-union tissue and (ii) non-union-related tissues, and the genetic predisposition to fracture non-union. This is crucially important as it could facilitate earlier identification and targeted treatment of high-risk patients, along with improving our understanding on pathophysiology of fracture non-union. Since this is an update on our previous systematic review, we searched the literature indexed in PubMed Medline; Ovid Medline; Embase; Scopus; Google Scholar; and the Cochrane Library using Medical Subject Heading (MeSH) or Title/Abstract words (non-union(s), non-union(s), human, tissue, bone morphogenic protein(s) (BMPs) and MSCs) from August 2014 (date of our previous publication) to 2 October 2021 for non-union tissue studies, whereas no date restrictions imposed on non-union-related tissue studies. Inclusion criteria of this systematic review are human studies investigating the characteristics and properties of non-union tissue and non-union-related tissues, available in full-text English language. Limitations of this systematic review are exclusion of animal studies, the heterogeneity in the definition of non-union and timing of tissue harvest seen in the included studies, and the search term MSC which may result in the exclusion of studies using historical terms such as 'osteoprogenitors' and 'skeletal stem cells'. A total of 24 studies (non-union tissue: n = 10; non-union-related tissues: n = 14) met the inclusion criteria. Soft tissue interposition, bony sclerosis of fracture ends and complete obliteration of medullary canal are commonest macroscopic appearances of non-unions. Non-union tissue colour and surrounding fluid are two important characteristics that could be used clinically to distinguish between septic and aseptic non-unions. Atrophic non-unions had a predominance of endochondral bone formation and lower cellular density, when compared against hypertrophic non-unions. Vascular tissues were present in both atrophic and hypertrophic non-unions, with no difference in vessel density between the two. Studies have found non-union tissue to contain biologically active MSCs with potential for osteoblastic, chondrogenic and adipogenic differentiation. Proliferative capacity of non-union tissue MSCs was comparable to that of bone marrow MSCs. Rates of cell senescence of non-union tissue remain inconclusive and require further investigation. There was a lower BMP expression in non-union site and absent in the extracellular matrix, with no difference observed between atrophic and hypertrophic non-unions. The reduced BMP-7 gene expression and elevated levels of its inhibitors (Chordin, Noggin and Gremlin) could potentially explain impaired bone healing observed in non-union MSCs. Expression of Dkk-1 in osteogenic medium was higher in non-union MSCs. Numerous genetic polymorphisms associated with fracture non-union have been identified, with some involving the BMP and MMP pathways. Further research is required on determining the sensitivity and specificity of molecular and genetic profiling of relevant tissues as a potential screening biomarker for fracture non-unions.
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http://dx.doi.org/10.1111/jcmm.17096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8817135PMC
February 2022

Case report: Restoration of an open 12 cm femoral defect treated with the Masquelet technique in a 20-year-old polytrauma.

Trauma Case Rep 2021 Dec 27;36:100563. Epub 2021 Nov 27.

Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom.

Infected post-traumatic femoral defects are challenging to treat, and limited options exist. The case of a 20-year-old polytrauma male who sustained a segmental femur fracture involving the femoral neck, distal femur and an intermediate diaphyseal bone defect of 12 cm is presented. The patient declined a long-term frame in his femur. The 2-stage Masquelet procedure resulted in successful outcome with limb preservation.
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http://dx.doi.org/10.1016/j.tcr.2021.100563DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8639465PMC
December 2021

Case report: Forearm infected non-united fracture managed with the Masquelet technique in a 71-year-old female patient.

Trauma Case Rep 2021 Dec 27;36:100562. Epub 2021 Nov 27.

Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom.

Infected non-union status post forearm fracture fixation is a challenge to treat and may be associated with unpredictable outcomes. The management of such a case involving a 71-year-old female suffering from Parkinson's disease is reported herein. The patient referred to our unit for a second opinion while she was under consideration for amputation at her local hospital. Utilising the two stage Masquelet technique successful limb salvage and excellent function were achieved.
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http://dx.doi.org/10.1016/j.tcr.2021.100562DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8640105PMC
December 2021

The induced membrane technique for treatment of bone defects: What have I learned?

Trauma Case Rep 2021 Dec 16;36:100556. Epub 2021 Nov 16.

Academic Department, Trauma & Orthopaedic Surgery, School of Medicine, University of Leeds, Leeds LS1 3EX, United Kingdom of Great Britain and Northern Ireland.

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http://dx.doi.org/10.1016/j.tcr.2021.100556DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8636848PMC
December 2021

Development and Validation of a Post-Operative Non-Union Risk Score for Subtrochanteric Femur Fractures.

J Clin Med 2021 Nov 29;10(23). Epub 2021 Nov 29.

Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds LS2 9LU, UK.

Background: Our objective was to develop and validate a predictive model for non-union following a subtrochanteric fracture of the femur.

Methods: Following institutional board approval, 316 consecutive patients presenting to our institution (84 non-unions) who fulfilled the inclusion criteria were retrospectively identified. To identify potential unadjusted associations with progression to non-union, simple logistic regression models were used, followed by a revised adjusted model of multiple logistic regression.

