Severe cartilage damage by broken poly-L-lactic acid (PLLA) interference screw after ACL reconstruction

Medial patellofemoral ligament reconstruction with simultaneous osteochondral fracture fixation is an effective treatment for adolescent patellar dislocation with osteochondral fractures

BACKGROUND

Osteochondral fractures can occur during patellar dislocation and often require treatment. The purpose of this study is to determine the incidence of recurrent instability and second surgery following osteochondral fracture fixation with concomitant medial patellofemoral ligament reconstruction.

METHODS

A retrospective review of a cohort of 365 medial patellofemoral ligament reconstructions by a single surgeon from 2008 to 2019 was performed to identify patients who underwent simultaneous osteochondral fracture fixation with bioabsorbable nails. Demographic data, surgical details, clinical follow-up, and subsequent procedures were collected.

RESULTS

Forty medial patellofemoral ligament reconstructions with osteochondral fracture fixation were performed by a single surgeon from 2008 to 2019. The average age at surgery was 14.6 years (range 10.7-19.6 years). The average length of follow-up was 2.6 years (range 0.7-7.0 years). Eleven (28%) patients required a second surgery on the ipsilateral knee. One patient had recurrent instability and required revision medial patellofemoral ligament reconstruction and osteochondral allograft. The other 10 patients underwent a second surgery to address cartilage damage or debridement of nails. Of the four patients who required nail debridement, the average number of nails initially placed was 7 ± 1.7. This was significantly more than the patients who did not require second surgery related to nail debridement (4.1 ± 1.6, p < .05).

CONCLUSION

28% of patients required a second procedure, most of which involved debridement of unhealed portions of the osteochondral fracture. At 2.6-year follow-up, only 2% of patients had a failure of their osteochondral fracture fixation requiring a cartilage restoration procedure. Osteochondral fracture fixation in adolescents with patellofemoral instability can be effectively treated with fixation and simultaneous medial patellofemoral ligament reconstruction.

LEVEL OF EVIDENCE

level IV.

Heat Sterilization Effects on Polymeric, FDM-Optimized Orthopedic Cutting Guide for Surgical Procedures

Improvements in software for image analysis have enabled advances in both medical and engineering industries, including the use of medical analysis tools to recreate internal parts of the human body accurately. A research analysis found that FDM-sourced elements have shown viability for a customized and reliable approach in the orthopedics field. Three-dimensional printing has allowed enhanced accuracy of preoperative planning, leading to reduced surgery times, fewer unnecessary tissue perforations, and fewer healing complications. Furthermore, using custom tools chosen for each procedure has shown the best results. Bone correction-related surgeries require customized cutting guides for a greater outcome. This study aims to assess the biopolymer-based tools for surgical operations and their ability to sustain a regular heat-sterilization cycle without compromising the geometry and fit characteristics for a proper procedure. To achieve this, a DICOM and FDM methodology is proposed for fast prototyping of the cutting guide by means of 3D engineering. A sterilization test was performed on HTPLA, PLA, and nylon polymers. As a result, the unique characteristics within the regular autoclave sterilization process allowed regular supplied PLA to show there were no significant deformations, whilst annealed HTPLA proved this material’s capability of sustaining repeated heat cycles due to its crystallization properties. Both of these proved that the sterilization procedures do not compromise the reliability of the part, nor the safety of the procedure. Therefore, prototypes made with a similar process as this proposal could be safely used in actual surgery practices, while nylon performed poorly because of its hygroscopic properties.

A novel biocompatible polymeric blend for applications requiring high toughness and tailored degradation rate

Finding the right balance in mechanical properties and degradation rate of biodegradable materials for biomedical applications is challenging, not only at the time of implantation but also during biodegradation. For instance, high elongation at break and toughness with a mid-term degradation rate are required for tendon scaffold or suture application, which cannot be found in each alpha polyester individually. Here, we hypothesise that blending semi-crystalline poly(p-dioxanone) (PDO) and poly(lactide-co-caprolactone) (LCL) in a specific composition will enhance the toughness while also enabling tailored degradation times. Hence, blends of PDO and LCL (PDO/LCL) were prepared in varying concentrations and formed into films by solvent casting. We thoroughly characterised the chemical, thermal, morphological, and mechanical properties of the new blends before and during hydrolytic degradation. Cellular performance was determined by seeding mouse fibroblasts onto the samples and culturing for 72 hours, before using proliferation assays and confocal imaging. We found that an increase in LCL content causes a decrease in hydrolytic degradation rate, as indicated by induced crystallinity, surface and bulk erosions, and tensile properties. Interestingly, the noncytotoxic blend containing 30% PDO and 70% LCL (PDO3LCL7) resulted in small PDO droplets uniformly dispersed within the LCL matrix and demonstrated a tailored degradation rate and toughening behaviour with a notable strain-hardening effect reaching 320% elongation at break; over 3 times the elongation of neat LCL. In summary, this work highlights the potential of PDO3LCL7 as a biomaterial for biomedical applications like tendon tissue engineering or high-performance absorbable sutures.

