BioMed Research International: Orthopedics The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Influence of Intra-Articular Administration of Trichostatin A on Autologous Osteochondral Transplantation in a Rabbit Model Wed, 18 Mar 2015 15:39:35 +0000 Autologous osteochondral transplantation (AOT) is a method for articular cartilage repair. However, several disadvantages of this method have been reported, such as transplanted cartilage degeneration and the lack of a connection between the grafted and adjacent cartilage tissues. To evaluate the effect of intra-articular administration of trichostatin A (TSA) on AOT, we conducted a case control study in a rabbit model. International Cartilage Repair Society (ICRS) macroscopic scores, the modified O’Driscoll histology scores, and real-time PCR were utilized to evaluate the results. At 4 weeks, both macroscopic and histological assessments showed that there was no significant difference between the TSA and control groups. However, the mean macroscopic and histological scores for the TSA-treated group were significantly higher than the scores for the control group at 12 weeks. TSA was shown to directly reduce collagen type II (COL2), aggrecan, matrix metalloproteinase (MMP), and a disintegrin and metalloproteinase domain with thrombospondin motifs 5 (ADAMTS-5) expression and to simultaneously repress the upregulation of MMP-3, MMP-9, and MMP-13 levels induced by interleukin 1β (IL-1β) in chondrocytes. In conclusion, TSA protects AOT grafts from degeneration, which may provide a benefit in the repair of articular cartilage injury. Huacheng Hou, Ke Zheng, Guanghu Wang, Shiro Ikegawa, Minghao Zheng, Xiang Gao, Jinzhong Qin, Huajian Teng, and Qing Jiang Copyright © 2015 Huacheng Hou et al. All rights reserved. Intraoperative Computed Tomography versus Perdriolle and Scoliometer Evaluation of Spine Rotation in Adolescent Idiopathic Scoliosis Tue, 10 Mar 2015 07:00:20 +0000 Numerous indirect methods for apical vertebral rotation (AVR) measurement have been reported and none of them seems to be as accurate as computed tomography evaluation. The aim of this study was to compare spinal rotation changes during innovative technique of intraoperative computed tomography (ICT) evaluation with indirect methods such as Perdriolle and clinical evaluation with scoliometer. We examined 42 adolescent idiopathic scoliosis (AIS) patients treated with posterior scoliosis surgery (PSS). The mean age at the time of surgery was 16 years. ICT evaluation was performed before and after scoliosis correction in prone position. Clinical rib hump measure with scoliometer and radiographic Perdriolle were performed before and after surgery. There was 71,5% of average rib hump correction with scoliometer but only 31% of correction with ICT () and there was no significant correlation between them (, ). Mean postcorrectional Perdriolle AVR had a decrease of 16,5°. The average ICT AVR had a decrease of only 1,2° (). There was no significant statistic correlation between ICT and Perdriolle AVR evaluation (, ). There is a significant discrepancy in AVR and rib hump assessment between scoliometer and Perdriolle methods and ICT evaluation, which seems to be the most accurate tool for spinal derotation measurement. Rafal Pankowski, Szymon Wałejko, Marek Rocławski, Marcin Ceynowa, and Tomasz Mazurek Copyright © 2015 Rafal Pankowski et al. All rights reserved. Cementless Hydroxyapatite Coated Hip Prostheses Mon, 23 Feb 2015 14:22:46 +0000 More than twenty years ago, hydroxyapatite (HA), calcium phosphate ceramics, was introduced as a coating for cementless hip prostheses. The choice of this ceramic is due to its composition being similar to organic apatite bone crystals. This ceramic is biocompatible, bioactive, and osteoconductive. These qualities facilitate the primary stability and osseointegration of implants. Our surgical experience includes the implantation of more than 4,000 cementless hydroxyapatite coated hip prostheses since 1990. The models implanted are coated with HA in the acetabulum and in the metaphyseal area of the stem. The results corresponding to survival and stability of implants were very satisfactory in the long-term. From our experience, HA-coated hip implants are a reliable alternative which can achieve long term survival, provided that certain requirements are met: good design selection, sound choice of bearing surfaces based on patient life expectancy, meticulous surgical technique, and indications based on adequate bone quality. Antonio Herrera, Jesús Mateo, Jorge Gil-Albarova, Antonio Lobo-Escolar, Elena Ibarz, Sergio Gabarre, Yolanda Más, and Luis Gracia Copyright © 2015 Antonio Herrera et al. All rights reserved. What Are the Risk Factors Associated with Urinary Retention after Orthopaedic Surgery? Wed, 18 Feb 2015 11:26:01 +0000 This study investigates the overall rate of urinary retention in a large cohort of unselected orthopaedic patients who had either general or regional anesthesia and defines the risk factors for postoperative urinary retention in that cohort of patients. A total of 15,681 patients who underwent major orthopaedic surgery with general or spinal/epidural anesthesia were included. Postoperative urinary retention was defined as any patient who required a postoperative consultation to the urologic department regarding voiding difficulty. Age at surgery, sex, type of surgery, medical history including hypertension and diabetes mellitus, and type of anesthesia were analyzed as potential predictor variables. There were 365 postoperative patients who required urology consults for urinary retention (2.3%). Older age at surgery (OR, 1.035; ), male sex (OR, 1.522; ), type of surgery (OR, 1.506; ), history of hypertension (OR, 1.288; ), and history of diabetes mellitus (OR, 2.038; ) were risk factors for urinary retention after orthopaedic surgery. Advanced age, male sex, joint replacement surgery, history of hypertension, and diabetes mellitus significantly increased the risk of urinary retention. In patients with these risk factors, careful postoperative urological management should be performed. Ki Hyuk Sung, Kyoung Min Lee, Chin Youb Chung, Soon-Sun Kwon, Seung Yeol Lee, Yoon Seong Ban, and Moon Seok Park Copyright © 2015 Ki Hyuk Sung et al. All rights reserved. The Results of Adductor Magnus Tenodesis in Adolescents with Recurrent Patellar Dislocation Mon, 16 Feb 2015 10:43:52 +0000 Recurrent dislocation of the patella is a common orthopaedic problem which occurs in about 44% of cases after first-time dislocation. In most cases of first-time patellar dislocation, the medial patellofemoral ligament (MPFL) becomes damaged. Between 2010 and 2012, 33 children and adolescents (39 knees) with recurrent patellar dislocation were treated with MPFL reconstruction using the adductor magnus tendon. The aim of our study is to assess the effectiveness of this surgical procedure. The outcomes were evaluated functionally (Lysholm knee scale, the Kujala Anterior Knee Pain Scale, and isokinetic examination) and radiographically (Caton index, sulcus angle, congruence angle, and patellofemoral angle). Four patients demonstrated redislocation with MPFL graft failure, despite the fact that patellar tracking was found to be normal before the injury, and the patients had not reported any symptoms. Statistically significant improvements in Lysholm and Kujala scales, in patellofemoral and congruence angle, were seen . A statistically significant improvement in the peak torque of the quadriceps muscle and flexor was observed for 60°/sec and 180°/sec angular velocities . Our results confirm the efficacy of MPFL reconstruction using the adductor magnus tendon in children and adolescents with recurrent patellar dislocation. Krzysztof Malecki, Jaroslaw Fabis, Pawel Flont, and Kryspin Ryszard Niedzielski Copyright © 2015 Krzysztof Malecki et al. All rights reserved. The Current Testing Protocols for Biomechanical Evaluation of Lumbar Spinal Implants in Laboratory Setting: A Review of the Literature Sun, 15 Feb 2015 10:03:44 +0000 In vitro biomechanical investigations have become a routinely employed technique to explore new lumbar instrumentation. One of the most important advantages of such investigations is the low risk present when compared to clinical trials. However, the best use of any experimental data can be made when standard testing protocols are adopted by investigators, thus allowing comparisons among studies. Experimental variables, such as the length of the specimen, operative level, type of loading (e.g., dynamic versus quasistatic), magnitude, and rate of load applied, are among the most common variables controlled during spinal biomechanical testing. Although important efforts have been made to standardize these protocols, high variability can be found in the current literature. The aim of this investigation was to conduct a systematic review of the literature to identify the current trends in the protocols reported for the evaluation of new lumbar spinal implants under laboratory setting. Sabrina A. Gonzalez-Blohm, James J. Doulgeris, William E. Lee III, Thomas M. Shea, Kamran Aghayev, and Frank D. Vrionis Copyright © 2015 Sabrina A. Gonzalez-Blohm et al. All rights reserved. Analysis for Clinical Effect of Virtual Windowing and Poking Reduction Treatment for Schatzker III Tibial Plateau Fracture Based on 3D CT Data Thu, 12 Feb 2015 14:22:49 +0000 Objective. To explore the applications of preoperative planning and virtual surgery including surgical windowing and elevating reduction and to determine the clinical effects of this technology on the treatment of Schatzker type III tibial plateau fractures. Methods. 32 patients with Schatzker type III tibial plateau fractures were randomised upon their admission to the hospital using a sealed envelope method. Fourteen were treated with preoperative virtual design and assisted operation (virtual group) and 18 with direct open reduction and internal fixation (control group). Results. All patients achieved primary incision healing. Compared with control group, virtual groups showed significant advantages in operative time, incision length, and blood loss . The virtual surgery was consistent with the actual surgery. Conclusion. The virtual group was better than control group in the treatment of tibial plateau fractures of Schatzker type III, due to shorter operative time, smaller incision length, and lower blood loss. The reconstructed 3D fracture model could be used to preoperatively determine the surgical windowing and elevating reduction method and simulate the operation for Schatzker type III tibial plateau fractures. Huafeng Zhang, Zhijun Li, Qian Xu, Yuan Zhang, Ke Xu, and Xinlong Ma Copyright © 2015 Huafeng Zhang et al. All rights reserved. Effect of Teriparatide on Unstable Pertrochanteric Fractures Tue, 10 Feb 2015 11:26:44 +0000 We retrospectively analyzed the radiographic and clinical outcomes of unstable pertrochanteric fractures (AO/OTA 31-A2) in 44 patients who underwent dynamic hip screw (DHS) fixation and compared the results with 29 patients who received teriparatide in addition to DHS fixation. A significantly shorter time for fracture healing was recorded in the teriparatide-treated group than in the control group. Rates of lag screw sliding, femoral shortening, and varus collapse were all significantly reduced in the teriparatide-treated group. There were no significant differences with regard to superficial wound infection, pneumonia, urinary tract infection, mortality, malunion, and cutting of the lag screw. The mean overall mobility scores were significantly better in the teriparatide-treated group at 3 and 6 months ( and , resp.) but not at 12 months or the last follow-up. The pain scores were also significantly better in the teriparatide-treated group at 3 and 6 months ( and , resp.) but not at 12 months or the last follow-up. Teriparatide improves radiographic outcomes and yields better clinical outcomes at 3 and 6 months postoperatively. The improvement in union time may be important for elderly populations with unstable pertrochanteric fractures to enable them to return to daily activities and reduce morbidity and mortality. Tsan-Wen Huang, Tien-Yu Yang, Kuo-Chin Huang, Kuo-Ti Peng, Mel S. Lee, and Robert Wen-Wei Hsu Copyright © 2015 Tsan-Wen Huang et al. All rights reserved. Multiple Sclerosis Increases Fracture Risk: A Meta-Analysis Sun, 01 Feb 2015 11:47:37 +0000 Purpose. The association between multiple sclerosis (MS) and fracture risk has been reported, but results of previous studies remain controversial and ambiguous. To assess the association between MS and fracture risk, a meta-analysis was performed. Method. Based on comprehensive searches of the PubMed, Embase, and Web of Science, we identified outcome data from all articles estimating the association between MS and fracture risk. The pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. Results. A significant association between MS and fracture risk was found. This result remained statistically significant when the adjusted RRs were combined. Subgroup analysis stratified by the site of fracture suggested significant associations between MS and tibia fracture risk, femur fracture risk, hip fracture risk, pelvis fracture risk, vertebrae fracture risk, and humerus fracture risk. In the subgroup analysis by gender, female MS patients had increased fracture risk. When stratified by history of drug use, use of antidepressants, hypnotics/anxiolytics, anticonvulsants, and glucocorticoids increased the risk of fracture risk in MS patients. Conclusions. This meta-analysis demonstrated that MS was significantly associated with fracture risk. Guixian Dong, Ning Zhang, Zhanpo Wu, Yumin Liu, and Litao Wang Copyright © 2015 Guixian Dong et al. All rights reserved. The Influence of Electromagnetic Radiation Generated by a Mobile Phone on the Skeletal System of Rats Sun, 01 Feb 2015 09:39:58 +0000 The study was focused on the influence of electromagnetic field generated by mobile phone on the skeletal system of rats, assessed by measuring the macrometric parameters of bones, mechanical properties of long bones, calcium and phosphorus content in bones, and the concentration of osteogenesis (osteocalcin) and bone resorption (NTX, pyridinoline) markers in blood serum. The study was carried out on male rats divided into two groups: experimental group subjected to 28-day cycle of exposures in electromagnetic field of 900 MHz frequency generated by mobile phone and a control, sham-exposed one. The mobile phone-generated electromagnetic field did not influence the macrometric parameters of long bones and L4 vertebra, it altered mechanical properties of bones (stress and energy at maximum bending force, stress at fracture), it decreased the content of calcium in long bones and L4 vertebra, and it altered the concentration of osteogenesis and bone resorption markers in rats. On the basis of obtained results, it was concluded that electromagnetic field generated by 900 MHz mobile phone does not have a direct impact on macrometric parameters of bones; however, it alters the processes of bone mineralization and the intensity of bone turnover processes and thus influences the mechanical strength of bones. Karolina Sieroń-Stołtny, Łukasz Teister, Grzegorz Cieślar, Dominik Sieroń, Zbigniew Śliwinski, Marek Kucharzewski, and Aleksander Sieroń Copyright © 2015 Karolina Sieroń-Stołtny et al. All rights reserved. Balancing Rigidity and Safety of Pedicle Screw Fixation via a Novel Expansion Mechanism in a Severely Osteoporotic Model Sun, 01 Feb 2015 07:00:59 +0000 Many successful attempts to increase pullout strength of pedicle screws in osteoporotic bone have been accompanied with an increased risk of catastrophic damage to the patient. To avoid this, a single-armed expansive pedicle screw was designed to increase fixation strength while controlling postfailure damage away from the nerves surrounding the pedicle. The screw was then subsequently tested in two severely osteoporotic models: one representing trabecular bone (with and without the presence of polymethylmethacrylate) and the other representing a combination of trabecular and cortical bone. Maximum pullout strength, stiffness, energy to failure, energy to removal, and size of the resulting block damage were statistically compared among conditions. While expandable pedicle screws produced maximum pullout forces less than or comparable to standard screws, they required a higher amount of energy to be fully removed from both models. Furthermore, damage to the cortical layer in the composite test blocks was smaller in all measured directions for tests involving expandable pedicle screws than those involving standard pedicle screws. This indicates that while initial fixation may not differ in the presence of cortical bone, the expandable pedicle screw offers an increased level of postfailure stability and safety to patients awaiting revision surgery. Thomas M. Shea, James J. Doulgeris, Sabrina A. Gonzalez-Blohm, William E. Lee III, Kamran Aghayev, and Frank D. Vrionis Copyright © 2015 Thomas M. Shea et al. All rights reserved. A Novel Fixation System for Acetabular Quadrilateral Plate Fracture: A Comparative Biomechanical Study Sat, 31 Jan 2015 11:16:59 +0000 This study aims to assess the biomechanical properties of a novel fixation system (named AFRIF) and to compare it with other five different fixation techniques for quadrilateral plate fractures. This in vitro biomechanical experiment has shown that the multidirectional titanium fixation (MTF) and pelvic brim long screws fixation (PBSF) provided the strongest fixation for quadrilateral plate fracture; the better biomechanical performance of the AFRIF compared with the T-shaped plate fixation (TPF), L-shaped plate fixation (LPF), and H-shaped plate fixation (HPF); AFRIF gives reasonable stability of treatment for quadrilateral plate fracture and may offer a better solution for comminuted quadrilateral plate fractures or free floating medial wall fracture and be reliable in preventing protrusion of femoral head. Guo-Chun Zha, Jun-Ying Sun, Sheng-Jie Dong, Wen Zhang, and Zong-Ping Luo Copyright © 2015 Guo-Chun Zha et al. All rights reserved. Is DBM Beneficial for the Enhancement of Bony Consolidation in Distraction Osteogenesis? A Randomized Controlled Trial Thu, 29 Jan 2015 09:57:49 +0000 The aim of the present study was to compare the radiographic and clinical outcomes of DBM injection and conventional treatment during tibial lengthening over an intramedullary nail in adult patients with short stature. Twenty-nine patients were randomized to receive DBM injection () or conventional treatment without any injection () and evaluated. The outcome was measured on the basis of the pixel value ratio (PVR) in the digital radiographs during the consolidation period; healing index; clinical assessment; and the rate of complications. In the DBM group, the mean PVR of 1 (mineral density of the callus is comparable to the adjacent bone) was reached by 40 weeks in anterior and medial cortices which was significantly different than that in the control group ( for anterior cortex; for medial cortex). The average healing index in the DBM group was 39.8 ± 5.3 days/cm compared to 44.3 ± 5.8 days/cm in the control group (). There were no significant differences in clinical outcomes () and functional status () including complications () between two groups. In this randomized clinical trial, injection of DBM at the time of initial operation enhanced consolidation of regenerate callus without interfering with clinical outcomes compared to that with conventional treatment. Sang-Heon Song, Sang-Gyun Kim, Sung-Eun Kim, and Hae-Ryong Song Copyright © 2015 Sang-Heon Song et al. All rights reserved. Evaluation of Osseous Integration of PVD-Silver-Coated Hip Prostheses in a Canine Model Wed, 28 Jan 2015 08:54:54 +0000 Infection associated with biomaterials used for orthopedic prostheses remains a serious complication in orthopedics, especially tumor surgery. Silver-coating of orthopedic (mega)prostheses proved its efficiency in reducing infections but has been limited to surface areas exposed to soft tissues due to concerns of silver inhibiting osseous integration of cementless stems. To close this gap in the bactericidal capacity of silver-coated orthopedic prostheses extension of the silver-coating on surface areas intended for osseous integration seems to be inevitable. Our study reports about a PVD- (physical-vapor-deposition-) silver-coated cementless stem in a canine model for the first time and showed osseous integration of a silver-coated titanium surface in vivo. Radiological, histological, and biomechanical analysis revealed a stable osseous integration of four of nine stems implanted. Silver trace elemental concentrations in serum did not exceed 1.82 parts per billion (ppb) and can be considered as nontoxic. Changes in liver and kidney functions associated with the silver-coating could be excluded by blood chemistry analysis. This was in accordance with very limited metal displacement from coated surfaces observed by laser ablation inductively coupled plasma-mass spectrometry (LA-ICP-MS) 12 months after implantation. In conclusion our results represent a step towards complete bactericidal silver-coating of orthopedic prostheses. Gregor Hauschild, Jendrik Hardes, Georg Gosheger, Sandra Stoeppeler, Helmut Ahrens, Franziska Blaske, Christoph Wehe, Uwe Karst, and Steffen Höll Copyright © 2015 Gregor Hauschild et al. All rights reserved. Modulation and Predictors of Periprosthetic Bone Mineral Density following Total Knee Arthroplasty Wed, 28 Jan 2015 08:37:10 +0000 Total knee arthroplasty (TKA) leads to a loss of periprosthetic bone mineral density (BMD). Great importance is attached to the prevention of periprosthetic bone loss with a view to ensuring a long service life of the prosthesis. In order to provide appropriate recommendations for preventive movement therapy measures to combat peri-implant bone loss, it is necessary to know the predictors of periprosthetic BMD. The aim of this study was (1) to determine the change of periprosthetic BMD of the femur and tibia and (2) to analyse the effects of different predictors on periprosthetic BMD. Twenty-three patients with primary TKA were evaluated 10 days and 3 months postoperatively. The data analysis comprised (1) the change in periprosthetic BMD from pretest to posttest and (2) the correlations between BMD and the variables isometric maximum voluntary force, lean mass, physical activity (step count), and BMI using multiple linear regression and structural equation modelling (SEM). BMD of the distal femur was significantly