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      Bone grafting via reamer-irrigator-aspirator for nonunion of open Gustilo-Anderson type III tibial fractures treated with multiplanar external fixator

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      SICOT-J
      EDP Sciences
      Tibial nonunion, Open tibial fracture, Reamer-irrigator-aspirator, External fixator

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          Abstract

          Introduction: The purpose of this investigation was to evaluate the outcomes following reamer-irrigator-aspirator (RIA) autogenous bone grafting (ABG) of high-grade open tibia fracture nonunions stabilized via multiplanar external fixation.

          Methods: We retrospectively reviewed all patients with Gustilo-Anderson type III open tibia fractures treated with multiplanar external fixation and who underwent RIA ABG for nonunion at our institutional Level 1 Trauma Center between 2008 and 2015. All patients between 15 and 65 years of age with a minimum of six-month follow-up were included. The primary outcomes of interest were achievement of union, time to union, and incidence of revision surgery. Complications and all-cause reoperation were recorded as secondary endpoints.

          Results: Fifteen patients met the inclusion criteria with a mean age of 41.1 ± 14.0 years. RIA ABG was harvested from the femur in all cases, with a mean volume of 34 ± 15 mL. At an average follow-up of 13.3 ± 6.8 months, all patients achieved union, including two who required repeat RIA ABG. One patient experienced a femoral shaft fracture four months following RIA that required intramedullary fixation. The average time to union was 6.0 ± 6.3 months. Twelve patients (80%) went on to union within six months and 13 (86.7%) within one year. Five patients experienced a total of six post-operative complications including three deep infections, one refracture through the nonunion site, and one gradual varus deformity. Two patients in this series required a subsequent RIA autografting procedure secondary to persistent nonunion despite initial RIA.

          Conclusion: We found that RIA ABG offered a reliable solution to nonunion of Gustilo-Anderson type III open tibial fractures treated with multiplanar external fixation, circumventing the need to change the method of fixation.

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          Most cited references26

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          Isolation and characterization of bone marrow multipotential mesenchymal progenitor cells.

          There is an increased interest in rheumatology in mesenchymal progenitor/stem cells (MPCs) and their roles in rheumatic diseases, but little is known about the phenotype of these cells in vivo. The aim of this study was to isolate and characterize human bone marrow (BM) MPCs. Fluorescence microscopy was used to identify putative MPCs among adherent BM cells. To purify them, a positive selection with antifibroblast microbeads was used, combined with fluorescence-activated cell sorting (FACS) for microbead+,CD45(low) cells. A more detailed phenotype of these cells was determined using 4-color flow cytometry, and standard chondrogenic, osteogenic, and adipogenic assays were used to investigate their differentiation potentials. Putative MPCs microscopically identified as large, fibroblast-like, D7-FIB+ cells were purified using positive selection with D7-FIB-conjugated (antifibroblast) microbeads followed by FACS for specifically bound microbead+,CD45(low) cells. These cells represented 0.01% of mononuclear cells in the BM. They were uniformly positive for CD105, LNGFR, HLA-DR, CD10, CD13, CD90, STRO-1, and bone morphogenetic protein receptor type IA (BMPRIA) and were negative for CD14, CD34, CD117, and CD133. Only cells with this phenotype could proliferate and produce adherent cell monolayers capable of chondrogenic, osteogenic, and adipogenic differentiation. D7-FIB- cells in the BM lacked any MPC activity. Uncultured skin fibroblasts had a phenotype similar to that of BM MPCs, but were negative for LNGFR, STRO-1, HLA-DR, and BMPRIA. This study shows the distinct phenotype, morphology, and method of isolation of BM MPCs. The findings may have implications for defining the physiologic roles of MPCs in arthritis, bone diseases, and joint regeneration.
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            Characterization of human bone marrow fibroblast colony-forming cells (CFU-F) and their progeny.

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              Tibia shaft fractures: costly burden of nonunions

              Background Tibia shaft fractures (TSF) are common for men and women and cause substantial morbidity, healthcare use, and costs. The impact of nonunions on healthcare use and costs is poorly described. Our goal was to investigate patient characteristics and healthcare use and costs associated with TSF in patients with and without nonunion. Methods We retrospectively analyzed medical claims in large U.S. managed care claims databases (Thomson Reuters MarketScan®, 16 million lives). We studied patients ≥ 18 years old with a TSF diagnosis (ICD-9 codes: 823.20, 823.22, 823.30, 823.32) in 2006 with continuous pharmaceutical and medical benefit enrollment 1 year prior and 2 years post-fracture. Nonunion was defined by ICD-9 code 733.82 (after the TSF date). Results Among the 853 patients with TSF, 99 (12%) had nonunion. Patients with nonunion had more comorbidities (30 vs. 21, pre-fracture) and were more likely to have their TSF open (87% vs. 70%) than those without nonunion. Patients with nonunion were more likely to have additional fractures during the 2-year follow-up (of lower limb [88.9% vs. 69.5%, P < 0.001], spine or trunk [16.2% vs. 7.2%, P = 0.002], and skull [5.1% vs. 1.3%, P = 0.008]) than those without nonunion. Nonunion patients were more likely to use various types of surgical care, inpatient care (tibia and non-tibia related: 65% vs. 40%, P < 0.001) and outpatient physical therapy (tibia-related: 60% vs. 42%, P < 0.001) than those without nonunion. All categories of care (except emergency room costs) were more expensive in nonunion patients than in those without nonunion: median total care cost $25,556 vs. $11,686, P < 0.001. Nonunion patients were much more likely to be prescribed pain medications (99% vs. 92%, P = 0.009), especially strong opioids (90% vs. 76.4%, P = 0.002) and had longer length of opioid therapy (5.4 months vs. 2.8 months, P < 0.001) than patients without nonunion. Tibia fracture patterns in men differed from those in women. Conclusions Nonunions in TSF’s are associated with substantial healthcare resource use, common use of strong opioids, and high per-patient costs. Open fractures are associated with higher likelihood of nonunion than closed ones. Effective screening of nonunion risk may decrease this morbidity and subsequent healthcare resource use and costs.
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                Author and article information

                Journal
                SICOT J
                SICOT J
                sicotj
                SICOT-J
                EDP Sciences
                2426-8887
                2017
                07 April 2017
                : 3
                : ( publisher-idID: sicotj/2017/01 )
                : 30
                Affiliations
                [1 ] Department of Orthopaedic Surgery and Rehabilitation, Texas Tech University Health Sciences Center El Paso TX 79905 USA
                Author notes
                [* ]Corresponding author: amr.abdelgawad@ 123456ttuhsc.edu
                Article
                sicotj160116 10.1051/sicotj/2017002
                10.1051/sicotj/2017002
                5384319
                28387196
                2f1728cc-7b88-4cb6-a6a5-1c8279681638
                © The Authors, published by EDP Sciences, 2017

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 30 September 2016
                : 27 December 2016
                Page count
                Figures: 1, Tables: 1, Equations: 0, References: 23, Pages: 6
                Categories
                Lower Limb
                Special Issue: "Deformity correction, limb lengthening and reconstruction" Guest Editor: Y. ElBatrawy
                Original Article

                tibial nonunion,open tibial fracture,reamer-irrigator-aspirator,external fixator

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