BioMed Research International: Orthopedics The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. Histological Identification of Propionibacterium acnes in Nonpyogenic Degenerated Intervertebral Discs Sun, 19 Mar 2017 09:09:22 +0000 Purpose. Low-virulence anaerobic bacteria, especially the Propionibacterium acnes (P. acnes), have been thought to be a new pathogeny for a series of disc diseases. However, until now, there has been no histological evidence to confirm this link. The purpose of this study was to confirm the presence of P. acnes in nonpyogenic intervertebral discs via histological observation. Method. Degenerated intervertebral discs were harvested from 76 patients with low back pain and/or sciatica but without any symptoms of discitis or spondylodiscitis. The samples were cultured under anaerobic conditions and then examined using 16S rDNA PCR to screen for P. acnes. Samples found to be positive for P. acnes were stained with hematoxylin-eosin (HE) and modified Brown-Brenn staining and observed under a microscope. Results. Here, 16 intervertebral discs were found to be positive for P. acnes via 16S rDNA PCR and the prevalence was 21.05% (16/76). Among them, 7 samples had visible microbes stained with HE and modified Brown-Brenn staining. Morphological examination showed the bacteria to be Gram-positive and rod-shaped, so they were considered P. acnes. Conclusion. P. acnes is capable of colonizing some degenerated intervertebral discs without causing discitis, and its presence could be further confirmed by histological evidence. Targeting these bacteria may be a promising therapy method for some disc diseases. Ye Yuan, Zezhu Zhou, Yucheng Jiao, Changwei Li, Yuehuan Zheng, Yazhou Lin, Jiaqi Xiao, Zhe Chen, and Peng Cao Copyright © 2017 Ye Yuan et al. All rights reserved. A 10-Year Follow-Up of Two-Incision and Modified Watson-Jones Total Hip Arthroplasty in Patients with Osteonecrosis of the Femoral Head Sun, 12 Mar 2017 08:55:32 +0000 Long-term data and information indicating whether minimally invasive surgery (MIS) approaches are safe and effective with total hip arthroplasty (THA) are lacking. Between 2004 and 2006, 75 patients with alcohol-related osteonecrosis of the femoral head (ONFH) who underwent 75 THAs with the two-incision approach were studied. The medical records, radiographic parameters, and functional outcomes were collected prospectively. All data were compared with those for matched patients who underwent a modified Watson-Jones (WJ) approach. THA using the two-incision approach was associated with longer operation time, more blood loss, more lateral femoral cutaneous nerve injury, and more periprosthetic femoral fractures ( for all four) than the modified WJ approach. The Harris Hip Score (HHS) and Western Ontario and McMaster University Osteoarthritis Index (WOMAC) increased significantly from the period preoperatively to 6 weeks postoperatively and thereafter up to the last follow-up in both groups. However, there were no significant differences in terms of radiographic parameters and functional outcomes between the two groups throughout the study period. Both the two-incision and the modified WJ approach provided satisfactory results and survival rates at a mean follow-up of 10.8 years. A prospective, randomized, large-scale cohort study is still warranted for evidence-based recommendations. Shih-Jie Lin, Tsan-Wen Huang, Po-Chun Lin, Feng-Chih Kuo, Kuo-Ti Peng, Kuo-Chin Huang, and Mel S. Lee Copyright © 2017 Shih-Jie Lin et al. All rights reserved. SOCS1 Regulates Apoptosis and Inflammation by Inhibiting IL-4 Signaling in IL-1β-Stimulated Human Osteoarthritic Chondrocytes Wed, 08 Mar 2017 08:11:38 +0000 Recently, Suppressor of Cytokine Signaling 1 (SOCS1) was identified as a potential therapeutic target for osteoarthritis (OA) treatment. However, the mechanisms and signaling pathways of SOCS1 in the regulation of OA development are unclear. The purpose of the current study was to investigate whether interleukin- (IL-) 4 was involved in regulatory mechanism of SOCS1 in human osteoarthritic chondrocytes. First, IL-1β was used to stimulate human osteoarthritic chondrocytes isolated from the articular cartilage of OA patients undergoing total knee replacement. The protein and mRNA expression levels of SOCS1 were upregulated in IL-1β-stimulated human osteoarthritic chondrocytes compared with control cells. The knockdown of SOCS1 increased cell viability and inhibited cell apoptosis. It was also found that IL-4 expression was increased by SOCS1 silencing. Additionally, knockdown of IL-4 reduced cell viability and increased cell apoptosis of osteoarthritic chondrocytes transfected with SOCS1 siRNA. Moreover, the decreased expression of inflammatory factors induced by SOCS1 was enhanced by IL-4 knockdown. In conclusion, IL-4 signaling plays a crucial role in the regulatory functions of SOCS1 in apoptosis and inflammation in human osteoarthritic chondrocytes. These findings provide a potential therapeutic target for the clinical treatment of OA. Qiang He, Caihong Sun, Wei Lei, and Jianbing Ma Copyright © 2017 Qiang He et al. All rights reserved. Clinical Results and Serum Metal Ion Concentrations following Ceramic-on-Metal Total Hip Arthroplasty at a Mean Follow-Up of 60 Months Wed, 08 Mar 2017 00:00:00 +0000 Background. Increased metal ion levels following total hip arthroplasty (THA) with metal-on-metal bearings are a highly debated topic. Local soft tissue reactions with chronic pain and systemic side effects such as neuropathy are described. The aim of the current study was to determine the serum metal ion concentrations of Cobalt (Co) and Chrome (Cr) after THA with a ceramic-on-metal (CoM) bearing. Patients and Methods. Between 2008 and 2010, 20 patients underwent THA using a CoM bearing. Clinical function was evaluated by standardized scores systems (Harris Hip Score and WOMAC Score) and radiological examination included X-rays. Patient’s blood samples were obtained for metal ion analysis and correlation analysis was done between these results and implant position. Results. Overall, 13 patients with 14 CoM devices were available for the current series. The mean age at time of surgery was 61 years (range, 41 to 85). The postoperative follow-up ranged from 49 to 68 months (mean, 58). Metal ion determination showed mean concentrations of 3,1 µg/L (range, 0,3–15,2 µg/L) for Co and 1,6 µg/L (range, 0,1–5,5 µg/L) for Cr, respectively. A correlation between cup anteversion and Co and Cr concentrations was shown. Conclusion. The current series showed increments for Co and Cr following CoM THA. However, these levels are lower compared to metal ion concentrations in patients with metal-on-metal bearings and the international accepted threshold for revision of MoM devices. We recommend routine follow-up including at least one obligatory evaluation of serum metal ion concentrations and an MRI once to exclude local soft tissue reactions. W. Maurer-Ertl, D. Pranckh-Matzke, J. Friesenbichler, G. Bratschitsch, L. A. Holzer, M. Maier, and A. Leithner Copyright © 2017 W. Maurer-Ertl et al. All rights reserved. Analysis of Early Neurovascular Complications of Pediatric Supracondylar Humerus Fractures: A Long-Term Observation Tue, 07 Mar 2017 00:00:00 +0000 Purpose. Analysis of early vascular and nerve complications of supracondylar humerus fractures in children. Material and Methods. 220 children hospitalized in the Pediatric Trauma-Orthopedic Department in the years 2004–2014. The group consisted of 143 males and 77 females. Results. Acute neurovascular complications occurred in 16.81% of patients with displaced supracondylar fracture (37 children). Nerve damage was found in 10% of patients with displaced fracture (22 children). The most injured nerve was median nerve; this complication occurred in 15 patients (68.18%). The total nerve function returned after average of 122 days (0–220 days after surgery). Symptoms of vascular injury occurred in 7.7% children with displaced fracture (17 children). Conclusions. In children with supracondylar fracture the most often injured nerve is median nerve. The incidence of vascular and nerve complications positively correlates with the progression of fracture according to Gartland classification. Ryszard Tomaszewski, Artur Wozowicz, and Paulina Wysocka-Wojakiewicz Copyright © 2017 Ryszard Tomaszewski et al. All rights reserved. Recombinant Human Bone Morphogenetic Protein-2 (rhBMP-2) for the Treatment of Nonunion of the Femur in Children and Adolescents: A Retrospective Analysis Thu, 02 Mar 2017 00:00:00 +0000 Background. The aim of this study was to examine clinical and radiographic healing after rhBMP-2 application in children and adolescents presenting with nonunion of the femur and to investigate the safety of rhBMP-2 use in these cases. Materials and Methods. We reviewed the medical records of five patients with a mean age of 11 years (5.4 to 16.2) with nonunion of the femur who were treated with rhBMP-2 and internal fixation using a locking plate at a single institution. Particular attention was paid to identify all adverse events that may be due to rhBMP-2 use. Results. Union occurred in four of five patients at a mean of 12.1 months (7.9 to 18.9). The locking plates were removed after a mean of 16 months (11 to 23). One patient had nonunion due to deep infection. After a mean follow-up of 62.5 months (17 to 100), union was still evident in all four patients and they were fully weight-bearing without pain. Discussion. In this retrospective study, rhBMP-2 combined with a locking plate has been used successfully to treat children and adolescents with nonunion of the femur in four of five cases. One major complication was thought to be possibly related to its use. Tim N. Hissnauer, Norbert Stiel, Kornelia Babin, Martin Rupprecht, Karsten Ridderbusch, Johannes M. Rueger, Ralf Stuecker, and Alexander S. Spiro Copyright © 2017 Tim N. Hissnauer et al. All rights reserved. Reliability of Baropodometry on the Evaluation of Plantar Load Distribution: A Transversal Study Thu, 02 Mar 2017 00:00:00 +0000 Introduction. Baropodometry is used to measure the load distribution on feet during rest and walking. The aim of this study was to evaluate changes in plantar foot pressures distribution due to period of working and due to stretching exercises of the posterior muscular chain. Methods. In this transversal study, all participants were submitted to baropodometric evaluation at two different times: before and after the working period and before and after stretching the muscles of the posterior chain. Results. We analyzed a total of 54 feet of 27 participants. After the working period, there was an average increase in the forefoot pressure of 0.16 Kgf/cm2 and an average decrease in the hindfoot pressure of 0.17 Kgf/cm2. After stretching the posterior muscular chain, the average increase in the forefoot pressure was 0.56 Kgf/cm2 and the hindfoot average pressure decrease was 0.56 Kgf/cm2. These changes were not statistically significant. Discussion. It was reported that the strength of the Achilles tendon generates greater forefoot load transferred from the hindfoot. In our study, no significant variation in the distribution of plantar pressure was observed. It can be inferred that baropodometry was a reliable instrument to determine the plantar pressure, regardless of the tension of the posterior chain muscles. Daniel Baumfeld, Tiago Baumfeld, Romário Lopes da Rocha, Benjamim Macedo, Fernando Raduan, Roberto Zambelli, Thiago Alexandre Alves Silva, and Caio Nery Copyright © 2017 Daniel Baumfeld et al. All rights reserved. The State of the Art in Minimally Invasive Spine Surgery Tue, 28 Feb 2017 09:16:10 +0000 Tsung-Jen Huang, Ki-Tack Kim, Hiroaki Nakamura, Anthony T. Yeung, and Jiancheng Zeng Copyright © 2017 Tsung-Jen Huang et al. All rights reserved. Percutaneous Transforaminal Endoscopic Lumbar Interbody Fusion: Clinical and Radiological Results of Mean 46-Month Follow-Up Mon, 27 Feb 2017 09:08:31 +0000 Background. Spinal fusion has been shown to be the preferred surgical option to reduce pain, recover function, and increase quality of life in the treatment of a variety of lumbar spinal disorders. The main goal of the present study is to report our clinical experience and results of percutaneous transforaminal endoscopic lumbar interbody fusion (PELIF) applications using the expandable spacer in a single institution. Methods. We performed a retrospective review of 18 patients with >12-month follow-up who had been operated on PELIF using expandable spacer from 2001 to 2007. Their clinical and radiological data were collected and analyzed. Results. The mean follow-up period was 46 months. The mean DH before the surgery was 8.3 mm which improved to 11.4 mm at the early postoperative period and regressed to 9.3 mm at the last follow-up visit. The VAS-B, VAS-L, and ODI scores at the last follow-up showed a 54%, 72%, and 69% improvement from the preoperative period, respectively. Conclusions. The presented PELIF technique with the expandable spacer seems to be a promising surgical technique for the treatment of a variety of lumbar spinal disorders. Conversely, radiological results including disc space subsidence make the stand-alone application of the expandable spacer debatable. Sang-Ho Lee, H. Yener Erken, and Junseok Bae Copyright © 2017 Sang-Ho Lee et al. All rights reserved. Predicting Factors for Allogeneic Blood Transfusion and Excessive Postoperative Blood Loss after Single Low-Dosage Intra-Articular Tranexamic Acid Application in Total Knee Replacement Sun, 26 Feb 2017 07:10:52 +0000 Background. Recently, intra-articular tranexamic acid (IA-TXA) application has become a popular method for perioperative blood loss (PBL) reduction in total knee replacement (TKR). Nevertheless, through our knowledge, no previous studies had shown the correlation perioperative factors and the risk of excessive PBL or need of blood transfusion (BT) after IA-TXA. Materials and Methods. A retrospective study was conducted in patients underwent 299 primary TKRs, using IA-TXA, during 2-year period (2013-2014). Patient’s characteristic and perioperative data were reviewed and collected. PBL was measured as total hemoglobin loss (THL), estimated total blood loss (ETBL), and drainage volume per kg (DV/kg). Excessive PBL was defined as PBL that exceeded 90th percentile. Results. From multivariate analysis, low preoperative hemoglobin (Hb) level and body mass index (BMI) were the significant predictors of postoperative BT ( and 0.003, resp.). Excessive THL significant associated with preoperative Hb (). Excessive ETBL significantly associated with preoperative Hb, height, preoperative range-of-motion, and creatinine clearance ( all). Low BMI and large prosthesis size were the significant predictors of excessive DV/kg ( and 0.002, resp.). Conclusions. Low preoperative Hb and BMI were the significant risks of postoperative transfusion after TKR with IA-TXA. Moreover, multiple perioperative factors could result in higher PBL. Paphon Sa-ngasoongsong, Siwadol Wongsak, Noratep Kulachote, Pongsthorn Chanplakorn, Patarawan Woratanarat, and Viroj Kawinwonggowit Copyright © 2017 Paphon Sa-ngasoongsong et al. All rights reserved. Could the Topping-Off Technique Be the Preventive Strategy against Adjacent Segment Disease after Pedicle Screw-Based Fusion in Lumbar Degenerative Diseases? A Systematic Review Wed, 22 Feb 2017 00:00:00 +0000 The “topping-off” technique is a new concept applying dynamic or less rigid fixation such as hybrid stabilization device (HSD) or interspinous process device (IPD) for the purpose of avoiding adjacent segment disease (ASD) proximal to the fusion construct. A systematic review of the literature was performed on the effect of topping-off techniques to prevent or decrease the occurrence of ASD after lumbar fusion surgery. We searched through major online databases, PubMed and MEDLINE, using key words related to “topping-off” technique. We reviewed the surgical results of “topping-off” techniques with either HSD or IPD, including the incidence of ASD at two proximal adjacent levels (index and supra-adjacent level) as compared to the fusion alone group. The results showed that the fusion alone group had statistically higher incidence of radiographic (52.6%) and symptomatic (11.6%) ASD at the index level as well as higher incidence (8.1%) of revision surgery. Besides, the HSD (10.5%) and fusion groups (24.7%) had statistically higher incidences of radiographic ASD at supra-adjacent level than the IPD (1%). The findings suggest that the “topping-off” technique may potentially decrease the occurrence of ASD at the proximal motion segments. However, higher quality prospective randomized trials are required prior to wide clinical application. Po-Hsin Chou, Hsi-Hsien Lin, Howard S. An, Kang-Ying Liu, Wei-Ren Su, and Cheng-Li Lin Copyright © 2017 Po-Hsin Chou et al. All rights reserved. Quality of Spine Surgery Research from the Arab Countries: A Systematic Review and Bibliometric Analysis Tue, 21 Feb 2017 00:00:00 +0000 Purpose. The purpose of our study is to evaluate the level of evidence (LOE) of spine surgery publications in the Arab countries and compare it with standard international literature in spine surgery and to determine the stand of the Arab nations academic production with that of the global one. Methods. An online search using “PubMed” and “Google Scholar” was carried out, using search terms related to spine surgery such as “Spine surgery,” “Scoliosis,” “Herniated disc.” Each article was reviewed and graded by two reviewers using Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence scale. Results. We have identified 434 articles that met the inclusion criteria; 56% were level IV studies. The most common study design was case reports (42%). The number of Arab countries with publications in spine surgery was 18 countries. The country with the highest rate of publications was Egypt (26%). The quantity of the published studies increased from 151 in (2000–2008) to 283 in (2009–2015). There is statistical significance between high and low LOE articles (). Conclusion. We have observed that LOE has