Comparison of Cup Alignment, Jump Distance, and Complications in Consecutive Series of Anterior Approach and Posterior Approach Total Hip Arthroplasty

The purpose of this study was to compare cup position, jump distance, and rate of dislocations in 100 total hip arthroplasty (THA) cases performed with the direct anterior approach (DAA) and 100 cases performed with the posterior approach (PA). Abduction and anteversion angles were measured using Martell Hip Analysis software. The average cup anteversion in the DAA group (17.6°) was significantly different than the PA average (22.6°), P<.001. The average cup abduction angle was similar between groups (DAA 44.2° vs. PA 44.3°, P=.87), but the variance was significantly reduced with the direct anterior approach, P=.02. The use of intraoperative fluoroscopy with the DAA allowed for more accurate cup placement and eliminated severely vertical cups (>55°) seen with the PA.

Metal elements in tissue with dental peri-implantitis: a pilot study

OBJECTIVES

Dental peri-implantitis is characterized by a multifactorial etiology. The role of metal elements as an etiological factor for peri-implantitis is still unclear. The aim of this study was to investigate the incidence of metal elements in bone and mucosal tissues around dental Grade 4 CP titanium implants with signs of peri-implantitis in human patients.

METHODS

In this prospective pilot study, all patients were enrolled consecutively in two study centers. Bone and soft tissue samples of patients with peri-implantitis with indication for explantation were analyzed for the incidence of different elements (Ca, P, Ti, Fe) by means of synchrotron radiation X-ray fluorescence spectroscopy (SRXRF) and polarized light microscopy (PLM). The existence of macrophages and lymphocytes in the histologic specimens was analyzed.

RESULTS

Biopsies of 12 patients (seven bone samples, five mucosal samples) were included and analyzed. In nine of the 12 samples (75%), the SRXRF examination revealed the existence of titanium (Ti) and an associated occurrence with Iron (Fe). Metal particles were detected in peri-implant soft tissue using PLM. In samples with increased titanium concentration, lymphocytes were detected, whereas M1 macrophages were predominantly seen in samples with metal particles.

CONCLUSION

Titanium and Iron elements were found in soft and hard tissue biopsies retrieved from peri-implantitis sites. Further histologic and immunohistochemical studies need to clarify which specific immune reaction metal elements/particles induce in dental peri-implant tissue.

Association between circulating adipokines, radiographic changes, and knee cartilage volume in patients with knee osteoarthritis

OBJECTIVES

To explore the associations between serum adipokine levels, radiographic osteoarthritis (ROA) severity, and articular cartilage volume in patients with knee OA.

METHOD

A cross-sectional sample of 205 patients (aged 45-74 years) with knee OA were consecutively recruited to the Anhui Osteoarthritis (AHOA) study. ROA was assessed using the Kellgren-Lawrence (KL) grading system (grades 0-4). Knee cartilage volume was determined using fat-saturated T1-weighted magnetic resonance imaging (MRI). Serum levels of the adipokines leptin, adiponectin, and resistin were measured by using an enzyme-linked immunosorbent assay (ELISA).

RESULTS

Serum adiponectin, but not serum leptin or resitin, was significantly associated with reduced ROA severity in univariable analyses and this association remained significant after adjustment for age, sex, body mass index (BMI), and disease duration [β = -0.012, 95% confidence interval (CI) -0.021 to -0.002]. In ROA patients, leptin was significantly and positively associated with knee cartilage volume at patellar and medial tibial sites in both unadjusted and adjusted analyses (β = 0.006, 95% CI 0.02-0.010 for medial tibia and β = 0.009, 95% CI 0.001-0.018 for patella sites) but adiponectin and resistin had no significant associations with cartilage volume. In non-ROA patients, leptin, adiponectin, and resistin were not significantly associated with cartilage volume at any site.

CONCLUSIONS

Serum levels of leptin are independently associated with increased knee cartilage volume. In addition, serum adiponectin is significantly and negatively associated with ROA severity, suggesting a potentially protective effect.

Directional specificity of postural threat on anticipatory postural adjustments during lateral leg raising

This study explored the directional specificity of fear of falling (FoF) effects on the stabilizing function of anticipatory postural adjustments (APA). Participants (N = 71) performed a series of lateral leg raises from an elevated surface in three conditions: in the "Control condition", participants stood at the middle of the surface; in the two test conditions, participants were positioned at the lateral edge of the surface so that the shift of the whole-body centre-of-mass during APA for leg raising was directed towards the edge ("Approach condition") or was directed away from the edge ("Avoidance condition"). Results showed that the amplitude of APA was lower in the "Approach condition" than in the "Control condition" (p < .01); this reduction was compensated for by an increase in APA duration (p < .05), so that both postural stability and motor performance (in terms of peak leg velocity, final leg posture and movement duration) remained unchanged. These changes in APA parameters were not present in the "Avoidance condition". Participants further self-reported a greater FoF (p < .001) and a lower ability to avoid a fall (p < .001) in the "Approach condition" (but not in the "Avoidance condition") than in the "Control condition". The results of this study show that the effects of FoF do not solely depend on initial environmental conditions, but also on the direction of APA relative to the location of the postural threat. These results support the so-called Motivational Direction Hypothesis, according to which approach and avoidance behaviours are primed by emotional state.

Mutual enhancement of differentiation of osteoblasts and osteocytes occurs through direct cell-cell contact

There is increasing evidence that osteocytes regulate multiple aspects of bone remodeling through bi-directional communication with osteoblasts. This is potentially mediated through cell-cell contact via osteocytic dendritic processes, through the activity of secreted factors, or both. To test whether cell-cell contact affects gene expression patterns in osteoblasts and osteocytes, we used a co-culture system where calvarial osteoblasts and IDG-SW3 osteocytes were allowed to touch through a porous membrane, while still being physically separated to allow for phenotypic characterization. Osteoblast/osteocyte cell-contact resulted in up-regulation of osteoblast differentiation genes in the osteoblasts, when compared to wells where no cell contact was allowed. Examination of osteocyte gene expression when in direct contact with osteoblasts also revealed increased expression of osteocyte-specific genes. These data suggest that physical contact mutually enhances both the osteoblastic and osteocytic character of each respective cell type. Interestingly, Gja1 (a gap junction protein) was increased in the osteoblasts only when in direct contact with the osteocytes, suggesting that Gja1 may mediate some of the effects of direct cell contact. To test this hypothesis, we treated the direct contact system with the gap junction inhibitor 18-alpha-glycyrrhetinic acid and found that Bglap expression was significantly inhibited. This suggests that osteocytes may regulate late osteoblast differentiation at least in part through Gja1. Identification of the specific factors involved in the enhancement of differentiation of both osteoblasts and osteocytes when in direct contact will uncover new biology concerning how these bone cells communicate.

Effects of extremity positioning on radiographic evaluation of femoral tunnel location with digitally reconstructed femoral lateral radiographs after anterior cruciate ligament reconstruction

Background

Radiographic imaging is a valuable tool in clinical practice for quick anatomical assessment. We aimed to radiographically assess (A) the anterior cruciate ligament (ACL) graft tunnel location after anatomic single-bundle (SB) reconstruction and (B) the effects of extremity positioning on the localization of the orifice of the tunnel in the distal femur in comparison with Blumensaat’s line (BL).

Methods

Three-dimensional computed tomography (3D CT) scan examinations of 22 knees of 22 subjects were evaluated. The 3D CT scan data was used to digitally reconstruct the true lateral radiographs. Graft tunnel location on the distal femoral shaft along the Blumensaat’s line and perpendicular to it were assessed on these radiographs. The femur was digitally rotated to simulate varus, valgus, internal rotation and external rotation in 5-degree increments from 0 to 20-degree. At each incremental rotated position of the femur, position of the ACL graft tunnel was calculated relative to BL and the difference from the true lateral x-ray was estimated.

Results

The position of the tunnel in the distal femur was 30.6 (±4.4) % along BL and 33.1 (±5.4) % perpendicular to BL. Ten and more degree of external, internal, valgus and varus rotations significantly affected the estimates of tunnel position (P < 0.05).

