BioMed Research International: Orthopedics The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. Biomechanical Effects of Posterior Condylar Offset and Posterior Tibial Slope on Quadriceps Force and Joint Contact Forces in Posterior-Stabilized Total Knee Arthroplasty Sun, 19 Nov 2017 08:06:02 +0000 This study aimed to determine the biomechanical effect of the posterior condylar offset (PCO) and posterior tibial slope (PTS) in posterior-stabilized (PS) fixed-bearing total knee arthroplasty (TKA). We developed ±1, ±2, and ±3 mm PCO models in the posterior direction and −3°, 0°, 3°, and 6° PTS models using a previously validated FE model. The influence of changes in the PCO and PTS on the biomechanical effects under deep-knee-bend loading was investigated. The contact stress on the PE insert increased by 14% and decreased by 7% on average as the PCO increased and decreased, respectively, compared to the neutral position. In addition, the contact stress on post in PE insert increased by 18% on average as PTS increased from −3° to 6°. However, the contact stress on the patellar button decreased by 11% on average as PTS increased from −3° to 6° in all different PCO cases. The quadriceps force decreased by 14% as PTS increased from −3° to 6° in all PCO models. The same trend was found in patellar tendon force. Changes in PCO had adverse biomechanical effects whereas PTS increase had positive biomechanical effects. However, excessive PTS should be avoided to prevent knee instability and subsequent failure. Kyoung-Tak Kang, Yong-Gon Koh, Juhyun Son, Oh-Ryong Kwon, Jun-Sang Lee, and Sae Kwang Kwon Copyright © 2017 Kyoung-Tak Kang et al. All rights reserved. Sciatic Nerve Palsy following Total Hip Replacement: Are Patients Personal Characteristics More Important than Limb Lengthening? A Systematic Review Wed, 15 Nov 2017 08:33:17 +0000 Sciatic nerve palsies are rare but potentially devastating complications, accounting for more than 90% of neurologic injuries following total hip replacement. A systematic literature screening was carried out searching papers evaluating an exclusive population of postarthroplasty sciatic nerve palsies to ascertain (1) the influence of limb lengthening itself on sciatic nerve palsy, (2) the most important risk factors, (3) the long-term prognosis, and (4) the outcomes of different treatments. Fourteen manuscripts were finally included. The wide prevalence of retrospective case series decreased the global methodological quality of the retrieved papers. A hazardous lengthening threshold cannot be surely identified. Developmental dysplasia of the hip and previous hip surgeries are the most frequently recognized risk factors. Rate of full nerve function restoration approximates two-thirds of the cases, independently of the extent of initial neural damage. Poor evidences are available about the best treatment strategy. Well-structured multicentric prospective comparative studies are needed to substantiate or contrast the finding of this review. Anyway, since the onset of palsies is probably due to a combination of individual factors, risk of nerve damage and potential for nerve recovery should be evaluated on an individual basis. Marcello De Fine, Matteo Romagnoli, Stefano Zaffagnini, and Giovanni Pignatti Copyright © 2017 Marcello De Fine et al. All rights reserved. Arthroscopic Management for the Unstable Inferior Leaf of the Lateral Meniscus Anterior Horn and Associated Cysts through a Direct Inframeniscal Portal: A Retrospective Study Mon, 13 Nov 2017 00:00:00 +0000 Introduction. To investigate the clinical results of arthroscopic management for the unstable inferior leaf of the lateral meniscus anterior horn and associated cysts through an inframeniscal portal. Methods. From March 2005 to October 2014, 64 patients with an unstable inferior leaf of the lateral meniscus anterior horn and associated cysts underwent arthroscopic management with an inframeniscal portal. The mean age of the patients was 36.9 years (range, 18 to 49 years). The mean follow-up period was 28 months (range, 24 to 44 months). Clinical results were assessed using physical examination, the Lysholm knee score, and postoperative magnetic resonance scanning. Results. The median Lysholm score improved significantly at 1 year after surgery and at final follow-up. Magnetic resonance scanning at least one year after the operation revealed no recurrent meniscal tears or cysts. No reoperations were required after an average follow-up of 28 months. All patients reported significant symptomatic relief after the operation. They had full range of motion at three months and returned to normal activities and sports one year after surgery. Conclusion. The direct inframeniscal portal can provide an effective approach to manage lesions in the anterior horn of the lateral meniscus with predictable clinical outcomes. Dongyang Chen, Qiangqiang Li, Ye Sun, Jianghui Qin, Yao Yao, and Qing Jiang Copyright © 2017 Dongyang Chen et al. All rights reserved. Intraoperative Myelography in Transpsoas Lateral Lumbar Interbody Fusion for Degenerative Lumbar Spinal Stenosis: A Preliminary Prospective Study Thu, 02 Nov 2017 00:00:00 +0000 Aim. To investigate the feasibility and effectiveness of intraoperative myelography in determining adequacy of indirect spinal canal decompression during transpsoas lateral lumbar interbody fusion (LLIF). Methods. Seven patients diagnosed with degenerative lumbar spinal stenosis (DLSS) were prospectively included to this study. All patients underwent LLIF and subsequently received intraoperative myelography to determine the effect of indirect spinal canal decompression, which was visualized in both anterior-posterior and lateral images. Those patients with insufficient indirect canal decompression were further resolved by microendoscopic canal decompression (MECD). Radiological parameters, including stenosis ratio and dural sac area of operated levels, were measured and compared before and after operation. Besides, all patients were followed up for at least one year using visual analogue scale (VAS) for back and leg, Japanese Orthopaedic Association score (JOA), and Oswestry disability index (ODI). Results. Seven patients with 8 operated levels underwent LLIF safely and demonstrated significant symptom relief postoperatively. Five operated levels showed adequate indirect canal decompression intraoperatively, while the remaining three levels did not achieve the adequacy, and their residual stenosis was resolved following MECD. Radiological parameters were improved statistically when compared with preoperation (). Furthermore, neurological symptoms of all patients were also improved significantly (), shown by improved VAS (back and leg), JOA, and ODI at both two-week and one-year follow-up. Conclusions. Intraoperative myelography during LLIF is able to assess adequacy of indirect canal decompression for DLSS, thus promising favorable clinical outcomes. Yang Yang, Liangming Zhang, Jianwen Dong, Zihao Chen, Peigen Xie, Ruiqiang Chen, Lei He, Feng Feng, Limin Rong, and Bin Liu Copyright © 2017 Yang Yang et al. All rights reserved. Effective Range of Percutaneous Posterior Full-Endoscopic Paramedian Cervical Disc Herniation Discectomy and Indications for Patient Selection Thu, 26 Oct 2017 00:00:00 +0000 The objective was to investigate the effective and safe range of paramedian CDH by percutaneous posterior full-endoscopy cervical intervertebral disc nucleus pulposus resection (PPFECD) to provide a reference for indications and patient selection. Sixteen patients with CDH satisfied the inclusion criteria. Before surgery the patients underwent cervical spine MRI, and the distance between the dural sac and herniated disc was measured. An assessment was performed by MRI immediately after surgery, measuring the distance between dural sac and medial border of discectomy (DSMD). The preoperative average distance between the dural sac and peak of the herniated disc (DSPHD) was 3.87 ± 1.32 mm; preoperative average distance between dural sac and medial border of herniated disc (DSMHD) was 6.91 ± 1.21 mm and an average distance of postoperative DSMD was 5.41 ± 1.40 mm. Postoperative VAS of neck and shoulder pain was significantly decreased but JOA was significantly increased in each time point compared with preoperative ones. In summary, the effective range of PPFECD to treat paramedian CDH was 5.41 ± 1.40 mm, indicating that DSMHD and DSPHD were within 6.91 ± 1.21 mm and 3.87 ± 1.32 mm, respectively. PPFECD surgery is, therefore, a safe and effective treatment option for patients with partial paramedian cervical disc herniation. Hongquan Wen, Xin Wang, Wenbo Liao, Weijun Kong, Jianpu Qin, Xing Chen, Hai Lv, and Thor Friis Copyright © 2017 Hongquan Wen et al. All rights reserved. Reference Values of Flexion and Supination in the Elbow Joint of a Cohort without Shoulder Pathologies Tue, 24 Oct 2017 08:44:09 +0000 Background. After surgery of the long head of the biceps tendon, the examination of the biceps brachii muscle function and strength is common clinical practice. The muscle strength is usually compared with the uninjured contralateral side or with a matched pair group assuming that the uninjured side can be used as an appropriate reference. Hypothesis/Purpose. The purpose of this study was to define reference values of the supination and flexion strength in the elbow joint and to investigate the influence of the arm positions and various anthropometric factors. Methods. 