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Summary: The management of bone defects and nonunions creates unique clinical challenges. Current treatment alternatives are often insufficient and frequently require multiple surgeries. One promising option is bone morphogenetic protein-2 (BMP-2), which is the most potent inducer of osteogenesis. However, its use is associated with many side effects, related to the delivery and high doses necessary. To address this need, we developed an ex vivo biomimetic hematoma (BH), replicating naturally healing fracture hematoma, using whole blood and the natural coagulants calcium and thrombin. It is an autologous carrier able to deliver reduced doses of rhBMP-2 to enhance bone healing for complex fractures. More than 50 challenging cases involving recalcitrant nonunions and bone defects have already been treated using the BH delivering reduced doses of rhBMP-2, to evaluate both the safety and efficacy. Preliminary data suggest the BH is currently the only clinically used carrier able to effectively deliver reduced doses (∼70% less) of rhBMP-2 with high efficiency, rapidly and robustly initiating the bone repair cascade to successfully reconstruct complex bone injuries without side effects. The presented case provides a clear demonstration of this technology's ability to significantly alter the clinical outcome in extremely challenging scenarios where other treatment options have failed or are considered unsuitable. A favorable safety profile would portend considerable promise for BH as an alternative to bone grafts and substitutes. Although further studies regarding its clinical efficacy are still warranted, this novel approach nevertheless has tremendous potential as a favorable treatment option for bone defects, open fractures, and recalcitrant nonunions., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Compare anterior minimally invasive plate osteosynthesis (MIPO) to open reduction/internal fixation (ORIF) for humeral shaft fractures, assessing complications and clinical outcomes., Design: Retrospective matched case-controlled cohort., Setting: Tertiary referral trauma centre., Patients/participants: Humeral shaft fractures identified retrospectively over 5 years; 31 were treated by MIPO and 54 by ORIF. Matched-case cohort assembled according to fracture pattern, sex, age, and comorbidities, with 56 total patients (28 per group)., Interventions: MIPO and ORIF., Main Outcome Measures: Complication rate was the primary outcome (radial nerve injury, nonunion, infection, and reoperation). Radiographic alignment and the Disabilities of the Arm, Shoulder and Hand Score were secondary outcomes., Results: Cumulative complication rates were 3.6% after anterior MIPO and 35.7% after ORIF (P = 0.0004). The only complication after anterior MIPO was a nonunion, managed with revision ORIF and bone graft. The ORIF group had 10 complications, including 5 superficial infections, 4 iatrogenic radial nerve injuries, and 1 nonunion. The mean Disabilities of the Arm, Shoulder and Hand score after MIPO was 17.0 ± 18.0 and after ORIF was 24.9 ± 19.5. The mean coronal plane angulation after MIPO was 1.8 ± 1.3 degrees and after ORIF was 1.0 ± 1.2 degrees. The mean sagittal plane angulation after MIPO was 3.0 ± 2.9 degrees and after ORIF was 1.0 ± 1.2 degrees., Conclusions: The cumulative complication rate was 10 times higher after ORIF of humeral shaft fractures compared with the MIPO technique. MIPO achieved nearly equivalent radiographic alignment, with no clinically meaningful differences observed. MIPO is the safer option and should be considered for patients with humeral shaft fractures that would benefit from surgical intervention., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To examine periprosthetic bone remodeling among the recipients of 2 types of lower-limb osseointegrated systems, the Integral Leg Prosthesis (ILP) and the Osseointegration Prosthetic Limb (OPL) type A, over a >24-month period., Design: Retrospective cohort study., Setting: Private hospital, with a specialized osseointegration unit., Patients: Twenty-eight patients with transfemoral lower-limb amputations were fitted with osseointegrated systems. Of these patients, 15 received the ILP and 13 the OPL osseointegrated implant., Intervention: Radiographic measurements were taken at baseline (0.4 ± 0.5 years) and at follow-up (3.0 ± 0.8 years) after the osseointegration procedure., Main Outcome Measurements: Radiographic bone density, longitudinal bone coverage, and bone width outcomes were measured in inverse "Gruen zones." Bone remodeling was evaluated by comparing changes between baseline and follow-up measurements., Results: Radiographic bone density decreased in all zones among both ILP and OPL groups. Cortical bone thickness increased among the OPL group in zones 3 (P < 0.05) and 5 (P < 0.05). Distal bone coverage of the ILP implant decreased by 2.3% (P < 0.01) and 4.1% (P < 0.05) of the total implant length on the medial and lateral sides, respectively., Conclusions: Decreased bone density with increased periprosthetic cortical thickness suggests a change in the bone architecture for the OPL group. The findings of this study raise concerns for the long-term success of the ILP implant. Radiographic analysis of x-rays seems to be a useful tool for clinicians to evaluate bone remodeling around osseointegrated prosthesis., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

In 16 years of conflict, primarily in Iraq and Afghanistan, wounded warriors have primarily been subjected to blast type of injuries. Evacuation strategies have led to unprecedented survival rates in blast-injured soldiers, resulting in large numbers of wounded warriors with complex limb trauma. Bone and soft tissue defects have resulted in increased use of complex reconstructive algorithms to restore limbs and function. In addition, in failed salvage attempts, advances in amputation options are being developed. In this review, we summarize state-of-the-art limb-salvage methods for both soft tissue and bone. In addition, we discuss advances in diagnostic methods with development of personalized clinical decision support tools designed to optimize outcomes after severe blast injuries. Finally, we present new advances in osteointegrated prostheses for above-knee amputations.