Conclusions

Femoral tunnel location can be reliably estimated from lateral radiographs after anatomic SB ACL reconstruction. Although, ten or more degree of rotations can introduce significant inaccuracies in tunnel location estimates, our study suggests that BL is overall reliable for assessing location of the distal femoral tunnel. Level of evidence: Level 2b (Retrospective Cohort Study).

Review of various treatment options and potential therapies for osteonecrosis of the femoral head

Size and location of the lesion, subchondral collapse occurrence, and articular cartilage involvement are general disease progression criteria for direct osteonecrosis of the femoral head (ONFH) classifications. Treatment options for ONFH are usually based on individual factors and lesion characteristics. Although spontaneous repair of ONFH occurs in some cases, untreated ONFH is unlikely to escape the fate of subchondral collapse and usually ends up with total hip arthroplasty. Operations to preserve the femoral head, e.g., core decompression and bone grafting, are usually recommended in younger patients. They are helpful to relieve pain and improve function in the affected femoral head without subchondral collapse, however, poor prognosis after surgical procedures remains the major problem for ONFH. Pharmacological and physical therapies only work in the early stage of ONFH and have also been recommended as a supplement or prevention treatment for osteonecrosis. Following advances in basic science, many new insights focus on bone tissue engineering to optimize therapies and facilitate prognosis of ONFH. In this review, disease classifications, current treatment options, potential therapies, and the relevant translational barriers are reviewed in the context of clinical application and preclinical exploration, which would provide guidance for preferable treatment options and translation into novel therapies.

Impact of storage conditions on electromechanical, histological and histochemical properties of osteochondral allografts

BACKGROUND

Osteochondral allograft transplantation has a good clinical outcome, however, there is still debate on optimization of allograft storage protocol. Storage temperature and nutrient medium composition are the most critical factors for sustained biological activity of grafts before implantation. In this study, we performed a time-dependent in vitro experiment to investigate the effect of various storage conditions on electromechanical, histological and histochemical properties of articular cartilage.

METHODS

Osteochondral grafts derived from goat femoral condyles were frozen at -70 °C or stored at 4 °C and 37 °C in the medium supplemented with or without insulin-like growth factor-1 (IGF-1). After 14 and 28 days the cartilage samples were quantitatively analysed for electromechanical properties, glycosaminoglycan distribution, histological structure, chondrocyte viability and apoptosis. The results were compared between the experimental groups and correlations among different evaluation methods were determined.

RESULTS

Storage at -70 °C and 37 °C significantly deteriorated cartilage electromechanical, histological and histochemical properties. Storage at 4 °C maintained the electromechanical quantitative parameter (QP) and glycosaminoglycan expression near the normal levels for 14 days. Although hypothermic storage revealed reduced chondrocyte viability and increased apoptosis, these parameters were superior compared with the storage at -70 °C and 37 °C. IGF-1 supplementation improved the electromechanical QP, chondrocyte viability and histological properties at 37 °C, but the effect lasted only 14 days. Electromechanical properties correlated with the histological grading score (r = 0.673, p < 0.001), chondrocyte viability (r = -0.654, p < 0.001) and apoptosis (r = 0.416, p < 0.02). In addition, apoptosis correlated with glycosaminoglycan distribution (r = -0.644, p < 0.001) and the histological grading score (r = 0.493, p = 0.006).

CONCLUSIONS

Our results indicate that quality of allografts is better preserved at currently established 4 °C storage temperature. Storage at -70 °C or at 37 °C is unable to maintain cartilage function and metabolic activity. IGF-1 supplementation at 37 °C can enhance chondrocyte viability and improve electromechanical and histological properties of the cartilage, but the impact persists only 14 days. The correlations between cartilage electromechanical quantitative parameter (QP) and metabolic activity were detected. Our findings indicate that non-destructive assessment of cartilage by Arthro-BST is a simple and reliable method to evaluate allograft quality, and could be routinely used before implantation.

Cell-based cartilage repair strategies in the horse

Damage to the articular cartilage surface is common in the equine athlete and, due to the poor intrinsic healing capabilities of cartilage, can lead to osteoarthritis (OA). Joint disease and OA are the leading cause of retirement in equine athletes and currently there are no effective treatments to stop the progression of OA. Several different cell-based strategies have been investigated to bolster the weak regenerative response of chondrocytes. Such techniques aim to restore the articular surface and prevent further joint degradation. Cell-based cartilage repair strategies include enhancement of endogenous repair mechanisms by recruitment of stem cells from the bone marrow following perforation of the subchondral bone plate; osteochondral implantation; implantation of chondrocytes that are maintained in defects by either a membrane cover or scaffold, and transplantation of mesenchymal stem cells into cartilage lesions. More recently, bioengineered cartilage and scaffoldless cartilage have been investigated for enhancing repair. This review article focuses on the multitude of cell-based repair techniques for cartilage repair across several species, with special attention paid to the horse.

Biomimetically enhanced demineralized bone matrix for bone regenerative applications

Demineralized bone matrix (DBM) is one of the most widely used bone graft materials in dentistry. However, the ability of DBM to reliably and predictably induce bone regeneration has always been a cause for concern. The quality of DBM varies greatly depending on several donor dependent factors and also manufacturing techniques. In order to standardize the quality and to enable reliable and predictable bone regeneration, we have generated a biomimetically-enhanced version of DBM (BE-DBM) using clinical grade commercial DBM as a control. We have generated the BE-DBM by incorporating a cell-derived pro-osteogenic extracellular matrix (ECM) within clinical grade DBM. In the present study, we have characterized the BE-DBM and evaluated its ability to induce osteogenic differentiation of human marrow derived stromal cells (HMSCs) with respect to clinical grade commercial DBM. Our results indicate that the BE-DBM contains significantly more pro-osteogenic factors than DBM and enhances HMSC differentiation and mineralized matrix formation in vitro and in vivo. Based on our results, we envision that the BE-DBM has the potential to replace DBM as the bone graft material of choice.

Can Total Wrist Arthroplasty Be an Option for Treatment of Highly Comminuted Distal Radius Fracture in Selected Patients? Preliminary Experience with Two Cases

We present two case reports of successful primary shortening of the forearm and total wrist arthroplasty (TWA) using the new angle-stable Maestro Wrist Reconstructive System (WRS) for treatment of highly comminuted distal radius fracture in selected autonomous patients. In a 56-year-old male patient with adequate bone stock, insertion of the noncemented Maestro WRS was combined with ulnar shortening osteotomy. In an 84-year-old female patient with poor osteoporotic bone stock, insertion of the radial cemented Maestro WRS was combined with ulnar head resection. Both patients could resume their work without additional surgery after TWA. At the 1-year follow-up, there were no changes in position of either implant without signs of loosening, no impingement, and no instability of the distal radioulnar joint or the distal ulna stump. All clinical parameters (DASH score, pain through VAS, and grip strength) were satisfactory. Both patients reported that they would have the same procedure again. Further experience is needed to validate this concept.

Possible Involvement of Serum and Synovial Fluid Resistin in Knee Osteoarthritis: Cartilage Damage, Clinical, and Radiological Links

BACKGROUND

Resistin is an adipocytokine associated with inflammation and insulin resistance. Recent studies have shown that resistin plays an important role in the pathogenesis and progression in osteoarthritis (OA) patients. The current study was aimed at investigating the relationship between resistin in serum and synovial fluid (SF) and disease severity in patients with knee osteoarthritis.

METHOD

Seventy-four patients diagnosed with knee OA and 79 healthy controls receiving regular body check in our hospital were recruited in the study. The Noyes score method was used to assess articular cartilage damage arthroscopically. The symptomatic severity was evaluated according to the Western Ontario McMaster University Osteoarthritis (WOMAC) scores. The radiographic disease severity of OA was assessed by the Kellgren-Lawrence (K-L) grading system. The resistin levels in serum and SF were determined by enzyme-linked immunosorbent assay. Cartilage degradation marker CTX-II in SF was also examined.