105 participants without any shoulder pathologies were enrolled. A full medical history was obtained and a physical examination was performed. The bilateral isometric testing included the supination torque in various forearm positions and elbow flexion strength with a custom engineered dynamometer. Multiple linear regression analysis was used to investigate the correlation of the strength and anthropometric factors. Results. Only age and gender were significant supination and flexion strength predictors of the elbow. Hence, it was possible to calculate a gender-specific regression line for each forearm position to predict the age-dependent supination torque. The supination strength was greatest with the arm in 90° elbow flexion and the upper arm in full pronation. Mehmet F. Güleçyüz, Matthias F. Pietschmann, Stefan Michalski, Ferdinand M. Eberhard, Alexander Crispin, Christian Schröder, Maximilian J. Mittermüller, and Peter E. Müller Copyright © 2017 Mehmet F. Güleçyüz et al. All rights reserved. Combined Treatment with an Anticoagulant and a Vasodilator Prevents Steroid-Associated Osteonecrosis of Rabbit Femoral Heads by Improving Hypercoagulability Thu, 19 Oct 2017 00:00:00 +0000 Steroid-associated osteonecrosis of the femoral head remains a challenging problem in orthopedics worldwide. One pathomechanism is ischemia of the femoral head, as a result of thrombus formation and vasoconstriction. The present study investigates the effects of combination prevention with enoxaparin and EGb 761 on steroid-associated ONFH in rabbits. Rabbits were randomly divided into 5 groups (control group, model group, enoxaparin group, ginkgo group, and combination group). With the exception of the control group, the groups of rabbits were modeled with lipopolysaccharide and methylprednisolone acetate. Starting with modeling, the enoxaparin group and ginkgo group were injected with 1 μg/kg/day enoxaparin subcutaneously and orally given 40 mg/kg/day EGb 761 for 4 weeks, respectively; the combination group received both treatments. After modeling for 6 weeks, the hematology data indicated prolonged PT and APTT in the three prevention groups. The micro-CT examination revealed higher bone density and better structure; histomorphometry revealed significant pathological changes. Immunohistochemistry revealed higher expression of BMP-2 and VEGF, thus revealing better osteogenesis and angiogenesis activities. Among the three prevention groups, the combination group had the most efficient results. In conclusion, the combined prevention with an anticoagulant and a vasodilator has the potential to decrease the incidence of steroid-associated ONFH in rabbits. Fang Cao, Ge Liu, Wei Wang, Benjie Wang, Xiaowei Wei, Faqiang Lu, Fan Yang, Kai Kang, Yongxuan Wang, Jiahui Yang, Kairong Qin, and Dewei Zhao Copyright © 2017 Fang Cao et al. All rights reserved. Isometric Tunnel Placement in Ulnar Collateral Ligament Reconstruction with Single CT Scan Wed, 18 Oct 2017 00:00:00 +0000 Background. Isometric tunnel placement for anterior bundle of the medial collateral ligament (MCL) reconstruction is mandatory for successful surgery. Purpose. This study aimed to demonstrate a useful method for identifying isometric tunnel placement using a single computed tomography (CT) scan. Study Design. Descriptive Laboratory Study. Methods. Five normal elbows were scanned at 4 different flexion angles at 45° increment. Three-dimensional models were analyzed using 2 different approaches: single and multiple CT scans methods. Ligament footprints in the humerus and the ulna were registered. Ligament length and isometric points were defined. The locations of the isometric points were imported into both methods to be compared. Results. There was no significant difference between 2 methods in calculating the length in every zone. There was also no significant difference in determining isometric ligament’s origin point, which is located approximately  mm and  mm for single and multiple CT, respectively, measured inferolaterally from medial epicondyle. Conclusions. A solid preoperative plan is critical when predicting tunnel locations due to the difficulty in finding isometric points and the individuality of optimal bone tunnel locations. Using single CT scan, optimal locations can be predicted with the same accuracy as a multiple CT scans with less radiation exposure. Erica Kholinne, Rizki Fajar Zulkarnain, Arnold Adikrishna, Bin Zhu, Han Pyo Hong, and In-Ho Jeon Copyright © 2017 Erica Kholinne et al. All rights reserved. Rheumatoid Arthritis Affecting the Upper Cervical Spine: Biomechanical Assessment of the Stabilizing Ligaments Wed, 18 Oct 2017 00:00:00 +0000 Diameters of anterior and posterior atlantodental intervals (AADI and PADI) are diagnostically conclusive regarding ongoing neurological disorders in rheumatoid arthritis. MRI and X-ray are mostly used for patients’ follow-up. This investigation aimed at analyzing these intervals during motion of cervical spine, when transverse and alar ligaments are damaged. AADI and PADI of 10 native, human cervical spines were measured using lateral fluoroscopy, while the spines were assessed in neutral position first, in maximal inclination second, and in maximal extension at last. First, specimens were evaluated under intact conditions, followed by analysis after transverse and alar ligaments were destroyed. Damage of the transverse ligament leads to an increase of the AADI’s diameter about 0.65 mm in flexion and damage of alar ligaments results in significant enhancement of 3.59 mm at mean. In extension, the AADI rises 0.60 mm after the transverse ligament was cut and 0.90 mm when the alar ligaments are damaged. After all ligaments are destroyed, AADI assessed in extension closely resembles AADI at neutral position. Ligamentous damage showed an average significant decrease of the PADI of 1.37 mm in the first step and of 3.57 mm in the second step in flexion, while it is reduced about 1.61 mm and 0.41 mm in the extended and similarly in the neutrally positioned spine. Alar and transverse ligaments are both of obvious importance in order to prevent AAS and movement-related spinal cord compression. Functional imaging is necessary at follow-up in order to identify patients having an advanced risk of neurological disorders. Carolin Meyer, Jan Bredow, Elisa Heising, Peer Eysel, Lars Peter Müller, and Gregor Stein Copyright © 2017 Carolin Meyer et al. All rights reserved. Evaluating the Use of Serum Inflammatory Markers for Preoperative Diagnosis of Infection in Patients with Nonunions Tue, 10 Oct 2017 00:00:00 +0000 Purpose. The aim of this study is to evaluate the effectiveness of laboratory serum tests in the diagnosis of infected nonunion. Methods. Forty-two patients suspected of having infected nonunion were investigated in the study. The serum levels of white blood-cell count (WBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and interleukin-6 (IL-6) were measured. A positive diagnosis of infection was made on the basis of the positive culture results. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of each test were calculated. Results. The sensitivity and specificity of CRP both were higher than IL-6: 60.0% versus 57.1% and 85.7% versus 57.1%, respectively. With one, two, three, and four positive tests, the predicted probabilities of infection were 66.7%, 90.9%, 100%, and 100%, respectively, but the number of patients who had three or four positive tests was small. Conclusions. The diagnostic utility of IL-6 is inferior to CRP and the finding conflicts with previous conclusions drawn from periprosthetic infections. Laboratory analysis of serum inflammatory markers alone is not an effective screening tool for patients suspected of having an infected nonunion. Song Wang, Peng Yin, Chenliang Quan, Kamran Khan, Guoqi Wang, Lijuan Wang, Lin Cui, Licheng Zhang, Lihai Zhang, and Peifu Tang Copyright © 2017 Song Wang et al. All rights reserved. Effect of Computer Navigation on Accuracy and Reliability of Limb Alignment Correction following Open-Wedge High Tibial Osteotomy: A Meta-Analysis Mon, 09 Oct 2017 09:53:04 +0000 Background. It is unclear whether computer navigation can improve the accuracy and reliability of targeted lower limb alignment correction following open-wedge high tibial osteotomy (HTO). This meta-analysis was designed to compare the accuracy and reliability of limb alignment correction between computer navigated and conventional open-wedge HTOs. Methods. Studies that compared postoperative coronal alignment, including mechanical axis (MA) and weight bearing line (WBL) ratio, outliers of alignment correction, and change in tibial posterior slope, following open-wedge HTO performed using computer navigated and conventional methods were included. Results. Ten studies were included in the meta-analysis. The MA (0.93°; 95% confidence interval [CI]: 0.45–1.41°; ) and WBL ratio (1.5%; 95% CI: 0.03–2.98%; ) were significantly greater for computer navigated HTO than for conventional HTO. Outliers of alignment correction after surgery were significantly lower in patients who underwent computer navigated HTO than in those who underwent conventional HTO (odds ratio: 0.25; 95% CI: 0.08–0.79; ). Changes in posterior tibial slope from before to after surgery, however, were similar for the two approaches. Conclusion. Computer navigated HTO resulted in slightly more valgus postoperative alignment and effectively reduced outliers of alignment correction but had no effect on change in posterior tibial slope when compared with conventional HTO. Seung-Beom Han, Hyun Jung Kim, and Dae-Hee Lee Copyright © 2017 Seung-Beom Han et al. All rights reserved. A Comparison of the Device-Related Complications of Intramedullary Lengthening Nails Using a New Classification System Mon, 09 Oct 2017 00:00:00 +0000 The purpose of this study was to understand the pros and cons of the lengthening nails which have their own mechanical mechanism; we propose a classification for “device-related complications” arising from mechanical properties of the nail itself. From March 2010 to March 2014, 115 segments of lower limb lengthening were performed using intramedullary lengthening nails (35 ISKD, 34 PRECICE1, and 46 PRECICE2). Device-related complications were sorted into three categories according to a new classification: distraction control-related (type I), stability related (type II), and other device-related (type III); these were subdivided using Paley’s concept of problems (a), obstacles (b), and sequel (c). Most common complications were distraction mechanism issues (type I) in ISKD and mechanical strength related ones (type II) in PRECICE1 and PRECICE2. Sixty percent (21/35) of ISKD had device-related problems. In PRECICE1 group, 8.8% (3/34) had device-related problems, and 8.8% (3/34) showed device-related obstacle. In PRECICE2, forty-four percent (20/46) had device-related problems. In conclusion, a new classification showed more clearly the differences of mechanical characteristics of different nails. The most essential thing of future lengthening nail development is minimizing the types I and II complications. Further study is necessary to compare the mechanical strength and stability of lengthening nails. Dong Hoon Lee, Sungmin Kim, Jung Woo Lee, Hoon Park, Tae Yoon Kim, and Hyun Woo Kim Copyright © 2017 Dong Hoon Lee et al. All rights reserved. A Randomized Controlled Trial Evaluating