not changed significantly over the period of 15 years and that much of the publications are of a low LOE (levels III and IV). We, herein, emphasize the need for spine surgeons in the Arab countries to conduct studies of higher LOE. Saleh S. Baeesa, Yazid Maghrabi, Abdul Karim Msaddi, and Richard Assaker Copyright © 2017 Saleh S. Baeesa et al. All rights reserved. A Descriptive Study of Open Fractures Contaminated by Seawater: Infection, Pathogens, and Antibiotic Resistance Mon, 20 Feb 2017 08:33:21 +0000 Aims. In this work, the main objectives were to investigate the clinical characteristics and bacterial spectrum present in open fractures contaminated by seawater. Methods. We conducted a retrospective cohort study and included all patients with open fractures from 1st January, 2012, to 31st December, 2015, in our hospital. Patients were grouped based on the presence of seawater contamination in wounds. We compared the infection rate, bacterial spectrum, and antibiotic resistance between the two groups. Results. We totally included 1337 cases of open fracture. Wounds from 107 cases (8.0%) were contaminated by seawater. The wound infection rate of seawater-contaminated group was significantly higher in patients with Gustilo-Anderson Type II and Type III open fractures. The bacterial spectrum from seawater-contaminated wounds was remarkably different from that of the remaining. Antibiotic sensitivity tests revealed that more than 90% of infecting pathogens in seawater-contaminated wounds were sensitive to levofloxacin and ciprofloxacin. Conclusion. Cephalosporin in combination with quinolone was recommended in the early-stage management of open fractures contaminated by seawater. Hongyi Zhu, Xingwei Li, and Xianyou Zheng Copyright © 2017 Hongyi Zhu et al. All rights reserved. Minimum Lateral Bone Coverage Required for Securing Fixation of Cementless Acetabular Components in Hip Dysplasia Sun, 19 Feb 2017 00:00:00 +0000 Objectives. To determine the minimum lateral bone coverage required for securing stable fixation of the porous-coated acetabular components (cups) in hip dysplasia. Methods. In total, 215 primary total hip arthroplasties in 199 patients were reviewed. The average follow-up period was 49 months (range: 24–77 months). The lateral bone coverage of the cups was assessed by determining the cup center-edge (cup-CE) angle and the bone coverage index (BCI) from anteroposterior pelvic radiographs. Further, cup fixation was determined using the modified DeLee and Charnley classification system. Results. All cups were judged to show stable fixation by bone ingrowth. The cup-CE angle was less than 0° in 7 hips (3.3%) and the minimum cup-CE angle was −9.2° (BCI: 48.8%). Thin radiolucent lines were observed in 5 hips (2.3%), which were not associated with decreased lateral bone coverage. Loosening, osteolysis, dislocation, or revision was not observed in any of the cases during the follow-up period. Conclusion. A cup-CE angle greater than −10° (BCI > 50%) was acceptable for stable bony fixation of the cup. Considering possible errors in manual implantation, we recommend that the cup position be planned such that the cup-CE angle is greater than 0° (BCI > 60%). Masanori Fujii, Yasuharu Nakashima, Tetsuro Nakamura, Yoshihiro Ito, and Toshihiko Hara Copyright © 2017 Masanori Fujii et al. All rights reserved. Application of Intraoperative CT-Guided Navigation in Simultaneous Minimally Invasive Anterior and Posterior Surgery for Infectious Spondylitis Thu, 16 Feb 2017 00:00:00 +0000 This study was aimed at evaluating the safety and efficacy of using intraoperative computed tomography- (iCT-) guided navigation in simultaneous minimally invasive anterior and posterior surgery for infectious spondylitis. Nine patients with infectious spondylitis were enrolled in this study. The average operative time was 327.6 min (range, 210–490) and intraoperative blood loss was 407 cc (range, 50–1,200). The average duration of hospital stay was 48.9 days (range, 11–76). Out of a total of 54 pedicle screws employed, 53 screws (98.1%) were placed accurately. A reduced visual analog scale on back pain (from 8.2 to 2.2) and Oswestry disability index (from 67.1% to 25.6%) were found at the 2-year follow-up. All patients had achieved resolution of spinal infection with reduced average erythrocyte sedimentation rate (from 83.9 to 14.1 mm/hr) and average C-reactive protein (from 54.4 to 4.8 mg/dL). Average kyphotic angle correction was 10.5° (range, 8.4°–12.6°) postoperatively and 8.5° (range, 6.9°–10.1°) after 2 years. In conclusion, the current iCT-guided navigation approach has been demonstrated to be an alternative method during simultaneous minimally invasive anterior and posterior surgery for infectious spondylitis. It can provide a good intraoperative orientation and visualization of anatomic structures and also a high pedicle screw placement accuracy in patient’s lateral decubitus position. Meng-Huang Wu, Navneet Kumar Dubey, Ching-Yu Lee, Yen-Yao Li, Chin-Chang Cheng, Chung-Sheng Shi, and Tsung-Jen Huang Copyright © 2017 Meng-Huang Wu et al. All rights reserved. Digital Lengthening to Treat Finger Deficiency: An Experience of 201 Digits in 104 Patients Sun, 12 Feb 2017 00:00:00 +0000 Objectives. We evaluated the results of digital lengthening by distraction and second-stage bone graft. Methods. We treated finger deficiency of 201 digits in 104 patients (68 males, 36 females) by digital distraction and second-stage bone graft. The distraction was performed with a rate of 1 mm/day (for the first ten days) and 0.5 mm/day followed by using a self-designed bilateral tubal-helical external fixator. The mean follow-up period was 42 months (range 6 to 60 months). Results. The mean lengthening was 29.2 mm (range 25 to 40 mm) and 18.7 mm (range 12 to 32 mm) for metacarpal bones and phalanges, respectively. The mean elongation rate was 174.4% (range 145% to 202%) and 184.8% (range 115% to 283%) for metacarpal bones and phalanges, respectively. The static two-point discriminations and SpO2 showed no significant differences before and after distraction. Four complications were observed (two skin ruptures and two phalangeal splitting). No pin tract infection or tendon rupture showed. Digital lengthening improved functions of the hand. Conclusion. Digital distraction and second-stage bone graft is an effective method to compensate disabilities caused by lack of finger length. It could be an alternative plan for patients with thumb deficiency instead of toe-to-thumb transplant and patients with finger deficiency instead of ray resection. Zhenyu Ding, Xiaozhong Zhu, Kai Fu, and Xianyou Zheng Copyright © 2017 Zhenyu Ding et al. All rights reserved. Autophagy Protects Advanced Glycation End Product-Induced Apoptosis and Expression of MMP-3 and MMP-13 in Rat Chondrocytes Tue, 07 Feb 2017 13:08:37 +0000 Aging is one of the most prominent risk factors for the pathological progression of osteoarthritis (OA). One feature of age-related changes in OA is advanced glycation end products (AGEs) accumulation in articular cartilage. Autophagy plays a cellular housekeeping role by removing dysfunctional cellular organelles and proteins. However, the relationship between autophagy and AGE-associated OA is unknown. The aim of this study is to determine whether autophagy participates in the pathology of AGE-treated chondrocytes and to investigate the exact role of autophagy in AGE-induced cell apoptosis and expression of matrix metalloproteinase- (MMP-) 3 and MMP-13. AGEs induced notable apoptosis that was detected by Annexin V/PI double-staining, and the upregulation of MMP-3 and MMP-13 was confirmed by Western blotting. Autophagy-related proteins were also determined by Western blotting, and chondrocytes were transfected with mCherry-GFP-LC3B-adenovirus to monitor autophagic flux. As a result, autophagy significantly increased in chondrocytes and peaked at 6 h. Furthermore, rapamycin (RA) attenuated AGE-induced apoptosis and expression of MMP-3 and MMP-13 by autophagy activation. In contrast, pretreatment with autophagy inhibitor 3-methyladenine (3-MA) enhanced the abovementioned effects of AGEs. We therefore demonstrated that autophagy is linked with AGE-related pathology in rat chondrocytes and plays a protective role in AGE-induced apoptosis and expression of MMP-3 and MMP-13. Wenzhou Huang, Peng Ao, Jian Li, Tianlong Wu, Libiao Xu, Zhongbo Deng, Wenjie Chen, Changchang Yin, and Xigao Cheng Copyright © 2017 Wenzhou Huang et al. All rights reserved. Enhancement of Bone-Marrow-Derived Mesenchymal Stem Cell Angiogenic Capacity by NPWT for a Combinatorial Therapy to Promote Wound Healing with Large Defect Tue, 24 Jan 2017 00:00:00 +0000 Poor viability of engrafted bone marrow mesenchymal stem cells (BMSCs) often hinders their application for wound healing, and the strategy of how to take full advantage of their angiogenic capacity within wounds still remains unclear. Negative pressure wound therapy (NPWT) has been demonstrated to be effective for enhancing wound healing, especially for the promotion of angiogenesis within wounds. Here we utilized combinatory strategy using the transplantation of BMSCs and NPWT to investigate whether this combinatory therapy could accelerate angiogenesis in wounds. In vitro, after 9-day culture, BMSCs proliferation significantly increased in NPWT group. Furthermore, NPWT induced their differentiation into the angiogenic related cells, which are indispensable for wound angiogenesis. In vivo, rat full-thickness cutaneous wounds treated with BMSCs combined with NPWT exhibited better viability of the cells and enhanced angiogenesis and maturation of functional blood vessels than did local BMSC injection or NPWT alone. Expression of angiogenesis markers (NG2, VEGF, CD31, and α-SMA) was upregulated in wounds treated with combined BMSCs with NPWT. Our data suggest that NPWT may act as an inductive role to enhance BMSCs angiogenic capacity and this combinatorial therapy may serve as a simple but efficient clinical solution for complex wounds with large defects. Kangquan Shou, Yahui Niu, Xun Zheng, Zhanjun Ma, Chao Jian, Baiwen Qi, Xiang Hu, and Aixi Yu Copyright © 2017 Kangquan Shou et al. All rights reserved. Are CT Scans a Satisfactory Substitute for the Follow-Up of RSA Migration Studies of Uncemented Cups? A Comparison of RSA Double Examinations and CT Datasets of 46 Total Hip Arthroplasties Tue, 24 Jan 2017 00:00:00 +0000 As part of the 14-year follow-up of a prospectively randomized radiostereometry (RSA) study on uncemented cup fixation, two pairs of stereo radiographs and a CT scan of 46 hips were compared. Tantalum beads, inserted during the primary operation, were detected in the CT volume and the stereo radiographs and used to produce datasets of 3D coordinates. The limit of agreement between the combined CT and RSA datasets was calculated in the same way as the precision of the double RSA examination. The precision of RSA corresponding to the 99% confidence interval was 1.36°, 1.36°, and 0.60° for -, -, and -rotation and 0.40, 0.17, and 0.37 mm for -, -, and -translation. The limit of agreement between CT and RSA was 1.51°, 2.17°, and 1.05° for rotation and 0.59, 0.56, and 0.74 mm for translation. The differences between CT and RSA are close to the described normal 99% confidence interval for precision in RSA: 0.3° to 2° for rotation and 0.15 to 0.6 mm for translation. We conclude that measurements using CT and RSA are comparable and that CT can be used for migration studies for longitudinal evaluations of patients with RSA markers. Volker Otten, Gerald Q. Maguire Jr., Marilyn E. Noz, Michael P. Zeleznik, Kjell G. Nilsson, and Henrik Olivecrona Copyright © 2017 Volker Otten et al. All rights reserved. A Special Golden Curve in Human Upper Limbs’ Length Proportion: A Functional Partition Which Is Different from Anatomy Mon, 23 Jan 2017 12:07:10 +0000 Aim. The purpose of this study was to investigate the relationship between upper limbs’ three functional partitions and the golden curve. Materials and Methods. We measured 30 subjects’ right or left upper limb data and investigate the relationship between them and the golden curve by use of SPSS version 20.0 statistical software (SPSS, Inc., Chicago, Illinois), one-sample -test. Results. There are four points on human’s upper limbs which have no difference with the four points on the golden curve. And there is one point of which the difference is obvious. But we still could draw the conclusion that human upper limbs are accordant with the golden curve. Conclusion. Human upper limbs are accordant with the golden curve. Nan Wang, Jie Ma, Dan Jin, and Bin Yu Copyright © 2017 Nan Wang et al. All rights reserved. Fragility Fractures in Orthopaedics: An Update Thu, 19 Jan 2017 08:50:15 +0000 Zhiyong Hou, Cyril Mauffrey, Wade R. Smith, and Marius M. Scarlat Copyright © 2017 Zhiyong Hou et al. All rights reserved. Acetabular Fractures in the Elderly: Midterm Outcomes of Column Stabilisation and Primary Arthroplasty Tue, 17 Jan 2017 00:00:00 +0000 Background. Interest in arthroplasty techniques for periarticular or intra-articular fractures in the elderly/osteoporotic patient continues to rise, including for geriatric acetabular fractures. In line with this, many acetabular fracture surgeons are now undertaking acute total hip arthroplasty in elderly/osteoporotic patients. Little is known however of the outcomes of this procedure, beyond the first year after surgery. Questions/Purposes. We determined the clinical outcomes of a series of elderly osteoporotic patients (mean age at surgery 77.4 years) treated for acetabular fractures with column fixation and simultaneous total hip arthroplasty, at a mean of 49 months after surgery. Methods. 24 patients (25 hips) were reviewed at a mean of 49 months after surgery. The surgical technique employed has previously been described. Radiographs were obtained, and clinical outcomes were assessed using Harris Hip Scores and the Merle d’Aubigné score. Results. 14 hips were available for assessment (9 deceased, 2 lost to follow-up). No patient suffered any complications beyond the perioperative period, no acetabular components were loose clinically or on latest radiographs, and the mean Harris Hip Score was 92. All but one patient scored good or excellent on the Merle d’Aubigné score. Conclusions. Column fixation and simultaneous total hip arthroplasty are a viable option for complex geriatric acetabular fractures, with encouraging midterm results. We conclude that THR is a viable long-term solution in this situation provided that the acetabular columns are stabilised prior to implantation, but more research is needed to aid in overall management decision making. A. Ortega-Briones, S. Smith, and M. Rickman Copyright © 2017 A. Ortega-Briones et al. All rights reserved. C2 Fracture Subtypes, Incidence, and Treatment Allocation Change with Age: A Retrospective Cohort Study of 233 Consecutive Cases Sun, 15 Jan 2017 00:00:00 +0000 The currently available data on the distribution of C2 fracture subtypes is sparse. This study was designed to identify the proportions of the second cervical vertebra (C2) fracture subtypes and to present age and gender specific incidences of subgroups. A dataset of all patients treated between 2002 and 2014 for C2 fractures was extracted from the regional hospital information system. C2 fractures were classified into odontoid fractures types 1, 2, and 3, Hangman’s fractures types 1, 2, and 3, and atypical C2 fractures. 233 patients (female 51%, age years) were treated for a C2 fracture. Odontoid fractures were found in 183 patients, of which 2 were type 1, 127 type 2, and 54 type 3, while 26 of C2 fractures were Hangman’s fractures and 24 were atypical C2 fractures. In the geriatric subgroup 89% of all C2 fractures were odontoid, of which 71% were type 2 and 29% type 3. There was an increasing incidence of odontoid fractures types 2 and 3 from 2002 to 2014. 40% of C2 fractures were treated surgically. This study presents reliable subset proportions of C2 fractures in a prospectively collected regional cohort. Knowledge of these proportions facilitates future epidemiological studies of C2 fractures. Anna-Lena Robinson, Anders Möller, Yohan Robinson, and Claes Olerud Copyright © 2017 Anna-Lena Robinson et al. All rights reserved. A Novel Nonpedicular Screw-Based Fixation in Lumbar Spondylolisthesis Tue, 10 Jan 2017 12:47:28 +0000 Objective. The authors present the clinical results obtained in patients who underwent interspinous fusion device (IFD) implantation following posterior lumbar interbody fusion (PLIF). The purpose of this study is investigating the feasibility of IFD with PLIF in the treatment of lumbar spondylolisthesis. Methods. Between September 2013 and November 2014, 39 patients underwent PLIF and subsequent IFD (Romeo®2 PAD, Spineart, Geneva, Switzerland) implantation. Medical records of these patients were retrospectively reviewed to collect relevant data such as blood loss, operative time, and length of hospital stay. Radiographs and clinical outcome were evaluated 6 weeks and 12 months after surgery. Results. All 39 patients were followed up for more than one year. There were no major complications such as dura tear, nerve injuries, cerebrospinal fluid leakage, or deep infection. Both interbody and interspinous fusion could be observed on radiographs one year after surgery. However, there were 5 patients having early retropulsion of interbody fusion devices. Conclusion. The interspinous fusion device appears to achieve posterior fixation and facilitate lumbar fusion in selected patients. However, further study is mandatory for proposing a novel anatomic and radiological scoring system to identify patients suitable for this treatment modality and prevent postoperative complications. Ming-Hong Chen and Jen-Yuh Chen Copyright © 2017 Ming-Hong Chen and Jen-Yuh Chen. All rights reserved. Impact of Sagittal Balance on Clinical Outcomes in Surgically Treated T12 and L1 Burst Fractures: Analysis of Long-Term Outcomes after Posterior-Only and Combined Posteroanterior Treatment Tue, 10 Jan 2017 00:00:00 +0000 Objective. Long-term radiological and clinical outcome retrospective study of surgical treatment for T12 and L1 burst fractures in perspective of sagittal balance measures. Methods. Patients with age of 16–60 years, complete radiographs, early surgical treatment surgery, and follow-up (F/U) > 18 months were included and strict exclusion criteria applied. Regional and thoracolumbar kyphosis angles (RKA and TLA) were measured preoperatively and at final F/U, as were parameters of the spinopelvic sagittal alignment. Clinical outcomes were assessed using validated measures. Results. 