BioMed Research International: Orthopedics The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. The Utility of a Digital Virtual Template for Junior Surgeons in Pedicle Screw Placement in the Lumbar Spine Sun, 22 May 2016 12:06:56 +0000 This study assessed the utility of three-dimensional preoperative image reconstruction as digital virtual templating for junior surgeons in placing a pedicle screw (PS) in the lumbar spine. Twenty-three patients of lumbar disease were operated on with bilateral PS fixation in our hospital. The two sides of lumbar pedicles were randomly divided into “hand-free group” (HFG) and “digital virtual template group” (DVTG) in each patient. Two junior surgeons preoperatively randomly divided into these two groups finished the placement of PSs. The accuracy of PS and the procedure time of PS insertion were recorded. The accuracy of PS in DVTG was 91.8% and that in HFG was 87.7%. The PS insertion procedure time of DVTG was s and that of HFG was s. Although no significant difference was reported in the accurate rate of PS between the two groups, the PS insertion procedure time was significantly shorter in DVTG than in HFG (). Digital virtual template is simple and can reduce the procedure time of PS placement. Xin Zhao, Jie Zhao, Youzhuan Xie, and Jie Mi Copyright © 2016 Xin Zhao et al. All rights reserved. Influence of Environmental Factors and Relationships between Vanadium, Chromium, and Calcium in Human Bone Wed, 18 May 2016 11:24:02 +0000 The aim of this study was to investigate the impact of environmental factors on the concentrations of vanadium (V), chromium (Cr), and calcium (Ca) and to examine the synergistic or antagonistic relationships between these metals, in cartilage (C), cortical bone (CB), and spongy bone (SB) samples obtained following hip joint surgery on patients with osteoarthritis in NW Poland. We found significantly higher concentrations of V and Cr in spongy bone in patients who consumed game meat and also those with prosthetic implants. Chromium levels were significantly lower in patients with kidney diseases. The greatest positive correlations were found between spongy bone V and (i) the amount of consumed beer and (ii) seafood diet. Correlation analysis also showed a significant correlation between Cr levels and seafood diet. To a certain extent these results indicate that the concentrations of V, Cr, and Ca in the human hip joint tissues are connected with occupational exposure, kidney diseases, diet containing game meat, sea food, beer, and the presence of implants. Furthermore, we noted new types of interactions in specific parts of the femoral head. Vanadium may contribute to the lower bone Ca levels, especially in the external parts (cartilage and cortical bone). Natalia Lanocha-Arendarczyk, Danuta I. Kosik-Bogacka, Elzbieta Kalisinska, Sebastian Sokolowski, Lukasz Kolodziej, Halina Budis, Krzysztof Safranow, Karolina Kot, Zaneta Ciosek, Natalia Tomska, and Katarzyna Galant Copyright © 2016 Natalia Lanocha-Arendarczyk et al. All rights reserved. Neurological Complications after Lateral Transpsoas Approach to Anterior Interbody Fusion with a Novel Flat-Blade Spine-Fixed Retractor Thu, 12 May 2016 07:49:02 +0000 Introduction. The lateral lumbar interbody fusion (LLIF) surgical approach has potential advantages over other approaches but is associated with some unique neurologic risks due to the proximity of the lumbosacral plexus. The present study analyzed complications following LLIF surgical approach using a novel single flat-blade retractor system. Methods. A retrospective data collection of patients receiving LLIF using a novel single flat-blade retractor system at two institutions in the US. Inclusion criteria were all patients receiving an LLIF procedure with the RAVINE® Lateral Access System (K2M, Inc., Leesburg, VA, USA). There was no restriction on preoperative diagnosis or number of levels treated. Approach-related neurologic complications were collected and analyzed postoperatively through a minimum of one year. Results. Analysis included 253 patients with one to four treated lateral levels. Immediate postoperative neurologic complications were present in 11.1% (28/253) of patients. At one-year follow-up the approach-related neurologic complications resolved in all except 5 patients (2.0%). Conclusion. We observed an 11.1% neurologic complication rate in LLIF procedures. There was resolution of symptoms for most patients by 12-month follow-up, with only 2% of patients with residual symptoms. This supports the hypothesis that the vast majority of approach-related neurologic symptoms are transient. Pierce Nunley, Faheem Sandhu, Kelly Frank, and Marcus Stone Copyright © 2016 Pierce Nunley et al. All rights reserved. Minimally Invasive Spinal Surgery with Intraoperative Image-Guided Navigation Sun, 24 Apr 2016 11:37:57 +0000 We present our perioperative minimally invasive spine surgery technique using intraoperative computed tomography image-guided navigation for the treatment of various lumbar spine pathologies. We present an illustrative case of a patient undergoing minimally invasive percutaneous posterior spinal fusion assisted by the O-arm system with navigation. We discuss the literature and the advantages of the technique over fluoroscopic imaging methods: lower occupational radiation exposure for operative room personnel, reduced need for postoperative imaging, and decreased revision rates. Most importantly, we demonstrate that use of intraoperative cone beam CT image-guided navigation has been reported to increase accuracy. Terrence T. Kim, J. Patrick Johnson, Robert Pashman, and Doniel Drazin Copyright © 2016 Terrence T. Kim et al. All rights reserved. Technical Aspects on the Use of Ultrasonic Bone Shaver in Spine Surgery: Experience in 307 Patients Mon, 18 Apr 2016 14:37:51 +0000 Aim. We discuss technical points, the safety, and efficacy of ultrasonic bone shaver in various spinal surgeries within our own series. Methods. Between June 2010 and January 2014, 307 patients with various spinal diseases were operated on with the use of an ultrasonic bone curette with microhook shaver (UBShaver). Patients’ data were recorded and analyzed retrospectively. The technique for the use of the device is described for each spine surgery procedure. Results. Among the 307 patients, 33 (10.7%) cases had cervical disorder, 17 (5.5%) thoracic disorder, 3 (0.9%) foramen magnum disorder, and 254 (82.7%) lumbar disorders. Various surgical techniques were performed either assisted or alone by UBShaver. The duration of the operations and the need for blood replacement were relatively low. The one-year follow-up with Neck Disability Index (NDI) and Oswestry Disability Index (ODI) scores were improved. We had 5 cases of dural tears (1.6%) in patients with lumbar spinal disease. No neurological deficit was found in any patients. Conclusion. We recommend this device as an assistant tool in various spine surgeries and as a primary tool in foraminotomies. It is a safe device in spine surgery with very low complication rate. Derya Burcu Hazer, Barış Yaşar, Hans-Eric Rosberg, and Aytaç Akbaş Copyright © 2016 Derya Burcu Hazer et al. All rights reserved. Navigated Transtubular Extraforaminal Decompression of the L5 Nerve Root at the Lumbosacral Junction: Clinical Data, Radiographic Features, and Outcome Analysis Mon, 04 Apr 2016 15:07:13 +0000 Purpose. Extraforaminal decompression of the L5 nerve root remains a challenge due to anatomic constraints, severe level-degeneration, and variable anatomy. The purpose of this study is to introduce the use of navigation for transmuscular transtubular decompression at the L5/S1 level and report on radiological features and clinical outcome. Methods. Ten patients who underwent a navigation-assisted extraforaminal decompression of the L5 nerve root were retrospectively analyzed. Results. Six patients had an extraforaminal herniated disc and four had a foraminal stenosis. The distance between the L5 transverse process and the para-articular notch of the sacrum was 12.1 mm in patients with a herniated disc and 8.1 mm in those with a foraminal stenosis. One patient had an early recurrence and another developed dysesthesia that resolved after 3 months. There was a significant improvement from preoperative to postoperative NRS with the results being sustainable at follow-up. ODI was also significantly improved after surgery. According to the Macnab grading scale, excellent or good outcomes were obtained in 8 patients and fair ones in 2. Conclusions. The navigated transmuscular transtubular approach to the lumbosacral junction allows for optimal placement of the retractor and excellent orientation particularly for foraminal stenosis or in cases of complex anatomy. P. Stavrinou, R. Härtl, B. Krischek, C. Kabbasch, A. Mpotsaris, and R. Goldbrunner Copyright © 2016 P. Stavrinou et al. All rights reserved. Magnetic Resonance Imaging of Postoperative Fracture Healing Process without Metal Artifact: A Preliminary Report of a Novel Animal Model Thu, 31 Mar 2016 17:24:53 +0000 Background. Early radiological diagnosis and continual monitoring are of ultimate importance for timely treatment of delayed union, nonunion, and infection after bone fracture surgery. Although magnetic resonance imaging (MRI) could provide superior detailed images compared with X-ray and computed tomography (CT) without ionizing radiation, metal implants used for fracture fixation lead to abundant artifacts on MRI and thus prohibit accurate interpretation. The authors develop a novel intramedullary fixation model of rat femoral fracture using polyetheretherketone (PEEK) threaded rods and investigate its feasibility for in vivo MRI monitoring of the fracture healing process without artifact. Methods. Femoral fractures of 3 adult male Sprague-Dawley rats were fixed with intramedullary PEEK threaded rods. X-ray and MRI examinations were performed at day 7 postoperatively. Radiological images were analyzed for the existence of artifact interruption and postoperative changes in bone and peripheral soft tissue. Results. Postoperative plain film revealed no loss of reduction. MRI images illustrated the whole length of femur and peripheral tissue without artifact interruption, and the cortical bone, implanted PEEK rod, and soft tissue were clearly illustrated. Conclusion. This preliminary study introduced a novel rat model for in vivo MRI monitoring of the fracture healing process without metal artifact, by using intramedullary fixation of femur with PEEK threaded rod. Zhe Jin, Yuheng Guan, Guibo Yu, and Yu Sun Copyright © 2016 Zhe Jin et al. All rights reserved. Cefazolin Irreversibly Inhibits Proliferation and Migration of Human Mesenchymal Stromal Cells Wed, 16 Mar 2016 13:11:29 +0000 Drugs may have a significant effect on postoperative bone healing by reducing the function of human mesenchymal stromal cells (hMSC) or mature osteoblasts. Although cefazolin is one of the most commonly used antibiotic drugs in arthroplasty to prevent infection worldwide, there is a lack of information regarding how cefazolin affects hMSC and therefore may have an effect on early bone healing. We studied the proliferation and migration capacity of primary hMSC during cefazolin treatment at various doses for up to 3 days, as well as the reversibility of the effects during the subsequent 3 days of culture without the drug. We found a time- and dose-dependent reduction of the proliferation rate and the migratory potential. Tests of whether these effects were reversible revealed that doses ≥250 μg/mL or treatments longer than 24 h irreversibly affected the cells. We are the first to show that application of cefazolin irreversibly inhibits the potential of hMSC for migration to the trauma site and local proliferation. Cefazolin should be administered only at the required dosage and time to prevent periprosthetic infection. If long-term administration is required and delayed bone healing is present, cefazolin application must be considered as a cause of delayed bone healing. Hakan Pilge, Julia Fröbel, Sabine Lensing-Höhn, Christoph Zilkens, and Rüdiger Krauspe Copyright © 2016 Hakan Pilge et al. All rights reserved. Early Pulmonary Complications following Total Knee Arthroplasty under General Anesthesia: A Prospective Cohort Study Using CT Scan Wed, 16 Mar 2016 09:34:36 +0000 Purpose. Postoperative pulmonary complications (PPCs) are common after major surgeries. However, the number of studies regarding PPCs following total knee arthroplasty (TKA) is limited. The aim of this study was to determine the incidence of early PPCs following TKA by computed tomography (CT) scan and to identify associated risk factors. Methods. Patients, who were diagnosed with osteoarthritis or rheumatoid arthritis and underwent primary TKA at our institution, were included in this prospective cohort study. Patients received a standard procedure of TKA under general anesthesia. Chest CT scan was performed during 5–7 days postoperatively. Univariate analysis and multivariate logistic regression analysis were employed to identify the risk factors. Results. The total incidence of early PPCs following TKA was 45.9%. Rates of pneumonia, pleural effusion, and atelectasis were 14.4%, 38.7%, and 12.6%, respectively. Lower body mass index and perioperative blood transfusion were independent risk factors for PPCs as a whole and associated with atelectasis. Postoperative acute episode of hypoxemia increased the risk of pneumonia. Blood transfusion alone was related to pleural effusion. Conclusions. The incidence of early PPCs following TKA was high. For patients with relevant risk factors, positive measures should be adopted to prevent PPCs. Kai Song, Zhen Rong, Xianfeng Yang, Yao Yao, Yeshuai Shen, Dongquan Shi, Zhihong Xu, Dongyang Chen, Minghao Zheng, and Qing Jiang Copyright © 2016 Kai Song et al. All rights reserved. Is It Time to Phase Out the Austin Moore Hemiarthroplasty? A Propensity Score Matched Case Control Comparison versus Cemented Hemiarthroplasty Sun, 06 Mar 2016 10:38:03 +0000 We compared the Austin Moore hemiarthroplasty versus cemented hemiarthroplasties using a propensity score matched cased control study. For a consecutive cohort of 450 patients with displaced intracapsular neck of femur fractures, 128 matched cases in each group were selected based on age, gender, walking status, nursing home residency, delays in surgery, ASA score, and the Charlson comorbidity score. At a mean follow-up of 16.3 months, we evaluated their outcomes. Significantly more patients with AMA experienced thigh pain (RR = 3.5, 95% CI: 1.67–7.33,), overall complications (RR = 4.47, 95% CI: 1.77–11.3, ), and implant loosening (RR = 8.42, 95% CI: 2.63–26.95, ). There were no definite cement related deaths in this series. There was no significant difference in mortality, walking status, and the number of revisions between the groups. We support the routine use of cemented hemiarthroplasty instead of the Austin Moore for treating elderlies with displaced intracapsular neck of femur fractures. Christian Fang, Rui-Ping Liu, Tak-Wing Lau, Anderson Leung, Tak-Man Wong, Terence Pun, and Frankie Leung Copyright © 2016 Christian Fang et al. All rights reserved. Does Subacromial Osteolysis Affect Shoulder Function after Clavicle Hook Plating? Mon, 29 Feb 2016 06:29:20 +0000 Purpose. To evaluate whether subacromial osteolysis, one of the major complications of the clavicle hook plate procedure, affects shoulder function. Methods. We had performed a retrospective study of 72 patients diagnosed with a Neer II lateral clavicle fracture or Degree-III acromioclavicular joint dislocation in our hospital from July 2012 to December 2013. All these patients had undergone surgery with clavicle hook plate and were divided into two groups based on the occurrence of subacromial osteolysis. By using the Constant-Murley at the first follow-up visit after plates removal, we evaluated patients’ shoulder function to judge if it has been affected by subacromial osteolysis. Results. We have analyzed clinical data for these 72 patients, which shows that there is no significant difference between group A (39 patients) and group B (33 patients) in age, gender, injury types or side, and shoulder function (the Constant-Murley scores are versus , ). Conclusion. The occurrence