BIOLOGICAL AND BIOPHYSICAL TECH TO ENHCNE FRACTURE REPAIR.pptx

orthopaedics

1. BIOLOGIC AND BIOPHYSICAL TECHNOLOGY TO ENHANCE FRACTURE HEALING DR. SHREYA SHENOY

2. Introduction Rates of non- union in fracture range from 2 to 20% for long bones. Leads to significant pain, loss of function, loss of pay and psychological distress Sometimes, some osteoporotic fracture may also need additional augmentation for fracture healing

3. How can we augment fracture healing ? Osteoinduction Osteoconduction Osteogenesis

4. How can we augment fracture healing ? OSTEOINDUCTION : Process of recruitment, proliferation and differentiation of host MSCs into chondroblasts and osteoblasts . Osteoconduction : process by which a graft acts as a scaffold passively hosting the cells required for living Osteogenesis : Direct stimulation of new bone cells

5. Factors required for bone healing

6. Bone graft and substitutes Bone graft : Gold standard for bone voids associated with on union Principle of osteoconduction Invasive Limitations the volume of graft available to harvest, donor site morbidity , surgery experienced by the patient as part of the harvesting process

7. BIOLOGICS / CELL BASED THERAPY FOR FRACTURE REPAIR Alternative non invasive/ minimally invasive/ invasive / augments intraop Developing

8. Local enhancement for fracture healing

9. Mesenchymal Stem cells Multiple progenitor cells which can differentiate Angiogenesis induction properties Trophic / reparative and immunomodulatory Secrete TGF β , Stem cell factor, IGF, EGF, G/MCSF Pro/ anti-inflammatory responses as needed with IL 10 interplay.

10. MESENCHYMAL STEM CELLS

11. PLATELET CONCENTRATES Platelet rich plasma / Platelet concentrates/ PRF has 6 times the normal physiological platelet count (1.5l to4.5L) Ideally 5 fold concentration is ideal for bone healing

12. PRP LR – leucocyte rich : most common – helps in soft tissue regeneration , proinflammatory cytokines LP – leucocyte poor : short lived, analgesic effect+ P – pure platelet rich

13. PRP Recent evidence : in vitro pre-clinical, in vivo pre-clinical, and clinical studies underscores the growing significance of PRP as a valuable adjunct in the domain of bone healing . Issues : Determining the right concentration for administration and a reliable follow up

14. Systemic enhancement of fracture healing

15. BONE MORPHOGENIC PROTEINS Activity mediated by TGF – that help in skeletal repair Signalling molecules that bind to serine-threonine transmembrane receptors (BMPRs)

16. BMPs powerful osteoinductive agents the high costs of BMP treatment and the paucity of evidence for treatment effectiveness, fracture region, type, and risk factors have to be identified to justify further usage

17. WNT SIGNALLING PATHWAY

18. Wnt Stimulation of wnt signalling – promotes bone healing by enhancing the enchondral and intramembranous ossification Wnt signaling can be activated by adding Wnt proteins to cells by viral transduction, in a purified form or as conditioned medium. Cell lines producing active wnt are commercially available.

19. GROWTH FACTORS Platelet derived growth factor Vascular endothelial GF TGF Fibroblast GF Not available in India

20. PARATHYROID HORMONE

21. PTH in fracture union

22. IGF/ GROWTH HORMONE IGF Signalling decides the osteoclast activation Stimulates bone healing after fracture

23. STATINS Statins inhibit RANKL and activate BMP Increase osteoblastic activity Decrease resorption of bone Reduces the fracture risk itself

24. STATINS Effectiveness depends on mode of administration Simvastatin Local delivery of Simvastatin through controlled drug delivery systems with much lower doses (0.25 mg/kg)

25. BIOPHYSICAL THERAPY

26. PHYSICAL STRESSES

27. LIPUS Low intensity pulsed ultrasound

28. LIPUS Increases osteoprogenitor cells at fracture site Additional pain relief No level 1 evidence More for fracture healing than non union Positive impact on healing

29. LIPUS

30. ELECTRICAL STIMULATION PRINCIPLE : Mechnically loaded bone has electric potential

31. ELECTRICAL STIMULATION Patients treated with electrical stimulation as an adjunct for bone healing have less pain are at reduced risk for radiographic nonunion; functional outcome data are limited and requires increased focus in future trials.

32. EXTRACORPOREAL SHOCK WAVE THERAPY Initially used for renal stones the shockwave is first generated in water and from there it is transferred through a medium to the skin and tissues as a sonic pulse. This creates expansion and compression within the bone

33. ESWT

34. ESWT More evidence for analgesia Lack of level 1 evidence

35. Intra op bone healing augments INDICATION OSTEOPOROTIC FRACTURE WITH IMPLANT FAILURE METS PATHOLOGICAL FRACTURE IN ELDERLY IMMUNOCOMPROMISED

36. Illuminos fracture fixation system

37. The IlluminOss system (IS) uses a light-curable polymer contained within an inflatable balloon catheter, forming a patient customized intramedullary implant.

38. ILLUMINOS – how it works

39. Enhances the holding power Fracture stabilisation Periprosthetic fracture augments

40. Thank you