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Lifka S, Rehberger Y, Pastl K, Rofner-Moretti A, Reichkendler M, Baumgartner W. The Development and Biomechanical Analysis of an Allograft Interference Screw for Anterior Cruciate Ligament Reconstruction. Bioengineering (Basel) 2023; 10:1174. [PMID: 37892904 PMCID: PMC10604633 DOI: 10.3390/bioengineering10101174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/06/2023] [Indexed: 10/29/2023] Open
Abstract
Graft fixation during cruciate ligament reconstruction using interference screws is a common and frequently used surgical technique. These interference screws are usually made of metal or bioabsorbable materials. This paper describes the development of an allograft interference screw from cortical human bone. During the design of the screw, particular attention was paid to the choice of the screw drive and the screw shape, as well as the thread shape. Based on these parameters, a prototype was designed and manufactured. Subsequently, the first biomechanical tests using a bovine model were performed. The test procedure comprised a torsion test to determine the ultimate failure torque of the screw and the insertion torque during graft fixation, as well as a pull-out test to asses the ultimate failure load of the graft fixation. The results of the biomechanical analysis showed that the mean value of the ultimate failure torque was 2633 Nmm, whereas the mean occurring insertion torque during graft fixation was only 1125 Nmm. The mean ultimate failure load of the graft fixation was approximately 235 N. The results of this work show a good overall performance of the allograft screw compared to conventional screws, and should serve as a starting point for further detailed investigations and studies.
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Affiliation(s)
- Sebastian Lifka
- Institute of Biomedical Mechatronics, Johannes Kepler University Linz, 4040 Linz, Austria;
| | | | - Klaus Pastl
- Surgebright GmbH, 4040 Lichtenberg, Austria; (Y.R.); (K.P.)
| | - Alexander Rofner-Moretti
- Department of Orthopedic and Trauma Surgery, District Hospital Schwaz, 6130 Schwaz, Austria; (A.R.-M.); (M.R.)
| | - Markus Reichkendler
- Department of Orthopedic and Trauma Surgery, District Hospital Schwaz, 6130 Schwaz, Austria; (A.R.-M.); (M.R.)
| | - Werner Baumgartner
- Institute of Biomedical Mechatronics, Johannes Kepler University Linz, 4040 Linz, Austria;
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Feichtinger X, Muji E, Domej MA, Pauzenberger L, Baierl A, Kocijan R, Loho G, Brandl G. Combined press-fit and extracortical fixation in patellar tendon anterior cruciate ligament reconstruction results in reliable graft fixation and early bone block incorporation. Knee 2023; 43:18-27. [PMID: 37210858 DOI: 10.1016/j.knee.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 02/19/2023] [Accepted: 05/02/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstruction with bone-patellar-tendon-bone (BPTB) autograft has the potential biological advantage of direct bone-to-bone healing over soft tissue grafts. The primary aim of this study was to investigate possible graft slippage and therefore fixation strength in a modified BPTB autograft technique with suspensory fixation on both sides for primary ACL reconstruction until bony integration takes place. METHODS Twenty-one patients undergoing primary ACL reconstruction with a modified BPTB autograft (bone-on-bone (BOB) technique) between August 2017 and August 2019 were included in this prospective study. A computed tomography (CT) scan of the affected knee was performed directly postoperatively, as well as 3 months postoperatively. Examiner-blinded parameters for graft slippage, early tunnel widening, bony incorporation, as well as remodeling of the autologous refilled patellar harvest site were investigated. RESULTS A series of 21 patients treated with a BPTB autograft with this technique underwent two CT investigations. Comparison of CT scans showed no bone block displacement and therefore no graft slippage in the patient cohort. Only one patient showed signs of early tunnel enlargement. Radiological bone block incorporation took place showing bony bridging of the graft to the tunnel wall in 90% of all patients. Furthermore, 90% showed less than 1 mm bone resorption of the refilled harvest site at the patella. CONCLUSIONS Our findings suggest graft fixation stability and reliability of anatomic BPTB ACL reconstruction with a combined press-fit and suspensory fixation technique by absence of graft slippage within the first 3 months postoperatively.