of subacromial osteolysis is not rare, and also it does not significantly affect shoulder function. Siwei Sun, Minfeng Gan, Han Sun, Guizhong Wu, Huilin Yang, and Feng Zhou Copyright © 2016 Siwei Sun et al. All rights reserved. Demineralized Bone Matrix Add-On for Acceleration of Bone Healing in Atypical Subtrochanteric Femoral Fracture: A Consecutive Case-Control Study Sun, 28 Feb 2016 13:55:40 +0000 Background. Delayed union and nonunion are common complications in atypical femoral fractures (AFFs) despite having good fracture fixation. Demineralized bone matrix (DBM) is a successfully proven method for enhancing fracture healing of the long bone fracture and nonunion and should be used in AFFs. This study aimed to compare the outcome after subtrochanteric AFFs (ST-AFFs) fixation with and without DBM. Materials and Methods. A prospective study was conducted on 9 ST-AFFs patients using DBM (DBM group) during 2013-2014 and compared with a retrospective consecutive case series of ST-AFFs patients treated without DBM (2010–2012) (NDBM group, 9 patients). All patients were treated with the same standard guideline and followed up until fractures completely united. Postoperative outcomes were then compared. Results. DBM group showed a significant shorter healing time than NDBM group (28.1 ± 14.4 versus 57.9 ± 36.8 weeks, ). Delayed union was found in 4 patients (44%) in DBM group compared with 7 patients (78%) in NDBM group (). No statistical difference of nonunion was demonstrated between both groups (DBM = 1 and NDBM = 2, ). Neither postoperative infection nor severe local tissue reaction was found. Conclusions. DBM is safe and effective for accelerating the fracture healing in ST-AFFx and possibly reduces nonunion after fracture fixation. Trial registration number is TCTR20151021001. Noratep Kulachote, Paphon Sa-ngasoongsong, Norachart Sirisreetreerux, Pongsthorn Chanplakorn, Praman Fuangfa, Chanyut Suphachatwong, and Wiwat Wajanavisit Copyright © 2016 Noratep Kulachote et al. All rights reserved. Cementless Titanium Mesh Fixation of Osteoporotic Burst Fractures of the Lumbar Spine Leads to Bony Healing: Results of an Experimental Sheep Model Thu, 25 Feb 2016 05:53:44 +0000 Introduction. Current treatment strategies for osteoporotic vertebral compression fractures (VCFs) focus on cement-associated solutions. Complications associated with cement application are leakage, embolism, adjacent fractures, and compromise in bony healing. This study comprises a validated VCF model in osteoporotic sheep in order to (1) evaluate a new cementless fracture fixation technique using titanium mesh implants (TMIs) and (2) demonstrate the healing capabilities in osteoporotic VCFs. Methods. Twelve 5-year-old Merino sheep received ovariectomy, corticosteroid injections, and a calcium/phosphorus/vitamin D-deficient diet for osteoporosis induction. Standardized VCFs (type AO A3.1) were created, reduced, and fixed using intravertebral TMIs. Randomly additional autologous spongiosa grafting (G1) or no augmentation was performed (G2, each). Two months postoperatively, macroscopic, micro-CT and biomechanical evaluation assessed bony consolidation. Results. Fracture reduction succeeded in all cases without intraoperative complications. Bony consolidation was proven for all cases with increased amounts of callus development for G2 (58.3%). Micro-CT revealed cage integration. Neither group showed improved results with biomechanical testing. Conclusions. Fracture reduction/fixation using TMIs without cement in osteoporotic sheep lumbar VCF resulted in bony fracture healing. Intravertebral application of autologous spongiosa showed no beneficial effects. The technique is now available for clinical use; thus, it offers an opportunity to abandon cement-associated complications. Anica Eschler, Paula Roepenack, Jan Roesner, Philipp Karl Ewald Herlyn, Heiner Martin, Martin Reichel, Robert Rotter, Brigitte Vollmar, Thomas Mittlmeier, and Georg Gradl Copyright © 2016 Anica Eschler et al. All rights reserved. Effect of Granulocyte-Colony Stimulating Factor on Endothelial Cells and Osteoblasts Wed, 24 Feb 2016 10:01:00 +0000 Objectives. Some animal studies showed that granulocyte-colony stimulating factor (G-CSF) provides beneficial environment for bone healing. It has been well documented that endothelial cells and osteoblasts play critical roles in multiple phases of bone healing. However, the biological effects of G-CSF on these cells remain controversial. This study aimed to investigate the influence of G-CSF at various concentrations on endothelial cells and osteoblasts. Materials and Methods. Human umbilical vein endothelial cells (HUVECs) and human osteoblasts (hOBs) were treated with G-CSF at 1000, 100, 10, and 0 ng/mL, respectively. The capacity of cell proliferation, migration, and tube formation of HUVECs was evaluated at 72, 8, and 6 hours after treatment, respectively. The capacity of proliferation, differentiation, and mineralization of hOBs was evaluated at 24 hours, 72 hours, and 21 days after treatment, respectively. Results. HUVECs treated with 100 and 1000 ng/mL G-CSF showed a significantly higher value comparing with controls in migration assay (, , resp.); the group treated with 1000 ng/mL G-CSF showed a significantly lower value on tube formation. No significant difference was detected in groups of hOBs. Conclusions. G-CSF showed favorable effects only on the migration of HUVECs, and no direct influence was found on hOBs. Xi Ling Liu, Xiang Hu, Wei Xin Cai, Weijia William Lu, and Li Wu Zheng Copyright © 2016 Xi Ling Liu et al. All rights reserved. Increased Fracture Collapse after Intertrochanteric Fractures Treated by the Dynamic Hip Screw Adversely Affects Walking Ability but Not Survival Wed, 03 Feb 2016 10:49:07 +0000 In osteoporotic hip fractures, fracture collapse is deliberately allowed by commonly used implants to improve dynamic contact and healing. The muscle lever arm is, however, compromised by shortening. We evaluated a cohort of 361 patients with AO/OTA 31.A1 or 31.A2 intertrochanteric fracture treated by the dynamic hip screw (DHS) who had a minimal follow-up of 3 months and an average follow-up of 14.6 months and long term survival data. The amount of fracture collapse and shortening due to sliding of the DHS was determined at the latest follow-up and graded as minimal (<1 cm), moderate (1-2 cm), or severe (>2 cm). With increased severity of collapse, more patients were unable to maintain their premorbid walking function (minimal collapse = 34.2%, moderate = 33.3%, severe = 62.8%, and ). Based on ordinal regression of risk factors, increased fracture collapse was significantly and independently related to increasing age (), female sex (), A2 fracture class (), increased operative duration (), poor reduction quality (), and suboptimal tip-apex distance of >25 mm (). Patients who had better outcome in terms of walking function were independently predicted by younger age (), higher MMSE marks (), higher MBI marks (), better premorbid walking status (), less fracture collapse (), and optimal lag screw position in centre-centre or centre-inferior position (). According to Kaplan-Meier analysis, fracture collapse had no association with mortality from 2.4 to 7.6 years after surgery. In conclusion, increased fracture collapse after fixation of geriatric intertrochanteric fractures adversely affected walking but not survival. Christian Fang, Paata Gudushauri, Tak-Man Wong, Tak-Wing Lau, Terence Pun, and Frankie Leung Copyright © 2016 Christian Fang et al. All rights reserved. Emerging Insights on Surgical Techniques and Biomaterials for Total Hip and Knee Arthroplasty Wed, 27 Jan 2016 08:46:12 +0000 Kengo Yamamoto, Michiaki Takagi, and Hiroshi Ito Copyright © 2016 Kengo Yamamoto et al. All rights reserved. Modic Changes and Disc Degeneration Caused by Inoculation of Propionibacterium acnes inside Intervertebral Discs of Rabbits: A Pilot Study Tue, 26 Jan 2016 12:18:33 +0000 Purpose. To investigate whether P. acnes could induce disc degeneration and Modic changes when inoculated into the discs of rabbits. Method. A wild-type strain of P. acnes isolated from a patient associated with Modic change and disc degeneration was inoculated into the intervertebral discs of rabbits. Meanwhile, S. aureus was injected into the discs to establish a model of discitis as the comparison and a standard strain of P. acnes was inoculated as the control. MRI and histological change were observed. Results. Both the P. acnes-inoculated and S. aureus-inoculated rabbits showed hyperintense signals at endplates and hypointense signals at nucleus pulposus on T2WI. However, P. acnes only resulted in moderate disc degeneration and endplates rupture in histological examination, which was different from the pathological change of discitis caused by S. aureus. In addition, higher death rates (2/3 versus 0/5) were observed in S. aureus-inoculated rabbits. Conclusion. Compared to S. aureus, the pathological change caused by P. acnes would be considered as Modic-I change and disc degeneration rather than a discitis. Zhe Chen, Yuehuan Zheng, Ye Yuan, Yucheng Jiao, Jiaqi Xiao, Zezhu Zhou, and Peng Cao Copyright © 2016 Zhe Chen et al. All rights reserved. The Role of a Primary Arthroplasty in the Treatment of Proximal Tibia Fractures in Orthogeriatric Patients Mon, 18 Jan 2016 11:55:22 +0000 The total knee arthroplasty (TKA) is the gold standard for patients with an advanced symptomatic gonarthrosis. However, there are very few publications dealing with the primary TKA for patients with a proximal tibia fracture. In our retrospective study we evaluated 30 patients treated with a TKA for a proximal tibia fracture in our institution between 01/2008 and 12/2014. We collected the following statistical data from each patient: age, classification of the fracture (AO-classification), type of prosthesis used, length of the operation and hospitalization, and complications during the follow-up. We used the Knee Society Score (KSS) and the WOMAC score to evaluate the function. The Knee Society Score showed an average “general knee score” (KSS1) of 81.1 points and an average “functional knee score” (KSS2) of 74.5 points. The average WOMAC score was 78.6 points. Immediate postoperative mobilization with the possibility of a full-weight bearing is of crucial importance for the geriatric patients to maintain the mobility they had prior to the operation and reduce medical complications. Because of these advantages, the primary TKA seems to be a promising alternative to the ORIF of a proximal tibia fracture in the orthogeriatric patient. Thomas Haufe, Stefan Förch, Peter Müller, Johannes Plath, and Edgar Mayr Copyright © 2016 Thomas Haufe et al. All rights reserved. Biomechanical Comparison of Pedicle Screw Augmented with Different Volumes of Polymethylmethacrylate in Osteoporotic and Severely Osteoporotic Synthetic Bone Blocks in Primary Implantation: An Experimental Study Sun, 17 Jan 2016 16:57:17 +0000 This study was designed to compare screw stabilities augmented with different volumes of PMMA and analyze relationship between screw stability and volume of PMMA and optimum volume of PMMA in different bone condition. Osteoporotic and severely osteoporotic synthetic bone blocks were divided into groups A0-A5 and B0-B5, respectively. Different volumes of PMMA were injected in groups A0 to A5 and B0 to B5. Axial pullout tests were performed and was measured. in groups A1-A5 were all significantly higher than group A0. Except between groups A1 and A2, A3 and A4, and A4 and A5, there were significant differences on between any other two groups. in groups B1-B5 were all significantly higher than group B0. Except between groups B1 and B2, B2 and B3, and B4 and B5, there were significant differences on between any other two groups. There was significantly positive correlation between and volume of PMMA in osteoporotic and severely osteoporotic blocks. PMMA can significantly enhance pedicle screw stability in osteoporosis and severe osteoporosis. There were positive correlations between screw stability and volume of PMMA. In this study, injection of 3 mL and 4 mL PMMA was preferred in osteoporotic and severely osteoporotic blocks, respectively. Da Liu, Xiao-jun Zhang, Dong-fa Liao, Jiang-jun Zhou, Zhi-qiang Li, Bo Zhang, Cai-ru Wang, Wei Lei, Xia Kang, and Wei Zheng Copyright © 2016 Da Liu et al. All rights reserved. One-Year Outcome of Geriatric Hip-Fracture Patients following Prolonged ICU Treatment Wed, 13 Jan 2016 06:00:30 +0000 Purpose. Incidence of geriatric fractures is increasing. Knowledge of outcome data for hip-fracture patients undergoing intensive-care unit (ICU) treatment, including invasive ventilatory management (IVM) and hemodiafiltration (CVVHDF), is sparse. Methods. Single-center prospective observational study including 402 geriatric hip-fracture patients. Age, gender, the American Society of Anesthesiologists (ASA) classification, and the Barthel index (BI) were documented. Underlying reasons for prolonged ICU stay were registered, as well as assessed procedures like IVM and CVVHDF. Outcome parameters were in-hospital, 6-month, and 1-year mortality and need for nursing care. Results. 15% were treated > 3 days and 68% < 3 days in ICU. Both cohorts had similar ASA, BI, and age. In-hospital, 6-month, and 12-month mortality of ICU > 3d cohort were significantly increased (). Most frequent indications were cardiocirculatory pathology followed by respiratory failure, renal impairment, and infection. 18% of patients needed CVVHDF and 41% IVM. In these cohorts, 6-month mortality ranged > 80% and 12-month mortality > 90%. 100% needed nursing care after 6 and 12 months. Conclusions. ICU treatment > 3 days showed considerable difference in mortality and nursing care needed after 6 and 12 months. Particularly, patients requiring CVVHDF or IVM had disastrous long-term results. Our study may add one further element in complex decision making serving this vulnerable patient cohort. Daphne Eschbach, Christopher Bliemel, Ludwig Oberkircher, Rene Aigner, Juliana Hack, Benjamin Bockmann, Steffen Ruchholtz, and Benjamin Buecking Copyright © 2016 Daphne Eschbach et al. All rights reserved. The Effect of Femoral Cutting Guide Design Improvements for Patient-Specific Instruments Thu, 31 Dec 2015 14:04:25 +0000 Although the application of patient-specific instruments (PSI) for total knee arthroplasty (TKA) increases the cost of the surgical procedure, PSI may reduce operative time and improve implant alignment, which could reduce the number of revision surgeries. We report our experience with TKA using PSI techniques in 120 patients from March to December 2014. PSI for TKA were created from data provided by computed tomography (CT) scans or magnetic resonance imaging (MRI); which imaging technology is more reliable for the PSI technique remains unclear. In the first 20 patients, the accuracy of bone resection and PSI stability were compared between CT and MRI scans with presurgical results as a reference; MRI produced better results. In the second and third groups, each with 50 patients, the results of bone resection and stability were compared in MRI scans with respect to the quality of scanning due to motion artifacts and experienced know-how in PSI design, respectively. The optimized femoral cutting guide design for PSI showed the closest outcomes in bone resection and PSI stability with presurgical data. It is expected that this design could be a reasonable guideline in PSI. Oh-Ryong Kwon, Kyoung-Tak Kang, Juhyun Son, Yun-Jin Choi, Dong-Suk Suh, and Yong-Gon Koh Copyright © 2015 Oh-Ryong Kwon et al. All rights reserved. Spinal Motion Preservation Surgery Wed, 30 Dec 2015 13:44:28 +0000 Jau-Ching Wu, Patrick C. Hsieh, Praveen V. Mummaneni, and Michael Y. Wang Copyright © 2015 Jau-Ching Wu et al. All rights reserved. Clinical Performance and Safety of 108 SpineJack Implantations: 1-Year Results of a Prospective Multicentre Single-Arm Registry Study Wed, 30 Dec 2015 13:13:27 +0000 This prospective, consecutive, multicentre observational registry aimed to confirm the safety and clinical performance of the SpineJack system for the treatment of vertebral compression fractures (VCF) of traumatic origin. We enrolled 103 patients (median age: 61.6 years) with 108 VCF due to trauma, or traumatic VCF with associated osteoporosis. Primary outcome was back pain intensity (VAS). Secondary outcomes were Oswestry Disability Index (ODI), EuroQol-VAS, and analgesic consumption. 