RESULTS

SF but not serum resistin levels are positively associated with Noyes scores, K-L grading scores WOMAC pain scores, physical functional scores and WOMAC total scores. In addition, SF resistin correlated positively with CTX-II.

CONCLUSION

Resistin in SF might serve as a potential biomarker for reflecting the disease severity and cartilage degenerative extent of knee OA.

Fluoroscopy-guided pedicle screw accuracy with a mini-open approach: a tomographic evaluation of 470 screws in 125 patients

BACKGROUND

Transpedicular screws are currently placed with open free hand and minimally invasive techniques assisted with either fluoroscopy or navigation. Screw placement accuracy had been investigated with several methods reaching accuracy rates from 71.9% to 98.8%. The objective of this study was to assess the accuracy and safety for 2-D fluoroscopy-guided screw placement assisted with electrophysiological monitoring and the inter-observer agreement for the breach classification.

METHODS

A retrospective review was performed on 125 consecutive patients who underwent minimally invasive transforaminal lumbar interbody fusion and transpedicular screws placement between the levels of T-12 and S-1. Screw accuracy was evaluated using a postoperative computed tomography by three independent observers. Pedicle breach was documented when there was a violation in any direction of the pedicle. Inter-observer agreement was assessed with the Kappa coefficient.

RESULTS

A total of 470 transpedicular screws were evaluated between the levels of T-12 and S-1. In 57 patients the instrumentation was bilateral and in 68 unilateral. A substantial degree of agreement was found between the observers AB (κ=0.769) and A-C (κ=0.784) and almost perfect agreement between observers B-C (κ=0.928). There were a total of 427.33 (90.92%) screws without breach, 39.33 (8.37%) minor breach pedicles and 3.33 (0.71%) major breach pedicles. The pedicle breach rate was 9.08% Trajectory pedicle breach percentages were as follows: minor medial pedicle breach 4.68%, minor lateral pedicle breach 3.47%, minor inferior pedicle breach 0.22%, and major medial breach 0.70%. No intraoperative instrumentation-related or postoperative clinical complications were encountered and no surgical revision was needed.

CONCLUSIONS

Our study demonstrated a high accuracy (90.2%) for 2-D fluoroscopy-guided pedicle screw using electromonitoring. Only 0.71% of the 470 screws had a major breach. Knowing the radiological spine pedicle anatomy and the correct interpretation of EMG are the key factors for this technique.

Remifentanil infusion during emergence moderates hemodynamic and cough responses to the tracheal tube: A randomized controlled trial

OBJECTIVE

To examine the severity of cough and straining at the time of emergence from anesthesia.

DESIGN

Double-blind randomized, placebo-controlled study.

SETTING

University-affiliated hospital.

PATIENTS

Sixty-two American Society of Anesthesiologists 2 patients undergoing craniotomy and excision of supratentorial cerebral tumors.

INTERVENTION

Intravenous infusion of remifentanil (REM) at 0.05 μg/kg/min or normal saline (NS) upon termination of the surgical procedure.

MEASUREMENTS

Heart rate (HR) and mean arterial pressure (MAP) along with the frequency and severity of cough response (Modified Minogue Scale) to the endotracheal tube were recorded at different time points. The frequency of cough and straining was analyzed with χ(2) tests. HRs and MAP were analyzed by repeated-measures analysis of variance between REM and NS groups.

MAIN RESULTS

There was no case of significant cough in the REM group, and all of the patients in the NS group developed some extent of cough varying from mild retching to severe coughing episodes (P < .001). Both the HR and MAPs were consistently lower in the REM group compared to the NS group.

CONCLUSION

Infusion of REM at the end of craniotomy procedures results in significant reduction of the frequency and severity of coughing and straining. Compared to placebo, REM moderates increases in MAP upon emergence from general anesthesia until the time of extubation.

Intrathecal Versus Oral Baclofen: A Matched Cohort Study of Spasticity, Pain, Sleep, Fatigue, and Quality of Life

BACKGROUND

Baclofen commonly is used to manage spasticity caused by central nervous system lesions or dysfunction. Although both intrathecal and oral delivery routes are possible, no study has directly compared clinical outcomes associated with these 2 routes of treatment.

OBJECTIVE

To compare spasticity levels, pain, sleep, fatigue, and quality of life between individuals receiving treatment with intrathecal versus oral baclofen.

DESIGN

Cross-sectional matched cohort survey study.

SETTING

Urban academic rehabilitation outpatient clinics.

PARTICIPANTS

Adult patients with spasticity, treated with intrathecal or oral baclofen for at least 1 year, matched 1:1 for age, gender, and diagnosis.

METHODS

Standardized surveys were administered during clinic appointments or by telephone.

MAIN OUTCOME MEASURES

Surveys included the Penn Spasm Frequency Scale, Brief Pain Inventory, Epworth Sleepiness Scale, Fatigue Severity Scale, Life Satisfaction Questionnaire, and Diener Satisfaction with Life Scale.

RESULTS

A total of 62 matched subjects were enrolled. The mean (standard deviation [SD]) age was 46 (11) years with a mean duration of intrathecal baclofen or oral baclofen treatment of 11 (6) and 13 (11) years, respectively. There were 40 (64%) male and 22 (36%) female subjects. Primary diagnoses included spinal cord injury (n = 38), cerebral palsy (n = 10), stroke (n = 10), and multiple sclerosis (n = 4). The mean (SD) dose of intrathecal and oral baclofen at the time of survey were 577 (1429) μg/day and 86 (50) mg/day, respectively. Patients receiving intrathecal compared with oral baclofen experienced significantly fewer (1.44 [0.92] versus 2.37 [1.12]) and less severe (1.44 [0.92] versus 2.16 [0.83]) spasms, respectively as measured by the Penn Spasm Frequency Scale (P < .01; P < .01). There were no significant differences in pain, sleep, fatigue, and quality of life between groups. Subanalysis of patients with SCI mirrored results of the entire study sample, with significant decreases in spasm frequency and severity associated with intrathecal compared to oral baclofen (P < .01; P < .01), but no other between group differences. The mean (SD) percent change in dose of oral (21% [33%]) compared with intrathecal (3% [28%]) baclofen was significantly larger two years prior to the date of survey (P = .02).

CONCLUSIONS

Long-term treatment with intrathecal compared with oral baclofen is associated with reduced spasm frequency and severity as well as greater dose stability. These benefits must be weighed against the risks of internal pump and catheter placement in patients considering intrathecal baclofen therapy.

Recent advances and future directions in the management of knee osteoarthritis: Can biological joint reconstruction replace joint arthroplasty and when?

In this article, a concise description of the recent advances in the field of osteoarthritis management is presented. The main focus is to highlight the most promising techniques that emerge in both biological joint replacement and artificial joint arthroplasty. A critical view of high quality evidence regarding outcome and safety profile of these techniques is presented. The potential role of kinematically aligned total knee replacement, navigation, and robotic-assisted surgery is outlined. A critical description of both primary and stem cell-based therapies, the cell homing theory, the use of biologic factors and recent advancements in tissue engineering and regenerative medicine is provided. Based on the current evidence, some thoughts on a realistic approach towards answering these questions are attempted.

Cystic lesion around the hip joint

This article presents a narrative review of cystic lesions around the hip and primarily consists of 5 sections: Radiological examination, prevalence, pathogenesis, symptoms, and treatment. Cystic lesions around the hip are usually asymptomatic but may be observed incidentally on imaging examinations, such as computed tomography and magnetic resonance imaging. Some cysts may enlarge because of various pathological factors, such as trauma, osteoarthritis, rheumatoid arthritis, or total hip arthroplasty (THA), and may become symptomatic because of compression of surrounding structures, including the femoral, obturator, or sciatic nerves, external iliac or common femoral artery, femoral or external iliac vein, sigmoid colon, cecum, small bowel, ureters, and bladder. Treatment for symptomatic cystic lesions around the hip joint includes rest, nonsteroidal anti-inflammatory drug administration, needle aspiration, and surgical excision. Furthermore, when these cysts are associated with osteoarthritis, rheumatoid arthritis, and THA, primary or revision THA surgery will be necessary concurrent with cyst excision. Knowledge of the characteristic clinical appearance of cystic masses around the hip will be useful for determining specific diagnoses and treatments.