the Effects of Diosmin in the Treatment of Radicular Pain Sun, 08 Oct 2017 00:00:00 +0000 Diosmin has been widely used to treat patients with vascular pain for its potent anti-inflammatory and analgesic effects. To evaluate the therapeutic effects of Diosmin in the treatment of radicular pain, we conducted an investigator-initiated, randomized, active-controlled noninferiority trial between January 1, 2009, and December 1, 2010. Diosmin (50 mg/kg/day) was orally administered to treat the radicular pain in 150 patients for one month. Another 150 patients with the same symptom were given 20% 250 ml mannitol (1 g/kg/day) for 7 days and dexamethasone (10 mg/day) for 3 days intravenously guttae. Short-term relief and long-term relief were measured. Secondary outcomes include improvement in functional and psychological status, return to work, and reduction in anti-inflammatory analgesic drugs intake. Patients treated with oral Diosmin achieved reduction in radicular pain. The total satisfaction rate of Diosmin group was 84.7% [95% confidence interval (CI): 77.9%, 90.0%], and the complete satisfaction rate was 50.7% (95% CI: 42.4%, 58.9%). No statistically significant difference was found between the Diosmin group and the active-control group regarding patient satisfaction. No adverse effects were found during the study period. Our study suggests that clinical application of Diosmin with a dose of 50 mg/kg/day might reduce the radicular pain. This trial is registered with ISRCTN97157037. Yinhe Wang, Xin Fang, Lei Ye, Yishan Li, Hongfei Shi, and Yang Cao Copyright © 2017 Yinhe Wang et al. All rights reserved. Use of Limiting Dilution Method for Isolation of Nucleus Pulposus Mesenchymal Stem/Progenitor Cells and Effects of Plating Density on Biological Characteristics and Plasticity Sun, 08 Oct 2017 00:00:00 +0000 Objectives. To evaluate the effects of the limiting dilution method and plating density in rat nucleus pulposus mesenchymal stem/progenitor cells (NPMSCs). Materials and Methods. Nucleus pulposus tissues were isolated from 12-week-old male Sprague-Dawley rats and NPMSCs were isolated using limiting dilution method. Cells were then classified into 3 groups according to plating density. Cell morphologies were observed, and colony-forming units, migration abilities, proliferative capacities, cell cycle percentages, multilineage differentiation capacities, stem cell biomarker expression levels, and immunophenotyping were also examined in each group. Results. Low density group (LD) had higher morphological homogeneity, stronger colony-forming ability, higher cell proliferation capacity, and enhanced cell migration ability relative to the other two groups (). Moreover, LD had more cells entering S phase, with fewer cells arrested in G0/G1 phase (). While all three density groups showed a multilineage differentiation potential, LD showed a higher degree of observed and semiquantified lineage specific staining (). Furthermore, LD displayed higher expression levels of stem cell biomarkers (Nanog, Oct4, and Sox2) and showed higher percentages of CD29+, CD44+, and CD90+ cells () following flow cytometry analysis. Conclusions. Limiting dilution method is suggested when isolating NPMSCs as a means of improving cell activity and plasticity. Linghan Lin, Zhiwei Jia, Yachao Zhao, Yaohong Wu, Xiyan Zhao, Yong Li, Ziming Guo, Jiahai Chen, Shi Cheng, Deli Wang, and Dike Ruan Copyright © 2017 Linghan Lin et al. All rights reserved. Differentiation of Human Amniotic Mesenchymal Stem Cells into Human Anterior Cruciate Ligament Fibroblast Cells by In Vitro Coculture Wed, 20 Sep 2017 00:00:00 +0000 Anterior cruciate ligament injuries are common in humans, though cellular components of the knee have little regenerative or proliferation potential. This study investigated the differentiation of human amnion-derived mesenchymal stem cells (hAMSCs) into human anterior cruciate ligament fibroblasts (hACLFs) in vitro through induction with bFGF and TGF-β1 with coculture systems. Groups A and B comprised hAMSCs at the 3rd passage cultured with and without bFGF and TGF-β1, respectively; Groups C and D consisted of hAMSCs and hACLFs in monolayer coculture with and without bFGF and TGF-β1, respectively; Groups E and F were composed of hAMSCs and hACLFs in Transwell coculture with and without bFGF and TGF-β1, respectively. Cell morphology and proliferation were recorded. Protein expression and relative mRNA expression were evaluated in each group. Cell proliferation was significantly higher in the induced groups than in the noninduced groups. Protein expression increased over time with the highest expression observed in Group E. mRNA levels were significantly higher in Group E than in other groups. This study is the first to demonstrate the use of the Transwell coculture system for this purpose, and hAMSCs were successfully differentiated into hACLFs. Thus, hAMSCs may be a superior choice for hACLF differentiation via Transwell coculture. Yuwan Li, Ziming Liu, Ying Jin, Xizhong Zhu, Shengmin Wang, Jibin Yang, Youliang Ren, Qiang Fu, Huazhang Xiong, Gang Zou, and Yi Liu Copyright © 2017 Yuwan Li et al. All rights reserved. Chronic Open Infective Lateral Malleolus Bursitis Management Using Local Rotational Flap Sun, 17 Sep 2017 00:00:00 +0000 Background. Using a sinus tarsi rotational flap is an uncommon approach to treating chronic open infective lateral malleolus bursitis. Methods. We treated eight patients, including six males, using this approach. First, we debrided all the infected tissues and used a negative pressure wound closure system where needed. After acute infection had been controlled, the local rotational flap was used for cases where the wound could not be closed by a simple suture or bone exposure. The rotational flap was detached with a curved skin incision at the sinus tarsi next to the open wound and sutured to the defect, paying careful attention to the superficial peroneal nerve. The donor site was managed with a split-thickness skin graft. Results. The patients’ mean age was 74.1 years. Six patients had a wound after suppurative infection, but two patients had ulcer-type bursitis. Six patients demonstrated full flap healing, but two patients had venous congestion necrosis. Conclusion. A sinus tarsi rotational flap is a useful method to ensure healing and coverage of chronic open lateral malleolus bursitis, especially for small to medium wounds with cavity and bone exposure. Yong-Beom Lee, Dae-Hwan Kim, Jong-Ho Jung, and Jae-Yong Park Copyright © 2017 Yong-Beom Lee et al. All rights reserved. Reliability of the Footscan® Platform System in Healthy Subjects: A Comparison of without Top-Layer and with Top-Layer Protocols Mon, 11 Sep 2017 00:00:00 +0000 The Footscan platform is a useful tool for plantar pressure measurement. However, there is still controversy over whether or not the platform should be covered by top-layer during the test. This study was designed to compare the reliability of the Footscan platform and identify the differences of the foot loading parameters between without top-layer (WOT) and with top-layer (WT) protocols. Measurements were taken from thirty-two healthy subjects. Participants were tested with a Footscan platform using the WOT and WT protocols. Three trials were performed during two separate testing sessions with a 7-day interval. Peak pressure, contact time, contact area, and pressure-time integral at ten foot zones were recorded and calculated for intra- and intersession reliability using intraclass correlation coefficients (ICCs) and coefficients of variation (CVs). The reliability and values of the analyzed parameters for the two protocols were compared. Both protocols produced a moderate to good level of intra- and intersession reliability. Compared with the WT protocol, the WOT protocol showed higher ICCs, lower CVs, and higher values in most of the parameters analyzed. The results suggest that the WOT protocol showed better reliability than the WT protocol. We recommend not using the top-layer when performing the plantar pressure test. Chao Xu, Xin-Xin Wen, Lu-Yu Huang, Lei Shang, Zhao Yang, Ya-Bo Yan, and Wei Lei Copyright © 2017 Chao Xu et al. All rights reserved. Internal Impingement of the Shoulder: A Risk of False Positive Test Outcomes in External Impingement Tests? Sun, 20 Aug 2017 09:25:08 +0000 Background. External impingement tests are considered as being particularly reliable for identifying subacromial and coracoid shoulder impingement mechanisms. The purpose of the present study was to evaluate if these tests are likely to provoke an internal shoulder impingement mechanism which, in cases of a pathologic condition, can lead to a positive test result. Method. In 37 subjects, the mechanical contact between the glenoid rim and the rotator cuff (RC) was measured quantitatively and qualitatively in external impingement test positions using an open MRI system. Results. Mechanical contact of the supraspinatus with the posterosuperior glenoid was present in 30 subjects in the Neer test. In the Hawkins test, the subscapularis was in contact with the anterosuperior glenoid in 33 subjects and the supraspinatus in 18. In the horizontal impingement test, anterosuperior contact of the supraspinatus with the glenoid was identified in 35 subjects. Conclusion. The Neer, Hawkins, and horizontal impingement tests are likely to provoke the mechanism of an internal shoulder impingement. A posterosuperior internal impingement mechanism is being provoked predominately in the Neer test. The Hawkins test narrows the distance between the insertions of the subscapularis and supraspinatus and the anterosuperior labrum, which leads to an anterosuperior impingement mechanism. Tim Leschinger, Christopher Wallraff, Dirk Müller, Matthias Hackenbroch, Henning Bovenschulte, and Jan Siewe Copyright © 2017 Tim Leschinger et al. All rights reserved. Responders to Platelet-Rich Plasma in Osteoarthritis: A Technical Analysis Sun, 20 Aug 2017 00:00:00 +0000 Purpose. To evaluate the similarities and differences between the variety of platelet-rich plasma (PRP) formulations, preparation, and uses to try to determine the best responses for the treatment of knee osteoarthritis. Materials and Methods. A comparison of the outcomes of randomized controlled trials (RCTs) included in the 3 most recent and high-quality meta-analyses to classify the different studies in 2 groups (bad responders group (BRG) and very good