Shorter, rough trunnion surfaces are associated with higher taper wear rates than longer, smooth trunnion surfaces in a contemporary large head metal-on-metal total hip arthroplasty system

Taper wear at the head-neck junction is a possible cause of early failure in large head metal-on-metal (LH-MoM) hip replacements. We hypothesized that: (i) taper wear may be more pronounced in certain product designs; and (ii) an increased abductor moment arm may be protective. The tapers of 104 explanted LH-MoM hip replacements revised for adverse reaction to metal debris (ARMD) from a single manufacturer were analyzed for linear and volumetric wear using a co-ordinate measuring machine. The mated stem was a shorter 12/14, threaded trunnion (n=72) or a longer, smooth 11/13 trunnion (n=32). The abductor moment arm was calculated from pre-revision radiographs. Independent predictors of linear and volumetric wear included taper angle, stem type, and the horizontal moment arm. Tapers mated with the threaded 12/14 trunnion had significantly higher rates of volumetric wear (0.402 mm3/yr vs. 0.123 mm3/yr [t=-2.145, p=0.035]). There was a trend to larger abductor moment arms being protective (p=0.055). Design variation appears to play an important role in taper-trunnion junction failure. We recommend that surgeons bear these findings in mind when considering the use of a short, threaded trunnion with a cobalt-chromium head.

Effects of Stretching and Strengthening Exercises, With and Without Manual Therapy, on Scapular Kinematics, Function, and Pain in Individuals With Shoulder Impingement: A Randomized Controlled Trial

STUDY DESIGN

Randomized controlled trial.

OBJECTIVE

To evaluate the effects of an exercise protocol, with and without manual therapy, on scapular kinematics, function, pain, and mechanical sensitivity in individuals with shoulder impingement syndrome.

BACKGROUND

Stretching and strengthening exercises have been shown to effectively decrease pain and disability in individuals with shoulder impingement syndrome. There is still conflicting evidence regarding the efficacy of adding manual therapy to an exercise therapy regimen.

METHODS

Forty-six patients were assigned to 1 of 2 groups, one of which received a 4-week intervention of stretching and strengthening exercises (exercise alone) and the other the same intervention, supplemented by manual therapy targeting the shoulder and cervical spine (exercise plus manual therapy). All outcomes were measured preintervention and postintervention at 4 weeks. Outcome measures were scapular kinematics in the scapular and sagittal planes during arm elevation, function as determined through the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, pain as assessed with a visual analog scale, and mechanical sensitivity as assessed with pressure pain threshold.

RESULTS

Independent of the intervention group, small, clinically irrelevant changes in scapular kinematics were observed postintervention. A significant group-by-time interaction effect (P = .001) was found for scapular anterior tilt during elevation in the sagittal plane, with a 3.0° increase (95% confidence interval [CI]: -1.5°, 7.5°) relative to baseline in the exercise-plus-manual therapy group compared to a decrease of 0.3° (95% CI: -4.2°, 4.8°) in the exercise-alone group. Pain, mechanical sensitivity, and the DASH score improved similarly for both groups by the end of the intervention period.

CONCLUSION

Adding manual therapy to an exercise protocol did not enhance improvements in scapular kinematics, function, and pain in individuals with shoulder impingement syndrome. The noted improvements in pain and function are not likely explained by changes in scapular kinematics.

Functional gain following knee replacement in patients aged 75 and older: a prospective follow-up study

BACKGROUND AND AIMS

The aim of this prospective follow-up study was to analyze which patient characteristics predict better functional ability, as well as improvement in the ability, following knee replacement in the aged. The focus was on the impact of specific comorbidities and radiologic data.

METHODS

Knee osteoarthritis patients aged ≥75 years (n = 167) scheduled for knee replacement answered to a questionnaire asking about performance in the activities of daily living (ADL) before the operation, and 1 year afterwards. Radiologic data were evaluated from the latest radiographs, and comorbidity data from patient records. The primary outcome was a sum score indicating how many ADLs (out of 10) the patient was able to perform without difficulty. The factors associated with ADL performance were analyzed with adjustment for age, gender, Charlson's comorbidity index and Kellgren-Lawrence score.

RESULTS

Knee replacement resulted in improved performance in almost all the analyzed ADL activities. Except for cardiac diseases, the effect of the analyzed comorbidities on ADL performance was not significant. Older patients and women attained lower final functional ability than younger patients and men, but improved similarly. In more progressed osteoarthritis, the final ability was lower, but the improvement gained was greater.

CONCLUSIONS

Comorbidity, age, or more progressed osteoarthritis should not be considered an impediment to knee replacement. Even though the final functional ability may be lower in some, the improvement gained by surgery is similar regardless of comorbidity, and was more pronounced in more progressed disease.

Platelet-Rich Plasma in the Animal Long-Bone Model: An Analysis of Basic Science Evidence

Platelet-rich plasma (PRP) has been suggested as an adjunct to aid in long-bone healing. The purpose of this study was to systematically review the basic science in vivo evidence for the use of PRP in the treatment of bone pathology. The PubMed/MEDLINE and EMBASE databases were screened using the following search criteria: "(Platelet-rich plasma OR PRP OR autologous conditioned plasma OR ACP) AND (bone OR osteocytes OR osteogenesis OR nonunion OR delayed union)." Studies were included if they fulfilled the following criteria: (1) studied the effect of PRP or a similar concentrated platelet product, defined as a blood product with platelet concentration elevated to higher than baseline; (2) established a control with which to compare PRP; (3) were published in a peer-reviewed journal; and (4) looked specifically at animal long-bone models. All review articles and clinical studies, including randomized controlled trials and case series, were excluded from the review. Studies examining the effects of PRP on bones of animals with confounding pathology were excluded. In studies that contained additional treatment variables, only the portion of the experiment that compared PRP directly with the control were evaluated. Data were then extracted with a standardized table. The search yielded 29 articles for inclusion. Seventy-two percent of the studies reported platelet concentrations. Eighty-nine percent of studies reported significant improvement in earlier bone healing on histologic/histomorphometric assessment. One hundred percent showed significant increase in bone formation on radiographs in the PRP group. Eighty percent of studies reported a significant increase in bone area on microcomputed tomography. One hundred percent of studies showed a higher torsional stiffness for the PRP-treated defects. In the in vivo studies evaluated, PRP confers several beneficial effects on animal long-bone models. Proof of concept for PRP as a biologic adjunct in long-bone models has been determined.

The National Neurosurgery Quality and Outcomes Database Qualified Clinical Data Registry: 2015 measure specifications and rationale

Meaningful quality measurement and public reporting have the potential to facilitate targeted outcome improvement, practice-based learning, shared decision making, and effective resource utilization. Recent developments in national quality reporting programs, such as the Centers for Medicare & Medicaid Services Qualified Clinical Data Registry (QCDR) reporting option, have enhanced the ability of specialty groups to develop relevant quality measures of the care they deliver. QCDRs will complete the collection and submission of Physician Quality Reporting System (PQRS) quality measures data on behalf of individual eligible professionals. The National Neurosurgery Quality and Outcomes Database (N2QOD) offers 21 non-PQRS measures, initially focused on spine procedures, which are the first specialty-specific measures for neurosurgery. Securing QCDR status for N2QOD is a tremendously important accomplishment for our specialty. This program will ensure that data collected through our registries and used for PQRS is meaningful for neurosurgeons, related spine care practitioners, their patients, and other stakeholders. The 2015 N2QOD QCDR is further evidence of neurosurgery’s commitment to substantively advancing the health care quality paradigm. The following manuscript outlines the measures now approved for use in the 2015 N2QOD QCDR. Measure specifications (measure type and descriptions, related measures, if any, as well as relevant National Quality Strategy domain[s]) along with rationale are provided for each measure.