The Treatment of Non-Traumatic Meniscus Lesions

BACKGROUND

Most meniscus lesions are of non-traumatic origin. The indications for partial meniscectomy are controversial.

METHODS

We systematically searched the literature for randomized controlled trials (RCTs) comparing partial meniscectomy with non-surgical treatment.

RESULTS

Of 6870 articles retrieved by the literature search, we were able to include six in this systematic review. Five trials showed no difference between the clinical outcomes of patients who underwent arthroscopic partial meniscectomy and those who underwent control treatment (arthroscopic lavage, physiotherapy, glucocorticoids). In three trials, however, symptoms improved in 21-30% of the patients in the physiotherapy group only after they underwent arthroscopic partial meniscectomy (crossover design). In two trials, the percentage of patients who crossed over from one treatment arm to the other was markedly lower; in one, the frequency of crossing over was not reported. In one RCT, the patients who underwent arthroscopic partial meniscectomy had significantly less pain and other symptoms. Five of the six trials had acceptable scores for method, but all had weaknesses. These mainly concerned the description of the surgical techniques and the failure to take account of analgesic use-in particular, the use of non-steroidal antiinflammatory drugs (NSAIDs).

CONCLUSION

For most patients with non-traumatic meniscus lesions, surgical and non-surgical treatments seem to be of equal value; only one of the six included trials revealed lower pain and symptom scores after arthroscopic partial meniscectomy. In multiple trials, however, the crossover analysis showed that non-surgical treatment fails for some patients. These patients may benefit from arthroscopic partial meniscectomy. Further trials are needed to better define this subgroup of patients.

Association between injury to the retinacula of Weitbrecht and femoral neck fractures: anatomical and clinical observations

Currently, there is no objective indicator for surgical procedures in elderly patients with femoral neck fractures. The purpose of this study was to determine the severity of damage to the retinacula of Weitbrecht based on the type of femoral neck fracture, anatomical and clinical observations. Data from 44 patients treated with artificial femoral head replacement were analyzed for the association between Garden type fracture and severity of injury to Weitbrecht's retinacula. Additionally, 18 cases (Pauwels type III fracture) after Watson-Jones surgical approach and internal fixations were used to investigate the bone healing and femoral head necrosis. Among 44 patients (Garden type was III-IV, 79.6%), significant associations were found between Garden type fracture and lateral (P < 0.001), anterior (P = 0.045), and medial (P = 0.004) retinacular injury. Significant positive Spearman correlation coefficients between Garden type and the severity of injury to Weitbrecht's retinacula were Ρ = 0.561 with P < 0.001 for lateral, Ρ = 0.338 with P = 0.025 for anterior, and Ρ = 0.469 with P = 0.001 for medial retinacula. Additionally, 4 out of 18 Pauwels type III fracture cases were observed severe damages on Weitbrecht's retinacula and resulting bone necrosis. In conclusion, this study provided the anatomical and histological correlations between fracture displacement and degree of retinacula injury.

Comparison of (18)F-FDG PET/CT and PET/MRI in patients with multiple myeloma

PET/MRI represents a promising hybrid imaging modality with several potential clinical applications. Although PET/MRI seems highly attractive in the diagnostic approach of multiple myeloma (MM), its role has not yet been evaluated. The aims of this prospective study are to evaluate the feasibility of (18)F-FDG PET/MRI in detection of MM lesions, and to investigate the reproducibility of bone marrow lesions detection and quantitative data of (18)F-FDG uptake between the functional (PET) component of PET/CT and PET/MRI in MM patients. The study includes 30 MM patients. All patients initially underwent (18)F-FDG PET/CT (60 min p.i.), followed by PET/MRI (120 min p.i.). PET/CT and PET/MRI data were assessed and compared based on qualitative (lesion detection) and quantitative (SUV) evaluation. The hybrid PET/MRI system provided good image quality in all cases without artefacts. PET/MRI identified 65 of the 69 lesions, which were detectable with PET/CT (94.2%). Quantitative PET evaluations showed the following mean values in MM lesions: SUVaverage=5.5 and SUVmax=7.9 for PET/CT; SUVaverage=3.9 and SUVmax=5.8 for PET/MRI. Both SUVaverage and SUVmax were significantly higher on PET/CT than on PET/MRI. Spearman correlation analysis demonstrated a strong correlation between both lesional SUVaverage (r=0.744) and lesional SUVmax (r=0.855) values derived from PET/CT and PET/MRI. Regarding detection of myeloma skeletal lesions, PET/MRI exhibited equivalent performance to PET/CT. In terms of tracer uptake quantitation, a significant correlation between the two techniques was demonstrated, despite the statistically significant differences in lesional SUVs between PET/CT and PET/MRI.

Comparison of Transforaminal and Parasagittal Epidural Steroid Injections in Patients With Radicular Low Back Pain

BACKGROUND

Epidural steroid injection (ESI), including transforaminal (TF) epidural injections and interlaminar (IL) epidural steroid injections are commonly performed procedures for the management of lumbosacral radicular pain. Parasagittal interlaminar (PIL) approach could enable higher ventral epidural spread, with fewer complications than TF.

OBJECTIVES

This study aims to compare the effectiveness of PIL and TF ESI in relieving the pain and disability of patients with lumbosacral pain.

PATIENTS AND METHODS

This prospective study enrolled 64 patients, aged between 18 to 75 years, with a diagnosis of low back pain and unilateral lumbosacral radicular pain. The patients were randomized to receive fluoroscopically guided epidural injection, through either the PIL or TF approach. Patients were evaluated for effective pain relief [numerical rating scale (NRS) < 3] by 0 - 10 numeric rating scale (NRS) and functional improvement by the Oswestry Disability Index (ODI).

RESULTS

Effective pain relief [numeric rating scale (NRS) < 3] was observed in 77.3% (95% CI: 67‒90.5%) of patients in PIL group and 74.2% (95% CI: 62.4 - 89.4%) of patients in the TF group (P = 0.34), at 4 weeks. Mean NRS score was not significantly different between the PIL group compared to the TF group, at 4 weeks (P = 0.19). Number of patients with improved disability (measured by ODI < 20%) was not significantly different in PIL group (78% of cases) compared to the TF group (76% of cases), at 4 weeks (P = 0.21). There were no adverse effects observed in any of our patients.

CONCLUSIONS

The PIL epidural injection is as effective as TF epidural injection in improving pain and functional status, in patients with chronic lumbosacral low back pain, due to disc degeneration.

Return to sport following acute lateral ligament repair of the ankle in professional athletes

PURPOSE

Recent literature supports early reconstruction of severe acute lateral ligament injuries in professional athletes, suggesting earlier rehabilitation and reduced recurrent instability incidence. Not previously reported, predicting the time to return to training and play is important to both athlete and club. We evaluate the effectiveness and complications of lateral ligament reconstruction in professional athletes. We aim to estimate the time to return to training and sports in both isolated injuries and patients with additional injuries.

METHODS

A consecutive series of 42 athletes underwent modified Broström repair for clinically and radiologically confirmed acute grade III lateral ligament injury. Of 42, 30 had isolated complete rupture of ATFL and CFL. Of 42, 12 had additional injuries (osteochondral lesions, deltoid ligament injuries). All patients received minimum of 2 years post-operative assessment.

RESULTS

The median return to training and sports for isolated injuries was 63 days (49-110) and 77 days (56-127), respectively. However, for concomitant injury results were 86 days (63-152) and 105 days (82-178). This delay was significant (p < 0.001). Despite no difference in pre- and post-op VAS scores between the groups, those with combined injuries had significantly lower FAOS pain and symptoms sub-scores post-operatively (p = 0.027, p < 0.001). Two superficial infections responded to oral antibiotics. No patient developed recurrent instability. All returned to their pre-injury level of professional sports.

