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Surgical Technology International XXVIII contains peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
April, 2016- ISSN:1090-3941
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Orhopaedic Surgery
Effect of Varying Posterior Cruciate Ligament (PCL) Recessions on Kinematics and Ligament Strains with Cruciate Retaining Total Knee Prostheses
Ran Schwarzkopf, MD, MSc, Assistant Professor, Department of Orthopaedic Surgery, Division of Adult Reconstruction, NYU Hospital for Joint Diseases, NYU Langone Medical Center, New York, NY, Scott K. Laster, BSc, Director of Knee Marketing and, Active Knee Business Leader, Smith & Nephew, Memphis, TN, Michael B. Cross, MD, Assistant Professor, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, Nathaniel M. Lenz, MSc, Product Development Engineer, Smith & Nephew Memphis, TN
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Introduction: Proper ligament tension in flexion with posterior cruciate retaining (CR) total knee arthroplasty (TKA) has long been associated with clinical success. The purpose of this study was to determine the effect of varying levels of posterior cruciate ligament (PCL) release on the tibiofemoral kinematics and PCL strain.
Materials and Methods: A computational analysis was performed and varying levels of PCL release were simulated. Tibiofemoral kinematics was evaluated. The maximum PCL strain was determined for each bundle to evaluate the risk of rupture based on the failure strain.
Results: The femoral AP position shifted anteriorly as the PCL stiffness was reduced. PCL strain in both bundles increased as stiffness was reduced. The model predicts that the AL bundle should not rupture for a 75% release. Risk of PM bundle rupture is greater than AL bundle.
Discussion: Our findings suggest that a partial PCL release impacts tibiofemoral kinematics and ligament tension and strain. The relationship is dynamic and care should be taken when seeking optimal balance intra-operatively.
What Is the Efficacy of Repeat Manipulations Under Anesthesia to Treat Stiffness Following Primary Total Knee Arthroplasty?
Kimona Issa, MD, PGY-2 Resident, Todd P. Pierce, MD, Research Fellow, Alexander Brothers, MD, PGY-3 Resident, Vincent K. McInerney, MD, Residency Program Director, Department of Orthopaedics, Seton Hall University, School of Health and Medical Sciences, South Orange, New Jersey, Morad Chughtai, MD, Jaydev B. Mistry, MD, Research Fellow, Wayne W. Bryant, MS, Research Assistant, Ronald E. Delanois, MD, Fellowship Director, Department of Orthopaedic Surgery, Steven F. Harwin, MD, Chief of Adult Reconstruction and Total Joint Replacement, Department of Orthopaedic Surgery, Beth Israel Medical Center, New York, New York, Michael A. Mont, MD, Director, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
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Background: Manipulation under anesthesia (MUA) can help post-total knee arthroplasty (TKA) patients who have knee stiffness regain range-of-motion. However, despite undergoing MUA, patients may have persistent knee stiffness. Often, this persistent knee stiffness is treated with a repeat MUA. Therefore, the purpose of this study was to evaluate repeat MUAs by assessing: (1) demographic characteristics, (2) range-of-motion, (3) clinical outcomes, and (4) rate of revision surgery in post-TKA patients with persistent knee stiffness who either underwent a single MUA or repeat MUAs.
Materials and Methods: One-hundred-and-sixty-seven post-TKA who had undergone an MUA between 2005 and 2011 at two institutions were reviewed. Patients were stratified into those who had a single-MUA (138 knees) and those who had a repeat MUA (29 knees). The mean follow-up period was 63 months (range, 36 to 90 months). The incidence of repeat MUA within this cohort was determined. Demographics and ROM were compared using Student t-test and Chi-square as appropriate. Functional outcomes were assessed using Knee Society scores (KSS) and compared between the two cohorts.
Results: Among the 167 patients who underwent a MUA, 29 (17%) required repeat manipulations. The repeat MUA cohort was younger and more likely to have osteonecrosis as the underlying cause of knee disease. For the repeat MUA cohort, 17 patients (59%) had achieved satisfactory mean gains in ROM after their repeat MUAs. These patients had also achieved excellent mean Knee Society objective and functional scores. However, another seven knees (24%) had further persistent knee stiffness requiring arthrolysis of adhesions and five patients (17%) had undergone revision of the polyethylene spacer or patellar component to improve range-of-motion.