Results: Having established the risk factors for non-union, the coefficients were used to produce a risk score for predicting non-union. To identify the high-risk patients in the early post-operative period, self-dynamisation was excluded. The revised scoring system was the sum of the following: diabetes (6); deep wound infection (35); simple or severe comminution (13); presence of an atypical fracture (14); lateral cortex gap size ≥5 mm (11), varus malreduction (5-10 degrees) (9); varus malreduction (>10 degrees) (20). On the ROC (receiver operating characteristic) curve, the area under the curve (0.790) demonstrated very good discriminatory capability of the scoring system, with good calibration (Hosmer-Lemeshow test; = 0.291). Moreover, 5-fold cross validation confirmed good fit of the model and internal validity (accuracy 0.806; Kappa 0.416). The cut-point determined by Youden's formula was calculated as 18.

Conclusion: This study demonstrates that the risk of non-union can be reliably estimated in patients presenting with a subtrochanteric fracture, from the immediate post-operative period. The resulting non-union risk score can be used not only to identify the high-risk patients early, offering them appropriate consultation and in some cases surgical intervention, but also informs surgeons of the modifiable surgery related factors that contribute to this risk.
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http://dx.doi.org/10.3390/jcm10235632DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8658386PMC
November 2021

A tribute to professor Panayotis Soucacos "Takis": A great surgeon, teacher and scholar.

Injury 2021 Dec;52(12):3553-3554

Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, UK; NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK.

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http://dx.doi.org/10.1016/j.injury.2021.09.010DOI Listing
December 2021

Exchange nailing and medial wall reconstruction following implant failure in a subtrochanteric femoral fracture.

Trauma Case Rep 2021 Dec 16;36:100555. Epub 2021 Nov 16.

Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds, United Kingdom.

Failure of fixation of subtrochanteric fractures has been reported in as high as 20% of cases. Several associations have been suggested to contribute to failed fixation. Discontinuity of the medial wall/column is considered to be one of the most significant risk factors for non-union and subsequent implant failure, especially if this defect is not addressed during the revision surgery. We present a case of failed fixation of a subtrochanteric fracture in an 86-year-old female where revision surgery paid special attention to restoring the medial wall continuity via bone grafting resulting in satisfactory union of the fracture. We advocate the necessity of reconstructing the medial column in similar cases in order to enhance healing and restore the biomechanical support of the subtrochanteric region.
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http://dx.doi.org/10.1016/j.tcr.2021.100555DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8605424PMC
December 2021

Musculoskeletal infections: A call for papers to continue the battle against this devastating global challenge.

Injury 2021 Nov;52(11):3187-3188

Professor-Section Head, Trauma & Orthopaedic Surgery, School of Medicine, University of Leeds, UK.

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http://dx.doi.org/10.1016/j.injury.2021.10.006DOI Listing
November 2021

Interrelationships between the structural, spectroscopic, and antibacterial properties of nanoscale (< 50 nm) cerium oxides.

Sci Rep 2021 10 22;11(1):20875. Epub 2021 Oct 22.

School of Chemical and Process Engineering, University of Leeds, Leeds, UK.

Bone healing is a complex process, and if not managed successfully, it can lead to non-union, metal-work failure, bacterial infections, physical and psychological patient impairment. Due to the growing urgency to minimise antibiotic dependency, alternative treatment strategies, including the use of nanoparticles, have attracted significant attention. In the present study, cerium oxide nanoparticles (Ce, Ce) have been selected due to their unique antibacterial redox capability. We found the processing routes affected the agglomeration tendency, particle size distribution, antibacterial potential, and ratio of Ce:Ce valence states of the cerium oxide nanoparticles. The antibacterial efficacy of the nanoparticles in the concentration range of 50-200 µg/ml is demonstrated against Escherichia coli, Staphylococcus epidermis, and Pseudomonas aeruginosa by determining the half-maximal inhibitory concentration (IC). Cerium oxide nanoparticles containing a more significant amount of Ce ions, i.e., FRNP, exhibited 8.5 ± 1.2%, 10.5 ± 4.4%, and 13.8 ± 5.8% increased antibacterial efficacy compared with nanoparticles consisting mainly of Ce ions, i.e., nanoparticles calcined at 815 °C.
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http://dx.doi.org/10.1038/s41598-021-00222-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8536756PMC
October 2021

The Impact of Peer Support on Patient Outcomes in Adults With Physical Health Conditions: A Scoping Review.

Cureus 2021 Aug 25;13(8):e17442. Epub 2021 Aug 25.

Academic Department of Trauma and Orthopaedics, University of Leeds, Leeds, GBR.

Little is known about the impact of peer support programmes on physical health populations or on the methods used to evaluate such programmes. The present study undertakes a scoping review of research related to peer support programmes or interventions in physical health populations, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). The search was carried out across the Medline, PsycINFO, and Cochrane databases and focused on papers that evaluated peer support intervention(s) in adults with physical health conditions. The search identified an initial 7,903 records, which were narrowed down to 21 records that met the inclusion criteria; their findings were narratively synthesized. The scoping review found considerable heterogeneity among eligible records in terms of their study design, outcome measurements and findings reported. Qualitative methods of evaluation generated more consistent findings compared to objective outcome measures and suggested that peer support was beneficial for patients' health and wellbeing by reducing feelings of isolation and creating a sense of community as well as providing an opportunity for information consolidation. The scoping review highlights the inconsistencies in methods used to evaluate peer support interventions and programmes in healthcare settings among different physical health populations. It also draws attention to the lack of peer support research in particular areas, including in acute physical health populations such as in major trauma. The scoping review emphasizes the need for future studies to address this gap in peer support research.
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http://dx.doi.org/10.7759/cureus.17442DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8462539PMC
August 2021
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