The Ponseti Method in Low and Middle Income Countries: Challenges and Lessons Learned

Diffusing a health care innovation like the Ponseti method in low and middle income countries requires more than the application of the traditional continuing medical education approach of providing lectures on the topic. Challenges include limited personnel, competing priorities, inadequate medical supplies, and limited resources. Experience has indicated that the best chances of success in establishing such a program include identifying and advising in-country "champions" to provide the leadership, energy, and direction to build the program.

Predicting Short-term Morbidity in Patients Undergoing Posterior Spinal Fusion for Neuromuscular Scoliosis

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim of this study was to determine the incidence and risk factors for short-term morbidity following posterior spinal fusion (PSF) for neuromuscular scoliosis (NMS).

SUMMARY OF BACKGROUND DATA

NMS is a challenging spinal deformity for which PSF is often recommended. There is a lack of information on risk factors for short-term adverse outcomes after PSF for NMS.

METHODS

Patients who underwent PSF for NMS during 2012 and 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric database. Patient characteristics were tested for association with adverse events, infectious complications, extended length of stay (LOS), and readmission using multivariate regression.

RESULTS

Of the 940 NMS patients identified, 133 (14.1%) had an adverse event and 99 (10.5%) had a severe adverse event. American Society of Anesthesiologists (ASA) classification ≥3 was found to be the only independent risk factor for any adverse event (relative risk [RR] 2.2, P = 0.012) and severe adverse events (RR 2.5, P = 0.008). Infectious complications were associated with body mass index (BMI)-for-age ≥95th percentile (RR 2.8, P = 0.005), ASA classification ≥3 (RR 5.9, P = 0.003), and instrumentation to the pelvis (RR 1.8, P = 0.039).A total of 254 patients (27%) spent longer than a week in the hospital postoperatively, and ASA classification ≥3 (RR 2.3, P < 0.001), preoperative seizure disorder (RR 1.4, P = 0.002), previous cardiac surgery (RR 1.6, P = 0.004), operative time ≥470 minutes (RR 1.8, P < 0.001), and ≥13 levels instrumented (RR 1.9, P = 0.001) were associated with extended LOS.Seventy-six patients (8.1%) were readmitted, and BMI-for-age ≥95th percentile (RR 1.8, P = 0.033) was the only risk factor found for readmission.

CONCLUSION

The identified factors associated with poor short-term outcomes after PSF for NMS can be used as benchmark data, be useful for optimizing patient care, and can inform future studies in these patients.

LEVEL OF EVIDENCE

3.

CISD2 serves a novel role as a suppressor of nitric oxide signalling and curcumin increases CISD2 expression in spinal cord injuries

BACKGROUND

CISD2 is known to have roles in calcium metabolism, anti-apoptosis, and longevity. However, whether CISD2 is involved in the inflammatory response associated with injuries of the central nervous system (CNS) remains unclear. This issue is particularly relevant for traumatic spinal cord injuries (SCIs), which lack therapeutic targeting and often cause long-term disability in patients. The authors previously demonstrated the neuroprotective effects of curcumin against RANTES-mediated neuroinflammation. In this study, we investigated (1) the role of CISD2 in injury-induced inflammation and (2) whether curcumin influences CISD2 expression in acute SCI.

MATERIALS AND METHODS

The efficacy of curcumin treatment (40 mg/kg i.p.) was evaluated in an animal model of SCI. In a neural cell culture model, lipopolysaccharide (LPS) was administrated to induce inflammation with the aim of mimicking the situation commonly encountered in SCI. Additionally, knockdown of CISD2 expression by siRNA (siCISD2) in LPS-challenged neural cells was performed to verify the causal relationship between CISD2 and SCI-related inflammation.

RESULTS

The injuries were shown to reduce CISD2 mRNA and protein expression in vivo, and CISD2-positive cells were upregulated by the curcumin treatment. LPS led to a decrease in CISD2 expression in vitro; however, treatment with 1 μM curcumin attenuated the downregulation of CISD2. Furthermore, in a cellular model of LPS-induced injury, the loss of CISD2 function caused by siCISD2 resulted in a pronounced iNOS increase as well as a decrease in BCL2 expression.

CONCLUSIONS

To the best of our knowledge, this is the first study to report the following: (1) CISD2 exerts anti-apoptotic and anti-inflammatory effects in neural cells; and (2) curcumin can attenuate the downregulation of CISD2 in SCI and LPS-treated astrocytes.

Does a titanium-coated polyethylene press-fit cup give reliable midterm results?

BACKGROUND

Uncemented acetabular components have demonstrated low revision rates and high patient satisfaction but with concerns regarding increased costs compared with monoblock cups. Some newer lower-cost uncemented monoblock options have become available in the last decade, but limited data are available on their performance.

QUESTIONS/PURPOSES

(1) Does an uncemented, titanium-backed all-polyethylene acetabular cup provide reliable fixation? (2) What is the frequency and what are the causes for revision with this cup?

METHODS

Between 2004 and 2008, we elected to use an uncemented, titanium-backed all-polyethylene acetabular cup in older patients with limited physical demands. We performed 615 hip replacements in 550 patients with greater than 5 years of clinical and radiographic followup. When patients who were dead (80 hips in 75 patients), lost to followup (98 hips in 93 patients), or revised (three hips in three patients) were excluded, there were 434 hips in 379 patients for comparison of the postoperative and 5-year radiographs. Two observers not involved in the index surgical procedures (NH, HS) assessed radiographs for signs of migration or loosening. Some degree of early movement sometimes is seen before cup stabilization; however, to be conservative, we defined cups with greater than 3° of change of position (even if they subsequently stabilized) as potentially at risk and report them separately. Revision surgery, time from the index procedure, and the reason for revision were recorded from the New Zealand Joint Registry.

RESULTS

By 5 years there was a median change in inclination of 2° (range, 0°-13°; 95% confidence interval [CI], 2.0-2.4; p < 0.001) and 2° of anteversion (range, 0°-11°; 95% CI, 2.0-2.4; p < 0.001). Although at last followup all cups appeared to have stabilized with no radiolucent lines or medial migration, 22% of the cups (94 of 434) had moved more than 3° and so were deemed to be potentially at risk. There were 11 revision procedures (of 429 hips; 2.5%) of which six were for recurrent dislocation, four for femoral fracture, and one for femoral loosening to give an overall all-cause revision rate for all components of 0.25 per 100 component years (95% CI, 0.13-0.43). No revisions were performed for acetabular loosening.

CONCLUSIONS

The short- to medium-term results of this all-polyethylene monoblock cup demonstrated a low frequency of revision. However, 94 cups were identified as potentially at risk based on movement of > 3° before apparent stabilization. Although those patients seem to be doing well enough now, the current duration of followup may not be sufficient to know that these cups will be durable, because other ongrowth designs have demonstrated a high frequency of late failure after apparent early success.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Clinical assessment of endothelial function in patients with rheumatoid arthritis: A meta-analysis of literature studies

BACKGROUND

Several studies reported an increased cardiovascular (CV) morbidity and mortality in patients with rheumatoid arthritis (RA). Flow-mediated (FMD) and nitrate-mediated dilation (NMD) are considered non-invasive methods to assess endothelial function and surrogate markers of subclinical atherosclerosis.