Conclusion: In this study, the majority of patients who had undergone a repeat MUA were able to achieve improvements in flexion range-of-motion and functional outcomes. However, the remaining patients required more invasive procedure to treat persistent knee stiffness. In patients who have persistent knee stiffness after MUAs, a repeat MUA may be helpful to increase range-of-motion and function.
Single-Use Instrumentation Technologies in Knee Arthroplasty: State of the Art
Giacomo Dell’Osso, MD , Specialist in Orthopedics and Traumatology, Fabio Celli, MD, Resident in Orthopedics and Traumatology, Vanna Bottai, MD, Specialist in Orthopedics and Traumatology, Giulia Bugelli, MD, Resident in Orthopedics and Traumatology, Carmine Citarelli, MD, Resident in Orthopedics and Traumatology, Giulio Agostini, MD, Resident in Orthopedics and Traumatology, Giulio Guido, MD, Professor of Orthopedics and Traumatology, Stefano Giannotti, MD, Specialist in Orthopedics and Traumatology, IInd Orthopaedic and Traumatologic Clinic, University of Pisa, Pisa, Italy
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The surgical site contamination and the resulting periprosthetic infections are an important cause of morbidity and socio-economic impact. In total knee arthroplasty, the single-use instrumentation is developed to simplify the surgical procedure, reduce the chance of instrument contamination, improve the operating room efficiency, and reduce overall costs (low cost of instrument washing and sterilization as well as personnel management).
Surgical single-use instrumentations on the market are complete with all you need for the surgical procedure—cutting guides, conventional or PSI (patient-specific instrumentation), femoral cutting block, re-cutting block, trials components, alignment rods, inserts, and impactors.
In recent years, PSI (patient-specific instrumentation) was introduced. It decreases operative time and blood loss without violating the intramedullary canal. It also allows the surgeon to preoperatively plan the patient’s component size, position, and alignment.
We reported an average of 30 minutes saved for each surgical procedure, a saving of 60€ for each surgical tray. Moreover, we avoided surgery cancellation or delay due to un-sterile, missing, or dysfunctional instruments.
We think that this technology is the first step in developing implants that are entirely customized for each patient, and we believe that it will have a more relevant role in knee surgery in the future.
Long-Term Survivorship and Clinical Outcomes of a Single Radius Total Knee Arthroplasty
Jaydev B. Mistry, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and, Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Randa K. Elmallah, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and, Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Morad Chughtai, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and, Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Melike Oktem, MD, Research Assistant, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and, Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Steven F. Harwin, MD, Chief, Adult Reconstruction Service, Mount Sinai Beth Israel, New York, New York, Michael A. Mont, MD, Director, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and, Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
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Introduction: To ensure the continued success of total knee arthroplasties (TKAs), we must employ ever-evolving modifications to our techniques and implant designs. As part of this process, a knee prosthesis with a single radius (SR) has been developed to more precisely emulate the anatomy and biomechanics of the native knee, but there is little data on long-term outcomes. Therefore, the purpose of this study was to evaluate (1) the long-term (10-year) survivorship; (2) clinical and patient-reported outcomes; (3) radiographic outcomes; and (4) incidence of complications in patients who underwent TKA with this SR prosthesis.
Materials and Methods: We evaluated 54 patients (67 TKAs) (24% men, 76% women) who had a mean age of 62 years at the time of surgery (range, 30 to 82 years). The mean follow-up was 10 years (minimum 9 years). All patients underwent a primary TKA using a newly developed single radius implant with posterior condylar flare. Kaplan-Meier analysis was performed to determine implant survivorship. The Knee Society Score (KSS), University of California Los Angeles (UCLA) activity scale, and Short Form-36 (SF-36) mental and physical component scores were used to evaluate clinical and patient-reported outcomes. Anteroposterior and lateral radiographs were reviewed for evidence of component loosening. Complications were identified through a comprehensive chart review and were classified as either surgical or medical.