responders group (VGRG)). Results and Discussion. From the 19 RCTs analyzed, 7 trials were included in the VGRG and 4 in the BRG. In VGRG, 1 or 2 injections were performed in 4/7 trials, time between injections was 2 to 3 weeks in 4/5 studies with many injections, volume injected varied from 2.5 to 8 mL, and single spinning technique was used in 5/7 studies. PRP classification was Mishra 4B and PAWP2Bβ in 5/7 studies. The use of PRP with leukocytes is only found in the BRG. Conclusion. There is a lack of standardization in PRP preparation technique for knee osteoarthritis. However it appears that the use of a single spinning technique, a platelet concentration lower than 5 times the baseline, and avoidance of leukocytes should be preferred. Christophe Milants, Olivier Bruyère, and Jean-François Kaux Copyright © 2017 Christophe Milants et al. All rights reserved. Biomechanical Measurement Error Can Be Caused by Fujifilm Thickness: A Theoretical, Experimental, and Computational Analysis Wed, 16 Aug 2017 09:04:49 +0000 This is the first study to quantify the measurement error due to the physical thickness of Fujifilm for several material combinations relevant to orthopaedics. Theoretical and experimental analyses were conducted for cylinder-on-flat indentation over a series of forces (750 and 3000 N), cylinder diameters (0 to 80 mm), and material combinations (metal-on-metal, MOM; metal-on-polymer, MOP; metal-on-bone, MOB). For the scenario without Fujifilm, classic Hertzian theory predicted the true line-type contact width as , where is compressive force, is cylinder diameter, is cylinder length, and are cylinder and flat Poisson’s ratios, and and are cylinder and flat elastic moduli. For the scenario with Fujifilm, experimental measurements resulted in contact widths of for MOM tests, for MOP tests, and for MOB tests, where is compressive force and is cylinder diameter. Fujifilm thickness error ratio showed a nonlinear decrease versus cylinder diameter, whilst error graphs shifted down as force increased. Computational finite element analysis for several test cases agreed with theoretical and experimental data, respectively, to within 3.3% and 1.4%. Despite its wide use, Fujifilm’s measurement errors must be kept in mind when employed in orthopaedic biomechanics research. Ahmed Sarwar, Simli Srivastava, Chris Chu, Alan Machin, Emil H. Schemitsch, Habiba Bougherara, Zahra S. Bagheri, and Radovan Zdero Copyright © 2017 Ahmed Sarwar et al. All rights reserved. Transpseudarthrosis Osteotomy with Interbody Fusion for Kyphotic Spinal Pseudarthrosis in Ankylosing Spondylitis by a Single Posterior Approach: A Retrospective Study and a Brief Relevant Literature Review Thu, 10 Aug 2017 00:00:00 +0000 Objective. To explore the safety and efficacy of transpseudarthrosis osteotomy with interbody fusion in the treatment of Ankylosing Spondylitis (AS) patients with kyphotic spinal pseudarthrosis by a single posterior approach. Methods. Twelve consecutive patients with spinal pseudarthrosis underwent transpseudarthrosis osteotomy and interbody fusion with a polyetheretherketone (PEEK) cage by a single posterior approach. The operative time, intraoperative blood loss, and complications were recorded. Radiographic and clinical results were assessed preoperatively and at the final follow-up. Results. The average operative time was 201.9 min and the mean blood loss was 817.5 ml. The visual analogue scale (VAS) improved significantly from 6.7 preoperatively to 1.1 at the final follow-up. The average correction of the segmental kyphosis at the level of the pseudarthrosis was 22.3°. Bony fusion was achieved in all patients, and there was no obvious loss of correction at follow-up. Conclusion. Transpseudarthrosis osteotomy at the level of the pseudarthrosis can be safely performed and surgical repair of pseudarthrosis with interbody fusion by a single posterior approach was feasible. Erzhu Yang, Liangliang Cao, Guowang Zhang, Xiaofeng Lian, and Jianguang Xu Copyright © 2017 Erzhu Yang et al. All rights reserved. Metabolic Tumor Volume by 18F-FDG PET/CT Can Predict the Clinical Outcome of Primary Malignant Spine/Spinal Tumors Wed, 09 Aug 2017 08:11:56 +0000 Background and Purpose. Primary malignant spine/spinal tumors (PMSTs) are rare and life-threatening diseases. In this study, we demonstrated the advantage of volume-based 18F-FDG PET/CT metabolic parameter, metabolic tumor volume (MTV), for assessing the aggressiveness of PMSTs. Materials and Methods. We retrospectively reviewed 27 patients with PMSTs and calculated , MTV, and total lesion glycolysis (TLG) to compare their accuracy in predicting progression-free survival (PFS) and overall survival (OS) by receiver operating characteristic (ROC) curve analysis. Univariate and multivariate analyses were used to compare the reliability of the metabolic parameters and various clinical factors. Results. MTV exhibited greater accuracy than or TLG. The cut-off values for PFS and OS derived from the AUC data were MTV 45 ml and 83 ml and TLG 250 SUVml and 257 SUVml, respectively. MTV above cut-off value, but not TLG, was identified as significant prognostic factor for PFS by log-lank test (). In addition, MTV was the only significant predictive factors for PFS and OS in the multivariate analysis. Conclusions. MTV was a more accurate predictor of PFS and OS in PMSTs compared to TLG or and helped decision-making for guiding rational treatment options. Yoshihiro Matsumoto, Shingo Baba, Makoto Endo, Nokitaka Setsu, Keiichiro Iida, Jun-Ichi Fukushi, Kenichi Kawaguchi, Seiji Okada, Hirofumi Bekki, Takuro Isoda, Yoshiyuki Kitamura, Hiroshi Honda, and Yasuharu Nakashima Copyright © 2017 Yoshihiro Matsumoto et al. All rights reserved. The Role of Three-Dimensional Scaffolds in Treating Long Bone Defects: Evidence from Preclinical and Clinical Literature—A Systematic Review Wed, 09 Aug 2017 00:00:00 +0000 Long bone defects represent a clinical challenge. Bone tissue engineering (BTE) has been developed to overcome problems associated with conventional methods. The aim of this study was to assess the BTE strategies available in preclinical and clinical settings and the current evidence supporting this approach. A systematic literature screening was performed on PubMed database, searching for both preclinical (only on large animals) and clinical studies. The following string was used: “(Scaffold OR Implant) AND (Long bone defect OR segmental bone defect OR large bone defect OR bone loss defect).” The search retrieved a total of 1573 articles: 51 preclinical and 4 clinical studies were included. The great amount of preclinical papers published over the past few years showed promising findings in terms of radiological and histological evidence. Unfortunately, this in vivo situation is not reflected by a corresponding clinical impact, with few published papers, highly heterogeneous and with small patient populations. Several aspects should be further investigated to translate positive preclinical findings into clinical protocols: the identification of the best biomaterial, with both biological and biomechanical suitable properties, and the selection of the best choice between cells, GFs, or their combination through standardized models to be validated by randomized trials. Alice Roffi, Gopal Shankar Krishnakumar, Natalia Gostynska, Elizaveta Kon, Christian Candrian, and Giuseppe Filardo Copyright © 2017 Alice Roffi et al. All rights reserved. Association between ADAM12 Single-Nucleotide Polymorphisms and Knee Osteoarthritis: A Meta-Analysis Tue, 08 Aug 2017 08:25:50 +0000 Objective. ADAM12 polymorphisms may be associated with the risk of knee osteoarthritis (KOA), but currently available evidence remains controversial. We performed this meta-analysis to confirm whether ADAM12 polymorphisms were associated with susceptibility of KOA. Methods. A comprehensive literature search in PubMed, EMBASE, and ISI Web of Science was conducted to identify observational studies assessing the association between ADAM12 polymorphisms and susceptibility of KOA. The strength of association was indicated as odds ratio (OR) and the corresponding 95% confidence interval (95%CI). Four types of genetic model (additive model, dominant model, recessive model, and allele model) were evaluated for each included study. Subgroup analysis by ethnicity was performed. Results. Seven case-control studies comprising a total of 3512 KOA patients and 5405 healthy controls were included in the meta-analysis. A significant association between rs1871054 and increased KOA risk was found in each genetic model. No significant association was found between KOA and rs3740199, rs1044122, or rs1278279 in any genetic model. Conclusion. Based on the findings of our study, there was a modest but statistically significant association between rs1871054 and risk of KOA in Asian population, while other polymorphisms (rs3740199, rs1044122, or rs1278279) in ADAM12 were not associated with KOA in any population. Zheng-tao Lv, Shuang Liang, Xiao-jian Huang, Peng Cheng, Wen-tao Zhu, and An-min Chen Copyright © 2017 Zheng-tao Lv et al. All rights reserved. The Effect of Patient-Specific Instrumentation Incorporating an Extramedullary Tibial Guide on Operative Efficiency for Total Knee Arthroplasty Thu, 03 Aug 2017 09:47:31 +0000 This retrospective study was to determine if patient-specific instrumentation (PSI) for total knee arthroplasty (TKA) leads to shortened surgical time through increased operating room efficiency according to different tibial PSI designs. 