METHODS

We performed a systematic review with meta-analysis and meta-regression of literature studies evaluating the impact of RA on FMD and NMD. Studies evaluating the relationship between RA and markers of CV risk (FMD and NMD) were systematically searched in the PubMed, Web of Science, Scopus and EMBASE databases. The random-effect method was used for analyses and results were expressed as mean difference (MD).

RESULTS

A total of 20 studies (852 RA patients, 836 controls) were included in the final analysis. In detail, 20 studies with data on FMD (852 cases, 836 controls) and 5 studies with data on NMD (207 cases, 147 controls) were analyzed. Compared to controls, RA patients showed a significantly lower FMD (MD: -2.16%; 95% CI: -3.33, -0.98; P=0.0003), with no differences in NMD (MD: -0.41%; 95% CI: -2.89, 2.06; P=0.74). Interestingly, a lower FMD (MD: -2.00%; 95% CI: -3.20, -0.80; P=0.001) and no differences in NMD (P=0.49) were confirmed when excluding data on patients with early-RA. Meta-regression models showed that a more severe inflammatory status was associated with a more significant impairment in FMD.

CONCLUSIONS

RA patients show impaired FMD, which is currently considered an independent predictor of CV events. The presence of endothelial dysfunction in RA should be taken into account to plan adequate prevention strategies and therapeutic approaches.

The utility of ultrasound for diagnosing purulent infections of the upper extremity

BACKGROUND

The purpose of this study was to determine the test characteristics of formal ultrasound when used to diagnose upper extremity soft tissue abscess in the setting of suspected infection.

METHODS

We completed a retrospective chart review of all patients who had formal ultrasounds at our institution for the indication of diagnosing upper extremity abscess between July 2010 and July 2013. Using presence of purulence as the gold standard for diagnosis of abscess, we calculated the test characteristics of ultrasound. We then performed a series of logistic regression models with ultrasound being the independent variable of interest.

RESULTS

Using search criteria consistent with upper extremity abscess, we identified 512 patients who underwent ultrasound examinations during our study period. Of these, 178 met the enrollment criteria. Ultrasound reports revealed 110 negative findings, 37 definitively positive findings, and 31 ambiguous findings. Forty-four patients had a final diagnosis of abscess, and 15 of these patients had negative or ambiguous ultrasounds. The sensitivity of definitively positive ultrasound was 65.9 %. The specificity was 94.0 %. Positive predictive value (PPV) of a definitively positive ultrasound result was 78.4 %, and negative predictive value (NPV) of a definitively negative result was 90 %. Logistic regression demonstrated a statistically significant association between definitively positive ultrasound and abscess, but no association between ambiguous ultrasound and abscess after adjustment for significant covariates.

CONCLUSIONS

Ultrasound is not a sensitive method to detect the presence of abscess in the setting of upper extremity infection. However, in this population of patients with suspected abscess, the negative predictive value was high with and without the inclusion of ambiguous results, suggesting reasonable utility of ultrasound as a rule-out test.

LEVEL OF EVIDENCE

Diagnostic study, Level II.

Is Electrocautery of Patella Useful in Patella Non-Resurfacing Total Knee Arthroplasty?: A Prospective Randomized Controlled Study

There is controversy over the need for electrocauterization of the patella in non-resurfacing total knee arthroplasty (TKA). We investigated whether this procedure is beneficial through a prospective randomized controlled trial. Fifty patients who underwent electrocautery were compared with 50 patients who did not undergo this procedure. We determined cartilage status, preoperative and postoperative American Knee Society (AKS) score, the Western Ontario and McMaster Universities score (WOMAC) and the Patellofemoral (PF) scores for a minimum of 5 years. The two groups did not differ significantly in demographics, intraoperative cartilage status, or preoperative or postoperative outcomes. No complications were detected in either group. We found no benefits of electrocautery of the patella in patellar non-resurfacing TKA up to 5 years.

Venous thromboembolism: identifying patients at risk and establishing prophylaxis

Venous thromboembolism (VTE) is a major cause of morbidity and mortality and is associated with substantial healthcare costs. Identification of patients at risk of developing VTE enables appropriate thromboprophylaxis to be implemented. Although no predisposing risk factors can be identified in many patients in whom VTE develops, most have at least one underlying risk factor which can be categorized according to whether it confers low, moderate, or high risk. Clinical trials have demonstrated the effectiveness of thromboprophylaxis, both non-pharmacological and pharmacological, in a host of medical settings and there is sufficient evidence to support routine prophylaxis in many groups of patients. The implementation of decision making tools based on risk factor assessment improves the prescription of appropriate VTE prophylaxis. Nonetheless, thromboprophylaxis is often inadequate, with haphazard risk assessment and application of guidelines, leading to easily preventable instances of VTE. The most commonly used agents for pharmacological thromboprophylaxis of VTE are low dose unfractionated heparin; a low molecular weight heparin such as dalteparin, enoxaparin or tinzaparin; fondaparinux; warfarin; or aspirin. However, these have a number of drawbacks, principally the need for parenteral administration (with heparins) and frequent coagulation monitoring (with warfarin). The optimal anticoagulant would be orally administered, with a wide therapeutic window, rapid onset of action, predictable pharmacodynamics and pharmacokinetics, minimal interactions with food and other drugs, an ability to inhibit free and clot-bound coagulation factors, low, non-specific binding, and no requirement for routine coagulation monitoring or dose adjustment. A number of novel, single-target oral anticoagulants have been developed that appear to fulfill many of these requirements. This narrative review discusses the use of guidelines and risk assessment tools to identify patients at risk of VTE; it provides an overview of appropriate prophylaxis strategies in these patients with a summary of clinical trial results with novel oral anticoagulants.

Psychometric evaluation of the PROMIS Physical Function Computerized Adaptive Test in comparison to the American Shoulder and Elbow Surgeons score and Simple Shoulder Test in patients with rotator cuff disease

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Computerized Adaptive Test (PF CAT) is a newly developed patient-reported outcome instrument designed by the National Institutes of Health to measure generalized physical function. However, the measurement properties of the PF CAT have not been compared with established shoulder-specific patient-reported outcomes.

METHODS

Patients with clinical diagnosis of rotator cuff disease completed the American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST), and PF CAT. Responses to each of the 3 instruments were statistically analyzed with a Rasch partial credit model. Associations between instruments, convergent validity, item and person reliability, ceiling and floor effects, dimensionality, and survey length were determined.

RESULTS

Responses from 187 patients were analyzed. The PF CAT required fewer questions than the ASES or SST (PF CAT, 4.3; ASES, 11; SST, 12). Correlation between all instruments was moderately high. Item reliability was excellent for all instruments, but person reliability of the PF CAT was superior (0.93, excellent) to the SST (0.71, moderate) and ASES (0.48, fair). Ceiling effects were similar among all instruments (PF CAT, 0.53%; SST, 6.1%; ASES, 2.3%). Floor effects were found in 21% of respondents to the SST but in only 3.2% of PF CAT and 2.3% of ASES respondents.

CONCLUSION

The measurement properties of the PROMIS PF CAT compared favorably with the ASES and SST despite requiring fewer questions to complete. The PROMIS PF CAT had improved person reliability compared with the ASES score and fewer floor effects compared with the SST.

Long Term Outcomes of Total Hip Arthroplasty With Custom Made Femoral Implants in Patients With Congenital Disease of Hip

We evaluated the outcomes of total hip arthroplasty in 67 patients (86 hips) with congenital hip disease and excessive abnormal anatomy of the proximal femur with the use of custom-made femoral stems. The design of the stem was based on CT data following the principles of CAD-CAE-CAM technique. No serious complications attributed to the femoral stem were seen. Within a median follow-up of 127.5 months the 10-year survival of any of the components was 95.4% and respective value when aseptic loosening of the stem was considered was 98.1%. Patients with high dislocations had a 10-fold risk for loosening compared to those with low dislocations. No other parameter was associated with outcomes. The clinical and radiological evaluation was in consistency with the above outcomes.