48 hours after surgery, a median relative decrease in pain intensity of 81.5% was observed associated with a significant reduction in analgesic intake. Improvements in disability (91.3% decrease in ODI score) and in quality of life (increase 21.1% of EQ-VAS score) were obtained 3 months after surgery. All results were maintained at 12 months. A reduction in the kyphotic angulation was observed postoperatively (; ), remained at 12 months (, ). No adverse events were implant-related and none required device removal. Three patients (2.9%) experienced procedure-related complications. The overall adjacent fracture rate up to 1 year after surgery was 2.9%. The SpineJack procedure is an effective, low-risk procedure for patients with traumatic VCF allowing a fast and sustained improvement in quality of life over 1 year after surgery. David Noriega, Gianluca Maestretti, Christian Renaud, Natale Francaviglia, Mourad Ould-Slimane, Steffen Queinnec, Helmut Ekkerlein, Frank Hassel, Rainer Gumpert, Pascal Sabatier, Hervé Huet, Miguel Plasencia, Nicolas Theumann, Alexander Kunsky, and Antonio Krüger Copyright © 2015 David Noriega et al. All rights reserved. Effect of Short-Term Stimulation with Interleukin-1β and Differentiation Medium on Human Mesenchymal Stromal Cell Paracrine Activity in Coculture with Osteoblasts Tue, 22 Dec 2015 08:36:17 +0000 Introduction. Human mesenchymal stromal cells (hMSCs) exhibit the potential to accelerate bone healing by enhanced osteogenic differentiation. Interleukin-1β is highly expressed during fracture healing and has been demonstrated to exert a significant impact on the differentiation behaviour of hMSCs. Here, we investigate the effect of 2-hour IL-1β stimulation on the differentiation and paracrine activity of hMSCs in coculture with osteosarcoma cells in vitro. Methods. hMSCs from 3 donors were incubated for 2 hours with 10 ng/mL IL-1β and subsequently cocultured with MG63-GFP cells either in control or in differentiation medium in a transwell system for 28 days. Genetic and functional effects were investigated. Results. hMSCs cultured in control medium exhibited a regulatory effect on cocultured MG63-GFP cells, resulting in upregulation of osteogenic gene expression in combination with increased ALP activity. However, while stimulated hMSCs cultured under differentiation conditions exhibit signs of osteogenic differentiation, osteogenic differentiation also caused an impaired regulatory effect on the cocultured MG63-GFP cells. Conclusion. Short stimulation of hMSCs has the potential to modify their long-term behaviour. In addition, undifferentiated hMSCs are able to regulate osteoblast differentiation; however, this regulatory function is lost upon osteogenic differentiation in vitro. This offers a novel approach for clinical cell therapy protocols. Jan O. Voss, Claudia Loebel, Jennifer J. Bara, Marc Anton Fussinger, Fabian Duttenhoefer, Mauro Alini, and Martin J. Stoddart Copyright © 2015 Jan O. Voss et al. All rights reserved. The Effect of Lumbar Lordosis on Screw Loosening in Dynesys Dynamic Stabilization: Four-Year Follow-Up with Computed Tomography Tue, 08 Dec 2015 11:47:53 +0000 Introduction. This study aimed to evaluate the effects of Dynesys dynamic stabilization (DDS) on clinical and radiographic outcomes, including spinal pelvic alignment. Method. Consecutive patients who underwent 1- or 2-level DDS for lumbar spondylosis, mild degenerative spondylolisthesis, or degenerative disc disease were included. Clinical outcomes were evaluated by Visual Analogue Scale for back and leg pain, Oswestry Disability Index, and the Japanese Orthopedic Association scores. Radiographic outcomes were assessed by radiographs and computed tomography. Pelvic incidence and lumbar lordosis (LL) were also compared. Results. In 206 patients with an average follow-up of 51.1 ± 20.8 months, there were 87 screws (8.2%) in 42 patients (20.4%) that were loose. All clinical outcomes improved at each time point after operation. Patients with loosened screws were 45 years older. Furthermore, there was a higher risk of screw loosening in DDS involving S1, and these patients were more likely to have loosened screws if the LL failed to increase after the operation. Conclusions. The DDS screw loosening rate was overall 8.2% per screw and 20.4% per patient at more than 4 years of follow-up. Older patients, S1 involvement, and those patients who failed to gain LL postoperatively were at higher risk of screw loosening. Chao-Hung Kuo, Peng-Yuan Chang, Tsung-Hsi Tu, Li-Yu Fay, Hsuan-Kan Chang, Jau-Ching Wu, Wen-Cheng Huang, and Henrich Cheng Copyright © 2015 Chao-Hung Kuo et al. All rights reserved. Minimal Invasive Percutaneous Osteosynthesis for Elderly Valgus Impacted Proximal Humeral Fractures with the PHILOS Thu, 26 Nov 2015 13:19:23 +0000 There is a growing concern about elderly valgus impacted proximal humeral fractures. The aim of this study was to evaluate the treatment and clinical outcomes following minimal invasive percutaneous plate osteosynthesis (MIPPO) with the proximal humeral internal locking system (PHILOS) for the treatment of elderly valgus impacted proximal humeral fracture. Between May 2008 and May 2012, 27 patients (average age 67.3, range 61–74) with valgus impacted proximal humeral fractures were enrolled in the study. The patients were treated with MIPPO using PHILOS-plate through the anterolateral delta-splitting approach. Rehabilitation exercises were done gradually. The NEER score and Constant-Murley score were used to evaluate shoulder function. All the patients were followed up by routine radiological imaging and clinical examination. There were 15 cases of II-part greater tuberosity fractures, 10 cases of III-part greater tuberosity fractures, and 2 cases of IV-part fractures according to the NEER classification. The surgery was successful in all patients with an average follow-up of 20.8 (range: 11–34) months. The fractures united in an average of 7.2 (6–14) weeks without implant loosening. According to NEER score, there were 17 excellent, 7 satisfactory, 2 unsatisfactory, and 1 poor. The mean Constant-Murley score was . No complication including axillary nerve damage, postoperative nerve or vessel damage, infections, DVT, or death was observed. In conclusion, the MIPPO technique with the PHILOS through the anterolateral delta-splitting approach seems to be a safe and easy treatment for elderly valgus impacted proximal humeral fractures. A case-control study and longer follow-up time are needed. Hang Chen, Xiaochuan Hu, Haochen Tang, Guoyong Yang, and Ming Xiang Copyright © 2015 Hang Chen et al. All rights reserved. Global Gene Expression Profiling and Alternative Splicing Events during the Chondrogenic Differentiation of Human Cartilage Endplate-Derived Stem Cells Sun, 15 Nov 2015 11:00:52 +0000 Low back pain (LBP) is a very prevalent disease and degenerative disc diseases (DDDs) usually account for the LBP. However, the pathogenesis of DDDs is complicated and difficult to elucidate. Alternative splicing is a sophisticated regulatory process which greatly increases cellular complexity and phenotypic diversity of eukaryotic organisms. In addition, the cartilage endplate-derived stem cells have been discovered and identified by our research group. In this paper, we continue to investigate gene expression profiling and alternative splicing events during chondrogenic differentiation of cartilage endplate-derived stem cells. We adopted Affymetrix Human Transcriptome Array 2.0 (HTA 2.0) to compare the transcriptional and splicing changes between the control and differentiated samples. RT-PCR and quantitative PCR are used to validate the microarray results. The GO and KEGG pathway analysis was also performed. After bioinformatics analysis of the data, we detected 1953 differentially expressed genes. In terms of alternative splicing, the Splicing Index algorithm was used to select alternatively spliced genes. We detected 4411 alternatively spliced genes. GO and KEGG pathway analysis also revealed several functionally involved biological processes and signaling pathways. To our knowledge, this is the first study to investigate the alternative splicing mechanisms in chondrogenic differentiation of stem cells on a genome-wide scale. Jin Shang, Xin Fan, Lei Shangguan, Huan Liu, and Yue Zhou Copyright © 2015 Jin Shang et al. All rights reserved. Vertebral Body Stapling versus Bracing for Patients with High-Risk Moderate Idiopathic Scoliosis Wed, 04 Nov 2015 07:18:18 +0000 Purpose. We report a comparison study of vertebral body stapling (VBS) versus a matched bracing cohort for immature patients with moderate (25 to 44°) idiopathic scoliosis (IS). Methods. 42 of 49 consecutive patients (86%) with IS were treated with VBS and followed for a minimum of 2 years. They were compared to 121 braced patients meeting identical inclusion criteria. 52 patients (66 curves) were matched according to age at start of treatment (10.6 years versus 11.1 years, resp. []) and gender. Results. For thoracic curves 25–34°, VBS had a success rate (defined as curve progression <10°) of 81% versus 61% for bracing . In thoracic curves 35–44°, VBS and bracing both had a poor success rate. For lumbar curves, success rates were similar in both groups for curves measuring 25–34°. Conclusion. In this comparison of two cohorts of patients with high-risk (Risser 0-1) moderate IS (25–44°), in smaller thoracic curves (25–34°) VBS provided better results as a clinical trend as compared to bracing. VBS was found not to be effective for thoracic curves ≥35°. For lumbar curves measuring 25–34°, results appear to be similar for both VBS and bracing, at 80% success. Laury Cuddihy, Aina J. Danielsson, Patrick J. Cahill, Amer F. Samdani, Harsh Grewal, John M. Richmond, M. J. Mulcahey, John P. Gaughan, M. Darryl Antonacci, and Randal R. Betz Copyright © 2015 Laury Cuddihy et al. All rights reserved. Three-Dimensional Analysis of the Curvature of the Femoral Canal in 426 Chinese Femurs Wed, 28 Oct 2015 08:36:46 +0000 Purpose. The human femur has long been considered to have an anatomical anterior curvature in the sagittal plane. We established a new method to evaluate the femoral curvature in three-dimensional (3D) space and reveal its influencing factors in Chinese population. Methods. 3D models of 426 femurs and the medullary canal were constructed using Mimics software. We standardized the positions of all femurs using 3ds Max software. After measuring the anatomical parameters, including the radius of femoral curvature (RFC) and banking angle, of the femurs using the established femur-specific coordinate system, we analyzed and determined the relationships between the anatomical parameters of the femur and the general characteristics of the population. Results. Pearson’s correlation analyses showed that there were positive correlations between the RFC and height (, ) and the femoral length and RFC (, ) and a negative correlation between the femoral length and banking angle (, ). Stepwise linear regression analyses showed that the most relevant factors for the RFC and banking angle were the femoral length and gender, respectively. Conclusions. This study concluded that the banking angle of the femur was significantly larger in female than in male. Xiu-Yun Su, Zhe Zhao, Jing-Xin Zhao, Li-Cheng Zhang, An-Hua Long, Li-Hai Zhang, and Pei-Fu Tang Copyright © 2015 Xiu-Yun Su et al. All rights reserved. A New CT Method for Assessing 3D Movements in Lumbar Facet Joints and Vertebrae in Patients before and after TDR Mon, 26 Oct 2015 14:14:37 +0000 This study describes a 3D-CT method for analyzing facet joint motion and vertebral rotation in the lumbar spine after TDR. Ten patients were examined before and then three years after surgery, each time with two CT scans: provoked flexion and provoked extension. After 3D registration, the facet joint 3D translation and segmental vertebral 3D rotation were analyzed at the operated level (L5-S1) and adjacent level (L4-L5). Pain was evaluated using VAS. The median (±SD) 3D movement in the operated level for the left facet joint was 3.2 mm (±1.9 mm) before and 3.5 mm (±1.7 mm) after surgery and for the right facet joint was 3.0 mm (±1.0 mm) before and 3.6 mm (±1.4 mm) after surgery. The median vertebral rotation in the sagittal plane at the operated level was 5.4° (±2.3°) before surgery and 6.8° (±1.7°) after surgery and in the adjacent level was 7.7° (±4.0°) before and 9.2° (±2.7°) after surgery. The median VAS was reduced from 6 (range 5–8) to 3 (range 2–8) in extension and from 4 (range 2–6) to 2 (range 1–3) in flexion. Per Svedmark, Svante Berg, Marilyn E. Noz, Gerald Q. Maguire Jr., Michael P. Zeleznik, Lars Weidenhielm, Gunnar Nemeth, and Henrik Olivecrona Copyright © 2015 Per Svedmark et al. All rights reserved. Does Computer-Assisted Femur First THR Improve Musculoskeletal Loading Conditions? Sun, 25 Oct 2015 13:04:08 +0000 We have developed a novel, computer-assisted operation method for minimal-invasive total hip replacement (THR) following the concept of “femur first/combined anteversion,” which incorporates various aspects of performing a functional optimization of the prosthetic stem and cup position (CAS FF). The purpose of this study is to assess whether the hip joint reaction forces and patient’s gait parameters are being improved by CAS FF in relation to conventional THR (CON). We enrolled 60 patients (28 CAS FF/32 CON) and invited them for gait analysis at three time points (preoperatively, postop six months, and postop 12 months). Data retrieved from gait analysis was processed using patient-specific musculoskeletal models. The target parameters were hip reaction force magnitude (hrf), symmetries, and orientation with respect to the cup. Hrf in the CAS FF group were closer to a young healthy normal. Phase-shift symmetry showed an increase in the CAS FF group. Hrf orientation in the CAS FF group was closer to optimum, though no edge or rim-loading occurred in the CON group as well. The CAS FF group showed an improved hrf orientation in an early stage and a trend to an improved long-term outcome. Tim A. Weber, Sebastian Dendorfer, Joachim Grifka, Gijsbertus J. Verkerke, and Tobias Renkawitz Copyright © 2015 Tim A. Weber et al. All rights reserved. Occult Infection in Aseptic Joint Loosening and the Diagnostic Role of Implant Sonication Sun, 25 Oct 2015 11:35:10 +0000 Our aim was to determine the incidence of occult infection and to examine the role of ultrasound sonication of the implants in cases of presumed aseptic loosening in a prospective trial. Joint swabs, aspirates, and deep tissue samples were obtained from around the prosthesis for routine microbiology. Each prosthesis was sonicated and the sonicate examined with Gram staining and extended cultures. There were 106 joints in the study of which 54 were revised for aseptic loosening and 52 were assigned to the control revision group. There were 9 positive cultures with 8/54 positive cultures in the aseptic loosening group and 1/52 in the control revision group (, associated OR 47.7). We found concordant results between sonication fluid culture and conventional samples in 5/9 cultures. Preoperative inflammatory markers were not prognostic for infection. Coagulase-negative Staphylococcus was the most commonly cultured organism (7/9). Previously unrecognised infection was present in 15% of patients undergoing revision for aseptic loosening. Ultrasound sonication of the removed prosthesis was less sensitive than conventional sampling techniques. We recommend routine intraoperative sampling for patients having revision for aseptic loosening, but we do not support the routine use of ultrasound sonication for its detection. J. T. Kempthorne, R. Ailabouni, S. Raniga, D. Hammer, and G. Hooper Copyright © 2015 J. T. Kempthorne et al. All rights reserved. Does Metal Transfer Differ on Retrieved Ceramic and CoCr Femoral Heads? Sun, 25 Oct 2015 11:33:40 +0000 Metal transfer has been observed on retrieved THA femoral heads for both CoCr and ceramic bearing materials. In vitro wear testing has shown increased wear to polyethylene acetabular liners with the presence