Microroughness induced biomimetic coating for biodegradation control of magnesium

Herein we explore a combination of anodization induced micro-roughness and biomimetic coating on pure magnesium (Mg) metal at different applied voltages to control adhesion, biodegradation, and corrosion performance in simulated body fluid solution. The anodic film was fabricated using two different potentials, 3 and 5 V, respectively, to create microroughness on the Mg surface. The microroughened Mg surface was subsequently coated with a biomimetic silk thin film; and the characteristics of the treated Mg-substrates were evaluated using various spectroscopic, microscopic, immersion, and electrochemical techniques. A number of independent measurements, including hydrogen evolution, weight loss and electrochemical methods were employed to assess the corrosion characteristics. The silk-coated anodized samples revealed dramatically reduced degradation rate in terms of volume of hydrogen gas generation and weight loss compared to the respective anodized but uncoated, which revealed that optimized biomimetic silk-coated Mg surface (anodized at 5 V and subsequently biomimetic silk-coated ANMg_5V) exhibited the best corrosion performance among all other tested samples. The ANMg_5V Silk showed the highest polarization resistance (46.12 kΩ·cm²), protection efficiency (>0.99) and lowest corrosion rate (only 0.017 mm/year) relative to untreated Mg (8.457 mm/year), and anodized Mg (1.039 for anodized at 3 V and 0.986 for anodized at 5 V) surface due to the formation of a pore-free dense biomimetic protective film over Mg surface. The results of the cytotoxicity test confirm that silk-coated samples are significantly less cytotoxic compared to bare and anodized Mg samples. With enhanced corrosion resistance and cytocompatibility, silk-coated Mg could be a potential material for clinical applications.

Biomechanical comparison of knotless vs. knotted suture anchors in the acetabular rim with respect to bone density

BACKGROUND

Acetabular labral tears are managed with suture anchors providing good clinical outcomes. Knotless anchors are easier to use and have a quicker insertion time compared to knotted anchors. The purpose of this study was to compare the biomechanical behavior of two different anchor designs (knotted vs. knotless) in ultimate load testing in correlation with bone density in the acetabular rim.

METHODS

Eighteen knotted Bio-FASTak and seventeen knotless PushLock anchors (both: Arthrex Inc., Naples, FL, USA) were inserted in the rims of two human acetabula, with known bone density distribution. The anchors were subjected to load-to-failure tests. Anchors were additionally tested in solid polyurethane foam with defined densities.

FINDINGS

The Bio-FASTak group showed higher survival rates at 1, 2, and 3 mm displacement and was able to withstand significantly higher loads at 3 mm displacement (p = 0.031). There was no statistically significant difference in stiffness (p = 0.087), yield- (p = 0.190), and ultimate load (p = 0.222) between the two groups. Only the PushLock group showed correlation between bone volume over total volume (BV/TV) and stiffness (R = 0.750, p = 0.086) and between BV/TV and yield load (R = 0.838, p = 0.037). Experiments on solid polyurethane foam confirmed the correlation between the mechanical properties and tissue density for the same anchor.

INTERPRETATION

PushLock shows similar biomechanical properties to the Bio-FASTak, but eliminates knot tying and potentially abrasive knots. In addition, biomechanical properties of the PushLock are governed by local bone density.

Clinical outcomes after absorbable suture fixation of patellar osteochondral fracture following patellar dislocation

Background

Osteochondral fracture (OCF) is one of the severe complications following a patellar dislocation. The appropriate fixation method for patients with OCF remains controversial.

Methods

Eighteen patients who had undergone surgery after a patellar dislocation were recruited retrospectively. Patellar OCF was fixed with an absorbable suture in an unreported method. The medial patellofemoral ligament (MPFL) was repaired or reconstructed if necessary. The Lysholm and Kujala knee scoring systems were used to evaluate the knee function. Imaging examinations were used to confirm the fracture healing.

Results

The mean period of follow-up was 36 months. All patients recovered well postoperatively without symptomatic complications. The Lysholm score and the Kujala score improved significantly from 37.6 (SD =6.8) and 45.9 (SD =6.4) preoperatively to 80.9 (SD =7.4) and 89.4 (SD =6.8) postoperatively at the latest follow-up, respectively. Imaging evidence including X-ray and MRI revealed good healing of the OCFs.

Conclusions

This study showed satisfactory mid-term outcomes of OCF fixation using absorbable suture, which supports this method's potential to be a novel surgical method in the treatment of patellar OCF caused by a patellar dislocation.

Treatment of trauma-induced femoral head necrosis with biodegradable pure Mg screw-fixed pedicle iliac bone flap

Introduction

The avascular necrosis of the femoral head represents the death of bone tissue due to the lack of blood supply. The disease has a progressive evolution; it leads to femoral head collapse and severe arthritis when left untreated. The application of a pedicled bone flap graft is an effective treatment for femoral head necrosis. A pure Mg screw is a kind of degradable screw that can fix the grafted bone flap and prevent long-term stress occlusion and secondary dissection.

Case presentation

The report shows the results of the treatment of traumatic femoral head necrosis with a pedicled bone flap with pure Mg screw. A patient had avascular necrosis of the femoral head after 2 years of internal fixation of the femoral neck fracture. We removed the patient's internal fixation hollow nail, cleaned the necrotic bone tissue and took part of the same ipsilateral pedicle iliac bone graft in the femoral head defect with biodegradable pure Mg screw fixation. Within 2 years after the surgery, the patients had no significant progressive necrosis of the femoral head. Postoperative Harris scores showed that the patient's left hip function was significantly improved compared with his preoperative state. The pure Mg screw in the body had gradually degraded. After 2 years, the screw's diameter had been significantly reduced compared with 3 days after the surgery. The postoperative Harris score showed that the patient's left hip function was significantly improved compared with the second preoperative examination.