36 patients with age mean age of 39 years and F/U of 69 months were included. 61% of patients were treated with bisegmental posterior instrumentation (POST-I) and 39% with combined posteroanterior instrumented fusion (PA-F). At F/U, several indicators for clinical outcomes showed a significant correlation with radiographic measures in the overall cohort with inferior clinical outcomes corresponding with increasing residual deformity and sagittal malalignment. Statistical analysis failed to reach level of significance for the differences between POST-I and PA-F group at final F/U. Only a strong trend towards better restoration of the thoracolumbar alignment was observed for the PA-F group in terms of the RKA and TLA. Conclusions. Results in a surgically treated cohort of T12 and L1 burst fracture patients indicate that superior clinical outcomes depend on restoration of sagittal alignment. M. Mayer, R. Ortmaier, H. Koller, J. Koller, W. Hitzl, A. Auffarth, H. Resch, and A. von Keudell Copyright © 2017 M. Mayer et al. All rights reserved. UTE- Analysis of Diseased and Healthy Achilles Tendons and Correlation with Clinical Score: An In Vivo Preliminary Study Thu, 05 Jan 2017 07:54:12 +0000 Objective. To compare value of healthy and diseased Achilles tendons (AT) with a recently introduced three-dimensional ultrashort echo time (3D-UTE) sequence and analyze the correlation between value and clinical scores. Methods. Ten patients with symptomatic Achilles tendon and ten healthy volunteers were investigated with 3D-UTE sequence on a 3T magnetic resonance (MR) scanner. values of four regions in Achilles tendons were calculated. The clinical outcomes of patients were evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) score and Achilles Tendon Rupture Score (ATRS). An independent sample -test was used to compare the differences of value and clinical scores between two groups. The Pearson correlation coefficient between clinical scores and values was assessed. Results. The values of Achilles tendon were statistically significantly different between patients and volunteers. The Pearson correlation coefficients between and AOFAS or ATRS scores of patients were and , respectively. Conclusion. The variability of in healthy and pathologic AT can be quantified by UTE-. may be a promising marker to detect and diagnose AT tendinopathy. UTE- could give a precise guidance to clinical outcome. Yang Qiao, Hong-Yue Tao, Kui Ma, Zi-Ying Wu, Jian-Xun Qu, and Shuang Chen Copyright © 2017 Yang Qiao et al. All rights reserved. The Outcomes of Minimally Invasive versus Open Posterior Approach Spinal Fusion in Treatment of Lumbar Spondylolisthesis: The Current Evidence from Prospective Comparative Studies Thu, 05 Jan 2017 00:00:00 +0000 Purpose. To investigate the evidence of minimally invasive (MI) versus open (OP) posterior lumbar fusion in treatment of lumbar spondylolisthesis from current prospective literatures. Methods. The electronic literature database of Pubmed, Embase, and Cochrane library was searched at April 2016. The data of operative time, estimated blood loss and length of hospital stay, visual analog scale (VAS) of both lower back pain and leg pain, Oswestry disability index (ODI), SF-36 PCS (physical component scores) and SF-36 MCS (mental component scores), complications, fusion rate, and secondary surgery were extracted and analyzed by STATA 12.0 software. Results. Five nonrandom prospective comparative studies were included in this meta-analysis. The meta-analysis showed that the MI group had a significantly longer operative time than OP group, less blood loss, and shorter hospital stay. No significant difference was found in back pain, leg pain, ODI, SF-36 PCS, SF-36 MCS, complications, fusion rate, and secondary surgery between MI and OP groups. Conclusion. The prospective evidence suggested that MI posterior fusion for spondylolisthesis had less EBL and hospital stay than OP fusion; however it took more operative time. Both MI and OP fusion had similar results in pain and functional outcomes, complication, fusion rate, and secondary surgery. Ai-Min Wu, Chun-Hui Chen, Zhi-Hao Shen, Zhen-Hua Feng, Wan-Qing Weng, Shu-Min Li, Yong-Long Chi, Li-Hui Yin, and Wen-Fei Ni Copyright © 2017 Ai-Min Wu et al. All rights reserved. Single-Session Combined Anterior-Posterior Approach for Treatment of Ankylosing Spondylitis with Obvious Displaced Lower Cervical Spine Fractures and Dislocations Wed, 04 Jan 2017 00:00:00 +0000 For patients with AS and lower cervical spine fractures, surgical methods have mainly included the single anterior approach, single posterior approach, and combined anterior-posterior approach. However, various surgical procedures were utilized because the fractures have not been clearly classified according to presence of displacement in these previous studies. Consequently, controversies have been raised regarding the selection of the surgical procedure. This study retrospective analysis was conducted in 12 patients with AS and lower cervical spine fractures and dislocations and explored single-session combined anterior-posterior approach for the treatment of AS with obvious displaced lower cervical spine fractures and dislocations which has demonstrated advantages such as good stabilization, satisfied fracture healing, and easy postoperative cares. However, to some extent, the difficulty and risk of this approach should be considered. Attention should be paid to the prevention of perioperative complications. Baohui Yang, Teng Lu, and Haopeng Li Copyright © 2017 Baohui Yang et al. All rights reserved. Trabecular Bone Score Reflects Trabecular Microarchitecture Deterioration and Fragility Fracture in Female Adult Patients Receiving Glucocorticoid Therapy: A Pre-Post Controlled Study Tue, 03 Jan 2017 08:47:01 +0000 A recently developed diagnostic tool, trabecular bone score (TBS), can provide quality of trabecular microarchitecture based on images obtained from dual-energy X-ray absorptiometry (DXA). Since patients receiving glucocorticoid are at a higher risk of developing secondary osteoporosis, assessment of bone microarchitecture may be used to evaluate risk of fragility fractures of osteoporosis. In this pre-post study of female patients, TBS and fracture risk assessment tool (FRAX) adjusted with TBS (T-FRAX) were evaluated along with bone mineral density (BMD) and FRAX. Medical records of patients with () and without () glucocorticoid treatment were retrospectively reviewed. All patients had undergone DXA twice within a 12- to 24-month interval. Analysis of covariance was conducted to compare the outcomes between the two groups of patients, adjusting for age and baseline values. Results showed that a significant lower adjusted mean of TBS () and a significant higher adjusted mean of T-FRAX for major osteoporotic fracture () were observed in the glucocorticoid group. Conversely, no significant differences were observed in the adjusted means for BMD and FRAX. These findings suggested that TBS and T-FRAX could be used as an adjunct in the evaluation of risk of fragility fractures in patients receiving glucocorticoid therapy. Mei-Hua Chuang, Tzyy-Ling Chuang, Malcolm Koo, and Yuh-Feng Wang Copyright © 2017 Mei-Hua Chuang et al. All rights reserved. Minimally Invasive TLIF Using Unilateral Approach and Single Cage at Single Level in Patients over 65 Thu, 29 Dec 2016 12:38:28 +0000 Background. Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is a widely accepted surgical procedure. But there are only a few reports of MIS-TLIF using the unilateral approach and single cage in elderly patients. Objective. The study investigated the clinical and radiological outcomes of MIS-TLIF using the unilateral approach and single cage in the patients over 65 years of age. Methods. Thirty-eight patients were followed for a mean of months. Radiological data include fusion rate, change of disc height, and central canal area. The numeric rating scale (NRS) and Oswestry disability index (ODI) were used to assess clinical outcomes. Results. The mean age of these patients at operation was years (range, 65–82 years). Evidence of fusion was observed radiologically in 64.71% at 6 months and 87.5% at 12 months after surgery, giving a final fusion rate of 100%. The mean NRS scores for back and leg pain and ODI scores improved significantly at the final follow-up. Conclusions. Clinical and radiologic outcomes of MIS-TLIF using unilateral approach and single cage in elderly patients indicate an acceptable method for the treatment of various kinds of lumbar spinal diseases. Hyeong-Jin Lee, Jin-Sung Kim, and Kyeong-Sik Ryu Copyright © 2016 Hyeong-Jin Lee et al. All rights reserved. A Prospective Study of Platelet-Rich Plasma as Biological Augmentation for Acute Achilles Tendon Rupture Repair Wed, 28 Dec 2016 10:05:45 +0000 Acute Achilles tendon rupture is one of the most common tendon injuries in adults. We hypothesized that Platelet-Rich Plasma (PRP) can be used as biological augmentation for surgical treatment of acute Achilles tendon rupture. Our study is a prospective randomized controlled trial. Patients with acute Achilles tendon rupture undergoing surgical repair were randomly assigned into either control group or PRP group. End-to-end modified Krackow suture was performed in both groups. In the PRP group, PRP was injected into the paratenon sheath and around the ruptured tissue after the tendon was repaired. Postoperatively we evaluated isokinetic muscle strength at 3, 6, 12, and 24 months. In addition, ankle ROM, calf circumference, Leppilahti score, and the SF-36 score were evaluated at 6, 12, and 24 months after operation. At 3 months, the PRP group had better isokinetic muscle. The PRP group also achieved higher SF-36 and Leppilahti scores at 6 and 12 months. At 24 months, the PRP group had an improved ankle range of motion compared to the control group. Our study results suggest that PRP can serve as a biological augmentation to acute Achilles tendon rupture repair and improves both short and midterm functional outcomes. Jian Zou, Xiaolian Mo, Zhongmin Shi, Tanzhu Li, Jianfeng Xue, Guohua Mei, and Xiaolin Li Copyright © 2016 Jian Zou et al. All rights reserved. The Effect of Sodium Hyaluronate on Ligamentation and Biomechanical Property of Tendon in Repair of Achilles Tendon Defect with Polyethylene Terephthalate Artificial Ligament: A Rabbit Tendon Repair Model Mon, 26 Dec 2016 13:25:49 +0000 The Achilles tendon is the most common ruptured tendon of human body. Reconstruction with polyethylene terephthalate (PET) artificial ligament is recommended in some serious cases. Sodium hyaluronate (HA) is beneficial for the healing of tendon injuries. We aimed to determine the effect of sodium hyaluronate in repair of Achilles tendon defect with PET artificial ligament in an animal tendon repair model. Sixteen New Zealand White rabbits were divided into two groups. Eight rabbits repaired with PET were assigned to PET group; the other eight rabbits repaired with PET along with injection of HE were assigned to HA-PET group. All rabbits were sacrificed at 4 and 8 weeks postoperatively for biomechanical and histological examination. The HA-PET group revealed higher biomechanical property compared with the PET group. Histologically, more collagen tissues grew into the HA-PET group compared with PET group. In conclusion, application of sodium hyaluronate can improve the healing of Achilles tendon reconstruction with polyethylene terephthalate artificial ligament. Shengkun Li, Kui Ma, Hong Li, Jia Jiang, and Shiyi Chen Copyright © 2016 Shengkun Li et al. All rights reserved. Comparing Dimensions of Four-Strand Hamstring Tendon Grafts with Native Anterior and Posterior Cruciate Ligaments Mon, 26 Dec 2016 12:35:12 +0000 Background. The aim of the study was to evaluate whether or not there was any incompatibility between four-strand hamstring tendons taken from the same knee and the dimensions of the ACL and PCL. Methods. 15 fresh frozen cadaver hamstrings were prepared as four-strand grafts and measurements made of the ACL and PCL circumferences in the midsection were made in the narrowest part of the midsection. The cross-section areas and diameters were calculated with geometric calculations used to measure the cross-sectional area of cylinders. Accepting that the geometric insertions were elliptical, the length, width, and area were calculated for entry areas. Results. A significant relationship at 96.2% was determined between the ACL mid and the hamstring diameter. A significant relationship at 96.7% was determined between the ACL and the hamstring mid area. A significant relationship at 96.4% was determined between the PCL mid and the hamstring diameter. A significant relationship at 95.7% was determined between the PCL and the hamstring mid area. Conclusion. For the reconstruction of ACL and PCL, it was determined that there is less incompatibility between the four-strand hamstring tendons taken from the same knee and the dimensions of the midsection PCL compared to the ACL dimensions. Barış Yılmaz, Güzelali Özdemir, Elif N. Keskinöz, Gamze Tümentemur, Kemal Gökkuş, and Bahtiyar Demiralp Copyright © 2016 Barış Yılmaz et al. All rights reserved. Endoscopic Radiofrequency Ablation of the Sacroiliac Joint Complex in the Treatment of Chronic Low Back Pain: A Preliminary Study of Feasibility and Efficacy of a Novel Technique Sun, 25 Dec 2016 12:15:48 +0000 Background. Radiofrequency ablation (RFA) is a less invasive technique for treatment of sacroiliac joint (SIJ) pain. Objective. To evaluate the feasibility and efficacy of endoscope-guided RFA for the treatment of CLBP from the SIJ complex. Methods. In this retrospective study, the medical records of 17 patients who underwent endoscope-guided RFA of the SIJ complex were reviewed. A bipolar radiofrequency probe was used to lesion the posterior capsule of the SIJ as well as the lateral branches of S1, S2, S3, and the L5 dorsal ramus in multiple locations. We visualized the ablation area using endoscope. We assessed visual analogue scale (VAS) and the Oswestry disability index (ODI) preoperatively, immediately postop, and at 1-, 3-, and 6-month postop outpatient clinic visits. Patient satisfaction of the procedure was assessed in percentages. Results. The mean duration of operation was 20 to 50 minutes. The mean VAS and the ODI scores decreased significantly immediately after the procedure and were kept significantly lower than baseline levels during the follow-up periods. No complications occurred perioperatively and during the follow-up periods. 88.6% of patients were satisfied with the procedure. Conclusions. Our preliminary results suggest that endoscope-guided RFA may be alternative option to treat CLBP secondary to SIJ complex. Won-Suh Choi, Jin-Sung Kim, Kyeong-Sik Ryu, Jung-Woo Hur, Ji-Hoon Seong, and Hyun-Jin Cho Copyright © 2016 Won-Suh Choi et al. All rights reserved. A Critical Review on Prosthetic Features Available for Reversed Total Shoulder Arthroplasty Sun, 25 Dec 2016 12:04:40 +0000 Reversed total shoulder arthroplasty is a popular treatment in rotator cuff arthropathy and in displaced proximal humeral fractures in elderly. In 2016, 29 models of commercially available designs express this popularity. This study describes all the different design parameters available on the market. Prosthetic differences are found for the baseplate, glenosphere, polyethylene, and humeral component and these differences need to be weighed out carefully for each patient knowing that a gain in one mechanical parameter can balance the loss of another. Patient specific implants may help in the future. Bart Middernacht, Alexander Van Tongel, and Lieven De Wilde Copyright © 2016 Bart Middernacht et al. All rights reserved. Risk Factors for In-Hospital Complications of Fall-Related Fractures among Older Chinese: A Retrospective Study Sun, 25 Dec 2016 06:52:56 +0000 Purpose. The aim of this study was to investigate the risk factors and the efficacy of the preventive measurements for the in-hospital complications of fall-related fractures. Methods. The data on older Chinese patients with fall-related fractures were collected, including information on the patients, diseases, and preventive measurements. The potential risk factors for the in-hospital complications included health status on admission, comorbidity, fractures, preventive measures of the complications, and drugs use for the comorbidity. After univariate analyses, multivariate logistic regression analyses were applied to investigate the impact of the potential risk factors on the number of the complications and each individual complication, respectively, and the efficacy of the preventive measurements. Results. A total of 525 male and 1367 female were included in this study. After univariate analyses, multiple logistic regression showed that dementia, pneumonia, antidepressant, postural hypotension, and cerebral infarction could increase the incidence and number of comorbidities. Meanwhile, dementia has shown the strongest association with each individual complication. Conclusions. Different combinations of comorbidity, medication use, and preventive measurements were related to the in-hospital complications of fall-related fractures. Dementia emerged as the most important risk factor for these complications, while most of the preventive measurements could not reduce their incidences. Hong-Ying Pi, Yuan Gao, Jing Wang, Meng-Meng Hu, Dan Nie, and Pei-Pei Peng Copyright © 2016 Hong-Ying Pi et al. All rights reserved. Video-Assisted Thoracoscopic Surgery and Minimal Access Spinal Surgery Compared in Anterior Thoracic or Thoracolumbar