of metal transfer. This study sought to investigate the extent of metal transfer on the bearing surface of CoCr and ceramic femoral heads and identify prevalent morphologies. Three bearing couple cohorts: M-PE (), C-PE (), and C-C (), were derived from two previously matched collections (/group) of CoCr and ceramic femoral heads. From the three cohorts, 75% of the femoral heads showed visual evidence of metal transfer. These femoral heads were analyzed using direct measurement, digital photogrammetry, and white light interferometry. Surface area coverage and curved median surface area were similar among the three cohorts. The most prevalent metal transfer patterns observed were random stripes (), longitudinal stripes (), and random patches (). Metal transfer arc length was shorter in the M-PE cohort. Understanding the morphology of metal transfer may be useful for more realistic recreation of metal transfer in in vitro pin-on-disk and joint simulators studies. Eliza K. Fredette, Daniel W. MacDonald, Richard J. Underwood, Antonia F. Chen, Michael A. Mont, Gwo-Chin Lee, Gregg R. Klein, Clare M. Rimnac, and Steven M. Kurtz Copyright © 2015 Eliza K. Fredette et al. All rights reserved. Effects of Surface Modification and Bulk Geometry on the Biotribological Behavior of Cross-Linked Polyethylene: Wear Testing and Finite Element Analysis Sun, 25 Oct 2015 11:32:22 +0000 The wear and creep deformation resistances of polymeric orthopedic bearing materials are both important for extending their longevity. In this study, we evaluated the wear and creep deformation resistances, including backside damage, of different polyethylene (PE) materials, namely, conventional PE, cross-linked PE (CLPE), and poly(2-methacryloyloxyethyl phosphorylcholine)- (PMPC-) grafted CLPE, through wear tests and finite element analysis. The gravimetric and volumetric degrees of wear of disks (3 or 6 mm in thickness) of these materials against a cobalt-chromium-molybdenum alloy pin were examined using a multidirectional pin-on-disk tester. Cross-linking and PMPC grafting decreased the gravimetric wear of the PE disks significantly. The volumetric wear at the bearing surface and the volumetric penetration in the backside of the 3-mm thick PE disk were higher than those of the 6-mm thick PE disk, regardless of the bearing material. The geometrical changes induced in the PE disks consisted of creep, because the calculated internal von Mises stress at the bearing side of all disks and that at the backside of the 3-mm thick disks exceeded their actual yield strengths. A highly hydrated bearing surface layer, formed by PMPC grafting, and a cross-linking-strengthened substrate of adequate thickness are essential for increasing the wear and creep deformation resistances. Kenichi Watanabe, Masayuki Kyomoto, Kenichi Saiga, Shuji Taketomi, Hiroshi Inui, Yuho Kadono, Yoshio Takatori, Sakae Tanaka, Kazuhiko Ishihara, and Toru Moro Copyright © 2015 Kenichi Watanabe et al. All rights reserved. Total Hip Arthroplasty Using the S-ROM-A Prosthesis for Anatomically Difficult Asian Patients Sun, 25 Oct 2015 11:10:10 +0000 Background. The S-ROM-A prosthesis has been designed for the Asian proximal femur with a small deformed shape and narrow canal. In this study, the clinical and radiological results using the S-ROM-A prosthesis for Japanese patients with severe deformity due to dysplasia and excessive posterior pelvic tilt were examined. Methods. 94 hips were followed up for a mean of 55 months, with a mean age at surgery of 61 years. The primary diagnoses were 94 coxarthritis cases, including 51 dysplasia and 37 primary OA, 1 avascular necrosis, 2 traumatic arthritis, and 3 Perthes disease. Thirty-one hips had been treated with osteotomy of the hip joints. Preoperative intramedullary canal shapes were stovepipe in 23 hips, normal in 51 hips, and champagne-flute in 5 hips. The maximum pelvic inclination angle was 56°. Results. The mean JOA score improved from 46 points preoperatively to 80 points at final follow-up. On radiological evaluation of the fixation of the implants according to the Engh classification, 92 (97%) hips were classified as “bone ingrown fixation.” Conclusion. In primary THA, using the S-ROM-A prosthesis for Asian patients with proximal femoral deformity, even after osteotomy and with posterior pelvic tilt, provided good short- to midterm results. Akira Hozumi, Kyousuke Kobayashi, Nobuhisa Tsuru, Chikara Miyamoto, Jyunichiro Maeda, Ko Chiba, Hisataka Goto, and Makoto Osaki Copyright © 2015 Akira Hozumi et al. All rights reserved. Iodine-Supported Hip Implants: Short Term Clinical Results Sun, 25 Oct 2015 11:08:19 +0000 We developed a new povidone iodine coating technology for titanium hip implants and performed a clinical trial to assess its usefulness in suppressing postoperative infection. Results indicate that iodine-supported titanium has favorable antibacterial activity, biocompatibility, and no cytotoxicity. Thirty joints in 28 patients were treated using iodine-supported implants. Fourteen joints were revision total hip arthroplasty (THA) after periprosthetic infection, 13 were primary THA for immunosuppressive conditions or pyogenic arthritis, and 3 were conversions from hemiarthroplasty to THA for immunosuppressive conditions. Two examinations were conducted sequentially until final follow-up: white blood cell (WBC) and C-reactive protein (CRP) were measured pre- and postoperatively and thyroid hormone levels in the blood were examined. The mean follow-up period was 33 months (14–78). There were no signs of infection in any patient at the last follow-up. WBC and CRP levels returned to normal within several weeks. No abnormalities of thyroid gland function were detected. Loosening of the implants did not occur in any patient. Excellent bone ingrowth and ongrowth were found around prostheses. No cytotoxicity or adverse effects were detected. These results suggest that iodine-supported THA implants can be highly effective in preventing and treating postoperative infections. Tamon Kabata, Toru Maeda, Yoshitomo Kajino, Kazuhiro Hasegawa, Daisuke Inoue, Takashi Yamamoto, Tomoharu Takagi, Takaaki Ohmori, and Hiroyuki Tsuchiya Copyright © 2015 Tamon Kabata et al. All rights reserved. An In Vivo Study of Low-Dose Intra-Articular Tranexamic Acid Application with Prolonged Clamping Drain Method in Total Knee Replacement: Clinical Efficacy and Safety Sun, 25 Oct 2015 11:05:49 +0000 Background. Recently, combined intra-articular tranexamic acid (IA-TXA) injection with clamping drain method showed efficacy for blood loss and transfusion reduction in total knee replacement (TKR). However, until now, none of previous studies revealed the effect of this technique on pharmacokinetics, coagulation, and fibrinolysis. Materials and Methods. An experimental study was conducted, during 2011-2012, in 30 patients undergoing unilateral TKR. Patients received IA-TXA application and then were allocated into six groups regarding clamping drain duration (2-, 4-, 6-, 8-, 10-, and 12-hours). Blood and drainage fluid were collected to measure tranexamic acid (TXA) level and related coagulation and fibrinolytic markers. Postoperative complication was followed for one year. Results. There was no significant difference of serum TXA level at 2 hour and 24 hour among groups . Serum TXA level at time of clamp release was significantly different among groups with the highest level at 2 hour . There was no significant difference of TXA level in drainage fluid, postoperative blood loss, blood transfusion, and postoperative complications .  Conclusions. Low-dose IA-TXA application in TKR with prolonged clamping drain method is a safe and effective blood conservative technique with only minimal systemic absorption and without significant increase in systemic absorption over time. Paphon Sa-ngasoongsong, Pongsthorn Chanplakorn, Siwadol Wongsak, Krisorn Uthadorn, Tanapong Panpikoon, Paisan Jittorntam, Katcharin Aryurachai, Pantap Angchaisukisiri, and Viroj Kawinwonggowit Copyright © 2015 Paphon Sa-ngasoongsong et al. All rights reserved. Titanium-Nitride Coating of Orthopaedic Implants: A Review of the Literature Sun, 25 Oct 2015 09:31:25 +0000 Surfaces of medical implants can be enhanced with the favorable properties of titanium-nitride (TiN). In a review of English medical literature, the effects of TiN-coating on orthopaedic implant material in preclinical studies were identified and the influence of these effects on the clinical outcome of TiN-coated orthopaedic implants was explored. The TiN-coating has a positive effect on the biocompatibility and tribological properties of implant surfaces; however, there are several reports of third body wear due to delamination, increased ultrahigh molecular weight polyethylene wear, and cohesive failure of the TiN-coating. This might be due to the coating process. The TiN-coating process should be optimized and standardized for titanium alloy articulating surfaces. The clinical benefit of TiN-coating of CoCrMo knee implant surfaces should be further investigated. Ruud P. van Hove, Inger N. Sierevelt, Barend J. van Royen, and Peter A. Nolte Copyright © 2015 Ruud P. van Hove et al. All rights reserved. Assessment of Hip Fracture Risk Using Cross-Section Strain Energy Determined by QCT-Based Finite Element Modeling Sun, 25 Oct 2015 09:00:26 +0000 Accurate assessment of hip fracture risk is very important to prevent hip fracture and to monitor the effect of a treatment. A subject-specific QCT-based finite element model was constructed to assess hip fracture risk at the critical locations of femur during the single-leg stance and the sideways fall. The aim of this study was to improve the prediction of hip fracture risk by introducing a novel failure criterion to more accurately describe bone failure mechanism. Hip fracture risk index was defined using cross-section strain energy, which is able to integrate information of stresses, strains, and material properties affecting bone failure. It was found that the femoral neck and the intertrochanteric region have higher fracture risk than other parts of the femur, probably owing to the larger content of cancellous bone in these regions. The study results also suggested that women are more prone to hip fracture than men. The findings in this study have a good agreement with those clinical observations reported in the literature. The proposed hip fracture risk index based on strain energy has the potential of more accurate assessment of hip fracture risk. However, experimental validation should be conducted before its clinical applications. Hossein Kheirollahi and Yunhua Luo Copyright © 2015 Hossein Kheirollahi and Yunhua Luo. All rights reserved. Long-Term Outcomes of Cervical Laminoplasty in the Elderly Sun, 25 Oct 2015 08:54:57 +0000 Incidences of cervical laminoplasty in the elderly are increasing; the influence of other age-related complications and neurological status must be considered for justifying surgery. This study identified the aforementioned influence on long-term outcomes of cervical laminoplasty in patients aged ≥75 years. Thirty-seven of 38 consecutive patients aged ≥75 years who underwent cervical laminoplasty were retrospectively evaluated. Minimum 5-year follow-up was acceptable if patients were complication-free. Follow-up was terminated when neurological evaluation was not possible, owing to death or other serious complications affecting activities of daily living (ADL). Postoperative neurological changes and newly developed severe complications were investigated. Postoperatively, one patient died of acute pneumonia, one remained nonambulatory owing to cerebral infarction, and 35 were ambulatory and were discharged. At a mean follow-up of 78 months, three patients died and nine developed serious complications severely affecting ADL. Of the 25 remaining patients, 23 remained ambulatory at mean follow-up of 105 months. Cox proportional hazard analysis revealed that postoperative motor upper and lower extremities JOA scores of ≤2 and ≤1, respectively, were risk factors for mortality or other severe complications. Postoperative neurological status can be maintained in the elderly if they remain complication-free. Poorer neurological status significantly affected their ADL and mortality. Yasushi Oshima, Kota Miyoshi, Yoji Mikami, Hideki Nakamoto, and Sakae Tanaka Copyright © 2015 Yasushi Oshima et al. All rights reserved. The Effect of Risk Factors on the Levels of Chemical Elements in the Tibial Plateau of Patients with Osteoarthritis following Knee Surgery Sun, 25 Oct 2015 07:17:25 +0000 The aim of this study was to evaluate the aforementioned chemical elements in tibial plateau samples obtained during knee arthroplasty. The gender-specific analysis of chemical element levels in the bone samples revealed that there were statistically significant differences in the concentration of Pb and Se/Pb ratio. The contents of elements in the tibial plateau in the patients with osteoarthritis (OA) can be arranged in the following descending order: F− > K > Zn > Fe > Sr > Pb > Mn > Se > Cd > THg. We observed statistical significant effects of environmental factors including smoking, seafood diet, and geographical distribution on the levels of the elements in tibial bone. Significant positive correlation coefficients were found for the relationships K-Cd, Zn-Sr, Zn-F−, THg-Pb, Pb-Cd, Se-Se/Pb, Se-Se/Cd, Se/Pb-Se/Cd, Pb-Cd/Ca, Cd-Cd/Ca, and F−-F−/Ca1000. Significant negative correlations were found for the relationships THg-Se/Pb, Pb-Se/Pb, Cd-Se/Pb, K-Se/Cd, Pb-Se/Cd, Cd-Se/Cd, THg-Se/THg, Pb-Se/THg, Se-Pb/Cd, Zn-Cd/Ca, and Se/Cd-Cd/Ca. The results reported here may provide a basis for establishing reference values for the tibial plateau in patients with OA who had undergone knee replacement surgery. The concentrations of elements in the bone with OA were determined by age, presence of implants, smoking, fish and seafood diet, and sport activity. Natalia Lanocha-Arendarczyk, Danuta Izabela Kosik-Bogacka, Adam Prokopowicz, Elzbieta Kalisinska, Sebastian Sokolowski, Maciej Karaczun, Pawel Zietek, Joanna Podlasińska, Bogumila Pilarczyk, Agnieszka Tomza-Marciniak, Irena Baranowska-Bosiacka, Izabela Gutowska, Krzysztof Safranow, and Dariusz Chlubek Copyright © 2015 Natalia Lanocha-Arendarczyk et al. All rights reserved. Radiographic Determination of Hip Rotation Center and Femoral Offset in Japanese Adults: A Preliminary Investigation toward the Preoperative Implications in Total Hip Arthroplasty Wed, 21 Oct 2015 13:02:37 +0000 The values of hip rotation center (HRC) and femoral offset (FO) evaluated according to Caucasian anatomical landmarks have been regarded as a useful reference also for Japanese patients in total hip arthroplasty (THA). In a strict sense, however, since there can be racial differences among their anatomical morphologies, it is clinically important to reconsider those parameters for the Japanese. In the present study, in order to investigate correlations among hip and pelvic morphometric parameters, frontal radiographs were taken from 98 Japanese adults (60 males and 38 females) without acetabular dysplasia and arthropathy in the standing position. Their mean age was 62.0 ± 16.7 years. The horizontal position of HRC was significantly correlated with the pelvic width in both genders ( and 0.0010 for the males and the females, resp.). The vertical position of HRC was significantly correlated with the teardrop-sacroiliac distance in the males and with the pelvic cavity height in the females . However, in both genders, there were no correlations among FO and the other parameters analyzed in this study. Our present findings might contribute to theoretical implications of an appropriate HRC position for Japanese OA patients in THA. Taichiro Takamatsu, Takaaki Shishido, Yasuhito Takahashi, Toshinori Masaoka, Toshiyuki Tateiwa, Kosuke Kubo, Kenji Endo, Masaya Aoki, and Kengo Yamamoto Copyright © 2015 Taichiro Takamatsu et al. All rights reserved. The Quantitative Assessment of Imaging Features for the Study of Hirayama Disease Progression Mon, 19 Oct 2015 14:26:56 +0000 Objective. To evaluate the forward shifting of cervical spinal cords in different segments of patients with Hirayama disease to determine whether the disease is self-limiting. Methods. This study was performed on 