reduced by 19.7% () 3 months after surgery, while no changes were found in BMD of the tibia. The results of SEM demonstrate that 55% of the BMD variance was explained by the model (; ; ; ; ; ; ). A significant direct effect was only evidenced by the variable lean mass (; ; ; ; ). It can be assumed that a large muscle mass with accompanying distribution of high mechanical load in the bones can contribute to local changes of periprosthetic BMD. Concrete recommendations for preventing peri-implant bone loss therefore include exercises which have the aim of maintaining or building up muscle mass. Anett Mau-Moeller, Martin Behrens, Sabine Felser, Sven Bruhn, Wolfram Mittelmeier, Rainer Bader, and Ralf Skripitz Copyright © 2015 Anett Mau-Moeller et al. All rights reserved. OSAS Surgery and Postoperative Discomfort: Phase I Surgery versus Phase II Surgery Wed, 28 Jan 2015 08:22:01 +0000 Introduction. This study aims to investigate the reasons that discourage the patients affected by OSAS to undergo orthognathic surgery and compares the postoperative discomfort of phase I (soft tissue surgery) and phase II (orthognathic surgery) procedures for treatment of OSAS. Material and Methods. A pool of 46 patients affected by OSAS was divided into two groups: “surgery patients” who accepted surgical treatments of their condition and “no surgery patients” who refused surgical procedures. The “surgery patients” group was further subdivided into two arms: patients who accepted phase I procedures (IP) and those who accepted phase II (IIP). To better understand the motivations behind the refusal of II phase procedures, we asked the patients belonging to both the IP group and “no surgery” group to indicate the main reason that influenced their decision to avoid II phase procedures. We also monitored and compared five parameters of postoperative discomfort: pain, painkiller assumption, length of hospitalization, foreign body sensation, and diet assumption following IP and IIP procedures. Results. The main reason to avoid IIP procedures was the concern of a more severe postoperative discomfort. Comparison of the postoperative discomfort following IP versus IIP procedures showed that the former scored worse in 4 out of 5 parameters analyzed. Conclusion. IIP procedures produce less postoperative discomfort. IIP procedures, namely, orthognathic surgery, should be the first choice intervention in patients affected by OSAS and dentoskeletal malformation. Giulio Gasparini, Andrea Torroni, Francesco Di Nardo, Sandro Pelo, Enrico Foresta, Roberto Boniello, Mario Romandini, Daniele Cervelli, Camillo Azzuni, and Tito Matteo Marianetti Copyright © 2015 Giulio Gasparini et al. All rights reserved. Feasibility and Efficacy of Percutaneous Lateral Lumbar Discectomy in the Treatment of Patients with Lumbar Disc Herniation: A Preliminary Experience Wed, 28 Jan 2015 07:36:39 +0000 Objective. This study was aimed at evaluating the effectiveness and safety of percutaneous lateral lumbar discectomy (PLLD) in treating patients with lumber disc herniation. Methods. A total of 183 patients with lumbar disc herniation were recruited to receive PLLD surgery from April 2006 to October 2011. All the adverse effects were recorded during the follow-up at 1, 3, 6, and 12 months after PLLD. The clinical outcomes were determined by visual analog scale and Japanese Orthopaedic Association score. Results. The surgery was performed successfully in all patients (102 males and 81 females aged from 21 to 66 years) with a mean 16.6-month follow-up (range from 26 to 65 months). No postoperative complications, including intestinal and vascular complications, nerve injuries, and postoperative infections, were associated with PLLD. At one month after surgery, visual analog scale ( versus , ) was significantly lower than the baseline and was sustained until 24 months after surgery ( versus , ). Besides that, Japanese Orthopaedic Association score ( versus , ) was increased when compared to the baseline. Conclusions. PLLD was a promising, mini-invasive, and effective treatment for lumber disc herniation. Wenjin Jiang, Bolin Sun, Qirui Sheng, Xuepeng Song, Yanbo Zheng, and Ligang Wang Copyright © 2015 Wenjin Jiang et al. All rights reserved. Medial Calcar Support and Radiographic Outcomes of Plate Fixation for Proximal Humeral Fractures Tue, 27 Jan 2015 11:24:03 +0000 Plate fixation remains one of the most popular surgical procedures for treating proximal humeral fractures (PHFx); however, substantial rates of complications have been reported in the literature. The objectives of the study were to examine how medial calcar support (MCS) affects the radiographic outcomes and to determine the prognostic factors predicting treatment failure. We performed a retrospective cohort study of 89 adult patients who had PHFx and were treated with plate fixation at our institution in 2007–2011. The enrolled patients were separated into two groups according to disruption of medial calcar. Our results revealed an increased rate of poor radiographic outcomes in patients with disrupted medial calcar. Osteonecrosis of the humeral head and redisplacement were the two radiographic outcomes which had a positive causality with disruption of medial calcar ( and 0.050, resp.). Deficient medial calcar, inadequate reduction, diabetes mellitus, chronic kidney disease, and chronic liver disease were all significant predictors for the development of osteonecrosis in patients after PHFx surgery. Inadequate reduction was also a predictor for redisplacement. We confirmed that the restoration of medial calcar as well as comorbid conditions plays key roles in treatment of patients having PHFx with disrupted medial calcar. Shih-Jie Lin, Yao-Hung Tsai, Tien-Yu Yang, Shih-Hsun Shen, Kuo-Chin Huang, and Mel S. Lee Copyright © 2015 Shih-Jie Lin et al. All rights reserved. Comparison of Two Reconstructive Techniques in the Surgical Management of Four-Level Cervical Spondylotic Myelopathy Tue, 27 Jan 2015 09:51:01 +0000 To compare the clinical efficacy and radiological outcome of treating 4-level cervical spondylotic myelopathy (CSM) with either anterior cervical discectomy and fusion (ACDF) or “skip” corpectomy and fusion, 48 patients with 4-level CSM who had undergone ACDF or SCF at our hospital were analyzed retrospectively between January 2008 and June 2011. Twenty-seven patients received ACDF (Group A) and 21 patients received SCF. Japanese Orthopaedic Association (JOA) score, Neck Disability Index (NDI) score, and Cobb’s angles of the fused segments and C2-7 segments were compared in the two groups. The minimum patient follow-up was 2 years. No significant differences between the groups were found in demographic and baseline disease characteristics, duration of surgery, or follow-up time. Our study demonstrates that there was no significant difference in the clinical efficacy of ACDF and SCF, but ACDF involves less intraoperative blood loss, better cervical spine alignment, and fewer postoperative complications than SCF. FengNing Li, ZhongHai Li, Xuan Huang, Zhi Chen, Fan Zhang, HongXing Shen, YiFan Kang, YinQuan Zhang, Bin Cai, and TieSheng Hou Copyright © 2015 FengNing Li et al. All rights reserved. The Benefit of a Human Bone Marrow Stem Cells Concentrate in addition to an Inorganic Scaffold for Bone Regeneration: An In Vitro Study Thu, 22 Jan 2015 13:18:09 +0000 Background. This work compares the osteoblastic behaviour of a bone marrow (BM) aspirate and a prepared BM concentrate of nucleated cells associated with a glass reinforced hydroxyapatite composite (GRHC) in a microporous pellet formulation. Methods. BM aspirate (30 mL) was collected during 3 orthopedic surgical procedures, and a concentration system was used to achieve 3 rapid preparations of a concentrate of nucleated cells (3 mL) from the BM aspirates. The BM aspirates (53% cell viability; nucleated cell/mL) and the BM concentrates (76% cell viability; nucleated cell/mL) were cultured over glass reinforced hydroxyapatite pellets, at the same volume/mass ratio, for 30 days. Cultures performed in standard tissue culture plates were used as control. Results. The colonized BM concentrate/material constructs exhibited a representative osteoblastic proliferation/differentiation pathway, evidenced by a high alkaline phosphatase (ALP) activity, expression of collagen type 1, ALP, BMP-2, M-CSF, RANKL, and OPG, and formation of a calcium phosphate mineralized matrix. A clear improved behaviour was noticed compared to the BM aspirate/material constructs. Conclusions. The results suggest the benefit of using an autologous BM concentrate/material construct in the clinical setting, in bone regeneration applications. J. Torres, A. Lopes, M. A. Lopes, M. Gutierres, A. T. Cabral, M. H. Fernandes, E. Monteiro, C. F. van Eck, and J. D. Santos Copyright © 2015 J. Torres et al. All rights reserved. The Correlations between Health-Related Quality of Life Changes and Pain and Anxiety in Orthodontic Patients in the Initial Stage of Treatment Thu, 22 Jan 2015 12:32:43 +0000 This study aimed to assess generic health-related quality of life (HRQoL), pain intensity, and anxiety levels and the relationship between the three aspects in healthy young Chinese orthodontic patients in the early stage of orthodontic treatment. We enrolled 252 eligible participants (10–29 years old) to complete validated Chinese versions of questionnaires, including the State-Trait Anxiety Inventory (S-AI), the visual analogue scale (VAS), and the Short-Form 36-Item Health Survey (SF-36) at baseline and on days 1, 2, 3, 7, 14, and 30 after initial archwire placement (SF-36 only at baseline and day 30). The response rate was 96% (243 of 252). SF-36 had moderate reliability (Cronbach's alpha coefficient exceeding 0.7, good fit on day 30). Statistical significant changes were observed in physical function (), body pain (), and general health () domains. Spearman correlation coefficients for SF-36 with S-AI were −0.131−0.515 (); SF-36 with VAS were −0.141−0.273 (), indicating significant but moderate negative correlations between HRQoL and pain/anxiety. Overall, the application of SF-36 in assessing HRQoL is reluctantly suitable for young Chinese orthodontic patients in the early stage of orthodontic treatment. Early treatment-related pain and anxiety are important factors in HRQoL. Jing Wang, Xiaoshan Tang, Yun Shen, Guangwei Shang, Li Fang, Raorao Wang, and Yuanzhi Xu Copyright © 2015 Jing Wang et al. All rights reserved. Effects of Lordotic Angle of a Cage on Sagittal Alignment and Clinical Outcome in One Level Posterior Lumbar Interbody Fusion with Pedicle Screw Fixation Thu, 22 Jan 2015 12:01:00 +0000 This study aims to assess the differences in the radiological and clinical results depending on the lordotic angles of the cage in posterior lumbar interbody fusion (PLIF). We reviewed 185 segments which underwent PLIF using two different lordotic angles of 4° and 8° of a polyetheretherketone (PEEK) cage. The segmental lordosis and total lumbar lordosis of the 4° and 8° cage groups were compared preoperatively, as well as on the first postoperative day, 6th and 12th months postoperatively. Clinical assessment was performed using the ODI and the VAS of low back pain. The pre- and immediate postoperative segmental lordosis angles were 12.9° and 12.6° in the 4° group and 12° and 12.0° in the 8° group. Both groups exhibited no significant different segmental lordosis angle and total lumbar lordosis over period and time. However, the total lumbar lordosis significantly increased from six months postoperatively compared with the immediate postoperative day in the 8° group. The ODI and the VAS in both groups had no differences. Cages with different lordotic angles of 4° and 8° showed insignificant results clinically and radiologically in short-level PLIF surgery. Clinical improvements and sagittal alignment recovery were significantly observed in both groups. Ji-Ho Lee, Dong-Oh Lee, Jae Hyup Lee, and Hee Jong Shim Copyright © 2015 Ji-Ho Lee et al. All rights reserved. Analysis of Single Nucleotide Polymorphisms within ADAM12 and Risk of Knee Osteoarthritis in a Chinese Han Population Thu, 15 Jan 2015 09:51:08 +0000 Objective. Osteoarthritis (OA) is a complex arthritic condition in which the genetic factor plays a major role. One of the candidate genes of is the ADAM12 gene, but no consistency has been reached till now. This study aims to investigate the potential role of four single nucleotide polymorphisms (SNPs) of the ADAM12 gene in susceptibility to knee OA and its progression in Chinese Han population. Methods. The rs1278279, rs3740199, rs1044122, and rs1871054 polymorphisms were genotyped and compared in a population based cohort consisting of 164 OA subjects and 200 age- and gender-matched controls. Results. The SNP rs1871054 was found with increased risk of OA susceptibility in comparing the genotype frequencies between the case and control groups no matter for which model of comparison (allele level, dominant model, recessive model, and extreme genotype model). Additionally, the SNP rs1871054 was found associated with increased OA severity according to the K/L grade. Conclusion. In summary, we have identified that the rs1871054 variant within the ADAM12 gene is a risk factor for increased osteoarthritis susceptibility and severity. Lin Wang, Lin Guo, Fengde Tian, Ruihu Hao, and Tiejun Yang Copyright © 2015 Lin Wang et al. All rights reserved. Clinical Outcome after the Use of a New Craniocaudal Expandable Implant for Vertebral Compression Fracture Treatment: One Year Results from a Prospective Multicentric Study Tue, 13 Jan 2015 06:54:18 +0000 The purpose of this prospective multicentric observational study was to confirm the safety and clinical performance of a craniocaudal expandable implant used in combination with high viscosity PMMA bone cement for the treatment of vertebral compression fractures. Thirty-nine VCFs in 32 patients were treated using the SpineJack minimally invasive surgery protocol. Outcome was determined by using the Visual Analogue Scale for measuring pain, the Oswestry Disability Index for scoring functional capacity, and the self-reporting European Quality of Life scores for the quality of life. Safety was evaluated by reporting all adverse events. The occurrence of cement leakages was assessed by either radiographs or CT scan or both. Statistically significant improvements were found regarding pain, function, and quality of life. The global pain score reduction at 1 year was 80.9% compared to the preoperative situation and the result of the Oswestry Disability Index showed a decrease from 65.0% at baseline to 10.5% at 12 months postoperatively. The cement leakage rate was 30.8%. No device- or surgery-related complications were found. This observational study demonstrates promising and persistent results consisting of immediate and sustained pain relief and durable clinical improvement after the procedure and throughout the 1-year follow-up period. David Noriega, Antonio Krüger, Francisco Ardura, Nils Hansen-Algenstaedt, Frank Hassel, Xavier Barreau, and Jörg Beyerlein Copyright © 2015 David Noriega et al. All rights reserved. In Vitro and In Vivo Evaluation of Vancomycin-Loaded PMMA Cement in Combination with Ultrasound and Microbubbles-Mediated Ultrasound Tue, 06 Jan 2015 08:56:50 +0000 Ultrasound (US) has been used to increase elution of antibiotic from an antibiotic-loaded poly(methyl methacrylate) (PMMA) bone cement (ALBC). We aimed to further investigate whether microbubbles-mediated US (US + MB) facilitate elution of vancomycin (VAN) from cylindrical specimens and enhance the activity of the eluted antibiotic against Staphylococcus aureus (S. aureus) in vitro. The study groups comprised cylindrical bone cement fabricated with VAN (VAN), ALBC using US (VAN + US), and ALBC using MB-mediated US (VAN + US + MB). We also carried out an in vivo study involving the activity of VAN from cylindrical cement implanted in tibiae of New Zealand white rabbits inoculated with S. aureus. We found that (1) in vitro, elution from VAN + US + MB cylinders was significantly higher than from either the VAN or VAN + US specimens; (2) the activity of the eluted VAN from the VAN + US + MB cylinders against planktonic S. aureus was significantly higher than from either the control or VAN or VAN + US specimens; and (3) in the rabbits, the activity of the eluted VAN from the VAN + US + MB cylinders against S. aureus was significantly higher than from either the control or VAN or VAN + US specimens. The present results suggest that VAN-loaded PMMA cement irradiated with MB-mediated US may have a role in controlling prosthetic joint infection. Tiao Lin, Xun-Zi Cai, Ming-Min Shi, Zhi-Min Ying, Bin Hu, Chen-He Zhou, Wei Wang, Zhong-Li Shi, and Shi-Gui Yan Copyright © 2015 Tiao Lin et al. All rights reserved. Kinematic Analysis of Healthy Hips during Weight-Bearing Activities by 3D-to-2D Model-to-Image Registration Technique Sun, 23 Nov 2014 00:00:00 +0000 Dynamic hip kinematics during weight-bearing activities were analyzed for six healthy subjects. Continuous X-ray images of gait, chair-rising, squatting, and twisting were taken using a flat panel X-ray detector. Digitally reconstructed radiographic images were used for 3D-to-2D model-to-image registration technique. The root-mean-square errors associated with tracking the pelvis and femur were less than 0.3 mm and 0.3° for translations and rotations. For gait, chair-rising, and squatting, the maximum hip flexion angles averaged 29.6°, 81.3°, and 102.4°, respectively. The pelvis was tilted anteriorly around 4.4° on average during full gait cycle. For chair-rising and squatting, the maximum absolute value of anterior/posterior pelvic tilt averaged 12.4°/11.7° and 10.7°/10.8°, respectively. Hip flexion peaked on the way of movement due to further anterior pelvic tilt during both chair-rising and squatting. For twisting, the maximum absolute value of hip internal/external rotation averaged 29.2°/30.7°. This study revealed activity dependent kinematics of healthy hip joints with coordinated pelvic and femoral dynamic movements. Kinematics’ data during activities of daily living may provide important insight as to the evaluating kinematics of pathological and reconstructed hips. Daisuke Hara, Yasuharu Nakashima, Satoshi Hamai, Hidehiko Higaki, Satoru Ikebe, Takeshi Shimoto, Masanobu Hirata, Masayuki Kanazawa, Yusuke Kohno, and Yukihide Iwamoto Copyright © 2014 Daisuke Hara et al. All rights reserved. Efficacy of Alendronate for Preventing Collapse of Femoral Head in Adult Patients with Nontraumatic Osteonecrosis Tue, 11 Nov 2014 13:23:55 +0000 The purpose of the current review was to determine the efficacy of alendronate for preventing collapse of femoral head in adult patients with nontraumatic avascular osteonecrosis of femoral head (ANFH). Five randomized controlled trials (RCTs) involving 305 hips were included in this review, of which 3 studies investigated alendronate versus control/placebo and the other 2 studies compared the combination of alendronate and extracorporeal shockwave therapy (ESWT) with ESWT alone. Our results suggested that even the patients with extensive necrosis encountered much less collapse in the alendronate group than control group. In these RCTs, their data also indicated a positive short- and middle-term efficacy of alendronate treatment in joint function improvement and hip pain diminishment. With the presence of the outlier study, only insignificant overall efficacy of alendronate could be observed with substantial heterogeneities. In addition, we did not find any additive benefits of alendronate in combination with ESWT for preventing collapse compared to ESWT alone. In conclusion, there is still lack of strong evidence for supporting application of alendronate in adult patients with nontraumatic ANFH, which justified that large scale, randomized, and double-blind studies should be developed to demonstrate the confirmed efficacies, detailed indication, and optimized strategy of alendronate treatment. Yu-Cai Hong, Ru-Bin Luo, Tiao Lin, Hui-Ming Zhong, and Jian-Bin Shi Copyright © 2014 Yu-Cai Hong et al. All rights reserved. Clinical Significance of Resistin Expression in Osteoarthritis: A Meta-Analysis Wed, 29 Oct 2014 13:25:20 +0000 Background. The objective of this study was to conduct a systematic review of literature evaluating human resistin expression as a diagnostic factor in osteoarthritis development and to quantify the overall diagnostic effect. Method. Relevant studies were identified and evaluated for quality through multiple search strategies. Studies analyzing resistin expression in the development of OA were eligible for inclusion. Data from eligible studies were extracted and included into the meta-analysis using a random-effects model. Results. Four case-control studies consisting of a total of 375 OA patients and 214 controls as well as three sex-stratified analyses composed of 53 males and 104 females were incorporated into our meta-analysis. Our results revealed that resistin levels were significantly higher in male OA subjects and OA patients overall. Country-stratified analysis yielded significantly different estimates in resistin levels between male OA subjects and female OA subjects in the Canadian subgroup but not among the French and USA subgroups. Based on the resistin levels in OA cases and controls, resistin levels were heightened in OA patients in the Dutch population. Conclusion. These results support the hypothesis that high expression of resistin represents a significant and reproducible marker of poor progression in OA patients, especially in males. Xiao-Chuan Li, Feng Tian, and Fei Wang Copyright © 2014 Xiao-Chuan Li et al. All rights reserved. Molecular, Phenotypic Aspects and Therapeutic Horizons of Rare Genetic Bone Disorders Wed, 22 Oct 2014 12:05:37 +0000 A rare disease afflicts less than 200,000 individuals, according to the National Organization for Rare Diseases (NORD) of the United States. Over 6,000 rare disorders affect approximately 1 in 10 Americans. Rare genetic bone disorders remain the major causes of disability in US patients. These rare bone disorders also represent a therapeutic challenge for clinicians, due to lack of understanding of underlying mechanisms. This systematic review explored current literature on therapeutic directions for the following rare genetic bone disorders: fibrous dysplasia, Gorham-Stout syndrome, fibrodysplasia ossificans progressiva, melorheostosis, multiple hereditary exostosis, osteogenesis imperfecta, craniometaphyseal dysplasia, achondroplasia, and hypophosphatasia. The disease mechanisms of Gorham-Stout