Clinical evaluation and surgical options in acetabular reconstruction: A literature review

The purpose of this paper is to review the clinical indications for acetabular reconstruction in patients with underlying peri-prosthetic segmental and cavitary defects, evaluate steps in pre-operative planning, and present the American Academy of Orthopaedic Surgeons (AAOS) and Paprosky classification systems to categorize acetabular defects. We also present a review of the current surgical techniques to reconstruct the acetabular socket which includes a cementless acetabular component with morselized bone, structural allograft, jumbo and oblong cups, reinforcement rings, bone cages, custom triflange acetabular constructs, and trabecular metal components.

Total elbow arthroplasty in distal humeral nonunion: clinical and radiographic evaluation after a minimum follow-up of three years

BACKGROUND

Total elbow arthroplasties (TEAs) are usually indicated in chronic inflammatory arthropathies. This procedure has also recently been used in complex distal humeral fractures and nonunions in selected patients. This study analyzed the clinical and radiographic outcomes in patients treated for nonunions around the elbow region with a minimum follow-up of 3 years.

METHODS

Between May 2002 and June 2012, 20 patients affected with distal humeral nonunions were treated with TEA. All patients were assessed clinically using the Mayo Elbow Performance Score and radiographically to evaluate the positioning of the prosthetic components and signs of loosening. Statistical analyses were performed to investigate the presence of clinical and radiographic variables as predictive factors of poor functional outcomes.

RESULTS

The Mayo Elbow Performance Score of the affected arm improved significantly between the preoperative period and follow-up. Results were good or excellent in 90% of the patients even if a high rate of complications (30%) was encountered. The development of complications after surgery and stages II, III, and IV radiolucency, according to the Morrey criteria, were predictive factors of poor outcomes.

CONCLUSIONS

According to the satisfactory results observed in this study, TEA could be indicated in selected patients aged older than 70 years with low functional demands and affected with distal humeral nonunions in which obtaining a stable fixation is difficult.

Treatment of Severe Recurrent Clubfoot

Understanding the pathoanatomy of severe recurrent clubfoot and its implication on treatment options is important for the successful treatment. A comprehensive clinical evaluation of the different components helps in selecting procedures. Individual needs and social and psychological factors influencing treatment and the impact of treatment on the child have to be considered. With increasing dissemination and improved understanding of the Ponseti method, a further decrease in the frequency of severe recurrent clubfoot can be hoped for and expected.

The obesity of bone

During the last decades, obesity and osteoporosis have become important global health problems, and the belief that obesity is protective against osteoporosis has recently come into question. In fact, some recent epidemiologic and clinical studies have shown that a high level of fat mass might be a risk factor for osteoporosis and fragility fractures. Several potential mechanisms have been proposed to explain the complex relationship between adipose tissue and bone. Indeed, adipose tissue secretes various molecules, named adipokines, which are thought to have effects on metabolic, skeletal and cardiovascular systems. Moreover, fat tissue is one of the major sources of aromatase, an enzyme that synthesizes estrogens from androgen precursors, hormones that play a pivotal role in the maintenance of skeletal homeostasis, protecting against osteoporosis. Moreover, bone cells express several specific hormone receptors and recent observations have shown that bone-derived factors, such as osteocalcin and osteopontin, affect body weight control and glucose homeostasis. Thus, the skeleton is considered an endocrine target organ and an endocrine organ itself, likely influencing other organs as well. Finally, adipocytes and osteoblasts originate from a common progenitor, a pluripotential mesenchymal stem cell, which has an equal propensity for differentiation into adipocytes or osteoblasts (or other lines) under the influence of several cell-derived transcription factors. This review will highlight recent insights into the relationship between fat and bone, evaluating both potential positive and negative influences between adipose and bone tissue. It will also focus on the hypothesis that osteoporosis might be considered the obesity of bone.

Total Disc Replacement in Lumbar Degenerative Disc Diseases

More than 10 years have passed since lumbar total disc replacement (LTDR) was introduced for the first time to the world market for the surgical management of lumbar degenerative disc disease (DDD). It seems like the right time to sum up the relevant results in order to understand where LTDR stands on now, and is heading forward to. The pathogenesis of DDD has been currently settled, but diagnosis and managements are still controversial. Fusion is recognized as golden standard of surgical managements but has various kinds of shortcomings. Lately, LTDR has been expected to replace fusion surgery. A great deal of LTDR reports has come out. Among them, more than 5-year follow-up prospective randomized controlled studies including USA IDE trials were expected to elucidate whether for LTDR to have therapeutic benefit compared to fusion. The results of these studies revealed that LTDR was not inferior to fusion. Most of clinical studies dealing with LTDR revealed that there was no strong evidence for preventive effect of LTDR against symptomatic degenerative changes of adjacent segment disease. LTDR does not have shortcomings associated with fusion. However, it has a potentiality of the new complications to occur, which surgeons have never experienced in fusion surgeries. Consequently, longer follow-up should be necessary as yet to confirm the maintenance of improved surgical outcome and to observe any very late complications. LTDR still may get a chance to establish itself as a substitute of fusion both nominally and virtually if it eases the concerns listed above.

Multiple recurrent postoperative spinal infections due to an unrecognized presacral abscess following placement of bicortical sacral screws: case report

Postoperative wound infections in spinal surgery remain an important complication to diagnose and treat successfully. In most cases of deep infection, even with instrumentation, aggressive soft-tissue debridement followed by intravenous antibiotics is sufficient. This report presents a patient who underwent L3-S1 laminectomy and pedicle screw placement including bicortical sacral screws. This patient went on to develop multiple (7) recurrent infections at the operative site over a 5-year period. Continued investigation eventually revealed a large presacral abscess, which remained the source of recurrent bacterial seeding via the remaining bone tracts of the bicortical sacral screws placed during the original lumbar surgery. Two years after drainage of this presacral collection via a retroperitoneal approach, the patient remains symptom free.

Post-surgical functional recovery, lumbar lordosis, and range of motion associated with MR-detectable redundant nerve roots in lumbar spinal stenosis

OBJECTIVE

T1- and T2-weighted magnetic resonance images (MRI) can reveal lumbar redundant nerve roots (RNRs), a result of chronic compression and nerve elongation associated with pathogenesis of cauda equina claudication (CEC) in degenerative lumbar canal stenosis (DLCS). The study investigated effects of lumbar lordosis angle and range of motion on functional recovery in lumbar stenosis patents with and without RNRs.

METHODS

A retrospective study was conducted of 93 lumbar spinal stenosis patients who underwent decompressive surgery. Eligible records were assessed by 3 independent blinded radiologists for presence or absence of RNRs on sagittal T2-weighted MR (RNR and non-RNR groups), pre- and post-operative JOA score, lumbar lordosis angle, and range of motion.

RESULTS

Of 93 total patients, the RNR group (n=37, 21/37 female) and non-RNR group (n=56; 31/56 female) had similar preoperative conditions (JOA score) and were not significantly different in age (mean 64.19 ± 8.25 vs. 62.8 ± 9.41 years), symptom duration (30.92 ± 22.43 vs. 28.64 ± 17.40 months), or follow-up periods (17.35 ± 4.02 vs. 17.75 ± 4.29 mo) (all p>0.4). The non-RNR group exhibited significantly better final JOA score (p=0.015) and recovery rate (p=0.002). RNR group patients exhibited larger lumbar lordosis angles in the neutral position (p=0.009) and extension (p=0.021) and larger range of motion (p=0.008).