CONCLUSION

Lateral ligament reconstruction is a safe and effective treatment for acute severe ruptures providing a stable ankle and expected return to sports at approximately 10 weeks. Despite return to the same level of competition, club and player should be aware that associated injuries may delay return and symptoms may continue. These results may act as a guide to predict the expected time to return to training and to sport after surgical repair of acute injuries and also the influence of associated injuries in prolonging rehabilitation.

LEVEL OF EVIDENCE

III.

Spinal Cord Hemisection Facilitates Aromatic L-Amino Acid Decarboxylase Cells to Produce Serotonin in the Subchronic but Not the Chronic Phase

Neuromodulators, such as serotonin (5-hydroxytryptamine, 5-HT) and noradrenalin, play an essential role in regulating the motor and sensory functions in the spinal cord. We have previously shown that in the rat spinal cord the activity of aromatic L-amino acid decarboxylase (AADC) cells to produce 5-HT from its precursor (5-hydroxytryptophan, 5-HTP) is dramatically increased following complete spinal cord transection. In this study, we investigated whether a partial loss of 5-HT innervation could similarly increase AADC activity. Adult rats with spinal cord hemisected at thoracic level (T11/T12) were used with a postoperation interval at 5 days or 60 days. Using immunohistochemistry, first, we observed a significant reduction in the density of 5-HT-immunoreactive fibers in the spinal cord below the lesion on the injured side for both groups. Second, we found that the AADC cells were similarly expressed on both injured and uninjured sides in both groups. Third, increased production of 5-HT in AADC cells following 5-HTP was seen in 5-day but not in 60-day postinjury group. These results suggest that plastic changes of the 5-HT system might happen primarily in the subchronic phase and for longer period its function could be compensated by plastic changes of other intrinsic and/or supraspinal modulation systems.

Factors Associated with Life Expectancy in Patients with Metastatic Spine Disease from Adenocarcinoma of the Lung

Study Design Retrospective study. Objective Our objective was to identify preoperative prognostic factors associated with survival in patients with spinal metastasis from lung carcinoma. Methods A retrospective analysis of 26 patients diagnosed with lung carcinoma metastatic to the spinal column was performed to determine factors associated with survival. We used 3 months survival as the clinical cutoff for whether surgical intervention should be performed. We analyzed patients who survived less than 3 months compared with those who survived more than 3 months. Demographic, preoperative, operative, and postoperative factors including functional scores were collected for analysis. Results The median survival for all patients in our study was 3.5 months. We found a statistically significant difference between the group that survived less than 3 months and the group that survived greater than 3 months in terms of extrathoracic metastasis, visceral metastasis, and average postoperative modified Rankin score. Conclusion Determining which patients with lung cancer spinal metastases will benefit from surgical intervention is often dictated by the patient's predicted life expectancy. Factors associated with poorer prognosis include age, functional status, visceral metastases, and extrathoracic metastases. Although the prognosis for patients with lung cancer spinal metastases is poor, some patients may experience long-term benefit from surgical intervention.

Combined transforaminal lumbar interbody fusion with posterolateral instrumented fusion for degenerative disc disease can be a safe and effective treatment for lower back pain

BACKGROUND

Lumbar fusion is a proven treatment for chronic lower back pain (LBP) in the setting of symptomatic spondylolisthesis and degenerative scoliosis; however, fusion is controversial when the primary diagnosis is degenerative disc disease (DDD). Our objective was to evaluate the safety and effectiveness of lumbar fusion in the treatment of LBP due to DDD.

MATERIALS AND METHODS

Two-hundred and five consecutive patients with single or multi-level DDD underwent lumbar decompression and instrumented fusion for the treatment of chronic LBP between the years of 2008 and 2011. The primary outcome measures in this study were back and leg pain visual analogue scale (VAS), patient reported % resolution of preoperative back pain and leg pain, reoperation rate, perioperative complications, blood loss and hospital length of stay (LOS).

RESULTS

The average resolution of preoperative back pain per patient was 84% (n = 205) while the average resolution of preoperative leg pain was 90% (n = 190) while a mean follow-up period of 528 days (1.5 years). Average VAS for combined back and leg pain significantly improved from a preoperative value of 9.0 to a postoperative value of 1.1 (P ≤ 0.0001), a change of 7.9 points for the cohort. The average number of lumbar disc levels fused per patient was 2.3 (range 1-4). Median postoperative LOS in the hospital was 1.2 days. Average blood loss was 108 ml perfused level. Complications occurred in 5% of patients (n = 11) and the rate of reoperation for symptomatic adjacent segment disease was 2% (n = 4). Complications included reoperation at index level for symptomatic pseudoarthrosis with hardware failure (n = 3); surgical site infection (n = 7); repair of cerebrospinal fluid leak (n = 1), and one patient death at home 3 days after discharge.

CONCLUSION

Lumbar fusion for symptomatic DDD can be a safe and effective treatment for medically refractory LBP with or without leg pain.

Pain After Total Knee Arthroplasty Due to Unrecognized 180° Rotation of the Mobile-Bearing Tibial Insert: A Case Report

CASE

A woman presented with continuously worsening right knee pain and stiffness six years after a total knee arthroplasty. During revision total knee arthroplasty, we discovered that the rotating-platform tibial component was rotated 180°. This likely occurred during a minor bedside fall on postoperative day one after the index procedure.

CONCLUSION

This case demonstrates that a 180° rotation of the rotating tibial insert can occur with minimal trauma, resulting in persistent pain and stiffness. This cause of pain should be added to the differential diagnosis of patients with pain after total knee arthroplasty with a rotating-platform tibial insert.

Proximal femur geometry assessed by hip structural analysis in hip fracture in women

INTRODUCTION

In the pathogenesis of hip fracture, proximal femur geometry plays a key role as well as decreased bone density. The hip structural analysis (HSA) processes dual energy X-ray absorptiometry (DXA) images containing information on the geometry closely related to the strength of the proximal femur. The objective of this study was to investigate bone mineral density (BMD) and mechanical properties of the proximal femur in a group of women with a previous contralateral hip fragility fracture compared to women without history of hip fracture.

MATERIALS AND METHODS

In a population of postmenopausal women, we evaluated bone density by DXA and bone geometry using the HSA parameters (femoral strength index, cross-sectional moment of inertia, cross-sectional area, section modulus, and buckling ratio) including hip axis length (HAL) and neck shaft angle.

RESULTS

Of a total of 62 postmenopausal women, twenty-six with a history of hip fracture had a mean femoral neck BMD significantly lower in comparison with 36 women in the control group (0.703 versus 0.768 g/cm(2), p = 0.0347). There was a statistically significant difference between groups also for HAL (106.75 mm in fracture group versus 100.93 mm in control group, p = 0.0015).

DISCUSSION AND CONCLUSIONS

Our results demonstrated that all the geometrical parameters resulted worst into the group of patients with history of hip fracture, even though only the HAL was significantly lower in control subjects. In our opinion HSA is useful to characterize the risk of hip fracture in postmenopausal women, providing additional data on the spatial distribution of bone mass strongly related to bone strength.

Does long-distance walking improve or deteriorate walking stability of transtibial amputees?

BACKGROUND

Falls are common in transtibial amputees which are linked to their poor stability. While amputees are encouraged to walk more, they are more vulnerable to fatigue which leads to even poorer walking stability. The objective of this study was to evaluate the dynamic stability of amputees after long-distance walking.

METHODS

Six male unilateral transtibial amputees (age: 53 (SD: 8.8); height: 170cm (SD: 3.4); weight: 75kg (SD: 4.7)) performed two sessions (30minutes each) of treadmill walking, separated by a short period of gait tests. Gait tests were performed before the walking (baseline) and after each session of treadmill walking. Gait parameters and their variability across repeated steps at each of the three conditions were computed.