11 healthy subjects and 64 patients. According to the duration, the patients were divided into 5 groups (≤1 year, 1-2 years, 2-3 years, 3-4 years, and ≥4 years). Cervical magnetic resonance imaging (MRI) of flexion and conventional position was performed. The distances between the posterior edge of the spinal cord and the cervical spinal canal (), the anterior and posterior wall of the cervical spinal canal (), and the anterior-posterior () and the transverse diameter () of spinal cord cross sections were measured at different cervical spinal segments (C4 to T1). Results. In cervical flexion position, a significant increase in of C4-5 segments was found in groups 2–5, the C5-6 and C6-7 segments in groups 1–5, and the C7-T1 segments in group 5 (). The degree of the increased and cervical flexion of C5-6 segments were different among the 5 groups (), which was likely due to rapid increases in during the course of Hirayama’s disease. Conclusion. The change progression indicates that Hirayama disease may not be self-limiting. Minghao Shao, Jun Yin, Feizhou Lu, Chaojun Zheng, Hongli Wang, and Jianyuan Jiang Copyright © 2015 Minghao Shao et al. All rights reserved. Material Science in Cervical Total Disc Replacement Wed, 07 Oct 2015 06:14:46 +0000 Current cervical total disc replacement (TDR) designs incorporate a variety of different biomaterials including polyethylene, stainless steel, titanium (Ti), and cobalt-chrome (CoCr). These materials are most important in their utilization as bearing surfaces which allow for articular motion at the disc space. Long-term biological effects of implanted materials include wear debris, host inflammatory immune reactions, and osteolysis resulting in implant failure. We review here the most common materials used in cervical TDR prosthetic devices, examine their bearing surfaces, describe the construction of the seven current cervical TDR devices that are approved for use in the United States, and discuss known adverse biological effects associated with long-term implantation of these materials. It is important to appreciate and understand the variety of biomaterials available in the design and construction of these prosthetics and the considerations which guide their implementation. Martin H. Pham, Vivek A. Mehta, Alexander Tuchman, and Patrick C. Hsieh Copyright © 2015 Martin H. Pham et al. All rights reserved. A Novel and Alternative Treatment Method for Diabetic Heel Ulceration Exposing the Calcaneus Which Is Not Suitable for Flap Surgery: Vacuum Assisted Sandwich Dermal Matrix Mon, 21 Sep 2015 11:15:17 +0000 Background. Currently, free flaps and pedicled flaps are the first treatment choices for large heel ulcer reconstruction. However, flap reconstruction of heel ulcerations cannot be performed in all diabetics especially with concurrent severe peripheral vascular disease because of higher flap failure rate. In recent years, the use of acellular dermal matrix (ADM) has emerged as an alternative treatment option for extremity ulcers. Methods. We present 13 diabetic patients with a large heel ulceration exposing the calcaneus, who were not eligible for flap surgery due to the presence of only one patent artery of trifurcation. These cases were treated with the vacuum assisted sandwich dermal matrix (VASDEM) method. Results. None of the patients required amputation. Skin grafting was successful in ten patients. Although partial losses were observed in three patients, they were healed spontaneously without surgical interventions. During the follow-up period none of the patients developed ulceration on the treatment area. All patients maintained their preoperative ambulatory ability. Conclusion. VASDEM is a novel method offering opportunity for treatment before proceeding to amputation in diabetic heel ulceration exposing the calcaneus which is not suitable for flap surgery. It also has the potential to close wounds of all sizes independent of the vessel status and wound size in selected diabetic patients. Ugur A. Bingol, Can Cinar, Hakan Arslan, and Muzaffer Altındas Copyright © 2015 Ugur A. Bingol et al. All rights reserved. Effect of Bone Cement Implantation on Haemodynamics in Elderly Patients and Preventive Measure in Cemented Hemiarthroplasty Sun, 30 Aug 2015 14:18:05 +0000 This study was to investigate the influence of bone cement implantation on haemodynamics and the preventive effect of epinephrine hydrochloride on pulmonary embolism in elderly patients with cemented semihip replacement. 128 patients were retrospectively analyzed. The patients were treated with (group A, 64 cases) or without (group B, 64 cases) epinephrine hydrochloride saline. The monitoring indicators included systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), and pulse oxygen saturation (SPO2). The indicators of the two groups were compared before and 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 minutes after bone cement implantation. Analysis of variance and SNK-q test were used for the statistical analysis. Blood pressure and SPO2 of group B decreased with statistical difference () and HR increased without statistical significance, comparing with those of group A. In group A, SBP, DBP, MAP, HR, and SPO2 after bone cement implantation did not change significantly at each time point comparing with before implantation (). Bone cement implantation has significant influence on hemodynamics in elderly patients with hemiarthroplasty. Flushing the bone marrow cavity with saline epinephrine hydrochloride is an effective measure to reduce the incidence of bone cement pulmonary embolism. Xiangbei Qi, Yingze Zhang, Jinshe Pan, Lijie Ma, Lin Wang, and Jianzhao Wang Copyright © 2015 Xiangbei Qi et al. All rights reserved. Knee Flexion and Daily Activities in Patients following Total Knee Replacement: A Comparison with ISO Standard 14243 Tue, 11 Aug 2015 06:06:58 +0000 Walking is only one of many daily activities performed by patients following total knee replacement (TKR). The purpose of this study was to examine the hypotheses (a) that subject activity characteristics are correlated with knee flexion range of motion (ROM) and (b) that there is a significant difference between the subject’s flexion/extension excursion throughout the day and the ISO specified input for knee wear testing. In order to characterize activity, the number of walking and stair stepping cycles, the time spent with dynamic and stationary activities, the number of activity sequences, and the knee flexion/extension excursion of 32 TKR subjects were collected during daily activity. Flexion/extension profiles were compared with the ISO 14243 simulator input profile using a level crossing classification algorithm. Subjects took an average of 3102 (range: 343–5857) walking cycles including 65 (range: 0–319) stair stepping cycles. Active and passive ROMs were positively correlated with stair walking time, stair step counts, and stair walking sequences. Simulated knee motion according to ISO showed significantly fewer level crossings at the flexion angles 20–40° and beyond 50° than those measured with the monitor. This suggests that implant wear testing protocols should contain more cycles and a variety of activities requiring higher knee flexion angles with incorporated resting/transition periods to account for the many activity sequences. Markus A. Wimmer, William Nechtow, Thorsten Schwenke, and Kirsten C. Moisio Copyright © 2015 Markus A. Wimmer et al. All rights reserved. Patient-Specific CT-Based Instrumentation versus Conventional Instrumentation in Total Knee Arthroplasty: A Prospective Randomized Controlled Study on Clinical Outcomes and In-Hospital Data Sun, 02 Aug 2015 11:38:06 +0000 Total knee arthroplasty (TKA) is a frequently performed procedure in orthopaedic surgery. Recently, patient-specific instrumentation was introduced to facilitate correct positioning of implants. The aim of this study was to compare the early clinical results of TKA performed with patient-specific CT-based instrumentation and conventional technique. A prospective, randomized controlled trial on 112 patients was performed between January 2011 and December 2011. A group of 112 patients who met the inclusion and exclusion criteria were enrolled in this study and randomly assigned to an experimental or control group. The experimental group comprised 52 patients who received the Signature CT-based implant positioning system, and the control group consisted of 60 patients with conventional instrumentation. Clinical outcomes were evaluated with the KSS scale, WOMAC scale, and VAS scales to assess knee pain severity and patient satisfaction with the surgery. Specified in-hospital data were recorded. Patients were followed up for 12 months. At one year after surgery, there were no statistically significant differences between groups with respect to clinical outcomes and in-hospital data, including operative time, blood loss, hospital length of stay, intraoperative observations, and postoperative complications. Further high-quality investigations of various patient-specific systems and longer follow-up may be helpful in assessing their utility for TKA. Andrzej Kotela, Jacek Lorkowski, Marek Kucharzewski, Magdalena Wilk-Frańczuk, Zbigniew Śliwiński, Bogusław Frańczuk, Paweł   Łęgosz, and Ireneusz Kotela Copyright © 2015 Andrzej Kotela et al. All rights reserved. The Effects of Dorsal Cortical Comminution on Radiographic Results following Percutaneous Pinning for Extra-Articular Colles’ Fracture Wed, 29 Jul 2015 08:53:25 +0000 A number of studies have demonstrated that dorsal cortical comminution (DCC) can predict redisplacement after nonoperative treatment of Colles’ fractures; however, the effects of a DCC defect on radiographic outcomes following percutaneous pinning for dorsally displaced extraarticular Colles’ fractures are unclear. We, therefore, performed a retrospective study on 85 patients who sustained such fractures treated with percutaneous pinning within 2006–2009. The main outcome measures included four radiographic parameters, including radial height, radial inclination, radial tilt, and ulnar variance. The radiological results showed that all fractures after percutaneous pinning followed the same time series changes and patterns of fracture collapse regardless of the presence of a DCC defect. The use of the pinning construct is to provide support for static loading but not for dynamic loading. Although the final radiographic outcomes were classified as acceptable in fractures with and without DCC, we recommend that a different approach in the management of displaced Colles’ fractures might be necessary in consideration of increasing patient expectations of health care. Po-Yao Chuang, Tien-Yu Yang, Shih-Hsun Shen, Yao-Hung Tsai, and Kuo-Chin Huang Copyright © 2015 Po-Yao Chuang et al. All rights reserved. Hypoxia-Inducible Factor 1 Is an Inductor of Transcription Factor Activating Protein 2 Epsilon Expression during Chondrogenic Differentiation Mon, 27 Jul 2015 13:53:36 +0000 The transcription factor AP-2ε (activating enhancer-binding protein epsilon) is expressed in cartilage of humans and mice. However, knowledge about regulatory mechanisms influencing AP-2ε expression is limited. Using quantitative real time PCR, we detected a significant increase in AP-2ε mRNA expression comparing initial and late stages of chondrogenic differentiation processes in vitro and in vivo. Interestingly, in these samples the expression pattern of the prominent hypoxia marker gene angiopoietin-like 4 (Angptl4) strongly correlated with that of AP-2ε suggesting that hypoxia might represent an external regulator of AP-2ε expression in mammals. In order to show this, experiments directly targeting the activity of hypoxia-inducible factor-1 (HIF1), the complex mediating responses to oxygen deprivation, were performed. While the HIF1-activating compounds 2,2′-dipyridyl and desferrioxamine resulted in significantly enhanced mRNA concentration of AP-2ε, siRNA against HIF1α led to a significantly reduced expression rate of AP-2ε. Additionally, we detected a significant upregulation of the AP-2ε mRNA level after oxygen deprivation. In sum, these different experimental approaches revealed a novel role for the HIF1 complex in the regulation of the AP-2ε gene in cartilaginous cells and underlined the important role of hypoxia as an important external regulatory stimulus during chondrogenic differentiation modulating the expression of downstream transcription factors. Stephan Niebler, Peter Angele, Richard Kujat, and Anja K. Bosserhoff Copyright © 2015 Stephan Niebler et al. All rights reserved. Effect of Fluoride-Modified Titanium Surface on Early Adhesion of Irradiated Osteoblasts Wed, 22 Jul 2015 13:25:59 +0000 Objective. The present study aimed to investigate the effect of fluoride-modified titanium surface on adhesion of irradiated osteoblasts. Materials and Methods. Fluoride-modified surface was obtained and the morphology, roughness, and chemical composition of the surface were evaluated by scanning electron microscopy, atomic force microscopy, and X-ray photoelectron spectroscopy, respectively. The adhesion of irradiated osteoblast-like cells, in terms of number, area, and fluorescence intensity on the titanium surface, was evaluated using immunofluorescence staining. Results. Numerous nanosize pits were seen only in the F-TiO surface. The pits were more remarkable and uniform on F-TiO surface than on TiO surface; however, the amplitude of peaks and bottoms on F-TiO surface appeared to be smaller than on TiO surface. The Sa value and Sdr percentage of TiO surfaces were significantly higher than those of F-TiO surface. The concentrations of main elements such as titanium, oxygen, and carbon were similar on both surfaces. The number of irradiated osteoblasts adhered on the control surface was larger than on fluoride-modified surface. Meanwhile, the cells on the fluoride-modified surface formed more actin filaments. Conclusions. The fluoride-modified titanium surface alters the adhesion of irradiated osteoblasts. Further studies are needed to investigate the proliferation, differentiation, maturation, gene expression, and cytokine production of irradiated osteoblasts on fluoride-modified titanium surface. Jun Yuan Li, Li Wu Zheng, Li Ma, Dora Lai Wan Kwong, Lim Kwong Cheung, and Edmond Ho Nang Pow Copyright © 2015 Jun Yuan Li et al. All rights reserved. Influence of Pelvic Tilt on Polyethylene Wear after Total Hip Arthroplasty Thu, 16 Jul 2015 07:39:05 +0000 We aimed to evaluate the effects of pelvic tilt on polyethylene wear after total hip arthroplasty (THA). A total of 105 joints treated with primary THA were included; conventional polyethylene (CPE) liners were used in 43 hips and highly cross-linked polyethylene (HXLPE) liners were used in the remaining 62 hips. The pelvis was tilted 6° posteriorly in the standing position as compared to the supine position, which resulted in significant increases of 1.7° and 2.8° in cup inclination in the CPE and HXLPE groups, respectively. Moreover, the change in pelvic tilt resulted in significant increases of 3.6° and 4.9° in cup anteversion in the CPE and HXLPE groups, respectively. For the CPE group, multiple regression analysis showed a significant association between the angle of pelvic tilt (PTA) and cup inclination and the polyethylene wear ratio. The adjusted of the regression model was larger for measures obtained in the standing position as compared to the supine position. For the HXLPE group, there was no significant relationship between radiographic parameters and polyethylene wear. Close observation of polyethylene wear is recommended for patients with severe posterior pelvic tilt who have undergone THA with conventional polyethylene. Taro Tezuka, Yutaka Inaba, Naomi Kobayashi, Hiroyuki Ike, So Kubota, Masaki Kawamura, and Tomoyuki Saito Copyright © 2015 Taro Tezuka et al. All rights reserved. Bearing-Foreign Material Deposition on Retrieved Co-Cr Femoral Heads: Composition and Morphology Sun, 05 Jul 2015 10:33:09 +0000 Bearing-foreign material deposition onto a femoral head can occur from contact with an acetabular shell due to dislocation, reduction, or subluxation. The purpose of this study was to comprehensively characterize deposit regions on retrieved cobalt-chrome femoral heads from metal-on-polyethylene total hip arthroplasties that had experienced such adverse events. The morphology, topography, and composition of deposition regions were characterized using macrophotography, optical profilometry, scanning electron microscopy, energy dispersive spectroscopy, and X-ray photoelectron spectroscopy. The deposit areas were relatively large, they were much rougher than the surrounding undamaged clean areas, and they displayed several distinct morphologies. Titanium alloy elements were the predominant constituents. Calcium and phosphorous were also detected within the deposit areas, in a composition that could nucleate abrasive hydroxyapatite. In addition, tungsten-rich particles, likely present as tungsten carbide, were observed on top of the titanium deposits. The increased roughness associated with these deposition features would be expected to accelerate damage and wear of the opposing liner and hence accelerate the development of osteolysis. Nishant M. Tikekar, Anneliese D. Heiner, Thomas E. Baer, Karen M. Kruger, John J. Callaghan, Thomas D. Brown, and John J. Lannutti Copyright © 2015 Nishant M. Tikekar et al. All rights reserved. Evaluation of Single-Impact-Induced Cartilage Degeneration by Optical Coherence Tomography Wed, 01 Jul 2015 07:04:04 +0000 Posttraumatic osteoarthritis constitutes a major cause of disability in our increasingly elderly population. Unfortunately, current imaging modalities are too insensitive to detect early degenerative changes of this disease. Optical coherence tomography (OCT) is a promising nondestructive imaging technique that allows surface and subsurface imaging of cartilage, at near-histological resolution, and is principally applicable in vivo during arthroscopy. Thirty-four macroscopically normal human cartilage-bone samples obtained from total joint replacements were subjected to standardized single impacts in vitro (range: 0.25 J to 0.98 J). 