CONCLUSIONS

Poorer surgical outcomes in patients with RNRs indicated that elevated lumbar lordosis angle and range of motion increased risks of RNR formation, which in turn may cause poorer post-surgical recovery, this information is possibly useful in prognostic assessment of lumbar stenosis complicated by RNRs.

Enhanced recovery after surgery (ERAS) and its applicability for major spine surgery

This article examines the relevance of applying the Enhanced Recovery after Surgery (ERAS) approach to patients undergoing major spinal surgery. The history of ERAS, details of the components of the approach and the underlying rationale are explained. Evidence on outcomes achieved by using the ERAS approach in other orthopaedic and complex surgical procedures is then outlined. Data on major spinal surgery rates and current practice are reviewed; the rationale for using ERAS in major spinal surgery is discussed, and potential challenges to its adoption are acknowledged. A thorough literature search is then undertaken to examine the use of ERAS pathways in major spinal surgery, and the results are presented. The article then reviews the evidence to support the application of individual ERAS components such as patient education, multimodal pain management, surgical approach, blood loss, nutrition and physiotherapy in major spinal surgery, and discusses the need for further robust research to be undertaken. The article concludes that given the rising costs of surgery and levels of patient dissatisfaction, an ERAS pathway that focuses on optimising clinical procedures by adopting evidence-based practice and improving logistics should enable major spinal surgery patients to recover more quickly with lower rates of morbidity and improved longer-term outcomes.

Inhibition of each module of connective tissue growth factor as a potential therapeutic target for rheumatoid arthritis

We previously reported the importance of connective tissue growth factor (CTGF) in rheumatoid arthritis (RA). CTGF contains four distinct modules connected in tandem, namely insulin-like growth factor-binding protein (IGFBP)-like, von Willebrand factor (vWF) type C repeat, thrombospondin type 1 (TSP-1) repeat, and carboxyl-terminal (CT) modules. The relationships between each of these modules of CTGF and RA remain unknown. Here, we analyzed how inhibition of each CTGF module affects the pathophysiology of RA. We conducted stimulation and suppression experiments on synovial cells (MH7A) obtained from patients with RA. Moreover, we examined angiogenesis by means of a tube-formation assay performed using human umbilical vein endothelial cells (HUVECs), and we used tartrate-resistant acid phosphatase (TRAP) staining to analyze osteoclastogenesis. Our results showed that M-CSF/RANKL-mediated osteoclastogenesis was enhanced when CTGF was added, but the effect of CTGF was neutralized by mAbs against CTGF modules 1-4. Furthermore, CTGF treatment of HUVECs induced formation of tubular networks, which resulted in acceleration of the angiogenesis of RA synoviocytes, and quantification showed that this tubular-network formation was also disrupted by anti-CTGF module 1-4 mAbs. Lastly, TNF-α enhanced the expression of CTGF and matrix metalloproteinase-3 (MMP3) in MH7A cells, and this enhancement was potently neutralized by mAbs against CTGF modules 1, 3 and 4. Thus, our results indicate that not only a mAb against CTGF but also mAbs against each specific module of CTGF might serve as potential therapeutic agents in the treatment of RA.

Treatment options for irreparable postero-superior cuff tears in young patients

Rotator cuff tears (RCTs) occur more commonly with advanced age, with most rotator cuff abnormalities in patients less than 30 years old being painful tendinoses or partial-thickness RCTs. Irreparable postero-superior cuff tears has been reported as frequent as 7% to 10% in the general population, and the incidence of irreparable RCTs in young patients is still unknown. Several surgical procedures have been proposed for young patients with irreparable postero-superior RCTs, such as rotator cuff debridement, partial rotator cuff repair, biceps tenotomy/tenodesis, rotator cuff grafting, latissimus dorsi tendon transfer, and reverse shoulder arthroplasty. After being thoroughly investigated in open surgery, arthroscopic techniques for latissimus dorsi tendon transfer have been recently described. They have been shown to be an adequate option to open surgery for managing irreparable postero-superior RCTs refractory to conservative management.

Effects of exercise on physical limitations and fatigue in rheumatic diseases

Physical activity covers not just sports but also simple everyday movements such as housework, walking and playing. Regular exercise has a great importance in maintaining good health, indeed inactivity is a risk factor for different chronic diseases. Physical exercise can play a crucial role in the treatment of rheumatic diseases, optimizing both physical and mental health, enhancing energy, decreasing fatigue and improving sleep. An exercise program for patients with rheumatic diseases aims to preserve or restore a range of motion of the affected joints, to increase muscle strength and endurance, and to improve mood and decrease health risks associated with a sedentary lifestyle. In this editorial I describe the benefits of the exercise on physical limitations and fatigue in rheumatic diseases that seem to have a short and long-term effectiveness. A literature review was conducted on PubMed, Scopus and Google Scholar using appropriate keywords based on the present editorial.

Collecting shoulder kinematics with electromagnetic tracking systems and digital inclinometers: A review

The shoulder complex presents unique challenges for measuring motion as the scapula, unlike any other bony segment in the body, glides and rotates underneath layers of soft tissue and skin. The ability for clinicians and researchers to collect meaningful kinematic data is dependent on the reliability and validity of the instrumentation utilized. The aim of this study was to review the relevant literature pertaining to the reliability and validity of electromagnetic tracking systems (ETS) and digital inclinometers for assessing shoulder complex motion. Advances in technology have led to the development of biomechanical instrumentation, like ETS, that allow for the collection of three-dimensional kinematic data. The existing evidence has demonstrated that ETS are reliable and valid instruments for collecting static and dynamic kinematic data of the shoulder complex. Similarly, digital inclinometers have become increasingly popular among clinicians due to their cost effectiveness and practical use in the clinical setting. The existing evidence supports the use of digital inclinometers for the collection of shoulder complex kinematics as these instruments have been demonstrated to yield acceptable reliability and validity. While digital inclinometers pose a disadvantage to ETS regarding accuracy, precision, and are limited to two-dimensional and static measurements, this instrument provides clinically meaningful data that allow clinicians and researchers the ability to measure, monitor, and compare shoulder complex kinematics.

A cross-sectional study to estimate associations between education level and osteoporosis in a Chinese postmenopausal women sample

BACKGROUND

Our research aims to investigate the associations between education level and osteoporosis (OP) in Chinese postmenopausal women.

METHODS

A large-scale, community-based, cross-sectional study was conducted to examine the associations between education level and OP. A self-reported questionnaire was used to access the demographical information and medical history of the participants. A total of 1905 postmenopausal women were available for data analysis in this study. Multiple regression models controlling for confounding factors to include education level were performed to investigate the relationship with OP.

RESULTS

The prevalence of OP was 28.29% in our study sample. Multivariate linear regression analyses adjusted for relevant potential confounding factors detected significant associations between education level and T-score (β = 0.025, P-value = 0.095, 95% CI: -0.004-0.055 for model 1; and β = 0.092, P-value = 0.032, 95% CI: 0.008-0.175 for model 2). Multivariate logistic regression analyses detected significant associations between education level and OP in model 1 (P-value = 0.070 for model 1, Table 5), while no significant associations was reported in model 2 (P value = 0.131). In participants with high education levels, the OR for OP was 0.914 (95% CI: 0.830-1.007).

CONCLUSION

The findings indicated that education level was independently and significantly associated with OP. The prevalence of OP was more frequent in Chinese postmenopausal women with low educational status.

