Treatment of the Failed Modular Neck Stems: Tips and Tricks

BACKGROUND

Modular femoral components emerged because of the advantages of recreating limb length, offset, and native femoral version in total hip arthroplasty. Despite its potential benefits, the increase in modularity at the head-neck junction can lead to corrosion and subsequently failure of the implant.

METHODS

We present 3 case examples of patients who underwent revision surgery secondary to corrosion of their modular femoral components.

RESULTS

Issues addressed include understanding corrosion at the head-neck junction, presentations of adverse local tissue reactions, efficacy of metal ion testing and metal artifact reduction sequence magnetic resonance imaging, and approaches to revision surgery for failed modular neck stems.

CONCLUSIONS

When revision surgery is indicated for failed modular neck stems, we recommend a thoughtful approach with contemporary extraction techniques and options to enhance stability. Furthermore, long-term follow-up is needed to define the growing effect of modularity in total hip arthroplasty.

Nonvascularized fibular grafting in nonunion of femoral neck fracture: A systematic review

Nonunion of femoral neck fractures following primary fixation and neglected femoral neck fracture in young adults is a challenging task. Every effort should be directed toward hip joint salvage in these patients. Among different available options of hip salvage, nonvascularized fibular graft (NVFG) osteosynthesis is simple, easy to perform, and a successful technique. In this review, the available literature on NVFG in neglected and nonunion femoral neck fractures has been analyzed. After review of 15 articles on NVFG, the average nonunion rate was estimated to be 7.86% (range 0-31%). Six articles that evaluated the preoperative and postoperative osteonecrosis reported improvement in 50% patients. The clinical and/or functional outcome was good to excellent in 56-96% patients following fibular osteosynthesis. Few complications such as coxa vara deformity, limb shortening, and intraarticular penetration of the graft or hardware have been reported. However, there are minimal donor site morbidities such as mild ankle pain, transient loss of toe flexors and extensors and transient lateral popliteal nerve palsy.

Magnetic resonance imaging characterization of individual ankle syndesmosis structures in asymptomatic and surgically treated cohorts

PURPOSE

Historically, syndesmosis injuries have been underdiagnosed. The purpose of this study was to characterize the 3.0-T MRI presentations of the distal tibiofibular syndesmosis and its individual structures in both asymptomatic and injured cohorts.

METHODS

Ten age-matched asymptomatic volunteers were imaged to characterize the asymptomatic syndesmotic anatomy. A series of 21 consecutive patients with a pre-operative 3.0-T ankle MRI and subsequent arthroscopic evaluation for suspected syndesmotic injury were reviewed and analysed. Prospectively collected pre-operative MRI findings were correlated with arthroscopy to assess diagnostic accuracy [sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV)].

RESULTS

Pathology diagnosed on pre-operative MRI correlated strongly with arthroscopic findings. Syndesmotic ligament disruption was prospectively diagnosed on MRI with excellent sensitivity, specificity, PPV, NPV, and accuracy: anterior inferior tibiofibular ligament (87.5, 100, 100, 71.4, 90.5 %); posterior inferior tibiofibular ligament (N/A, 95.2, 0.0, 100, 95.2 %); and interosseous tibiofibular ligament (66.7, 86.7, 66.7, 86.7, 81.0 %).

CONCLUSIONS

Pre-operative 3.0-T MRI demonstrated excellent accuracy in the diagnosis of syndesmotic ligament tears and allowed for the visualization of relevant individual syndesmosis structures. Using a standard clinical ankle MRI protocol at 3.0-T, associated ligament injuries could be readily identified. Clinical implementation of optimal high-field MRI sequences in a standard clinical ankle MRI exam can aid in the diagnosis of syndesmotic injuries, augment pre-operative planning, and facilitate anatomic repair by providing additional details regarding the integrity of individual syndesmotic structures not discernible through physical examination and radiographic assessments.

LEVEL OF EVIDENCE

II.

Total joint replacement: A multiple risk factor analysis of physical activity level 1-2 years postoperatively

Background and purpose - The effect of total joint arthroplasty (TJA) on physical activity is not fully understood. We investigated the change in physical activity after TJA and patient factors associated with change. Patients and methods - Using a total joint replacement registry, primary total hip arthroplasty (THA) patients (n = 5,678) and knee arthroplasty (TKA) patients (n = 11,084) between January 1, 2010 and December 31, 2012 were identified. Median age at THA was 68 and median age at TKA was 67. Change in self-reported physical activity (minutes per week) from before TJA (within 1 year of surgery) to after TJA (1-2 years) was the outcome of interest. Patient demographics and comorbidities were evaluated as risk factors. Multiple linear regression was used. Results - Median physical activity before surgery was 50 min/week (IQR: 0-140) for THA patients and 58 (IQR: 3-143) for TKA patients. Median physical activity after surgery was 150 min/week (IQR: 60-280) for both THA patients and TKA patients. Following TJA, 50% of patients met CDC/WHO physical activity guideline criteria. Higher body mass index was associated with lower change in physical activity (THA: -7.1 min/week; TKA: -5.9 min/week). Females had lower change than males (THA: -11 min/week; TKA: -9.1 min/week). In TKA patients, renal failure was associated with lower change (-17 min/week), as were neurological disorders (-30 min/week). Interpretation - Self-reported minutes of physical activity increased from before to after TJA, but 50% of TJA patients did not meet recommended physical activity guideline criteria. Higher body mass index, female sex, and specific comorbidities were found to be associated with low change in physical activity. Patient education on the benefits of physical activity should concentrate on these subgroups of patients.

Analysis of Dual Mobility Liner Rim Damage Using Retrieved Components and Cadaver Models

BACKGROUND

The objective of this study was to assess the retentive rim of retrieved dual mobility liners for visible evidence of deformation from femoral neck contact and to use cadaver models to determine if anterior soft tissue impingement could contribute to such deformation.

METHODS

Fifteen surgically retrieved polyethylene liners were assessed for evidence of rim deformation. The average time in vivo was 31.4 months, and all patients were revised for reasons other than intraprosthetic dislocation. Liner interaction with the iliopsoas was studied visually and with fluoroscopy in cadaver specimens using a dual mobility system different than the retrieval study. For fluoroscopic visualization, a metal wire was sutured to the iliopsoas and wires were also embedded into grooves on the outer surface of the liner and the inner head.

RESULTS

All retrievals showed evidence of femoral neck contact. The cadaver experiments showed that liner motion was impeded by impingement with the iliopsoas tendon in low flexion angles. When observing the hip during maximum hyperextension, 0°, 15°, and 30° of flexion, there was noticeable tenting of the iliopsoas caused by impingement with the liner.

CONCLUSION

Liner rim deformation resulting from contact with the femoral neck likely begins during early in vivo function. The presence of deformation is indicative of a mechanism inhibiting mobility of the liner. The cadaver studies showed that liner motion could be impeded because of its impingement with the iliopsoas. Such soft tissue impingement may be one mechanism by which liner motion is routinely inhibited, which can result in load transfer from the neck to the rim.

The roles of Tenascin C and Fibronectin 1 in adhesive capsulitis: a pilot gene expression study

OBJECTIVES

We evaluated mRNA expression levels of genes that encode TGF-β1; the TGF-β1 receptor; the collagen-modifying enzymes LOX, PLOD1, and PLOD2; and the extracellular matrix proteins COMP, FN1, TNC and TNXB in synovial/capsule specimens from patients with idiopathic adhesive capsulitis. Possible associations between the measured mRNA levels and clinical parameters were also investigated.

METHODS

We obtained glenohumeral joint synovium/capsule specimens from 9 patients with idiopathic adhesive capsulitis who had not shown improvement in symptoms after 5 months of physiotherapy. Adhesive capsulitis was confirmed in all patients by magnetic resonance imaging. We also obtained specimens from 8 control patients who had underwent surgery for acute acromioclavicular joint dislocation and who had radiological indication of glenohumeral capsule alteration based on arthroscopic evaluation. mRNA expression in the synovium/capsule specimens was analyzed by quantitative reverse transcription PCR. The B2M and HPRT1 genes were used as references to normalize target gene expression in the shoulder tissue samples.