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Affiliation(s)
- Xaver Feichtinger
- Department of Orthopedic Surgery II, Herz-Jesu Hospital Vienna, Austria.
| | - Edin Muji
- Department of Orthopedic Surgery II, Herz-Jesu Hospital Vienna, Austria
| | - Marija Ana Domej
- Department of Orthopedic Surgery II, Herz-Jesu Hospital Vienna, Austria
| | - Leo Pauzenberger
- Department of Orthopedic Surgery II, Herz-Jesu Hospital Vienna, Austria
| | - Andreas Baierl
- Department of Statistics and Operations Research, The University of Vienna, Vienna, Austria
| | - Roland Kocijan
- Ludwig Boltzmann Institute of Osteology, 1st Medical Department at Hanusch Hospital, Vienna, Austria
| | - Gerald Loho
- Department of Orthopedic Surgery II, Herz-Jesu Hospital Vienna, Austria
| | - Georg Brandl
- Department of Orthopedic Surgery II, Herz-Jesu Hospital Vienna, Austria
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Kačarević ŽP, Rider P, Elad A, Tadic D, Rothamel D, Sauer G, Bornert F, Windisch P, Hangyási DB, Molnar B, Kämmerer T, Hesse B, Bortel E, Bartosch M, Witte F. Biodegradable magnesium fixation screw for barrier membranes used in guided bone regeneration. Bioact Mater 2022; 14:15-30. [PMID: 35310352 PMCID: PMC8892133 DOI: 10.1016/j.bioactmat.2021.10.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/25/2021] [Accepted: 10/25/2021] [Indexed: 12/29/2022] Open
Abstract
An ideal fixation system for guided bone (GBR) regeneration in oral surgery must fulfil several criteria that includes the provision of adequate mechanical fixation, complete resorption when no longer needed, complete replacement by bone, as well as be biocompatible and have a good clinical manageability. For the first time, a biodegradable magnesium fixation screw made of the magnesium alloy WZM211 with a MgF2 coating has been designed and tested to fulfill these criteria. Adequate mechanical fixation was shown for the magnesium fixation screw in several benchtop tests that directly compared the magnesium fixation screw with an equivalent polymeric resorbable device. Results demonstrated slightly superior mechanical properties of the magnesium device in comparison to the polymeric device even after 4 weeks of degradation. Biocompatibility of the magnesium fixation screw was demonstrated in several in vitro and in vivo tests. Degradation of the magnesium screw was investigated in in vitro and in vivo tests, where it was found that the screw is resorbed slowly and completely after 52 weeks, providing adequate fixation in the early critical healing phase. Overall, the magnesium fixation screw demonstrates all of the key properties required for an ideal fixation screw of membranes used in guided bone regeneration (GBR) surgeries. The first comprehensive report on experimental data for a biodegradable metallic fixation pin for use in oral surgery is presented. Results demonstrated superior mechanical properties of the Mg fixation pin in comparison to the polymeric pin even after 4 weeks of degradation. The MgF2 coated Mg pin made of alloy WZM211 has a slow corrosion rate with a service time of 4 weeks and is fully resorped at 52 weeks after implantation.