disease, melorheostosis, and multiple hereditary exostosis are not fully elucidated. Inhibitors of the ACVR1/ALK2 pathway may serve as possible therapeutic intervention for FOP. The use of bisphosphonates and IL-6 inhibitors has been explored to be useful in the treatment of fibrous dysplasia, but more research is warranted. Cell therapy, bisphosphonate polytherapy, and human growth hormone may avert the pathology in osteogenesis imperfecta, but further studies are needed. There are still no current effective treatments for these bone disorders; however, significant promising advances in therapeutic modalities were developed that will limit patient suffering and treat their skeletal disabilities. Taha Faruqi, Naveen Dhawan, Jaya Bahl, Vineet Gupta, Shivani Vohra, Khin Tu, and Samir M. Abdelmagid Copyright © 2014 Taha Faruqi et al. All rights reserved. Transforming Growth Factor-Beta (TGF-β) Signaling in Paravertebral Muscles in Juvenile and Adolescent Idiopathic Scoliosis Mon, 15 Sep 2014 08:10:31 +0000 Most researchers agree that idiopathic scoliosis (IS) is a multifactorial disease influenced by complex genetic and environmental factors. The onset of the spinal deformity that determines the natural course of the disease, usually occurs in the juvenile or adolescent period. Transforming growth factors β (TGF-βs) and their receptors, TGFBRs, may be considered as candidate genes related to IS susceptibility and natural history. This study explores the transcriptional profile of TGF-βs, TGFBRs, and TGF-β responsive genes in the paravertebral muscles of patients with juvenile and adolescent idiopathic scoliosis (JIS and AIS, resp.). Muscle specimens were harvested intraoperatively and grouped according to the side of the curve and the age of scoliosis onset. The results of microarray and qRT-PCR analysis confirmed significantly higher transcript abundances of TGF-β2, TGF-β3, and TGFBR2 in samples from the curve concavity of AIS patients, suggesting a difference in TGF-β signaling in the pathogenesis of juvenile and adolescent curves. Analysis of TGF-β responsive genes in the transcriptomes of patients with AIS suggested overrepresentation of the genes localized in the extracellular region of curve concavity: LTBP3, LTBP4, ITGB4, and ITGB5. This finding suggests the extracellular region of paravertebral muscles as an interesting target for future molecular research into AIS pathogenesis. Roman Nowak, Magdalena Kwiecien, Magdalena Tkacz, and Urszula Mazurek Copyright © 2014 Roman Nowak et al. All rights reserved. Evaluating the Bone Tissue Regeneration Capability of the Chinese Herbal Decoction Danggui Buxue Tang from a Molecular Biology Perspective Thu, 11 Sep 2014 00:00:00 +0000 Large bone defects are a considerable challenge to reconstructive surgeons. Numerous traditional Chinese herbal medicines have been used to repair and regenerate bone tissue. This study investigated the bone regeneration potential of Danggui Buxue Tang (DBT), a Chinese herbal decoction prepared from Radix Astragali (RA) and Radix Angelicae Sinensis (RAS), from a molecular biology perspective. The optimal ratio of RA and RAS used in DBT for osteoblast culture was obtained by colorimetric and alkaline phosphatase (ALP) activity assays. Moreover, the optimal concentration of DBT for bone cell culture was also determined by colorimetric, ALP activity, nodule formation, Western blotting, wound-healing, and tartrate-resistant acid phosphatase activity assays. Consequently, the most appropriate weight ratio of RA to RAS for the proliferation and differentiation of osteoblasts was 5 : 1. Moreover, the most effective concentration of DBT was 1,000 μg/mL, which significantly increased the number of osteoblasts, intracellular ALP levels, and nodule numbers, while inhibiting osteoclast activity. Additionally, 1,000 μg/mL of DBT was able to stimulate p-ERK and p-JNK signal pathway. Therefore, DBT is highly promising for use in accelerating fracture healing in the middle or late healing periods. Wen-Ling Wang, Shi-Yuan Sheu, Yueh-Sheng Chen, Shung-Te Kao, Yuan-Tsung Fu, Tzong-Fu Kuo, Kuo-Yu Chen, and Chun-Hsu Yao Copyright © 2014 Wen-Ling Wang et al. All rights reserved. Spine Curvature Analysis between Participants with Obesity and Normal Weight Participants: A Biplanar Electromagnetic Device Measurement Tue, 09 Sep 2014 08:51:54 +0000 To analyse and compare standing thoracolumbar curves in normal weight participants and participants with obesity, using an electromagnetic device, and to analyse the measurement reliability. Material and Methods. Cross-sectional study was carried out. 36 individuals were divided into two groups (normal-weight and participants with obesity) according to their waist circumference. The reference points (T1–T8–L1–L5 and both posterior superior iliac spines) were used to perform a description of thoracolumbar curvature in the sagittal and coronal planes. A transformation from the global coordinate system was performed and thoracolumbar curves were adjusted by fifth-order polynomial equations. The tangents of the first and fifth lumbar vertebrae and the first thoracic vertebra were determined from their derivatives. The reliability of the measurement was assessed according to the internal consistency of the measure and the thoracolumbar curvature angles were compared between groups. Results. Cronbach’s alpha values ranged between 0.824 (95% CI: 0.776–0.847) and 0.918 (95% CI: 0.903–0.949). In the coronal plane, no significant differences were found between groups; however, in sagittal plane, significant differences were observed for thoracic kyphosis. Conclusion. There were significant differences in thoracic kyphosis in the sagittal plane between two groups of young adults grouped according to their waist circumference. Manuel González-Sánchez, Jin Luo, Raymond Lee, and Antonio I. Cuesta-Vargas Copyright © 2014 Manuel González-Sánchez et al. All rights reserved. Characterization of Individuals with Sacroiliac Joint Bridging in a Skeletal Population: Analysis of Degenerative Changes in Spinal Vertebrae Mon, 08 Sep 2014 07:55:20 +0000 The aim of this study was to characterize the individuals with sacroiliac joint bridging (SIB) by analyzing the degenerative changes in their whole vertebral column and comparing them with the controls. A total of 291 modern Japanese male skeletons, with an average age at death of 60.8 years, were examined macroscopically. They were divided into two groups: individuals with SIB and those without bridging (Non-SIB). The degenerative changes in their whole vertebral column were evaluated, and marginal osteophyte scores (MOS) of the vertebral bodies and degenerative joint scores in zygapophyseal joints were calculated. SIB was recognized in 30 individuals from a total of 291 males (10.3%). The average of age at death in SIB group was significantly higher than that in Non-SIB group. The values of MOS in the thoracic spines, particularly in the anterior part of the vertebral bodies, were consecutively higher in SIB group than in Non-SIB group. Incidence of fused vertebral bodies intervertebral levels was obviously higher in SIB group than in Non-SIB group. SIB and marginal osteophyte formation in vertebral bodies could coexist in a skeletal population of men. Some systemic factors might act on these degenerative changes simultaneously both in sacroiliac joint and in vertebral column. Takeshi Imamura, Kazunobu Saiki, Keishi Okamoto, Junichiro Maeda, Hiroaki Matsuo, Tetsuaki Wakebe, Keiko Ogami, Yoshitaka Manabe, Hironobu Koseki, Masato Tomita, Atsushi Tagami, Makoto Osaki, Hiroyuki Shindo, and Toshiyuki Tsurumoto Copyright © 2014 Takeshi Imamura et al. All rights reserved. Hyperuricemic PRP in Tendon Cells Mon, 08 Sep 2014 00:00:00 +0000 Platelet-rich plasma (PRP) is injected within tendons to stimulate healing. Metabolic alterations such as the metabolic syndrome, diabetes, or hyperuricemia could hinder the therapeutic effect of PRP. We hypothesise that tendon cells sense high levels of uric acid and this could modify their response to PRP. Tendon cells were treated with allogeneic PRPs for 96 hours. Hyperuricemic PRP did not hinder the proliferative actions of PRP. The gene expression pattern of inflammatory molecules in response to PRP showed absence of IL-1b and COX1 and modest expression of IL6, IL8, COX2, and TGF-b1. IL8 and IL6 proteins were secreted by tendon cells treated with PRP. The synthesis of IL6 and IL8 proteins induced by PRP is decreased significantly in the presence of hyperuricemia (P = 0.017 and P = 0.012, resp.). Concerning extracellular matrix, PRP-treated tendon cells displayed high type-1 collagen, moderate type-3 collagen, decorin, and hyaluronan synthase-2 expression and modest expression of scleraxis. Hyperuricemia modified the expression pattern of extracellular matrix proteins, upregulating COL1 (P = 0.036) and COMP (P = 0.012) and downregulating HAS2 (P = 0.012). Positive correlations between TGF-b1 and type-1 collagen (R = 0.905, P = 0.002) and aggrecan (R = 0.833, P = 0.010) and negative correlations between TGF-b1 and IL6 synthesis (R = −0.857, P = 0.007) and COX2 (R = −0.810, P = 0.015) were found. I. Andia, E. Rubio-Azpeitia, and N. Maffulli Copyright © 2014 I. Andia et al. All rights reserved. Craniofacial and Cervical Morphology Related to Sagittal Spinal Posture in Children and Adolescents Sun, 07 Sep 2014 11:40:03 +0000 Studies on the relationship between body posture and craniofacial parameters often focus on the cervical spine. Thus, less attention has been paid to the morphology of the vertebra C2 that serves as both a structural and functional link between the craniofacial area and the other part of the spine. The objective of this study was to assess the relation of craniofacial features to certain morphological and positional characteristics of the cervical vertebrae and the spine during growth. We determined body posture indices for 69 children and adolescents by means of a radiation-free method (rasterstereography). The morphological and positional analysis of the craniofacial area and the cervical vertebrae was based on standardized lateral X-ray cephalograms. Medium to strong correlations were found between body posture, C2 morphology, and craniofacial parameters. We found significant correlations between the C2 dens axis height and maxillary indices as well as between the C2 dens axis inclination and cephalometrical values of the mandibular area. Similarly the correlation between the C2 dens axis inclination and the postural index flèche cervicale was highly significant (, ). These results suggest that morphological features of the odontoid process may serve as valuable predictive markers in interdisciplinary orthopedic-orthodontic diagnostics. Emil Segatto, Angyalka Segatto, Gábor Braunitzer, Christian Kirschneck, Jochen Fanghänel, Gholamreza Danesh, and Carsten Lippold Copyright © 2014 Emil Segatto et al. All rights reserved. Efficacy of Autologous Bone Marrow Concentrate for Knee Osteoarthritis with and without Adipose Graft Sun, 07 Sep 2014 07:41:35 +0000 Introduction. We investigated the use of autologous bone marrow concentrate (BMC) with and without an adipose graft, for treatment of knee osteoarthritis (OA). Methods. Treatment registry data for patients who underwent BMC procedures with and without an adipose graft were analyzed. Pre- and posttreatment outcomes of interest included the lower extremity functional scale (LEFS), the numerical pain scale (NPS), and a subjective percentage improvement rating. Multivariate analyses were performed to examine the effects of treatment type adjusting for potential confounding factors. The frequency and type of adverse events (AE) were also examined. Results. 840 procedures were performed, 616 without and 224 with adipose graft. The mean LEFS score increased by 7.9 and 9.8 in the two groups (out of 80), respectively, and the mean NPS score decreased from 4 to 2.6 and from 4.3 to 3 in the two groups, respectively. AE rates were 6% and 8.9% in the two groups, respectively. Although pre- and posttreatment improvements were statistically significant, the differences between the groups were not. Conclusion. BMC injections for knee OA showed encouraging outcomes and a low rate of AEs. Addition of an adipose graft to the BMC did not provide a detectible benefit over BMC alone. Christopher Centeno, John Pitts, Hasan Al-Sayegh, and Michael Freeman Copyright © 2014 Christopher Centeno et al. All rights reserved. Determining the Best Treatment for Coronal Angular Deformity of the Knee Joint in Growing Children: A Decision Analysis Wed, 03 Sep 2014 12:50:48 +0000 This study aimed to determine the best treatment modality for coronal angular deformity of the knee joint in growing children using decision analysis. A decision tree was created to evaluate 3 treatment modalities for coronal angular deformity in growing children: temporary hemiepiphysiodesis using staples, percutaneous screws, or a tension band plate. A decision analysis model was constructed containing the final outcome score, probability of metal failure, and incomplete correction of deformity. The final outcome was defined as health-related quality of life and was used as a utility in the decision tree. The probabilities associated with each case were obtained by literature review, and health-related quality of life was evaluated by a questionnaire completed by 25 pediatric orthopedic experts. Our decision analysis model favored temporary hemiepiphysiodesis using a tension band plate over temporary hemiepiphysiodesis using percutaneous screws or stapling, with utilities of 0.969, 0.957, and 0.962, respectively. One-way sensitivity analysis showed that hemiepiphysiodesis using a tension band plate was better than temporary hemiepiphysiodesis using percutaneous screws, when the overall complication rate of hemiepiphysiodesis using a tension band plate was lower than 15.7%. Two-way sensitivity analysis showed that hemiepiphysiodesis using a tension band plate was more beneficial than temporary hemiepiphysiodesis using percutaneous screws. Ki Hyuk Sung, Chin Youb Chung, Kyoung Min Lee, Seung Yeol Lee, In Ho Choi, Tae-Joon Cho, Won Joon Yoo, and Moon Seok Park Copyright © 2014 Ki Hyuk Sung et al. All rights reserved. Platelet Rich Plasma and Knee Surgery Tue, 02 Sep 2014 14:14:21 +0000 In orthopaedic surgery and sports medicine, the knee joint has traditionally been considered the workhorse. The reconstruction of every damaged element in this joint is crucial in achieving the surgeon’s goal to restore the knee function and prevent degeneration towards osteoarthritis. In the last fifteen years, the field of regenerative medicine is witnessing a boost of autologous blood-derived platelet rich plasma products (PRPs) application to effectively mimic and accelerate the tissue healing process. The scientific rationale behind PRPs is the delivery of growth factors, cytokines, and adhesive proteins present in platelets and plasma, as well as other biologically active proteins conveyed by the plasma such as fibrinogen, prothrombin, and fibronectin; with this biological engineering approach, new perspectives in knee surgery were opened. This work describes the use of PRP to construct and repair every single anatomical structure involved in knee surgery, detailing the process conducted in ligament, meniscal, and chondral surgery. Mikel Sánchez, Diego Delgado, Pello Sánchez, Nicolás Fiz, Juan Azofra, Gorka Orive, Eduardo Anitua, and Sabino Padilla Copyright © 2014 Mikel Sánchez et al. All rights reserved. Are Applied Growth Factors Able to Mimic the Positive Effects of Mesenchymal Stem Cells on the Regeneration of Meniscus in the Avascular Zone? Sun, 31 Aug 2014 10:49:11 +0000 Meniscal lesions in the avascular zone are still a problem in traumatology. Tissue Engineering approaches with mesenchymal stem cells (MSCs) showed successful regeneration of meniscal defects in the avascular zone. However, in daily clinical practice, a single stage regenerative treatment would be preferable for meniscus injuries. In particular, clinically applicable bioactive substances or isolated growth factors like platelet-rich plasma (PRP) or bone morphogenic protein 7 (BMP7) are in the focus of interest. In this study, the effects of PRP and BMP7 on the regeneration of avascular meniscal defects were evaluated. In vitro analysis showed that PRP secretes multiple growth factors over a period of 8 days. BMP7 enhances the collagen II deposition in an aggregate culture model of MSCs. However applied to meniscal defects PRP or BMP7 in combination with a hyaluronan collagen composite matrix failed to significantly improve meniscus healing in the avascular zone in a rabbit model after 3 months. Further information of the repair mechanism at the defect site is needed to develop special release systems or carriers for the appropriate application of growth factors to support biological augmentation of meniscus regeneration. Johannes Zellner, Christian Dirk Taeger, Markus Schaffer, J. Camilo Roldan, Markus Loibl, Michael B. Mueller, Arne Berner, Werner Krutsch, Michaela K. I. Huber, Richard Kujat, Michael Nerlich, and Peter Angele Copyright © 2014 Johannes Zellner et al. All rights reserved. Accuracy of Patient Specific Cutting Blocks in Total Knee Arthroplasty Sun, 31 Aug 2014 09:03:06 +0000 Background. Long-term survival of total knee arthroplasty (TKA) is mainly determined by optimal positioning of the components and prosthesis alignment. Implant positioning can be optimized by computer assisted surgery (CAS). Patient specific cutting blocks (PSCB) seem to have the potential to improve component alignment compared to the conventional technique and to be comparable to CAS. Methods. 113 knees were selected for PSI and included in this study. Pre- and postoperative mechanical axis, represented by the hip-knee-angle (HKA), the proximal tibial angle (PTA), the distal femoral angle (DFA), and the tibial slope (TS) were measured and the deviation from expected ideal values was calculated. Results. With a margin of error of ±3°, success rates were 81.4% for HKA, 92.0% for TPA, and 94.7% for DFA. With the margin of error for alignments extended to ±4°, we obtained a success rate of 92.9% for the HKA, 98.2% for the PTA, and 99.1% for the DFA. The TS showed postoperative results of 2.86 ± 2.02° (mean change 1.76 ± 2.85°). Conclusion. PSCBs for TKA seem to restore the overall leg alignment. Our data suggest that each individual component can be implanted accurately and the results are comparable to the ones in CAS. Naeder Helmy, Mai Lan Dao Trong, and Stefanie P. Kühnel Copyright © 2014 Naeder Helmy et al. All rights reserved. Arthroscopic Fixation of Cell Free Polymer-Based Cartilage Implants with a Bioinspired Polymer Surface on the Hip Joint: A Cadaveric Pilot Study Thu, 28 Aug 2014 00:00:00 +0000 This study investigates the adhesion capacity of a polyglycolic acid- (PGA-) hyaluronan scaffold with a structural modification based on a planar polymer (PM) surface in a cadaver cartilage defect model. Two cadaver specimens were used to serially test multiple chondral matrices. In a cadaver hip model, cell free polymer-based cartilage implants with a planar bioinspired PM surface (PGA-PM-scaffolds) were implanted arthroscopically on 10 mm × 15 mm full-thickness femoral hip cartilage lesions. Unprocessed cartilage implants without a bioinspired PM surface were used as control group. The cartilage implants were fixed without and with the use of fibrin glue on femoral hip cartilage defects. After 50 movement cycles and removal of the distraction, a rearthroscopy was performed to assess the outline attachment and integrity of the scaffold. The fixation techniques without and with fibrin fixation showed marginal differences for outline attachment, area coverage, scaffold integrity, and endpoint fixation after 50 cycles. The PGA-PM-scaffolds with fibrin fixation achieved a higher score in terms of the attachment, integrity, and endpoint fixation than the PGA-scaffold on the cartilage defect. Relating to the outline attachment, area coverage, scaffold integrity, and endpoint fixation, the fixation with PGA-PM-scaffolds accomplished significantly better results compared to the PGA-scaffolds . PGA-PM-scaffolds demonstrate increased observed initial fixation strength in cadaver femoral head defects relative to PGA-scaffold, particularly when fibrin glue is used for fixation. Matthias Lahner, Christian Duif, Andreas Ficklscherer, Christian Kaps, Lukas Kalwa, and Tobias Seidl Copyright © 2014 Matthias Lahner et al. All rights reserved. Study of the Polycarbonate-Urethane/Metal Contact in Different Positions during Gait Cycle Wed, 27 Aug 2014 09:09:29 +0000 Nowadays, a growing number of young and more active patients receive hip replacement. More strenuous activities in such patients involve higher friction and wear rates, with friction on the bearing surface being crucial to ensure arthroplasty survival in the long term. Over the last years, the polycarbonate-urethane has offered a feasible alternative to conventional bearings. A finite element model of a healthy hip joint was developed and adjusted to three gait phases (heel strike, mid-stance, and toe-off), serving as a benchmark for the assessment of the results of joint replacement model. Three equivalent models were made with the polycarbonate-urethane Tribofit system implanted, one for each of the three gait phases, after reproducing a virtual surgery over the respective healthy models. Standard body-weight loads were considered: 230% body-weight toe-off, 275% body-weight mid-stance, and 350% body-weight heel strike. Contact pressures were obtained for the different models. When comparing the results corresponding to the healthy model to polycarbonate-urethane joint, contact areas are similar and so contact pressures are within a narrower value range. In conclusion, polycarbonate-urethane characteristics are similar to those of the joint cartilage. So, it is a favorable alternative to traditional bearing surfaces in total hip arthroplasty, especially in young patients. Sergio Gabarre, Antonio Herrera, Jesús Mateo, Elena Ibarz, Antonio Lobo-Escolar, and Luis Gracia Copyright © 2014 Sergio Gabarre et al. All rights reserved. Perforator Based Propeller Flaps in Limb Reconstructive Surgery: Clinical Application and Literature Review Wed, 27 Aug 2014 09:08:50 +0000 The reconstruction of loss of substance due to trauma or oncological excision may have relevant functional and aesthetic implications. We report our experience in twenty-one cases of propeller flaps for the treatment of loss of substance of the upper and lower limbs. The etiology of defect was tumor