Discussion

The discussion includes the reasons for the choices of surgical approaches, the mode of pure Mg screw degradation and the postoperative functional assessment of the patient's left hip.

Conclusion

Pure Mg screw fixation pedicled bone flap transplantation is an effective surgical treatment for femoral head necrosis in young patients. Pure Mg screw is a biodegradable internal fixation device with good biocompatibility, which has a good clinical application prospects.

The translational potential of this article

Degradable pure Mg screw has the potential to preserve hip joint therapy for the treatment of femoral head necrosis.

Uncommon Complications after Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament reconstruction (ACL-R) is a common surgical procedure, with good outcome in 75 to 97% of the cases. However, different complications have been described including infection, hemarthrosis, deep vein thrombosis (DVT), and pulmonary embolism (PE) with a rate ranging from 1 to 15%. There are few case reports in the literature describing rare complications after ACL-R and they can be divided into: (1) complications related to the fixation device (rupture, migration); (2) fractures (tibial or femoral side); (3) infections due to uncommon bacteria, mycobacterium, and mycosis; (4) rare vascular injuries; (5) nerve injuries; and (6) other rare complications. In case of fixation device rupture or migration, device removal can be easy but the diagnosis may be challenging. Patellar fracture after ACL-R may be related to harvesting and it is not uncommon. Conversely, femoral or tibial fractures are most frequently due to bone weakness related to bone tunnels. Some rare infections related to uncommon bacteria or mycosis are also described with potentially devastating joint damage. Popliteal artery injuries are uncommon in ACL-R but minor vessels damages are described with possible severe consequences for patients. Injuries to the infrapatellar branch of the saphenous nerve are not uncommon in ACL-R. However, there are few case reports also describing injuries to the saphenous nerve, the common peroneal nerve and the sciatic nerve. The aim of this paper is to review the literature describing uncommon complications after ACL-R, giving some more information about diagnosis and treatment.

Anodization of magnesium for biomedical applications - Processing, characterization, degradation and cytocompatibility

This article reports anodization of Mg in KOH electrolyte and the associated surface, degradation, and biological properties for bioresorbable implant applications. The preparation procedures for electrodes and anodization setup significantly enhanced reproducibility of samples. The results of anodization performed at the applied potentials of 1.8, 1.9, or 2.0V showed that the sample anodized at 1.9V and annealed, referred to as the 1.9 AA sample, had homogenous surface microstructure and elemental composition, and a reduction in corrosion current density in the electrochemical testing. In comparison with Mg control, the 1.9 AA sample showed a distinct mode of degradation, e.g., continuous growth of a passivation layer enriched with Ca and P instead of typical localized pitting and undermining, and a greater release rate of Mg²⁺ ions when immersed in physiologically relevant media. In the direct culture with bone marrow derived mesenchymal stem cells (BMSCs) in vitro, the 1.9 AA sample did not affect BMSC adhesion and morphology under indirect contact; however, the 1.9 AA sample showed a reduction in cell spreading under direct contact. The change in surface topography/composition at the dynamic interface of the anodized-annealed Mg sample might have contributed to the change in BMSC morphology. In summary, this study demonstrated the potential of anodic oxidation to modulate the degradation behaviors of Mg-based biomaterials and BMSC responses in vitro, and confirmed the value of direct culture method for studying cytocompatibility of Mg-based biomaterials for medical implant applications.

STATEMENT OF SIGNIFICANCE

Magnesium (Mg)-based biomaterials have been specifically designed and actively explored for biodegradable implant applications since the early 2000s. To realize the benefits of Mg-based materials for medical implant applications, it is critical to control the rate of Mg degradation (i.e. corrosion) in the body. We investigated an environmentally friendly anodization process using KOH electrolyte for modifying the surface of Mg-based materials, and the resulted surface, degradation, and biological properties for biomedical applications. This study reported critical considerations that are important for repeatability of anodization process, homogeneity of surface microstructure and composition, and in vitro evaluations of the degradation and biological properties of surface treated Mg samples. The details in preparation of electrodes, anodization setup, annealing, and sample handling before and after surface treatment (e.g. re-embedding) reported in this article are valuable for studying a variety of electrochemical processes for surface treatment of Mg-based metals, because of enhanced reproducibility.

Biomechanical characteristics of bioabsorbable magnesium-based (MgYREZr-alloy) interference screws with different threads

PURPOSE

Degradable magnesium implants have received increasing interest in recent years. In anterior cruciate ligament reconstruction surgery, the well-known osteoconductive effects of biodegradable magnesium alloys may be useful. The aim of this study was to examine whether interference screws made of MgYREZr have comparable biomechanical properties to commonly used biodegradable screws and whether a different thread on the magnesium screw has an influence on the fixation strength.