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Affiliation(s)
- Željka Perić Kačarević
- Department of Anatomy Histology, Embryology, Pathology Anatomy and Pathology Histology, Faculty of Dental Medicine and Health, University of Osijek, Osijek, 31000, Croatia
- Department of Prosthodontics, Geriatric Dentistry and Craniomandibular Disorders, Charité – Universitätsmedizin Berlin, Aßmannshauser Straße 4–6, 14197, Berlin, Germany
- Botiss Biomaterials AG, Ullsteinstrasse 108, 12109, Berlin, Germany
| | - Patrick Rider
- Department of Prosthodontics, Geriatric Dentistry and Craniomandibular Disorders, Charité – Universitätsmedizin Berlin, Aßmannshauser Straße 4–6, 14197, Berlin, Germany
- Botiss Biomaterials AG, Ullsteinstrasse 108, 12109, Berlin, Germany
| | - Akiva Elad
- Botiss Biomaterials AG, Ullsteinstrasse 108, 12109, Berlin, Germany
| | - Drazen Tadic
- Botiss Biomaterials AG, Ullsteinstrasse 108, 12109, Berlin, Germany
| | - Daniel Rothamel
- CMF Surgery, Johannes BLA Hospital, Mönchengladbach, Germany
| | - Gerrit Sauer
- CMF Surgery, Johannes BLA Hospital, Mönchengladbach, Germany
| | | | - Peter Windisch
- Department of Periodontology, Semmelweis University, Budapest, Hungary
| | | | - Balint Molnar
- Department of Periodontology, Semmelweis University, Budapest, Hungary
| | - Till Kämmerer
- University Hospital Munich, Department of Dermatology and Allergy, Frauenlobstr. 9-11, 80337, Munich, Germany
| | | | - Emely Bortel
- Xploraytion GmbH, Bismarkstrasse 11, Berlin, Germany
| | - Marco Bartosch
- Biotrics Bioimplants AG, Ullsteinstrasse 108, 12109, Berlin, Germany
| | - Frank Witte
- Department of Prosthodontics, Geriatric Dentistry and Craniomandibular Disorders, Charité – Universitätsmedizin Berlin, Aßmannshauser Straße 4–6, 14197, Berlin, Germany
- Biotrics Bioimplants AG, Ullsteinstrasse 108, 12109, Berlin, Germany
- Corresponding author. Department of Prosthodontics, Geriatric Dentistry and Craniomandibular Disorders, Charité – Universitätsmedizin Berlin, Assmannshauser Straße 4–6, 14197, Berlin, Germany.
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Jeong JH, Jin ES, Kim JY, Min J, Jeon SR, Lee M, Choi KH. Bone formation effect of highly concentrated tricalcium phosphate biocomposite screws in a rabbit osteoporosis model. J Orthop Res 2022; 40:1321-1328. [PMID: 34432337 DOI: 10.1002/jor.25171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 07/11/2021] [Accepted: 08/13/2021] [Indexed: 02/04/2023]
Abstract
The purpose of this study was to determine the efficacy of highly concentrated tricalcium phosphate (TCP) biocomposite screws on local bone formation in a rabbit model of osteoporosis induced by bilateral ovariohysterectomy (OHE). Fourteen 24-week-old female New Zealand rabbits (weight, 3-3.5 kg) were divided into two groups: (1) OHE and biodegradable poly(lactic-co-glycolic acid) (PLGA) without ß-TCP plate or screw insertion (OHE/Bio ScRew [BSR]) group and (2) OHE and biocomposite PLGA with highly concentrated ß-TCP plate and screw insertion (OHE/highly concentrated ß-triCalcium phosphate [HCCP]). Both groups underwent bilateral OHE and had two different types of screws and plates inserted at the proximal tibia. Bilateral tibiae were extracted at 25 weeks post-OHE. The extracted tibiae were scanned with ex vivo microcomputed tomography (micro-CT). Parameters including bone mineral density (BMD), trabecular bone volume (BV/TV), trabecular number (Tb.N), trabecular thickness (Tb. Th), and trabecular separation (Tb. Sp) were evaluated after staining the tibial samples with hematoxylin and eosin (H&E) and Masson's trichrome. We then performed pathological assessments. Micro-CT images revealed improved new bone formation near the implant in the OHE/HCCP group with higher values of BMD, BV/TV, and Tb.N but lower values of Tb. Th and Tb. Sp than the OHE/BSR group. Analyses of H&E and Masson's trichrome staining showed better new bone formation around the implant in the OHE/HCCP group than in the OHE/BSR group. The use of highly concentrated TCP biocomposite screw and plate might improve local bone formation and facilitate osteoconductivity in an osteoporotic rabbit model.