166 patients underwent primary TKA and were categorized into three groups as follows: PSI without extramedullary (EM) tibial guide (group 1, ), PSI with EM tibial guide (group 2, ), and conventional instrumentation (CI) group (group 3, ). Four factors were compared between groups, namely, operative room time, thickness of bone resection, tibial slope, and rotation of the component. The mean surgical time was significantly shorter in the PSI with EM tibial guide group (group 2,  min) compared to the CI group (group 3,  min) (). However, there was no significant difference in the PSI without EM tibial guide group (group 1,  min). This study suggests that PSI incorporating an EM tibial guide may lead to high operative efficiency in TKA compared to CI. This trial is registered with KCT0002384. Oh-Ryong Kwon, Kyoung-Tak Kang, Juhyun Son, Dong-Suk Suh, Dong Beom Heo, and Yong-Gon Koh Copyright © 2017 Oh-Ryong Kwon et al. All rights reserved. Autologous Stem Cells Combined Core Decompression for Treatment of Avascular Necrosis of the Femoral Head: A Systematic Meta-Analysis Thu, 03 Aug 2017 00:00:00 +0000 Objective. This study aims to systematically evaluate the efficacy and safety of core decompression combined transplantation of autologous bone marrow stem cells (CDBMSCs) for treatment of avascular necrosis of the femoral head (ANFH). Methods. Randomized controlled trials (RCTs) regarding effectiveness of core decompression combined transplantation of autologous bone marrow stem cells for treating ANFH were searched in 8 comprehensive databases prior to September 2016. The data analysis was performed by using the RevMan version 5.3. Results. A total of 11 studies with 507 participants were included. Results showed that CDBMSCs group was more effective than CD group in increasing Harris hip score, decreasing necrotic area of femoral head, collapse of femoral head, and conversion to total hip replacement incidence. In the subgroup analysis, the results did not change in different intervention measure substantially. In addition, the safety of CDBMSCs for ANFH is reliable. Conclusion. Based on the systematic review, our findings suggest that core decompression combined transplantation of autologous bone marrow stem cells appeared to be more efficacious in the treatment at early stages of ANFH. Shibing Xu, Lei Zhang, Hongting Jin, Letian Shan, Li Zhou, Luwei Xiao, and Peijian Tong Copyright © 2017 Shibing Xu et al. All rights reserved. Arthroscopically Assisted Coracoclavicular Fixation Using a Single Flip Button Device Technique: What Are the Main Factors Affecting the Maintenance of Reduction? Wed, 02 Aug 2017 00:00:00 +0000 Background. Among coracoclavicular (CC) fixation techniques, the use of flip button device was demonstrated to have successful outcomes with the advantage of being able to accommodate an arthroscopic procedure. Purpose. This study was conducted to investigate the factors associated with loss of fixation after arthroscopically assisted CC fixation using a single flip button device for acromioclavicular (AC) joint dislocations. Materials and Methods. We enrolled a total of 47 patients (35 men and 12 women). Plain radiography was performed at a mean of 24 months postoperatively to evaluate the final radiological outcome. The primary outcome measure was a long-term reduction of the AC joint for at least 24 months. Results. We found that 29 patients had a high quality reduction (61.7%) and 18 patients had a low quality reduction (38.3%) in initial postoperative CT findings. Our study showed that the duration (5 days) from injury to treatment and the quality of initial postoperative reduction were significantly associated with the maintenance of reduction at final follow-up. Conclusion. Our study showed that maintaining stable reduction after arthroscopically assisted CC fixation using a single flip button device technique is difficult especially in patients who received delayed treatment or whose initial reduction quality was poor. Yong-Beom Lee, Jeehyoung Kim, Ho-Won Lee, Byung-Su Kim, Won-Yong Yoon, and Yon-Sik Yoo Copyright © 2017 Yong-Beom Lee et al. All rights reserved. AQUACEL® Ag Surgical Dressing Reduces Surgical Site Infection and Improves Patient Satisfaction in Minimally Invasive Total Knee Arthroplasty: A Prospective, Randomized, Controlled Study Wed, 02 Aug 2017 00:00:00 +0000 The use of modern surgical dressings to prevent wound complications and surgical site infection (SSI) after minimally invasive total knee arthroplasty (MIS-TKA) is lacking. In a prospective, randomized, controlled study, 240 patients were randomized to receive either AQUACEL Ag Surgical dressing (study group) or a standard dressing (control group) after MIS-TKA. The primary outcome was wound complication (SSI and blister). The secondary outcomes were wear time and number of dressing changes in the hospital and patient satisfaction (pain, comfort, and ease of use). In the intention-to-treat analysis, there was a significant reduction in the incidence of superficial SSI (0.8%, 95% CI 0.00–2.48) in the study group compared to 8.3% (95% CI 3.32–13.3) in the control group (). There were no differences in blister and deep/organ-space SSIs between the two groups. Multivariate analysis revealed that AQUACEL Ag Surgical dressing was an independent risk factor for reduction of SSI (odds ratio: 0.07, 95% CI: 0.01–0.58, ). The study group had longer wear time ( versus days, ) and lower number of dressing changes ( versus times, ). Increased patient satisfaction () was also noted in the study group. AQUACEL Ag Surgical dressing is an ideal dressing to provide wound care efficacy, patient satisfaction, reduction of SSI, and cost-effectiveness following MIS-TKA. Feng-Chih Kuo, Bradley Chen, Mel S. Lee, Shih-Hsiang Yen, and Jun-Wen Wang Copyright © 2017 Feng-Chih Kuo et al. All rights reserved. Pathoanatomic Risk Factors for Instability and Adjacent Segment Disease in Lumbar Spine: How to Use Topping Off? Mon, 31 Jul 2017 08:39:20 +0000 Purpose. The goal of this review is to identify criteria indicating implantation of hybrid system into lumbar spine and to evaluate general benefits of use. Methods. A systematic review of literature was performed using current randomized clinical trials, reviews, and meta-analyses. Data sources included relevant literature of human studies identified through searches of Medline Library until May 2015. Results. Predisposing factors for Adjacent Segment Disease (ASDi) are discussed in literature: laminar horizontalization, insufficiency of fascia thoracolumbalis, facet tropism, and facet sagittalization. Currently there is no evidence for topping off. There are only 12 studies and these have no consistent statements about use of a hybrid system for avoidance of ASDi. Conclusion. Hybrid instrumentation of lumbar spine, either with pedicle-based technique or additional spacer, might possibly prevent ASDi from developing in previously damaged segment adjacent to a fusion. Good clinical data proving effectiveness of this new implant technique is as yet unavailable. Thus, currently one must speak of an unevaluated procedure. Various radiological classifications can assist in making a reliable decision as to whether hybrid instrumentation is an appropriate choice of therapy. Pathoanatomical conditions of facet joints and laminae as well as preservation of sagittal balance must also be considered. J. Bredow, L. Löhrer, J. Oppermann, M. J. Scheyerer, R. Sobottke, P. Eysel, and J. Siewe Copyright © 2017 J. Bredow et al. All rights reserved. Effect of Tranexamic Acid on Hematologic Values and Blood Loss in Reverse Total Shoulder Arthroplasty Thu, 27 Jul 2017 00:00:00 +0000 Purpose. Use of tranexamic acid (TXA) in the setting of arthroplasty of the lower extremity has been previously described. The aim of this study was to evaluate the benefit of a single dose of TXA (500 mg vial) administered intravenously just prior to RTSA in an Asian population. Methods. The records of 48 patients (no TXA, , versus TXA, ) that underwent RTSA for cuff tear arthropathy were retrospectively reviewed. All patients had a Hemovac drain positioned for 2 days after surgery. Hemoglobin (Hb) and hematocrit (Hct) were checked on postoperative day 2 and compared with preoperative levels. Results. Hematologic change on postoperative day 2 as determined by Hb level after surgery was statistically lower in the TXA group ( versus (mg/dL), ). Mean fall in Hct level was also significantly less in the TXA group ( versus (L/L), ). Total Hemovac drainage tended to be lower in the TXA group ( versus (ml), ). TXA was found to have no noticeable side effects. Conclusion. The use of a single intravenous dose of TXA immediately prior to RTSA reduces hematologic deterioration postoperatively and the amount of Hemovac drainage. TXA could avoid unnecessary transfusion and its associated medical side effects and cost. Sae Hoon Kim, Whan Ik Jung, Young Jun Kim, Do Hyeon Hwang, and Young Eun Choi Copyright © 2017 Sae Hoon Kim et al. All rights reserved. Interleukin-17 Can Induce Osteoarthritis in Rabbit Knee Joints Similar to Hulth’s Method Wed, 26 Jul 2017 09:22:29 +0000 Interleukin-17 (IL-17) is closely related to osteoarthritis (OA), but animal studies that employ IL-17 to induce OA are currently lacking. Therefore, this study evaluated the effect of IL-17 in the rabbit knee joint. The right knees served as the control group. The left knees were divided randomly into 4 groups: a Hulth group and 3 IL-17 groups (1-ng, 10-ng, and 50-ng groups). OA was induced in the Hulth group using Hulth’s method. The IL-17 groups were injected with 1, 10, or 50 ng of IL-17 as indicated. Specimens were collected at 72 h, 1 week, 3 weeks, 6 weeks, and 12 weeks after surgery or the last injection. Subsequently, the following experiments were conducted: X-ray analysis, histological evaluation, and polymerase chain reaction (PCR) analysis of the mRNA expression levels of cartilage degeneration-related markers. At 12 weeks, like the Hulth group, the 10-ng and 50-ng IL-17 groups displayed typical manifestations of OA. The X-ray results, histological scores, and mRNA expression levels showed statistically significant differences between the control group and the 10-ng and 50-ng IL-17 groups. In sum, injecting 10 ng of IL-17 into the rabbit knee joint can induce OA similar to OA induced by Hulth’s method. Zili Wang, Chenhuang Zheng, Yunbin Zhong, Jinshen He, Xu Cao, Hansong Xia, Hongliang Ba, Pei Li, Song Wu, and Cheng Peng Copyright © 2017 Zili Wang et al. All rights reserved. Evaluation of Risk Factors for Vertebral Compression Fracture after Carbon-Ion Radiotherapy for Primary Spinal and Paraspinal Sarcoma Wed, 26 Jul 2017 08:56:11 +0000 Background and Purpose. Carbon-ion radiotherapy (C-ion RT) was effective therapy for inoperable spinal and paraspinal sarcomas. However, a significant adverse event following radiotherapies is vertebral compression fractures (VCFs). In this study, we investigated the incidence of and risk factors for post-C-ion RT VCFs in patients with spinal or paraspinal sarcomas. Material and Methods. Thirty consecutive patients with spinal or paraspinal sarcomas treated with C-ion RT were retrospectively reviewed. Various clinical parameters and the Spinal Instability Neoplastic Score (SINS) were used to evaluate the risk factors for post-C-ion RT