METHODS

Five magnesium (MgYREZr-alloy) screws were tested per group. Three different groups with variable thread designs (Designs 1, 2, and 3) were produced and compared with the commercially available bioabsorbable Bioacryl rapid polylactic-co-glycolic acid screw Milagro^®. In vitro testing was performed in synthetic bone using artificial ligament fixed by an interference screw. The constructs were pretensioned with a constant load of 60 N for 30 s followed by 500 cycles between 60 N and 250 N at 1 Hz. Construct displacements between the 1st and 20th and the 21st and 500th cycles were recorded. After a 30 s break, a maximum load to failure test was performed at 1 mm/s measuring the maximum pull-out force.

RESULTS

The maximum loads to failure of all three types of magnesium interference screws (Design 1: 1,092 ± 133.7 N; Design 2: 1,014 ± 103.3 N; Design 3: 1,001 ± 124 N) were significantly larger than that of the bioabsorbable Milagro^® interference screw (786.8 ± 62.5 N) (p < 0.05). However, the greatest maximum load was found with magnesium screw Design 1. Except for a significant difference between Designs 1 and 2, there were no further significant differences among the four groups in displacement after the 20th cycle.

CONCLUSIONS

Biomechanical testing showed higher pull-out forces for magnesium compared with a commercial polymer screw. Hence, they suggest better stability and are a potential alternative. The thread geometry does not significantly influence the stability provided by the magnesium implants. This study shows the first promising results of a degradable material, which may be a clinical alternative in the future.

Severe cartilage damage from a broken absorbable screw head after fixation of an avulsion fracture of the tibial attachment of the posterior cruciate ligament: A case report

INTRODUCTION

The use of bioabsorbable interference screws has become popular for treatment of avulsion fractures of the posterior cruciate ligament (PCL). Complications are uncommon. We report a case of severe chondral damage caused by the early breakage of an absorbable screw head after fixation of an avulsion fracture of the tibial attachment of the PCL. The patient felt a sudden locking of the knee when getting off a car at 4 months after the PCL surgery. MRI revealed intraarticular migration of the head of the interference screw. During revision surgery, the broken part was removed without incident, and severe cartilage damage was observed. The patient experienced a complete resolution of symptoms at the 6-month follow-up.

CONCLUSION

MRI examination is recommended in case of sudden locking of the knee for patients undergoing PCL fixation with bioabsorbable interference screws. Surgical treatment should be performed immediately when screw breakage was confirmed.

Biomechanical Properties of a Novel Biodegradable Magnesium-Based Interference Screw

Magnesium-based interference screws may be an alternative in anterior/posterior cruciate ligament reconstruction. The well-known osteoconductive effects of biodegradable magnesium alloys may be useful. It was the purpose of this study to evaluate the biomechanical properties of a magnesium based interference screw and compare it to a standard implant. A MgYREZr-alloy interference screw and a standard implant (Milagro®; De Puy Mitek, Raynham, MA, USA) were used for graft fixation. Specimens were placed into a tensile loading fixation of a servohydraulic testing machine. Biomechanical analysis included pretensioning of the constructs at 20 N for 1 min following cyclic pretensioning of 20 cycles between 20 and 60 N. Biomechanical elongation was evaluated with cyclic loading of 1000 cycles between 50 and 200 N at 0.5 Hz. Maximum load to failure was 511.3±66.5 N for the Milagro® screw and 529.0±63.3 N for magnesium-based screw (ns, P=0.57). Elongations after preload, during cyclical loading and during failure load were not different between the groups (ns, P>0.05). Stiffness was 121.1±13.8 N/mm for the magnesium-based screw and 144.1±18.4 for the Milagro® screw (ns, P=0.32). MgYREZr alloy interference screws show comparable results in biomechanical testing to standard implants and may be an alternative for anterior cruciate reconstruction in the future.

A systemic study on key parameters affecting nanocomposite coatings on magnesium substrates

Nanocomposite coatings offer multiple functions simultaneously to improve the interfacial properties of magnesium (Mg) alloys for skeletal implant applications, e.g., controlling the degradation rate of Mg substrates, improving bone cell functions, and providing drug delivery capability. However, the effective service time of nanocomposite coatings may be limited due to their early delamination from the Mg-based substrates. Therefore, the objective of this study was to address the delamination issue of nanocomposite coatings, improve the coating properties for reducing the degradation of Mg-based substrates, and thus improve their cytocompatibility with bone marrow derived mesenchymal stem cells (BMSCs). The surface conditions of the substrates, polymer component type of the nanocomposite coatings, and post-deposition processing are the key parameters that contribute to the efficacy of the nanocomposite coatings in regulating substrate degradation and bone cell responses. Specifically, the effects of metallic surface versus alkaline heat-treated hydroxide surface of the substrates on coating quality were investigated. For the nanocomposite coatings, nanophase hydroxyapatite (nHA) was dispersed in three types of biodegradable polymers, i.e., poly(lactic-co-glycolic acid) (PLGA), poly(l-lactic acid) (PLLA), or poly(caprolactone) (PCL) to determine which polymer component could provide integrated properties for slowest Mg degradation. The nanocomposite coatings with or without post-deposition processing, i.e., melting, annealing, were compared to determine which processing route improved the properties of the nanocomposite coatings most significantly. The results showed that optimizing the coating processes addressed the delamination issue. The melted then annealed nHA/PCL coating on the metallic Mg substrates showed the slowest degradation and the best coating adhesion, among all the combinations of conditions studied; and, it improved the adhesion density of BMSCs. This study elucidated the key parameters for optimizing nanocomposite coatings on Mg-based substrates for skeletal implant applications, and provided rational design guidelines for the nanocomposite coatings on Mg alloys for potential clinical translation of biodegradable Mg-based implants.