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Affiliation(s)
- Je Hoon Jeong
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea.,Laboratory of Stem Cell Therapy, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Eun-Sun Jin
- Laboratory of Stem Cell Therapy, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.,Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - Ji Yeon Kim
- Laboratory of Stem Cell Therapy, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - JoongKee Min
- Laboratory of Stem Cell Therapy, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang Ryong Jeon
- Laboratory of Stem Cell Therapy, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.,Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Minsu Lee
- OSTEONIC Co., Ltd., Seoul, Republic of Korea
| | - Kyoung Hyo Choi
- Laboratory of Stem Cell Therapy, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.,Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Barbosa NC, Campos JP, Capelão V, Kandhari V, Vieira TD, Sonnery-Cottet B. A comprehensive scoping review of tibial cysts after anterior cruciate ligament reconstruction. J Exp Orthop 2021; 8:40. [PMID: 34151381 PMCID: PMC8215013 DOI: 10.1186/s40634-021-00356-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/19/2021] [Indexed: 11/10/2022] Open
Abstract
Purpose The purpose of this study was to perform a scoping review of published literature reporting on surgical management of tibial cysts which developed after ACLR. Methods A scoping review was conducted following the Arksey and O’Malley framework for scoping studies and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) guidelines. A search strategy using the terms [“Tibial Cyst” AND “ACL”], [“Pretibial Cyst” AND “ACL”] was applied to the PUBMED database. Results Thirty-seven studies published between 1990 and 2019 were a part of this scoping review. Non-absorbable implants for tibial graft fixation were used in 10 studies (comprising a total 21 patients), while bio-absorbable implants were used in 27 studies (comprising a total 115 patients). Incidence of tibial cyst was reported in 3 studies (434 primary ACLRs) from whom 3.9% (n = 17) developed tibial cyst. Tibial cyst development in relation to use of bio-absorbable screws for tibial ACL graft fixation was reported in 16 studies (42.1%). Use of bio-absorbable screws with another factor was found to be related to tibial cyst development in another 1 study (2.6%). Most common symptoms were presence of mass or swelling, pain, tenderness, drainage, instability and effusion. Conclusion This scoping review demonstrated that tibial cysts is more frequently related to bioabsorbable screws, however it can also occur due to other causes. Current literature on tibial cyst after ACLR is of low-quality evidence. Future research is required to better understand aetiology, risk factors for cyst formation and the best possible mode of management. Level of evidence IV Supplementary Information The online version contains supplementary material available at 10.1186/s40634-021-00356-9.
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Affiliation(s)
- Nuno Camelo Barbosa
- Hospital Pedro Hispano, Hospital Pedro Hispano Rua Dr. Eduardo Torres, Matosinhos, Portugal.
| | - João Pedro Campos
- Hospital Pedro Hispano, Hospital Pedro Hispano Rua Dr. Eduardo Torres, Matosinhos, Portugal
| | | | | | - Thais Dutra Vieira
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
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Lind M, Nielsen T, Sørensen OG, Mygind-Klavsen B, Faunø P, Leake-Gardner S. Bone ingrowth into open architecture PEEK interference screw after ACL reconstruction. J Exp Orthop 2020; 7:68. [PMID: 32948982 PMCID: PMC7501394 DOI: 10.1186/s40634-020-00285-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/08/2020] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Open or fenestrated interference screw design that allow bone ingrowth is a concept for improved bone healing to softtissue graft and bone filling in bone tunnels after anterior cruciate ligament reconstruction (ACLR) The aim of the current study was to assess CT scanning evaluated bone ingrowth into an open architecture interference screws in the tibial tunnel of patients undergoing ACL with soft tissue grafts. It was hypothesized that open architecture interference screws would stimulate bone ingrowth into the screw cavities. METHODS Twelve patients requiring ACLR were included. They underwent arthroscopic ACLR with semitendinosus-/gracilis tendon graft and an open architecture polyetheretherketone (PEEK) interference