excision in nine cases, trauma in seven cases, surgical wound complications in four cases, and chronic osteomyelitis in one case. Clinical results were favorable in most cases and eighteen flaps survived. We observed an overall complication rate of 33% with four cases of superficial epidermolysis that spontaneously healed and three cases of partial flap loss ranging from 10 to 50% that required surgical revision by means of skin graft (two cases) or ALT free flap (one case). Propeller flap harvesting requires great care and experience, and potential complications may occur even in expert hands. When indicated by the characteristic of the defect, these flaps can be a useful surgical option for the treatment of loss of substance of upper and lower limbs. Stefano Artiaco, Bruno Battiston, Giulia Colzani, Pasquale Bianchi, Gabriele Scaravilli, Elena Boux, and Pierluigi Tos Copyright © 2014 Stefano Artiaco et al. All rights reserved. Highly Cross-Linked Polyethylene in Total Hip and Knee Replacement: Spatial Distribution of Molecular Orientation and Shape Recovery Behavior Wed, 27 Aug 2014 00:00:00 +0000 The present study investigated effects of processing procedures on morphology of highly cross-linked and re-melted UHMWPE (XLPE) in total hip and knee arthroplasty (THA, TKA). The shape recovery behavior was also monitored via uniaxial compression test at room temperature after non-destructive characterizations of the in-depth microstructure by confocal/polarized Raman spectroscopy. The goal of this study was to relate the manufacturing-induced morphology to the in vivo micromechanical performance, and ultimately to explore an optimal structure in each alternative joint bearing. It was clearly confirmed that the investigated XLPE hip and knee implants, which were produced from different orthopaedic grade resins (GUR 1050 and GUR 1020), consisted of two structural regions in the as-received states: the near-surface transitional anisotropic layer (≈100 μm thickness) and the bulk isotropic structural region. These XLPEs exhibited a different crystalline anisotropy and molecular texture within the near-surface layers. In addition, the knee insert showed a slightly higher efficiency of shape recovery against the applied strain over the hip liner owing to a markedly higher percentage of the bulk amorphous phase with intermolecular cross-linking. The quantitative data presented in this study might contribute to construct manufacturing strategies for further rationalized structures as alternative bearings in THA and TKA. Yasuhito Takahashi, Toshinori Masaoka, Giuseppe Pezzotti, Takaaki Shishido, Toshiyuki Tateiwa, Kosuke Kubo, and Kengo Yamamoto Copyright © 2014 Yasuhito Takahashi et al. All rights reserved. Evolution of Autologous Chondrocyte Repair and Comparison to Other Cartilage Repair Techniques Mon, 18 Aug 2014 07:03:32 +0000 Articular cartilage defects have been addressed using microfracture, abrasion chondroplasty, or osteochondral grafting, but these strategies do not generate tissue that adequately recapitulates native cartilage. During the past 25 years, promising new strategies using assorted scaffolds and cell sources to induce chondrocyte expansion have emerged. We reviewed the evolution of autologous chondrocyte implantation and compared it to other cartilage repair techniques. Methods. We searched PubMed from 1949 to 2014 for the keywords “autologous chondrocyte implantation” (ACI) and “cartilage repair” in clinical trials, meta-analyses, and review articles. We analyzed these articles, their bibliographies, our experience, and cartilage regeneration textbooks. Results. Microfracture, abrasion chondroplasty, osteochondral grafting, ACI, and autologous matrix-induced chondrogenesis are distinguishable by cell source (including chondrocytes and stem cells) and associated scaffolds (natural or synthetic, hydrogels or membranes). ACI seems to be as good as, if not better than, microfracture for repairing large chondral defects in a young patient’s knee as evaluated by multiple clinical indices and the quality of regenerated tissue. Conclusion. Although there is not enough evidence to determine the best repair technique, ACI is the most established cell-based treatment for full-thickness chondral defects in young patients. Ashvin K. Dewan, Matthew A. Gibson, Jennifer H. Elisseeff, and Michael E. Trice Copyright © 2014 Ashvin K. Dewan et al. All rights reserved. Regenerative Medicine in Rotator Cuff Injuries Wed, 13 Aug 2014 00:00:00 +0000 Rotator cuff injuries are a common source of shoulder pathology and result in an important decrease in quality of patient life. Given the frequency of these injuries, as well as the relatively poor result of surgical intervention, it is not surprising that new and innovative strategies like tissue engineering have become more appealing. Tissue-engineering strategies involve the use of cells and/or bioactive factors to promote tendon regeneration via natural processes. The ability of numerous growth factors to affect tendon healing has been extensively analyzed in vitro and in animal models, showing promising results. Platelet-rich plasma (PRP) is a whole blood fraction which contains several growth factors. Controlled clinical studies using different autologous PRP formulations have provided controversial results. However, favourable structural healing rates have been observed for surgical repair of small and medium rotator cuff tears. Cell-based approaches have also been suggested to enhance tendon healing. Bone marrow is a well known source of mesenchymal stem cells (MSCs). Recently, ex vivo human studies have isolated and cultured distinct populations of MSCs from rotator cuff tendons, long head of the biceps tendon, subacromial bursa, and glenohumeral synovia. Stem cells therapies represent a novel frontier in the management of rotator cuff disease that required further basic and clinical research. Pietro Randelli, Filippo Randelli, Vincenza Ragone, Alessandra Menon, Riccardo D’Ambrosi, Davide Cucchi, Paolo Cabitza, and Giuseppe Banfi Copyright © 2014 Pietro Randelli et al. All rights reserved. Greater Trochanteric Fixation Using a Cable System for Partial Hip Arthroplasty: A Clinical and Finite Element Analysis Sun, 10 Aug 2014 11:48:58 +0000 The aim of the study was to investigate the efficacy of greater trochanteric fixation using a multifilament cable to ensure abductor lever arm continuity in patients with a proximal femoral fracture undergoing partial hip arthroplasty. Mean age of the patients (12 men, 20 women) was 84.12 years. Mean follow-up was 13.06 months. Fixation of the dislocated greater trochanter with or without a cable following load application was assessed by finite element analysis (FEA). Radiological evaluation was based on the distance between the fracture and the union site. Harris hip score was used to evaluate final results: outcomes were excellent in 7 patients (21.8%), good in 17 patients (53.1%), average in 5 patients (15.6%), and poor in 1 patient (9.3%). Mean abduction angle was 20.21°. Union was achieved in 14 patients (43.7%), fibrous union in 12 (37.5%), and no union in 6 (18.7%). FEA showed that the maximum total displacement of the greater trochanter decreased when the fractured bone was fixed with a cable. As the force applied to the cable increased, the displacement of the fractured trochanter decreased. This technique ensures continuity of the abductor lever arm in patients with a proximal femoral fracture who are undergoing partial hip arthroplasty surgery. Fırat Ozan, Şemmi Koyuncu, Mahmut Pekedis, Taşkın Altay, Hasan Yıldız, and Gökhan Toker Copyright © 2014 Fırat Ozan et al. All rights reserved. Clinical Outcome and Wound Healing following Carpal Tunnel Decompression: A Comparison of Two Common Suture Materials Thu, 07 Aug 2014 00:00:00 +0000 Introduction. Debate exists amongst surgeons regarding the ideal suture material for skin closure in carpal tunnel decompression (CTD). This study compares wound related complications, patient satisfaction, and functional outcome following open carpal tunnel decompression in patients undergoing wound closure with either of two common absorbable and nonabsorbable suture types. Materials and Methods. 53 patients underwent CTD with either 4/0 polypropylene (ProleneTM, = 28) or 4/0 polyglactin (Vicryl RapideTM, = 25) for skin closure. QuickDASH, VAS satisfaction scores, and Southampton wound scores were assessed preoperatively and at 2 and 6 weeks postoperatively. Results. At 6 weeks the mean QuickDASH scores postoperatively were 18.54 and 17.70 for absorbable and nonabsorbable sutures, respectively, ( = 0.86). The mean VAS scores were 0.61 and 0.42 ( = 0.91), respectively. All patients achieved a Southampton wound score of 0 by 6 weeks except one, who achieved 1C in the nonabsorbable group, equivalent to mild erythema. There were no complications in either group. Conclusion. Both suture types are safe and effective materials for CTD, and we recommend surgeons to choose according to personal preference, handling properties, and resources available for suture removal. Robert J. MacFarlane, Thomas D. Donnelly, Yousaf Khan, Syam Morapudi, Mohammad Waseem, and Jochen Fischer Copyright © 2014 Robert J. MacFarlane et al. All rights reserved. Lower Limb Core Scale: A New Application to Evaluate and Compare the Outcomes of Bone and Soft-Tissue Tumours Resection and Reconstruction Sun, 03 Aug 2014 06:46:26 +0000 Several methods are used to evaluate the functional outcome of tumour resections and reconstructions in the lower limb. However, one of their most common limitations is that they are specifically developed to evaluate only oncological patients. We introduced the Lower Limb Core Scale (LLCS) to overcome this limitation. The aim of this study was to evaluate the functional and subjective results in the lower limb and to evaluate the use of the LLCS. We conducted a retrospective cohort study using various tools to investigate the outcomes. The results of the LLCS were correlated with the results of other functional tests. A total of 44 patients were included in the study. None of the demographic variables correlated with the functional or health-related quality of life (QoL) scores except for gender, whereby male patients had an increased functional score. The correlation between LLCS and other scores was positive . The satisfactory QoL scores, and functional outcomes scores indicated the LLCS to be a reliable option for general and specific evaluation of lower limb reconstructions. We suggest using the LLCS for comparisons of oncological reconstructions with lower limb reconstructions in different disciplines. Andrea Monticelli, Davide Ciclamini, Michele Boffano, Elena Boux, Paolo Titolo, Bernardino Panero, Bruno Battiston, Raimondo Piana, and Pierluigi Tos Copyright © 2014 Andrea Monticelli et al. All rights reserved. Platelet Concentration in Platelet-Rich Plasma Affects Tenocyte Behavior In Vitro Wed, 23 Jul 2014 07:00:53 +0000 Since tendon injuries and tendinopathy are a growing problem, sometimes requiring surgery, new strategies that improve conservative therapies are needed. Platelet-rich plasma (PRP) seems to be a good candidate by virtue of its high content of growth factors, most of which are involved in tendon healing. This study aimed to evaluate if different concentrations of platelets in PRP have different effects on the biological features of normal human tenocytes that are usually required during tendon healing. The different platelet concentrations tested (up to 5 × 106 plt/µL) stimulated differently tenocytes behavior; intermediate concentrations (0.5 × 106, 1 × 106 plt/µL) strongly induced all tested processes (proliferation, migration, collagen, and MMPs production) if compared to untreated cells; on the contrary, the highest concentration had inhibitory effects on proliferation and strongly reduced migration abilities and overall collagen production but, at the same time, induced increasing MMP production, which could be counterproductive because excessive proteolysis could impair tendon mechanical stability. Thus, these in vitro data strongly suggest the need for a compromise between extremely high and low platelet concentrations to obtain an optimal global effect when inducing in vivo tendon healing. Ilaria Giusti, Sandra D’Ascenzo, Annalisa Mancò, Gabriella Di Stefano, Marianna Di Francesco, Anna Rughetti, Antonella Dal Mas, Gianfranco Properzi, Vittorio Calvisi, and Vincenza Dolo Copyright © 2014 Ilaria Giusti et al. All rights reserved. Human Endogenous Retrovirus W Activity in Cartilage of Osteoarthritis Patients Tue, 22 Jul 2014 08:33:56 +0000 The etiology of viruses in osteoarthritis remains controversial because the prevalence of viral nucleic acid sequences in peripheral blood or synovial fluid from osteoarthritis patients and that in healthy control subjects are similar. Until now the presence of virus has not been analyzed in cartilage. We screened cartilage and chondrocytes from advanced and non-/early osteoarthritis patients for parvovirus B19, herpes simplex virus-1, Epstein Barr virus, cytomegalovirus, human herpes virus-6, hepatitis C virus, and human endogenous retroviruses transcripts. Endogenous retroviruses transcripts, but none of the other viruses, were detected in 15 out the 17 patients. Sequencing identified the virus as HERV-WE1 and E2. HERV-W activity was confirmed by high expression levels of syncytin, dsRNA, virus budding, and the presence of virus-like particles in all advanced osteoarthritis cartilages examined. Low levels of HERV-WE1, but not E2 envelope RNA, were observed in 3 out of 8 non-/early osteoarthritis patients, while only 3 out of 7 chondrocytes cultures displayed low levels of syncytin, and just one was positive for virus-like particles. This study demonstrates for the first time activation of HERV-W in cartilage of osteoarthritis patients; however, a causative role for HERV-W in development or deterioration of the disease remains to be proven. Signy Bendiksen, Inigo Martinez-Zubiavrra, Conny Tümmler, Gunnar Knutsen, Jan Elvenes, Elisabeth Olsen, Randi Olsen, and Ugo Moens Copyright © 2014 Signy Bendiksen et al. All rights reserved. Clinical Applications of Platelet-Rich Plasma in Patellar Tendinopathy Mon, 21 Jul 2014 00:00:00 +0000 Platelet-rich plasma (PRP), a blood derivative with high concentrations of platelets, has been found to have high levels of autologous growth factors (GFs), such as transforming growth factor-β (TGF-β), platelet-derived growth factor (PDGF), fibroblastic growth factor (FGF), vascular endothelial growth factor (VEGF), and epidermal growth factor (EGF). These GFs and other biological active proteins of PRP can promote tissue healing through the regulation of fibrosis and angiogenesis. Moreover, PRP is considered to be safe due to its autologous nature and long-term usage without any reported major complications. Therefore, PRP therapy could be an option in treating overused tendon damage such as chronic tendinopathy. Here, we present a systematic review highlighting the clinical effectiveness of PRP injection therapy in patellar tendinopathy, which is a major cause of athletes to retire from their respective careers. D. U. Jeong, C.-R. Lee, J. H. Lee, J. Pak, L.-W. Kang, B. C. Jeong, and S. H. Lee Copyright © 2014 D. U. Jeong et al. All rights reserved. Does Platelet-Rich Plasma Freeze-Thawing Influence Growth Factor Release and Their Effects on Chondrocytes and Synoviocytes? Thu, 17 Jul 2014 14:56:21 +0000 PRP cryopreservation remains a controversial point. Our purpose was to investigate the effect of freezing/thawing on PRP molecule release, and its effects on the metabolism of chondrocytes and synoviocytes. PRP was prepared from 10 volunteers, and a half volume underwent one freezing/thawing cycle. IL-1, HGF, PDGF AB/BB, TGF-1, and VEGF were assayed 1 hour and 7 days after activation. Culture media of chondrocytes and synoviocytes were supplemented with fresh or frozen PRP, and, at 7 days, proliferation, gene expression, and secreted proteins levels were evaluated. Results showed that in the freeze-thawed PRP the immediate and delayed molecule releases were similar or slightly lower than those in fresh PRP. TGF-1 and PDGF AB/BB concentrations were significantly reduced after freezing both at 1 hour and at 7 days, whereas HGF concentration was significantly lower in frozen PRP at 7 days. In fresh PRP IL-1 and HGF concentrations underwent a significant further increase after 7 days. Similar gene expression was found in chondrocytes cultured with both PRPs, whereas in synoviocytes HGF gene expression was higher in frozen PRP. PRP cryopreservation is a safe procedure, which sufficiently preserves PRP quality and its ability to induce proliferation and the production of ECM components in chondrocytes and synoviocytes. Alice Roffi, Giuseppe Filardo, Elisa Assirelli, Carola Cavallo, Annarita Cenacchi, Andrea Facchini, Brunella Grigolo, Elizaveta Kon, Erminia Mariani, Loredana Pratelli, Lia Pulsatelli, and Maurilio Marcacci Copyright © 2014 Alice Roffi et al. All rights reserved. Biomechanical Assessment of a Patient-Specific Knee Implant Design Using Finite Element Method Mon, 30 Jun 2014 11:06:14 +0000 Rheumatoid arthritis is the leading cause of disability in young adults. Total knee arthroplasty has been successfully used to restore the joint function. Due to small bone size, osteoporosis, and severe soft tissue disease, standard knee implant sometimes cannot be directly applied clinically and patient-specific designs may be a more rational choice. The purpose of this study was to evaluate the biomechanical behavior of a patient-specific knee implant. A three-dimensional finite element of total knee arthroplasty was developed. The mechanical strength and the wear damage of the articular surfaces were analyzed. The results show that there exist high risks of component fracture and wear damage; the proposed implant design should be abandoned. The presurgery analysis is helpful in avoiding the potential failure. Qiguo Rong, Jianfeng Bai, Yongling Huang, and Jianhao Lin Copyright © 2014 Qiguo Rong et al. All rights reserved. The Impact of Arthroscopic Capsular Release in Patients with Primary Frozen Shoulder on Shoulder Muscular Strength Tue, 24 Jun 2014 12:11:16 +0000 The aim of this study was to evaluate the impact of arthroscopic capsular release in patients with primary frozen shoulder on muscular strength of nonaffected and treated shoulder after at least two-year follow-up after the surgery. The assessment included twenty-seven patients, who underwent arthroscopic capsular release due to persistent limitation of range of passive and active motion, shoulder pain, and limited function of upper limb despite 6-month conservative treatment. All the patients underwent arthroscopic superior, anteroinferior, and posterior capsular release. After at least two-year follow-up, measurement of muscular strength of abductors, flexors, and external and internal rotators of the operated and nonaffected shoulder, as well as determination of range of motion (ROM) and function (ASES) in the operated and nonaffected shoulder, was performed. Measurement of muscular strength in the patient group did not reveal statistically significant differences between operated and nonaffected shoulder. The arthroscopic capsular release does not have significant impact on the decrease in the muscular strength of the operated shoulder. Michał Waszczykowski, Michał Polguj, and Jarosław Fabiś Copyright © 2014 Michał Waszczykowski et al. All rights reserved. Effect of Autologous Platelet Rich Fibrin on the Healing of Experimental Articular Cartilage Defects of the Knee in an Animal Model Tue, 17 Jun 2014 06:23:51 +0000 The effect of autologous platelet rich fibrin (PRF), a second generation platelet product, on the healing of experimental articular cartilage lesions was evaluated in an animal model. Full thickness cartilage lesions with a diameter of 6 mm and depth of 5 mm were created in the weight bearing area of femoral condyles of both hind limbs in 12 adult mixed breed dogs. Defects in the left hind limb of each dog were repaired by PRF implantation whereas those in the right hind limb were left empty. The animals were euthanized at 4, 16, and 24 weeks following surgery and the resultant repair tissue was investigated macroscopically and microscopically. The results of macroscopic and histological evaluations indicated that there were significant differences between the PRF treated and untreated defects. In conclusion, the present study indicated that the use of platelet rich fibrin as a source of autologous growth factors leads to improvement in articular cartilage repair. Davoud Kazemi, Ashraf Fakhrjou, Vahid Mirzazadeh Dizaji, and Majid Khanzadeh Alishahi Copyright © 2014 Davoud Kazemi et al. All rights reserved. Morphological Study of the Newly Designed Cementless Femoral Stem Mon, 16 Jun 2014 00:00:00 +0000 A morphology study was essential to the development of the cementless femoral stem because accurate dimensions for both the periosteal and endosteal canal ensure primary fixation stability for the stem, bone interface, and prevent stress shielding at the calcar region. This paper focused on a three-dimensional femoral model for Asian patients that applied preoperative planning and femoral stem design. We measured various femoral parameters such as the femoral head offset, collodiaphyseal angle, bowing angle, anteversion, and medullary canal diameters from the osteotomy level to 150 mm below the osteotomy level to determine the position of the isthmus. Other indices and ratios for the endosteal canal, metaphyseal, and flares were computed and examined. The results showed that Asian femurs are smaller than Western femurs, except in the metaphyseal region. The canal flare index (CFI) was poorly correlated () to the metaphyseal canal flare index (MCFI), but correlated well () with the corticomedullary index (CMI). The diversity of the femoral size, particularly in the metaphyseal region, allows for proper femoral stem design for Asian patients, improves osseointegration, and prolongs the life of the implant. Mohd Yusof Baharuddin, Sh-Hussain Salleh, Ahmad Hafiz Zulkifly, Muhammad Hisyam Lee, and Alias Mohd Noor Copyright © 2014 Mohd Yusof Baharuddin et al. All rights reserved. Endplates Changes Related to Age and Vertebral Segment Thu, 12 Jun 2014 12:21:08 +0000 Endplate separations are defined as the presence of a space between the hyaline cartilage and the cortical bone of the adjacent vertebral body. This study evaluates endplate separations from the vertebral body and intervertebral discs and verifies if endplate