VCFs. Results. The overall incidence of VCFs was 23% (median time: 7 months). Patients with VCFs showed a markedly higher SINS score (median value, 9 points) than those without VCF (5 points). The area under the receiver operating characteristic curve for the SINS score was 0.88, and the optimum SINS cut-off score was 8 points. The cumulative incidence of VCFs at 1 year was 9% for patients with a SINS score under 8 points, versus 80% for those with a SINS score of 8 points or higher (). Conclusions. In patients with a SINS score of 8 points or higher, referral to a spine surgeon for stabilization and multidisciplinary discussion is appropriate. Yoshihiro Matsumoto, Makoto Shinoto, Makoto Endo, Nokitaka Setsu, Keiichiro Iida, Jun-Ichi Fukushi, Kenichi Kawaguchi, Seiji Okada, Hirofumi Bekki, Reiko Imai, Tadashi Kamada, Yoshiyuki Shioyama, and Yasuharu Nakashima Copyright © 2017 Yoshihiro Matsumoto et al. All rights reserved. Surgical Approach May Influence Survival of Large-Diameter Head Metal-on-Metal Total Hip Arthroplasty: A 6- to 10-Year Follow-Up Study Mon, 24 Jul 2017 00:00:00 +0000 Large-diameter head (LDH) metal-on-metal (MoM) total hip arthroplasty (THA) has lost popularity because of metal allergy or ALTRs (adverse local tissue reactions) in the past decade. Whether the surgical approach may influence the survival of LDH-MoM-THA has not been reported. From 2006 to 2009, we performed 96 LDH-MoM-THAs on 80 patients using an in situ head-neck assembly technique through a modified Watson-Jones approach. With a mean follow-up of 8.4 years (range, 6.3–10.1 years), the implant survival rate was 100%. All patients were satisfied with the results and the Harris Hip Score improved from 52 points to 98 points. No ALTRs were found, but 17.7% of the 96 hips (17 adverse events) experienced adverse events related to the cup, including 5 cases of outlier cup malposition, 11 cases of inadequate cup seating, and 1 acetabular fracture. The tissue tension that was improved by a muscle-sparing approach might lessen the chance of microseparation or edge-loading that is taken as the major risk for early implant failure. Further investigation of whether these LDH-MoM-THAs would fail or not would require a longer follow-up or even retrieval analysis in the future. Chih-Chien Hu, Tsan-Wen Huang, Shih-Jie Lin, Po-Chun Lin, Feng-Chih Kuo, Kuo-Ti Peng, Kuo-Chin Huang, Hsin-Nung Shih, and Mel S. Lee Copyright © 2017 Chih-Chien Hu et al. All rights reserved. Open Wedge High Tibial Osteotomy with Distal Tubercle Osteotomy Lessens Change in Patellar Position Tue, 18 Jul 2017 08:00:46 +0000 The purpose of this study was to investigate the change in patellar position after open wedge high tibial osteotomy (OWHTO) with distal tubercle osteotomy (DTO), comparing outcomes of conventional OWHTO in young adults with proximal tibia varus deformity but no arthritic manifestations. Thirty-three patients (mean age, 31.8 years) subjected to OWHTO/DTO were matched with 30 patients (mean age, 33.5 years) undergoing conventional OWHTO. Patellar position, as measured in pre- and postoperative standing lateral radiographs, was compared. Patellar height was assessed via Insall-Salvati ratio, modified Insall-Salvati ratio, Blackburne-Peel (BP) index, Caton-Deschamps (CD) index, and modified Miura-Kawamura index. Computed tomography was used to measure lateral patellar tilt and shift. In the OWHTO group, all patellar height indices decreased significantly following surgery. Although mean values of BP and CD indices decreased significantly in the OWHTO/DTO group, other determinants of patellar height showed no significant postoperative differences. Significant postoperative declines in average lateral patellar tilt were also evident in both groups, but pre- and postoperative lateral patellar shift did not differ significantly. OWHTO/DTO can be performed without significant changes in patellar height. The results obtained support that OWHTO/DTO is suitable for relatively young patients with proximal tibia vara but no arthritic change. Hoon Park, Hyun Woo Kim, Jin Hwa Kam, and Dong Hoon Lee Copyright © 2017 Hoon Park et al. All rights reserved. Corrigendum to “Percutaneous Transforaminal Endoscopic Lumbar Interbody Fusion: Clinical and Radiological Results of Mean 46-Month Follow-Up” Wed, 12 Jul 2017 09:10:51 +0000 Sang-Ho Lee, H. Yener Erken, and Junseok Bae Copyright © 2017 Sang-Ho Lee et al. All rights reserved. Focal Defects of the Knee Articular Surface: Evidence of a Regenerative Potential Pattern in Osteochondritis Dissecans and Degenerative Lesions Sun, 09 Jul 2017 00:00:00 +0000 The surgical treatment of knee articular focal lesions may offer heterogeneous clinical results. Osteochondritis dissecans (OCD) lesions showed to heal better than degenerative lesions (DL) but the underlying biological reasons are unknown. We evaluated the basal histological and immunohistochemical characteristics of these lesions analyzing a series of osteochondral fragments from young patients with similar age but presenting different etiology. Osteochondral tissue samples were stained with Safranin O and graded using a histological score. Markers of mesenchymal progenitor cells (CD146), osteoclasts (tartrate-resistant acid phosphatase, TRAP), and vessels (CD34) were evaluated. Histological score showed a higher degeneration of both cartilage and bone compartments in OCD compared to DL fragments. Only CD146-positive cells were found at the same percentage in cartilage compartment of both DL and OCD patients. By contrast, in the bone compartment a significantly higher percentage of CD146, TRAP, and CD34 markers was found in OCD compared to DL patients. These data showed distinct histological characteristics of osteochondral focal lesions located in the same anatomical region but having a different etiology. The higher percentages of these markers in OCD than in DL, mainly associated with a high bone turnover, could help to explain the higher clinical healing potential of OCD patients. Elena Gabusi, Cristina Manferdini, Francesca Paolella, Laura Gambari, Elizaveta Kon, Giuseppe Filardo, Erminia Mariani, and Gina Lisignoli Copyright © 2017 Elena Gabusi et al. All rights reserved. Basic Fibroblast Growth Factor-Anchored Multilayered Mesenchymal Cell Sheets Accelerate Periosteal Bone Formation Thu, 06 Jul 2017 09:46:58 +0000 Cell-based regenerative therapy has the potential to repair bone injuries or large defects that are recalcitrant to conventional treatment methods, including drugs and surgery. Here, we developed a multilayered cell-based bone formation system using cells coated with fibronectin-gelatin (FN-G) nanofilms. The multilayered mesenchymal cells (MLMCs) were formed after two days of culture and were shown to express higher levels of BMP-2 and VEGF compared to monolayer cultures of MCs. The MLMCs were used as a graft material in combination with a fusion protein consisting of basic fibroblast growth factor (bFGF), polycystic kidney disease (PKD) domain, and the collagen-binding domain (CBD) of Clostridium histolyticum collagenase. In femur sites grafted with the MLMCs, significantly higher levels of callus volume and bone mineral content were observed compared to the sham controls. The callus volume and bone mineral content were further increased in femur sites grafted with bFGF-PKD-CBD/MLMCs. Taken together, these results suggest that bFGF-PKD-CBD/MLMCs, which can be simply and rapidly generated in vitro, have the potential to promote bone repair when grafted into large defect sites. Kentaro Uchida, Gen Inoue, Osamu Matsushita, Kyosuke Horikawa, Hiroyuki Sekiguchi, Wataru Saito, Shotaro Takano, Hisako Fujimaki, Masayuki Miyagi, and Masashi Takaso Copyright © 2017 Kentaro Uchida et al. All rights reserved. Corrigendum to “Assessment of Hip Fracture Risk Using Cross-Section Strain Energy Determined by QCT-Based Finite Element Modeling” Mon, 03 Jul 2017 07:53:03 +0000 Hossein Kheirollahi and Yunhua Luo Copyright © 2017 Hossein Kheirollahi and Yunhua Luo. All rights reserved. Efficacy of Platelet-Rich Plasma in Retarding Intervertebral Disc Degeneration: A Meta-Analysis of Animal Studies Sun, 02 Jul 2017 09:59:00 +0000 Objectives. Several animal studies have demonstrated the positive effects of platelet-rich plasma (PRP) on disc degeneration retardation. The present meta-analysis was to verify the efficacy of PRP in retarding disc degeneration in animal. Methods. Relevant studies were identified and evaluated according to our inclusion and exclusion criteria. The standardized mean difference (SMD) and related 95% confidence interval (95% CI) were estimated to assess PRP efficiency. Results. In total, eleven studies were included in this meta-analysis. Significant differences were found in the PRP treatment group, which showed increased disc height (SMD = 2.66, 95% CI: 1.86, 3.47, ), increased MRI T2 signal intensity (SMD = −3.29, 95% CI: −4.44, −2.13, ), and decreased histological degeneration grade (SMD = −4.28, 95% CI: −5.26, −3.30, ). However, no significant increase in collagen II expression was found (SMD = 25389.74, 95% CI: −27585.72, 78365.21, ). Apart from the subgroup analysis of the disc height based on animal species (pig) and disc degeneration model (chymopapain induction), other subgroup analysis based on animal species (rabbit and rat), study design, disc degeneration model, and follow-up period demonstrated that PRP treatment can significantly restore disc height and increase MRI T2 signal intensity. Conclusions. PRP treatment is potentially effective in restoring disc height of rodent rabbit and rat, reducing histological degeneration grade, and increasing MRI T2 image signal. PRP injection may be promising therapy for retarding disc degeneration. Pei Li, Ruijie Zhang, and Qiang Zhou Copyright © 2017 Pei Li et al. All rights reserved. Comparison of Minimally Invasive Percutaneous Plate Osteosynthesis and Open Reduction Internal Fixation on Proximal Humeral Fracture in Elder Patients: A Systematic Review and Meta-Analysis Thu, 15 Jun 2017 09:21:48 +0000 Objective. The study aims to compare minimally invasive percutaneous plate osteosynthesis (MIPO) and open reduction internal fixation (ORIF) in the treatment of proximal humeral fracture in elder patients. Method. PubMed, Medline, EMbase, Ovid, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wangfang, and VIP Database for Chinese Technical Periodicals were searched to identify all relevant studies