FINDINGS

There were no significant differences in walking speed, step length, stance time, time of occurrence, and magnitude of peak angular velocities of the knee and hip joint (P>0.05). However, variability of knee and hip angular velocity after 30-minute walking was significantly higher than the baseline (P<0.05) and after a total of 60-minute walking (P<0.05). The variability of lateral sway velocity after 30-minute walking was significantly higher than the baseline (P<0.05).

INTERPRETATION

The significant increase in variability after 30-minute walking could indicate poorer walking stability when fatigue was developed, while the significant reduction after 60-minute walking might indicate the ability of amputees to restore their walking stability after further continuous walking.

Impaired bone remodeling and its correction by combination therapy in a mouse model of mucopolysaccharidosis-I

Mucopolysaccharidosis-I (MPS-I) is a lysosomal storage disease (LSD) caused by inactivating mutations of IDUA, encoding the glycosaminoglycan-degrading enzyme α-l-iduronidase. Although MPS-I is associated with skeletal abnormalities, the impact of IDUA deficiency on bone remodeling is poorly defined. Here we report that Idua-deficient mice progressively develop a high bone mass phenotype with pathological lysosomal storage in cells of the osteoblast lineage. Histomorphometric quantification identified shortening of bone-forming units and reduced osteoclast numbers per bone surface. This phenotype was not transferable into wild-type mice by bone marrow transplantation (BMT). In contrast, the high bone mass phenotype of Idua-deficient mice was prevented by BMT from wild-type donors. At the cellular level, BMT did not only normalize defects of Idua-deficient osteoblasts and osteocytes but additionally caused increased osteoclastogenesis. Based on clinical observations in an individual with MPS-I, previously subjected to BMT and enzyme replacement therapy (ERT), we treated Idua-deficient mice accordingly and found that combining both treatments normalized all histomorphometric parameters of bone remodeling. Our results demonstrate that BMT and ERT profoundly affect skeletal remodeling of Idua-deficient mice, thereby suggesting that individuals with MPS-I should be monitored for their bone remodeling status, before and after treatment, to avoid long-term skeletal complications.

Change in acetabular version after lumbar pedicle subtraction osteotomy to correct post-operative flat back: EOS® measurements of 38 acetabula

BACKGROUND

Abnormalities in acetabular orientation can promote the development of hip osteoarthritis, femoro-acetabular impingement, or even acetabular cup malposition. The objective of the present study was to determine whether pedicle substraction osteotomy (PSO) to correct sagittal spinal imbalance affected acetabular orientation.

HYPOTHESIS

PSO performed to correct sagittal spinal imbalance affects acetabular orientation by changing the pelvic parameters.

MATERIALS AND METHODS

This was a descriptive study in which two observers measured the acetabular parameters on both sides in 19 patients (38 acetabula) before and after PSO for post-operative flat-back syndrome. Mean time from PSO to post-operative measurements was 19months. Measurements were taken twice at a 2-week interval, on standing images obtained using the EOS(®) imaging system and sterEOS(®) software to obtain 3D reconstructions of synchronised 2D images. Acetabular anteversion and inclination were measured relative to the vertical plane. Mean pre-PSO and post-PSO values were compared using the paired t-test, and P values lower than 0.05 were considered significant. To assess inter-observer and intra-observer reproducibility, we computed the intra-class correlation coefficients (ICCs).

RESULTS

The measurements showed significant acetabular retroversion after PSO, of 7.6° on the right and 6.5° on the left (P<0.001). Acetabular inclination diminished significantly, by 4.5° on the right and 2.5° on the left (P<0.01). Inclination of the anterior pelvic plane decreased by 8.4° (P<0.01). Pelvic incidence was unchanged, whereas sacral slope increased by 10.5° (P<0.001) and pelvic tilt decreased by 10.9° (P<0.001). The ICC was 0.98 for both inter-observer and intra-observer reproducibility.

CONCLUSION

Changing the sagittal spinal alignment modifies both the pelvic and the acetabular parameters. PSO significantly increases sacral slope, thus inducing anterior pelvic tilt with significant acetabular retroversion. The measurements obtained using sterEOS(®) showed good inter-observer and intra-observer reproducibility. To our knowledge, this is the first study of changes in acetabular version after PSO.

Aspects of postoperative magnetic resonance imaging of patients with avascular necrosis of the femoral head, treated by advanced core decompression

OBJECTIVE

To analyze remodeling processes after advanced core decompression (ACD) in patients with avascular femoral head necrosis by means of 3T MRI and to identify indicators for clinical outcome considering the defect size and characteristics of the bone graft and of the neighboring regeneration tissue.

MATERIALS AND METHODS

Thirty-four hips, with preexisting preoperative MRIs in 21 cases, were examined 1-34 months (mean 12.7) postoperatively by 3T MRI. The volume of necrosis was measured manually pre- and postoperatively to calculate absolute as well as percentage necrosis reduction. The signal intensity of the bone graft was quantified using a 4-point scale. Border phenomena between the bone graft and bone were described and classified into groups. Wilcoxon sign-rank test was used to identify correlations between the analyzed items and clinical signs of femoral head collapse after a mean follow-up time of 28.6 months (10.4-46.8).

RESULTS

Mean percentage reduction of necrosis was significantly higher in asymptomatic patients (59.36%) compared to patients with signs of femoral head collapse (28.78%, p = 0.008). Signal intensity of the bone graft increased in T1w and T2w TIRM sequences over time after surgery and was significantly higher in asymptomatic patients. Five border phenomena between the bone graft and healthy bone were identified. Among them, the so-called "rail sign" representing three layers of remodeling tissue correlated with the histological observations.

CONCLUSION

A variety of border phenomena representing remodeling processes have been described using 3T MRI. Beneath the percentage amount of necrosis reduction, we identified the signal intensity of the bone graft as an indicator for clinical outcome.

Peripheral Arterial Disease and Spinal Cord Injury: A Retrospective Nationwide Cohort Study

The aim of this study was to elucidate the relationship between spinal cord injury (SCI) and the risk of peripheral arterial disease (PAD) in a cohort study with a large representative sample.The National Health Insurance Database was used to select patients who were diagnosed from 2000 to 2010. Patients with a history of PAD were excluded. The SCI group comprised 42,673 patients diagnosed with SCI, and we enrolled 170,389 matched controls (non-SCI group). We used a Cox proportional hazards regression model to analyze the adjusted risk of PAD between the case and control patients.Patients with SCI exhibited a significantly higher risk (hazard ratio [HR] = 1.37; 95% confidence interval [CI] = 1.22-1.53) of PAD than patients without SCI. Patients with diabetes were at the highest risk of developing PAD (adjusted HR = 3.11, 95% CI = 2.80-3.44). Among patients without comorbidity, SCI patients exhibited a significantly higher risk of PAD than non-SCI patients. Furthermore, lumbar, sacral, or coccygeal spine, and multiple spine SCI were significantly associated with an increased risk of PAD (HR = 1.56, 95% CI = 1.33-1.84, HR = 2.11, 95% CI = 1.59-2.79, respectively).SCI is associated with an increased risk of PAD. Future studies should focus on modifying risk factors to reduce PAD risk among patients with SCI.

Osteoclast fusion is initiated by a small subset of RANKL-stimulated monocyte progenitors, which can fuse to RANKL-unstimulated progenitors

Osteoclasts are multinucleated, bone-resorbing cells formed via fusion of monocyte progenitors, a process triggered by prolonged stimulation with RANKL, the osteoclast master regulator cytokine. Monocyte fusion into osteoclasts has been shown to play a key role in bone remodeling and homeostasis; therefore, aberrant fusion may be involved in a variety of bone diseases. Indeed, research in the last decade has led to the discovery of genes regulating osteoclast fusion; yet the basic cellular regulatory mechanism underlying the fusion process is poorly understood. Here, we applied a novel approach for tracking the fusion processes, using live-cell imaging of RANKL-stimulated and non-stimulated progenitor monocytes differentially expressing dsRED or GFP, respectively. We show that osteoclast fusion is initiated by a small (~2.4%) subset of precursors, termed "fusion founders", capable of fusing either with other founders or with non-stimulated progenitors (fusion followers), which alone, are unable to initiate fusion. Careful examination indicates that the fusion between a founder and a follower cell consists of two distinct phases: an initial pairing of the two cells, typically lasting 5-35 min, during which the cells nevertheless maintain their initial morphology; and the fusion event itself. Interestingly, during the initial pre-fusion phase, a transfer of the fluorescent reporter proteins from nucleus to nucleus was noticed, suggesting crosstalk between the founder and follower progenitors via the cytoplasm that might directly affect the fusion process, as well as overall transcriptional regulation in the developing heterokaryon.