RESULTS

The synovium/capsule samples from the patients with adhesive capsulitis had significantly higher TNC and FN1 expression than those from the controls. Additionally, symptom duration directly correlated with expression of TGFβ1 receptor I.

CONCLUSION

Elevated levels of TNC and FN1 expression may be a marker of capsule injury. Upregulation of TGFβ1 receptor I seems to be dependent on symptom duration; therefore, TGFβ signaling may be involved in adhesive capsulitis. As such, TNC, FN1 and TGFβ1 receptor I may also play roles in adhesive capsulitis by contributing to capsule inflammation and fibrosis.

Insulin and vanadium protect against osteoarthritis development secondary to diabetes mellitus in rats

OBJECTIVE

Diabetic complications such as cardiovascular disease and osteoarthritis (OA) are among the common public health problems. The effect of insulin on OA secondary to diabetes has not been investigated before in animal models. Therefore, we sought to determine whether insulin and the insulin-mimicking agent, vanadium can protect from developing OA in diabetic rats.

METHODS

Type 1 diabetes mellitus (T1DM) was induced in Sprague-Dawley rats and treated with insulin and/or vanadium. Tissues harvested from the articular cartilage of the knee joint were examined by scanning electron microscopy, and blood samples were assayed for oxidative stress and inflammatory biomarkers.

RESULTS

Eight weeks following the induction of diabetes, a profound damage to the knee joint compared to the control non-diabetic group was observed. Treatment of diabetic rats with insulin and/or vanadium differentially protected from diabetes-induced cartilage damage and deteriorated fibrils of collagen fibers. The relative biological potencies were insulin + vanadium >> insulin > vanadium. Furthermore, there was about 2- to 5-fold increase in TNF-α (from 31.02 ± 1.92 to 60.5 ± 1.18 pg/ml, p < 0.0001) and IL-6 (from 64.67 ± 8.16 to 338.0 ± 38.9 pg/ml, p < 0.0001) cytokines and free radicals measured as TBARS (from 3.21 ± 0.37 to 11.48 ± 1.5 µM, p < 0.0001) in the diabetic group, which was significantly reduced with insulin and or vanadium. Meanwhile, SOD decreased (from 17.79 ± 8.9 to 8.250.29, p < 0.0001) and was increased with insulin and vanadium. The relative potencies of the treating agents on inflammatory and oxidative stress biomarkers were insulin + vanadium >> insulin > vanadium.

CONCLUSION

The present study demonstrates that co-administration of insulin and vanadium to T1DM rats protect against diabetes-induced OA possibly by lowering biomarkers of inflammation and oxidative stress.

A Comparison of the Contact Force Distributions on the Acetabular Surface Due to Orthopedic Treatments for Developmental Hip Dysplasia

We used a three-dimensional rigid body spring model (RBSM) to compare the contact force distributions on the acetabular surface of the infant hip joint that are produced by three orthopedic treatments for developmental dysplasia of the hip (DDH). We analyzed treatments using a Pavlik harness, a generic rigid splint, and a spica cast. The joint geometry was modeled from tomography images of a 1-year-old female. The articular cartilage was modeled as linear springs connecting the surfaces of the acetabulum and the femoral head, whereas the femur and the hip bone were considered as rigid bodies. The hip muscles were modeled as tensile-only preloaded springs. The treatments with the Pavlik harness and the generic rigid splint were modeled for an infant in supine position with a hip flexion angle of 90 deg. Also, since rigid splints are often recommended when children are initiating their gait phase, we modeled the treatment with the infant in standing position. For the spica cast, we only considered the infant in standing position with a flexion angle of 0 deg, and the fixation bar at two heights: at the ankle and at the knee. In order to analyze the effect of the hip abduction angle over the contact force distribution, different abduction angles were used for all the treatments modeled. We have found that the treatments with the infant in supine position, with a flexion angle of 90 deg and abduction angles between 60 deg and 80 deg, produce a more homogenous contact force distribution compared to those obtained for the treatments with the infant in standing position.

UNCEMENTED ARTHROPLASTY AFTER HIP METASTATIC DISEASE AND MULTIPLE MYELOMA

Objective:

To describe a case series using a combination of narrative, graphical exploratory analysis and Bayesian Network modeling.

Methods:

Case series with 34 patients undergoing uncemented and hybrid arthroplasty procedures secondary to hip pain or fracture secondary to metastatic disease or multiple myeloma.

Results:

The most common tumors included gastrointestinal, multiple myeloma and breast cancer. Most devices were total arthroplasty (n = 16, 84.2%) rather than partial and uncemented arthroplasty (n = 12, 63.2%) rather than hybrid. The average time between surgery and deambulation was 20 days, the average length of hospital stay was 13 days, and the average patient survival was 589 days. Only one infection was reported. Uncemented and hybrid arthroplasty devices did not differ regarding time to walk, as well as the length of hospital stay in this sample.

Conclusion:

Our model may be used as a prior for the addition of subsequent patient samples, personalizing, thus, its recommendations to other patient populations. Level of Evidence IV, Case series.

FDG-PET imaging in hematological malignancies

The majority of aggressive lymphomas is characterized by an up regulated glycolytic activity, which enables the visualization by F-18 FDG-PET/CT. One-stop hybrid FDG-PET/CT combines the functional and morphologic information, outperforming both, CT and FDG-PET as separate imaging modalities. This has resulted in several recommendations using FDG-PET/CT for staging, restaging, monitoring during therapy, and assessment of treatment response as well as identification of malignant transformation. FDG-PET/CT may obviate the need for a bone marrow biopsy in patients with Hodgkin's lymphoma and diffuse large B cell lymphoma. FDG-PET/CT response assessment is recommended for FDG-avid lymphomas, whereas CT-based response evaluation remains important in lymphomas with low or variable FDG avidity. The treatment induced change in metabolic activity allows for assessment of response after completion of therapy as well as prediction of outcome early during therapy. The five-point scale Deauville Criteria allows the assessment of treatment response based on visual FDG-PET analysis. Although the use of FDG-PET/CT for prediction of therapeutic response is promising it should only be conducted in the context of clinical trials. Surveillance FDG-PET/CT after complete remission is discouraged due to the relative high number of false-positive findings, which in turn may result in further unnecessary investigations. Future directions include the use of new PET tracers such as F-18 fluorothymidine (FLT), a surrogate biomarker of cellular proliferation and Ga-68 CXCR4, a chemokine receptor imaging biomarker as well as innovative digital PET/CT and PET/MRI techniques.

The influence of different non-articular proximal forearm orthoses (brace) widths in the wrist extensors muscle activity, range of motion and grip strength in healthy volunteers

PURPOSE

The purpose this study was perform a biomechanical evaluation to compare the influence of commercial models of different non-articular proximal forearm orthoses widths (2.5 cm, 5.5 cm, 7.5 cm and 12.0 cm) in the extensor muscle activation, range of motion and grip strength in healthy subjects.

METHODS

Was analyzed data from extensor carpi radialis, extensor carpi ulnares and extensor digitorum comunis using surface electromyography, simultaneous with a wrist electrogoniometer MiotecTM and a hydraulic dynamometer JamarTM. The sequence of tests with all the commercial orthoses models was randomized. Statistics analyses were performed by linear model with mixed effects.

RESULTS

According to our findings the non-articular proximal forearm orthoses (2.5 cm - narrowest) positioned close to lateral epicondyle provided lesser muscle activation on extensor carpi radialis brevis/longus and extensor digitorum comunis, decreased wrist extension and grip strength during submaximal grip task (p< 0.01).

CONCLUSIONS

A narrow non-articular proximal forearm orthosis positioned close to the lateral epicondyle might decrease the extensor muscle activation and therefore could reduce mechanical stress on its insertion, based on this sample. Clinical studies must be conducted to confirm these findings.