screw. The patients were scanned with a multi-slice CT scanner two weeks, six and twelve months postoperatively. On CT reconstruction slices bone ingrowth into the screw was measured. Subjective and objective clinical outcome international knee documentation committee score and instrumented knee laxity determination were collected. RESULTS At six months no implants demonstrated more than 10% bone ingrowth. At twelve months 42% (5/12) implants had more than 10% bone ingrowth (p = 0.009). The average bone filling into the screws was 7.7%. There was no tunnel widening or cyst formation seen in relation to any of the implants. Subjective IKDC score improved significantly from 50.6 baseline to 80.1 at 24 month follow-up. Preoperative side-to-side knee laxity improved from 3.7 (2.1) to 1.4 (1.2) mm at twelve months. There were no serious adverse events in relation to the new open architecture thread PEEK interference screw during or after hamstring ACL reconstruction. CONCLUSION The present study demonstrated that open architecture thread PEEK interference screw can stimulate bone ingrowth into the screws after soft tissue ACL reconstruction with at 12 months with an average bone filling into screws was 7.7%. Knee stability, functional, subjective and objective outcomes were similar to large volume ACL outcome studies. TRIAL REGISTRATION The study was registered at ClinicalTrials # NCT02382341 . 12-09-2014. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Martin Lind
- Department of Orthopedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Torsten Nielsen
- Department of Orthopedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Ole Gade Sørensen
- Department of Orthopedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Bjarne Mygind-Klavsen
- Department of Orthopedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Peter Faunø
- Department of Orthopedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Stacy Leake-Gardner
- Smith & Nephew Clinical, Scientific & Medical Affairs, Global R&D, 7135 Goodlett Farms Parkway, Cordova, TN, 38016, USA
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Ramos DM, Dhandapani R, Subramanian A, Sethuraman S, Kumbar SG. Clinical complications of biodegradable screws for ligament injuries. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2020; 109:110423. [DOI: 10.1016/j.msec.2019.110423] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 10/18/2019] [Accepted: 11/11/2019] [Indexed: 12/22/2022]
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Chevallier R, Klouche S, Gerometta A, Bohu Y, Herman S, Lefevre N. Bioabsorbable screws, whatever the composition, can result in symptomatic intra-osseous tibial tunnel cysts after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2019; 27:76-85. [PMID: 29961095 DOI: 10.1007/s00167-018-5037-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 06/25/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To describe the clinical results of patients who underwent surgical treatment for a intra-osseous tibial tunnel cyst on a bioabsorbable interference screw following anterior cruciate ligament reconstruction (ACL). METHODS This retrospective study included all patients who underwent surgery between 2004 and 2016 for an intra-osseous tibial tunnel cyst on bioabsorbable interference screw following ACL reconstruction. The diagnosis was suggested clinically by pretibial pain at the incision site, sometimes associated with a palpable subcutaneous nodule and then confirmed on MRI. The first stage of surgery included exploratory arthroscopy followed by open excision/curettage of the cyst and then the tunnel was filled. The main criterion for outcome was a clinically normal knee (no pain, 0-120 range of motion, stable, with no effusion) at 6 months of follow-up. RESULTS This series included 53 patients, mean age 35.3 ± 9.9 years old w ith a mean 4.6 ± 3.1 years (between 3.1 months and 19 years) of follow-up after ligament reconstruction. The tibial screw was completely absorbed in 9/53 (17%) of patients, and fragmented in 22/53 (41.5%). At the 6-month follow-up, 42/53 (79.2%) patients had a normal knee, 11/53 (20.8%) persistent pain in the cyst area, 52/53 (98.1%) normal range of motion and 53 (100%) a stable knee. A recurrent cyst developed at 2 years of follow-up in one patient. CONCLUSION Complete absorption of a bioabsorbable interference screw is long, increasing the risk of developing intra-osseous tibial cysts during this period. The development of new materials with improved absorption properties is needed. LEVEL OF EVIDENCE IV-Retrospective study.