Results: Assessment of aseptic loosening revealed that survivorship of the tibial and femoral components was 100%. Evaluation of revisions for any reason showed that Kaplan-Meier aseptic and all-cause survivorship of the femoral and tibial components was 99%. When only polyethylene exchanges were included, the all-cause overall and aseptic survivorships were 94% and 96% respectively. Additionally, the mean KSS and UCLA activity scores were 64 (range, 5 to 100 points) and 5 points (range, 1 to 9 points) at final follow-up. The mean SF-36 mental and physical component scores were 53 (range, 23 to 66 points) and 39 points (range, 15 to 61 points). Surgical complications included arthrofibrosis, extensor mechanism disruption, patellar component revision, and peroneal nerve palsy. No medical complications were reported.
Conclusion: Single radius total knee arthroplasties have demonstrated excellent long-term survivorship and functional outcomes, as demonstrated by this preliminary report.
Mobile Application Use in Monitoring Patient Adherence to Perioperative Total Knee Arthroplasty Protocols
Kelvin Kim, BA, Research Assistant, Penn State College of Medicine, Hershey, Pennsylvania, Diep Pham, FNP, MN, MBA, Professor of Nursing, School of Nursing, Golden West College, Huntington Beach, California, Ran Schwarzkopf, MD, MSc, Assistant Professor of Orthopaedic Surgery, Division of Adult Reconstruction Surgery, New York University Hospital For Joint Diseases, New York University Langone Medical Center, New York, New York
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The potential for using mobile applications (apps) as an effective tool to monitor patients in an outpatient setting is promising. Past studies have investigated the use of applications in preoperative and postoperative settings as well as in monitoring and treating chronic illnesses such as diabetes, congestive heart failure (CHF), and multiple sclerosis. However, there is limited data on its specific use in the context of total knee arthroplasty. Given the complicated nature and crucial role of patient adherence to protocols during the preparatory and recovery phases of the procedure, the use of an app can serve as a helpful tool in aiding patients throughout this process. We present a pilot study to assess the efficacy of using such an app in order to monitor patient adherence to total knee arthroplasty-specific preoperative and postoperative protocols. Preoperative protocols used in this study included a 5-item medication protocol and multiple activity instructions. Postoperative patient protocols included following instructions on topics such as recording responses to quality-of-life questions, when and how to contact the clinical team if patients had non-emergent concerns or questions, and carrying out daily physical therapy (PT) exercises. Patients received and recorded responses to these preoperative and postoperative instructions using the iGetBetter program application installed on an iPad Mini, provided to the participants. Patient adherence was based on the data gathered from the patient responses inputted on this app. Adherence rates were comparable to those reported in various past studies that also investigated rates of adherence to health management-related instructions communicated through mobile apps.
What Influences How Patients Rate Their Hospital After Total Knee Arthroplasty?
Morad Chughtai, MD, Research Fellow, Julio J. Jauregui, MD, Research Fellow, Jaydev B. Mistry, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Randa K. Elmallah, MD, Research Fellow, Aloise M. Diedrich, BS, Peter M. Bonutti, MD, Orthopedic Surgeon, Bonutti Clinic, Effingham, Illinois, Ronald Delanois, MD, Orthopedic Surgeon, Michael A. Mont, MD, Director, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
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Introduction: There is increasing pressure from Centers for Medicare and Medicaid Services (CMS) to report quality measures for all hospitalizations. These quality measures are determined based on results from satisfaction surveys, such as Press Ganey® (PG) (Press Ganey® Performance Solutions, Wakefield, Massachusetts). Included in this particular survey element are questions regarding staff, including nurses and doctors, as well as items such as pain control. The results of these surveys will dictate the amount doctors are compensated for their services. Therefore, this study was undertaken to evaluate the effect of treating orthopaedists and nurses, as well as pain control, on PG surveys in patients who underwent total knee arthroplasty (TKA). Specifically, we aimed to ascertain the effect of these factors on how post-TKA patients perceive: 1) their orthopaedist, and 2) their overall surgical experience.