3D OCT measurements of impact area and adjacent tissue were performed prior to impaction, directly after impaction, and 1, 4, and 8 days later. OCT images were assessed qualitatively (DJD classification) and quantitatively using established parameters (OII, Optical Irregularity Index; OHI, Optical Homogeneity Index; OAI, Optical Attenuation Index) and compared to corresponding histological sections. While OAI and OHI scores were not significantly changed in response to low- or moderate-impact energies, high-impact energies significantly increased mean DJD grades (histology and OCT) and OII scores. In conclusion, OCT-based parameterization and quantification are able to reliably detect loss of cartilage surface integrity after high-energy traumatic insults and hold potential to be used for clinical screening of early osteoarthritis. Florence de Bont, Nicolai Brill, Robert Schmitt, Markus Tingart, Björn Rath, Thomas Pufe, Holger Jahr, and Sven Nebelung Copyright © 2015 Florence de Bont et al. All rights reserved. Alendronate-Eluting Biphasic Calcium Phosphate (BCP) Scaffolds Stimulate Osteogenic Differentiation Mon, 29 Jun 2015 07:18:39 +0000 Biphasic calcium phosphate (BCP) scaffolds have been widely used in orthopedic and dental fields as osteoconductive bone substitutes. However, BCP scaffolds are not satisfactory for the stimulation of osteogenic differentiation and maturation. To enhance osteogenic differentiation, we prepared alendronate- (ALN-) eluting BCP scaffolds. The coating of ALN on BCP scaffolds was confirmed by scanning electron microscopy (FE-SEM), energy-dispersive X-ray spectroscopy (EDS), and attenuated total reflectance-Fourier transform infrared spectroscopy (ATR-FTIR). An in vitro release study showed that release of ALN from ALN-eluting BCP scaffolds was sustained for up to 28 days. In vitro results revealed that MG-63 cells grown on ALN-eluting BCP scaffolds exhibited increased ALP activity and calcium deposition and upregulated gene expression of Runx2, ALP, OCN, and OPN compared with the BCP scaffold alone. Therefore, this study suggests that ALN-eluting BCP scaffolds have the potential to effectively stimulate osteogenic differentiation. Sung Eun Kim, Young-Pil Yun, Deok-Won Lee, Eun Young Kang, Won Jae Jeong, Boram Lee, Myeong Seon Jeong, Hak Jun Kim, Kyeongsoon Park, and Hae-Ryong Song Copyright © 2015 Sung Eun Kim et al. All rights reserved. The Thermal Sensitivity Test in Evaluating Outcome after Peripheral Nerve Injury Tue, 23 Jun 2015 09:45:01 +0000 The purpose of this study was to evaluate the ability to discriminate temperatures in patients following peripheral nerve injury. Knowing that temperature sensibility is mediated by different receptors, the scores were compared to other functional hand scores in order to determine whether the ability to discriminate temperatures is restored to a different extent compared with other commonly evaluated hand function modalities. The test was performed using the NTE-2 device (Physitemp Instruments Inc., 154 Huron Avenue, Clifton, New Jersey, USA). Out of 57 patients, 27 had normal thermal discrimination scores, and 9 could not tell the temperatures apart in the differences set on the measuring device. Overall, patients with better thermal discrimination had also better hand function as evaluated with different methods. However, some patients who did regain the ability to differentiate temperatures correctly did not have any measurable return of hand function in other tests. Thermal discrimination scores correlated similarly with different functional scores, except for vibration sensibility, which did not show any significant correlation. The development and severity of cold intolerance seem to be unrelated to temperature sense. Marcin Ceynowa, Tomasz Mazurek, Rafał Pankowski, Marek Rocławski, and Mariusz Treder Copyright © 2015 Marcin Ceynowa et al. All rights reserved. Biomechanics of Lower Limbs during Walking among Candidates for Total Knee Arthroplasty with and without Low Back Pain Thu, 11 Jun 2015 07:08:28 +0000 The effect of joint pathologies, such as unilateral knee osteoarthritis (UKOA) or low back pain (LBP), on bilateral gait symmetry has gained increased attention during the past decade. This study is the first to compare gait patterns between patients with UKOA and LBP in combination and with UKOA only. Temporal, kinematic, and kinetic variables were measured bilaterally during gait stance phase in 31 subjects with UKOA and LBP (Group I) and 11 subjects with only UKOA (Group II). Group I patients exhibited less hip rotation in the affected limb (A) than in the nonaffected (NA) limb during walking in contrast to Group II patients. Group I patients had minimal bilateral differences in hip abduction and flexion, but Group II patients displayed significantly larger values in the NA limb compared to the A limb for both parameters. Hip flexion patterns were significantly different between Groups I and II. Subjects in both groups adapted gait patterns that minimized vertical ground reaction force, knee flexion motion, and stance time on the UKOA affected limb. The distinct kinematic gait patterns that were revealed in this study may provide clinical value for assessment of patients with UKOA in conjunction with LBP. David R. Burnett, Naira H. Campbell-Kyureghyan, Robert V. Topp, and Peter M. Quesada Copyright © 2015 David R. Burnett et al. All rights reserved. Effect of Leukocyte-Rich and Platelet-Rich Plasma on Healing of a Horizontal Medial Meniscus Tear in a Rabbit Model Tue, 09 Jun 2015 07:33:18 +0000 There are limited reports on the effect of platelet-rich plasma (PRP) on meniscus healing. The purpose of this study was to investigate the effect of leukocyte-rich PRP (L-PRP) on potential healing of the horizontal medial meniscus tears in a rabbit model. A horizontal medial meniscus tear was created in both knees of nine skeletally mature adult rabbits. Left or right knees were randomly assigned to a L-PRP group, or a control group. 0.5 mL of L-PRP from 10 mL of each rabbit’s whole blood was prepared and injected into the horizontal tears in a L-PRP group. None was applied to the horizontal tears in a control group. The histological assessment of meniscus healing was performed at two, four, and six weeks after surgery. We found that there were no significant differences of quantitative histologic scoring between two groups at 2, 4, and 6 weeks after surgery (). This study failed to show the positive effect of single injection of L-PRP on enhancing healing of the horizontal medial meniscus tears in a rabbit model. Single injection of L-PRP into horizontal meniscus tears may not effectively enhance healing of horizontal medial meniscus tears. Kyun Ho Shin, Haseok Lee, Seonghyun Kang, You-Jin Ko, Seung-Yup Lee, Jung-Ho Park, and Ji-Hoon Bae Copyright © 2015 Kyun Ho Shin et al. All rights reserved. A Novel Shape Memory Plate Osteosynthesis for Noninvasive Modulation of Fixation Stiffness in a Rabbit Tibia Osteotomy Model Mon, 08 Jun 2015 13:53:06 +0000 Nickel-titanium shape memory alloy (NiTi-SMA) implants might allow modulating fracture healing, changing their stiffness through alteration of both elastic modulus and cross-sectional shape by employing the shape memory effect (SME). Hypotheses: a novel NiTi-SMA plate stabilizes tibia osteotomies in rabbits. After noninvasive electromagnetic induction heating the alloy exhibits the SME and the plate changes towards higher stiffness (inverse dynamization) resulting in increased fixation stiffness and equal or better bony healing. In 14 rabbits, 1.0 mm tibia osteotomies were fixed with our experimental plate. Animals were randomised for control or induction heating at three weeks postoperatively. Repetitive X-ray imaging and in vivo measurements of bending stiffness were performed. After sacrifice at 8 weeks, macroscopic evaluation, µCT, and post mortem bending tests of the tibiae were carried out. One death and one early implant dislocation occurred. Following electromagnetic induction heating, radiographic and macroscopic changes of the implant proved successful SME activation. All osteotomies healed. In the treatment group, bending stiffness increased over time. Differences between groups were not significant. In conclusion, we demonstrated successful healing of rabbit tibia osteotomies using our novel NiTi-SMA plate. We demonstrated shape-changing SME in-vivo through transcutaneous electromagnetic induction heating. Thus, future orthopaedic implants could be modified without additional surgery. Christian W. Müller, Ronny Pfeifer, Karen Meier, Sebastian Decker, Janin Reifenrath, Thomas Gösling, Volker Wesling, Christian Krettek, Christof Hurschler, and Manuel Krämer Copyright © 2015 Christian W. Müller et al. All rights reserved. Promoting Effects on Proliferation and Chondrogenic Differentiation of Bone Marrow-Derived Mesenchymal Stem Cells by Four “Kidney-Tonifying” Traditional Chinese Herbs Sun, 07 Jun 2015 09:13:32 +0000 Traditional Chinese medicine can promote the proliferation of bone marrow-derived mesenchymal stem cells (BMSCs). We chose four “Kidney-tonifying” Chinese herbal medicines, Radix Astragali, Salvia, Herba Epimedii, and Saussurea Involucrata, to evaluate whether they had positive effects on the proliferation of BMSCs and TGF-β1-induced chondrogenic differentiation of BMSCs. The four Chinese herbal medicines were intragastrically administered to Sprague-Dawley rats, respectively, to prepare drug-containing serums of corresponding Chinese herbs. BMSCs were isolated, cultured, and exposed to culture solution containing 1%, 5%, 10%, and 15% (v/v) Radix Astragali-, Salvia-, Herba Epimedii-, and Saussurea Involucrata-containing serum, respectively. TGF-β1-induced BMSCs were addressed in the same manner. Collagen type II protein was assessed by immunofluorescence methods. To assess whether the drug-containing serums had positive effects on the proliferation of BMSCs and TGF-β1-induced BMSCs, MTT method was assessed. The proliferation of BMSCs was significantly enhanced when exposed to culture solutions containing 1% and 5% Radix Astragali-, 1% and 5% Salvia-, 5% Herba Epimedii-, and 1%, 5%, and 10% Saussurea Involucrata-containing serum. The proliferation of TGF-β1-induced BMSCs was significantly enhanced when exposed to 1%, 5%, and 15% Radix Astragali-, 10% and 15% Salvia-, 5%, and 15% Herba Epimedii-, and 1%, 5%, and 10% Saussurea Involucrata-containing serum. Bin Cai, Ai-guo Zhang, Xian Zhang, Wen-jie Ge, Guo-da Dai, Xiang-ling Tan, Gopaul Roodrajeetsing, and Jian-ping Cai Copyright © 2015 Bin Cai et al. All rights reserved. Three-Dimensional Analysis of the Characteristics of the Femoral Canal Isthmus: An Anatomical Study Sun, 07 Jun 2015 08:00:22 +0000 Purpose. To establish a new approach for measuring and locating the femoral intramedullary canal isthmus in 3-dimensional (3D) space. Methods. Based on the computed tomography data from 204 Chinese patients, 3D models of the whole femur and the corresponding femoral isthmus tube were reconstructed using Mimics software (Materialise, Haasrode, Belgium). The anatomical parameters of the femur and the isthmus, including the femur length and radius, and the isthmus diameter and height, were measured accordingly. Results. The mean ratio of the isthmus height versus the femoral height was 55 ± 4.8%. The mean diameter of the isthmus was 10.49 ± 1.52 mm. The femoral length, the isthmus diameter, and the isthmus tube length were significantly larger in the male group. Significant correlations were observed between the femoral length and the isthmus diameter (, ) and between the femoral length and the isthmus height (, ). Stepwise linear regression analyses demonstrated that the femoral length and radius were the most important factors influencing the location and dimension of the femoral canal isthmus. Conclusion. The current study developed a new approach for measuring the femoral canal and for optimization of customer-specific femoral implants. Xiu-yun Su, Jing-xin Zhao, Zhe Zhao, Li-cheng Zhang, Chen Li, Jian-tao Li, Jian-feng Zhou, Li-hai Zhang, and Pei-fu Tang Copyright © 2015 Xiu-yun Su et al. All rights reserved. Environmental Stability and Residual Stresses in Zirconia Femoral Head for Total Hip Arthroplasty: In Vitro Aging versus Retrieval Studies Wed, 03 Jun 2015 08:20:27 +0000 The objective of this study was to compare the low temperature degradation (LTD) behavior of femoral heads made of 3Y-TZP as observed on retrievals with that induced in vitro upon prolonged exposures to a hydrothermal environment. The time-dependent evolution of tetragonal-to-monoclinic transformation and the related residual stresses were nondestructively monitored by Raman microspectroscopy. An increasing intensification of tensile and compressive stresses was detected with increasing hydrothermal aging duration in tetragonal and monoclinic phases, respectively. The dependence of monoclinic fraction upon exposure time was rationalized through the Mehl-Avrami-Johnson (MAJ) formalism in order to interpret the LTD process according to a two-step mechanism of formation and growth of monoclinic nuclei. In vitro results were compared to in vivo monoclinic contents in the same type of 3Y-TZP head retrievals after implantation periods of 1.6–16.6 y, also including literature data previously reported by other authors. One-hour exposure under the selected aging condition is estimated to correspond to in vivo exposures of 4 and 2 years according to ISO and ASTM criteria, respectively. A critical review of these two criteria according to the present analyses revealed that the ASTM simulation predicts more closely the in vivo results as compared to the ISO one. Masanori Arita, Yasuhito Takahashi, Giuseppe Pezzotti, Takaaki Shishido, Toshinori Masaoka, Keiji Sano, and Kengo Yamamoto Copyright © 2015 Masanori Arita et al. All rights reserved. Percutaneous Dorsal Instrumentation of Vertebral Burst Fractures: Value of Additional Percutaneous Intravertebral Reposition—Cadaver Study Tue, 02 Jun 2015 07:10:23 +0000 Purpose. The treatment of vertebral burst fractures is still controversial. The aim of the study is to evaluate the purpose of additional percutaneous intravertebral reduction when combined with dorsal instrumentation. Methods. In this biomechanical cadaver study twenty-eight spine segments (T11-L3) were used (male donors, mean age 64.9 ± 6.5 years). Burst fractures of