separation is related to age and the spinal level. Groups were formed based on age (20–40 and 41–85 years old) and the vertebral segment (T7-T8 and L4-L5 segments). Histological analysis included assessment of the length of the vertebral endplates, the number and dimensions of the separations, and orientation of the collagen fibers, in the mid-sagittal slice. Two indexes were created: the separation index (number of separations/vertebral length) and separation extension index (sum of all separations/vertebral length). The results of the study demonstrated a direct relationship between the density of separations in the endplate and two variables: age and spinal level. Carlos Fernando P. S. Herrero, Sergio Britto Garcia, Luis Vicente Garcia, and Helton Luiz Aparecido Defino Copyright © 2014 Carlos Fernando P. S. Herrero et al. All rights reserved. Outcomes of a Joint Replacement Surgical Home Model Clinical Pathway Thu, 12 Jun 2014 11:29:20 +0000 Optimizing perioperative care to provide maximum benefit at minimum cost may be best achieved using a perioperative clinical pathway (PCP). Using our joint replacement surgical home (JSH) model PCP, we examined length of stay (LOS) following total joint arthroplasty (TJA) to evaluate patient care optimization. We reviewed a spectrum of clinical measurements in 190 consecutive patients who underwent TJA. Patients who had surgery earlier in the week and who were earlier cases of the day had a significantly lower LOS than patients whose cases started both later in the week and later in the day. Patients discharged home had significantly lower LOS than those discharged to a secondary care facility. Patients who received regional versus general anesthesia had a significantly lower LOS. Scheduling patients discharged to home and who will likely receive regional anesthesia for the earliest morning slot and earlier in the week may help decrease overall LOS. Avinash Chaurasia, Leslie Garson, Zeev L. Kain, and Ran Schwarzkopf Copyright © 2014 Avinash Chaurasia et al. All rights reserved. The Biological Effects of Sex Hormones on Rabbit Articular Chondrocytes from Different Genders Tue, 03 Jun 2014 05:57:13 +0000 The aim of this study was to investigate the biological effects of sex hormones (17β-estradiol and testosterone) on rabbit articular chondrocytes from different genders. We cultured primary rabbit articular chondrocytes from both genders with varying concentration of sex hormones. We evaluate cell proliferation and biochemical functions by MTT and GAG assay. The chondrocyte function and phenotypes were analyzed by mRNA level using RT-PCR. Immunocytochemical staining was also used to evaluate the generation of collagen-II. This study demonstrated that 17β-estradiol had greater positive regulation on the biological function and gene expressions of articular chondrocytes than testosterone, with the optimal concentrations of 10−6 and 10−7 M, particularly for female chondrocytes. Shwu Jen Chang, Shyh Ming Kuo, Yen Ting Lin, and Shan-Wei Yang Copyright © 2014 Shwu Jen Chang et al. All rights reserved. Cementless Fixation of Osteoporotic VCFs Using Titanium Mesh Implants (OsseoFix): Preliminary Results Mon, 02 Jun 2014 06:36:49 +0000 Introduction. Vertebral compression fractures (VCFs) affect 20% of people over the age of 70 with increasing incidence. Kypho-/vertebroplasty as standard operative procedures are associated with limitations like cement leakage, limited reduction capabilities, and risk for adjacent fractures. To address these shortcomings, we introduce a new minimal invasive cementless VCF fixation technique. Methods. Four patients (72.3 years, range 70–76) with VCFs type AO/Müller A1.3 and concomitant osteoporosis were treated by minimal invasive transpedicular placement of two intervertebral mesh cages for fracture reduction and maintenance. Follow-up included functional/radiological assessment and clinical scores and averaged 27.7 months (24–28). Results. Endplate reduction was achieved in all cases (mean surgery time: 28.5 minutes). Kyphotic (KA) and Cobb angle revealed considerable improvements postoperatively (KA 14.5° to 10.7°/Cobb 10.1° to 8.3°). Slight loss of vertebral reduction (KA: 12.6°) and segment rekyphosis (Cobb: 10.7°) were observed for final follow-up. Pain improved from 8.8 to 2.8 (visual analogue scale). All cases showed signs of bony healing. No perioperative complications and no adjacent fractures occurred. Conclusion. Preliminary results in a small, selected patient collective indicate the ability of bony healing for osteoporotic VCFs. Cementless fixation using intravertebral titanium mesh cages revealed substantial pain relief, adequate reduction, and reduction maintenance without complications. Trial registration number is DRKS00005657, German Clinical Trials Register (DKRS). Anica Eschler, Stephan Albrecht Ender, Benjamin Ulmar, Philipp Herlyn, Thomas Mittlmeier, and Georg Gradl Copyright © 2014 Anica Eschler et al. All rights reserved. Sensitivities, Specificities, and Predictive Values of Microbiological Culture Techniques for the Diagnosis of Prosthetic Joint Infection Sun, 25 May 2014 12:46:44 +0000 Background. Identifying the microorganism in a prosthetic joint infection is the key to appropriately targeting antimicrobial treatment. Despite the availability of various techniques, no single test is considered the definitive gold standard. Aim. Our aim was to determine the sensitivity, specificity, and positive/negative predictive values for a variety of culture techniques. Methods. We performed a retrospective case series of 219 patients undergoing revision surgery of their hip or knee replacement between May 2004 and February 2013. The patients were classified as either infected or noninfected according to criteria set out by the Musculoskeletal Infection Society. The number and type of samples taken intraoperatively varied between cases but included tissue samples and fluid sent in either blood culture vials or sterile containers. Results. The highest sensitivity was found with blood culture vials (0.85) compared to fluid in sterile containers (0.26) and tissues samples (0.32). Blood culture vials also had a better specificity and positive and negative predictive values profile. Conclusion. We conclude that, of the techniques studied, fluid in blood culture vials had the best profile for the correct identification of microorganisms and advocate its use. Robert W. Jordan, Nicholas A. Smith, Adnan Saithna, Andrew P. Sprowson, and Pedro Foguet Copyright © 2014 Robert W. Jordan et al. All rights reserved. The Technological Development of Minimally Invasive Spine Surgery Wed, 21 May 2014 11:14:39 +0000 Minimally invasive spine surgery has its roots in the mid-twentieth century with a few surgeons and a few techniques, but it has now developed into a large field of progressive spinal surgery. A wide range of techniques are now called “minimally invasive,” and case reports are submitted constantly with new “minimally invasive” approaches to spinal pathology. As minimally invasive spine surgery has become more mainstream over the past ten years, in this paper we discuss its history and development. Laura A. Snyder, John O'Toole, Kurt M. Eichholz, Mick J. Perez-Cruet, and Richard Fessler Copyright © 2014 Laura A. Snyder et al. All rights reserved. Early Intra-Articular Complement Activation in Ankle Fractures Wed, 21 May 2014 09:29:44 +0000 Cytokine regulation possibly influences long term outcome following ankle fractures, but little is known about synovial fracture biochemistry. Eight patients with an ankle dislocation fracture were included in a prospective case series and matched with patients suffering from grade 2 osteochondritis dissecans (OCD) of the ankle. All fractures needed external fixation during which joint effusions were collected. Fluid analysis was done by ELISA measuring aggrecan, bFGF, IL-1β, IGF-1, and the complement components C3a, C5a, and C5b-9. The time periods between occurrence of fracture and collection of effusion were only significantly associated with synovial aggrecan and C5b-9 levels (). Furthermore, synovial expressions of both proteins correlated with each other (). Although IL-1β expression was relatively low, intra-articular levels correlated with C5a () and serological C-reactive protein concentrations 2 days after surgery (). Joint effusions were initially dominated by neutrophils, but the portion of monocytes constantly increased reaching 50% at day 6 after fracture (). Whereas aggrecan and IL-1β concentrations were not different in fracture and OCD patients, bFGF, IGF-1, and all complement components were significantly higher concentrated in ankle joints with fractures (). Complement activation and inflammatory cell infiltration characterize the joint biology following acute ankle fractures. Hagen Schmal, Gian M. Salzmann, Philipp Niemeyer, Elia Langenmair, Renfeng Guo, Conny Schneider, Maria Habel, and Niels Riedemann Copyright © 2014 Hagen Schmal et al. All rights reserved. Acetabular Reconstruction with the Burch-Schneider Antiprotrusio Cage and Bulk Allografts: Minimum 10-Year Follow-Up Results Wed, 21 May 2014 07:36:30 +0000 Reconstruction of severe pelvic bone loss is a challenging problem in hip revision surgery. Between January 1992 and December 2000, 97 hips with periprosthetic osteolysis underwent acetabular revision using bulk allografts and the Burch-Schneider antiprotrusio cage (APC). Twenty-nine patients (32 implants) died for unrelated causes without additional surgery. Sixty-five hips were available for clinical and radiographic assessment at an average follow-up of 14.6 years (range, 10.0 to 18.9 years). There were 16 male and 49 female patients, aged from 29 to 83 (median, 60 years), with Paprosky IIIA (27 cases) and IIIB (38 cases) acetabular bone defects. Nine cages required rerevision because of infection (3), aseptic loosening (5), and flange breakage (1). The average Harris hip score improved from 33.1 points preoperatively to 75.6 points at follow-up (). Radiographically, graft incorporation and cage stability were detected in 48 and 52 hips, respectively. The cumulative survival rates at 18.9 years with removal for any reason or X-ray migration of the cage and aseptic or radiographic loosening as the end points were 80.0% and 84.6%, respectively. The use of the Burch-Schneider APC and massive allografts is an effective technique for the reconstructive treatment of extensive acetabular bone loss with long-lasting survival. Dario Regis, Andrea Sandri, and Ingrid Bonetti Copyright © 2014 Dario Regis et al. All rights reserved. Comparison of the Sagittal Spine Lordosis by Supine Computed Tomography and Upright Conventional Radiographs in Patients with Spinal Trauma Wed, 21 May 2014 06:28:53 +0000 Study Design. Retrospective data analysis. Objective. To compare the sagittal lordosis of the lumbar spine by supine computed tomography (CT) and upright conventional radiographs. Summary of Background Data. There is sparse data about position and modality dependent changes of radiographic measurements in the sagittal lumbar spine. Methods. The anatomical and functional Cobb angles of the thoracolumbar spine in 153 patients with spinal injury were measured by conventional upright sagittal radiographs and supine CT scans. Patients were assigned either to group A (), with radiologically confirmed vertebral fractures, or to group B (), without any osseous lesions. The interchangeability of the two imaging modalities was calculated using a ±3° and 5° range of acceptance. Results. Group A showed a mean intraindividual difference of −3.8° for both the anatomical and the functional Cobb angle. Only 25.7% and 27.7% of the 101 patients showed a difference within the tolerated ±3° margin. Using the ±5° limits, only 46 and 47 individuals fell within the acceptable range, respectively. In the patients in group B, the mean intraindividual difference was −2.1° for the anatomical and −1.5° for the functional Cobb angle. Of the 52 patients, only 14 and 13 patients, respectively demonstrated an intraindividual difference within ±3°. With regard to a threshold of ±5°, both the functional and anatomical values were within the defined margins in only 25 (48%) patients. Conclusion. The use of supine CT measurements as a baseline assessment of the sagittal lordosis of the injured thoracolumbar spine does not appear to be appropriate when upright conventional sagittal plane radiographs are used for follow-up measurements. Samy Bouaicha, Claudia Lamanna, Thorsten Jentzsch, Hans-Peter Simmen, and Clément M. L. Werner Copyright © 2014 Samy Bouaicha et al. All rights reserved. Influence on Therapeutic Decision Making of SPECT-CT for Different Regions of the Foot and Ankle Sun, 18 May 2014 08:23:59 +0000 Background. Single-photon emission computed tomography and computed tomography (SPECT-CT) has a high impact on diagnosis and treatment decision of different joints. The aim of this study was to evaluate whether there is a different gain of SPECT-CT for different foot regions. Material and Methods. We retrospectively identified 86 patients who received a SPECT-CT of the foot and ankle between April 2011 and December 2012. We divided all patients into the following subgroups: ankle (group 1), subtalar (group 2), Chopart (group 3), and Lisfranc (group 4). The local ethical committee approved the study. Results. The clinical treatment decision was changed based on SPECT-CT results in 64.5% of group 1, 65.2% of group 2, and 75% each of groups 3 and 4. Eighty patients (93%) had pain relief after treatment based on SPECT-CT. The overall SPECT-CT sensitivity was 0.94 and the specificity was 0.57. The positive and negative predictive values were 0.87 and 0.75, respectively. Conclusion. The impact of SPECT-CT on treatment decision is slightly higher in diseases of the Chopart and Lisfranc joints than in the upper ankle and subtalar joints. The additional information has a clinical relevance due to the high rate of pain relief by treatment based on SPECT-CT diagnosis. Leif Claassen, Theodor Uden, Max Ettinger, Kiriakos Daniilidis, Christina Stukenborg-Colsman, and Christian Plaass Copyright © 2014 Leif Claassen et al. All rights reserved. Minimally Invasive Transforaminal Lumbar Interbody Fusion with Unilateral Pedicle Screw Fixation: Comparison between Primary and Revision Surgery Wed, 14 May 2014 10:48:00 +0000 Minimally invasive surgery with a transforaminal lumbar interbody fusion (MIS TLIF) is an important minimally invasive fusion technique for the lumbar spine. Lumbar spine reoperation is challenging and is thought to have greater complication risks. The purpose of this study was to compare MIS TLIF with unilateral screw fixation perioperative results between primary and revision surgeries. This was a prospective study that included 46 patients who underwent MIS TLIF with unilateral pedicle screw. The patients were divided into two groups, primary and revision MIS TLIF, to compare perioperative results and complications. The two groups were similar in age, sex, and level of operation, and were not significantly different in the length of follow-up or clinical results. Although dural tears were more common with the revision group (primary 1; revision 4), operation time, blood loss, total perioperative complication, and fusion rates were not significantly different between the two groups. Both groups showed substantial improvements in VAS and ODI scores one year after surgical treatment. Revision MIS TLIF performed by an experienced surgeon does not necessarily increase the risk of perioperative complication compared with primary surgery. MIS TLIF with unilateral pedicle screw fixation is a valuable option for revision lumbar surgery. Moo Sung Kang, Jeong Yoon Park, Kyung Hyun Kim, Sung Uk Kuh, Dong Kyu Chin, Keun Su Kim, and Yong Eun Cho Copyright © 2014 Moo Sung Kang et al. All rights reserved. The Use of a Modular Titanium Baseplate with a Press-Fit Keel Implanted with a Surface Cementing Technique for Primary Total Knee Arthroplasty Wed, 14 May 2014 09:41:56 +0000 Little data exists regarding outcomes following TKA performed with surface-cementation for the fixation of modular tibial baseplates with press-fit keels. Thus, we retrospectively reviewed the clinical and radiographic outcomes of 439 consecutive primary TKAs performed with surface cemented tibial components. There were 290 female patients and 149 male patients with average age of 62 years (range 30–84). Two tibial components were revised for aseptic loosening (0.5%) and four tibial components (0.9%) were removed to improve instability () or malalignment (). Complications included 13 deep infections treated with 2-stage revision (12) and fusion (1). These results support the surface cement technique with a modular grit-blasted titanium surface and cruciform stem during primary TKA. Christopher E. Pelt, Jill Erickson, Bryt A. Christensen, Benjamin Widmer, Erik P. Severson, David Evans, and Christopher L. Peters Copyright © 2014 Christopher E. Pelt et al. All rights reserved. Low Body Mass Index and Blood Loss in Primary Total Hip Arthroplasty: Results from 236 Consecutive Ankylosing Spondylitis Patients Wed, 14 May 2014 00:00:00 +0000 Objective. To evaluate the effect of low body mass index (BMI) on blood loss during primary total hip arthroplasty (THA) in ankylosing spondylitis (AS) patients. Methods. Two hundred seventy-seven consecutive AS patients who underwent primary THA were retrospectively studied. The patients were divided by BMI into an underweight group (BMI < 18.5 kg/m2) and a normal weight group (18.5 kg/m2 < BMI < 25 kg/m2). Demographics, perioperative laboratory values, intraoperative data, blood loss, transfusion rate, transfusion reactions, surgical complications, hospitalization cost, and length of stay (LOS) were collected and analyzed. Results. Of 277 AS patients, 236 were eligible for inclusion in the study. A total of 91 (39%) patients were underweight. The hidden blood loss, transfusion rate, transfusion reactions, and hospitalization cost in the underweight group were significantly higher than those in the normal weight group. Conclusions. For AS patients, BMI appears to be correlated with blood loss during primary THA. Compared with patients of normal weight, low BMI patients have the potential to suffer more postoperative hidden blood loss and to require a higher transfusion rate. Jinzhu Zhao, Jia Li, Wei Zheng, Denghui Liu, Xiaofeng Sun, and Weidong Xu Copyright © 2014 Jinzhu Zhao et al. All rights reserved. The Hypoxia-Inducible Factor Pathway, Prolyl Hydroxylase Domain Protein Inhibitors, and Their Roles in Bone Repair and Regeneration Sun, 11 May 2014 00:00:00 +0000 Hypoxia-inducible factors (HIFs) are oxygen-dependent transcriptional activators that play crucial roles in angiogenesis, erythropoiesis, energy metabolism, and cell fate decisions. The group of enzymes that can catalyse the hydroxylation reaction of HIF-1 is prolyl hydroxylase domain proteins (PHDs). PHD inhibitors (PHIs) activate the HIF pathway by preventing degradation of HIF-α via inhibiting PHDs. Osteogenesis and angiogenesis are tightly coupled during bone repair and regeneration. Numerous studies suggest that HIFs and their target gene, vascular endothelial growth factor (VEGF), are critical regulators of angiogenic-osteogenic coupling. In this brief perspective, we review current studies about the HIF pathway and its role in bone repair and regeneration, as well as the cellular and molecular mechanisms involved. Additionally, we briefly discuss the therapeutic manipulation of HIFs and VEGF in bone repair and bone tumours. This review will expand our knowledge of biology of HIFs, PHDs, PHD inhibitors, and bone regeneration, and it may also aid the design of novel therapies for accelerating bone repair and regeneration or inhibiting bone tumours. Lihong Fan, Jia Li, Zefeng Yu, Xiaoqian Dang, and Kunzheng Wang Copyright © 2014 Lihong Fan et al. All rights reserved. Hip Reconstruction Osteotomy by Ilizarov Method as a Salvage Option for Abnormal Hip Joints Tue, 06 May 2014 14:04:25 +0000 Hip joint instability can be secondary to congenital hip pathologies like developmental dysplasia (DDH) or acquired such as sequel of infective or neoplastic process. An unstable hip is usually associated with loss of bone from the proximal femur, proximal migration of the femur, lower-extremity length discrepancy, abnormal gait, and pain. In this case series of 37 patients coming to our institution between May 2005 and December 2011, we report our results in treatment of unstable hip joint by hip reconstruction osteotomy using the Ilizarov method and apparatus. This includes an acute valgus and extension osteotomy of the proximal femur combined with gradual varus and distraction (if required) for realignment and lengthening at a second, more distal, femoral osteotomy. 