Bone remodeling in the context of cellular and systemic regulation: the role of osteocytes and the nervous system

Bone is a dynamic tissue that undergoes constant remodeling. The appropriate course of this process determines development and regeneration of the skeleton. Tight molecular control of bone remodeling is vital for the maintenance of appropriate physiology and microarchitecture of the bone, providing homeostasis, also at the systemic level. The process of remodeling is regulated by a rich innervation of the skeleton, being the source of various growth factors, neurotransmitters, and hormones regulating function of the bone. Although the course of bone remodeling at the cellular level is mainly associated with the activity of osteoclasts and osteoblasts, recently also osteocytes have gained a growing interest as the principal regulators of bone turnover. Osteocytes play a significant role in the regulation of osteogenesis, releasing sclerostin (SOST), an inhibitor of bone formation. The process of bone turnover, especially osteogenesis, is also modulated by extra-skeletal molecules. Proliferation and differentiation of osteoblasts are promoted by the brain-derived serotonin and hypothetically inhibited by its intestinal equivalent. The activity of SOST and serotonin is either directly or indirectly associated with the canonical Wnt/β-catenin signaling pathway, the main regulatory pathway of osteoblasts function. The impairment of bone remodeling may lead to many skeletal diseases, such as high bone mass syndrome or osteoporosis. In this paper, we review the most recent data on the cellular and molecular mechanisms of bone remodeling control, with particular emphasis on the role of osteocytes and the nervous system in this process.

Primary cup stability in THA with augmentation of acetabular defect. A comparison of healthy and osteoporotic bone

BACKGROUND CONTEXT

Reconstruction of acetabular defect has been advocated as standard procedure in total hip arthroplasty. The presence of bony defects at the acetabulum is viewed as a cause of instability and acetabular wall augmentation is often used without proper consideration of surrounding bone density. The initial cup-bone stability is, however, a challenge and a number of studies supported by clinical follow-ups of patients suggested that if the structural graft needs supporting more than 50% of the acetabular component, a reconstruction cage device spanning ilium to ischium should be preferred to protect the graft and provide structural stability. This study aims to (1) investigate the relationship between cup motion and bone density and (2) quantify the re-distribution of stress at the defect site after augmentation.

HYPHOTESIS

Paprosky type I or II, acetabular defects, when reconstructed with bone screws supported by bioabsorbable calcified triglyceride bone cement are significantly less effective for osteoporotic bone than healthy bone.

MATERIALS AND METHODS

Acetabular wall defects were reconstructed on six cadaveric subjects with bioabsorbable calcified triglyceride bone cement using a re-bar technique. Data of the specimen with higher bone density was used to validate a Finite Element Model. Values of bone apparent density ranging from healthy to osteoporotic were simulated to evaluate (1) the cup motion, through both displacement and rotation, (2) and the von Mises stress distribution.

RESULTS

Defect reconstruction with bone screws and bioabsorbable calcified triglyceride bone cement results in a re-distribution of stress at the defect site. For a reduction of 65% in bone density, the cup displacement was similar to a healthy bone for loads not exceeding 300 N, as load progressed up to 1500 N, the reconstructed defect showed increase of 99 μm (128%) in displacement and of 0.08° in rotation angle.

CONCLUSIONS

Based on the results, we suggest that an alternative solution to wall defect augmentation with bone screws supported by bioabsorbable calcified triglyceride bone cement, be used for osteoporotic bone.

LEVEL OF EVIDENCE

Level IV, experimental and cadaveric study.

Intra-prosthetic dislocation of dual-mobility cups after total hip arthroplasty: potential causes from a clinical and biomechanical perspective

INTRODUCTION

Recurrent dislocation of total hip arthroplasty is a frequent indication for revision surgery. Hip joint stability depends on implant design, cup position and crucially on femoral head diameter. Due to an effective ultra-large diameter femoral head, dual-mobility cups are considered an attractive solution to prevent dislocation in unstable conditions. Although patients obviously benefit for many years in terms of mobility and pain, an increase of intra-prosthetic dislocation reports using dual-mobility cups has been recently observed. However, the failure mechanism of this implant-specific complication, which is characterized by the loss of the positive-locking between the femoral head and the mobile liner, is not yet completely understood.

METHODS

A comprehensive search was performed with the PubMed database and a search engine to overview this topic and to identify potential causes for this implant-specific failure from a clinical and biomechanical perspective.

RESULTS

Peri-operative findings indicate extensive fibrosis at the large articulation as well as cup loosening as potential causes. In addition, current research has shown that the failure mechanism is affected by the surface topography of the femoral neck and in particular by the design of the mobile liner.

DISCUSSION

In clinical practice it is necessary to differentiate a classic dislocation between the mobile liner and the metallic shell from an intra-prosthetic dislocation between the femoral head and the liner.

CONCLUSION

Due to the increasing popularity of dual-mobility cups in total hip arthroplasty, the understanding of which implant-specific features or tissue response may increase the risk of intra-prosthetic dislocation is of major importance for reduced revision rates by using optimized surgical techniques and implant designs.

Obesity is associated with increased postoperative complications after operative management of distal humerus fractures

BACKGROUND

Distal humerus fractures commonly require surgical intervention, including open reduction and internal fixation (ORIF) and, more recently in elderly, low-demand individuals, total elbow arthroplasty (TEA). The association of obesity with complications after either of these procedures has not previously been examined.

METHODS

A national insurance database was queried for ORIF or TEA for management of a distal humerus fracture using procedural and diagnostic codes. Patients in each operative group were then divided into nonobese and obese cohorts. These cohorts were then queried for postoperative complications within 90 days after the surgical procedure using diagnostic and procedural codes. χ(2) tests were calculated to determine statistical significance, with P < .05 considered significant.

RESULTS

A total of 6928 patients who underwent operative management of a distal humerus fracture were identified, including 4215 ORIF and 2713 TEA procedures. The obese ORIF patients had a significantly increased risk of 90-day local (odds ratio [OR], 2.5; P < .0001) and systemic (OR, 5.9; P < .0001) complications. The rates of postoperative infection, venous thromboembolism, and medical complications were significantly higher in the obese ORIF cohort than in nonobese patients. The obese TEA patients had a significantly increased risk of 90-day local (OR, 2.6; P < .0001) and systemic (OR, 4.4; P < .0001) complications. The rates of postoperative infection, venous thromboembolism, and medical complications were higher in the obese TEA cohort than in nonobese patients.

CONCLUSIONS

Obesity is associated with significantly higher rates of complications after ORIF and TEA for distal humerus fractures than in nonobese patients.

Femoral cortical index: an indicator of poor bone quality in patient with hip fracture

BACKGROUND

Osteoporosis is a common disease in elderly, characterized by poor bone quality as a result of alterations affecting trabecular bone. However, recent studies have described also an important role of alterations of cortical bone in the physiopathology of osteoporosis. Although dual-energy X-ray absorptiometry (DXA) is a valid method to assess bone mineral density, in the presence of comorbidities real bone fragility is unable to be evaluated. The number of hip fractures is rising, especially in people over 85 years old.

AIMS

The aim is to evaluate an alternative method so that it can indicate fracture risk, independent of bone mineral density (BMD). Femoral cortical index (FCI) assesses cortical bone stock using femur X-ray.

METHODS

A retrospective study has been conducted on 152 patients with hip fragility fractures. FCI has been calculated on fractured femur and on the opposite side. The presence of comorbidities, osteoporosis risk factors, vitamin D levels, and BMD have been analyzed for each patient.