L1 were generated using a standardised protocol. After fracture all spines were allocated to four similar groups and randomised according to surgical techniques (posterior instrumentation; posterior instrumentation + intravertebral reduction device + cement augmentation; posterior instrumentation + intravertebral reduction device without cement; and intravertebral reduction device + cement augmentation). After treatment, 100000 cycles (100–600 N, 3 Hz) were applied using a servohydraulic loading frame. Results. Overall anatomical restoration was better in all groups where the intravertebral reduction device was used (). In particular, it was possible to restore central endplates (). All techniques decreased narrowing of the spinal canal. After loading, clearance could be maintained in all groups fitted with the intravertebral reduction device. Narrowing increased in the group treated with dorsal instrumentation. Conclusions. For height and anatomical restoration, the combination of an intravertebral reduction device with dorsal instrumentation showed significantly better results than sole dorsal instrumentation. Antonio Krüger, Maya Schmuck, David C. Noriega, Steffen Ruchholtz, Gamal Baroud, and Ludwig Oberkircher Copyright © 2015 Antonio Krüger et al. All rights reserved. New Developments in the Use of Biologics and Other Modalities in the Management of Lateral Epicondylitis Sun, 31 May 2015 14:09:52 +0000 Lateral epicondylitis is a common source of elbow pain. Though it is often a self-limited condition, refractory lateral epicondylitis can lead to problems with activities of daily living and sometimes requires sick leave from work. Therefore prompt treatment is essential. Histopathologic studies have suggested that lateral epicondylitis is a tendinopathy, associated with apoptosis and autophagy, rather than a tendonitis associated with inflammation. Although corticosteroids have been used for short-term treatment, recent studies have suggested that they are not helpful and may even be harmful and delay healing in the treatment of lateral epicondylitis. Researchers have recently begun to investigate the use of biologics as potential treatment options for lateral epicondylitis. Autologous blood preparations including platelet rich plasma (PRP) and autologous whole blood injections (ABIs) have been proposed in order to deliver growth factors and other nutrients to the diseased tendon. Stem cell therapies have also been suggested as a method of improving tendon healing. This review discusses the current evidence for the use of PRP, ABI, and stem cell therapies for treatment of lateral epicondylitis. We also review the evidence for nonbiologic treatments including corticosteroids, prolotherapy, botulinum toxin A, and nitric oxide. Cynthia A. Kahlenberg, Michael Knesek, and Michael A. Terry Copyright © 2015 Cynthia A. Kahlenberg et al. All rights reserved. The Effect of Phospholipids (Surfactant) on Adhesion and Biomechanical Properties of Tendon: A Rat Achilles Tendon Repair Model Mon, 25 May 2015 12:12:30 +0000 Adhesion of the tendon is a major challenge for the orthopedic surgeon during tendon repair. Manipulation of biological environment is one of the concepts to prevent adhesion. Lots of biochemicals have been studied for this purpose. We aimed to determine the effect of phospholipids on adhesion and biomechanical properties of tendon in an animal tendon repair model. Seventy-two Wistar rats were divided into 4 groups. Achilles tendons of rats were cut and repaired. Phospholipids were applied at two different dosages. Tendon adhesion was determined histopathologically and biomechanical test was performed. At macroscopic evaluation of adhesion, there are statistically significant differences between multiple-dose phospholipid injection group and Control group and also hyaluronic acid group and Control group (). At microscopic evaluation of adhesion, there was no statistically significant difference (). Ultimate strength was highest at hyaluronic acid injection group and lowest at multiple-dose phospholipid injection group. Single-dose phospholipids (surfactant) application may have a beneficial effect on the tendon adhesion. Although multiple applications of phospholipids seem the most effective regime to reduce the tendon adhesion among groups, it deteriorated the biomechanical properties of tendon. T. Kursat Dabak, Omer Sertkaya, Nuray Acar, B. Ozgur Donmez, and Ismail Ustunel Copyright © 2015 T. Kursat Dabak et al. All rights reserved. The Long Noncoding RNA MEG3 Is Downregulated and Inversely Associated with VEGF Levels in Osteoarthritis Thu, 21 May 2015 15:58:19 +0000 Osteoarthritis (OA) is becoming a major public health problem in China, especially considering the increase in average life expectancy of the population. Thus, enhanced understanding of the molecular changes associated with OA is urgently needed to develop more effective strategies for the diagnosis and treatment of this debilitating disease. LncRNAs play an important role in the processes of bone and cartilage development. Maternally expressed gene 3 (MEG3) is a maternally expressed lncRNA and may function as a tumor suppressor by inhibiting angiogenesis. OA is closely associated with angiogenesis and the inhibition of angiogenesis presents a novel therapeutic approach to reduce inflammation and pain in OA. In this study, we detected the mRNA expression of MEG3 and VEGF in articular cartilage samples from 20 OA patients and 10 healthy volunteers by real-time RT-PCR. VEGF protein is detected by ELISA in cartilage samples. The results show that human MEG3 is significantly downregulated in OA patients compared to normal cartilage samples. However, higher levels of VEGF mRNA and protein are found in OA compared to the control. Moreover, MEG3 levels are inversely associated with VEGF levels, suggesting that MEG3 may be involved in OA development through the regulation of angiogenesis. Wei Su, Wen Xie, Qingkun Shang, and Bing Su Copyright © 2015 Wei Su et al. All rights reserved. Improving Osteogenesis Activity on BMP-2-Immobilized PCL Fibers Modified by the γ-Ray Irradiation Technique Mon, 18 May 2015 15:45:32 +0000 The purpose of this study was to demonstrate the ability of BMP-2-immobilized polycaprolactone (PCL) fibers modified using the γ-ray irradiation technique to induce the osteogenic differentiation of MG-63 cells. Poly acrylic acid (AAc) was grafted onto the PCL fibers by the γ-ray irradiation technique. BMP-2 was then subsequently immobilized onto the AAc-PCL fibers (BMP-2/AAc-PCL). PCL and surface-modified PCL fibers was characterized by evaluation with a scanning electron microscope (SEM), X-ray photoelectron spectroscopy (XPS), and contact angle. The biological activity of the PCL and surface-modified PCL fibers were characterized by alkaline phosphatase (ALP) activity, calcium deposition, and the mRNA expression of osteocalcin and osteopontin in MG-63 cells. Successfully grafted AAc and PCL fibers with immobilized BMP-2 were confirmed by XPS results. The results of the contact angle showed that BMP-2/AAc-PCL fibers have more hydrophilic properties in comparison to PCL fibers. The ALP activity, calcium deposition, and gene expressions of MG-63 cells grown on BMP-2/AAc-PCL fibers showed greatly induced osteogenic differentiation in comparison to the PCL fibers. In conclusion, these results demonstrated that BMP-2/AAc-PCL fibers have the potential to effectively induce the osteogenic differentiation of MG-63 cells. Young-Pil Yun, Jae Yong Lee, Won Jae Jeong, Kyeongsoon Park, Hak-Jun Kim, Jae-Jun Song, Sung Eun Kim, and Hae-Ryong Song Copyright © 2015 Young-Pil Yun et al. All rights reserved. Do Nonsteroidal Anti-Inflammatory Drugs Cause Endoprosthetic Loosening? Mid- to Long-Term Follow-Up of 100 Total Hip Arthroplasties after Local NSAID Infiltration Mon, 18 May 2015 12:06:23 +0000 We evaluated the effect of local infiltration of NSAIDs on prosthetic fixation at mid- to long-term follow-up of total hip arthroplasties. Intra-articular local NSAID (ketorolac) was injected into hip joints and surrounding tissues intraoperatively and postoperatively as a part of multimodal pain management protocol. Clinical and radiographic evaluation was performed for any evidence of component loosening or failure and clinical outcomes in 100 total hip joint arthroplasties with a mean follow-up of 7.3 years (4.9 to 11 yrs). Radiographic analysis at the most recent follow-up showed no evidence of loosening, subsidence, or migration and no evidence of impending failure. Clinical outcomes showed improved Harris hip scores. Intra-articular NSAID used in the intraoperative/postoperative period in hip arthroplasty showed no evidence of prosthetic loosening at mid- to long-term follow-up. Ikram Nizam, Lawrence Kohan, Clarice Field, and Dennis Kerr Copyright © 2015 Ikram Nizam et al. All rights reserved. Comment on “Efficacy of Alendronate for Preventing Collapse of Femoral Head in Adult Patients with Nontraumatic Osteonecrosis” Tue, 12 May 2015 09:30:33 +0000 Hengfeng Yuan Copyright © 2015 Hengfeng Yuan. All rights reserved. Platelet Rich Plasma and Orthopedics: Why, When, and How Sun, 10 May 2015 08:16:38 +0000 Mikel Sánchez, Giuseppe Filardo, and Tomokazu Yoshioka Copyright © 2015 Mikel Sánchez et al. All rights reserved. New and Emerging Strategies in Platelet-Rich Plasma Application in Musculoskeletal Regenerative Procedures: General Overview on Still Open Questions and Outlook Tue, 05 May 2015 12:18:08 +0000 Despite its pervasive use, the clinical efficacy of platelet-rich plasma (PRP) therapy and the different mechanisms of action have yet to be established. This overview of the literature is focused on the role of PRP in bone, tendon, cartilage, and ligament tissue regeneration considering basic science literature deriving from in vitro and in vivo studies. Although this work provides evidence that numerous preclinical studies published within the last 10 years showed promising results concerning the application of PRP, many key questions remain unanswered and controversial results have arisen. Additional preclinical studies are needed to define the dosing, timing, and frequency of PRP injections, different techniques for delivery and location of delivery, optimal physiologic conditions for injections, and the concomitant use of recombinant proteins, cytokines, additional growth factors, biological scaffolds, and stems cells to develop optimal treatment protocols that can effectively treat various musculoskeletal conditions. Francesca Salamanna, Francesca Veronesi, Melania Maglio, Elena Della Bella, Maria Sartori, and Milena Fini Copyright © 2015 Francesca Salamanna et al. All rights reserved. PRP Augmentation for ACL Reconstruction Tue, 05 May 2015 07:54:01 +0000 Current research is investigating new methods to enhance tissue healing to speed up recovery time and decrease the risk of failure in Anterior Cruciate Ligament (ACL) reconstructive surgery. Biological augmentation is one of the most exploited strategies, in particular the application of Platelet Rich Plasma (PRP). Aim of the present paper is to systematically review all the preclinical and clinical papers dealing with the application of PRP as a biological enhancer during ACL reconstructive surgery. Thirty-two studies were included in the present review. The analysis of the preclinical evidence revealed that PRP was able to improve the healing potential of the tendinous graft both in terms of histological and biomechanical performance. Looking at the available clinical evidence, results were not univocal. PRP administration proved to be a safe procedure and there were some evidences that it could favor the donor site healing in case of ACL reconstruction with patellar tendon graft and positively contribute to graft maturation over time, whereas the majority of the papers did not show beneficial effects in terms of bony tunnels/graft area integration. Furthermore, PRP augmentation did not provide superior functional results at short term evaluation. Luca Andriolo, Berardo Di Matteo, Elizaveta Kon, Giuseppe Filardo, Giulia Venieri, and Maurilio Marcacci Copyright © 2015 Luca Andriolo et al. All rights reserved. PRP and Articular Cartilage: A Clinical Update Tue, 05 May 2015 07:35:00 +0000 The convincing background of the recent studies, investigating the different potentials of platelet-rich plasma, offers the clinician an appealing alternative for the treatment of cartilage lesions and osteoarthritis. Recent evidences in literature have shown that PRP may be helpful both as an adjuvant for surgical treatment of cartilage defects and as a therapeutic tool by intra-articular injection in patients affected by osteoarthritis. In this review, the authors introduce the trophic and anti-inflammatory properties of PRP and the different products of the available platelet concentrates. Then, in a complex scenario made of a great number of clinical variables, they resume the current literature on the PRP applications in cartilage surgery as well as the use of intra-articular PRP injections for the conservative treatment of cartilage degenerative lesions and osteoarthritis in humans, available as both case series and comparative studies. The result of this review confirms the fascinating biological role of PRP, although many aspects yet remain to be clarified and the use of PRP in a clinical setting has to be considered still exploratory. Antonio Marmotti, Roberto Rossi, Filippo Castoldi, Eliana Roveda, Gianni Michielon, and Giuseppe M. Peretti Copyright © 2015 Antonio Marmotti et al. All rights reserved. Improved Monosegment Pedicle Instrumentation for Treatment of Thoracolumbar Incomplete Burst Fractures Mon, 04 May 2015 08:25:22 +0000 Aim. Comparing the clinical results of improved monosegment pedicle instrumentation (iMSPI) and short-segment pedicle instrumentation (SSPI) retrospectively. Method. 63 patients with thoracolumbar incomplete burst fracture were managed with iMSPI or SSPI. 30 patients were managed with iMSPI and fusion. 