Ultrasound-Guided Percutaneous Electrolysis and Eccentric Exercises for Subacromial Pain Syndrome: A Randomized Clinical Trial

Objective. To compare effects of ultrasound- (US-) guided percutaneous electrolysis combined with an eccentric exercise program of the rotator cuff muscles in subacromial pain syndrome. Methods. Thirty-six patients were randomized and assigned into US-guided percutaneous electrolysis (n = 17) group or exercise (n = 19) group. Patients were asked to perform an eccentric exercise program of the rotator cuff muscles twice every day for 4 weeks. Participants assigned to US-guided percutaneous electrolysis group also received the application of galvanic current through acupuncture needle on each session once a week (total 4 sessions). Shoulder pain (NPRS) and disability (DASH) were assessed at baseline, after 2 sessions, and 1 week after the last session. Results. The ANOVA revealed significant Group∗Time interactions for shoulder pain and disability (all, P < 0.01): individuals receiving US-guided percutaneous electrolysis combined with the eccentric exercises experienced greater improvement than those receiving eccentric exercise alone. Conclusions. US-guided percutaneous electrolysis combined with eccentric exercises resulted in small better outcomes at short term compared to when only eccentric exercises were applied in subacromial pain syndrome. The effect was statistically and clinically significant for shoulder pain but below minimal clinical difference for function. Future studies should investigate the long-term effects and potential placebo effect of this intervention.

(99m)Tc-MDP bone scintigraphy of the hand: comparing the use of novel cadmium zinc telluride (CZT) and routine NaI(Tl) detectors

Background

Cadmium zinc telluride (CZT) solid-state detectors have been recently introduced in the field of nuclear medicine in cardiology and breast imaging. The aim of the current study was to evaluate the performance of the novel detectors (CZT) compared to that of the routine NaI(Tl) in bone scintigraphy. A dual-headed CZT-based camera dedicated originally to breast imaging has been used, and in view of the limited size of the detectors, the hands were chosen as the organ for assessment. This is a clinical study.

Methods

Fifty-eight consecutive patients (total 116 hands) referred for bone scan for suspected hand pathology gave their informed consent to have two acquisitions, using the routine camera and the CZT-based camera. The latter was divided into full-dose full-acquisition time (FD CZT) and reduced-dose short-acquisition time (RD CZT) on CZT technology, so three image sets were available for analysis. Data analysis included comparing the detection of hot lesions and identification of the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints.

Results

A total of 69 hot lesions were detected on the CZT image sets; of these, 61 were identified as focal sites of uptake on NaI(Tl) data. On FD CZT data, 385 joints were identified compared to 168 on NaI(Tl) data (p < 0.001). There was no statistically significant difference in delineation of joints between FD and RD CZT data as the latter identified 383 joints.

Conclusions

Bone scintigraphy using a CZT-based gamma camera is associated with improved lesion detection and anatomic definition. The superior physical characteristics of this technique raised a potential reduction in administered dose and/or acquisition time without compromising image quality.

Current Trends in Anterior Cruciate Ligament Reconstruction: A Review

Anterior cruciate ligament reconstruction (ACLR) is an accepted and established surgical technique for anterior cruciate ligament (ACL) injuries and is now being practiced across the globe in increasing numbers. Although most patients get good to excellent results in the short-term after ACLR, its consequences in the long-term in prevention or acceleration of knee osteoarthritis (OA) are not yet well-defined. Still, there are many debatable issues related to ACLR, such as the appropriate timing of surgery, graft selection, fixation methods of the graft, operative techniques, rehabilitation after surgery, and healing augmentation techniques. Most surgeons prefer not to wait long after an ACL injury to do an ACLR, as delayed reconstruction is associated with secondary damages to the intra- and periarticular structures of the knee. Autografts are the preferred choice of graft in primary ACLR, and hamstring tendons are the most popular amongst surgeons. Single bundle ACLR is being practiced by the majority, but double bundle ACLR is getting popular due to its theoretical advantage of providing more anatomical reconstruction. A preferred construct is the interference fixation (Bio-screw) at the tibial site and the suspensory method of fixation at the femoral site. In a single bundle hamstring graft, a transportal approach for creating a femoral tunnel has recently become more popular than the trans-tibial technique. Various healing augmentation techniques, including the platelet rich plasma (PRP), have been tried after ACLR, but there is still no conclusive proof of their efficacy. Accelerated rehabilitation is seemingly more accepted immediately after ACLR.

Ultrasound-guided procedures to treat sport-related muscle injuries

Ultrasound is well known as a low-cost, radiation-free and effective imaging technique to guide percutaneous procedures. The lower limb muscles represent a good target to perform such procedures under ultrasound guidance, thus allowing for clear and precise visualization of the needle during the whole procedure. The knowledge of guidelines and technical aspects is mandatory to act in the most safe and accurate way on target tissues that can be as small as a few millimetres. This review will focus above the local treatments of traumatic lower limb muscle injuries described in literature, focusing on new and promising approaches, such as platelet-rich plasma treatment of muscle tears in athletes. For each procedure, a brief how-to-do practical guide will be provided, emphasizing precautions and tricks based on day-by-day experience that may help to improve the outcome of percutaneous ultrasound-guided procedures around the lower limb muscles.

Differentiation of deer tendons from cattle tendons by a loop-mediated isothermal amplification (LAMP) test and bone remodeling bioassays

BACKGROUND

Deer tendons are believed more effective than cattle tendons in tonifying kidney yang (shen yang) and enhancing bone and tendons. This study aims to differentiate the two types of tendons by a loop-mediated isothermal amplification (LAMP) test and bone remodeling bioassays.

METHODS

Internal control primers to detect both types of tendons and specific primers for deer tendons were designed according to a sequence analysis. The LAMP test was set up and the results were analyzed by conventional gel electrophoresis, real-time fluorescence observation, and colorimetric detection. Crude tendon extracts were prepared by water extraction to compare their effects on bone. The anti-osteoclastic effects were investigated on mouse pre-osteoclast Raw264.7 cells by cell viability determination and tartrate-resistant acid phosphatase staining. The osteogenic effects were examined using rat osteoblast-like UMR106 cells by evaluation of cell proliferation, alkaline phosphatase activity, and calcium deposition. The relative gene expressions of bone remodeling-related markers, including nuclear factor of activated T-cells cytoplasmic 1, tartrate-resistant acid phosphatase, cathepsin K, and osteoprotegerin/receptor activator of NF-κB ligand, were determined by real-time PCR.

RESULTS

In the LAMP test, both deer and cattle tendons were detected in the control reactions, while only deer tendons were amplified by the specific LAMP test. In the bioassays, both tendons inhibited the viability and differentiation of pre-osteoclast Raw264.7 cells, and promoted the proliferation and mineralization of osteoblast-like UMR106 cells. The mRNA expressions of bone remodeling-related markers were consistent with the results of the bioassays.

CONCLUSION

This study demonstrated that the isothermal LAMP test can distinguish between deer tendons and cattle tendons. Both types of tendons exhibited similar beneficial effects on bone remodeling according to the bioassay findings.