STATEMENT OF SIGNIFICANCE

This manuscript describes the systemic optimization of nanocomposite coatings to control the degradation and bioactivity of magnesium for skeletal implant applications. The key parameters influencing the integrity and functions of the nanocomposite coatings on magnesium were identified, guidelines for the optimization of the coatings were established, and the benefits of coating optimization were demonstrated through reduced magnesium degradation and increased bone marrow derived mesenchymal stem cell (BMSC) adhesion in vitro. The guidelines developed in this manuscript are valuable for the biometal field to improve the design of bioresorbable implants and devices, which will advance the clinical translation of magnesium-based implants.

Examination of a biodegradable magnesium screw for the reconstruction of the anterior cruciate ligament: A pilot in vivo study in rabbits

The reconstruction of the anterior cruciate ligament is, for the most part, currently performed with interference screws made of titanium or degradable polymers. The aim of this study was to investigate the use of biodegradable magnesium interference screws for such a procedure because of their known biocompatibility and reported osteoconductive effects. The left tibiae of each of 18 rabbits were implanted with a magnesium-based (MgYREZr-alloy) screw, and another 18 with a titanium-based control. Each group was divided into observation periods of 4, 12 and 24weeks. After sacrifice, μCT scans were acquired to assess the amount of the gas liberated and the degradation rate of the implant. Histological evaluations were performed to investigate the local tissue response adjacent to the implant and to assess the status of the attachment between the tendon and the bone tissue. The μCT scans showed that liberation of gas was most prominent 4weeks after implantation and was significantly decreased by 24weeks. All screws remained in situ and formed a sufficient connection with the tendon and sufficient osseous integration at 24weeks. Histological evaluations showed neither inflammatory reactions nor necrosis of the tendon. The results of this pilot study in rabbits indicate that this magnesium-based interference screw should be considered as an alternative to conventional implant materials.

Bioabsorbable interference screw failure in anterior cruciate ligament reconstruction: A case series and review of the literature

BACKGROUND

To report a case series of failures of bioabsorbable interference screws with possible identification of a novel failure mechanism.

METHODS

A retrospective review of ACL reconstructions by the senior author utilizing BioComposite™ Interference Screws (Arthrex, Inc., Naples, FL) was performed. Complications related to screw placement, including fracture, breakage or bending were examined. Our rate and methods of failure were compared to those quoted in the current literature.

RESULTS

Eighty-seven patients of average age 23.8 years met inclusion criteria. There were eight screw failures in six patients, with femoral failure in seven and tibial failure in one. The femoral screw fractured halfway between the tip and head in five, while the head of the screw broke in one and the screw bent in another. In the case of tibial interference screw fracture, failure occurred halfway between the tip and head. The insertion device that was used was replaced after recognition of material deformation and considered a potential contributor to the breakage risk as no further screw failures have occurred since.

CONCLUSIONS

We demonstrate a unique failure mechanism of bio-absorbable interference screws. In each case, the reconstruction was salvaged. Regular inspection of materials and implants can ensure optimal outcomes and decrease complications intra-operatively.

Meta-analysis comparing bioabsorbable versus metal interference screw for adverse and clinical outcomes in anterior cruciate ligament reconstruction

PURPOSE

To compare bioabsorbable screw (BS) against metal screw (MS) primarily on adverse effects and secondarily on clinical outcomes after single-bundle primary anterior cruciate ligament reconstruction.

METHODS

Electronic searches were performed using search strategies meeting the mentioned purposes. Retrieved articles were selected for randomised controlled trials (RCTs) reporting at least 1-year follow-up. Potential studies were selected under inclusion and exclusion criteria. Risk of biases and data extraction was completed by two review authors. Discrepancies were resolved through discussion. Mean difference and risk ratio with 95 % confidence interval (CI) were used for continuous and binary outcomes, respectively. Heterogeneity was assessed using I (2). Pooled treatment effects with 95 % CI were estimated using the fixed- or random-effect model where appropriate.

RESULTS

Eleven RCTs with 878 randomly allocated patients were included, and 711 patients (81 %) with eligible follow-up time up to 8 years were analysed. Comparing with the MS group, BS group using medial hamstring graft showed evidence of larger tunnel widening on the femoral side measured from radiographs or magnetic resonance imaging, though data could not be pooled because diverse measurement methods had been used. Significantly higher rates of effusion and screw breakage, and fewer cases of complete tunnel healing were reported in the BS group. Nevertheless, functional and clinical results were not deteriorated by the presence of these adverse effects for both short- and longer-term follow-ups.

CONCLUSION

This is the first systematic review focusing on adverse effects of the BS, such as larger tunnel widening and higher rates of other complications. With these effects, routine use of the BS should be balanced with the advantages claimed. Cost-effectiveness is another issue, and well-designed RCTs are needed to better validate the implication.