RESULTS

Average values of FCI have been 0.42 for fractured femurs and 0.48 at the opposite side with a statistically significant difference (p = 0.002). Patients with severe hypovitaminosis D had a minor FCI compared to those with moderate deficiency (0.41 vs. 0.46, p < 0.011). 42 patients (27.6%) with osteopenic or normal BMD have presented low values of FCI.

DISCUSSION AND CONCLUSION

A significant correlation among low values of FCI, comorbidities, severe hypovitaminosis D. and BMD in patients with hip fractures has been found. FCI could be a useful tool to evaluate bone fragility and to predict fracture risk even in the normal and osteopenic BMD patients.

Trends for Spine Surgery for the Elderly: Implications for Access to Healthcare in North America

The proportion of the population over age 65 in the United States continues to increase over time, from 12% in 2000 to a projected 20% by 2030. There is an associated rise in the prevalence of degenerative spinal disorders with this aging population. This will lead to an increase in demand for both nonsurgical and surgical treatment for these disabling conditions, which will stress an already overburdened healthcare system. Utilization of spinal procedures and services has grown considerably. Comparing 1999 to 2009, lumbar epidural steroid injections have increased by nearly 900,000 procedures performed per year, while physical therapy evaluations have increased by nearly 1.4 million visits per year. We review the literature regarding the cost-effectiveness of spinal surgery compared to conservative treatment. Decompressive lumbar spinal surgery has been shown to be cost-effective in several studies, while adult spinal deformity surgery has higher total cost per quality-adjusted life year gained in the short term. With an aging population and unsustainable healthcare costs, we may be faced with a shortfall of beneficial spine care as demand for spinal surgery in our elderly population continues to rise.

ABBREVIATION

QALY, quality-adjusted life year.

Gait variability and motor control in people with knee osteoarthritis

Knee osteoarthritis (OA) is a common disease that impairs walking ability and function. We compared the temporal gait variability and motor control in people with knee OA with healthy controls. The purpose was to test the hypothesis that the temporal gait variability would reflect a more stereotypic pattern in people with knee OA compared with healthy age-matched subjects. To assess the gait variability the temporal structure of the ankle and knee joint kinematics was quantified by the largest Lyapunov exponent and the stride time fluctuations were quantified by sample entropy and detrended fluctuation analysis. The motor control was assessed by the soleus (SO) Hoffmann (H)-reflex modulation and muscle co-activation during walking. The results showed no statistically significant mean group differences in any of the gait variability measures or muscle co-activation levels. The SO H-reflex amplitude was significantly higher in the knee OA group around heel strike when compared with the controls. The mean group difference in the H-reflex in the initial part of the stance phase (control-knee OA) was -6.6% Mmax (95% CI: -10.4 to -2.7, p=0.041). The present OA group reported relatively small impact of their disease. These results suggest that the OA group in general sustained a normal gait pattern with natural variability but with suggestions of facilitated SO H-reflex in the swing to stance phase transition. We speculate that the difference in SO H-reflex modulation reflects that the OA group increased the excitability of the soleus stretch reflex as a preparatory mechanism to avoid sudden collapse of the knee joint which is not uncommon in knee OA.

Does spinal stenosis correlate with MRI findings and pain, psychologic factor and quality of life?

BACKGROUND

To investigate and analyze MRI findings in relation to visual analogue scale (VAS), Oswestry Disability Index (ODI), psychological-factor, sleep-quality, and Short-Form Health Survey (SF-36) scores among patients with central lumbar spinal stenosis (LSS) for the purpose of elucidating a correlation.

METHODS

From July 2013 to May 2014, 117 consecutive patients with central LSS were included in this study. All of the MRIs were evaluated by one of the authors, and the evaluated items were the dural sac cross-sectional area (DSCSA), the number of stenotic levels, and the presence and levels of spondylolisthesis. The ODI, VAS, 36-item SF-36, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and Pittsburgh Sleep Quality Index (PSQI) questionnaires were used to evaluate the participants.

RESULTS

There are no correlations between the ODI, VAS, BDI, BAI, PSQI, and SF-36 scores and the minimum DSCSA; however, a significant correlation was found between the ODI scores and multilevel LSS. The BDI, BAI, and PSQI scores are higher for multilevel LSS compared with single-level LSS, but the difference of this mean value is not statistically significant.

CONCLUSIONS

A significant correlation was shown between those patients with multilevel LSS and the ODI scores; however, significant correlations were not found between the MRI findings and the psychological factors pertaining to sleep and life qualities.

Effect of therapeutic plasma exchange on plasma levels and total removal of adipokines and inflammatory markers

Background

Aside from well-established inflammatory mediators adipokines have recently been found to play an important role in a variety of immunologic diseases. Therapeutic plasma exchange (TPE) is an established treatment modality for the acute removal of pathophysiological relevant disease mediators. The aim of this study was to determine adipokine removal during TPE therapy.

Methods

21 Caucasian patients (10 females, 11 males) with an indication for TPE using albumin as exchange fluid received two consecutive TPE sessions. Blood samples for measurement of resistin, leptin, sICAM-1, sCD40L, MCP-1, and sTNF-R were drawn before and at the end of each TPE session. Samples from the total removed plasma were collected at the end of every treatment.

Results

We found a significant reduction in pre- vs. post-TPE plasma concentrations for sICAM-1 (517 ± 246 vs. 260 ± 159 ng/ml, p < 0.0001), sTNF-R (8.1 ± 6.4 vs. 5.7 ± 3.9 ng/ml, p < 0.05), and resistin plasma levels (14.3 ± 6.9 vs. 9.5 ± 4.7 ng/ml, p < 0.001). Solely sICAM-1 reduction persisted for 25 ± 5 h between the first and second TPE treatment, while the other investigated mediators increased to baseline levels. Substantial amounts of all measured mediators could be recovered from the removed plasma.

Conclusions

TPE provides a persistent reduction in sICAM-1 levels and temporarily affects several adipokine and cytokine plasma levels. Our findings are of importance not only for the interpretation of blood levels of cytokines in patients undergoing TPE but provide solid evidence that TPE markedly decreases sICAM-1.

Asymptomatic Versus Symptomatic Ankle Joints in Rheumatoid Arthritis: A High-Resolution B-Mode and Power Doppler Ultrasound Study

OBJECTIVE

Ankle joints are frequently neglected in activity scoring systems, including the Disease Activity Score in 28 joints (DAS28). Only a few studies have assessed pathologies detected by ultrasonography of the ankles in symptomatic rheumatoid arthritis (RA) patients. We evaluated ankle joints in RA patients regardless of symptomatology, using musculoskeletal ultrasound (MSUS) as well as power Doppler ultrasound (PDUS).

METHODS

A total of 160 ankle joints of 80 RA patients were examined using MSUS and PDUS, according to the European League Against Rheumatism MSUS guidelines. Additionally, the talonavicular joints (TNJs) and the medial and the lateral tendon compartments were examined. The visual analog scale (VAS) score was recorded for each patient.

RESULTS

A total of 80 RA patients with a median age of 60 years and disease duration of 5 years were enrolled in our study. The median DAS28 score was 5. A total of 97 ankles were painful (VAS 1-10), whereas 63 ankles were asymptomatic (VAS 0). Overall, the predominant pathology was arthritis of the tibiotalar joint (TTJ) and/or TNJ in 124 ankles (77%), followed by tenosynovitis of the medial compartment tendons in 44 ankles (28%). Arthritis of the TTJ was present in 59% and synovitis of the TNJ in 35% of the symptomatic ankles. In asymptomatic ankles, TTJ synovitis was detected in 35%, whereas TNJ arthritis was observed in 18%. PDUS activity was higher in the subgroup of symptomatic ankles.

CONCLUSION

The most frequent pathologies detected by MSUS were arthritis of the TTJ and TNJ, followed by tenosynovitis of the medial compartment tendons. Pathologic findings were more frequent in symptomatic but also common in asymptomatic patients, whereas PDUS activity was generally low and mainly observed in symptomatic patients.