A cross-sectional study investigating impressions and opinions of medical rehabilitation professionals on the effectiveness of the Ponseti method for treatment of clubfoot in Harare, Zimbabwe

Background

The Ponseti method of managing clubfoot was introduced in Zimbabwe in 2011. This followed massive training of health workers such as medical rehabilitation practitioners through a programme called the Zimbabwe Sustainable Clubfoot Programme. Today, the Ponseti method is the technique of choice for managing clubfoot in hospitals. However, since then, there is no published evidence documenting the efficacy and the relevance of the technique especially comparing to previously used methods. This is a significant shortcoming if sustainability issues are to be considered. Therefore, this study was designed to investigate the impressions and opinions of medical rehabilitation practitioners on the method in terms of its effectiveness, perceived challenges and possible recommendations for improvement of the technique application in their setting.

Methods

A descriptive cross-sectional study was conducted targeting medical rehabilitation practitioners previously trained on the method and working in public or private clinics that offer clubfoot management in Harare. A questionnaire was self-administered to 41 participants who volunteered to participate in the study. Data from open-ended questions was analysed thematically. Statistica version 12 was used for analysis for quantitative data.

Results

The Ponseti method was perceived as an effective method in the treatment of children with clubfoot by all the participants. All the participants 41 (100 %) felt that the method was relevant because of better clinical outcomes. Amongst challenges faced when using Ponseti method, 25 (61 %) participants agreed that caregivers to the children with clubfoot were not compliant to treatment. A total of 22 (54 %) participants felt that lack of adequate insight by the caregivers of this new method was a challenge which hinder progress in treating clubfoot.

Conclusions

The medical rehabilitation professionals in Harare, Zimbabwe trained to use the Ponseti technique for the management of clubfoot, perceived the method as an effective method resulting in better clinical outcome than previous methods. This probably highlights the need to continue training medical rehabilitation professionals so that there is widespread use of the technique in the country. However, there is need to increase awareness of the method among caregivers to improve compliance, which is key to successful rehabilitation of the clubfoot.

Propionibacterium avidum as an Etiological Agent of Prosthetic Hip Joint Infection

Propionibacterium acnes is well-established as a possible etiologic agent of prosthetic joint infections (PJIs). Other Propionibacterium spp. have occasionally been described as a cause of PJIs, but this has not previously been the case for P. avidum despite its capacity to form biofilm. We describe two patients with prosthetic hip joint infections caused by P. avidum. Both patients were primarily operated with an anteriorly curved skin incision close to the skin crease of the groin, and both were obese. Initial treatment was performed according to the DAIR procedure (debridement, antibiotics, and implant retention). In case 1, the outcome was successful, but in case 2, a loosening of the cup was present 18 months post debridement. The P. avidum isolate from case 1 and two isolates from case 2 (obtained 18 months apart) were selected for whole genome sequencing. The genome of P. avidum obtained from case 1 was approximately 60 kb larger than the genomes of the two isolates of case 2. These latter isolates were clonal with the exception of SNPs in the genome. All three strains possessed the gene cluster encoding exopolysaccharide synthesis.

P. avidum has a pathogenic potential and the ability to cause clinically relevant infections, including abscess formation, in the presence of foreign bodies such as prosthetic joint components. Skin incision in close proximity to the groin or deep skin crease, such as the anteriorly curved skin incision approach, might pose a risk of PJIs by P. avidum, especially in obese patients.

Effectiveness of Bicycle Safety Helmets in Preventing Facial Injuries in Road Accidents

BACKGROUND

The effectiveness of bicycle safety helmets in preventing head injuries is well- documented. Recent studies differ regarding the effectiveness of bicycle helmets in preventing facial injuries, especially those of the mid-face and the mandible.

OBJECTIVES

The present study was conducted to determine the protective effect of a bicycle helmet in preventing mid-face and mandibular fractures.

PATIENTS AND METHODS

Data from an accident research unit were analyzed to collect technical collision details (relative collision speed, type of collision, collision partner, and use of a helmet) and clinical data (type of fracture).

RESULTS

Between 1999 and 2011, 5,350 bicycle crashes were included in the study. Of these, 175 (3.3%) had fractures of the mid-face or mandible. In total, 228 mid-face or mandibular fractures were identified. A significant correlation was found between age and relative collision speed, and the incidence of a fracture. While no significant correlation was found between the use of a helmet and the incidence of mid-facial fractures, the use of a helmet was correlated with a significantly increased incidence of mandibular fractures.

CONCLUSIONS

Higher age of cyclists and increasing speed of the accident opponent significantly increase the likelihood of sustaining facial fractures. The use of bicycle helmets does not significantly reduce the incidence of mid-facial fractures, while being correlated with an even increased incidence of mandibular fractures.

Fretting and Corrosion in Modular Shoulder Arthroplasty: A Retrieval Analysis

Tribocorrosion in taper junctions of retrieved anatomic shoulder arthroplasty implants was evaluated. A comparison of the tribocorrosion between cobalt-chromium and titanium alloy stems was conducted and the observations were correlated with the individual's clinical data. Adverse effects caused by metal debris and subsequent elevated serum metal ion levels are frequently reported in total hip arthroplasty. In total shoulder arthroplasty, to date only a small number of retrieval analyses are available and even fewer address the issue of tribocorrosion at the taper junctions. A total of 36 retrieved hemiarthroplasties and total shoulder arthroplasties were assessed using the modified Goldberg score. The prevalence of fretting and corrosion was confirmed in this cohort. Titanium stems seem to be more susceptible to damage caused by tribocorrosion than cobalt-chromium stems. Furthermore, stemless designs offered less tribocorrosion at the taper junction than stemmed designs. A weak correlation between time to revision and increased levels of tribocorrosion was seen. Whether or not tribocorrosion can lead to adverse clinical reactions and causes failure of shoulder arthroplasties remains to be examined.

Analysis of scapular kinematics during active and passive arm elevation

[Purpose] Early postoperative passive motion exercise after arthroscopic rotator cuff repair remains controversial. To better understand this issue, this study was aimed at evaluating scapular kinematics and muscle activities during passive arm elevation in healthy subjects. [Subjects and Methods] The dominant shoulders of 27 healthy subjects were examined. Electromagnetic sensors attached to the scapula, thorax, and humerus were used to determine three-dimensional scapular kinematics during active arm elevation with or without external loads and passive arm elevation. Simultaneously, the activities of seven shoulder muscles were recorded with surface and intramuscular fine-wire electrodes. [Results] Compared with active arm elevation, passive elevation between 30° and 100° significantly decreased the scapular upward rotation and increased the glenohumeral elevation angle. However, no significant differences in scapular posterior tilt and external rotation were observed between active and passive arm elevation, and scapular plane kinematics were not affected by muscle activity. [Conclusion] Unlike active motion with or without an external load, passive arm elevation significantly decreased the scapular upward rotation and significantly increased the mid-range glenohumeral elevation. These data, which suggest that passive arm elevation should be avoided during the early postoperative period, may expand the understanding of rehabilitation after arthroscopic rotator cuff repair.

Hip Arthroplasty in Obese Patients: Rising Prevalence-Standard Procedures?

We examined our experience and, in particular, complications associated with total hip arthroplasty in obese and morbidly obese patients. We prospectively gathered 50 patients in a matched control series including 25 obese and morbidly obese patients. All patients were operated using the direct lateral approach and standard postoperative protocols. Operating room time, complications, dislocations, blood loss, cup position and clinical parameters using the Harris Hip Score and the Western Ontario and McMaster Universities Arthritis Index results were compared. Although there were some significant differences in clinical outcomes, standard procedures yielded good overall results and an acceptable rate of complications. Details approaching this patient entity are being discussed.

Cytokine and Growth Factor Activation In Vivo and In Vitro after Spinal Cord Injury

Spinal cord injury results in a life-disrupting series of deleterious interconnected mechanisms encompassed by the primary and secondary injury. These events are mediated by the upregulation of genes with roles in inflammation, transcription, and signaling proteins. In particular, cytokines and growth factors are signaling proteins that have important roles in the pathophysiology of SCI. The balance between the proinflammatory and anti-inflammatory effects of these molecules plays a critical role in the progression and outcome of the lesion. The excessive inflammatory Th1 and Th17 phenotypes observed after SCI tilt the scale towards a proinflammatory environment, which exacerbates the deleterious mechanisms present after the injury. These mechanisms include the disruption of the spinal cord blood barrier, edema and ion imbalance, in particular intracellular calcium and sodium concentrations, glutamate excitotoxicity, free radicals, and the inflammatory response contributing to the neurodegenerative process which is characterized by demyelination and apoptosis of neuronal tissue.