Junctional Spinal Reconstruction: A Case-Control Study and Review of the Literature Thu, 22 Dec 2016 11:46:34 +0000 There are no published reports that compare the outcomes of video-assisted thoracoscopic surgery (VATS) and minimal access spinal surgery (MASS) in anterior spinal reconstruction. We conducted a retrospective case-control study in a single center and systematically reviewed the literature to compare the efficacy and safety of VATS and MASS in anterior thoracic (T) and thoracolumbar junctional (TLJ) spinal reconstruction. From 1995 to 2012, there were 111 VATS patients and 76 MASS patients treated at our hospital. VATS patients had significantly () longer operating times and significantly () higher thoracotomy conversion rates. We reviewed 6 VATS articles and 10 MASS articles, in which there were 625 VATS patients and 399 MASS patients. We recorded clinical complications and a thoracotomy conversion rate from our cases and the selected articles. The incidence of approach-related complications was significantly () higher in VATS patients. The conversion rate was 2% in VATS patients and 0% in MASS patients (). In conclusion, MASS is associated with reduction in operating time, approach-related complications, and the thoracotomy conversion rate. Ching-Yu Lee, Meng-Huang Wu, Yen-Yao Li, Chin-Chang Cheng, Chien-Yin Lee, and Tsung-Jen Huang Copyright © 2016 Ching-Yu Lee et al. All rights reserved. Extracellular Vesicles and Autophagy in Osteoarthritis Sun, 18 Dec 2016 14:48:58 +0000 Osteoarthritis (OA) is a type of chronic joint disease that is characterized by the degeneration and loss of articular cartilage and hyperplasia of the synovium and subchondral bone. There is reasonable knowledge about articular cartilage physiology, biochemistry, and chondrocyte metabolism. However, the etiology and pathogenesis of OA remain unclear and need urgent clarification to guide the early diagnosis and treatment of OA. Extracellular vesicles (EVs) are small membrane-linking particles that are released from cells. In recent decades, several special biological properties have been found in EV, especially in terms of cartilage. Autophagy plays a critical role in the regulation of cellular homeostasis. Likewise, more and more research has gradually focused on the effect of autophagy on chondrocyte proliferation and function in OA. The synthesis and release of EV are closely associated with autophagy. At the same time, both EV and autophagy play a role in OA development. Based on the mechanism of EV and autophagy in OA development, EV may be beneficial in the early diagnosis of OA; on the other hand, the combination of EV and autophagy-related regulatory drugs may provide insight into possible OA therapeutic strategies. Tianyang Gao, Weimin Guo, Mingxue Chen, Jingxiang Huang, Zhiguo Yuan, Yu Zhang, Mingjie Wang, Penghao Li, Jiang Peng, Aiyuan Wang, Yu Wang, Xiang Sui, Li Zhang, Wenjing Xu, Shibi Lu, Xifeng Zhang, Shuyun Liu, and Quanyi Guo Copyright © 2016 Tianyang Gao et al. All rights reserved. Anatomical Location of the Common Iliac Veins at the Level of the Sacrum: Relationship between Perforation Risk and the Trajectory Angle of the Screw Sun, 18 Dec 2016 14:16:45 +0000 Purpose. To determine the safety of transarticular surface screw (TASS) insertion and the anatomical location of the common iliac veins (CIVs) at the level of the promontorium. Materials and Methods. The locations of the CIVs on 1 mm computed tomography-myelography slices of 50 patients at the level of the promontorium and 20 human cadavers were investigated. Results. Among the patients, the left CIV was closer to the S1 anterior wall than the right CIV (mean distance: 5.0 ± 3.0 and 7.0 ± 4.2 mm, resp.). The level of the inferior vena cava (IVC) formation varied among the cadavers. The mean distance between the IVC formation and promontorium tip was 30.2 ± 12.8 mm. The height of the IVC formation and distance between the right and the left CIVs at the level of the promontorium were significantly correlated (). Conclusion. The TASS trajectory is safe as long as the screw does not penetrate the anterior cortex of S1. The level of the IVC formation can help to predict the distance between the right and the left CIVs at the level of the promontorium. The CIVs do not have a uniform anatomical location; therefore, preoperative computed tomography is necessary to confirm their location. Javid Akhgar, Hidetomi Terai, Mohammad Suhrab Rahmani, Koji Tamai, Akinobu Suzuki, Hiromitsu Toyoda, Masatoshi Hoshino, Sayed Abdullah Ahmadi, Kazunori Hayashi, and Hiroaki Nakamura Copyright © 2016 Javid Akhgar et al. All rights reserved. The Double-Row Suture Technique: A Better Option for the Treatment of Haglund Syndrome Sun, 18 Dec 2016 12:02:56 +0000 Purpose. The purpose of this study is to investigate whether double-row suture technique is a better option for the treatment of Haglund syndrome than single-row suture technique regarding the surgical outcomes. Methods. Thirty-two patients with Haglund syndrome were recruited in this study. Patients were divided into Group 1 (treated with single-row suture technique) and Group 2 (treated with double-row suture technique). There were 16 patients in each group. The AOFAS-ankle-hindfoot scale, VISA-A scores, and Arner-Lindholm standard were used to assess the clinical outcomes. The pre- and postoperative X-rays were used to assess the radiological outcome. Results. Both AOFAS-ankle-hindfoot scale score and VISA-A score had varying degrees of improvement in both groups. In latest follow-up assessment, the Arner-Lindholm standard investigation showed there were 7 excellent, 7 good, and 2 bad outcomes in Group 1 and 12 excellent and 4 good outcomes in Group 2. In Group 2 patients, there were no more posterosuperior bony prominence of the calcaneum in post-op X-rays and there were no recurrent cases. The ankle-related scale score was statistically significantly higher in Group 2 than in Group 1 (). Conclusion. The double-row suture technique seems to be a better option to treat Haglund syndrome than single-row suture technique. Yiqiu Jiang, Yang Li, Tianqi Tao, Wang Li, Kaibin Zhang, Jianchao Gui, and Yong Ma Copyright © 2016 Yiqiu Jiang et al. All rights reserved. Application of Computed Tomography Processed by Picture Archiving and Communication Systems in the Diagnosis of Acute Achilles Tendon Rupture Sun, 18 Dec 2016 09:20:47 +0000 The applications of CT examination in the diagnosis of the acute Achilles tendon rupture (AATR) were investigated. A total of 36 patients with suspected acute Achilles tendon rupture were tested using physical examination, ultrasound, and 3DCT scanning, respectively. Then, surgery was performed for the patients who showed positive result in at least two of the three tests for AATR. 3DVR, MPR, and the other CT scan image processing and diagnosis were conducted in PACS (picture archiving and communication system). PACS was also used to measure the length of distal broken ends of the Achilles tendon (AT) to tendon calcaneal insertion. Our study indicated that CT has the highest accuracy in diagnosis of acute Achilles tendon complete rupture. The length measurement is matched between PACS and those actually measured in operation. CT not only demonstrates more details directly in three dimensions especially with the rupture involved calcaneal insertion flap but also locates the rupture region for percutaneous suture by measuring the length of distal stump in PACS without the effect of the position of ankle. The accuracy of CT diagnosis for Achilles tendon partial rupture is yet to be studied. Hai-Peng Xue, Xin-Wei Liu, Jing Tian, Bing Xie, Chao Yang, Hao Zhang, and Da-Peng Zhou Copyright © 2016 Hai-Peng Xue et al. All rights reserved. Effect of Negative Pressure on Proliferation, Virulence Factor Secretion, Biofilm Formation, and Virulence-Regulated Gene Expression of Pseudomonas aeruginosa In Vitro Thu, 15 Dec 2016 14:01:35 +0000 Objective. To investigate the effect of negative pressure conditions induced by NPWT on P. aeruginosa. Methods. P. aeruginosa was cultured in a Luria–Bertani medium at negative pressure of −125 mmHg for 24 h in the experimental group and at atmospheric pressure in the control group. The diameters of the colonies of P. aeruginosa were measured after 24 h. ELISA kit, orcinol method, and elastin-Congo red assay were used to quantify the virulence factors. Biofilm formation was observed by staining with Alexa Fluor® 647 conjugate of concanavalin A (Con A). Virulence-regulated genes were determined by quantitative RT-PCR. Results. As compared with the control group, growth of P. aeruginosa was inhibited by negative pressure. The colony size under negative pressure was significantly smaller in the experimental group than that in the controls (). Besides, reductions in the total amount of virulence factors were observed in the negative pressure group, including exotoxin A, rhamnolipid, and elastase. RT-PCR results revealed a significant inhibition in the expression level of virulence-regulated genes. Conclusion. Negative pressure could significantly inhibit the growth of P. aeruginosa. It led to a decrease in the virulence factor secretion, biofilm formation, and a reduction in the expression level of virulence-regulated genes. Guo-Qi Wang, Tong-Tong Li, Zhi-Rui Li, Li-Cheng Zhang, Li-Hai Zhang, Li Han, and Pei-Fu Tang Copyright © 2016 Guo-Qi Wang et al. All rights reserved. The Modified Femoral Neck-Shaft Angle: Age- and Sex-Dependent Reference Values and Reliability Analysis Wed, 14 Dec 2016 05:58:47 +0000 Background. The femoral neck-shaft angle (NSA) is of high importance for the diagnostics and treatment of various conditions of the hip. However, rotational effects limit its precision and applicability using plain radiographs. This study introduces a novel method to measure the femoral NSA: the modified NSA (mNSA), possibly being less susceptible against rotational effects compared to the conventional NSA. Patients and Methods. The method of measurement is described and its applicability was tested in 400 pelvis computed tomography scans (800 hips). Age- and gender-dependent reference values are given and intra- and interrater reliability are analyzed. Results. The mean age of all 400 patients (800 hips) was 54.32 years (18–100, SD 22.05 years). The mean mNSA was 147.0° and the 95% confidence interval was 146.7°–147.4°. Differences of the mNSA between sexes, age groups, and sides were nonsignificant. The absolute difference between NSA and mNSA was 16.3° (range 3–31°; SD 4.4°); the correlation was high (0.738; ). Overall, the intra- and interrater reliability were excellent for the mNSA. Interpretation. We introduced a novel concept for the analysis of the neck-shaft angle. The high reliability of the measurement has been proven and its robustness to hip rotation was demonstrated. Christoph Kolja Boese, Michael Frink, Janine Jostmeier, Stefan Haneder, Jens Dargel, Peer Eysel, and Philipp Lechler Copyright © 2016 Christoph Kolja Boese et al. All rights reserved. Significant Associations of SOX9 Gene Polymorphism and Gene Expression with the Risk of Osteonecrosis of the Femoral Head in a Han Population in Northern China Wed, 07 Dec 2016 12:07:32 +0000 Sex determining region Y-box 9 (SOX9) is a key transcription factor involved in cartilage formation during the embryonic development stage and cartilage growth and repair after birth. To explore the roles of polymorphism and expression of the SOX9 gene in the development of osteonecrosis of the femoral head (ONFH), we analyzed the polymorphism of rs12601701 [A/G] and rs1042667 [A/C] and the serum protein expression of the SOX9 gene in 182 patients with ONFH and 179 healthy control subjects. Results revealed that the A-A haplotype of SOX9 gene as well as the GG and AA genotypes of rs12601701 was significantly associated with increased ONFH risk () and the risk of bilateral hip lesions of ONFH (), respectively. The C-A, A-A, and A-G haplotypes were also statistically associated with the decreased and increased risk of bilateral hip lesions of ONFH (, , and ), respectively, while the A-A haplotype closely related to the clinical stages of ONFH (). More importantly, the serum SOX9 protein expression of the ONFH group was greatly decreased compared to control group (). Our results first showed that the gene polymorphism and gene expression of SOX9 were significantly associated with the risk and clinical phenotypes of ONFH and also indicate that the SOX9 gene may play a key role in the development of ONFH. Yang Song, Zhenwu Du, Ming Ren, Qiwei Yang, Yujie Sui, Qingyu Wang, Ao Wang, Haiyue Zhao, Jincheng Wang, and Guizhen Zhang Copyright © 2016 Yang Song et al. All rights reserved. Modular Endoprostheses for Nonneoplastic Conditions: Midterm Complications and Survival Mon, 05 Dec 2016 13:04:37 +0000 The use of modular endoprostheses is a viable option to manage both tumor resection and severe bone loss due to nonneoplastic conditions such as fracture sequelae, failed osteoarticular grafts, arthroplasty revisions, and periprosthetic fractures. We sought to investigate both midterm complications and failures occurred in 87 patients who underwent a megaprosthetic reconstruction in a nonneoplastic setting. After a mean follow-up of 58 (1–167) months, overall failure-free survival was 91.5% at 1 year, 80% at 2 years, 71.6% at 5 years, and 69.1% at 5 and 10 years. There was no significant difference in the survival rate according to the diagnosis at the index procedure (), nor to the reconstruction site (). The use of megaprostheses in a postneoplastic setting did not affect survival rate in comparison with endoprosthetic reconstruction of pure nonneoplastic conditions (). Perimegaprosthetic infection was the leading complication, occurring in 10 (11.5%) patients and implying a megaprosthetic revision in all but one case. Physicians should consider these results when discussing with patients desired outcomes of endoprosthetic reconstructions of a nonneoplastic disease. Marco De Gori, Guido Scoccianti, Filippo Frenos, Leonardo Bettini, Filippo Familiari, Giorgio Gasparini, Giovanni Beltrami, Pierluigi Cuomo, Pietro De Biase, and Rodolfo Capanna Copyright © 2016 Marco De Gori et al. All rights reserved. Effect of Melatonin and Calmodulin in an Idiopathic Scoliosis Model Wed, 30 Nov 2016 14:33:07 +0000 Background. To explore influence of continuous illumination, luzindole, and Tamoxifen on incidence of scoliosis model of rats. Methods. Thirty-two one-month-old female rats were rendered into bipedal rats. The bipedal rats were divided into 4 groups: group A by intraperitoneal injection of luzindole and continuous illumination; group B by intraperitoneal injection of luzindole only; group C by intraperitoneal injection of luzindole and oral administration of Tamoxifen; and group D by intraperitoneal injection of equivalent saline. Radiographs were taken at 8th week and 16th week, and incidence and the Cobb angles of scoliosis were calculated. At 16th week, all rats were sacrificed. Before the sacrifice, the levels of calmodulin were measured in each group. Results. At 8th week, scoliosis occurred in groups A and B, with an incidence of 75% and 12.5%, respectively, while rats in group C or D had no scoliosis. At 16th week, scoliosis incidences in groups A and B were 57% and 62.5%, respectively. No scoliosis occurred in group C or D. Calmodulin in platelets in group B was significantly different, compared with groups A and D. There was no significant difference in calmodulin in platelets in groups B and C. Conclusion. By intraperitoneal injection of luzindole in bipedal rats, scoliosis rat models could be successfully made. Under light, incidence of scoliosis may be increased at an early period but it is reversible. Tamoxifen can suppress natural process of scoliosis. Jun-Zhe Wu, Wen-Hua Wu, Li-Jiang He, Qing-Feng Ke, Long Huang, Zhang-Sheng Dai, and Yu Chen Copyright © 2016 Jun-Zhe Wu et al. All rights reserved. Outcome of Extracorporeal Shock Wave Therapy for Insertional Achilles Tendinopathy with and without Haglund’s Deformity Wed, 30 Nov 2016 09:22:31 +0000 Purpose. To compare the results of extracorporeal shock wave therapy (ESWT) for insertional Achilles tendinopathy (IAT) with or without Haglund’s deformity. Methods. Between September 2014 and May 2015, all patients who underwent ESWT were retrospectively enrolled in this study. A total of 67 patients were available for follow-up and assigned into nondeformtiy group () and deformtiy group (). Clinical outcomes were evaluated by VISA-A Score and 6-point Likert scale. Results. The VISA-A score increased in both groups, from at baseline to at months after treatment in nondeformity group () and from at baseline to at months after treatment in deformity group (). However, there was a greater improvement in VISA-A Score for the nondeformity group compared with deformity group (). For the 6-point Likert scale, there were decreases from at baseline to at the follow-up time point in nondeformity group () and from at baseline to at the follow-up time point in deformity group (). There was no significant difference in improvement of the 6-point Likert scale between both groups (). Conclusions. ESWT resulted in greater clinical outcomes in patients without Haglund’s deformity compared with patients with Haglund’s deformity. Ziying Wu, Wei Yao, Shiyi Chen, and Yunxia Li Copyright © 2016 Ziying Wu et al. All rights reserved. Utility of Ultrasonography in Assessing the Effectiveness of Extracorporeal Shock Wave Therapy in Insertional Achilles Tendinopathy Mon, 28 Nov 2016 13:53:06 +0000 Introduction. The aim of this study was to investigate the utility of ultrasonography (US) for predicting and assessing the effectiveness of extracorporeal shock wave therapy (ESWT) in insertional Achilles tendinopathy (IAT). Methods. A total of 42 patients with an established diagnosis of chronic IAT were examined by US before ESWT and at 4 weeks and 12 weeks after ESWT. The thickness and cross-sectional area (CSA) of the Achilles tendon, size of calcific plaques, tendon structure score, and neovascularization score were measured at each time point. Results. After therapy, Victorian Institute of Sport Assessment-Achilles (VISA-A) scores increased significantly, and the size of calcific plaques decreased (). Neovascularization scores increased at the 4th week and then decreased at the 12th week (). The thickness, CSA, and structure of the Achilles tendon did not change. Variables observed by US at baseline were not associated with changes in VISA-A scores at follow-up. However, the changes in calcific plaque size and neovascularization scores were related to the improvement of VISA-A scores between pre- and posttherapy (). Conclusion. Ultrasonography can reveal some changes in the insertion of the Achilles tendon after ESWT, but the outcome of ESWT in IAT cannot be predicted by the variables observed by US. Yi Cheng, Jian Zhang, and Yehua Cai Copyright © 2016 Yi Cheng et al. All rights reserved. Accuracy Assessment of Using Rapid Prototyping Drill Templates for Atlantoaxial Screw Placement: A Cadaver Study Mon, 28 Nov 2016 06:04:00 +0000 Purpose. To preliminarily evaluate the feasibility and accuracy of using rapid prototyping drill templates (RPDTs) for C1 lateral mass screw (C1-LMS) and C2 pedicle screw (C2-PS) placement. Methods. 