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Affiliation(s)
- Romain Chevallier
- Clinique du Sport Paris, 36, Boulevard Saint Marcel, 75005, Paris, France
| | - Shahnaz Klouche
- Clinique du Sport Paris, 36, Boulevard Saint Marcel, 75005, Paris, France. .,Institut de l'Appareil Locomoteur Nollet, 23, Rue Brochant, 75013, Paris, France.
| | - Antoine Gerometta
- Clinique du Sport Paris, 36, Boulevard Saint Marcel, 75005, Paris, France.,Institut de l'Appareil Locomoteur Nollet, 23, Rue Brochant, 75013, Paris, France
| | - Yoann Bohu
- Clinique du Sport Paris, 36, Boulevard Saint Marcel, 75005, Paris, France.,Institut de l'Appareil Locomoteur Nollet, 23, Rue Brochant, 75013, Paris, France
| | - Serge Herman
- Clinique du Sport Paris, 36, Boulevard Saint Marcel, 75005, Paris, France.,Institut de l'Appareil Locomoteur Nollet, 23, Rue Brochant, 75013, Paris, France
| | - Nicolas Lefevre
- Clinique du Sport Paris, 36, Boulevard Saint Marcel, 75005, Paris, France.,Institut de l'Appareil Locomoteur Nollet, 23, Rue Brochant, 75013, Paris, France
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Jeong JH, Jin ES, Kim JY, Lee B, Min J, Jeon SR, Lee M, Choi KH. The Effect of Biocomposite Screws on Bone Regeneration in a Rat Osteoporosis Model. World Neurosurg 2017; 106:964-972. [DOI: 10.1016/j.wneu.2017.07.083] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 07/14/2017] [Accepted: 07/15/2017] [Indexed: 11/29/2022]
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Effects of hydroxyapatite (HA) particles on the PLLA polymeric matrix for fabrication of absorbable interference screws. Polym Bull (Berl) 2017. [DOI: 10.1007/s00289-017-2158-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Biomechanical comparison of pure magnesium interference screw and polylactic acid polymer interference screw in anterior cruciate ligament reconstruction-A cadaveric experimental study. J Orthop Translat 2016; 8:32-39. [PMID: 30035092 PMCID: PMC5987054 DOI: 10.1016/j.jot.2016.09.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 08/23/2016] [Accepted: 09/09/2016] [Indexed: 01/13/2023] Open
Abstract
Background Polylactic acid polymer interference screws are commonly used in anterior cruciate ligament (ACL) reconstructions, especially in proximal tibia fixation. However, several concerns have been raised, including the acid products during its degradation in vivo. In recent years, biodegradable magnesium (Mg)-based implants have become attractive because of their favourable mechanical properties, which are more similar to those of natural bone when compared with other degradable materials, such as polymers, apart from their alkaline nature during degradation. Methods We developed a pure Mg interference screw for ACL reconstruction. In the present study, 24 fresh cadaver knees were used to compare the mechanical properties of pure Mg interference screws and polylactic acid polymer interference screws for ACL reconstruction via their application on the proximal tibia tested using specific robotics. Results Results showed that the pure Mg interference screw group showed similar mechanical stability to the polylactic acid polymer interference screw group, implying comparable postoperative fixation effects. Conclusion As there are no commercially available Mg-based interference screws for ACL reconstruction clinically and the in vivo degradation of pure Mg promotes bone formation, our cadaveric study supports its clinical tests for ACL reconstruction.