Prediction of Quality of Life and Survival After Surgery for Symptomatic Spinal Metastases: A Multicenter Cohort Study to Determine Suitability for Surgical Treatment

BACKGROUND

Surgery for symptomatic spinal metastases aims to improve quality of life, pain, function, and stability. Complications in the postoperative period are not uncommon; therefore, it is important to select appropriate patients who are likely to benefit the greatest from surgery. Previous studies have focused on predicting survival rather than quality of life after surgery.

OBJECTIVE

To determine preoperative patient characteristics that predict postoperative quality of life and survival in patients who undergo surgery for spinal metastases.

METHODS

In a prospective cohort study of 922 patients with spinal metastases who underwent surgery, we performed preoperative and postoperative assessment of EuroQol EQ-5D quality of life, visual analog score for pain, Karnofsky physical functioning score, complication rates, and survival.

RESULTS

The primary tumor type, number of spinal metastases, and presence of visceral metastases were independent predictors of survival. Predictors of quality of life after surgery included preoperative EQ-5D (P = .002), Frankel score (P < .001), and Karnofsky Performance Status (P < .001).

CONCLUSION

Data from the largest prospective surgical series of patients with symptomatic spinal metastases revealed that tumor type, the number of spinal metastases, and the presence of visceral metastases are the most useful predictors of survival and that quality of life is best predicted by preoperative Karnofsky, Frankel, and EQ-5D scores. The Karnofsky score predicts quality of life and survival and is easy to determine at the bedside, unlike the EQ-5D index. Karnofsky score, tumor type, and spinal and visceral metastases should be considered the 4 most important prognostic variables that influence patient management.

Contribution of human osteoblasts and macrophages to bone matrix degradation and proinflammatory cytokine release after exposure to abrasive endoprosthetic wear particles

One of the major reasons for failure after total joint arthroplasty is aseptic loosening of the implant. At articulating surfaces, defined as the interface between implant and surrounding bone cement, wear particles can be generated and released into the periprosthetic tissue, resulting in inflammation and osteolysis. The aim of the present study was to evaluate the extent to which osteoblasts and macrophages are responsible for the osteolytic and inflammatory reactions following contact with generated wear particles from Ti-6Al-7Nb and Co-28Cr-6Mo hip stems. To this end, human osteoblasts and THP-1 monocytic cells were incubated with the experimentally generated wear particles as well as reference particles (0.01 and 0.1 mg/ml) for 48 h under standard culture conditions. To evaluate the impact of these particles on the two cell types, the release of different bone matrix degrading matrix metalloproteinases (MMPs), tissue inhibitors of MMPs (TIMPs), and relevant cytokines were determined by multiplex enzyme-linked immunosorbent assays. Following incubation with wear particles, human osteoblasts showed a significant upregulation of MMP1 and MMP8, whereas macrophages reacted with enhanced MMP3, MMP8 and MMP10 production. Moreover, the synthesis of TIMPs 1 and 2 was inhibited. The osteoblasts and macrophages also responded with modified expression of the inflammatory mediators interleukin (IL)-6, IL-8, monocyte chemoattractant protein-1 and vascular endothelial growth factor. These results demonstrate that the release of wear particles affects the release of proinflammatory cytokines and has a negative impact on bone matrix formation during the first 48 h of particle exposure. Human osteoblasts are directly involved in the proinflammatory cascade of bone matrix degradation. The simultaneous activation and recruitment of monocytes/macrophages boosted osteolytic processes in the periprosthetic tissue. By the downregulation of TIMP production and the concomitant upregulation of MMPs as a response to particle exposure, bone formation around implants may be suppressed, resulting in implant failure.

Greater trochanter chip fractures in the direct anterior approach for total hip arthroplasty

BACKGROUND

The direct anterior approach (DAA) for the treatment of total hip arthroplasty (THA) has gained popularity in recent years. Chip fractures of the greater trochanter are frequently seen, but the risk factors for such fractures are unknown. The study aimed to identify the risk factors for chip fractures in patients undergoing primary THA by the DAA during the surgeons' learning curve.

MATERIALS AND METHODS

From November 2011 to April 2015, the first experiences of three surgeons who performed 120 THAs by the DAA (120 hips; 40 cases per beginner surgeon) were included. The incidence of chip fracture of the greater trochanter, the size of the greater trochanter as measured by computed tomography, and the patients' characteristics were retrospectively investigated.

RESULTS

After exclusion of 11 hips, the remaining 109 hips were investigated. Chip fracture of the greater trochanter was identified in 32 hips (29.4 %). Univariate analysis with and without fractures showed that the width and depth of the greater trochanter were statistically significant risk factors (p = 0.02 and p < 0.001, respectively). Multivariate analysis using a logistic regression model demonstrated that the depth of the greater trochanter was an independent risk factor for chip fracture of the greater trochanter (OR 1.725; 95 % CI 1.367-2.177; p < 0.001).

CONCLUSION

The size of the greater trochanter was identified as a risk factor for chip fracture of the greater trochanter. Novice surgeons should pay attention to the size of the greater trochanter when performing THA by the DAA.

Allograft tissue irradiation and failure rate after anterior cruciate ligament reconstruction: A systematic review

AIM: To evaluate whether anterior cruciate ligament (ACL) allograft irradiation is effective for sterility without compromising graft integrity and increasing failure rate.

METHODS: A literature search was conducted using PubMed, Cochrane, and Google. The following search terms were used: “Gamma irradiation AND anterior cruciate ligament AND allograft” with a return of 30 items. Filters used included: English language, years 1990-2015. There were 6 hits that were not reviewed, as there were only abstracts available. Another 5 hits were discarded, as they did not pertain to the topic of interest. There were 9 more articles that were excluded: Three studies were performed on animals and 6 studies were meta-analyses. Therefore, a total of 10 articles were applicable to review.

RESULTS: There is a delicate dosing crossover where gamma irradiation is both effective for sterility without catastrophically compromising the structural integrity of the graft. Of note, low dose irradiation is considered less than 2.0 Mrad, moderate dose is between 2.1-2.4 Mrad, and high dose is greater than or equal to 2.5 Mrad. Based upon the results of the literature search, the optimal threshold for sterilization was found to be sterilization at less than 2.2 Mrad of gamma irradiation with the important caveat of being performed at low temperatures. The graft selection process also must include thorough donor screening and testing as well as harvesting the tissue in a sterile fashion. Utilization of higher dose (≥ 2.5 Mrad) of irradiation causes greater allograft tissue laxity that results in greater graft failure rate clinically in patients after ACL reconstruction.

CONCLUSION: Allograft ACL graft gamma irradiated with less than 2.2 Mrad appears to be a reasonable alternative to autograft for patients above 25 years of age.

The LDL/HDL ratio and atherosclerosis in ankylosing spondylitis

OBJECTIVES

In ankylosing spondylitis (AS) patients, cardiac and vascular involvement may manifest as atherosclerosis and coronary artery disease. Systemic inflammation, oxidative stress, increased low-density lipoprotein (LDL) cholesterol and decreased high-density lipoprotein (HDL) cholesterol constitute a significant risk for atherosclerosis. This study investigated the relationship between carotid intima-media thickness (CIMT), LDL/HDL ratio, total oxidant status (TOS; an indicator of oxidative stress) and ischemic modified albumin (IMA; an ischemic marker in AS patients).

PATIENTS AND METHODS

Sixty AS patients were diagnosed using the Modified New York Criteria; 54 age- and gender-matched participants were included as controls. CIMT, LDL/HDL ratio, TOS and IMA were measured using the most appropriate methods.