In vitro degradation of four magnesium-zinc-strontium alloys and their cytocompatibility with human embryonic stem cells

Magnesium alloys have attracted great interest for medical applications due to their unique biodegradable capability and desirable mechanical properties. When designed for medical applications, these alloys must have suitable degradation properties, i.e., their degradation rate should not exceed the rate at which the degradation products can be excreted from the body. Cellular responses and tissue integration around the Mg-based implants are critical for clinical success. Four magnesium-zinc-strontium (ZSr41) alloys were developed in this study. The degradation properties of the ZSr41 alloys and their cytocompatibility were studied using an in vitro human embryonic stem cell (hESC) model due to the greater sensitivity of hESCs to known toxicants which allows to potentially detect toxicological effects of new biomaterials at an early stage. Four distinct ZSr41 alloys with 4 wt% zinc and a series of strontium compositions (0.15, 0.5, 1, and 1.5 wt% Sr) were produced through metallurgical processing. Their degradation was characterized by measuring total mass loss of samples and pH change in the cell culture media. The concentration of Mg ions released from ZSr41 alloy into the cell culture media was analyzed using inductively coupled plasma atomic emission spectroscopy. Surface microstructure and composition before and after culturing with hESCs were characterized using field emission scanning electron microscopy and energy dispersive X-ray spectroscopy. Pure Mg was used as a control during cell culture studies. Results indicated that the Mg-Zn-Sr alloy with 0.15 wt% Sr provided slower degradation and improved cytocompatibility as compared with pure Mg control.

Migration of "bioabsorbable" screws in ACL repair. How much do we know? A systematic review

PURPOSE

Although bioabsorbable screws promise to degrade within months up to several years after implantation, often this does not happen. In fact, other problems such as screw breakage, tunnel enlargement, allergic or foreign body reactions, cyst or abscess formation, and delayed migration of "biodegradable" screws have been reported. This study aims to provide relevant basic science knowledge and recent insights concerning "biomaterials" currently used in fixation devices for anterior cruciate ligament (ACL) repair. A systematic review on the topic of screw "migration" is provided.

METHODS

A PubMed search combining all the key terms was done looking for complications related to late migration of "bioabsorbable" screws used in ACL reconstruction without inferior time limitation up to January 2012. Only clinical reports were included. Reference lists of reports were checked to detect others not identified by the original search. A pre-publication search was performed to identify the most recent relevant articles.

RESULTS

A total of ten articles referred to migration of "bioabsorbable" interference screws. Most cases reported on poly-L-lactic acid-based screws. Migration was noticed between 3 and 22 months postoperatively. It was noticed both in the tibia and the femur and with the application of several types of graft.

CONCLUSION

Migration is a possible complication of "bioabsorbable" interference screws. The information related to all clinical implications of the so-called "biodegradable screws" remains scarce and probably suffers from the phenomenon of publication bias. The complexity of possible reactions occurring in the human body is difficult to reproduce under controlled laboratory conditions.

Bone screws have advantages in repair of experimental osteochondral fragments

BACKGROUND

Cartilage defects are created on intraarticular osteochondral fragments at the entrance holes of fixation devices when these fragments are fixed to the original sites. Conventional fixation devices hinder repair of these defects and there is a latent risk of secondary osteoarthritis. We therefore developed a novel fixation device system consisting of bone screws made of cortical bone for osteochondral fragments to improve repair of these surface defects.

QUESTIONS/PURPOSES

We asked whether bone screws had advantages over poly-L-lactic acid (PLLA) screws in terms of (1) gross assessment of the surface, (2) volume and histologic quality of the repair tissue, and (3) biomechanical assessment of the tissue stiffness.

METHODS

We examined gross morphology, microCT, histology, and stiffness of the repaired tissue with PLLA (n = 32) and bone (n = 32) screws in a rabbit model of osteochondral fracture, compared with normal controls (n = 16).

RESULTS

Gross morphology and histology revealed better quality with bone screws than with PLLA screws. Mean repaired volumes in microCT were 70.6% ± 14% with bone screws and 50.3% ± 15% with PLLA screws. Average stiffness values for PLLA screws, bone screws, and normal cartilage were 1.67 ± 0.54 N/mm, 2.63 ± 0.42 N/mm, and 3.15 ± 0.49 N/mm, respectively.

CONCLUSIONS

Our results show better repaired tissue was observed for quality and quantity when chondral fractures were treated with bone screws than when treated with PLLA screws.

CLINICAL RELEVANCE

Bone screws made of cortical bone may have applications in clinical situations for the fixation of intraarticular osteochondral fragments.

Extrusion of tibial tunnel bioabsorbable screw 15 months after anterior cruciate ligament reconstruction

The use of bioabsorbable implants in orthopaedic surgery has become a common practice. Despite their many theoretical advantages, recent reports have proposed certain concerns and complications associated with their use. We report the case of a bioabsorbable screw that extruded from the tibial insertion site 15 months after anterior cruciate ligament reconstruction.