18 males and 19 females participated in the study. There were 17 patients with DDH, 12 with sequelae of septic arthritis, 2 with tuberculous arthritis, 4 with posttraumatic arthritis, and 2 with focal proximal femoral deficiency. Outcomes were evaluated by using Harris Hip Scoring system. At the mean follow-up of 37 months, Harris Hip Score had significantly improved in all patients. To conclude, illizarov hip reconstruction can successfully improve Trendelenburg’s gait. It supports the pelvis and simultaneously restores knee alignment and corrects lower-extremity length discrepancy (LLD). Masood Umer, Haroon Rashid, Hafiz Muhammad Umer, and Hasnain Raza Copyright © 2014 Masood Umer et al. All rights reserved. Radiographic Outcomes of Percutaneous Pinning for Displaced Extra-Articular Fractures of the Distal Radius: A Time Course Study Mon, 05 May 2014 13:39:32 +0000 Introduction. Although not all malunited distal radius fractures are symptomatic, the goal of treatment for displaced extra-articular fractures of the distal radius should be to restore and to maintain the radial geometry until bone healing. However, the time course change after surgery for these fractures is unclear. Methods. We, therefore, performed a retrospective cohort study on patients who sustained such fractures treated with percutaneous pinning. The main outcome measures in this study included four radiographic measurements: radial height, radial inclination, radial tilt, and ulnar variance. Results. Assessment of the monthly changes in these measurements revealed that early fracture collapse with loss of the reduced radial tilt occurred. Besides, among the 4 measurements, the normal radial tilt was the most difficult to be achieved when repositioning and pinning the fractured fragments. Conclusions. Even though the modified Kapandji technique provided a superior ability to maintain the reduced position until bone healing over the Willenegger method, we recommended that refinement of surgical techniques and postoperative hand care program may be necessary to fulfill the treatment objectives of stable surgical fixation and early joint motion. Tien-Yu Yang, Yao-Hung Tsai, Shih-Hsun Shen, and Kuo-Chin Huang Copyright © 2014 Tien-Yu Yang et al. All rights reserved. Serum C-Reactive Protein and Procalcitonin Kinetics in Patients Undergoing Elective Total Hip Arthroplasty Sun, 04 May 2014 13:56:10 +0000 Background. The sensitivity and the specificity of different methods to detect periprosthetic infection have been questioned. The current study aimed to investigate the kinetics of C-reactive protein (CRP) and procalcitonin (PCT) in patients undergoing uncomplicated elective total hip arthroplasty (THA), to provide a better interpretation of their levels in noninfectious inflammatory reaction. Methods. A total of 51 patients were included. Serum CRP and PCT concentrations were obtained before surgery, on the 1st, 3rd, and 7th postoperative days and after discharge on the 14th and 30th days and at 2 years. Results. Both markers were confirmed to increase after surgery. The serum CRP showed a marked increase on the 3rd postoperative day while the peak of serum PCT was earlier, even if much lower, on the first day. Then, they declined slowly approaching the baseline values by the second postoperative week. PCT mean values never exceed concentrations typically related to bacterial infections. Conclusions. CRP is very sensitive to inflammation. It could be the routine screening test in the follow-up of THA orthopaedic patients, but it should be complemented by PCT when there is the clinical suspicion of periprosthetic infection. Sandra Battistelli, Mattia Fortina, Serafino Carta, Roberto Guerranti, Francesco Nobile, and Paolo Ferrata Copyright © 2014 Sandra Battistelli et al. All rights reserved. Vastus Medialis Obliquus Muscle Morphology in Primary and Recurrent Lateral Patellar Instability Tue, 29 Apr 2014 07:36:54 +0000 The morphology of the vastus medialis obliquus (VMO) muscle in the anatomical setting of an unstable patella has not been described. Therefore, the purpose of this study was to investigate the morphological parameters of the VMO muscle that delineate its importance in the maintenance of patellofemoral joint stability. Eighty-two consecutive subjects were prospectively enrolled in this study. The groups were composed of thirty patients with an acute primary patellar dislocation, thirty patients with recurrent patellar dislocation, and twenty-two controls. Groups were adjusted according to sex, age, body mass index, and physical activity. Magnetic resonance imaging was used to measure the VMO cross-sectional area, muscle-fiber angulation, and the craniocaudal extent of the muscle in relation to the patella. No significant difference was found with respect to all measured VMO parameters between primary dislocation, recurrent dislocation, and control subjects with a trend noted for only the VMO cross-sectional area and the VMO muscle-fiber angulation. This finding is notable in that atrophy of the VMO has often been suggested to play an important role in the pathophysiology of an unstable patellofemoral joint. Peter Balcarek, Swantje Oberthür, Stephan Frosch, Jan Philipp Schüttrumpf, and Klaus Michael Stürmer Copyright © 2014 Peter Balcarek et al. All rights reserved. The Significance of Serum Phosphate Level on Healing Index and Its Relative Effects in Skeletally Immature and Mature Patients with Hypophosphatemic Rickets Thu, 24 Apr 2014 06:39:07 +0000 The aim of this study was to find out the ideal cut-off level of phosphate for safe healing when deformity correction and concomitant lengthening are indicated in the two different skeletal maturity groups of patients with rickets. Thirty-nine hypophosphatemic rickets patients were selected for the study and were divided into two groups: 27 skeletally immature (group IM) and 12 skeletally mature (group M). The outcomes were evaluated with respect to the healing index (HI), laboratory findings, and complications with the mean follow-up of 5.1 years (range, 3.1–7.9). The healing index (HI) of group IM was 1.44 month/cm and HI of group M was 1.68 month/cm. The negative correlation between the level of serum phosphate and HI in group M (coefficient = −0.94) was evaluated to be less than the correlation in group IM (coefficient = −0.50), indicating that the HI is more likely to be affected by serum phosphate in group M than in group IM. Preoperative serum phosphate levels of 2.3 mg/dL and 2.6 mg/dL were analyzed to be the cut-off values of group IM and group M, respectively, in which the cut-off points divided the series into two groups having the most significantly different HI. Sang-Heon Song, Hanna Lee, Ji-Min Jeong, Woo-In Cho, Sung Eun Kim, and Hae-Ryong Song Copyright © 2014 Sang-Heon Song et al. All rights reserved. Bone Formation in a Rat Tibial Defect Model Using Carboxymethyl Cellulose/BioC/Bone Morphogenic Protein-2 Hybrid Materials Sun, 06 Apr 2014 11:10:22 +0000 The objective of this study was to assess whether carboxymethyl cellulose- (CMC-) based hydrogel containing BioC (biphasic calcium phosphate (BCP); tricalcium phosphate (TCP) : hydroxyapatite (Hap) = 70 : 30) and bone morphogenic protein-2 (BMP-2) led to greater bone formation than CMC-based hydrogel containing BioC without BMP-2. In order to demonstrate bone formation at 4 and 8 weeks, plain radiographs, microcomputed tomography (micro-CT) evaluation, and histological studies were performed after implantation of all hybrid materials on an 8 mm defect of the right tibia in rats. The plain radiographs and micro-CT analyses revealed that CMC/BioC/BMP-2 (0.5 mg) led to much greater mineralization at 4 and 8 weeks than did CMC/BioC or CMC/Bio/BMP-2 (0.1 mg). Likewise, bone formation and bone remodeling studies revealed that CMC/BioC/BMP-2 (0.5 mg) led to a significantly greater amount of bone formation and bone remodeling at 4 and 8 weeks than did CMC/BioC or CMC/BioC/BMP-2 (0.1 mg). Histological studies revealed that mineralized bone tissue was present around the whole circumference of the defect site with CMC/BioC/BMP-2 (0.5 mg) but not with CMC/BioC or CMC/BioC/BMP-2 (0.1 mg) at 4 and 8 weeks. These results suggest that CMC/BioC/BMP-2 hybrid materials induced greater bone formation than CMC/BioC hybrid materials. Thus, CMC/BioC/BMP-2 hybrid materials may be used as an injectable substrate to regenerate bone defects. Sang-Heon Song, Young-Pil Yun, Hak-Jun Kim, Kyeongsoon Park, Sung Eun Kim, and Hae-Ryong Song Copyright © 2014 Sang-Heon Song et al. All rights reserved. Primary Stability Recognition of the Newly Designed Cementless Femoral Stem Using Digital Signal Processing Tue, 01 Apr 2014 16:20:20 +0000 Stress shielding and micromotion are two major issues which determine the success of newly designed cementless femoral stems. The correlation of experimental validation with finite element analysis (FEA) is commonly used to evaluate the stress distribution and fixation stability of the stem within the femoral canal. This paper focused on the applications of feature extraction and pattern recognition using support vector machine (SVM) to determine the primary stability of the implant. We measured strain with triaxial rosette at the metaphyseal region and micromotion with linear variable direct transducer proximally and distally using composite femora. The root mean squares technique is used to feed the classifier which provides maximum likelihood estimation of amplitude, and radial basis function is used as the kernel parameter which mapped the datasets into separable hyperplanes. The results showed 100% pattern recognition accuracy using SVM for both strain and micromotion. This indicates that DSP could be applied in determining the femoral stem primary stability with high pattern recognition accuracy in biomechanical testing. Mohd Yusof Baharuddin, Sh-Hussain Salleh, Mahyar Hamedi, Ahmad Hafiz Zulkifly, Muhammad Hisyam Lee, Alias Mohd Noor, Arief Ruhullah A. Harris, and Norazman Abdul Majid Copyright © 2014 Mohd Yusof Baharuddin et al. All rights reserved. Effect of Different rhBMP-2 and TG-VEGF Ratios on the Formation of Heterotopic Bone and Neovessels Mon, 24 Mar 2014 12:25:52 +0000 Bioengineered bone substitutes might represent alternatives to autologous bone grafts in medically compromised patients due to reduced operation time and comorbidity. Due to the lack of an inherent vascular system their dimension is limited to the size of critical bone size defect. To overcome this shortcoming, the experiment tried to create heterotopic bone around vessels. In vivo, a two-component fibrin and thrombin gel containing recombinant bone morphogenic protein (rhBMP-2) and transglutamate vascular endothelial growth factor (TG-VEGF) in different ratios, respectively, was injected into a dimensionally stable membrane tube, wrapped around the femoral vessel bundle in twelve New Zealand white rabbits. Sacrifice occurred eight weeks postoperatively. Microcomputed tomography of the specimens showed significantly increased bone volume in the rhBMP-2 to TG-VEGF ratio of 10 to 1 group. Histology showed new bone formation in close proximity to the vessel bundle. Immunohistochemistry detected increased angiogenesis within the newly formed bone in the rhBMP-2 to TG-VEGF ratios of 3 to 1 and 5 to 1. Heterotopic bone was engineered in vivo around vessels using different rhBMP-2 and TG-VEGF ratios in a fibrin matrix injected into a dimensionally stable membrane tube which prevented direct contact with skeletal muscles. Wei Xin Cai, Li Wu Zheng, Chun Lei Li, Li Ma, Martin Ehrbar, Franz E. Weber, and Roger A. Zwahlen Copyright © 2014 Wei Xin Cai et al. All rights reserved. Matrilin-2 Is a Widely Distributed Extracellular Matrix Protein and a Potential Biomarker in the Early Stage of Osteoarthritis in Articular Cartilage Tue, 11 Mar 2014 06:48:47 +0000 In this study, we first generated and characterized a polyclonal antibody against unique domain of matrlin-2 and then used this specific antibody to assess the expression pattern of matrilin-2 by immunohistochemistry. We found that marilin-2 is widely distributed in the connective tissues of many mouse tissues including heart, colon, penis, esophagus, lung, kidney, tracheal cartilage, developmental bone, and adult bone. The expression level of matrilin-2 was remarkably increased in the tissues of osteoarthritis developmental articular cartilage, compared to normal healthy tissues. Furthermore, we determined matrilin-2 expression in specific epithelial cells in stomach and ductal epithelial cells of salivary gland. In other tissues, the positive signals were mainly located around cardiac muscle cells and Purkinje fibers in the heart; corpus spongiosum in the penis; submucosa in the colon and esophagus; extracellular matrix of cartilage in the tracheal cartilage; and, glomerulus, the basement membrane of distal convoluted tubule and renal matrix in kidney. These observations indicated that the distribution pattern of matrilin-2 is heterogeneous in each tissue. Matrilin-2 may play an important role in the communication of matrix to matrix and matrix to cells and will be used as a potential biomarker in the early stage of osteoarthritis of articular cartilage. Shukun Zhang, Jinwu Peng, Yan Guo, Sara Javidiparsijani, Guirong Wang, Yichun Wang, Honggang Liu, Jingshi Liu, and Junming Luo Copyright © 2014 Shukun Zhang et al. All rights reserved. A Novel Pedicle Screw with Mobile Connection: A Pilot Study Mon, 03 Mar 2014 09:35:09 +0000 To prevent adjacent disc problems after spinal fusion, a pedicle screw with a mobile junction between the head and threaded shaft was newly developed. The threaded shaft of the screw has 10 degrees mobility in all directions, but its structure is to prevent abnormal translation and tilting. This screw was evaluated as follows: (1) endurance test: 106 times rotational stress was applied; (2) biological reactions: novel screws with a mobile head and conventional screws with a fixed head were inserted into the bilateral pedicles of the L3, L4, and L5 in two mini pigs with combination. Eight months after surgery, vertebral units with the screw rod constructs were collected. After CT scan, the soft and bony tissues around the screws were examined grossly and histologically. As a result, none of the screws broke during the endurance test stressing. The mean amount of abrasion wear was 0.0338 g. In the resected mini pig section, though zygapophyseal joints between fixed-head screws showed bony union, the amount of callus in the zygapophyseal joints connected with mobile-head screws was small, and joint space was confirmed by CT. No metalloses were noted around any of the screws. Novel screws were suggested to be highly durable and histologically safe. Yasuaki Tokuhashi, Masashi Oshima, Yasumitsu Ajiro, and Hiroshi Uei Copyright © 2014 Yasuaki Tokuhashi et al. All rights reserved. In Vivo Analysis of Trapeziometacarpal Joint Kinematics during Pinch Tasks Mon, 10 Feb 2014 12:19:11 +0000 This study investigated how the posture of the thumb while performing common pinch movements and the levels of pinch force applied by the thumb affect the arthrokinematics of the trapeziometacarpal joint in vivo. Fifteen subjects performed the pinch tasks at the distal phalange (DP), proximal interphalangeal (PIP) joint, and metacarpophalangeal (MP) joint of the index finger with 0%, 50%, and 80% of maximal pinch forces by a single-axis load cell. 3D images of the thumb were obtained using the computed tomography. The results show that the reference points moved from the central region to the dorsal-radial region when changing from pinching the DP to the MP joint without pinching force being applied. Pinching with 80% of the maximum pinching force resulted in reference points being the closest to the volar-ulnar direction. Significant differences were seen between 0% and 50% of maximum pinch force, as well as between 0% and 80%, when pinching the MP joint in the distal-proximal direction. The effects of posture of the thumb and applied pinch force on the arthrokinematics of the joint were investigated with a 3D model of the trapeziometacarpal joint. Pinching with more than 50% of maximum pinch force might subject this joint to extreme displacement. Li-Chieh Kuo, Chien-Ju Lin, Guan-Po Chen, I-Ming Jou, Chien-Kuo Wang, Irina G. Goryacheva, Marat Z. Dosaev, and Fong-Chin Su Copyright © 2014 Li-Chieh Kuo et al. All rights reserved. Measurement of the “Safe Zone” and the “Dangerous Zone” for the Screw Placement on the Quadrilateral Surface in the Treatment of Pelvic and Acetabular Fractures with Stoppa Approach by Computational 3D Technology Wed, 29 Jan 2014 13:29:44 +0000 This study is aimed at definition of the safe and dangerous zone for screw placement with Stoppa approach for rapid identification during operation and a new way for the studies on the “safe zone.” Pelvic CT data of 84 human subjects were recruited to reconstruct the three-dimensional (3D) models. The distances between the edges of the “safe zone,” “dangerous zone,” and specific anatomic landmarks such as the obturator canal and the pelvic brim were precisely measured, respectively. The results show that the absolute “dangerous zone” was from the pelvic brim to 3.07 cm below it and within 2.86 cm of the obturator canal, while the region 3.56 cm below the pelvic brim or 3.85 cm away from the obturator canal was the absolute “safe zone” for screw placement. The region between the absolute “safe zone” and the absolute “dangerous zone” was the relatively “dangerous zone.” As a conclusion, application of computer-assisted 3D modeling techniques aids in the precise measurement of “safe zone” and “dangerous zone” in combination with Stoppa incision. It was not recommended to place screws on the absolute dangerous zone, while, for the relatively “dangerous zone,” it depends on the individual variations in bony anatomy and the fracture type. Sheng Zhang, Wanhan Su, Qiang Luo, Frankie Leung, and Bin Chen Copyright © 2014 Sheng Zhang et al. All rights reserved. Immediate Care of Open Extremity Fractures: Where Can We Improve? Tue, 21 Jan 2014 07:52:53 +0000 Clear guidelines are set by the British Orthopaedic Association (BOA) and British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) on the preoperative management of open fractures. This as well as the clinical consequences of poor management of open fractures means the patient workup for surgery is important as well as the timing of surgery. Experience suggests few patients are managed 100% as per the guidelines and we look to test this hypothesis. A retrospective analysis was undertaken of all open long bone fractures (total 133), excluding hand injuries, which presented to a district general hospital over a 5-year period. The implementation of 7 defined key tasks for initial management was recorded. 101 cases were eligible, with the majority of cases (71.4%) having initial orthopaedic assessment outside normal working hours. The mean number of tasks completed was 3.23/7. Assessment out of hours was associated with less tasks being implemented but doctor seniority and the presence of polytrauma made no difference to the quality of acute care. Staff involved in the acute care of open fractures require targeted education to improve the delivery of initial preoperative care. We recommend that other centres assess their performance against this data. R. Walton, J. Manara, S. E. Elamin, I. Braithwaite, and E. Wood Copyright © 2014 R. Walton et al. All rights reserved. Diabetic Ankle Fractures: A Review of the Literature and an Introduction to the Adelaide Fracture in the Diabetic Ankle Algorithm and Score Sun, 05 Jan 2014 09:15:10 +0000 Diabetics who have acquired an ankle fracture may be easily missed given their atypical presentation. As such, it is not infrequently seen that these patients are either initially misdiagnosed or ineffectively managed resulting in unnecessary hospital length of stay and procedures. Multiple review articles and retrospective studies have been previously published in the literature, but complete guidelines to assist in accurate diagnosis and cost-effective management for this complex problem do not currently exist. Through a critical analysis of the current literature, a proposed diagnostic and management algorithm and scoring system that can be used to quantify risks in the surgical management are presented for consideration. Joshua Yee, Anand Pillai, and Linda Ferris Copyright © 2014 Joshua Yee et al. All rights reserved. Autoclaved Tumor Bone for Skeletal Reconstruction in Paediatric Patients: A Low Cost Alternative in Developing Countries Wed, 18 Dec 2013 09:56:04 +0000 We reviewed in this series forty patients of pediatric age who underwent resection for malignant tumors of musculoskeletal system followed by biological reconstruction. Our surgical procedure for reconstruction included (1) wide en bloc resection of the tumor; (2) curettage of tumor from the resected bone; (3) autoclaving for 8 minutes (4) bone grafting from the fibula (both vascularized and nonvascularized fibular grafts used); (5) reimplantation of the autoclaved bone into the host bone defect and fixation with plates. Functional evaluation was done using MSTS scoring system. At final followup of at least 18 months (mean 29.2 months), 31 patients had recovered without any complications. Thirty-eight patients successfully achieved a solid bony union between the graft and recipient bone. Three patients had surgical site infection. They were managed with wound debridement and flap coverage of the defect. Local recurrence and nonunion occurred in two patients each. One patient underwent disarticulation at hip due to extensive local disease and one died of metastasis. For patients with non-union, revision procedure with bone graft and compression plates was successfully used. The use of autoclaved tumor grafts provides a limb salvage option that is inexpensive and independent of external resources and is a viable option for musculoskeletal tumor management in developing countries. Masood Umer, Hafiz Muhammad Umer, Irfan Qadir, Haroon Rashid, Rabia Awan, Raza Askari, and Shamvil Ashraf Copyright © 2013 Masood Umer et al. All rights reserved. Assessment of Normal Sagittal Alignment of the Spine and Pelvis in Children and Adolescents Mon, 09 Dec 2013 18:17:57 +0000 Aim. We aimed to determine spinopelvic balance in 8–19-year-old-people in order to assess pelvic and spinal parameters in sagittal view. Methods. Ninety-eight healthy students aged 8–19 years, who lived in the central parts of Tehran, were assessed. Demographic data, history of present and past diseases, height (cm), and weight (kg) were collected. Each subject was examined by an orthopedic surgeon and spinal radiographs in lateral view were obtained. Eight spinopelvic parameters were measured by 2 orthopedic spine surgeons. Results. Ninety-eight subjects, among which 48 were girls (49%) and 50 boys (51%), with a mean age of years (range: 8–19) were evaluated. Mean height and weight of children were kgs, respectively. Mean TK, LL, TT, LT, and PI of subjects were 37.1 ± 9.9°, 39.6 ± 12.4°, 7.08 ± 4.9°, 12.0 ± 5.9°, and 45.37 ± 10.7°, respectively. Conclusion. Preoperation planning for spinal fusion surgeries via applying PI seems reasonable. Predicating “abnormal” to lordosis and kyphosis values alone without considering overall sagittal balance is incorrect. Mean of SS and TK in our population is slightly less than that in Caucasians. Hasan Ghandhari, Hamid Hesarikia, Ebrahim Ameri, and Abolfazl Noori Copyright © 2013 Hasan Ghandhari et al. All rights reserved. Use of Tekscan K-Scan Sensors for Retropatellar Pressure Measurement Avoiding Errors during Implantation and the Effects of Shear Forces on the Measurement Precision Tue, 03 Dec 2013 10:16:42 +0000 Pressure-sensitive K-Scan 4000 sensors (Tekscan, USA) provide new possibilities for the dynamic measurement of force and pressure in biomechanical investigations. We examined the sensors to determine in particular whether they are also suitable for reliable measurements of retropatellar forces and pressures. Insertion approaches were also investigated and a lateral parapatellar arthrotomy supplemented by parapatellar sutures proved to be the most reliable method. The ten human cadaver knees were tested in a knee-simulating machine at a torque of 30 and 40 Nm. Each test cycle involved a dynamic extension from 120° flexion. All recorded parameters showed