33 patients were managed with SSPI and fusion. Operative time, blood loss, postoperative drainage, and complications were recorded. Percentage of anterior body height compression (ABHC%) and sagittal index (SI) were obtained preoperatively, one week postoperatively, and at the last followup. Results. The blood loss and postoperative drainage were significantly less in the iMSPI group than in SSPI group . The follow-up duration of the two groups was not significantly different . At 12 months postoperatively posterolateral fusion was obtained satisfactorily. Neither preoperative ABHC% and SI nor postoperative SI were significantly different , but there was a significant difference in postoperative ABHC% . The ABHC% and SI were not significantly different between the two groups at the last followup . There were no fixation failures or other complications. Summary. IMSPI yielded satisfactory results similar to those of SSPI in patients with type A3.1/3.2 thoracolumbar fractures. IMSPI is recommended for minor trauma, reducing one-segment fusion, and maximization of the remaining motor function. Liehua Liu, Yibo Gan, Qiang Zhou, Haoming Wang, Fei Dai, Fei Luo, Tianyong Hou, Chengmin Zhang, Chen Zhao, Jinsong Zhang, Jianzhong Xu, and Yingwen Lü Copyright © 2015 Liehua Liu et al. All rights reserved. Quantification of Osseointegration of Plasma-Polymer Coated Titanium Alloyed Implants by means of Microcomputed Tomography versus Histomorphometry Thu, 30 Apr 2015 17:15:57 +0000 A common method to derive both qualitative and quantitative data to evaluate osseointegration of implants is histomorphometry. The present study describes a new image reconstruction algorithm comparing the results of bone-to-implant contact (BIC) evaluated by means of µCT with histomorphometry data. Custom-made conical titanium alloyed (Ti6Al4V) implants were inserted in the distal tibial bone of female Sprague-Dawley rats. Different surface configurations were examined: Ti6Al4V implants with plasma-polymerized allylamine (PPAAm) coating and plasma-polymerized ethylenediamine (PPEDA) coating as well as implants without surface coating. After six weeks postoperatively, tibiae were explanted and BIC was determined by µCT (3D) and afterwards by histomorphometry (2D). In comparison to uncoated Ti6Al4V implants demonstrating low BIC of 32.4% (histomorphometry) and 51.3% (µCT), PPAAm and PPEDA coated implants showed a nonsignificant increase in BIC (histomorphometry: 45.7% and 53.5% and µCT: 51.8% and 62.0%, resp.). Mean BIC calculated by µCT was higher for all surface configurations compared to BIC detected by histomorphometry. Overall, a high correlation coefficient of 0.70 () was found between 3D and 2D quantification of BIC. The μCT analysis seems to be suitable as a nondestructive and accurate 3D imaging method for the evaluation of the bone-implant interface. Carolin Gabler, Carmen Zietz, Richard Bieck, Rebecca Göhler, Tobias Lindner, Maximilian Haenle, Birgit Finke, Jürgen Meichsner, Holger Testrich, Mathias Nowottnick, Bernhard Frerich, and Rainer Bader Copyright © 2015 Carolin Gabler et al. All rights reserved. Two-Stage Revision Arthroplasty for Periprosthetic Hip Infection: Mean Follow-Up of Ten Years Wed, 29 Apr 2015 12:25:15 +0000 Background. Two-stage revision hip arthroplasty is the gold standard for treatment of patients with chronic periprosthetic joint infection (PJI), but few studies have reported outcomes beyond short-term follow-up. Methods. A total of 155 patients who underwent two-stage revision arthroplasty for chronic PJI in 157 hips were retrospectively enrolled in this study between January 2001 and December 2010. The mean patient age was 57.5 years, the mean prosthetic age was 3.6 years, and the interim interval was 17.8 weeks. These patients were followed up for an average of 9.7 years. Results. At the latest follow-up, 91.7% of the patients were free of infection. The mean Harris hip score improved significantly from 28.3 points before operation to 85.7 points at the latest follow-up. Radiographically, there was aseptic loosening of the stem or acetabular components in 4 patients. In the multivariate survival analysis using a Cox regression model, repeated debridement before final reconstruction, an inadequate interim period, bacteriuria or pyuria, and cirrhosis were found to be the independent risk factors for treatment failure. Conclusion. Our data show that two-stage revision hip arthroplasty provides reliable eradication of infection and durable reconstruction of the joint in patients with PJI caused by a variety of pathogens. Szu-Yuan Chen, Chi-Chien Hu, Chun-Chieh Chen, Yu-Han Chang, and Pang-Hsin Hsieh Copyright © 2015 Szu-Yuan Chen et al. All rights reserved. In Vivo MicroCT Monitoring of Osteomyelitis in a Rat Model Wed, 29 Apr 2015 12:15:44 +0000 Infection associated with orthopedic implants often results in bone loss and requires surgical removal of the implant. The aim of this study was to evaluate morphological changes of bone adjacent to a bacteria-colonized implant, with the aim of identifying temporal patterns that are characteristic of infection. In an in vivo study with rats, bone changes were assessed using in vivo microCT at 7 time points during a one-month postoperative period. The rats received either a sterile or Staphylococcus aureus-colonized polyetheretherketone screw in the tibia. Bone-implant contact, bone fraction, and bone changes (quiescent, resorbed, and new bone) were calculated from consecutive scans and validated against histomorphometry. The screw pullout strength was estimated from FE models and the results were validated against mechanical testing. In the sterile group, bone-implant contact, bone fraction, and mechanical fixation increased steadily until day 14 and then plateaued. In the infected group, they decreased rapidly. Bone formation was reduced while resorption was increased, with maximum effects observed within 6 days. In summary, the model presented is capable of evaluating the patterns of bone changes due to implant-related infections. The combined use of longitudinal in vivo microCT imaging and image-based finite element analysis provides characteristic signs of infection within 6 days. Vincent A. Stadelmann, Inga Potapova, Karin Camenisch, Dirk Nehrbass, R. Geoff Richards, and T. Fintan Moriarty Copyright © 2015 Vincent A. Stadelmann et al. All rights reserved. Seasonal Temperature and Pin Site Care Regimen Affect the Incidence of Pin Site Infection in Pediatric Supracondylar Humeral Fractures Wed, 29 Apr 2015 06:20:16 +0000 Pin site infection is a common complication after fracture fixation and bone lengthening, and daily pin site care is recommended. Weather is a strong environmental factor of infection, but few articles studied the issue of weather and pin site infection. We performed a prospective comparative study of 61 children with supracondylar humeral fractures treated by closed reduction and percutaneous pinning. The patients were divided into high-temperature season or low-temperature season by the months they received surgery. The patients within each season were further allocated to 2 groups by the different postoperative pin site care methods of daily care or noncare. The infection rate per patient was significantly higher in the high-temperature season compared to low-temperature season (45% versus 19%, P = 0.045). In the high-temperature season, the infection rate per patient was significantly higher in the daily care group versus the noncare group (70% versus 20%, P = 0.001). In the low-temperature season, the infection rate per patient was not significantly different in the daily care group versus the noncare group (10% versus 27.3%, P = 0.33). We recommend that careful monitoring of infection signs, rather than pin site cleaning, would be appropriate in the treatment of pediatric supracondylar humeral fractures, especially during the summer months. Hsuan-Kai Kao, Mei-Chuan Chen, Wei-Chun Lee, Wen-E Yang, and Chia-Hsieh Chang Copyright © 2015 Hsuan-Kai Kao et al. All rights reserved. Risk Factors for Delayed Inpatient Functional Recovery after Total Knee Arthroplasty Thu, 16 Apr 2015 12:07:49 +0000 Purpose. To determine the predictive value of surgery-related variables for delayed inpatient functional recovery (i.e., ≥3 days to reach functional independence) after TKA. Method. 193 consecutive people undergoing TKA were included in this prospective cohort study. Inpatient functional recovery was measured daily using the Iowa Level of Assistance scale (ILAS). Two persons reviewed medical records to extract patient characteristics (i.e., age, sex, and BMI) and surgical factors (i.e., blood loss, tourniquet time, postoperative morphine use, and surgical experience). Odds ratios (OR) and area under the curves (AUC) were calculated to determine the predictive value of the putative factors and of the model on delayed functional recovery, respectively. Results. Delayed functional recovery was apparent in 76 (39%) people. Higher age, female sex, and higher BMI were all independent risk factors for delayed functional recovery (AUC (95%-CI); 0.72 (0.65–0.80)), whereas blood loss (OR (95%-CI); 1.00 (0.99–1.01)), tourniquet time (OR = 1.00 (0.98–1.02)), and postoperative morphine use (OR = 0.88 (0.37–2.06)) did not statistically improve the predictive value of the model, while surgical experience did (OR = 0.31 (0.16–0.64); AUC = 0.76 (0.69–83)). Conclusions. Surgery-related factors contribute little to the patient-related characteristics in a predictive model explaining delayed functional recovery after TKA in daily orthopaedic practice. Thomas J. Hoogeboom, Nico L. U. van Meeteren, Kristin Schank, Raymond H. Kim, Todd Miner, and Jennifer E. Stevens-Lapsley Copyright © 2015 Thomas J. Hoogeboom et al. All rights reserved. What Augmented Physical Activity and Empowerment Can Bring to Patients Receiving Total Knee Replacement: Content, Implementation, and Comparative Effectiveness of a New Function-Tailored Care Pathway in a Routine Care Setting Thu, 16 Apr 2015 10:13:06 +0000 Background. In the routine setting of the 20-bed orthopaedic ward of a regional hospital in Netherlands, we developed, implemented, and evaluated a new, function-tailored perioperative care pathway for patients receiving total knee replacement (TKR), aimed at faster functional recovery by reduction of inactivity and stimulation of self-efficacy of the patients. Methods. To assess effectiveness, we compared, using prospectively collected data from medical files, patient groups before and after introduction of the new care pathway with respect to time to recovery of physical functioning during hospitalisation (five milestones), length of hospital stay (LoS), referrals to an inpatient rehabilitation facility, and readmissions. Multivariable regression was used to adjust results for differences between the two groups in preoperatively assessed risk factors for delayed recovery. Results. Comparison of patient groups before and after introduction of the tailored care pathway showed that the tailored rehabilitation pathway decreased the time to recovery of physical functioning (from 4.5 to 4.1 days, ), the mean LoS (from 5.2 days to 4.2 days, ). Conclusion. We demonstrated that the introduction of a function-tailored care pathway shortens the hospital stay and accelerates the recovery of physical functioning. G. van der Sluis, R. A. Goldbohm, R. Bimmel, F. Galindo Garre, J. Elings, T. J. Hoogeboom, and N. L. U. van Meeteren Copyright © 2015 G. van der Sluis et al. All rights reserved. Home-Based versus Hospital-Based Rehabilitation Program after Total Knee Replacement Thu, 16 Apr 2015 09:40:07 +0000 Objectives. To compare home-based rehabilitation with the standard hospital rehabilitation in terms of improving knee joint mobility and recovery of muscle strength and function in patients after a total knee replacement. Materials and Methods. A non-randomised controlled trial was conducted. Seventy-eight patients with a prosthetic knee were included in the study and allocated to either a home-based or hospital-based rehabilitation programme. Treatment included various exercises to restore strength and joint mobility and to improve patients’ functional capacity. The primary outcome of the trial was the treatment effectiveness measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Results. The groups did not significantly differ in the leg side (right/left) or clinical characteristics (). After the intervention, both groups showed significant improvements () from the baseline values in the level of pain (visual analogue scale), the range of flexion-extension motion and muscle strength, disability (Barthel and WOMAC indices), balance, and walking. Conclusions. This study reveals that the rehabilitation treatments offered either at home or in hospital settings are equally effective. Remedios López-Liria, David Padilla-Góngora, Daniel Catalan-Matamoros, Patricia Rocamora-Pérez, Sagrario Pérez-de la Cruz, and Manuel Fernández-Sánchez Copyright © 2015 Remedios López-Liria et al. All rights reserved. Head-Neck Taper Corrosion in Hip Arthroplasty Tue, 14 Apr 2015 14:00:34 +0000 Modularity at the head-neck junction of the femoral component in THA became popular as a design feature with advantages of decreasing implant inventory and allowing adjustment of leg length, offset, and soft tissue balancing through different head options. The introduction of a new modular interface to femoral stems that were previously monoblock, or nonmodular, comes with the potential for corrosion at the taper junction through mechanically assisted crevice corrosion. The incidence of revision hip arthroplasty is on the rise and along with improved wear properties of polyethylene and ceramic, use of larger femoral head sizes is becoming increasingly popular. Taper corrosion appears to be related to all of its geometric parameters, material combinations, and femoral head size. This review article discusses the pathogenesis, risk factors, clinical assessment, and management of taper corrosion at the head-neck junction. S. Hussenbocus, D. Kosuge, L. B. Solomon, D. W. Howie, and R. H. Oskouei Copyright © 2015 S. Hussenbocus et al. All rights reserved. Kinematics of Rotation in Joints of the Lower Limbs and Pelvis during Gait: Early Results—SB ACLR Approach versus DB ACLR Approach Wed, 01 Apr 2015 09:46:04 +0000 It is difficult to find publications comparing rotation kinematics in large joints of the lower limbs and pelvis during gait in patients after single-bundle (SB) reconstruction of the anterior cruciate ligament (ACLR) with double-bundle (DB) ACLR of the knee. The aim of this study was to compare rotation kinematics in ankle, knee, and hip joints and the pelvis during gait in the 14th week after SB and DB ACLR. The subjects were males after SB () and DB () ACLR and a control group (). The values of kinematic parameters were recorded during internal (IR) and external (ER) rotation in the joints during gait using the BTS SMART. The SB ACLR group obtained significantly higher values of ER in the involved knee comparing to DB ACLR and controls and excessive IR in the hip comparing to controls. In the DB ACLR group, excessive ER was noted in the involved leg's foot. Comparing with the DB ACLR and control groups, SB ACLR subjects had more substantial disorders of rotation kinematics in the lower limb joints. However, in both ACLR groups, 14 weeks of postoperative physiotherapy were not enough to fully restore rotation kinematics in joints of the lower limbs during gait. Andrzej Czamara, Iga Markowska, Aleksandra Królikowska, Andrzej Szopa, and Małgorzata Domagalska Szopa Copyright © 2015 Andrzej Czamara et al. All rights reserved. Temporal Changes of Microarchitectural and Mechanical Parameters of Cancellous Bone in the Osteoporotic Rabbit Tue, 31 Mar 2015 11:57:44 +0000 This study was aimed at elucidating the temporal changes of microarchitectural and mechanical parameters of cancellous bone in the osteoporotic rabbit model induced by ovariectomy (OVX) combined with glucocorticoid (GC) administration. Osteoporotic (OP) group received bilateral OVX combined with injections of GC, while sham group only received sham operation. Cancellous bone quality in vertebrae and femoral condyles in each group was assessed by DXA, μCT, nanoindentation, and biomechanical tests at pre-OVX and 4, 6, and 8 weeks after injection. With regard to femoral condyles, nanoindentation test could detect significant decline in tissue modulus and hardness at 4 weeks. However, BMD and microarchitecture of femoral condylar cancellous bone changed significantly at 6 weeks. In vertebrae, BMD, microarchitecture, nanoindentation, and biomechanical tests changed significantly at 4 weeks. Our data demonstrated that temporal changes of microarchitectural and mechanical parameters of cancellous bone in the osteoporotic rabbit were significant. The temporal changes of cancellous bone in different anatomical sites might be different. The nanoindentation method could detect the changes of bone quality at an earlier stage at both femoral condyle and vertebra in the osteoporotic rabbit model than other methods (μCT, BMD). Xin-Xin Wen, Chao Xu, Fa-Qi Wang, Ya-Fei Feng, Xiong Zhao, Ya-Bo Yan, and Wei Lei Copyright © 2015 Xin-Xin Wen et al. All rights reserved. Influence of Simvastatin-Loaded Implants on Osseointegration in an Ovariectomized Animal Model Sun, 29 Mar 2015 11:21:10 +0000 The success of bone implants in the presence of osteoporosis is limited by lack of osseointegration between the implant and the natural bone. This study applied an electrochemical process to deposit simvastatin-nanohydroxyapatite (HA) coatings on porous implant surfaces and investigated the effects of these simvastatin-HA coatings on implant surfaces in an animal model of osteoporosis. In this study, simvastatin-HA coated implants were inserted into the tibia of osteoporotic rats. After 2, 4, and 12 weeks, tissue was retrieved for histomorphometric evaluation. The results indicated that the simvastatin-HA coatings increased bone-implant contact and new bone formation around implant surfaces. In conclusion, implants loaded with simvastatin by an electrochemical process improved implant osseointegration in osteoporotic rats. Furthermore, the increased concentration of simvastatin could affect the osseointegration, but the dose-effects also need further investigation. Wen Fang, Shifang Zhao, Fuming He, Li Liu, and Guoli Yang Copyright © 2015 Wen Fang et al. 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 cm and 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.