Tibial tunnel widening after bioresorbable poly-lactide calcium carbonate interference screw usage in ACL reconstruction

Developing bio-absorbable interference screws for anterior cruciate ligament (ACL) reconstruction has proven to be a challenging task. The aim of this study was to investigate the osteogenetic response of poly-lactide carbonate (PLC) interference screws in ACL reconstruction in humans. Ten patients (median age, 28 years) underwent arthroscopic ACL reconstruction with semitendinosus/gracilis tendon graft and a PLC interference screw. The patients were scanned with a multi-slice CT scanner 2 weeks and 1 year postoperatively. Fourteen days postoperatively a mean tunnel widening of 78% [52%; 110%] was observed. At 1-year follow-up, the mean tunnel widening was 128% [84%; 180%]. No sign of bone replacement or bone ingrowth was observed. Factors such as accelerated rehabilitation, micro-motions, and early screw degradation might be responsible for this large tunnel widening. Our results demonstrate the difficulty in translation of preclinical data. This study illustrates the need for extensive preclinical investigation of new materials for clinical purposes.

The unpredictable material properties of bioabsorbable PLC interference screws and their adverse effects in ACL reconstruction surgery

The aim of this study was to look at the clinical outcome of polylactide carbonate (PLC) interference screws in knee ligament reconstruction surgery. We prospectively followed up 59 patients who underwent primary hamstring anterior cruciate ligament (ACL) reconstructions using PLC (Calaxo screw; Smith and Nephew, Andover, MA) screws to secure the graft in the tibial tunnel. The average age was 34 years (range 17-55 years, SD 8.93). Twenty-three (39%) patients presented with complications [synovitis in 15% (nine) patients, prominent tibial swelling in 34% (20) patients and both in seven patients]. In comparison, similar complications were not seen in two groups of 59 age and sex matched patients in whom PLLA (Bio RCI; Smith and Nephew, Andover, MA) screws or Titanium (RCI; Smith and Nephew, Andover, MA) screws were used by the same surgeon. The problems encountered in the PLC screw group did not adversely affect knee stability. Six patients underwent exploration of the tibial tunnel site. A sterile white cheesy substance was removed, leaving an empty tibial tunnel. The ACL graft was found to be well attached to tibial tunnel in all cases. The PLC screw diameter, surface area or tibial tunnel diameter did not have any correlation to the occurrence of complications. Two patients required multiple washouts, one of whom developed a deep infection. The degradation of PLC screws does not follow the gradual and controlled pattern demonstrated in the ovine model. The unpredictable screw degradation, and the reaction to it can lead to serious clinical consequences.

A clinical review of bioabsorbable interference screws and their adverse effects in anterior cruciate ligament reconstruction surgery

Bioabsorbable material screws are widely used in various surgical specialties. One popular application is their use as interference screws in anterior cruciate ligament (ACL) reconstruction surgery. Despite their routine use, a major concern with bioabsorbable materials in surgery has been the incidence of adverse events. Various case reports, series reports and studies in the past years have reported complications specific to the use of bioabsorbable interference screws intra operatively and at different time periods post operatively. The aim of this literature review is to summarize the clinical studies where bioabsorbable screws have been used in ACL reconstruction surgery and in particular to highlight any specific complications and adverse effects related to the use of these materials.

Tibial fixation of bone-patellar tendon-bone grafts in anterior cruciate ligament reconstruction: a cadaveric study of bovine bone screw and biodegradable interference screw

BACKGROUND

The use of interference screw fixation for bone-patellar tendon-bone grafts in anterior cruciate ligament fixation is well established. No previous study has compared bovine bone screws and biodegradable interference screws or demonstrated their efficacy for requirements associated with early rehabilitation.

HYPOTHESIS

There is no difference in tension loss and pull-out strength between bovine bone screws and biodegradable interference screws.

STUDY DESIGN

Controlled laboratory study.

METHODS

Anterior cruciate ligament reconstructions with bone-patellar tendon-bone allografts were performed in 40 human tibiae from 20 donors. A bovine bone screw and a polylevolactide interference screw were used for tibial fixation in each pair. A cyclic testing protocol with varying magnitude and orientation of the graft loading was developed. Cyclic tests were performed at 1 Hz for 5000 cycles with a peak force of 200 N applied to the graft. Survival rate and postcyclic-test pull-out strength were compared.

RESULTS

Fifteen of 20 reconstructions fixed with bovine bone screws and 17 of 20 fixed with biodegradable screws reached 5000 cycles. Graft tension drop after the 5000 cycles averaged 19.7 N ( +/- 12.9) for bovine bone screws and 18.9 N ( +/- 16.3) for biodegradable screws. There were no significant differences in tension loss and pull-out strength between the 2 types of screws.

CONCLUSION

Bovine bone screws are comparable to biodegradable interference screws in providing stable tibial fixation in anterior cruciate ligament reconstruction using bone-patellar tendon-bone allografts.

CLINICAL RELEVANCE

The use of bovine bone screws may be comparable to the popular biodegradable interference screws used for anterior cruciate ligament reconstruction in postsurgery rehabilitation.

Recurrent locking of knee joint caused by intraarticular migration of bioabsorbable tibial interference screw after arthroscopic ACL reconstruction

Two cases are reported in which, after ACL reconstruction with autologous hamstring grafts, tibial polylactide interference screws migrated into the knee joint. Clinically, both patients presented with recurrent locking of the joint. In one case, a broken 15 mm-long tip of the screw was found intra-articularly. In the other case, the whole screw had migrated into the joint cavity. The degradation process of polylactic acid, operative technique and bone quality are discussed as possible reasons for these complications.