from inception to October 2016. Data were analyzed with Cochrane Collaboration’s Review Manage 5.2. Results. A total of 630 patients from 8 publications were included in the systematic review and meta-analysis. The pooled results showed that MIPO was superior to ORIF in the treatment of proximal humeral fracture in elder patients. It was reflected in reducing blood loss, operation time, postoperative pain, or fracture healing time of the surgery and in improving recovery of muscle strength. Concerning complications, no significant difference was seen between MIPO and ORIF. Conclusion. The MIPO was more suitable than ORIF for treating proximal humeral fracture in elder patients. Wei Zhao, Yuhui Zhang, Dongni Johansson, Xingyu Chen, Fang Zheng, and Liangman Li Copyright © 2017 Wei Zhao et al. All rights reserved. Secure Screw Placement in Management of Acetabular Fractures Using the Suprapectineal Quadrilateral Buttress Plate Thu, 15 Jun 2017 08:09:44 +0000 Acetabular fractures involving predominantly the anterior column associated with a disruption of the quadrilateral surface can be treated with instrumentation implementing the stabilization of the quadrilateral surface. The recently introduced suprapectineal quadrilateral buttress plate is specifically designed to prevent secondary medial subluxation of the femoral head, especially in elderly patients with reduced ability for partial weight bearing. Whereas there are guidelines available for safe screw fixation for the anterior and posterior columns, there might be a concern for intra-articular placement of screws placed through the infrapectineal part of the quadrilateral buttress plate. Within this report we analyzed retrospectively screw placement in 30 plates in postoperative CT scans using algorithms for metal artifact reduction. None of the screws of the buttress plate penetrated the hip joint. We describe the placement, length, and spatial orientation of the screws used for fracture fixation and suggest that the use of intraoperative image intensifiers with a combined inlet-obturator view of 30–45° best projects the screws and the hip joint. Preoperative knowledge of approximate screw placement and information for accurate intraoperative imaging may contribute to safe acetabular fracture fixation and may reduce operating time and limit radiation exposure to the patient and the personnel. This trial is registered with KEK-BE: 266/2014. R. J. Egli, M. J. B. Keel, J. L. Cullmann, and J. D. Bastian Copyright © 2017 R. J. Egli et al. All rights reserved. Standard versus Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Prospective Randomized Study Thu, 15 Jun 2017 00:00:00 +0000 Symptomatic spondylolisthesis patients may benefit from surgical decompression and stabilization. The standard (S) technique is a transforaminal lumbar interbody fusion (TLIF). Newer, minimally invasive (MI) techniques seem to provide similar results with less morbidity. We enrolled patients with at least 6 months of symptoms and image-confirmed low-grade spondylolisthesis, at a single academic institution, between 2011 and 2015. The patients were randomized to either S or MI TLIF. The primary outcome measure was the Oswestry Disability Index (ODI) improvement at 1 year. Secondary outcome measures included length of operation, estimated blood loss, length of hospitalization, and fusion rates at 1 year. Forty patients were enrolled in each group. The differences in mean operative time and estimated blood loss were not statistically significant between the two groups. The patients were discharged after surgery at 4.12 days for the S TLIF group and 1.92 days for the MI TLIF group. The ODI improvement was similar and statistically significant in both groups. The fusion was considered solid in 36 (90%) of patients at 1 year in both groups. In conclusion, the two techniques provided similar clinical and radiological outcomes at 1 year. The patients undergoing MI TLIF had a shorter hospital stay. This trial is registered with NCT03155789. Daniel Serban, Niki Calina, and Gabriel Tender Copyright © 2017 Daniel Serban et al. All rights reserved. Protective and Predisposing Morphological Factors in Suprascapular Nerve Entrapment Syndrome: A Fundamental Review Based on Recent Observations Tue, 13 Jun 2017 00:00:00 +0000 Suprascapular nerve entrapment syndrome (SNES) is a neuropathy caused by compression of the nerve along its course. The most common compression sites include the suprascapular notch and the spinoglenoid notch. The aim of this article was to review the anatomical factors influencing the occurrence of SNES in the light of the newest reports. Potential predisposing morphological factors include a V-shaped, narrow, or “deep” suprascapular notch; a band-shaped, bifurcated, or completely ossified superior transverse scapular ligament (STSL); particular arrangements of the suprascapular nerve and vessels at the suprascapular notch. A very recent report indicates structures at the suprascapular notch region that may protect from SNES, such as the suprascapular notch veins (SNV). The role of the anterior coracoscapular ligament (ACSL) is still not clear. While some studies indicate that it may predispose for SNES, the newest study proposes a protective function. Knowledge of these variations is essential for arthroscopic and other surgical procedures of this area in order to avoid iatrogenic injury of the suprascapular nerve or unexpected bleeding from the suprascapular vessels running alongside the STSL. Piotr Łabętowicz, Marek Synder, Mariusz Wojciechowski, Krzysztof Orczyk, Hubert Jezierski, Mirosław Topol, and Michał Polguj Copyright © 2017 Piotr Łabętowicz et al. All rights reserved. Antibiotic Elution from Hip and Knee Acrylic Bone Cement Spacers: A Systematic Review Mon, 05 Jun 2017 06:58:06 +0000 Knowledge about the elution from antibiotic-loaded cement spacers is an indispensable premise for guarantee of clinical success. A systematic literature search was performed through PubMed. Search terms were “antibiotic elution” and “antibiotic release” in combination with “spacer,” “hip spacer,” and “knee spacer,” respectively. A total of 11 studies could be identified. Seven studies reported on the release of antibiotics after spacer implantation, three studies at spacer removal, and one study on both time points. Seven studies reported on hip spacers, one study on knee spacers, and three studies on both. In eight studies, custom-made spacers have been implanted and in three prefabricated ones. In the majority of the studies, the cement has been loaded with an antibiotic combination, mostly consisting of aminoglycoside (either gentamicin or tobramycin) and vancomycin. Measured concentrations exceeded the minimal inhibitory concentration of the particular pathogen organisms in each case. However, large discrepancies were observed with regard to the height of the antibiotic concentration depending on the antibiotic combination and the antibiotic ratio used. Current literature data indicate a sufficient elution of antibiotics after spacer implantation and at spacer removal, respectively. Future studies are required to optimize the local antibiotic therapy at the site of spacer implantation. Konstantinos Anagnostakos and Christof Meyer Copyright © 2017 Konstantinos Anagnostakos and Christof Meyer. All rights reserved. Chronic Expanding Hematoma in the Extremities: A Clinical Problem of Adhesion to the Surrounding Tissues Wed, 31 May 2017 07:44:03 +0000 Chronic expanding hematoma is characterized by continuous growth of a blood collection. We analyzed the clinical features of 7 patients with chronic expanding hematomas in the extremities, with an average age of 65.6 years. All lesions occurred in the lower extremities, with 4 seen in the thigh and 3 in the knee region. Six patients had subcutaneous hematomas, while 1 was deep-seated in the thigh. The magnetic resonance features of the lesion were compatible with those of a standard hematoma. A low signal intensity on T1- and T2-weighted imaging at the pseudocapsule was also characteristic. Cystic features were seen in 5 of 7 patients. All lesions were resected together with their pseudocapsule. In the subcutaneous lesions, it was necessary to resect adherent fascia, with or without involved skin. In the deep-seated thigh lesion, the common peroneal nerve was completely adherent to the pseudocapsule, a phenomenon from absence of the common peroneal nerve which appeared after resection. Chronic expanding hematomas of the extremities are predominantly located in the subcutaneous tissue of the lower extremity. The surrounding pseudocapsule is adherent to the adjacent tissues, and clinicians must be aware of this, especially when resecting a deep-seated lesion. Akio Sakamoto, Takeshi Okamoto, and Shuichi Matsuda Copyright © 2017 Akio Sakamoto et al. All rights reserved. MicroRNA-16-5p Inhibits Osteoclastogenesis in Giant Cell Tumor of Bone Mon, 15 May 2017 00:00:00 +0000 Giant cell tumor (GCT) of bone is an aggressive skeletal tumor characterized by localized bone resorption. MicroRNA-16-5p (miR-16-5p) has been reported to be downregulated in lesions of patients with GCT, but little is known about its role in GCT. To explore the underlying function of miR-16-5p in GCT, we first detected its expression in patients with GCT. The results showed that osteoclast formation increased, whereas miR-16-5p expression considerably decreased with the severity of bone destruction. Furthermore, we found that miR-16-5p expression considerably decreased with the progression of receptor activator of nuclear factor-κB ligand- (RANKL-) induced osteoclastogenesis. Functionally, miR-16-5p mimics significantly reduced RANKL-induced osteoclast formation. However, treatment with an inhibitor of miR-16-5p significantly promoted osteoclastogenesis. These findings reveal that miR-16-5p inhibits osteoclastogenesis and that it may represent a therapeutic target for giant cell tumor of bone. Shang Sang, Zhichang Zhang, Shu Qin, Changwei Li, and Yang Dong Copyright © 2017 Shang Sang et al. All rights reserved. The Risk of Achilles Tendon Rupture in the Patients with Achilles Tendinopathy: Healthcare Database Analysis in the United States Sun, 30 Apr 2017 08:15:00 +0000 Introduction. Disorders of the Achilles tendon can be broadly classified into acute and chronic entities. Few studies have established chronic Achilles tendinopathy as a precursor to acute Achilles