RESULTS

IMA was higher in AS patients compared to controls (p < 0.0001). TOS was also increased in AS patients (p = 0.005); as was CIMT (p < 0.0001). The LDL/HDL ratio was also greater in AS patients compared to controls (p = 0.047). A positive correlation was found between CIMT and LDL/HDL ratio among AS patients.

CONCLUSION

Elevated CIMT, IMA and TOS levels suggest an increased risk of atherosclerotic heart disease in AS patients. The LDL/HDL ratio was higher in AS patients compared to controls, and there was a correlation between LDL/HDL ratio and CIMT, albeit statistically weak. Therefore, the LDL/HDL ratio is not a reliable marker to predict atherosclerotic heart disease in AS patients.

Anterior cervical discectomy and fusion (ACDF) versus cervical disc arthroplasty (CDA) for two contiguous levels cervical disc degenerative disease: a meta-analysis of randomized controlled trials

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) has been considered as a gold standard for symptomatic cervical disc degeneration (CDD), which may result in progressive degeneration of the adjacent segments. The artificial cervical disc was designed to reduce the number of lesions in the adjacent segments. Clinical studies have demonstrated equivalence of cervical disc arthroplasty (CDA) for anterior cervical discectomy and fusion in single segment cervical disc degeneration. But for two contiguous levels cervical disc degeneration (CDD), which kind of treatment method is better is controversial.

PURPOSE

To evaluate the clinical effects requiring surgical intervention between anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) at two contiguous levels cervical disc degeneration.

METHODS

We conducted a comprehensive search in multiple databases, including PubMed, Cochrane Central Register of Controlled Trials, EBSCO and EMBASE. We identified that six reports meet inclusion criteria. Two independent reviewers performed the data extraction from archives. Data analysis was conducted with RevMan 5.3.

RESULTS

After applying inclusion and exclusion criteria, six papers were included in meta-analyses. The overall sample size at baseline was 650 patients (317 in the TDR group and 333 in the ACDF group). The results of the meta-analysis indicated that the CDA patients had significant superiorities in mean blood loss (P < 0.00001, standard mean differences (SMD) = -0.85, 95 % confidence interval (CI) = -1.22 to -0.48); reoperation (P = 0.0009, risk ratio (RR) = 0.28, 95 % confidence interval (CI) = 0.13-0.59), adjacent segment degeneration (P < 0.00001, risk ratio (RR) = 0.48, 95 % confidence interval (CI) = 0.40-0.58) and Neck Disability Index (P = 0.002, SMD = 0.31, 95 % CI = 0.12-0.50). No significant difference was identified between the two groups regarding mean surgical time (P = 0.84, SMD = -0.04, 95 % CI = -0.40 to 0.32), neck and arm pain scores (P = 0.52, SMD = 0.06, 95 % CI = -0.13 to 0.25) reported on a visual analog scale and rate of postoperative complications [risk ratio (RR) = 0.79; 95 % CI = 0.50-1.25; P = 0.31]. The CDA group of sagittal range of motion (ROM) of the operated and adjacent levels, functional segment units (FSU) and C2-7 is superior to ACDF group by radiographic data of peroperation, postoperation and follow-up.

CONCLUSION

We can learn from this meta-analysis that the cervical disc arthroplasty (CDA) group is equivalent and in some aspects has more significant clinical outcomes than the ACDF group at two contiguous levels CDD.

Benefit and risk in short term after total hip arthroplasty by direct anterior approach combined with dual mobility cup

PURPOSE

No previous reports have described the benefits and risks associated with the dual mobility cup (DMC) in primary THA via direct anterior approach (DAA). The aim of this study was to compare the safety and rate of early postoperative complication of the DAA with the DMC for THA with those of the DAA with a single standard cup, and to investigate the influence of the learning curve of the use of DMC on intra- and perioperative outcomes.

METHODS

We retrospectively investigated 60 hips treated in the single-DAA group and 60 hips treated in the dual-DAA group. A primary/secondary outcome variable was the presence of any intra- or perioperative complication within the first 6 months/the operative time and hip function at 6 months postoperatively. We also analyzed influence of the learning curve of the use of DMC on intra- and perioperative outcomes.

RESULTS

No intraoperative complications were observed in either group. One anterior dislocation and one periprosthetic hip fracture were occurred in the single-DAA group. The surgical times in the single-DAA and dual-DAA groups were 112.0 ± 20.9 and 121.0 ± 26.9 min (p < 0.001). There was no significant difference in the 6-month postoperative hip function scores between the two groups. There was no influence of the learning curve of the use of DMC on intra- and perioperative outcomes.

CONCLUSION

We have demonstrated the short-term safety and lack of inferiority of using the DMC in the DAA compared with the standard single mobility cup.

Platelet Rich Plasma and Hyaluronic Acid Blend for the Treatment of Osteoarthritis: Rheological and Biological Evaluation

Introduction

Osteoarthritis (OA) is the most common musculoskeletal disease. Current treatments for OA are mainly symptomatic and inadequate since none results in restoration of fully functional cartilage. Hyaluronic Acid (HA) intra-articular injections are widely accepted for the treatment of pain associated to OA. The goal of HA viscosupplementation is to reduce pain and improve viscoelasticity of synovial fluid. Platelet-rich plasma (PRP) has been also employed to treat OA to possibly induce cartilage regeneration. The combination of HA and PRP could supply many advantages for tissue repair. Indeed, it conjugates HA viscosupplementation with PRP regenerative properties. The aim of this study was to evaluate the rheological and biological properties of different HA compositions in combination with PRP in order to identify (i) the viscoelastic features of the HA-PRP blends, (ii) their biological effect on osteoarthritic chondrocytes and (iii) HA formulations suitable for use in combination with PRP.

Materials and Methods

HA/PRP blends have been obtained mixing human PRP and three different HA at different concentrations: 1) Sinovial, 0.8% (SN); 2) Sinovial Forte 1.6% (SF); 3) Sinovial HL 3.2% (HL); 4) Hyalubrix 1.5% (HX). Combinations of phosphate buffered saline (PBS) and the four HA types were used as control. Rheological measurements were performed on an Anton PaarMCR-302 rheometer. Amplitude sweep, frequency sweep and rotational measurements were performed and viscoelastic properties were evaluated. The rheological data were validated performing the tests in presence of Bovine Serum Albumin (BSA) up to ultra-physiological concentration (7%). Primary osteoarthritic chondrocytes were cultured in vitro with the HA and PRP blends in the culture medium for one week. Cell viability, proliferation and glycosaminoglycan (GAG) content were assessed.

Results

PRP addition to HA leads to a decrease of viscoelastic shear moduli and increase of the crossover point, due to a pure dilution effect. For viscosupplements with HA concentration below 1% the viscoelasticity is mostly lost. Results were validated also in presence of proteins, which in synovial fluid are more abundant than HA.

Chondrocytes proliferated overtime in all different culture conditions. The proliferation rate was higher in chondrocytes cultured in the media containing PRP compared to the cultures with different HA alone. GAG content was significantly higher in chondrocytes cultured in PRP and HL blend.

Discussion

We investigated the rheological and biological properties of four different HA concentrations when combined with PRP giving insights on viscoelastic and biological properties of a promising approach for future OA therapy. Our data demonstrate that PRP addition is not detrimental to the viscosupplementation effect of HA. Viscosupplements containing low HA concentration are not indicated for combination with PRP, as the viscoelastic properties are lost. Although having the same rheological behavior of SF and HX, HL was superior in stimulating extracellular matrix production in vitro.