23 formalin-fixed craniocervical cadaver specimens were randomly divided into two groups. In the conventional method group, intraoperative fluoroscopy was used to assist the screw placement. In the RPDT navigation group, specific RPDTs were constructed for each specimen and were used intraoperatively for screw placement navigation. The screw position, the operating time, and the fluoroscopy time for each screw placement were compared between the 2 groups. Results. Compared with the conventional method, the RPDT technique significantly increased the placement accuracy of the C2-PS (). In the axial plane, using RPDTs also significantly increased C1-LMS placement accuracy (). In the sagittal plane, although using RPDTs had a very high accuracy rate (100%) in C1-LMS placement, it was not statistically significant compared with the conventional method (). Moreover, the RPDT technique significantly decreased the operating and fluoroscopy times. Conclusion. Using RPDTs significantly increases the accuracy of C1-LMS and C2-PS placement while decreasing the screw placement time and the radiation exposure. Due to these advantages, this approach is worth promoting for use in the Harms technique. Shuai Guo, Teng Lu, Qiaolong Hu, Baohui Yang, Xijing He, and Haopeng Li Copyright © 2016 Shuai Guo et al. All rights reserved. Evidence for Altered Canonical Wnt Signaling in the Trabecular Bone of Elderly Postmenopausal Women with Fragility Femoral Fracture Thu, 24 Nov 2016 06:10:40 +0000 Wnt signaling, a major regulator of bone formation and homeostasis, might be involved in the bone loss of osteoporotic patients and the consequent impaired response to fracture. Therefore we analyzed Wnt-related, osteogenic, and adipogenic genes in bone tissue of elderly postmenopausal women undergoing hip replacement for either femoral fracture or osteoarthritis. Bone specimens derived from the intertrochanteric region of the femurs of 25 women with fracture (F) and 29 with osteoarthritis without fracture (OA) were analyzed. Specific miRNAs were analyzed in bone and in matched blood samples. RUNX2, BGP, and OPG showed lower expression in F than in OA samples, while OSX, OPN, BSP, and RANKL were not different. Inhibitory genes of Wnt pathway were lower in F versus OA. -Catenin protein levels were higher in F versus OA, whereas its cotranscriptional regulator (Lef1) was lower in F group. miR-204, which targets RUNX2, and miR-130a, which inhibits PPARγ, were lower and higher, respectively, in F versus OA serum samples. The present study showed an inefficient Wnt signal transduction in F group despite higher -catenin protein levels, consistent with the expected overall postfracture systemic activation towards osteogenesis. This transcriptional inefficiency could contribute to the osteoporotic bone fragility. Simona Bolamperti, Isabella Villa, Alice Spinello, Greta Manfredini, Emanuela Mrak, Umberto Mezzadri, Marco Ometti, Gianfranco Fraschini, Francesca Guidobono, and Alessandro Rubinacci Copyright © 2016 Simona Bolamperti et al. All rights reserved. How Sublaminar Bands Affect Postoperative Sagittal Alignment in AIS Patients with Preoperative Hypokyphosis? Results of a Series of 34 Patients with 2-Year Follow-Up Wed, 23 Nov 2016 12:44:06 +0000 Hypokyphosis is currently observed in thoracic idiopathic scoliosis. The use of sublaminar bands allows a good restoration of sagittal balance of the spine. The aim of the study was to provide a middle-term radiographic analysis of patients with adolescent idiopathic scoliosis with preoperative hypokyphosis treated by posterior arthrodesis with sublaminar bands. This retrospective study included 34 patients with Lenke 1 scoliosis associated with hypokyphosis (TK < 20°). A radiographic evaluation was performed with a 2-year follow-up. Cobb angle, cervical lordosis, thoracic kyphosis, lumbar lordosis, and pelvic parameters were measured preoperatively, postoperatively, and at 6-month and 2-year follow-up. The mean preoperative thoracic kyphosis was 10.5° versus 24.1° postoperatively (), representing a mean gain of 13°. Cobb angle ranged from 59.3° to 17.9° postoperatively (mean correction 69%, ). Cobb angle increased between the immediate postoperative measurement and the 6-month follow-up (17.9 versus 19.9, ). Cervical curvature changed from a 5.6° kyphosis to a 3.5° lordosis (). Concerning lumbar lordosis, preoperative measurement was 39.7° versus 41.3° postoperatively (). At 6-month follow-up, lumbar lordosis significantly increased to 43.6° (). All parameters were stable at final follow-up. Correction performed by sublaminar bands is efficient for both fontal and sagittal planes. Moreover, the restoration of normal thoracic kyphosis is followed by an adaptation of the adjacent curvatures with improved cervical lordosis and lumbar lordosis. Sébastien Pesenti, Antoine Chalopin, Emilie Peltier, Elie Choufani, Matthieu Ollivier, Stéphane Fuentes, Benjamin Blondel, and Jean-Luc Jouve Copyright © 2016 Sébastien Pesenti et al. All rights reserved. Structural Femoral Shaft Allografts for Anterior Spinal Column Reconstruction in Osteoporotic Spines Tue, 22 Nov 2016 12:11:22 +0000 This study was to investigate the clinical and radiographical outcomes of anterior spinal column reconstruction using structural femoral shaft allografts in osteoporotic patients. Retrospective analyses of medical records, radiographic parameters, and postoperative complications were performed in twenty-one patients who underwent anterior spinal column reconstruction surgery for osteoporotic vertebral collapse or nonunion. Surgical invasiveness, clinical outcomes, postoperative complications, and radiographic outcomes were evaluated. Ambulatory status and back pain significantly improved. The Cobb’s angle of segmental kyphosis significantly improved immediately after surgery with slight progression at the final follow-up. There were two cases of failed reconstruction with marked progression of kyphosis; both were related to loosening of screws rather than subsidence of the graft. Anterior spinal column reconstruction using femoral shaft allografts improved kyphosis and resulted in minimal subsidence and therefore is recommended as an effective treatment option for dealing with osteoporotic vertebral collapse and kyphotic deformity. Bong-Soon Chang, Jong-Hun Jung, Sang-Min Park, Seung Hoo Lee, Choon-Ki Lee, and Hyoungmin Kim Copyright © 2016 Bong-Soon Chang et al. All rights reserved. Spatiotemporal Changes of Calcitonin Gene-Related Peptide Innervation in Spinal Fusion Mon, 21 Nov 2016 11:31:53 +0000 Few studies have investigated the role calcitonin gene-related peptide (CGRP) plays in the process of spinal fusion. The aim of the present study is to observe the temporal and spatial changes of CGRP induced by experimental fusion surgery in rats and elucidate the role of CGRP in spinal fusion. Male Sprague-Dawley rats were used in the study and the specimens were collected on the 7th, 14th, 21st, and 28th day, respectively. Then, histological and immunohistochemical analysis were applied to evaluate the fusion mass and spatiotemporal changes of CGRP chronologically. The results demonstrated that density of CGRP reached peak on the 21st day after surgery and most of the CGRP expression located surrounding the interface of allograft and fibrous tissue where the cells differentiate into osteoblasts, indicating that CGRP might be involved in the process of bone formation and absorption. Xiao-Yi Zhou, Xi-Ming Xu, Sui-Yi Wu, Fei Wang, Yi-Lin Yang, Ming Li, and Xian-Zhao Wei Copyright © 2016 Xiao-Yi Zhou et al. All rights reserved. Corrigendum to “Effect of Short-Term Stimulation with Interleukin-1β and Differentiation Medium on Human Mesenchymal Stromal Cell Paracrine Activity in Coculture with Osteoblasts” Mon, 21 Nov 2016 07:09:04 +0000 Jan O. Voss, Claudia Loebel, Jennifer J. Bara, Marc Anton Fuessinger, Fabian Duttenhoefer, Mauro Alini, and Martin J. Stoddart Copyright © 2016 Jan O. Voss et al. All rights reserved. Metformin Prevents Nonunion after Three-Cannulated-Screw Fixation in Displaced Femoral Neck Fractures: A Retrospective Study Sun, 20 Nov 2016 11:41:41 +0000 Patients aged from 40 to 60 with displaced fractures of the femoral neck (Garden III or IV) who received fixation with three cannulated screws from January 2005 to December 2012 were evaluated retrospectively for the development of nonunion. Plasma HbA1C, a marker for long-term plasma glucose level, anti-T2DM medication, and other potential risk factors were recorded for the purpose of this study. There were no differences between the union and nonunion groups with respect to age, gender, Garden classification, Pauwel’s angle, reduction quality, and T2DM presence. There were significant differences in reduction quality and preoperative plasma HbA1C level between patients with and those without union. The odds ratio (OR) for fracture nonunion was 2.659 (95% confidence interval [CI], 1.530–4.620) in subjects with anatomical reduction compared with those without anatomical reduction, 4.797 (95% CI, 1.371–16.778), in subjects with poor blood glucose control (HbA1C > 10%). The metformin usage showed a preventive effect on nonunion development (OR: 0.193 and CI: 0.060–0.616). The nonunion rate of metformin group (6.7%, 6/89) was even much lower than that of patients without T2DM (17.4%, 80/460). Xiao-zhong Zhu and Xian-you Zheng Copyright © 2016 Xiao-zhong Zhu and Xian-you Zheng. All rights reserved. Atypical Complete Femoral Fractures Associated with Bisphosphonate Use or Not Associated with Bisphosphonate Use: Is There a Difference? Sun, 20 Nov 2016 07:46:22 +0000 The purpose of this study is to compare clinical characteristics and surgical outcome of atypical complete femoral fractures associated with bisphosphonates (BPs) use and those of fractures not associated with BPs use. Seventy-six consecutive patients (81 fractures) who had been operatively treated for a complete atypical femoral fracture were recruited. Of the 81 fractures, 73 occurred after BPs medication of at least 3 years (BP group) while 8 occurred without a history of BP medication (non-BP group). There were no differences in demographic data and fracture- and surgery-associated factors between the two groups. Of 76 patients (81 fractures), 54 (66.7%) fractures showed bony union within 6 months after the index surgery and 23 (28.4%) showed delayed union at a mean of 11.2 months (range, 8–18 months). The remaining 4 fractures were not healed, even 18 months after the index surgery. There was no difference in healing rate between the BP group and the non-BP group. There were strong correlations between the fracture height and the degree of bowing regardless of BPs medication. All fractures except 1 occurred at the diaphyseal region of the femur when not associated with BP medication. Sang-Min Kim, Youn-Soo Park, Young-Wan Moon, Seung-Hoon Kang, Ingwon Yeo, Seung-Min Oh, and Seung-Jae Lim Copyright © 2016 Sang-Min Kim et al. All rights reserved. Minimally Invasive Treatment of Displaced Proximal Humeral Fractures in Patients Older Than 70 Years Using the Humerusblock Thu, 17 Nov 2016 08:22:43 +0000 Background. Surgical treatment of proximal humeral fractures (PHF) in osteoporotic bone of elderly patients is challenging. The aim of this retrospective study was to evaluate the clinical and radiological outcome after percutaneous reduction and internal fixation of osteoporotic PHF in geriatric patients using the semirigid Humerusblock device. Methods. In the study period from 2005 to 2010, 129 patients older than 70 years were enrolled in the study. After a mean follow-up of 23 months, a physical examination, using the Constant-Murley score and the VAS pain scale, was performed. Furthermore radiographs were taken to detect signs of malunion, nonunion, and avascular necrosis. Results. The recorded Constant-Murley score was 67.7 points (87.7% of the noninjured arm) for two-part fractures, 67.9 points (90.8%) for three-part fractures, and 43.0 points (56.7%) for four-part fractures. In ten shoulders (7.8%) loss of reduction and in four shoulders (3.1%) nonunion were the reason for revision surgery. Avascular humeral head necrosis developed in eight patients (6.2%). Conclusions. In two- and three-part fractures postoperative results are promising. Sufficient ability for the activities of daily living was achieved. In four-part fractures the functional results were less satisfying regarding function and pain with a high postoperative complication rate. In those patients other treatment strategies should be considered. Study design. Therapeutic retrospective case series (evidence-based medicine (EBM) level IV). Robert Bogner, Reinhold Ortmaier, Philipp Moroder, Stefanie Karpik, Christof Wutte, Stefan Lederer, Alexander Auffarth, and Herbert Resch Copyright © 2016 Robert Bogner et al. All rights reserved. Biomechanical Comparison of Modified Suture Bridge Using Rip-Stop versus Traditional Suture Bridge for Rotator Cuff Repair Tue, 15 Nov 2016 09:46:45 +0000 Purpose. To compare the biomechanical properties of 3 suture-bridge techniques for rotator cuff repair. Methods. Twelve pair-matched fresh-frozen shoulder specimens were randomized to 3 groups of different repair types: the medially Knotted Suture Bridge (KSB), the medially Untied Suture Bridge (USB), and the Modified Suture Bridge (MSB). Cyclic loading and load-to-failure test were performed. Parameters of elongation, stiffness, load at failure, and mode of failure were recorded. Results. The MSB technique had the significantly greatest load to failure (, for KSB group; for USB group), stiffness (, for KSB group; for USB group), and lowest elongation (, for KSB group; for USB group) among 3 groups. The KSB repair had significantly higher ultimate load () than USB repair (, ). However, there was no statistical difference in stiffness and elongation between KSB and USB technique ( for stiffness and for elongation, resp.). The failure mode for all specimens was suture pulling through the cuff tendon. Conclusions. Our modified suture bridge technique (MSB) may provide enhanced biomechanical properties when compared with medially knotted or knotless repair. Clinical Relevance. Our modified technique may represent a promising alternative in arthroscopic rotator cuff repair. ZiYing Wu, Chong Zhang, Peng Zhang, TianWu Chen, ShiYi Chen, and JiWu Chen Copyright © 2016 ZiYing Wu et al. All rights reserved. Clinical Effects of the Probing Method with Depth Gauge for Determining the Screw Depth of Locking Proximal Humeral Plate Tue, 15 Nov 2016 07:35:29 +0000 Background. The use of locking plates has gained popularity to treat proximal humeral fractures. However, the complication rates remain high. Biomechanical study suggested that subchondral screw-tip abutment significantly increased the stability of plant. We present a simple method to obtain the proper screw length through the depth gauge in elderly patients and compared the clinical effects with traditional measuring method. Methods. 