ruptures. In this study, we assessed the relationship between Achilles tendinopathy and rupture, clarifying the incidence of rupture in the setting of underlying tendinopathy. Methods. The United Healthcare Orthopedic Dataset from the PearlDiver Patient Record Database was used to identify patients with ICD-9 codes for Achilles rupture and/or Achilles tendinopathy. The number of patients with acute rupture, chronic tendinopathy, and rupture following a prior diagnosis of tendinopathy was assessed. Results. Four percent of patients with an underlying diagnosis of Achilles tendinopathy went on to sustain a rupture (7,232 patients). Older patients with tendinopathy were most vulnerable to subsequent rupture. Conclusions. The current study demonstrates that 4.0% of patients who were previously diagnosed with Achilles tendinopathy sustained an Achilles tendon rupture. Additionally, older patients with Achilles tendinopathy were most vulnerable. These findings are important as they can help clinicians more objectively council patients with Achilles tendinopathy. Youichi Yasui, Ichiro Tonogai, Andrew J. Rosenbaum, Yoshiharu Shimozono, Hirotaka Kawano, and John G. Kennedy Copyright © 2017 Youichi Yasui et al. All rights reserved. Achilles Tendinopathy: From the Basic Science to the Clinic Sun, 30 Apr 2017 00:00:00 +0000 Hong-Yun Li, Youichi Yasui, Seung Hwan Han, Wataru Miyamoto, and Ying-Hui Hua Copyright © 2017 Hong-Yun Li et al. All rights reserved. Chondrocyte-Specific Knockout of TSC-1 Leads to Congenital Spinal Deformity in Mice Mon, 24 Apr 2017 00:00:00 +0000 Congenital spinal deformity is the most severe clinical orthopedic issue worldwide. Among all the pathological processes of congenital spinal deformity, the imbalance of endochondral ossification is considered to be the most important developmental cause of spinal dysplasia. We established chondrocyte-specific TSC-1 knockout (KO) mice to overactivate the energy metabolic component, mammalian target of rapamycin complex 1 (mTORC1), and measured the spinal development by general, imaging, histological, and Western-blot assessments. In addition to skeletal dysplasia, the KO mice displayed severe congenital spinal deformity and significant intervertebral disc changes. This study suggests that, in the process of endochondral ossification, excessive activation of mTORC1 signaling in chondrocytes induces obvious spinal deformity, and the chondrocytes may be the cell type responsible for congenital spinal deformity. Cheng Yang, Yuhui Chen, Zhen Li, He Cao, Keming Chen, Pinglin Lai, Bo Yan, Bin Huang, Jiajun Tang, Shicai Fan, Daozhang Cai, Dadi Jin, Xiaochun Bai, and Rongping Zhou Copyright © 2017 Cheng Yang et al. All rights reserved. Learning Curve and Clinical Outcomes of Performing Surgery with the InterTan Intramedullary Nail in Treating Femoral Intertrochanteric Fractures Wed, 19 Apr 2017 07:15:17 +0000 Purpose. The purpose of this study is to evaluate the learning curve of performing surgery with the InterTan intramedullary nail in treating femoral intertrochanteric fractures, to provide valuable information and experience for surgeons who decide to learn a new procedure. Methods. We retrospectively analyzed data from 53 patients who underwent surgery using an InterTan intramedullary nail at our hospital between July 2012 and September 2015. The negative exponential curve-fit regression analysis was used to evaluate the learning curve. According to 90% learning milestone, patients were divided into two group, and the outcomes were compared. Results. The mean operative time was 69.28 (95% CI 64.57 to 74.00) minutes; with the accumulation of surgical experience, the operation time was gradually decreased. 90% of the potential improvement was expected after 18 cases. In terms of operative time, intraoperative blood loss, hospital stay, and Harris hip score significant differences were found between two groups (, , , and , resp.). Partial weight bearing time, fracture union time, tip apex distance, and the number of blood transfusions and complications were similar between two groups (). Conclusion. This study demonstrated that the learning curve of performing surgery with the InterTan intramedullary nail is acceptable and 90% of the expert’s proficiency level is achieved at around 18 cases. A-Bing Li, Wei-Jiang Zhang, Ji-Qi Wang, You-Ming Zhao, and Wei-Jun Guo Copyright © 2017 A-Bing Li et al. All rights reserved. The Influence of Tribological Pairings and Other Factors on Migration Patterns of Short Stems in Total Hip Arthroplasty Thu, 13 Apr 2017 00:00:00 +0000 Over the last decade, the number of short stem total hip arthroplasty procedures has increased. Along with the possible benefits associated with short stems is a smaller implant-bone contact surface, which may have a negative influence on primary stability and impair osseointegration. Previous studies observed migration of short stems, especially within the first three months. The variables that influence migration in short stem hip implants remain unknown. Therefore, the purpose of this study was to associate the migration of short stems with its possible influencing variables. Migration data from two different short stem studies were retrospectively analyzed. Migration within the first two postoperative years was determined by model-based Roentgen stereophotogrammetric analysis. Migration was correlated to bearing couple, type and size of stem, size of acetabular cup, and age, gender, weight, and height of patients using a multiple factor analysis. Eigenvalue analysis explained 80.7% of the overall variance for the first three dimensions. The four most dominant variables in the first dimension were weight, stem size, acetabular cup size, and patient height (correlations of 0.81, 0.80, 0.71, and 0.70, resp.). None of the analyzed parameters (bearing couple, type and size of stem, size of acetabular cup, and age, gender, weight, and height of patients) affected the migration pattern of short stem THA with primary metaphyseal fixation. Thilo Floerkemeier, Michael Schwarze, Christof Hurschler, Jens Gronewold, Henning Windhagen, Gabriela von Lewinski, and Stefan Budde Copyright © 2017 Thilo Floerkemeier et al. All rights reserved. Morphometric Analysis of the Clavicles in Chinese Population Wed, 12 Apr 2017 00:00:00 +0000 The clavicle has a complex geometry that makes plate fixation technically difficult. The current study aims to measure the anatomical parameters of Chinese clavicles as reference for plate design. One hundred clavicles were analyzed. The clavicle bone model was reconstructed by using computed tomography images. The length, diameters, and curvatures of the clavicle were then measured. The female clavicle was shorter, more slender, and less curved in lateral part than the male clavicle. There was a positive relationship between height and clavicle parameters except lateral curve and depth. The measurements of Chinese clavicles were generally smaller than Caucasians. The clavicle curves were correlated with the bone length; thus consideration of the curve variations may be necessary as designing size distribution of clavicle plate. Jesse Chieh-Szu Yang, Kun-Jhih Lin, Hung-Wen Wei, Cheng-Lun Tsai, Kang-Ping Lin, and Pei-Yuan Lee Copyright © 2017 Jesse Chieh-Szu Yang et al. All rights reserved. Biomechanical Analysis of Cuboid Osteotomy Lateral Column Lengthening for Stage II B Adult-Acquired Flatfoot Deformity: A Cadaveric Study Mon, 10 Apr 2017 06:28:42 +0000 Purpose. To investigate the effect of cuboid osteotomy lateral column lengthening (LCL) for the correction of stage II B adult-acquired flatfoot deformity in cadaver. Methods. Six cadaver specimens were loaded to 350 N. Flatfoot models were established and each was evaluated radiographically and pedobarographically in the following conditions: (1) intact foot, (2) flatfoot, and (3) cuboid osteotomy LCL (2, 3, 4, and 5 mm). Results. Compared with the flatfoot model, the LCLs showed significant correction of talonavicular coverage on anteroposterior radiographs and talus-first metatarsal angle on both anteroposterior and lateral radiographs (). Compared with the intact foot, the above angles of the LCLs showed no significant difference except the 2 mm LCL. In terms of forefoot pressure, medial pressure of the 2 mm LCL () and lateral pressure of the 3, 4, and 5 mm LCLs showed statistical differences (), but lateral pressure of the 3 mm LCL was not more than the intact foot as compared to the 4 and 5 mm LCLs, which was less than medial pressure. Conclusion. Cuboid osteotomy LCL procedure avoids damage to subtalar joint and has a good effect on correction of stage II B adult-acquired flatfoot deformity with a 3 mm lengthening in cadavers. Haichao Zhou, Haoyang Ren, Chunguang Li, Jiang Xia, Guangrong Yu, and Yunfeng Yang Copyright © 2017 Haichao Zhou et al. All rights reserved. miR-155 Inhibits Mouse Osteoblast Differentiation by Suppressing SMAD5 Expression Mon, 03 Apr 2017 07:16:47 +0000 Osteogenesis from preosteoblasts is important for bone tissue engineering. MicroRNAs are a class of endogenous small RNA molecules that potentially modulate osteogenesis. In this study, we found that miR-155 expression was downregulated in a time-dependent manner in cells of the preosteoblast cell line MC3T3-E1 after osteogenic induction using bone morphogenetic protein 2 (BMP2). Transfection with miR-155 decreased alkaline phosphatase (ALP) activity, ALP expression, and the staining intensity of Alizarin Red in MC3T3-E1 cells treated with BMP2, whereas treatment with miR-155 inhibitor promoted BMP2-induced osteoblast differentiation. The luciferase assay confirmed that miR-155 can bind to the 3′ untranslated region of SMAD5 mRNA. miR-155 transfection significantly decreased the expression of SMAD5 protein and mRNA in MC3T3-E1 cells under control media and the p-SMAD5 protein level during osteogenesis. After transfecting cells with the SMAD5 overexpression plasmids, the inhibitory effect of miR-155 on osteogenesis was significantly attenuated. In conclusion, miR-155 inhibited osteoblast differentiation by downregulating the translation of SMAD5 in mouse preosteoblast cells. Inhibition of miR-155 promoted osteogenic potential and thus it can be used as a potential target in the treatment of bone defects. Yue Gu, Lianjun Ma, Lei Song, Xiaoping Li, Dong Chen, and Xiaoxue Bai Copyright © 2017 Yue Gu et al. 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.