A neoflavonoid dalsissooal isolated from heartwood of Dalbergia sissoo Roxb. has bone forming effects in mice model for osteoporosis

Dalbergia sissoo Roxb. is a well known medicinal plant of India, enriched with various flavonoids used for treating multiple diseases. Earlier, we have shown that extract of Dalbergia sissoo Roxb. leaves mitigate ovariectomy induced bone loss and pure compounds (neoflavonoids) isolated from it, promote osteoblastogenesis in primary calvarial osteoblasts cells in vitro. Here, we hypothesize that dalsissooal (DSL), a novel neoflavonoid isolated from the heartwood of Dalbergia sissoo Roxb. is an important constituent of the extract that imparts bone forming effects. Treatment with DSL enhanced trabecular bone micro-architecture parameters, biomechanical strength, increased bone formation rate and mineral apposition rate in OVx mice comparable to 17β-estradiol. It increased bone formation by enhancing osteoblast gene expression and reduced bone turnover by decreasing osteoclastic gene expressions. Interestingly, we observed that DSL has no uterine estrogenic effects. At cellular levels, DSL promoted differentiation of bone marrow cells as well as calvaria osteoblast cells towards osteoblast lineage by enhancing differentiation and mineralizing ability to form mineralizing nodules via stimulating BMP-2 and RunX-2 expressions. Overall, our data suggest that oral supplementation of a novel neoflavonoid dalsissooal isolated from heartwood of Dalbergia sissoo Roxb. exhibited bone anabolic action by improving structural property of bone, promoting new bone formation and reducing bone turnover rate in post-menopausal model for osteoporosis with no uterine hyperplasia.

Subchondral Insufficiency Fracture of the Femoral Head Caused by Excessive Lateralization of the Acetabular Rim

We present a case of a 53-year-old woman with subchondral insufficiency fracture (SIF) of the femoral head without history of severe osteoporosis or overexertion. Plain radiographs showed acetabular overcoverage with excessive lateralization of the acetabular rim. A diagnosis of SIF was made by typical MRI findings of SIF. The lesion occurred at the antipodes of the extended rim. Increased mechanical stress over the femoral head due to impingement against the excess bone was suspected as a cause of SIF. The distinct femoral head deformity is consistent with this hypothesis. This is the first report of SIF associated with acetabular overcoverage.

Failed vascularized fibular graft in treatment of osteonecrosis of the femoral head. A histopathological analysis

PURPOSE

vascularized fibular grafting has been used to treat osteonecrosis of the femoral head in younger patients. Although the results described in the literature are promising, the failure rate is still significant, especially in steroid users. This study was undertaken to learn more, on a histopathological level, about the mechanism of vascularized fibular graft failure.

METHODS

fifteen femoral heads removed at conversion to total hip arthroplasty were analyzed. The case load comprised 10 men and 5 women. They ranged in age from 28 to 39 years and had a median age of 35 years. The interval between the vascularized fibular implant procedure and the conversion to total hip arthroplasty ranged from 22 months to 30 months; the median interval was 26 months. All the patients were steroid users. The heads were sectioned and axial and coronal sections were taken and stained using the WHO method (hematoxylin, phloxine, saffron and Alcian green). A quantitative and qualitative analysis of graft-host interaction at the head (zone 1), neck (zone 2) and epiphysis (zone 3) was performed.

RESULTS

all the specimens showed recognizable collapse of the articular surface over the area of necrosis. Thirteen femoral heads showed the presence of an osteochondral flap attached only at the margins of the area of avascular necrosis, and 10 of these 13 femoral heads also showed loss of the articulating surface with an ulcer crater corresponding to the exposed area of avascular necrosis.

CONCLUSIONS

vascularized fibular graft failure seems to be related to a negative effect of creeping substitution: the revascularization becomes a negative force as it supports unbalanced bone resorption, which, as is well known, is enhanced by corticosteroids.

CLINICAL RELEVANCE

creeping substitution is an undermining force in the repair and revascularization of the necrotic area in the femoral head.

Core Decompression Augmented With Autologous Bone Marrow Aspiration Concentrate for Early Avascular Necrosis of the Femoral Head

Lack of necessary perfusion to the femoral head can lead to necrosis of the underlying bone (avascular necrosis) and result in femoral and acetabular surface changes in advanced stages. Numerous treatments have been reported in the literature, including nonoperative and surgical procedures. In addition to the standard core decompression, we describe the use of bone marrow aspirate to stimulate a healing response and bone grafting, allowing for immediate weight bearing postoperatively. The purpose of this article was to describe our method of core decompression augmented with bone marrow aspirate concentrate and bone grafting for the treatment of early avascular necrosis of the femoral head.

The use of autologous neurogenically-induced bone marrow-derived mesenchymal stem cells for the treatment of paraplegic dogs without nociception due to spinal trauma

The aim of this study was to investigate the effects of percutaneous transplanted autologous neurogenically-induced bone marrow-derived mesenchymal stem cells (NIBM-MSCs) in paraplegic dogs without deep pain perception (DPP) secondary to external spinal trauma. Thirteen client owned dogs that had failed in improvement neurologically at least 42 days after conservative management, decompression and decompression-stabilization were included in the study. Each dog received two doses of autologous 5.0 × 10⁶ NIBM-MSCs suspension, which were positive to 2',3'-Cyclic-nucleotide-3'-phosphodiesterase (CNPase) and Microtubule-associated protein 2 (MAP-2), as well as to Glial fibrillary acidic protein (GFAP) and beta III tubulin. The cells were injected into the spinal cord through the hemilaminectomy or laminectomy defects percutaneously with 21 days interval for 2 times. The results were evaluated using Texas Spinal Cord Injury Scale (TSCIS), somatosensory evoked potentials (SEP) and motor evoked potentials (MEP) at the admission time, cell transplantation procedures and during 2, 5, 7 and 12th months after the second cell transplantation. Improvement after cell transplantation in gait, nociception, proprioception, SEP and MEP results was observed in just 2 cases, and only gait score improvement was seen in 6 cases, and no improvement was recorded in 5 cases. All progresses were observed until 2nd month after the second cell transplantation, however, there was no improvement after this period. In conclusion, percutaneous transplantation of autologous NIBM-MSCs is a promising candidate modality for cases with spinal cord injury after spinal trauma and poor prognosis.

Effects of Leisure-Time Physical Activity on Vertebral Dimensions in the Northern Finland Birth Cohort 1966

Vertebral fractures are a common burden amongst elderly and late middle aged people. Vertebral cross-sectional area (CSA) is a major determinant of vertebral strength and thus associated with vertebral fracture risk. Previous studies suggest that physical activity affects vertebral CSA. We aimed to investigate the relationship between leisure-time physical activity (LTPA) from adolescence to middle age and vertebral dimensions in adulthood. We utilized the Northern Finland Birth Cohort 1966, of which 1188 subjects had records of LTPA at 14, 31 and 46 years, and had undergone lumbar magnetic resonance imaging (MRI) at the mean age of 47 years. Using MRI data, we measured eight dimensions of the L4 vertebra. Socioeconomic status, smoking habits, height and weight were also recorded at 14, 31 and 46 years. We obtained lifetime LTPA (14-46 years of age) trajectories using latent class analysis, which resulted in three categories (active, moderately active, inactive) in both genders. Linear regression analysis was used to analyze the association between LTPA and vertebral CSA with adjustments for vertebral height, BMI, socioeconomic status and smoking. High lifetime LTPA was associated with larger vertebral CSA in women but not men. Further research is needed to investigate the factors behind the observed gender-related differences.

Impact of intraprosthetic drilling on the strength of the femoral stem in periprosthetic fractures: A finite element investigation

Treatment of periprosthetic femur fractures after total hip arthroplasty remains a major challenge in orthopedic surgery. Recently, a novel surgical technique using intraprosthetic screw fixation has been suggested. The purpose of this study was to evaluate the influence of drilling the femoral hip stem on integrity and strength of the implant. The hypothesis was that intraprosthetic drilling and screw fixation would not cause the load limit of the prosthesis to be exceeded and that deformation would remain within the elastic limit. A sawbone model with a conventional straight hip stem was used and a Vancouver C periprosthetic fracture was created. The fracture was fixed with a nine-hole less invasive stabilization system plate with two screws drilled and inserted through the femoral hip stem. Three different finite element models were created using ANSYS software. The models increased in complexity including joint forces and stress risers from three different dimensions. A variation of drilling positions was analyzed. Due to the complexity of the physiological conditions in the human femur, the most complex finite element model provided the most realistic results. Overall, significant changes in the stresses to the prosthesis caused by the drilling procedure were observed. While the stresses at the site of the bore hole decreased, the load increased in the surrounding stem material. This effect is more pronounced and further the holes were apart, and it was found that increasing the number of holes could counteract this. The maximum load was still found to be in the area of the prosthesis neck. No stresses above the load limit of titanium alloy were detected. All deformations of the prosthesis stem remained in the elastic range. These results may indicate a potential role for intraprosthetic screw fixation in the future treatment of periprosthetic femur fractures.