Materials and Methods: We queried the Press Ganey® Database for all patients who underwent a TKA at our institution between November 2009 and January 2015. A weighted mean of question domains was utilized since each had multiple questions. In order to assess if pain management influences orthopaedist perception, a correlation analysis was performed between pain control and perception. In order to assess the influence of pain management on surgical experience, we performed a correlation analysis between pain control and overall hospital rating. A multiple regression analysis was performed using the hospital rating as the dependent variable to determine the most influential factors on surgical experience.
Results: Our analysis demonstrated a significantly positive correlation between patient perception of their pain control and their orthopaedist. There was a significant positive correlation between patient’s perception of their pain control and their overall surgical experience. Multiple regression analysis using overall surgical experience as the dependent variable demonstrated a significant positive influence of perception of nurses and orthopaedists. Pain management positively influenced surgical experience; however, this was not significant.
Conclusions: We found that perception of pain control in post-TKA patients affects perception of the treating orthopaedists, as well as their overall surgical experience. In addition, perception of orthopaedists and nurses both outweigh perception of pain control on overall surgical experience, with nurses being the most important. Orthopaedists should focus on staff education—particularly nurses—and educate them in order to optimize results on PG surveys and, ultimately, improve patient satisfaction. Further studies should correlate current standardized scoring systems and questionnaires for TKA with PG surveys in order to recognize gaps that need to be bridged to improve post-TKA patient satisfaction.
An Assessment of the Comprehensiveness of Various Hip Outcome Scores
Jaydev B. Mistry, MD, Research Fellow, Julio J. Jauregui, MD, Research Fellow, Aaron L. Lerner, BS, Research Volunteer, Morad Chughtai, MD, Research Fellow, Randa K. Elmallah, MD, Research Fellow, Michael A Mont, MD, Director, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
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Introduction: Evaluating outcomes following total hip arthroplasty (THA) has been essential for improving satisfaction and quality of care. However, finding systems that fully encompass these outcomes poses a challenge for physicians, and often still do not provide an adequate picture of a patient’s recovery. Therefore, we evaluated different scoring systems to determine the most efficient method of assessing the outcomes of patients undergoing THA.
Materials and Methods: We evaluated all hip scoring systems currently available in the literature and identified the parameters assessed in the questionnaires. The parameters were then subdivided into subjective, objective, rehabilitative, and quality of life outcome measures. We identified the most commonly referenced questionnaires and assessed multiple permutations of these with other scoring systems to determine the combinations that would most efficiently and comprehensively evaluate the outcomes of patients undergoing THA.
Results: The 42 identified scoring systems covered the following parameters: 4 subjective, 5 objective, 17 rehabilitative, and 18 quality of life. The Harris Hip Score (HHS) was the most cited system (5,613), but the Hip Disability and Osteoarthritis Outcome Score (HOOS) had the greatest coverage of all the parameters (49%). On combinatorial analysis, the 2-, 3-, and 4-item permutations that had the greatest coverage were HOOS and 36-Item Short-Form Health Survey (SF-36) (59%), HOOS, SF-36, and Larson (75%), and HOOS, SF-36, Larson, and Lower Extremity Functional Scale (LEFS) (80%).
Conclusion: Physicians and researchers have attempted to fully assess the outcomes of patients undergoing THA. Utilizing existing scoring systems in particular combinations may allow us to form an ideal questionnaire that provides sufficient coverage of parameters, thus providing a more comprehensive way to cost-effectively evaluate outcomes. Further analysis is required to determine whether or not these permutations provide a sufficient evaluation in a clinical setting.
Outcomes of Second-Generation Tapered Wedge Femoral Stem
Frank R. Kolisek, MD, Orthopaedic Surgeon, OrthoIndy, Greenwood, Indiana, Morad Chughtai, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Jaydev B. Mistry, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Randa K. Elmallah, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Charles Jaggard, MS, Research Coordinator, OrthoIndy, Greenwood, Indiana, Arthur L. Malkani, MD, Orthopaedic Surgeon, University of Louisville, Adult Reconstruction Program, Louisville, Kentucky, Michael A. Masini, MD, Orthopaedic Surgeon, St. Joseph Mercy Hospital, Ann Arbor, Michigan, Steven F. Harwin, MD, Chief, Adult Reconstruction Service, Mount Sinai Beth Israel, New York, New York, Michael A. Mont, MD, Director, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
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Introduction: Newer generation cementless femoral stems have been designed to emulate more precisely the anatomy of the native femur. However, few studies have evaluated these designs. The purpose of this study was therefore to evaluate outcomes of primary total hip arthroplasty (THA) in patients who received a second-generation, tapered wedge stem by analyzing (1) all-cause and aseptic implant survivorships; (2) clinical and patient-reported outcomes; (3) radiographic outcomes; and (4) incidence of complications.