40 patients were separated into two groups according to the two surgical methods: the probing method with depth gauge and the traditional measuring method. The intraoperative indexes and postoperative complications were recorded. The Constant and Murley score was used for the functional assessment in the 12th month. Results. Operative time and intraoperative blood loss indicated no statistical differences. X-ray exposure time and the patients with screw path penetrating the articular cartilage significantly differed. Postoperative complications and Constant and Murley score showed no statistical differences. Conclusions. Probing method with depth gauge is an appropriate alternative to determine the screw length, which can make the screw-tip adjoin the subchondral bone and keep the articular surface of humeral head intact and at the same time effectively avoid frequent X-ray fluoroscopy and adjusting the screws. Lin Jin, Jialiang Guo, Junfei Guo, Yingchao Yin, Zhiyong Hou, and Yingze Zhang Copyright © 2016 Lin Jin et al. All rights reserved. Halo Gravity Traction Is Associated with Reduced Bone Mineral Density of Patients with Severe Kyphoscoliosis Tue, 08 Nov 2016 13:41:31 +0000 Background. Halo gravity traction (HGT) is one of the most commonly used perioperative techniques for the treatment of severe kyphoscoliosis. This study was to explore the influence of HGT on the BMD of these patients. Methods. Patients with severe kyphoscoliosis treated by preoperative HGT for at least 2 months were included. Patients’ BMD were assessed by dual-energy X-ray absorptiometry at lumbar spine (LS, L2–L4) and femur neck (FN) of the nondominant side. The weight and duration of traction, as well as baseline characteristics, were recorded. Results. Twenty patients were recruited. The average traction duration was days while the mean traction weight was % of total body weight. Remarkable decrease of BMD was observed at LS of 17 (85%) patients and at FN of 18 (90%) patients. After HGT, 75% of patients were found to have osteoporosis, the incidence of which was significantly higher than that before HGT (35%). The correlation analysis revealed BMD reduction was only significantly correlated with the traction duration. Conclusions. The current study showed that preoperative HGT can have obvious impact on the BMD. The BMD reduction is associated with traction duration, suggesting that long traction duration may bring more bone mineral loss. Xiao Han, Weixiang Sun, Yong Qiu, Leilei Xu, Shifu Sha, Benlong Shi, Huang Yan, Zhen Liu, and Zezhang Zhu Copyright © 2016 Xiao Han et al. All rights reserved. Achilles Tendinopathy: Current Concepts about the Basic Science and Clinical Treatments Thu, 03 Nov 2016 13:55:05 +0000 Achilles tendinopathy is one of the most frequently ankle and foot overuse injuries, which is a clinical syndrome characterized by the combination of pain, swelling, and impaired performance. The two main categories of Achilles tendinopathy are classified according to anatomical location and broadly include insertional and noninsertional tendinopathy. The etiology of Achilles tendinopathy is multifactorial including both intrinsic and extrinsic factors. Failed healing response and degenerative changes were found in the tendon. The failed healing response includes three different and continuous stages (reactive tendinopathy, tendon disrepair, and degenerative tendinopathy). The histological studies have demonstrated an increased number of tenocytes and concentration of glycosaminoglycans in the ground substance, disorganization and fragmentation of the collagen, and neovascularization. There are variable conservative and surgical treatment options for Achilles tendinopathy. However, there has not been a gold standard of these treatments because of the controversial clinical results between various studies. In the future, new level I researches will be needed to prove the effect of these treatment options. Hong-Yun Li and Ying-Hui Hua Copyright © 2016 Hong-Yun Li and Ying-Hui Hua. All rights reserved. Miniopen Transforaminal Lumbar Interbody Fusion with Unilateral Fixation: A Comparison between Ipsilateral and Contralateral Reherniation Thu, 03 Nov 2016 11:26:12 +0000 The aim of this study was to evaluate the risk factors between ipsilateral and contralateral reherniation and to compare the effectiveness of miniopen transforaminal lumbar interbody fusion (TLIF) with unilateral fixation for each group. From November 2007 to December 2014, clinical and radiographic data of each group (ipsilateral or contralateral reherniation) were collected and compared. Functional assessment (Visual Analog Scale (VAS) score and Japanese Orthopaedic Association (JOA)) and radiographic evaluation (fusion status, disc height, lumbar lordosis (LL), and functional spine unit (FSU) angle) were applied to compare surgical effect for each group preoperatively and at final followup. MacNab questionnaire was applied to further evaluate the satisfactory rate after the discectomy and fusion. No difference except pain-free interval was found between ipsilateral and contralateral groups. There was a significant difference in operative time between two groups. No differences were found in clinical and radiographic data for assessment of surgical effect between two groups. The satisfactory rate was decreasing in both groups with time passing after discectomy. Difference in pain-free interval may be a distinction for ipsilateral and contralateral reherniation. Miniopen TLIF with unilateral pedicle screw fixation can be a recommendable way for single level reherniation regardless of ipsilateral or contralateral reherniation. Zheng Li, Fubing Liu, Shuhao Liu, Zixian Chen, Chun Jiang, Zhenzhou Feng, and Xiaoxing Jiang Copyright © 2016 Zheng Li et al. All rights reserved. Applying the Mini-Open Anterolateral Lumbar Interbody Fusion with Self-Anchored Stand-Alone Polyetheretherketone Cage in Lumbar Revision Surgery Thu, 03 Nov 2016 07:22:36 +0000 The author retrospectively studied twenty-two patients who underwent revision lumbar surgeries using ALLIF with a self-anchored stand-alone polyetheretherketone (PEEK) cage. The operation time, blood loss, and perioperative complications were evaluated. Oswestry disability index (ODI) scores and visual analog scale (VAS) scores of leg and back pain were analyzed preoperatively and at each time point of postoperative follow-up. Radiological evaluation including fusion, disc height, foraminal height, and subsidence was assessed. The results showed that the ALLIF with a self-anchored stand-alone PEEK cage is safe and effective in revision lumbar surgery with minor surgical trauma, low access-related complication rates, and satisfactory clinical and radiological results. Lei Kuang, Yuqiao Chen, Lei Li, Guohua Lü, and Bing Wang Copyright © 2016 Lei Kuang et al. All rights reserved. Controlled Release of Interleukin-1 Receptor Antagonist from Hyaluronic Acid-Chitosan Microspheres Attenuates Interleukin-1β-Induced Inflammation and Apoptosis in Chondrocytes Sun, 30 Oct 2016 12:32:38 +0000 This paper investigates the protective effect of interleukin-1 receptor antagonist (IL-1Ra) released from hyaluronic acid chitosan (HA-CS) microspheres in a controlled manner on IL-1β-induced inflammation and apoptosis in chondrocytes. The IL-1Ra release kinetics was characterized by an initial burst release, which was reduced to a linear release over eight days. Chondrocytes were stimulated with 10 ng/ml IL-1β and subsequently incubated with HA-CS-IL-1Ra microspheres. The cell viability was decreased by IL-1β, which was attenuated by HA-CS-IL-1Ra microspheres as indicated by an MTT assay. ELISA showed that HA-CS-IL-1Ra microspheres inhibited IL-1β-induced inflammation by attenuating increases in and prostaglandin E2 levels as well as increase in glycosaminoglycan release. A terminal deoxyribonucleotide transferase deoxyuridine triphosphate nick-end labeling assay revealed that the IL-1β-induced chondrocyte apoptosis was decreased by HA-CS-IL-1Ra microspheres. Moreover, HA-CS-IL-1Ra microspheres blocked IL-1β-induced chondrocyte apoptosis by increasing B-cell lymphoma 2 (Bcl-2) and decreasing Bcl-2-associated X protein and caspase-3 expressions at mRNA and protein levels, as indicated by reverse-transcription quantitative polymerase chain reaction and western blot analysis, respectively. The results of the present study indicated that HA-CS-IL-1Ra microspheres as a controlled release system of IL-1Ra possess potential anti-inflammatory and antiapoptotic properties in rat chondrocytes due to their ability to regulate inflammatory factors and apoptosis associated genes. Bo Qiu, Ming Gong, Qi-Ting He, and Pang-Hu Zhou Copyright © 2016 Bo Qiu et al. All rights reserved. Surgical Strategy for the Chronic Achilles Tendon Rupture Tue, 25 Oct 2016 06:19:33 +0000 Background. Chronic Achilles tendon rupture is usually misdiagnosed and treated improperly. This study aims to better understand the treatment of chronic Achilles tendon rupture. Methods. Patients who were not able to perform a single-limb heel rise were chosen. Pre- and postoperative magnetic resonance imaging (MRI) were conducted. By evaluating the presence or absence of Achilles tendon stumps and the gap length of rupture, V-Y advancement, gastrocnemius fascial turndown flap, or flexor halluces longus tendon transfer were selected for tendon repair. The function of ankle and foot was assessed by American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores and Achilles Tendon Total Rupture Score (ATRS). Results. Twenty-nine patients were followed up. One patient had superficial incision infection, which was healed after debridement and oral antibiotics. Three months postoperatively, MRI showed some signs of inflammation, which disappeared at one or two years postoperatively. All patients were able to perform a single-limb heel rise. Mean AOFAS scores and ATRS scores were increased at the latest follow-up. Conclusion. Surgical options can be determined by evaluating the presence of the Achilles tendon stumps and the gap length, which can avoid using the nearby tendon and yield satisfactory functional results. Yangjing Lin, Liu Yang, Li Yin, and Xiaojun Duan Copyright © 2016 Yangjing Lin et al. All rights reserved. Low-Energy Extracorporeal Shock-Wave Therapy in the Treatment of Chronic Insertional Achilles Tendinopathy: A Case Series Mon, 24 Oct 2016 13:39:21 +0000 Introduction. We report the results of a series of 40 patients with chronic insertional Achilles tendinopathy treated with low-energy ESWT after the failure of a 3-month program of eccentric exercises alone. Methods and Materials. 40 patients, 28 (70%) males and 12 (30%) females, were treated between January and December 2014. All patients were previously treated with only eccentric exercises for a 3-month period. The treatment protocol included 4 sessions of ESWT with a 2-week interval, from 800 shots in each one (4 Hz, 14 KeV), together with eccentric exercises. Visual Analogue Scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) Hindfoot score were recorded. Results. At the 12-month follow-up, 26 (65.0%) patients did not complain about pain (VAS < 2), 11 (27.5%) patients got back to normal activities despite residual pain (VAS 2–4), and 3 (7.5%) of the patients still complained about pain (VAS > 4). There was no significative improvement in both scores after eccentric exercises alone. Mean VAS improvement was SD points (). Mean AOFAS Hindfoot score improvement was SD points (). Conclusions. ESWT is recommended, in combination with an eccentric exercise program, in patients with chronic Achilles tendinopathy being both insertional and not. Vito Pavone, Luca Cannavò, Antonio Di Stefano, Gianluca Testa, Luciano Costarella, and Giuseppe Sessa Copyright © 2016 Vito Pavone et al. All rights reserved. Interspinous Process Decompression: Expanding Treatment Options for Lumbar Spinal Stenosis Thu, 13 Oct 2016 08:15:27 +0000 Interspinous process decompression is a minimally invasive implantation procedure employing a stand-alone interspinous spacer that functions as an extension blocker to prevent compression of neural elements without direct surgical removal of tissue adjacent to the nerves. The Superion® spacer is the only FDA approved stand-alone device available in the US. It is also the only spacer approved by the CMS to be implanted in an ambulatory surgery center. We computed the within-group effect sizes from the Superion IDE trial and compared them to results extrapolated from two randomized trials of decompressive laminectomy. For the ODI, effect sizes were all very large (>1.0) for Superion and laminectomy at 2, 3, and 4 years. For ZCQ, the 2-year Superion symptom severity (1.26) and physical function (1.29) domains were very large; laminectomy effect sizes were very large (1.07) for symptom severity and large for physical function (0.80). Current projections indicate a marked increase in the number of patients with spinal stenosis. Consequently, there remains a keen interest in minimally invasive treatment options that delay or obviate the need for invasive surgical procedures, such as decompressive laminectomy or fusion. Stand-alone interspinous spacers may fill a currently unmet treatment gap in the continuum of care and help to reduce the burden of this chronic degenerative condition on the health care system. Pierce D. Nunley, A. Nick Shamie, Scott L. Blumenthal, Douglas Orndorff, Jon E. Block, and Fred H. Geisler Copyright © 2016 Pierce D. Nunley et al. All rights reserved. Is Hardware Removal Recommended after Ankle Fracture Repair? Thu, 13 Oct 2016 07:32:20 +0000 The indications and clinical necessity for routine hardware removal after treating ankle or distal tibia fracture with open reduction and internal fixation are disputed even when hardware-related pain is insignificant. Thus, we determined the clinical effects of routine hardware removal irrespective of the degree of hardware-related pain, especially in the perspective of patients’ daily activities. This study was conducted on 80 consecutive cases (78 patients) treated by surgery and hardware removal after bony union. There were 56 ankle and 24 distal tibia fractures. The hardware-related pain, ankle joint stiffness, discomfort on ambulation, and patient satisfaction were evaluated before and at least 6 months after hardware removal. Pain score before hardware removal was 3.4 (range 0 to 6) and decreased to 1.3 (range 0 to 6) after removal. 58 (72.5%) patients experienced improved ankle stiffness and 65 (81.3%) less discomfort while walking on uneven ground and 63 (80.8%) patients were satisfied with hardware removal. These results suggest that routine hardware removal after ankle or distal tibia fracture could ameliorate hardware-related pain and improves daily activities and patient satisfaction even when the hardware-related pain is minimal. Hong-Geun Jung, Jin-Il Kim, Jae-Yong Park, Jong-Tae Park, Joon-Sang Eom, and Dong-Oh Lee Copyright © 2016 Hong-Geun Jung et al. All rights reserved. Modification of Mechanical Properties, Polymerization Temperature, and Handling Time of Polymethylmethacrylate Cement for Enhancing Applicability in Vertebroplasty Wed, 12 Oct 2016 14:32:18 +0000 Polymethylmethacrylate (PMMA) bone cement is a popular bone void filler for vertebroplasty. However, the use of PMMA has some drawbacks, including the material’s excessive stiffness, exothermic polymerization, and short handling time. This study aimed to create an ideal modified bone cement to solve the above-mentioned problems. Modified bone cements were prepared by combining PMMA with three different volume fractions of castor oil (5%, 10%, and 15%). The peak polymerization temperatures, times to achieve the peak polymerization temperature, porosities, densities, modulus and maximum compression strengths of standard (without castor oil), and modified cements were investigated following storage at ambient temperature (22°C) or under precooling conditions (3°C). Six specimens were tested in each group of the aforementioned parameters. Increasing castor oil content and precooling treatment effectively decreased the peak polymerization temperatures and increased the duration to achieve the peak polymerization temperature (). Furthermore, the mechanical properties of the material, including density, modulus, and maximum compression strength, decreased with increasing castor oil content. However, preparation temperature (room temperature versus precooling) had no significant effect () on these mechanical properties. In conclusion, the addition of castor oil to PMMA followed by precooling created an ideal modified bone cement with a low modulus, low polymerization temperature, and long handling time, enhancing its applicability and safety for vertebroplasty. Ching-Lung Tai, Po-Liang Lai, Wei-De Lin, Tsung-Tin Tsai, Yen-Chen Lee, Mu-Yi Liu, and Lih-Huei Chen Copyright © 2016 Ching-Lung Tai et al. All rights reserved. The Prevalence of Fragility Fractures in a Population of a Region of Southern Italy Affected by Thyroid Disorders Tue, 11 Oct 2016 10:10:00 +0000 In the literature there is no clear evidence of a relationship between thyropathies and fragility fractures. The aim of our study is to define the prevalence of thyroid disease in a study sample made up of subjects with fragility fractures and from the same geographical area. We retrospectively studied the “hospital discharge records” (HDR) in the Apulian Database for the period 2008–2013 in order to identify all those patients with fragility fractures that required hospitalization. After detecting the prevalent population, we identified the patients affected by thyroid disease. We observed that, between 2008 and 2013 in Apulia, 16,636 patients were affected by hyperthyroidism. In the same period there were 92,341 subjects with hypothyroidism. The incidence of fragility fractures was 4.5% in the population with hyperthyroidism. As regards the population with hypothyroidism, the incidence of fragility fractures was 3.7%. Furthermore, we assessed the statistical connection between thyroid disease and fragility fractures revealing a higher incidence in patients with hyperthyroidism and clinical hypothyroidism. Giuseppe Maccagnano, Angela Notarnicola, Vito Pesce, Simona Mudoni, Silvio Tafuri, and Biagio Moretti Copyright © 2016 Giuseppe Maccagnano et al. All rights reserved. Extrapedicular Infiltration Anesthesia as an Improved Method of Local Anesthesia for Unipedicular Percutaneous Vertebroplasty or Percutaneous Kyphoplasty Wed, 28 Sep 2016 14:24:57 +0000 Aim. This report introduces extrapedicular infiltration anesthesia as an improved method of local anesthesia for unipedicular percutaneous vertebroplasty or percutaneous kyphoplasty. Method. From March 2015 to March 2016, 44 patients (11 males and 33 females) with osteoporotic vertebral compression fractures with a mean age of years (range: 60 to 89) received percutaneous vertebroplasty or percutaneous kyphoplasty. 