Centenarian Rates and Life Expectancy Related to the Death Rates of Multiple Sclerosis, Asthma, and Rheumatoid Arthritis and the Incidence of Type 1 Diabetes in Children

The autoimmune diseases are among the 10 leading causes of death for women and the number two cause of chronic illness in America as well as a predisposing factor for cardiovascular diseases and cancer. Patients of some autoimmune diseases have shown a shorter life span and are a model of accelerated immunosenescence. Conversely, centenarians are used as a model of successful aging and have shown several immune parameters that are better preserved and lower levels of autoantibodies. The study reported here focused on clarifying the connection between longevity and some autoimmune and allergic diseases in 29 developed Organisation for Economic Co-operation and Development (OECD) countries, because multidisciplinary analyses of the accelerated or delayed aging data could show a distinct relationship pattern, help to identify common factors, and determine new important factors that contribute to longevity and healthy aging. The relationships between the mortality rates data of multiple sclerosis (MS), rheumatoid arthritis (RA), asthma, the incidence of type 1 diabetes (T1D) from one side and centenarian rates (two sets) as well as life expectancy data from the other side were assessed using regression models and Pearson correlation coefficients. The data obtained correspond to an inverse linear correlation with different degrees of linearity. This is the first observation of a clear tendency of diminishing centenarian rates or life expectancy in countries having higher death rates of asthma, MS, and RA and a higher incidence of T1D in children. The conclusion is that most probably there are common mechanistic pathways and factors affecting the above diseases and at the same time but in the opposite direction the processes of longevity. Further study, comparing genetic data, mechanistic pathways, and other factors connected to autoimmune diseases with those of longevity could clarify the processes involved, so as to promote longevity and limit the expansion of those diseases in the younger and older population.

Acetabular reconstruction with a reinforcement device and bone grafting in revision arthroplasty-a mean five years of follow-up

PURPOSE

To evaluate the clinical and radiological outcomes of acetabular reconstruction using a reinforcement device (RD) in combination with bone grafting in Paprosky type 2 and 3 acetabular bone defects.

METHODS

Morselised bone grafts were used to fill cavitary defects and a structural graft placed in the superior part of the acetabulum in cases of cranial bone defects, with a proximally fixed RD (Protetim, Hódmezővásárhely, Hungary) implanted in all cases. Construct stability, device positioning, hip centre of rotation and medial acetabular wall thickness were evaluated radiologically. Survival rates were estimated with aseptic loosening and revision for any reason as endpoints.

RESULTS

The 28 patients (29 hips) were followed for 4.8 ± 2.7 years (range, 2-10.4 years). Hip centre of rotation was lowered in all cases, with no significant differences between the mean values obtained post-operatively and at the last follow-up. Medial acetabular wall thickness and RD abduction angle were maintained up to the last evaluation. Bone grafts integrated by two years post-operatively in the majority of cases. Kaplan-Meier survival rates were 85.2 % and 82.1 % for the two endpoints at ten years.

CONCLUSIONS

Acetabular reconstruction using a proximally fixed RD in combination with bone grafting offered good mid-term results in the treatment of acetabular bone defects. In cases of severe bone loss, the structural allograft allowed placement of the RD with ischial contact, rendering survival rates similar to RDs with both iliac and ilioischial fixation. The technique was successful in restoring and maintaining medial acetabular bone stock and construct stability for up to ten years.

Numerical and experimental investigations for the evaluation of the wear coefficient of reverse total shoulder prostheses

In the present study, numerical and experimental wear investigations on reverse total shoulder arthroplasties (RTSAs) were combined in order to estimate specific wear coefficients, currently not available in the literature. A wear model previously developed by the authors for metal-on-plastic hip implants was adapted to RTSAs and applied in a double direction: firstly, to evaluate specific wear coefficients for RTSAs from experimental results and secondly, to predict wear distribution. In both cases, the Archard wear law (AR) and the wear law of UHMWPE (PE) were considered, assuming four different k functions. The results indicated that both the wear laws predict higher wear coefficients for RTSA with respect to hip implants, particularly the AR law, with k values higher than twofold the hip ones. Such differences can significantly affect predictive wear model results for RTSA, when non-specific wear coefficients are used. Moreover, the wear maps simulated with the two laws are markedly different, although providing the same wear volume. A higher wear depth (+51%) is obtained with the AR law, located at the dome of the cup, while with the PE law the most worn region is close to the edge. Taking advantage of the linear trend of experimental volume losses, the wear coefficients obtained with the AR law should be valid despite having neglected the geometry update in the model.

Impaired osteoclast homeostasis in the cystatin B-deficient mouse model of progressive myoclonus epilepsy

Progressive myoclonus epilepsy of Unverricht–Lundborg type (EPM1) is an autosomal recessively inherited disorder characterized by incapacitating stimulus-sensitive myoclonus and tonic-clonic epileptic seizures with onset at the age of 6 to 16 years. EPM1 patients also exhibit a range of skeletal changes, e.g., thickened frontal cranial bone, arachnodactyly and scoliosis. Mutations in the gene encoding cystatin B (CSTB) underlie EPM1. CSTB is an inhibitor of cysteine cathepsins, including cathepsin K, a key enzyme in bone resorption by osteoclasts. CSTB has previously been shown to protect osteoclasts from experimentally induced apoptosis and to modulate bone resorption in vitro. Nevertheless, its physiological function in bone and the cause of the bone changes in patients remain unknown. Here we used the CSTB-deficient mouse (Cstb^−/−) model of EPM1 to evaluate the contribution of defective CSTB protein function on bone pathology and osteoclast differentiation and function. Micro-computed tomography of hind limbs revealed thicker trabeculae and elevated bone mineral density in the trabecular bone of Cstb^−/− mice. Histology from Cstb^−/− mouse bones showed lower osteoclast count and thinner growth plates in long bones. Bone marrow-derived osteoclast cultures revealed lower osteoclast number and size in the Cstb^−/− group. Cstb^−/− osteoclasts formed less and smaller resorption pits in an in vitro assay. This impaired resorptive capacity was likely due to a decrease in osteoclast numbers and size. These data imply that the skeletal changes in Cstb^−/− mice and in EPM1 patients are a result of CSTB deficiency leading to impaired osteoclast formation and consequently compromised resorptive capacity. These results suggest that the role of CSTB in osteoclast homeostasis and modulation of bone metabolism extends beyond cathepsin K regulation.

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μCT reveals changes in trabecular bone of the Cstb^−/− mouse model of EPM1, compatible with findings in human patients.

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Bone histology in Cstb^−/− mice shows lower osteoclast number and thinner growth plates in long bones.

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Cultured osteoclasts of Cstb^−/− mice show decreased size and number of mature osteoclasts with impaired bone resorption.

•

Impaired osteoclast formation and resorption are likely to underlie the bone phenotype associated with CSTB deficiency.

Modulation of unloading-induced bone loss in mice with altered ERK signaling

Genetic variations mediate skeletal responsiveness to mechanical unloading, with individual space travelers exhibiting large variations in the extent of bone loss. We previously identified genomic regions harboring several hundred genes that can modulate the magnitude of skeletal adaptation to mechanical unloading. Here, bioinformatic filters aided in shortlisting 30 genes with bone-related and mechanoregulatory roles. The genes CD44, FGF2, NOD2, and Fas, all associated with ERK signaling, were then functionally tested in hindlimb-unloaded (HLU) knockout (KO) mice. Compared to their respective normally ambulating wildtype (WT) controls, all KO strains, except Fas mice, had lower trabecular bone volume, bone volume fraction, and/or trabecular number. For cortical bone and compared to ambulatory WT mice, CD44(-/-) had impaired properties while FGF2(-/-) showed enhanced indices. NOD2(-/-) and Fas(-/-) did not have a cortical phenotype. In all KO and WT groups, HLU resulted in impaired trabecular and cortical indices, primarily due to trabecular tissue loss and mitigation of cortical bone growth. The difference in trabecular separation between HLU and ambulatory controls was significantly greater in CD44(-/-) and NOD2(-/-) mice than in WT mice. In cortical bone, differences in cortical thickness, total pore volume, and cortical porosity between HLU and controls were aggravated in CD44(-/-) mice. In contrast, deletion of NOD2 and Fas genes mitigated the differences in Po.V between HLU and control mice. Together, we narrowed a previous list of QTL-derived candidate genes from over 300 to 30, and showed that CD44, NOD2, and Fas have distinct functions in regulating changes in trabecular and cortical bone indices during unloading.