Immediate post-operative pain in anterior cruciate ligament reconstruction surgery with bone patellar tendon bone graft versus hamstring graft

Background

Pain in the immediate post-operative period after anterior cruciate ligament (ACL) surgery, apart from an unpleasant experience for the patient, can act as a barrier for static quadriceps contractions and optimum execution of the initial rehabilitation protocol resulting in slow recovery and a later return to full function for a sportsperson. There is no report in the literature comparing pain in the immediate post-operative period after using the two most widely used autografts, bone patellar tendon bone (BPTB) graft and hamstring graft.

Methods

The present study compared the visual analogue scale (VAS) pain score in the immediate post-operative period after arthroscopic ACL reconstruction with the BPTB and hamstring autografts. Both groups consisted of 50 patients each. The mean age of the BPTB and hamstring cohorts was 26.9 ± 7.3 years (age range 18–59 years) and 26.7 ± 9.0 years (age range 17–52 years), respectively. Unpaired t test was applied to compare pain scores between the BPTB and hamstring cohorts.

Results

In the present study, patients in the BPTB cohort showed higher mean pain scores across all the post-operative time intervals except at 6 h. However, the difference in the mean VAS pain score at post-operative 6, 12,18, 24, 36 and 48 h in the two groups was statistically not significant (p value of 1, 0.665, 0.798, 0.377, 0.651 and 0.215 at 6, 12, 18, 24, 36 and 48 h, respectively).

Conclusions

Our study concludes that the arthroscopic ACL reconstruction with BPTB autograft and hamstring autograft is associated with similar pain in the immediate post-operative period. As a result, aggressive physiotherapy regime is not affected by the type of graft being used for ACL reconstruction, as the pain scores in the immediate post-operative period are similar for both techniques.

Trial registration

Clinical Trials Registry-India, CTRI/2016/01/006502

The influence of a home-based exercise intervention on human health indices in individuals with chronic spinal cord injury (HOMEX-SCI): study protocol for a randomised controlled trial

BACKGROUND

Spinal cord injury (SCI) creates a complex pathology that can lead to an increase in sedentary behaviours and deleterious changes in body composition. Consequently, individuals with SCI are at increased risk of developing cardiovascular disease and type-2 diabetes mellitus. While the role of physical activity on the reduction of chronic disease risk is well documented in non-disabled individuals the evidence is less conclusive for persons with SCI. The aim of this methodological paper is to outline the design of a study that will assess the role of a home-based exercise intervention on biomarkers of metabolic and cardiovascular health in persons with SCI: the HOMEX-SCI study.

METHODS/DESIGN

Eligible participants will be inactive (physical activity level ≤1.60) individuals, with a chronic (more than 1 year) spinal cord lesion between the second thoracic and the fifth lumbar vertebrae, and aged between 18 and 65 years. Following baseline laboratory testing and lifestyle monitoring, participants will be randomly allocated to a control (CON) group or a 6-week home-based exercise intervention (INT) group. The INT consists of 45 minutes of moderate-intensity (60-65 % peak oxygen uptake) arm-crank exercise four times per week. Participants assigned to the CON group will be asked to maintain their normal lifestyle. The main outcomes of this study (biomarkers of metabolic and cardiovascular health) are obtained from venous blood samples, collected in the fasted and postprandial state. Eight other measurement categories will be assessed: (1) body composition, (2) physical activity, (3) energy intake, (4) measures of health and wellbeing, (5) resting metabolic rate, heart rate and blood pressure, (6) aerobic capacity, (7) immune function, and (8) adipose tissue gene expression.

DISCUSSION

This study will explore the feasibility of home-based moderate-intensity exercise and ascertain its impact on metabolic and cardiovascular health in comparison to a lifestyle maintenance CON group. Findings from this study may help to inform new evidence-based physical activity guidelines and also help to elucidate the physiological mechanisms whereby exercise might exert beneficial effects in persons with chronic SCI. The results will also act as a scientific platform for further intervention studies in other diverse and at-risk populations.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number: ISRCTN57096451 . Registered on 11 July 2014.

Disorder-related risk factors for revision total hip arthroplasty after hip hemiarthroplasty in displaced femoral neck fracture patients: a nationwide population-based cohort study

Background

The choice of primary hip hemiarthroplasty or total hip arthroplasty for displaced femoral neck fracture is still controversial. Revision hip arthroplasty not only increases risk and cost but also could result in worse outcome. Determining the risk factors for revision can help inform medical decision-making and aid in risk stratification of publicly reported outcomes. Therefore, we conducted a nationwide population-based study to identify the disease-related risk factors and construct a risk score nomogram to predict revision surgery.

Methods

Records of all 68,030 femoral neck fracture patients receiving partial hemiarthroplasty (HA) in 2000–2010, with no total hip arthroplasty (THA) or revision HA history, were collected from the National Health Insurance Research Database. Cox proportional hazard regression was used to estimate the risk of revision hip replacement (RHA). The score of each risk factor was the quotient of the regression coefficient of the variable by the regression coefficient for a 10-year increase in age. The predictive accuracy was tested using the area under the receiver operating characteristic curve (AUROC).

Results

The revision risk for hemiarthroplasty increased in male, those with schizophrenia and end-stage renal disease patients had 1.58-, 1.88-, and 1.74-fold revision HA risk (95 % confidence interval (CI) = 1.40–1.78, 1.26–2.79, and 1.29–2.34, respectively). In a predictive model, the cumulative risk score ranged from 0 to 13 with a 5.08 to 91.82 % 10-year predicted RHA risk. The percentage of AUROC for 10-year RHA risk in nomogram was 61.9 (95 % CI = 60.0–63.4).

Conclusions

Males, schizophrenia and end-stage renal disease patients have higher risk of revision surgery after hemiarthroplasty for femoral neck fracture.

Older, vulnerable patient view: a pilot and feasibility study of the patient measure of safety (PMOS) with patients in Australia

OBJECTIVES

The UK-developed patient measure of safety (PMOS) is a validated tool which captures patient perceptions of safety in hospitals. We aimed (1) to investigate the extent to which the PMOS is appropriate for use with stroke, acute myocardial infarction (AMI) and hip fracture patients in Australian hospitals and (2) to pilot the PMOS for use in a large-scale, national study 'Deepening our Understanding of Quality in Australia' (DUQuA).

PARTICIPANTS

Stroke, AMI and hip fracture patients (n=34) receiving care in 3 wards in 1 large hospital.

METHODS

2 phases were conducted. First, a 'think aloud' study was used to determine the validity of PMOS with this population in an international setting, and to make amendments based on patient feedback. The second phase tested the revised measure to establish the internal consistency reliability of the revised subscales, and piloted the recruitment and administration processes to ensure feasibility of the PMOS for use in DUQuA.

RESULTS

Of the 43 questions in the PMOS, 13 (30%) were amended based on issues patients highlighted for improvement in phase 1. In phase 2, a total of 34 patients were approached and 29 included, with a mean age of 71.3 years (SD=16.39). Internal consistency reliability was established using interitem correlation and Cronbach's α for all but 1 subscale. The most and least favourably rated aspects of safety differed between the 3 wards. A study log was categorised into 10 key feasibility factors, including liaising with wards to understand operational procedures and identify patterns of patient discharge.

CONCLUSIONS

Capturing patient perceptions of care is crucial in improving patient safety. The revised PMOS is appropriate for use with vulnerable older adult groups. The findings from this study have informed key decisions made for the deployment of this measure as part of the DUQuA study.

Automatic detection of osteoporosis based on hybrid genetic swarm fuzzy classifier approaches

OBJECTIVES

This study proposed a new automated screening system based on a hybrid genetic swarm fuzzy (GSF) classifier using digital dental panoramic radiographs to diagnose females with a low bone mineral density (BMD) or osteoporosis.