24 patients were managed with conventional local infiltration anesthesia (CLIA) and 20 patients with both CLIA and extrapedicular infiltration anesthesia (EPIA). Patients evaluated intraoperative pain by means of the visual analogue score and were monitored during the procedure for additional sedative analgesia needs and for adverse nerve root effects. Results. VAS of CLIA + EPIA and CLIA group was and respectively, and there was significant difference (). In CLIA group, 1 patient required additional sedative analgesia, but in CLIA + EPIA group, no patients required that. In the two groups, no adverse nerve root effects were noted. Summary. Extrapedicular infiltration anesthesia provided good local anesthetic effects without significant complications. This method deserves further consideration for use in unipedicular percutaneous vertebroplasty and percutaneous kyphoplasty. Liehua Liu, Shiming Cheng, Rui Lu, and Qiang Zhou Copyright © 2016 Liehua Liu et al. All rights reserved. Platelet-Rich Plasma: The Choice of Activation Method Affects the Release of Bioactive Molecules Thu, 08 Sep 2016 13:43:33 +0000 Platelet-Rich Plasma (PRP) is a low-cost procedure to deliver high concentrations of autologous growth factors (GFs). Platelet activation is a crucial step that might influence the availability of bioactive molecules and therefore tissue healing. Activation of PRP from ten voluntary healthy males was performed by adding 10% of CaCl2, 10% of autologous thrombin, 10% of a mixture of CaCl2 + thrombin, and 10% of collagen type I. Blood derivatives were incubated for 15 and 30 minutes and 1, 2, and 24 hours and samples were evaluated for the release of VEGF, TGF-β1, PDGF-AB, IL-1β, and TNF-α. PRP activated with CaCl2, thrombin, and CaCl2/thrombin formed clots detected from the 15-minute evaluation, whereas in collagen-type-I-activated samples no clot formation was noticed. Collagen type I produced an overall lower GF release. Thrombin, CaCl2/thrombin, and collagen type I activated PRPs showed an immediate release of PDGF and TGF- that remained stable over time, whereas VEGF showed an increasing trend from 15 minutes up to 24 hours. CaCl2 induced a progressive release of GFs from 15 minutes and increasing up to 24 hours. The method chosen to activate PRP influences both its physical form and the releasate in terms of GF amount and release kinetic. Carola Cavallo, Alice Roffi, Brunella Grigolo, Erminia Mariani, Loredana Pratelli, Giulia Merli, Elizaveta Kon, Maurilio Marcacci, and Giuseppe Filardo Copyright © 2016 Carola Cavallo et al. All rights reserved. Minimally Invasive Spinal Surgery Thu, 08 Sep 2016 05:57:46 +0000 Jin-Sung Kim, Roger Härtl, and H. Michael Mayer Copyright © 2016 Jin-Sung Kim et al. All rights reserved. Functional Assessment of the Foot Undergoing Percutaneous Achilles Tenotomy in Term of Gait Analysis Mon, 29 Aug 2016 09:01:24 +0000 Background. This study was designed to evaluate the function of the foot undergoing the procedure of percutaneous Achilles tenotomy (PAT) in case of clubfoot management in terms of gait analysis. Methods. Nineteen patients with unilateral clubfeet were retrospectively reviewed from our database from July 2012 to June 2016. The result in all the cases was rated as excellent according to the scale of International Clubfoot Study Group (ICSG). The affected sides were taken as Group CF and the contralateral sides as Group CL. Three-dimensional gait analysis was applied for the functional evaluation of the involved foot. Results. Statistical difference was found in physical parameters of passive ankle dorsiflexion and plantar-flexion. No statistical difference was found in temporal-spatial parameters. There was statistical difference in kinematic parameters of total ankle rotation, ankle range of motion, and internal foot progression angle and in kinetic parameters of peak ankle power. No statistical difference was found in other kinematic and kinetic parameters. Conclusions. It is demonstrated that the procedure of PAT is safe and efficient for correcting the equinus deformity in case of clubfoot management and preserving the main function of Achilles tendon at the minimum of four-year follow-up. Yu-Bin Liu, Shu-Yun Jiang, Li Zhao, Yan Yu, Xu-Chen Tao, and Da-Hang Zhao Copyright © 2016 Yu-Bin Liu et al. All rights reserved. The Strategy and Early Clinical Outcome of Percutaneous Full-Endoscopic Interlaminar or Extraforaminal Approach for Treatment of Lumbar Disc Herniation Thu, 25 Aug 2016 16:04:39 +0000 Objective is to analyze the surgical strategy, safety, and clinical results of percutaneous full-endoscopic discectomy through interlaminar or extraforaminal puncture technique for LDH. Preoperative CT and MRI were analyzed, which were based on the main location of the herniated disc and its relationship with compressed nerve root. Sixty-two patients satisfied the inclusion criteria during the period from August 2012 to March 2014. We use percutaneous full-endoscopic discectomy through different puncture technique to remove the protrusive NP for LDH. Sixty patients completed the full-endoscopic operation successfully. Their removed disc tissue volume ranged from 1.5 mL to 3.8 mL each time. Postoperative ODI and VAS of low back and sciatica pain were significantly decreased in each time point compared to preoperative ones. No nerve root injury, infection, and other complications occurred. The other two patients were shifted to open surgery. No secondary surgery was required and 91.6% of excellent-to-good ratio was achieved on the basis of Macnab criteria at postoperative 12 months. Acquired benefits are fewer complications, rapid recovery, complete NP removal, effective nerve root decompression, and satisfactory cosmetic effect as well. This is a safe, effective, and rational minimally invasive spine-surgical technology with excellent clinical outcome. Weijun Kong, Wenbo Liao, Jun Ao, Guangru Cao, Jianpu Qin, and Yuqiang Cai Copyright © 2016 Weijun Kong et al. All rights reserved. Experimental Model of Proximal Junctional Fracture after Multilevel Posterior Spinal Instrumentation Wed, 17 Aug 2016 17:34:08 +0000 There is a high risk of proximal junctional fractures (PJF) with multilevel spinal instrumentation, especially in the osteoporotic spine. This problem is associated with significant morbidity and possibly the need for reoperation. Various techniques have been proposed in an attempt to decrease the risk of PJF but there is no experimental model described for in vitro production of PJF after multilevel instrumentation. The objective of this study is to develop an experimental model of PJF after multilevel posterior instrumentation. Initially, four porcine specimens including 4 vertebrae and instrumented at the 3 caudal vertebrae using a pedicle screw construct were subjected to different loading conditions. Loading conditions on porcine specimens involving cyclic loading along the axis of the center vertebral body line, with constrained flexion between 0° and 15° proximally, and fully constraining the specimen distally resulted in a fracture pattern most representative of a PJF seen clinically in humans, so to undergo human cadaveric testing with similar loading conditions was decided. Clinically relevant PJF were produced in all 3 human specimens. The experimental model described in this study will allow the evaluation of different parameters influencing the incidence and prevention of PJF after multilevel posterior spinal instrumentation. Jean-Marc Mac-Thiong, Annie Levasseur, Stefan Parent, and Yvan Petit Copyright © 2016 Jean-Marc Mac-Thiong et al. All rights reserved. PRP Treatment Efficacy for Tendinopathy: A Review of Basic Science Studies Tue, 16 Aug 2016 14:22:14 +0000 Platelet-Rich Plasma (PRP) has been widely used in orthopaedic surgery and sport medicine to treat tendon injuries. However, the efficacy of PRP treatment for tendinopathy is controversial. This paper focuses on reviewing the basic science studies on PRP performed under well-controlled conditions. Both in vitro and in vivo studies describe PRP’s anabolic and anti-inflammatory effects on tendons. While some clinical trials support these findings, others refute them. In this review, we discuss the effectiveness of PRP to treat tendon injuries with evidence presented in basic science studies and the potential reasons for the controversial results in clinical trials. Finally, we comment on the approaches that may be required to improve the efficacy of PRP treatment for tendinopathy. Yiqin Zhou and James H-C. Wang Copyright © 2016 Yiqin Zhou and James H-C. Wang. All rights reserved. A Comparison of Surgical Invasions for Spinal Nerve Ligation with or without Paraspinal Muscle Removal in a Rat Neuropathic Pain Model Thu, 11 Aug 2016 14:44:05 +0000 L5 spinal nerve ligation (SNL) in rats is one of the most popular models for studying neuropathic pain because of its high reproducibility. During the surgery, a part of the L5 paraspinal muscle is usually removed, which produces extra trauma and may potentially affect the physiological processes involved in neuropathic pain. To reduce the surgical trauma, the paraspinal muscle retraction was developed for exposure of the spinal nerve. The current study was aimed at comparing the surgical invasions between the L5 SNL models with paraspinal muscle removal or retraction. The results showed that both methods induced similar neuropathic pain behavior. However, the paraspinal muscle retraction group exhibited an average of 2.7 mg less blood loss than the muscle removal group. This group also showed a significantly lower increase in serum myoglobin and creatine phosphokinase levels on postoperative days 1 and 2, as well as a lower increase in interleukin-1β and interleukin-6 levels on postoperative day 1. The paraspinal muscle maintained normal morphological features following paraspinal muscle retraction. Our results indicate that the SNL rat model with paraspinal muscle retraction is a reliable physiological model that is reproducible, readily available, and less invasive than the model with muscle removal. Yi-Gang Huang, Qing Zhang, Hao Wu, and Chang-Qing Zhang Copyright © 2016 Yi-Gang Huang et al. All rights reserved. Percutaneous Pedicle Screw Fixation with Polymethylmethacrylate Augmentation for the Treatment of Thoracolumbar Intravertebral Pseudoarthrosis Associated with Kummell’s Osteonecrosis Wed, 10 Aug 2016 11:13:58 +0000 Purpose. The purpose of our study is to evaluate the therapeutic efficacy of short-segment percutaneous pedicle screw fixation with polymethylmethacrylate (PMMA) augmentation for the treatment of osteoporotic thoracolumbar compression fracture with osteonecrosis. Methods. Osteoporotic thoracolumbar compression fractures with avascular necrosis were treated by short-segment PPF with PMMA augmentation. Eighteen were followed up for more than 2 years. The kyphotic angle, compression ratio, visual analog scale (VAS) score for back pain, and the Oswestry Disability Index (ODI) were analyzed. In addition, radiologic and clinical parameters of PPF group were compared with percutaneous vertebroplasty (PVP) group. Results. Vertebral height and kyphotic angle of the compressed vertebral bodies were significantly corrected after the operation (). Further, restored vertebral height was maintained during the 2 or more years of postoperative follow-up. Compared to the PVP group the postoperative compression ratio and kyphotic angle were significantly lower in the PPF group (). The postoperative ODI and VAS of the PVP group were significantly higher than the PPF (). Conclusions. According to our results, short-segment PPF with PMMA augmentation may be an effective minimally invasive treatment for osteoporosis in cases of osteoporotic vertebral compression fractures with Kummell’s osteonecrosis. Hyeun-Sung Kim and Dong-Hwa Heo Copyright © 2016 Hyeun-Sung Kim and Dong-Hwa Heo. All rights reserved. The Diagnosis of Iliac Bone Destruction in Children: 22 Cases from Two Centres Mon, 08 Aug 2016 06:16:18 +0000 Iliac bone destruction in children is uncommon and presents various imaging features. Correct diagnosis based on clinical and imaging features is difficult. This research aimed to retrospectively explore the clinical features, imaging, and histopathological diagnosis of children with iliac bone destruction. A total of 22 children with iliac bone destruction were enrolled in this retrospective analysis from two children’s hospitals during July 2007 to April 2015. Clinical features, imaging, and histopathological findings were analysed. The mode of iliac bone destruction, lesion structure, and the relationship between the range of soft tissue mass and cortical destruction were determined based on imaging data. The data were analysed using descriptive methods. Of the iliac bone destruction cases, eight cases were neuroblastoma iliac bone metastasis, seven cases were bone eosinophilic granuloma, two cases were Ewing’s sarcoma, two cases were osteomyelitis, one case was bone cyst, one case was bone fibrous dysplasia, and one case was non-Hodgkin’s lymphoma. Iliac bone destruction varies widely in children. Metastatic neuroblastoma and eosinophilic granuloma are the most commonly involved childhood tumours. Xiangshui Sun, Yue Lou, and Xiaodong Wang Copyright © 2016 Xiangshui Sun et al. All rights reserved. The Midterm Surgical Outcome of Modified Expansive Open-Door Laminoplasty Wed, 03 Aug 2016 06:51:15 +0000 Laminoplasty is a standard technique for treating patients with multilevel cervical spondylotic myelopathy. Modified expansive open-door laminoplasty (MEOLP) preserves the unilateral paraspinal musculature and nuchal ligament and prevents facet joint violation. The purpose of this study was to elucidate the midterm surgical outcomes of this less invasive technique. We retrospectively recruited 65 consecutive patients who underwent MEOLP at our institution in 2011 with at least 4 years of follow-up. Clinical conditions were evaluated by examining neck disability index, Japanese Orthopaedic Association (JOA), Nurick scale, and axial neck pain visual analog scale scores. Sagittal alignment of the cervical spine was assessed using serial lateral static and dynamic radiographs. Clinical and radiographic outcomes revealed significant recovery at the first postoperative year and still exhibited gradual improvement 1–4 years after surgery. The mean JOA recovery rate was 82.3% and 85% range of motion was observed at the final follow-up. None of the patients experienced aggravated or severe neck pain 1 year after surgery or showed complications of temporary C5 nerve palsy and lamina reclosure by the final follow-up. As a less invasive method for reducing surgical dissection by using various modifications, MEOLP yielded satisfactory midterm outcomes. Kuang-Ting Yeh, Ru-Ping Lee, Ing-Ho Chen, Tzai-Chiu Yu, Cheng-Huan Peng, Kuan-Lin Liu, Jen-Hung Wang, and Wen-Tien Wu Copyright © 2016 Kuang-Ting Yeh et al. All rights reserved. “Slalom”: Microsurgical Cross-Over Decompression for Multilevel Degenerative Lumbar Stenosis Mon, 18 Jul 2016 17:29:04 +0000 Objective. Selective, bilateral multisegmental microsurgical decompression of lumbar spinal canal stenosis through separate, alternating cross-over approaches. Indications. Two-segmental and multisegmental degenerative central and lateral lumbar spinal stenosis. Contraindications. None. Surgical Technique. Minimally invasive, muscle, and facet joint-sparing bilateral decompression of the lumbar spinal canal through 2 or more alternating microsurgical cross-over approaches from one side. Results. From December 2010 until December 2015 we operated on 202 patients with 2 or multisegmental stenosis (115 f; 87 m; average age 69.3 yrs, range 51–91 yrs). All patients were suffering from symptoms typical of a degenerative lumbar spinal stenosis. All patients complained about back pain; however the leg symptoms were dominant in all cases. Per decompressed segment, the average OR time was 36 min and the blood loss 45.7 cc. Patients were mobilized 6 hrs postop and hospitalization averaged 5.9 days. A total of 116/202 patients did not need submuscular drainage. 27/202 patients suffered from a complication (13.4%). Dural tears occurred in 3.5%, an epidural hematoma in 5.5%, a deep wound infection in 1.98%, and a temporary radiculopathy postop in 1.5%. Postop follow-up ranged from 12 to 24 months. There was a significant improvement of EQ 5 D, Oswestry Disability Index (ODI), VAS for Back and Leg Pain, and preoperative standing times and walking distances. H. Michael Mayer and Franziska Heider Copyright © 2016 H. Michael Mayer and Franziska Heider. All rights reserved. Historical ESWT Paradigms Are Overcome: A Narrative Review Sun, 17 Jul 2016 13:15:23 +0000 Extracorporeal Shock Wave Therapy (ESWT) is a conservative treatment modality with still growing interest in musculoskeletal disorders. This narrative review aims to present an overview covering 20-year development in the field of musculoskeletal ESWT. Eight historical paradigms have been identified and put under question from a current perspective: energy intensity, focus size, anesthesia, imaging, growth plates, acuteness, calcifications, and number of sessions. All paradigms as set in a historical consensus meeting in 1995 are to be revised. First, modern musculoskeletal ESWT is divided into focused and radial technology and the physical differences are about 100-fold with respect to the applied energy. Most lesions to be treated are easy to reach and clinical focusing plays a major role today. Lesion size is no longer a matter of concern. With the exception of nonunion fractures full, regional, or even local anesthesia is not helpful in musculoskeletal indications. Juvenile patients can also effectively be treated without risk of epiphyseal damage. Further research is needed to answer the question about if and which acute injuries can be managed effectively. Treatment parameters like the number of sessions are still relying on empirical data and have to be further elucidated. Heinz Lohrer, Tanja Nauck, Vasileios Korakakis, and Nikos Malliaropoulos Copyright © 2016 Heinz Lohrer et al. All rights reserved. An Effective and Feasible Method, “Hammering Technique,” for Percutaneous Fixation of Anterior Column Acetabular Fracture Thu, 14 Jul 2016 06:23:30 +0000 Objective. The objective of this study was to evaluate the effectiveness and advantages of percutaneous fixation of anterior column acetabular fracture with “hammering technique.” Materials and Methods. We retrospectively reviewed 16 patients with percutaneous fixation of anterior column acetabular fracture with “hammering technique.” There were 11 males and 5 females with an average age of 38.88 years (range: 24–54 years) in our study. Our study included 7 nondisplaced fractures, 6 mild displaced fractures (<2 mm), and 5 displaced fractures (>2 mm). The mean time from injury to surgery was 4.5 days (range: 2–7 days). Results. The average of operation time was 27.56 minutes (range: 15–45 minutes), and the mean blood loss was 55.28 mL (range: 15–100 mL). The mean fluoroscopic time was 54.78 seconds (range: 40–77 seconds). The first pass of the guide wire was acceptable without cortical perforation or intra-articular perforation in 88.89% (16/18) of the procedures, and