Patient-related medical risk factors for periprosthetic joint infection of the hip and knee

Despite advancements and improvements in methods for preventing infection, periprosthetic joint infection (PJI) is a significant complication following total joint arthroplasty (TJA). Prevention is the most important strategy to deal with this disabling complication, and prevention should begin with identifying patient-related risk factors. Medical risk factors, such as morbid obesity, malnutrition, hyperglycemia, uncontrolled diabetes mellitus, rheumatoid arthritis (RA), preoperative anemia, cardiovascular disorders, chronic renal failure, smoking, alcohol abuse and depression, should be evaluated and optimized prior to surgery. Treating patients to get laboratory values under a specified threshold or cessation of certain modifiable risk factors can decrease the risk of PJI. Although significant advances have been made in past decades to identify these risk factors, there remains some uncertainty regarding the risk factors predisposing TJA patients to PJI. Through a review of the current literature, this paper aims to comprehensively evaluate and provide a better understanding of known medical risk factors for PJI after TJA.

Investigation of the cytokine response to NF-κB decoy oligonucleotide coated polysaccharide based nanoparticles in rheumatoid arthritis in vitro models

Introduction

The transcription factor nuclear factor-kappa B (NF-κB) is highly involved in regulation of a number of cellular processes, including production of inflammatory mediators. Thus, this transcription factor plays a role in pathology of many diseases, including rheumatoid arthritis, an autoimmune disease hallmarked by an imbalance of pro and anti-inflammatory cytokines. Small nucleic acids with sequences that mimic the native binding site of NF-κB have been proposed as treatment options for RA; however due to low cellular penetration and a high degree of instability, clinical applications of these therapeutics have been limited.

Methods

Here, we describe the use of N-trimethyl chitosan-polysialic acid (PSA-TMC) nanoparticles coated with decoy oligodeoxynucleotides (ODNs) specific to transcription factor NF-κB (PSA-TMC-ODN) as a method to enhance the stability of the nucleic acids and facilitate increased cellular penetration. In addition to decoy ODN, PSA-TMC nanoparticles were loaded with RA therapeutic methotrexate (MTX), to assess the anti-inflammatory efficacy of a combination therapy approach. Two different in vitro models, a cell line based model as well as a primary RA cell model were used to investigate anti-inflammatory activity. One way ANOVA followed by Holm-Sidak stepdown comparisons was used to determine statistical significance.

Results

In general, free ODN did not significantly affect secretion of pro-inflammatory cytokines interleukin-6 (IL-6) and interleukin-8, (IL-8) while free MTX had variable efficacy. However, PSA-TMC-ODN and PSA-TMC-ODN-MTX resulted in significant decreases in the inflammatory mediators IL-6 and IL-8 in both cell models. In addition, PSA-TMC exhibited sufficient cellular uptake, as observed through fluorescence microscopy.

Conclusions

These results support our previous findings that PSA-TMC nanoparticles are an effective delivery vehicle for small nucleic acids, and effectively alter the pro-inflammatory state characteristic of RA.

ISAKOS classification of meniscal tears-illustration on 2D and 3D isotropic spin echo MR imaging

Magnetic Resonance Imaging is modality of choice for the non-invasive evaluation of meniscal tears. Accurate and uniform documentation of meniscal pathology is necessary for optimal multi-disciplinary communication, to guide treatment options and for validation of patient outcomes studies. The increasingly used ISAKOS arthroscopic meniscus tear classification system has been shown to provide sufficient interobserver reliability among the surgeons. However, the terminology is not in common use in the radiology world. In this article, the authors discuss the MR imaging appearances of meniscal tears based on ISAKOS classification on 2D and multiplanar 3D isotropic spin echo imaging techniques and illustrate the correlations of various meniscal pathologies with relevant arthroscopic images.

Vanishing Mandible: A Rare Case Report with Accent to Recent Concepts on Aetio-pathogenesis

Massive osteolysis is a rare idiopathic bone disease resulting in progressive destruction of bone. Considering the rarity of encountering this fascinating bone disease, it is often misinterpreted as some other osteolytic disease. Hence, we present a well-documented case of massive osteolysis in a 29-year-old female patient with complete clinical, radiographic, macroscopic and microscopic features along with surgical photographs, which has been effectively managed at our hospital.

Preliminary results of the treatment of proximal femoral fractures with the AFFIXUS nail

Contemporary fixation of the proximal femur is performed utilising a number of implants adopting different concepts and techniques. Cephalomedullary nails in particular represent one of two main options, the other being dynamic hip screw (DHS). The aim of this cohort study is to present the early experience of two large units from different countries of the use of the AFFIXUS nail for stabilisation of proximal femoral fractures. Over a period of almost three years, data from 476 proximal femoral fractures were collected and analysed using a specific research protocol, assessing data relevant to basic demographic details, in-hospital stay, surgical technique and post discharge outcomes with a minimum follow up of 6 months. Both the short and long versions of the nail were used in both centres, however, with some statistically significant differences as far as the type of fractures stabilised with the nail, which also translated to differences in the combination or not of 2 lag screws, and the static or dynamic mode of the proximal fixation construct. Other areas of difference amongst the 2 units, were the length of hospital stay and return of patients to their pre-injury residence, most likely reflecting the different social circumstances between the 2 countries. Overall mortality at a median follow up period of 17 months (range 6 to 35) was limited to 6.3%, nonunion and cut out rates 2.7%, whilst revision surgery occurred in just 2.5%. Over the first 6 months of follow up 63.6% returned to their pre-injury ambulatory status and 90.5% to their pre-injury residence. Further studies and higher level of scientific evidence is needed to verify the findings of this retrospective cohort study as to the effectiveness and safety of this new cephalomedullary nail.

Rheumatoid arthritis-celiac disease relationship: joints get that gut feeling

Rheumatoid arthritis (RA) and celiac disease (CD) belong to the autoimmune disease family. Despite being separate entities they share multiple aspects. Epidemiologically they share comparable incidence environmental influences, associated antibodies and a recent incidental surge. They differ in their HLA pre-dispositions and specific predictive and diagnostic biomarkers. At the clinical level, celiac disease exhibits extra-intestinal rheumatic manifestations and RA gastrointestinal ones. Small bowel pathology exists in rheumatic patients. A trend towards responsiveness to a gluten free diet has been observed, ameliorating celiac rheumatic manifestations, whereas dietary interventions for rheumatoid arthritis remain controversial. Pathophysiologically, both diseases are mediated by endogenous enzymes in the target organs. The infectious, dysbiotic and increased intestinal permeability theories, as drivers of the autoimmune cascade, apply to both diseases. Contrary to their specific HLA pre-disposition, the diseases share multiple non-HLA loci. Those genes are crucial for activation and regulation of adaptive and innate immunity. Recently, light was shed on the interaction between host genetics and microbiota composition in relation to CD and RA susceptibility, connecting bugs and us and autoimmunity. A better understanding of the above mentioned similarities in the gut-joint inter-relationship, may elucidate additional facets in the mosaic of autoimmunity, relating CD to RA.