Materials and Methods: We evaluated 202 primary THA patients (37% men, 63% women) who had a mean age of 63 years (range, 18 to 88) and a mean body mass index (BMI) of 29 (range, 18 to 40). All patients underwent THA using a press-fit, tapered wedge stem with a morphometric design containing a size-specific medial curvature, which optimizes initial press-fit stability. Kaplan-Meier analysis was performed to determine implant survivorship, and Harris Hip Scores (HHS) and the Short form-36 (SF-36) were used to evaluate clinical and patient-reported outcomes. Early postoperatively and annually thereafter, pelvic radiographs were reviewed for evidence of osteolysis or loosening. Complications were identified through a comprehensive chart review and were classified as either surgical or medical.
Results: At final follow-up, the all-cause and aseptic survivorships for the femoral stem were 99.5% and 100%, respectively. At final follow-up, the mean HHS was 87 (range, 35 to 100). The SF-36 mental and physical component scores were 47 (range, 19 to 65) and 47 (range, 23 to 65), respectively, at final follow-up. No progressive radiolucencies or loosening were observed. Surgical complications included nerve palsy, posterior trochanteric avulsion, arthrofibrosis, and periprosthetic fracture. The only medical complication was acute renal failure.
Conclusion: This second-generation stem demonstrated excellent short-term survivorship and functional outcomes. The improved patient fit of this stem may yield continued favorable results with longer-term follow-up.
Time Burden of Standardized Hip, Questionnaires
Morad Chughtai, MD, Research Fellow, Anton Khlopas, MD, Research Assistant, Jaydev B. Mistry, MD, Research Fellow, Chukwuweike U. Gwam, MD, Research Assistant, Randa K. Elmallah, MD, Research Fellow, Michael A. Mont, MD, Director, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
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Introduction: Many standardized scales and questionnaires have been developed to assess outcomes of patients undergoing total hip arthroplasty (THA). However, these surveys can be a burden to both patients and orthopaedists as some are time-inefficient. In addition, there is a paucity of reports assessing the time it takes to complete them. In this study we aimed to: (1) assess how long it takes to complete the most common standardized hip questionnaires; (2) determine the presence of variation in completion time; and (3) evaluate the effects of age, gender, and level of education on completion time.
Materials and Methods: Based on a previous study, we selected the seven most commonly used hip scoring systems—Western Ontario and McMaster Universities Hip Outcome Assessment (WOMAC), Harris Hip Score (HHS), Hip Disability and Osteoarthritis Outcome Score (HOOS), Larson Score, Short-form 36 (SF-36), modified Merle d’Aubigne and Postel Score (MDA), and Lower Extremity Functional Scale (LEFS). The standardized scales and questionnaires were randomly administered to 70 subjects. The subjects were unaware that they were being timed during completion of the questionnaire. We obtained the coefficients of variation of time for each questionnaire. The mean time to complete the questionnaire was then stratified and compared based on age, gender, and level of education.
Results: The mean time to complete each of the systems is listed in ascending order: Modified Merle d’Aubigne and Postel Score (MDA), Lower Extremity Functional Scale (LEFS), Western Ontario and McMaster Universities Hip Outcome Assessment (WOMAC), Harris Hip Score (HHS), Larson Score, Hip Disability and Osteoarthritis Outcome Score (HOOS), and Short-form 36 (SF-36). The WOMAC and Larson Score coefficients of variation were the largest, and the HOOS and MDA were the smallest. There was a significantly higher mean time to completion in those who were above or equal to the age of 55 years as compared to those who were below the age of 55 (227 vs. 166 seconds). There was no significant association found in time of completion between gender or education level.