the second attempt was in 11.11% (2/18). Conclusion. Our study suggested that percutaneous fixation of anterior column acetabular fracture with “hammering technique” acquired satisfying surgical and clinical outcomes. It may be an alternative satisfying treatment for percutaneous fixation of anterior column acetabular fracture by 2D fluoroscopy using a C-arm with less fluoroscopic time. Lihai Zhang, Peng Yin, Wei Zhang, Tongtong Li, Jiantao Li, Hua Chen, Qi Yao, and Peifu Tang Copyright © 2016 Lihai Zhang et al. All rights reserved. Involvement of the Nonneuronal Cholinergic System in Bone Remodeling in Rat Midpalatal Suture after Rapid Maxillary Expansion Sun, 10 Jul 2016 12:55:14 +0000 Few studies sought to analyze the expression and function of the nonneuronal acetylcholine system in bone remodeling in vivo due to the lack of suitable models. We established a rat maxilla expansion model in which the midline palatine suture of the rat was rapidly expanded under mechanical force application, inducing tissue remodeling and new bone formation, which could be a suitable model to investigate the role of the nonneuronal acetylcholine system in bone remodeling in vivo. During the expansion, the expression pattern changes of the nonneuronal cholinergic system components and the mRNA levels of OPG/RANKL were detected by immunohistochemistry or real-time PCR. The value of the RANKL/OPG ratio significantly increased after 1 day of expansion, indicating dominant bone resorption induced by the mechanical stimulation; however after 3 days of expansion, the value of the RANKL/OPG ratio significantly decreased, suggesting a dominant role of the subsequent bone formation process. Increasing expression of Ach was detected after 3 days of expansion which indicated that ACh might play a role in bone formation. The mRNA expression levels of other components also showed observable changes during the expansion which confirmed the involvement of the nonneuronal cholinergic system in the process of bone remodeling in vivo. Further researches are still needed to figure out the detailed functions of the nonneuronal cholinergic system and its components. Xiaoxia Che, Jie Guo, Lue Wang, Cong Miao, Lihua Ge, Zhenchuan Tian, and Jianhong Wang Copyright © 2016 Xiaoxia Che et al. All rights reserved. Leukocyte-Reduced Platelet-Rich Plasma Treatment of Basal Thumb Arthritis: A Pilot Study Tue, 05 Jul 2016 14:30:57 +0000 A positive effect of intra-articular platelet-rich plasma (PRP) injection has been discussed for osteoarthritic joint conditions in the last years. The purpose of this study was to evaluate PRP injection into the trapeziometacarpal (TMC) joint. We report about ten patients with TMC joint osteoarthritis (OA) that were treated with 2 intra-articular PRP injections 4 weeks apart. PRP was produced using the Double Syringe System (Arthrex Inc., Naples, Florida, USA). A total volume of  mL PRP was injected at the first injection and  mL at the second injection, depending on the volume capacity of the joint. Patients were evaluated using VAS, strength measures, and the Mayo Wrist score and DASH score after 3 and 6 months. VAS significantly decreased from to at six-month follow-up (). The DASH score was unaffected; however, the Mayo Wrist score significantly improved from to at six-month follow-up (). Grip was unaffected, whereas pinch declined from to at six-month follow-up (). We did not observe adverse events after the injection of PRP, except one occurrence of a palmar wrist ganglion, which resolved without treatment. PRP injection for symptomatic TMC OA is a reasonable therapeutic option in early stages TMC OA and can be performed with little to no morbidity. Markus Loibl, Siegmund Lang, Lena-Marie Dendl, Michael Nerlich, Peter Angele, Sebastian Gehmert, and Michaela Huber Copyright © 2016 Markus Loibl et al. All rights reserved. Success and Recurrence Rate after Radial Extracorporeal Shock Wave Therapy for Plantar Fasciopathy: A Retrospective Study Tue, 05 Jul 2016 11:08:10 +0000 Background and Aims. The exploration of an individualised protocol of radial extracorporeal shock wave therapy (rESWT) for plantar fasciopathy, assessing success rates and the recurrence rate over a 1-year period after treatment, is not yet identified in literature. Methods and Results. Between 2006 and 2013, 68 patients (78 heels) were assessed for plantar fasciopathy. An individualised rESWT treatment protocol was applied and retrospectively analysed. Heels were analysed for mean number of shock wave impulses, mean pressure, and mean frequency applied. Significant mean pain reductions were assessed through Visual Analogue Scale (VAS) after 1-month, 3-month, and 1-year follow-up. Success rates were estimated as the percentage of patients having more than 60% VAS pain decrease at each follow-up. 1-year recurrence rate was estimated. The mean VAS score before treatment at 6.9 reduced to 3.6, 1 month after the last session, and to 2.2 and 0.9, after 3 months and 1 year, respectively. Success rates were estimated at 19% (1 month), 70% (3 months), and 98% (1 year). The 1-year recurrence rate was 8%. Moderate positive Spearman’s rho correlation (, ) was found between pretreatment pain duration and the total number of rESWT sessions applied. Conclusions. Individualised rESWT protocol constitutes a suitable treatment for patients undergoing rESWT for plantar fasciitis. Nikos Malliaropoulos, Georgina Crate, Maria Meke, Vasileios Korakakis, Tanja Nauck, Heinz Lohrer, and Nat Padhiar Copyright © 2016 Nikos Malliaropoulos et al. All rights reserved. Combination of Intra-Articular and Intraosseous Injections of Platelet Rich Plasma for Severe Knee Osteoarthritis: A Pilot Study Mon, 04 Jul 2016 07:37:19 +0000 The aim of this study was to assess a novel approach to treating severe knee osteoarthritis by targeting synovial membrane, superficial articular cartilage, synovial fluid, and subchondral bone by combining intra-articular injections and intraosseous infiltrations of platelet rich plasma. We explored a new strategy consisting of intraosseous infiltrations of platelet rich plasma into the subchondral bone in combination with the conventional intra-articular injection in order to tackle several knee joint tissues simultaneously. We assessed the clinical outcomes through osteoarthritis outcome score (KOOS) and the inflammatory response by quantifying mesenchymal stem cells in synovial fluid. There was a significant pain reduction in the KOOS from baseline to week 24 , after treatment , in the secondary outcomes (symptoms, ; ADL, ; sport/rec., ; QOL, ), as well as VAS score () and Lequesne Index . The presence of mesenchymal stem cells in synovial fluid and colony-forming cells one week after treatment decreased substantially from  MSC/μL to  MSC/μL and from to   , respectively. Intra-articular injections combined with intraosseous infiltrations of platelet rich plasma reduce pain and mesenchymal stem cells in synovial fluid, besides significantly improving knee joint function in patients with severe knee osteoarthritis. This trial is registered on EudraCT with the number 2013-003982-32. Mikel Sánchez, Diego Delgado, Pello Sánchez, Emma Muiños-López, Bruno Paiva, Froilán Granero-Moltó, Felipe Prósper, Orlando Pompei, Juan Carlos Pérez, Juan Azofra, Sabino Padilla, and Nicolás Fiz Copyright © 2016 Mikel Sánchez et al. All rights reserved. Application of 3D Printing in the Surgical Planning of Trimalleolar Fracture and Doctor-Patient Communication Sun, 03 Jul 2016 10:43:50 +0000 To evaluate the effect of 3D printing in treating trimalleolar fractures and its roles in physician-patient communication, thirty patients with trimalleolar fractures were randomly divided into the 3D printing assisted-design operation group (Group A) and the no-3D printing assisted-design group (Group B). In Group A, 3D printing was used by the surgeons to produce a prototype of the actual fracture to guide the surgical treatment. All patients underwent open reduction and internal fixation. A questionnaire was designed for doctors and patients to verify the verisimilitude and effectiveness of the 3D-printed prototype. Meanwhile, the operation time and the intraoperative blood loss were compared between the two groups. The fracture prototypes were accurately printed, and the average overall score of the verisimilitude and effectiveness of the 3D-printed prototypes was relatively high. Both the operation time and the intraoperative blood loss in Group A were less than those in Group B (). Patient satisfaction using the 3D-printed prototype and the communication score were points. A 3D-printed prototype can faithfully reflect the anatomy of the fracture site; it can effectively help the doctors plan the operation and represent an effective tool for physician-patient communication. Long Yang, Xian-Wen Shang, Jian-Nan Fan, Zhi-Xu He, Jian-Ji Wang, Miao Liu, Yong Zhuang, and Chuan Ye Copyright © 2016 Long Yang et al. All rights reserved. Four-Strand Core Suture Improves Flexor Tendon Repair Compared to Two-Strand Technique in a Rabbit Model Thu, 30 Jun 2016 14:01:28 +0000 Introduction. This study was designed to investigate the influence of the amount of suture material on the formation of peritendinous adhesions of intrasynovial flexor tendon repairs. Materials and Methods. In 14 rabbits, the flexor tendons of the third and the fourth digit of the right hind leg were cut and repaired using a 2- or 4-strand core suture technique. The repaired tendons were harvested after three and eight weeks. The range of motion of the affected toes was measured and the tendons were processed histologically. The distance between the transected tendon ends, the changes in the peritendinous space, and cellular and extracellular inflammatory reaction were quantified by different staining. Results. A 4-strand core suture resulted in significantly less gap formation. The 2-strand core suture showed a tendency to less adhesion formation. Doubling of the intratendinous suture material was accompanied by an initial increase in leukocyte infiltration and showed a greater amount of formation of myofibroblasts. From the third to the eighth week after flexor tendon repair, both the cellular and the extracellular inflammation decreased significantly. Conclusion. A 4-strand core suture repair leads to a significantly better tendon healing process with less diastasis between the sutured tendon ends despite initially pronounced inflammatory response. Alice Wichelhaus, Sascha Tobias Beyersdoerfer, Brigitte Vollmar, Thomas Mittlmeier, and Philip Gierer Copyright © 2016 Alice Wichelhaus et al. All rights reserved. Fragility Fracture Care and Orthogeriatric Comanagement Mon, 27 Jun 2016 06:21:48 +0000 Christian Kammerlander, Hitendra K. Doshi, Wolfgang Böcker, and Markus Gosch Copyright © 2016 Christian Kammerlander et al. All rights reserved. The Effect of Teriparatide on Fracture Healing of Osteoporotic Patients: A Meta-Analysis of Randomized Controlled Trials Sun, 26 Jun 2016 13:30:09 +0000 Purpose. This meta-analysis is to assess the effectiveness of teriparatide in fracture healing and clinical function improvement of the osteoporotic patients. Methods. We searched PubMed, Embase, Web of Science, and the Cochrane databases for randomized and quasi-randomized controlled trials comparing teriparatide to placebo, no treatment, or comparator interventions in the osteoporotic patients. Results. Five studies with 251 patients were included. Patients treated with teriparatide therapy had a significant shorter radiological fracture healing time compared with those in the control group (mean difference [MD] −4.54 days, 95% confidence interval [CI] −8.80 to −0.28). Stratified analysis showed that lower limb group had significant shorter healing time (MD −6.24 days, 95% CI −7.20 to −5.29), but upper limb group did not (MD −1 days, 95% CI −2.02 to 0.2). Patients treated with teriparatide therapy showed better functional outcome than those in the control group (standardized mean difference [SMD] −1.02, 95% CI −1.81 to −0.22). Patients with therapy duration over 4 weeks would have better functional outcome (SMD −1.68, 95% CI −2.07 to −1.29). Conclusions. Teriparatide is effective in accelerating fracture healing and improving functional outcome of osteoporotic women. However, more clinical studies are warranted in order to determine whether the results are applicable to males and the clinical indications for teriparatide after osteoporotic fractures. Shenghan Lou, Houchen Lv, Guoqi Wang, Licheng Zhang, Ming Li, Zhirui Li, Lihai Zhang, and Peifu Tang Copyright © 2016 Shenghan Lou et al. All rights reserved. Outcomes and National Trends for the Surgical Treatment of Lumbar Spine Trauma Wed, 15 Jun 2016 06:23:18 +0000 Introduction. Operative treatment of lumbar spine compression fractures includes fusion and/or cement augmentation. Our aim was to evaluate postoperative differences in patients treated surgically with fusion, vertebroplasty, or kyphoplasty. Methods. The Nationwide Inpatient Sample Database search for adult vertebral compression fracture patients treated 2004–2011 identified 102,316 surgical patients: 30.6% underwent spinal fusion, 17.1% underwent kyphoplasty, and 49.9% underwent vertebroplasty. Univariate analysis of patient and hospital characteristics, by treatment, was performed. Multivariable analysis was used to determine factors associated with mortality, nonroutine discharge, complications, and patient safety. Results. Average patient age: fusion (46.2), kyphoplasty (78.5), vertebroplasty (76.7) (). Gender, race, household income, hospital-specific characteristics, and insurance differences were found (). Leading comorbidities were hypertension, osteoporosis, and diabetes. Risks for higher mortality (OR 2.0: CI: 1.6–2.5), nonroutine discharge (OR 1.6, CI: 1.6–1.7), complications (OR 1.1, CI: 1.0–1.1), and safety related events (OR 1.1, CI: 1.0–1.1) rose consistently with increasing age, particularly among fusion patients. Preexisting comorbidities and longer in-hospital length of stay were associated with increased odds of nonroutine discharge, complications, and patient safety. Conclusions. Fusion patients had higher rates of poorer outcomes compared to vertebroplasty and kyphoplasty cohorts. Mortality, nonroutine discharge, complications, and adverse events increased consistently with older age. Doniel Drazin, Miriam Nuno, Faris Shweikeh, Alexander R. Vaccaro, Eli Baron, Terrence T. Kim, and J. Patrick Johnson Copyright © 2016 Doniel Drazin et al. All rights reserved. A Comparison of the Effects of Neuronal Nitric Oxide Synthase and Inducible Nitric Oxide Synthase Inhibition on Cartilage Damage Mon, 13 Jun 2016 09:11:58 +0000 The objective of this study was to investigate the effects of selective inducible nitric oxide synthase and neuronal nitric oxide synthase inhibitors on cartilage regeneration. The study involved 27 Wistar rats that were divided into five groups. On Day 1, both knees of 3 rats were resected and placed in a formalin solution as a control group. The remaining 24 rats were separated into 4 groups, and their right knees were surgically damaged. Depending on the groups, the rats were injected with intra-articular normal saline solution, neuronal nitric oxide synthase inhibitor 7-nitroindazole (50 mg/kg), inducible nitric oxide synthase inhibitor amino-guanidine (30 mg/kg), or nitric oxide precursor L-arginine (200 mg/kg). After 21 days, the right and left knees of the rats were resected and placed in formalin solution. The samples were histopathologically examined by a blinded evaluator and scored on 8 parameters. Although selective neuronal nitric oxide synthase inhibition exhibited significant () positive effects on cartilage regeneration following cartilage damage, it was determined that inducible nitric oxide synthase inhibition had no statistically significant effect on cartilage regeneration. It was observed that the nitric oxide synthase activation triggered advanced arthrosis symptoms, such as osteophyte formation. The fact that selective neuronal nitric oxide synthase inhibitors were observed to have mitigating effects on the severity of the damage may, in the future, influence the development of new agents to be used in the treatment of cartilage disorders. Nevzat Selim Gokay, Ibrahim Yilmaz, Baran Komur, Ahu Senem Demiroz, Alper Gokce, Sergülen Dervisoglu, and Banu Vural Gokay Copyright © 2016 Nevzat Selim Gokay et al. All rights reserved. Combined V-Y Fasciocutaneous Advancement and Gluteus Maximus Muscle Rotational Flaps for Treating Sacral Sores Mon, 06 Jun 2016 09:59:59 +0000 The sacral area is the most common site of pressure sore in bed-ridden patients. Though many treatment methods have been proposed, a musculocutaneous flap using the gluteus muscles or a fasciocutaneous flap is the most popular surgical option. Here, we propose a new method that combines the benefits of these 2 methods: combined V-Y fasciocutaneous advancement and gluteus maximus muscle rotational flaps. A retrospective review was performed for 13 patients who underwent this new procedure from March 2011 to December 2013. Patients’ age, sex, accompanying diseases, follow-up duration, surgical details, complications, and recurrence were documented. Computed tomography was performed postoperatively at 2 to 4 weeks and again at 4 to 6 months to identify the thickness and volume of the rotational muscle portion. After surgery, all patients healed within 1 month; 3 patients experienced minor complications. The average follow-up period was 13.6 months, during which time 1 patient had a recurrence (recurrence rate, 7.7%). Average thickness of the rotated muscle was 9.43 mm at 2 to 4 weeks postoperatively and 9.22 mm at 4 to 6 months postoperatively (). Muscle thickness had not decreased, and muscle volume was relatively maintained. This modified method is relatively simple and easy for reconstructing sacral sores, provides sufficient padding, and has little muscle donor-site morbidity. Hyun Ho Han, Eun Jeong Choi, Suk Ho Moon, Yoon Jae Lee, and Deuk Young Oh Copyright © 2016 Hyun Ho Han et al. 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.