Objectives: To compare the risk of major complications after either minimally invasive plate osteosynthesis (MIPO) or intramedullary nailing (IMN) of humeral shaft fractures., Design: Retrospective, case-match controlled study., Setting: A major metropolitan tertiary referral trauma center in Australia., Patients: Thirty patients with fractures of the humeral shaft., Intervention: Either MIPO or IMN were performed on 15 patients each with traumatic humeral shaft fractures., Primary Outcome Measure: The cumulative risk of 3 major complications associated with these procedures: nonunion, infection, and iatrogenic radial nerve injury., Results: An overall major complication rate of 53% was observed in the patients treated with IMN; one complication (7%) was identified in those managed with humeral MIPO, a nonunion. Complications after IMN included 4 patients (27%) with nonunion, 3 patients (20%) with iatrogenic radial nerve injuries, and 1 patient (7%) with a wound infection. Statistical analysis revealed a significant between-group difference (P = 0.01) in the cumulative rate of major complications. When each of these complications was considered independently, no statistically significant difference was demonstrated., Conclusions: This study suggests that humeral MIPO results in a significantly lower pooled major complication rate than that of IMN, and it should therefore be considered an attractive alternative to IMN in those patients requiring surgical stabilization of a traumatic humeral shaft fracture., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To highlight a technique combining fluoroscopy and arthroscopy to aid percutaneous reduction and internal fixation of selected displaced intra-articular calcaneal fractures, assess outcome scores, and compare this method with other previously reported percutaneous methods., Design: Retrospective review of all patients treated by this technique between June 2009 and June 2012., Setting: A tertiary care center located in Brisbane, Queensland, Australia., Patients: Thirteen consecutive patients were treated by this method during this period. All patients had a minimum of 13 months follow-up and were available for radiological checks and assessment of complications; functional outcome scores were available for 9 patients., Intervention: The patient was placed in a lateral decubitus position. Reduction was achieved with the aid of both intraoperative fluoroscopy and subtalar arthroscopy and held with cannulated screws in orthogonal planes. The patient was mobilized non-weight bearing for 10 weeks., Main Outcome Measurement: Outcomes measured were improvement in Bohler angle, postoperative complications, and 3 functional outcome scores (American Orthopaedic Foot and Ankle Society ankle-hindfoot score, Foot Function Index, and Calcaneal Fracture Scoring System)., Results: Mean postoperative improvement in Bohler angle was 18.3 degrees, with subsidence of 1.7 degrees. Functional outcome scores compared favorably with the prior literature. Based on available postoperative computed tomography scans (8/13), maximal residual articular incongruity measured 2 mm or less in 87.5% of our cases., Conclusions: Early results indicate that this technique, when combined with careful patient selection, offers a valid therapeutic option for the treatment of a distinct subset of displaced intra-articular calcaneal fractures, with diminished risk of wound complications. Large, prospective multicenter studies will be necessary to better evaluate the potential benefits of this technique., Level of Evidence: Level IV Therapeutic. See Instructions for Authors for a complete description of levels of evidence.