Intraarticular migration of a broken biodegradable interference screw after anterior cruciate ligament reconstruction

Poly-L: -lactic acid biodegradable screws have been used effectively for graft fixation in anterior cruciate ligament (ACL) reconstruction. The overall complication rate associated with the use of this implant is low, although some authors reported complications, such as osteolysis and aseptic effusion of the knee joint. We report a case of a 29-year-old female patient with a failure of a biodegradable interference screw at 22 months after ACL reconstruction using bone-patellar tendon-bone graft. In this illustrated case, the screw broke and migrated into the knee joint. In addition, we performed a detailed review of the medical literature from 1990-2005 to identify possible causes of biodegradable screw failures. We identified six published cases of bioabsorbable interference screw failure with migration into the knee joint. Several authors have reported small diameter of the screw, poor bone quality, bone resorption, and screw divergence as potential causes for intraarticular migration of metallic interference screws. With regard to bioscrews, no specific risk factors for screw breakage and intraarticular migration have been reported. ACL reconstruction with the use of bioabsorbable interference screws for fixation is considered to be reliable. However, we need to be aware of potential problems associated with the use of this implant. Early recognition of bioscrew failure may prevent associated morbidities, such as subsequent cartilage damage.

Prospective evaluation of patellar tendon graft fixation in anterior cruciate ligament reconstruction comparing composite bioabsorbable and allograft interference screws

PURPOSE

Bioabsorbable interference screws have proved to be biologically safe and to provide adequate graft fixation. Metallic interference screws have therefore been continuously replaced over the years. However, degradation times are highly variable, and bony replacement of the screw does not always occur in human beings. Composite interference screws have recently been introduced to enhance bony integration. We evaluated 2 different composite interference screws and compared them with an allograft interference screw over a 2-year period after anterior cruciate ligament (ACL) reconstruction with an autologous bone-patellar tendon-bone graft.

METHODS

Three groups of patients were prospectively evaluated. Poly-L-lactid acid/hydroxyapatite composite screws (BioRCI-HA; Smith & Nephew, Andover, MA) (group A), poly-L-lactid acid/beta-tricalcium phosphate composite screws (Bilok; Atlantech, Radevormwald, Germany) (group B), or allograft interference screws (CorlS; Regeneration Technologies, Alachua, FL) (group C) were used for tibial fixation of a patellar tendon autograft in ACL reconstruction. Each group consisted of 20 patients (mean age, 32.2 +/- 10.9 years in group A, 32.3 +/- 10.6 years in group B, and 31.1 +/- 6.6 years in group C) with no significant (P < .05) differences in age, sex, and time of follow-up. Subjective and clinical International Knee Documentation Committee parameters were evaluated preoperatively and at 3, 12, and 24 months postoperatively; computed tomography scans were obtained postoperatively and at 3, 12, and 24 months; and magnetic resonance imaging (MRI) scans were obtained at 3 and 24 months postoperatively.

RESULTS

Screw breakage during insertion occurred in 2 cases (1 in group A and 1 in group B). There was no significant (P < .05) difference in subjective and clinical results at any time of follow-up. No inflammatory response could be detected on MRI in any of the patients in all groups. Computed tomography scans documented complete bone block incorporation at 3 months in all groups. Both composite interference screws showed signs of degradation but were still clearly visible 24 months after ACL reconstruction. At 12 months, a sclerotic rim around the screw cavity could be outlined in group B only. No bony replacement had taken place up to 24 months postoperatively in group A or B. In group C the allograft bone screw was completely integrated and barely visible after 24 months.

CONCLUSIONS

All 3 screw types provided adequate graft fixation and were associated with excellent clinical results and no inflammatory response on MRI. Ultimately, a resorbable screw has to be replaced by bone to facilitate revision surgery. Formation of a sclerotic rim around the outline of the screw makes later bony replacement (group B) unlikely. After 24 months, complete bony integration had only taken place when allograft screws were used.

CLINICAL RELEVANCE

At 24 months, no advantage of composite screw materials over conventional bioabsorbable screws could be detected. If composite materials will be of any advantage with respect to bony replacement has to be observed with longer-term follow-up. The allograft bone screw was completely incorporated and replaced by cancellous bone after 24 months. Unfortunately, the screw's more complicated handling, higher cost, and limited availability impair the possibilities for its standard clinical use.

Biodegradable Materials in Arthroscopy

The use of biodegradable materials as implants has revolutionized the way medicine is practiced today. This review provides a general description of salient biodegradable polymeric materials currently used in arthroscopy. These materials include polyglycolic acid, self-reinforced polyglycolic acid, poly-L-lactic acid, self-reinforced polylactic-L-acid, poly-D-L-lactic acid, copolymer of poly-D-L-lactic acid polyglycolic acid, and polyglyconate. The mechanical strength, degradation properties, and widespread use of these materials, especially in the knee and shoulder, are discussed individually. Also discussed are the relatively few complications that are related to these materials' arthroscopic use. Future directions in biodegradable materials, including smart polymers, are also considered. In the future, novel techniques to identify the ideal polymer for a particular application will need to be developed to minimize the risk for implant complications.