METHODS

The geometrical attributes of both the mandibular cortical bone and trabecular bone were acquired using previously developed software. Designing an automated system for osteoporosis screening involved partitioning of the input attributes to generate an initial membership function (MF) and a rule set (RS), classification using a fuzzy inference system and optimization of the generated MF and RS using the genetic swarm algorithm. Fivefold cross-validation (5-FCV) was used to estimate the classification accuracy of the hybrid GSF classifier. The performance of the hybrid GSF classifier has been further compared with that of individual genetic algorithm and particle swarm optimization fuzzy classifiers.

RESULTS

Proposed hybrid GSF classifier in identifying low BMD or osteoporosis at the lumbar spine and femoral neck BMD was evaluated. The sensitivity, specificity and accuracy of the hybrid GSF with optimized MF and RS in identifying females with a low BMD were 95.3%, 94.7% and 96.01%, respectively, at the lumbar spine and 99.1%, 98.4% and 98.9%, respectively, at the femoral neck BMD. The diagnostic performance of the proposed system with femoral neck BMD was 0.986 with a confidence interval of 0.942-0.998. The highest mean accuracy using 5-FCV was 97.9% with femoral neck BMD.

CONCLUSIONS

The combination of high accuracy along with its interpretation ability makes this proposed automatic system using hybrid GSF classifier capable of identifying a large proportion of undetected low BMD or osteoporosis at its early stage.

New synthesis of phenyl-isothiocyanate C-functionalised cyclams. Bioconjugation and (64)Cu phenotypic PET imaging studies of multiple myeloma with the te2a derivative

Azamacrocyclic bifunctional chelating agents (BCAs) are essential for the development of radiopharmaceuticals in nuclear medicine and we wish to prove that their bioconjugation by a function present on a carbon atom of the macrocyclic skeleton is a solution of choice to maintain their in vivo inertness. Based on our very recent methodology using a bisaminal template and selective N-alkylation approach, a new synthesis of conjugable C-functionalised teta, te2a and cb-te2a has been developed. These chelators have indeed a growing interest in nuclear medicine for positron emission tomography (PET) and radioimmunotherapy (RIT) where they show in several cases better complexation properties than dota or dota-like macrocycles, especially with (64)Cu or (67)Cu radioisotopes. Chelators are bearing an isothiocyanate grafting function introduced by C-alkylation to avoid as much as possible a critical decrease of their chelating properties. The synthesis is very efficient and yields the targeted ligands, teta-Ph-NCS, te2a-Ph-NCS and cb-te2a-Ph-NCS without fastidious work-up and could be easily extended to other cyclam based-BCAs. The newly synthetised te2a-Ph-NCS has been conjugated to an anti mCD138 monoclonal antibody (mAb) to evaluate its in vivo behavior and potentiality as BCA and to explore a first attempt of PET-phenotypic imaging in multiple myeloma (MM). Mass spectrometry analysis of the immunoconjugate showed that up to 4 chelates were conjugated per 9E7.4 mAb. The radiolabeling yield and specific activity post-purification of the bioconjugate 9E7.4-CSN-Ph-te2a were 95 ± 2.8% and 188 ± 27 MBq mg(-1) respectively and the immunoreactivity of (64)Cu-9E7.4-CSN-Ph-te2a was 81 ± 7%. Animal experiments were carried out on 5T33-Luc(+) tumor bearing mice, either in subcutaneous or orthotopic. To achieve PET imaging, mice were injected with (64)Cu-9E7.4-CNS-Ph-te2a and acquisitions were conducted 2 and 20 h post-injection (PI). A millimetric bone uptake was localised in a sacroiliac of a MM orthotopic tumor. Nonspecific uptakes were observed at 2 h PI but, unlike for the tumor, a significant decrease was observed at 20 h PI which improves the contrast of the images.

Polymers in Cartilage Defect Repair of the Knee: Current Status and Future Prospects

Cartilage defects in the knee are often seen in young and active patients. There is a need for effective joint preserving treatments in patients suffering from cartilage defects, as untreated defects often lead to osteoarthritis. Within the last two decades, tissue engineering based techniques using a wide variety of polymers, cell sources, and signaling molecules have been evaluated. We start this review with basic background information on cartilage structure, its intrinsic repair, and an overview of the cartilage repair treatments from a historical perspective. Next, we thoroughly discuss polymer construct components and their current use in commercially available constructs. Finally, we provide an in-depth discussion about construct considerations such as degradation rates, cell sources, mechanical properties, joint homeostasis, and non-degradable/hybrid resurfacing techniques. As future prospects in cartilage repair, we foresee developments in three areas: first, further optimization of degradable scaffolds towards more biomimetic grafts and improved joint environment. Second, we predict that patient-specific non-degradable resurfacing implants will become increasingly applied and will provide a feasible treatment for older patients or failed regenerative treatments. Third, we foresee an increase of interest in hybrid construct, which combines degradable with non-degradable materials.

Enterococcus faecalis promotes osteoclast differentiation within an osteoblast/osteoclast co-culture system

OBJECTIVE

To investigate the effects of heat-killed Enterococcus faecalis ATCC 29212 and P25RC clinical strain (derived from an obturated root canal with apical periodontitis) on osteoclast differentiation within an osteoblast/osteoclast co-culture system.

RESULTS

Heat-killed E. faecalis significantly increased the proportion of multinucleated osteoclastic cells (MNCs) within the co-culture system. The IL-6 level was significantly increased upon exposure to heat-killed E. faecalis. Gene expression levels of NFATc1 and cathepsin K were significantly up-regulated compared to the untreated control. EphrinB2 and EphB4 expressions at both the mRNA and protein levels were also significantly upregulated compared to the untreated control.

CONCLUSIONS

Heat-killed E. faecalis can induce osteoclast differentiation within the osteoblast/osteoclast co-culture system in vitro, possibly through ephrinB2-EphB4 bidirectional signaling.

Minimally invasive, endoscopic Achilles tendon reconstruction using semitendinosus and gracilis tendons with Endobutton stabilization

Background

Plantaris tendon, peronus brevis tendon and flexor hallucis longus tendon augmentation, commonly used in Achilles tendon rupture, often lead to weakening of injured foot and they require the immobilization after the surgery. It is essential to develop the technique, which gives no such limitation and allows for immediate functional improvement.

Methods

We present our method of minimally invasive, endoscopic Achilles tendon reconstruction using semitendinosus and gracilis tendons with Endobutton stabilization.

Results

Posterolateral and posteromedial portals were made approximately 3 cm above the posterosuperior part of the calcaneus to clean the area of the Achilles tendon endoscopically. Then the hamstrings are harvested and prepared for the “Endobutton” system. A midline incision of the skin is performed approximately 1 cm above the posterosuperior part of the calcaneus to approach to the posterosuperior part of the calcaneus. Then under fluoroscopy the calcaneus was drilled through using K-wire. The distal end of the graft equipped with an Endobutton loop was entered into the drilled tunnel in the calcaneus. Later, 8 consecutive skin incisions are performed. Proximal ends of the graft were brought out through the native Achilles tendon reaching medial and lateral skin incisions. The final step was to transfer and tie the graft ends through the most proximal skin incision.

Conclusions

This minimally invasive, endoscopic technique allows reconstruction of the Achilles tendon using semitendinosus and gracilis tendons with Endobutton stabilization and can be used in so-called “difficult”, resistant cases as a “salvage procedure”.

Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains

Lateral ankle sprains (LASs) are the most prevalent musculoskeletal injury in physically active populations. They also have a high prevalence in the general population and pose a substantial healthcare burden. The recurrence rates of LASs are high, leading to a large percentage of patients with LAS developing chronic ankle instability. This chronicity is associated with decreased physical activity levels and quality of life and associates with increasing rates of post-traumatic ankle osteoarthritis, all of which generate financial costs that are larger than many have realised. The literature review that follows expands this paradigm and introduces emerging areas that should be prioritised for continued research, supporting a companion position statement paper that proposes recommendations for using this summary of information, and needs for specific future research.