a decrease of 1-2% per measurement cycle. Although we supplemented the sensors with a Teflon film, the decrease, which was likely caused by shear force, was significant. We evaluated 12 cycles and observed a linear decrease in parameters up to 17.2% (coefficient of regression 0.69–0.99). In our opinion, the linear decrease can be considered a systematic error and can therefore be quantified and accounted for in subsequent experiments. That will ensure reliable retropatellar usage of Tekscan sensors and distinguish the effects of knee joint surgeries from sensor wear-related effects. A. Wilharm, Ch. Hurschler, T. Dermitas, and M. Bohnsack Copyright © 2013 A. Wilharm et al. All rights reserved. Shelf Acetabuloplasty in the Treatment of Severe Legg-Calvé-Perthes Disease: Good Outcomes at Midterm Follow-Up Wed, 27 Nov 2013 15:52:24 +0000 The aim of the study was to retrospectively review results of operative treatment for coverage deficit of femoral head in children with severe epiphysis displacement in Legg-Calvé-Perthes (LCP) disease. The material included 23 shelf acetabuloplasty procedures for LCP disease. The average age at diagnosis was 8.1 years (range 4–12). Mean follow-up was 5.8 years (range from 2.2 to 11.2 years). Mean Reimer's index decreased statistically significantly from a mean of 32% before surgery to 10.0% at the last follow-up (). The mean Wiberg center-edge angle increased also statistically significantly from a mean of 17.3° before procedure to 32.3° at the last follow-up (). According to the Stulberg classification, type I was observed in 2, type II in 13, type III in 6, and type IV in 2 hips. There were no differences in the range of motion or leg length discrepancy in preoperative and postoperative standing. Partial, not significant, bone graft resorption was noted in 6 cases in the first 6–9 months after surgery. To conclude, shelf acetabuloplasty allows achieving good midterm results in the treatment of severe stages of LCP disease. The procedure improves coverage of femoral head and allows its remodelling. Andrzej Grzegorzewski, Marek Synder, Krysztof Kmieć, Karol Krajewski, Michał Polguj, and Marcin Sibiński Copyright © 2013 Andrzej Grzegorzewski et al. All rights reserved. A Biomechanical Research of Growth Control of Spine by Shape Memory Alloy Staples Sun, 17 Nov 2013 14:17:55 +0000 Shape memory alloy (SMA) staples in nickel titanium with shape memory effect are effective for spinal growth control. This study was designed to evaluate the biomechanical properties of the staples and observe the stability of the fixed segments spine after the staples were implanted. According to the vertical distance of the vertebrae, SMA staples of 5, 6.5, and 8 mm were designed. The recovery stress of 24 SMA staples in three groups was measured. The pullout strength of SMA staples and stainless steel staples in each functional spinal unit was measured. Each of the six fresh specimens was divided into three conditions: normal, single staple, and double staples. Under each condition, the angle and torque of spinal movements in six directions were tested. Results show that the differences in recovery stress and maximum pullout strength between groups were statistically significant. In left and right bending, flextion, and extention, the stability of spine was decreased in conditions of single staple and double staples. Biomechanical function of SMA staples was superior to stainless steel staple. SMA staples have the function of hemiepiphyseal compression and kyphosis and scoliosis model of thoracic vertebrae in goat could be successfully created by the fusionless technique. Wei Zhang, Yonggang Zhang, Guoquan Zheng, Ruyi Zhang, and Yan Wang Copyright © 2013 Wei Zhang et al. All rights reserved. Lithium Chloride Enhances Cathepsin H Expression and BMP-4 Degradation in C3H10T1/2 Cells Sun, 10 Nov 2013 14:07:39 +0000 The effect of canonical Wnt/β-catenin signaling on chondrogenic differentiation induced by transfection of BMP4 expressing plasmid was analyzed. Lithium chloride (LiCl) which mimics canonical Wnt/β-catenin signaling was added to cells transfected with BMP4 expressing plasmid. Although BMP4 mRNA expression was not affected by LiCl, LiCl decreased BMP4 protein accumulation. Gene expression analysis exhibited upregulation of cathepsin H by LiCl treatment. Gene silencing of cathepsin H enhanced BMP4 protein accumulation from BMP4 expressing cells. These results suggested that cathepsin H is regulated by Wnt/β-catenin signaling and plays an important role in the regulation of BMP4 biological activity. Koshi N. Kishimoto and Eiji Itoi Copyright © 2013 Koshi N. Kishimoto and Eiji Itoi. All rights reserved. Percutaneous Vertebroplasty in Adult Degenerative Scoliosis for Spine Support: Study for Pain Evaluation and Mobility Improvement Thu, 24 Oct 2013 16:17:29 +0000 We evaluate the efficacy-safety of percutaneous vertebroplasty (PV) as primary treatment in adult degenerative scoliosis. During the last 4 years, PV was performed in 18 adult patients (68 vertebral bodies) with back pain due to degenerative scoliotic spine. Under anaesthesia and fluoroscopy, direct access to most deformed vertebral bodies was obtained by 13G needles, and PMMA for vertebroplasty was injected. Scoliosis’ inner arch was supported. Clinical evaluation included immediate and delayed studies of patient’s general condition and neurological status. An NVS scale helped assessing pain relief, life quality, and mobility improvement. Comparing patients’ scores prior to (mean value  NVS units), the morning after (mean value  NVS units), at 12 (mean value  NVS units), and 24 months after vertebroplasty (mean value  NVS units) treatment, patients presented a mean decrease of  NVS units on terms of life quality improvement and pain relief (). Overall mobility improved in 18/18 (100%) patients. No complications were observed. During follow-up period (mean value 17.66 months), all patients underwent a mean of 1.3 sessions for facet joint and nerve root infiltrations. Percutaneous vertebroplasty in the inner arch seems to be an effective technique for supporting adult degenerative scoliotic spine. Dimitrios K. Filippiadis, Panagiotis Papagelopoulos, Maria Kitsou, Nikolaos Oikonomopoulos, Elias Brountzos, Nikolaos Kelekis, and Alexis Kelekis Copyright © 2013 Dimitrios K. Filippiadis et al. All rights reserved. Use of the Vascularized Iliac-Crest Flap in Musculoskeletal Lesions Tue, 22 Oct 2013 18:41:13 +0000 Bone loss was in the past treated by several methods, such as bone distraction and the use of nonvascularized or tissue-bank bone grafts. With the advent of modern microsurgical techniques, the vascularized bone flap has been used with good results; it resolves local nutritional problems, repairs soft tissue that is often damaged by severe trauma, and treats bone loss due to tumors, pseudarthroses, and osteomyelitis. This paper reports the authors’ experience with the use of vascularized iliac-crest flaps to treat orthopedic pathologies in five patients with traumatic bone loss (<10 cm), three with osteomyelitis, and three with atrophic nonunion. In all cases, the same surgeon obtained a vascularized iliac-crest flap with a pedicle based on the deep iliac circumflex artery. All flaps consolidated within a mean period of 3 months. These findings demonstrate that the use of an iliac-crest flap is a treatment option in cases of bone loss and that it is associated with good functional results and minimal donor-site morbidity. Cristiane Tonoli, Alexandre H. S. Bechara, Roberto Rossanez, William D. Belangero, and Bruno Livani Copyright © 2013 Cristiane Tonoli et al. All rights reserved. An Isolated Medial Patellofemoral Ligament Reconstruction with Patellar Tendon Autograft Sun, 13 Oct 2013 16:07:26 +0000 The aim of the study was to evaluate the results of the medial patellofemoral ligament reconstruction with a medial strip of patellar tendon autograft after a minimum 2-year followup. Ten patients (10 knees) were operated on by one surgeon, according to the modified technique, described by Camanho, without any bone plug at free graft end. The mean age of the patients was 27.2 years (ranging from 18 to 42 years). The mean follow-up period was 3 years and 7 months. All patients were reviewed prospectively. At the last follow-up visit, all the patients demonstrated a significant improvement in terms of patellofemoral joint stability, all aspects of the KOOS questionnaire, and Kujala et al.’s score (59.7 points preoperatively and 84.4 points at the last followup). No patient revealed recurrent dislocation. The SF-36 score revealed a significant improvement in bodily pain, general health, physical role functioning, social role functioning, and physical functioning domains. The described MPFL reconstruction with the use of the medial 1/3rd of patella tendon is an effective procedure that gives satisfactorily patellofemoral joint functions, improves the quality of life, and provides much pain relief. It is relatively simple, surgically not extensive, and economically cost-effective procedure. Dariusz Witoński, Rafał Kęska, Marek Synder, and Marcin Sibiński Copyright © 2013 Dariusz Witoński et al. All rights reserved. Hybrid Total Knee Arthroplasty Revisited: Midterm Followup of Hybrid versus Cemented Fixation in Total Knee Arthroplasty Wed, 25 Sep 2013 14:44:22 +0000 The optimal method of fixation in total knee arthroplasty is still debated. Hybrid total knee arthroplasty (TKA), with cemented tibial and cementless femoral components, is a proposed method of fixation to improve outcomes. Although several studies have shown favorable outcomes, there is still lack of consensus in the literature. We hypothesized that hybrid TKA yields similar clinical, radiographic, and survivorship results compared to fully cemented TKA. The clinical and radiographic outcomes of 304 cruciate retaining TKAs with minimum two-year followup, including 193 hybrid (mean followup of 4.1 years) and fully cemented TKAs (mean followup of 3.2 years) were evaluated. Knee society scores were similar between the two groups. The total number of femoral radiolucencies was also similar between the two groups, while a greater number of femoral Zone 4 radiolucencies were seen in the cemented group (9% versus 1.6%, ). The hybrid group demonstrated a 99.2% survival rate of the femoral component out to seven years for aseptic loosening. No significant difference in survivorship was seen between the groups for all cause or aseptic failure at seven years. We conclude that hybrid fixation leads to similar intermediate-term outcomes as fully cemented components and remains a viable option in total knee arthroplasty. Christopher E. Pelt, Jeremy M. Gililland, Justin Doble, Benjamin M. Stronach, and Christopher L. Peters Copyright © 2013 Christopher E. Pelt et al. All rights reserved. In Vivo Spinal Posture during Upright and Reclined Sitting in an Office Chair Tue, 24 Sep 2013 11:27:39 +0000 Increasing numbers of people spend the majority of their working lives seated in an office chair. Musculoskeletal disorders, in particular low back pain, resulting from prolonged static sitting are ubiquitous, but regularly changing sitting position throughout the day is thought to reduce back problems. Nearly all currently available office chairs offer the possibility to alter the backrest reclination angles, but the influence of changing seating positions on the spinal column remains unknown. In an attempt to better understand the potential to adjust or correct spine posture using adjustable seating, five healthy subjects were analysed in an upright and reclined sitting position conducted in an open, upright MRI scanner. The shape of the spine, as described using the vertebral bodies’ coordinates, wedge angles, and curvature angles, showed high inter-subject variability between the two seating positions. The mean lumbar, thoracic, and cervical curvature angles were °, °, and ° for the upright and °, °, and ° for the reclined sitting positions. Thus, a wide range of seating adaptation is possible through modification of chair posture, and dynamic seating options may therefore provide a key feature in reducing or even preventing back pain caused by prolonged static sitting. Roland Zemp, William R. Taylor, and Silvio Lorenzetti Copyright © 2013 Roland Zemp et al. All rights reserved. Interdisciplinary Approach to Tool-Handle Design Based on Medical Imaging Thu, 19 Sep 2013 14:44:27 +0000 Products are becoming increasingly complex; therefore, designers are faced with a challenging task to incorporate new functionality, higher performance, and optimal shape design. Traditional user-centered design techniques such as designing with anthropometric data do not incorporate enough subject data to design products with optimal shape for best fit to the target population. To overcome these limitations, we present an interdisciplinary approach with medical imaging. The use of this approach is being presented on the development of an optimal sized and shaped tool handle where the hand is imaged using magnetic resonance imaging machine. The obtained images of the hand are reconstructed and imported into computer-aided design software, where optimal shape of the handle is obtained with Boolean operations. Methods can be used to develop fully customized products with optimal shape to provide best fit to the target population. This increases subjective comfort rating, performance and can prevent acute and cumulative trauma disorders. Provided methods are especially suited for products where high stresses and exceptional performance is expected (high performance tools, professional sports, and military equipment, etc.). With the use of these interdisciplinary methods, the value of the product is increased, which also increases the competitiveness of the product on the market. G. Harih and A. Čretnik Copyright © 2013 G. Harih and A. Čretnik. All rights reserved. Effects of Neuromuscular Electrical Stimulation Combined with Exercises versus an Exercise Program on the Pain and the Function in Patients with Knee Osteoarthritis: A Randomized Controlled Trial Sat, 14 Sep 2013 08:44:48 +0000 Objectives. To investigate the effect of 8 weeks of NMES + Ex (neuromuscular electrical stimulation combined with exercises) on pain and functional improvement in patients with knee osteoarthritis (OA) compared to exercise (Ex) alone. Design. Randomized controlled trial. Setting. A specialty outpatient clinic. Participants. Patients (; women = 86, men = 14; age range, 50–75 years) with knee OA. Interventions. Participants were randomly assigned to NMES + Ex or Ex group. Outcome Measures. Numerical Rating Scale 0 to 10 (NRS) and the Timed Up and Go (TUG) test were the primary outcomes. The secondary outcomes used were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Results. Following the interventions, a statistically significant improvement in both groups was observed in all outcomes assessed. For the comparison between the groups, no statistically significant difference was found between the NMES + Ex and the Ex groups in NRS (), TUG test (), and aspects of WOMAC: pain (), function (), and stiffness (). Conclusion. The addition of NMES to exercise did not improve the outcomes assessed in knee OA patients. This study was registered at the Australian Clinical Trials Registry (ACTRN012607000357459). Aline Mizusaki Imoto, Stella Peccin, Kelson Nonato Gomes da Silva, Lucas Emmanuel Pedro de Paiva Teixeira, Marcelo Ismael Abrahão, and Virgínia Fernandes Moça Trevisani Copyright © 2013 Aline Mizusaki Imoto et al. All rights reserved. The Mode of Inheritance of Scheuermann’s Disease Thu, 12 Sep 2013 13:32:08 +0000 The mode of Scheuermann’s disease inheritance and its phenotypic traits in probands and their relatives were studied in 90 pedigrees (90 probands and 385 relatives). The disorder was identified as a genetically related pathology inherited by autosomal dominant type, controlled by a mutant major gene, as a kyphotic deformity without signs of vertebral bodies’ anomaly and torsion. Morphological and biochemical studies showed disturbance in the structure of vertebral growth plate anterior aspects at the level of deformity, defects in proliferation and differentiation of chondrocytes, and change in proteoglycan spectrum in cells and matrix. Twelve candidate genes were studied in chondrocytes isolated from vertebral growth plates of patients with Scheuermann’s disease. The study results included disorder in the IHH gene expression and preservation of the expression of PAX1, two aggrecan isoforms, link protein, types I and II collagen, lumican, versican, growth hormone and growth factor receptor genes, and proliferation gene. Preservation of the SOX9 gene (transcription gene) probably indicates posttranscriptional genetic disorders. The study is under way. A. M. Zaidman, M. N. Zaidman, E. L. Strokova, A. V. Korel, E. V. Kalashnikova, T. V. Rusova, and M. V. Mikhailovsky Copyright © 2013 A. M. Zaidman et al. All rights reserved. Transforaminal Lumbar Interbody Fusion Using a Modified Distractor Handle: A Midterm Clinicoradiological Follow-Up Study Mon, 09 Sep 2013 11:21:06 +0000 In current TLIF practice, the choice of the cage size is empirical and primarily depends on the case volume and experience of the surgeon. We used a self-made modified distractor handle in TLIF procedure with the goal of standardizing the intervertebral space tension and determining the proper cage size. Abuduaini Rewuti, Zixian Chen, Zhenzhou Feng, Yuanwu Cao, Xiaoxing Jiang, and Chun Jiang Copyright © 2013 Abuduaini Rewuti et al. All rights reserved. The Effect of Very High versus Very Low Sustained Loading on the Lower Back and Knees in Middle Life Thu, 05 Sep 2013 08:50:04 +0000 To evaluate the effect of the extremes of long term high and low physical activities on musculoskeletal heath in middle age, a historical cohort study was performed. The MRI knee and back findings of 25 randomly selected subjects who were inducted into the armed forces in 1983 and served at least 3 years as elite infantry soldiers were compared 25 years later, with 20 randomly selected subjects who were deferred from army service for full time religious studies at the same time. Both cohorts were from the same common genome. The two primary outcome measures were degenerative lumbar disc disease evaluated by the Pfirrmann score and degenerative knee changes evaluated by the WORMS score. At the 25-year follow up, the mean Pfirrmann score (8.6) for the L1 to S1 level of the elite infantry group was significantly higher than that of the sedentary group (6.7), (). There was no statistically significant difference between the WORMS knee scores between the two cohorts (). In spite of the much greater musculoskeletal loading history of the elite infantry cohort, only their lumbar spines but not their knees showed increased degenerative changes at middle age by MRI criteria. Yael Milgrom, Charles Milgrom, Naama Constantini, Yaakov Applbaum, Denitsa Radeva-Petrova, and Aharon S. Finestone Copyright © 2013 Yael Milgrom et al. All rights reserved. The Utility of Digital Linear Tomosynthesis Imaging of Total Hip Joint Arthroplasty with Suspicion of Loosening: A Prospective Study in 40 Patients Tue, 03 Sep 2013 11:17:15 +0000 Aim. The clinical utility of digital linear tomosynthesis in musculoskeletal applications has been validated in only a few reports. Technical performance and utility in hip prosthesis imaging have been discussed in technical reports, but no clinical evaluation has been reported. The purpose of the current study was to assess the added clinical utility of digital linear tomosynthesis compared to radiography in loosening of total hip joint arthroplasty. Materials and Methods. In a prospective study, radiography and digital tomosynthesis were performed in 40 consecutive patients with total hip arthroplasty referred for suspect prosthesis loosening. Tomosynthesis images were compared to anterior-posterior (AP) and cross-table lateral radiographs regarding demarcation and extent of demineralization and osteolysis. Further noted were skeletal fractures, cement fractures, fragmentation, and artifacts interfering with the diagnosis. Results. Tomosynthesis was superior to radiography with sharper delineation of demineralization and osteolysis in the AP projection. A limitation was the inability to generate lateral tomosynthesis images, with inferior assessment of the area anterior and posterior to the acetabular cup compared to cross-table radiographs. Artifacts interfering with diagnosis were found in one hip. Conclusion. Tomosynthesis improved evaluation of total hip arthroplasty in the AP projection but was limited by the lack of lateral projections. Jan H. Göthlin and Mats Geijer Copyright © 2013 Jan H. Göthlin and Mats Geijer. All rights reserved. Evidence for the Treatment of Osteoporosis with Vitamin D in Residential Care and in the Community Dwelling Elderly Sat, 24 Aug 2013 09:06:27 +0000 Introduction. Vitamin D is common treatment for osteoporosis. Both age >70 years and living in residential care are associated with increased fracture risk. Community dwelling elderly are a heterogeneous group who may have more similatiry with residential care groups than younger community dwelling counterparts. Aims. To review the evidence for cholecalciferol or ergocalciferol tretment of osteoporosis in either community dwelling patients aged ≥70 years of age, or redidential care patients. Secondly endpoints were changes in bone mineral denisty, and in bone turnover markers. Methods. We performed a literature search using search terms for osteoporosis and vitamin D. Treatment for at least one year was required. Results. Only one residential care study using cholecalciferol, showed non-vertebral and hip fracture reduction in vitamin D deficient subjects. In the community setting one quasi randomised study using ergocalciferol showed reduction in total but not hip or non-vertebral fracture, and a second randomised study showed increased hip fracture risk. Three studies reported increases in hip bone mineral denisty. Discussion. A minority of studies demonstrated a fracture benefit form vitamin D and one suggested possible harm in a community setting. Current practice should be to only offer this treatment to subjects identified as deficient. John A. A. Geddes and Charles A. Inderjeeth Copyright © 2013 John A. A. Geddes and Charles A. Inderjeeth. All rights reserved. Degenerative Spondylolisthesis Is Associated with Low Spinal Bone Density: A Comparative Study between Spinal Stenosis and Degenerative Spondylolisthesis Mon, 19 Aug 2013 08:11:29 +0000 Spinal stenosis and degenerative spondylolisthesis share many symptoms and the same treatment, but their causes remain unclear. Bone mineral density has been suggested to play a role. The aim of this study was to investigate differences in spinal bone density between spinal stenosis and degenerative spondylolisthesis patients. 