Conclusion: Standardized scales and questionnaire which assess THA patients can be burdensome and time-inefficient, which may lead to task-induced fatigue. This may result in inaccurate THA patient assessments, which do not reflect the patient’s true state. Future studies should aim to create an encompassing questionnaire that is time efficient and can replace all currently used validated systems.
Giant Schwannoma of the Saphenous Nerve in The Distal Thigh: A Case Report
Giulia Bugelli, MD , Resident in Orthopedics and Traumatology, Giacomo Dell’Osso, MD , Specialist in Orthopedics and Traumatology, Vanna Bottai, MD, Specialist in Orthopedics and Traumatology, Fabio Celli, MD, Resident in Orthopedics and Traumatology, Barbara Loggini, MD, Specialist in Anatomical Pathology, Giulio Guido, MD, Professor of Orthopedics and Traumatology, Stefano Giannotti, MD, Specialist in Orthopedics and Traumatology, Department of Orthopedic and Traumatology, University of Pisa, Pisa, Italy
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Case: Schwannomas are benign nerve myelin sheath tumors that can occur anywhere in the peripheral nervous system. It is very rare for Schwannomas to become malignant, but surgery is still the principal treatment to eliminate symptoms and to correctly diagnosis the tumor. We report an interesting case of a schwannoma of the saphenous nerve at the distal third of the posteromedial thigh: the patient complained of muscle weakness at left lower limb and vague anteromedial knee pain, mimicking a meniscal tear. Magnetic resonance images of the thigh showed a well-defined and oval mass lesion measuring 8.5 cm x 4.5 cm. Before investigating for a possible meniscal tear, we decided to remove the mass from the thigh, because we felt that it could itself be the cause of the mild pain complained about by the patient. Post-surgery, histological analysis conducted confirmed that this was a benign schwannoma.
Discussion: Schwannomas generally can be asymptomatic or present as a mass. The clinical presentation of this rare tumor makes the diagnosis difficult.
Conclusion: This reported case is particularly interesting because of the rarity of the lesion localization along the course of the saphenous nerve. The combination of the location, and especially the large size of the tumor, led us to believe that there is a correlation with the particular clinical presentation.
Grafting of Expanded Mesenchymal Stem Cells without Associated Procedure in a Healed Case of Ulna Pseudarthrosis: A Case Report
Giacomo Dell’Osso, MD, Specialist in Orthopedics and Traumatology, Department of Orthopedic and Traumatology, University of Pisa, Pisa, Italy, Giulia Bugelli, MD, Resident in Orthopedics and Traumatology, Department of Orthopedic and Traumatology, University of Pisa, Pisa, Italy, Fabio Celli, MD, Resident in Orthopedics and Traumatology, Department of Orthopedic and Traumatology, University of Pisa, Pisa, Italy, Mario Petrini, MD, Professor of Hematology, Hematology Division, Department of Oncology, University of Pisa, Pisa, Italy, Luisa Trombi, MD , Specialist in Hematology, Hematology Division, Department of Oncology, University of Pisa, Pisa, Italy, Giulio Guido, MD, Professor of Orthopedics and Traumatology, Department of Orthopedic and Traumatology, University of Pisa, Pisa, Italy, Stefano Giannotti, MD, Specialist in Orthopedics and Traumatology, Department of Orthopedic and Traumatology, University of Pisa, Pisa, Italy
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Background: The surgical management of pseudoarthrosis is often a challenge. The use of mesenchymal multipotent cells expanded and manipulated in the laboratory is an interesting treatment of pseudoarthrosis, because they can lead to differentiation into osteocytes and thus the formation of bone tissue.
Case Description: We present a case of a 47-years-old man with isolate ulna fracture, treated with plate and screws and evolved in non-union. The patient underwent an expanded stem cells graft on the site of non-union with a small incision of approximately 3cm, without changing the synthesis system. After one year, the X-ray showed a complete fracture consolidation.
Discussion: In our opinion, this case is interesting because it highlights the cellular action that is the only healing factor; it is an important demonstration of the biological action of expanded mesenchymal stem cells (MSCs).
Conclusion: To validate the use of MSCs, it is necessary to perform comparative studies for age, sex, general condition, location, and mechanism of injury as a further clinical validation of the efficiency of this cell line.