81 patients older than 60 years, who underwent DXA-scanning of their lumbar spine one year after a lumbar spinal fusion procedure, were included. Radiographs were assessed for disc height, vertebral wedging, and osteophytosis. Pain was assessed using the Low Back Pain Rating Scale pain index. -score of the lumbar spine was significantly lower among degenerative spondylolisthesis patients compared with spinal stenosis patients (−1.52 versus −0.52, ). Thirty-nine percent of degenerative spondylolisthesis patients were classified as osteoporotic and further 30% osteopenic compared to only 9% of spinal stenosis patients being osteoporotic and 30% osteopenic (). Pain levels tended to increase with poorer bone status (). Patients treated surgically for symptomatic degenerative spondylolisthesis have much lower bone mass than patients of similar age treated surgically for spinal stenosis. Low BMD might play a role in the development of the degenerative spondylolisthesis, further studies are needed to clarify this. Thomas Andersen, Finn B. Christensen, Bente L. Langdahl, Carsten Ernst, Søren Fruensgaard, Jørgen Østergaard, Jens Langer Andersen, Sten Rasmussen, Bent Niedermann, Kristian Høy, Peter Helmig, Randi Holm, Niels Egund, and Cody Bünger Copyright © 2013 Thomas Andersen et al. All rights reserved. Development of a Detailed Volumetric Finite Element Model of the Spine to Simulate Surgical Correction of Spinal Deformities Wed, 07 Aug 2013 16:08:53 +0000 A large spectrum of medical devices exists; it aims to correct deformities associated with spinal disorders. The development of a detailed volumetric finite element model of the osteoligamentous spine would serve as a valuable tool to assess, compare, and optimize spinal devices. Thus the purpose of the study was to develop and initiate validation of a detailed osteoligamentous finite element model of the spine with simulated correction from spinal instrumentation. A finite element of the spine from T1 to L5 was developed using properties and geometry from the published literature and patient data. Spinal instrumentation, consisting of segmental translation of a scoliotic spine, was emulated. Postoperative patient and relevant published data of intervertebral disc stress, screw/vertebra pullout forces, and spinal profiles was used to evaluate the models validity. Intervertebral disc and vertebral reaction stresses respected published in vivo, ex vivo, and in silico values. Screw/vertebra reaction forces agreed with accepted pullout threshold values. Cobb angle measurements of spinal deformity following simulated surgical instrumentation corroborated with patient data. This computational biomechanical analysis validated a detailed volumetric spine model. Future studies seek to exploit the model to explore the performance of corrective spinal devices. Mark Driscoll, Jean-Marc Mac-Thiong, Hubert Labelle, and Stefan Parent Copyright © 2013 Mark Driscoll et al. All rights reserved. The Age-Related Changes in Cartilage and Osteoarthritis Mon, 22 Jul 2013 08:36:29 +0000 Osteoarthritis (OA) is closely associated with aging, but its underlying mechanism is unclear. Recent publications were reviewed to elucidate the connection between aging and OA. With increasing OA incidence, more senior people are facing heavy financial and social burdens. Age-related OA pathogenesis is not well understood. Recently, it has been realized that age-related changes in other tissues besides articular cartilage may also contribute to OA development. Many factors including senescence-related secretory phenotypes, chondrocytes’ low reactivity to growth factors, mitochondrial dysfunction and oxidative stress, and abnormal accumulation of advanced glycation end products (AGEs) may all play key roles in the pathogenesis of age-related OA. Lately, epigenetic regulation of gene expression was recognized for its impact on age-related OA pathogenesis. Up to now, few studies have been reported about the role of miRNA and long-noncoding RNA (lncRNA) in age-related OA. Research focusing on this area may provide valuable insights into OA pathogenesis. OA-induced financial and social burdens have become an increasingly severe threat to older population. Age-related changes in noncartilage tissue should be incorporated in the understanding of OA development. Growing attention on oxidative stress and epigenetics will provide more important clues for the better understanding of the age-related OA. YongPing Li, XiaoChun Wei, JingMing Zhou, and Lei Wei Copyright © 2013 YongPing Li et al. All rights reserved. Pharmacokinetic Properties and Systemic Safety of Vancomycin-Impregnated Cancellous Bone Grafts in the Treatment of Spondylodiscitis Wed, 17 Jul 2013 10:13:57 +0000 The aim of the present study was to investigate the local pharmacokinetic properties and the systemic safety of vancomycin-impregnated cancellous bone grafts in the treatment of spondylodiscitis. Between 2010 and 2012, 8 patients (5 females, 3 males, mean age 68.75 y.) were treated with this method. Local vancomycin concentrations reached median values of 179 µg/mL (maximum 365 µg/mL) on day 1, decreasing to 98 µg/mL on day 3. The urine vancomycin concentrations showed similar pharmacokinetic properties as those locally determined. On day 1, median values were at 28.05 µg/mL (maximum 287 µg/mL). All serum vancomycin concentrations were in all cases and on every day below <2 µg/mL. The median serum creatinine values were preoperatively 0.87 mg/dL, followed by 0.625 mg/dL, 0.705 mg/dL, and 0.835 mg/dL on day 7, 14, and 28, respectively. No cases of ototoxicity could be observed. At a mean follow-up of 16.5 [4–36] months no cases of reinfections or persistent infections could be seen. In conclusion, the implantation of vancomycin-loaded cancellous bone grafts is an effective option in the treatment of spondylodiscitis with a high infection eradication rate and no risk of any systemic toxicity. The pharmacokinetic properties can be easily monitored locally, in the urine and the serum. Konstantinos Anagnostakos and Katrin Koch Copyright © 2013 Konstantinos Anagnostakos and Katrin Koch. All rights reserved. The Diagnostic Accuracy of Radionuclide Arthrography for Prosthetic Loosening in Hip and Knee Arthroplasty Mon, 15 Jul 2013 07:52:57 +0000 Purpose of Study. Diagnosis of prosthetic loosening in hip and knee arthroplasty remains a challenge. Although there are a number of diagnostic tools, no single test or combination is 100% sensitive or specific. There has been a recent interest in the use of radionuclide arthrography (RNA) for detection of prosthetic loosening. Methods. A retrospective review of 45 consecutive RNA scans from 2005 to 2010 was conducted. RNA findings were compared with intraoperative findings at revision and/or serial radiographic examinations to confirm loosening. A component was considered loose if sequential radiographs demonstrated macromotion, gross subsidence, or progressive radiolucency. Results. There were 26 females and 17 males, with mean age at RNA of 71 years (range of 53–89 years) and mean time from index surgery, 6.4 years (range of 0.5–23 years). There were 23 total knee replacements (TKR) (19 primary and 4 revision) and 20 total hip replacements (THR) (11 primary and 9 revision). 15 patients underwent revision surgery following RNA. Strict inclusion criteria allowed 27 patients for further analysis. Sixteen RNA scans were suggestive of loosening, of which 14 were confirmed loose. Eleven scans were suggestive of a stable prosthesis, of which 10 were confirmed well fixed. RNA had a sensitivity of 93%, specificity of 83%, positive predictive value of 88%, and negative predictive value of 91%. Conclusion. Radionuclide arthrography should be considered a useful adjunct in the diagnosis of prosthetic loosening in the challenging patient. Timothy H. French, Nicholas Russell, and Anand Pillai Copyright © 2013 Timothy H. French et al. All rights reserved. Mean 5-Year Clinical and Radiographic Outcomes of Cementless Total Hip Arthroplasty in Patients under the Age of 30 Mon, 24 Jun 2013 15:54:15 +0000 We performed a retrospective review of 40 consecutive modern cementless THAs with 65-month mean followup in 34 patients under the age of 30 primarily for diagnoses other than inflammatory arthritis. We found acceptable functional improvement and radiographic outcomes at mean 5-year followup. We found a high transfusion rate, dislocation rate (10%), and midterm overall aseptic revision rate (17%). Twenty-eight (67.5%) of hips in this series were metal on metal, with a large percentage of aseptic revisions related to metallosis (57%). When revisions due to metallosis were excluded, the aseptic revision rate was 7.5%. The high prevalence of prior pediatric hip surgery in these patients (50%) may predispose to increased technical difficulty resulting in increased complications and higher revision rates. Although our revision rate was high in these young patients, it is favorable compared to older techniques and consistent with the limited data available with modern cementless techniques in patients of similar age. Cementless THA with modern designs remains a viable option for the treatment of arthritis in the young patient. Jeremy M. Gililland, Lucas A. Anderson, Jill Erickson, Christopher E. Pelt, and Christopher L. Peters Copyright © 2013 Jeremy M. Gililland et al. All rights reserved. Incidence of Heterotopic Ossification after Surface and Conventional Total Hip Arthroplasty: A Comparative Study Using Anterolateral Approach and Indomethacin Prophylaxis Mon, 24 Jun 2013 15:12:10 +0000 The incidence and severity of heterotopic ossification (HO) in two homogeneous groups of patients that received surface replacement arthroplasty (SRA) and conventional total hip arthroplasty (THA) were evaluated retrospectively. Thirty-nine patients undergoing 42 hip resurfacing procedures and 41 primary cementless THAs through an anterolateral approach received a 10-day course of 150 mg/die of indomethacin postoperatively. The median surgical time was 190 minutes and 156 minutes, respectively (). At a minimum 1-year followup, the development of HO was assessed on standard X-ray using Brooker grading. Ectopic bone formation was detected in five cases (11.9%, two Brooker grade I and three grade II) in the SRA group and in 14 hips (34.1%, 12 grade I and two grade II) treated with conventional THA, but the difference was not significant (). No clinically relevant periprosthetic ossification (Brooker III or IV) occurred in both groups. Although the difference was not statistically significant, the incidence of HO after SRA was lower than conventional THA. More extensive soft tissue trauma, bone debris, and longer operative time in hip resurfacing are not likely to be absolute risk factors for HO. Further investigations including larger patient populations are needed to confirm these findings. Dario Regis, Andrea Sandri, and Elena Sambugaro Copyright © 2013 Dario Regis et al. All rights reserved. Fracture of Ceramic Bearing Surfaces following Total Hip Replacement: A Systematic Review Thu, 13 Jun 2013 11:31:03 +0000 Ceramic bearing surfaces are increasingly used for total hip replacement, notwithstanding that concern is still related to ceramic brittleness and its possible mechanical failure. The aim of this systematic review is to answer three questions: (1) Are there risk factors for ceramic component fracture following total hip replacement? (2) Is it possible to perform an early diagnosis of ceramic component failure before catastrophic fracture occurs? (3) Is it possible to draw guidelines for revision surgery after ceramic components failure? A PubMed and Google Scholar search was performed and reference citations from publications identified in the literature search were reviewed. The use of 28 mm short-neck femoral head carries an increased risk of fracture. Acetabular component malposition might increase the risk of ceramic liner fractures. Synovial fluid microanalysis and CT scan are promising in early diagnosis of ceramic head and liner failure. Early revision is suggested in case of component failure; no consensus exists about the better coupling for revision surgery. Ceramic brittleness remains a major concern. Due to the increased number of ceramic on ceramic implants, more revision surgeries and reports on ceramic components failure are expected in the future. An algorithm of diagnosis and treatment for ceramic hip failure is proposed. Francesco Traina, Marcello De Fine, Alberto Di Martino, and Cesare Faldini Copyright © 2013 Francesco Traina et al. All rights reserved. Intraosseous Ganglia: A Series of 17 Treated Cases Thu, 13 Jun 2013 10:25:55 +0000 Background. Intraosseous ganglion is a cystic lesion that contains gelatinous material, most often occurs in middle-aged patients, and is regarded as similar to soft-tissue ganglion. The etiology is unknown, but association with degenerative joint disease has been considered. Materials and Methods. At a single institute, 17 patients (8 men, 9 women) with a mean age of 48.9 years (22–72 years) were surgically treated for an intraosseous ganglion. The lesions were located in 9 long bones (5 tibiae, 2 humeri, 1 ulna, and 1 femur); 4 flat bones (2 scapulae, 2 ilia); and 4 small bones (2 scaphoid, 1 metacarpal bone, and 1 talus). The diagnosis was confirmed based both on the gross intraoperative finding of intralesional gelatinous material and on histopathology. Results. All lesions occurred at the epiphysis or near the joint. The plain radiographs showed a lesion with marginal osteosclerosis. The average lesion size was 22.4 mm (range 6–40 mm). Among the 17 patients, 2 (12%) had osteoarthritis, 3 (18%) had pathological fracture, and 4 (24%) had extraskeletal extension. Discussion and Conclusion. The periosteum and cortex of bone represent physical barriers. Therefore, it seems much more likely that primary bone lesions will spread to the soft tissues. Intraosseous ganglion does not appear to be associated with either soft-tissue ganglion or with osteoarthritis. This clinical information and the appearance on plain radiographs, particularly the marginal osteosclerosis, are of differential diagnostic importance. Akio Sakamoto, Yoshinao Oda, and Yukihide Iwamoto Copyright © 2013 Akio Sakamoto et al. All rights reserved. In Vivo Caprine Model for Osteomyelitis and Evaluation of Biofilm-Resistant Intramedullary Nails Tue, 11 Jun 2013 15:34:38 +0000 Bone infection remains a formidable challenge to the medical field. The goal of the current study is to evaluate antibacterial coatings in vitro and to develop a large animal model to assess coated bone implants. A novel coating consisting of titanium oxide and siloxane polymer doped with silver was created by metal-organic methods. The coating was tested in vitro using rapid screening techniques to determine compositions which inhibited Staphylococcus aureus growth, while not affecting osteoblast viability. The coating was then applied to intramedullary nails and evaluated in vivo in a caprine model. In this pilot study, a fracture was created in the tibia of the goat, and Staphylococcus aureus was inoculated directly into the bone canal. The fractures were fixed by either coated (treated) or non-coated intramedullary nails (control) for 5 weeks. Clinical observations as well as microbiology, mechanical, radiology, and histology testing were used to compare the animals. The treated goat was able to walk using all four limbs after 5 weeks, while the control was unwilling to bear weight on the fixed leg. These results suggest the antimicrobial potential of the hybrid coating and the feasibility of the goat model for antimicrobial coated intramedullary implant evaluation. Nhiem Tran, Phong A. Tran, John D. Jarrell, Julie B. Engiles, Nathan P. Thomas, Matthew D. Young, Roman A. Hayda, and Christopher T. Born Copyright © 2013 Nhiem Tran et al. All rights reserved. Hip Fracture Surgery: Does Type of Anesthesia Matter? Sun, 02 Jun 2013 09:25:58 +0000 Background. Hip fracture surgery is a common procedure, and the geriatric population with its multiple comorbid conditions is at most at risk of developing anesthesia-related complications. Data on the impact of type anesthesia on postoperative morbidity and mortality is limited. The effects of regional and general anesthesia on postoperative outcomes need to be clearly elucidated. Methods. In this study, all patients who underwent dynamic hip screw (DHS) fixation for intertrochanteric fractures, between January 2005 and December 2010, at the Aga Khan University Hospital, were included. Patients were divided into two groups; group A included those patients who received general anesthesia, and group B consisted of patients who had received regional anesthesia. The two groups were compared for differences in morbidity, mortality, and intraoperative complications based on the type of anesthesia administered. Results. During this period, 194 patients underwent DHS fixation. One hundred and seven patients received general anesthesia whereas eighty-seven patients received regional anesthesia. The mean operative time was significantly lower in the group receiving regional anesthesia ( hrs) as compared to those who received general anesthesia ( hrs) (). There were no statistically significant differences in the rates of wound infections, length of hospital stay, postoperative ambulation status, intraoperative blood loss, postoperative complications, and mortality between the regional and general anesthesia groups. Conclusion. Even though administration of regional anesthesia was positively correlated with shorter operative duration, the type of anesthesia was not found to affect surgical outcomes in the two study groups. Based on these results, we recommend that anesthesia should be tailored to individual patient requirements. Rizwan Haroon Rashid, Adil Aijaz Shah, Amarah Shakoor, and Shahryar Noordin Copyright © 2013 Rizwan Haroon Rashid et al. All rights reserved. Measurement of the Silver Ion Concentration in Wound Fluids after Implantation of Silver-Coated Megaprostheses: Correlation with the Clinical Outcome Wed, 29 May 2013 08:45:23 +0000 Background. Tumor patients and patients after traumas are endangered by a reduced immune defense, and a silver coating on their megaprostheses may reduce their risks of infection. The aim of this study was to determine the silver ion concentration directly measured from the periprosthetic tissue and the influence on the clinical outcome. Material and Methods. Silver ions were evaluated in 5 mL wound fluids two days postoperatively and in blood patients 7 and 14 days after surgery using inductively coupled plasma emission spectrometry in 18 patients who underwent total joint replacement with a silver-coated megaendoprosthesis. Results. The concentration of silver ions averaged 0.08 parts per million. Patients who showed an increased silver concentration in the blood postoperatively presented a lower silver concentration in the wound fluids and a delayed decrease in C-reactive protein levels. There were significantly fewer reinfections and shorter hospitalization in comparison with a group that did not receive a silver-coated megaprosthesis. Conclusion. An increased concentration of silver in the immediate surroundings of silver-coated prostheses was demonstrated for the first time in cohorts of patients with trauma or tumors. An elevated concentration of silver ions in the direct periprosthetic tissue may have reduced the infection rate. B. Hussmann, I. Johann, M. D. Kauther, S. Landgraeber, Marcus Jäger, and S. Lendemans Copyright © 2013 B. Hussmann et al. All rights reserved. A New Piezoelectric Actuator Induces Bone Formation In Vivo: A Preliminary Study Thu, 31 May 2012 09:00:16 +0000 This in vivo study presents the preliminary results of the use of a novel piezoelectric actuator for orthopedic application. The innovative use of the converse piezoelectric effect to mechanically stimulate bone was achieved with polyvinylidene fluoride actuators implanted in osteotomy cuts in sheep femur and tibia. The biological response around the osteotomies was assessed through histology and histomorphometry in nondecalcified sections and histochemistry and immunohistochemistry in decalcified sections, namely, through Masson's trichrome, and labeling of osteopontin, proliferating cell nuclear antigen, and tartrate-resistant acid phosphatase. After one-month implantation, total bone area and new bone area were significantly higher around actuators when compared to static controls. Bone deposition rate was also significantly higher in the mechanically stimulated areas. In these areas, osteopontin increased expression was observed. The present in vivo study suggests that piezoelectric materials and the converse piezoelectric effect may be used to effectively stimulate bone growth. Joana Reis, Clara Frias, Carlos Canto e Castro, Maria Luísa Botelho, António Torres Marques, José António Oliveira Simões, Fernando Capela e Silva, and José Potes Copyright © 2012 Joana Reis et al. All rights reserved. Significance of Nano- and Microtopography for Cell-Surface Interactions in Orthopaedic Implants Thu, 27 Sep 2007 00:00:00 +0000 Cell-surface interactions play a crucial role for biomaterial application in orthopaedics. It is evident that not only the chemical composition of solid substances influence cellular adherence, migration, proliferation and differentiation but also the surface topography of a biomaterial. The progressive application of nanostructured surfaces in medicine has gained increasing interest to improve the cytocompatibility and osteointegration of orthopaedic implants. Therefore, the understanding of cell-surface interactions is of major interest for these substances. In this review, we elucidate the principle mechanisms of nano- and microscale cell-surface interactions in vitro for different cell types onto typical orthopaedic biomaterials such as titanium (Ti), cobalt-chrome-molybdenum (CoCrMo) alloys, stainless steel (SS), as well as synthetic polymers (UHMWPE, XLPE, PEEK, PLLA). In addition, effects of nano- and microscaled particles and their significance in orthopaedics were reviewed. The significance for the cytocompatibility of nanobiomaterials is discussed critically. M. Jäger, C. Zilkens, K. Zanger, and R. Krauspe Copyright © 2007 M. Jäger et al. All rights reserved.