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Debieux P, Franciozi CES, Lenza M, Tamaoki MJ, Magnussen RA, Faloppa F, Belloti JC. Bioabsorbable versus metallic interference screws for graft fixation in anterior cruciate ligament reconstruction. Cochrane Database Syst Rev 2016; 7:CD009772. [PMID: 27450741 PMCID: PMC6458013 DOI: 10.1002/14651858.cd009772.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) tears are frequently treated with surgical reconstruction with grafts, frequently patella tendon or hamstrings. Interference screws are often used to secure the graft in bone tunnels in the femur and tibia. This review examines whether bioabsorbable interference screws give better results than metal interference screws when used for graft fixation in ACL reconstruction. OBJECTIVES To assess the effects (benefits and harms) of bioabsorbable versus metallic interference screws for graft fixation in ACL reconstruction. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL (the Cochrane Library), MEDLINE, Embase, LILACS, trial registers and reference lists of articles. Date of search: January 2016. SELECTION CRITERIA We included randomised controlled trials and quasi-randomised trials comparing bioabsorbable with metallic interferences screws in ACL reconstruction. The main outcomes sought were subjective-rated knee function, failure of treatment, and activity level. DATA COLLECTION AND ANALYSIS At least two review authors selected eligible trials, independently assessed risk of bias, and cross-checked data. Data were pooled whenever relevant and possible. Requests for further information were sent to the original study authors. MAIN RESULTS We included 12 trials (11 randomised and one quasi-randomised) involving a total of 944 participants, and reporting follow-up results for 774. Participants in the 12 trials underwent ACL reconstruction with either hamstring tendon grafts (five trials) or patellar tendon grafts (seven trials). Trials participants were randomly allocated to bioabsorbable or metallic interference screws for graft fixation in both femur and tibia (seven trials); femur only (three trials); tibia only (one trial); location was not reported in the remaining trial. A variety of materials was used for the bioabsorbable screws, Poly-L-lactic acid (PLLA) being the most common. The metallic screws, where reported, were titanium.All trials were at high risk of bias, which invariably included performance bias. Seven trials were at high risk of attrition bias and eight at high risk of reporting bias. The quasi-randomised trial was assessed as being at high risk for selection bias. Based on these study limitations and insufficiency of the available data, we judged the quality of evidence for all outcomes was very low.The majority of the available data for patient-reported knee function was presented as Lysholm scores (0 to 100; higher scores = better function). There was very low quality but consistent evidence of no clinically important differences between the two groups in Lysholm scores at 12 months follow-up (mean difference (MD) -0.08, 95% confidence interval (CI) -1.48 to 1.32; three trials, 168 participants); 24 months (MD 0.35, 95% CI -1.27 to 1.98; three trials, 113 participants) or five or more years follow-up (MD 1.23, 95% CI -2.00 to 4.47; two trials, 71 participants). This lack of between-group differences was also reported for Lysholm scores in several trials that did not provide sufficient data for pooling as well as for other self-reported knee function scores reported in several trials.Treatment failure was represented by the summed data for implant breakage during surgery and major postoperative complications (implant failure, graft rupture, symptomatic foreign body reactions, effusion and treated arthrofibrosis and related conditions) that were usually described in the trial reports as requiring further substantive treatment. There is very low-quality evidence of greater treatment failure in the bioabsorbable screw group (60/451 versus 29/434; risk ratio (RR) 1.94 favouring metallic screw fixation, 95% CI 1.29 to 2.93; 885 participants, 11 studies). In a population with an assumed risk (based on the median control group risk) of 56 participants per 1000 having treatment failure after metallic screw fixation, this equates to 53 more (95% CI 17 to 108 more) per 1000 participants having treatment failure after bioabsorbable screw fixation. All 16 intraoperative complications in the bioabsorbable screw group were implant breakages upon screw insertion. Treatment failure defined as postoperative complications only still favoured the metallic screw group but the 95% CI also included the potential for a greater risk of treatment failure after metallic screw fixation: 44/451 versus 29/434; RR 1.44, 95% CI 0.93 to 2.23. Based on the assumed risk of 56 participants per 1000 having postoperative treatment failure after metallic screw fixation, this equates to 25 more (95% CI 4 fewer and 69 more) per 1000 participants having this outcome after bioabsorbable screw fixation.There was very low-quality evidence of very similar activity levels in the two groups at 12 and 24 months follow-up measured via the Tegner score (0 to 10; higher scores = greater activity): 12 months (MD 0.08, 95% CI -0.39 to 0.55; 122 participants, two studies); 24 months (MD 0.01, 95% CI -0.54 to 0.57; 72 participants, two studies). AUTHORS' CONCLUSIONS There is very low-quality evidence of no difference in self-reported knee function and levels of activity between bioabsorbable and metallic interference screws for graft fixation in ACL reconstruction. There is very low-quality evidence that bioabsorbable screws may be associated with more overall treatment failures, including implant breakage during surgery. Further research does not appear to be a priority, but if undertaken, should also examine costs.
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Affiliation(s)
| | - Carlos ES Franciozi
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyRua Borges Lagoa, 783 ‐ 5th FloorSão PauloBrazil04038‐032
| | - Mário Lenza
- Hospital Israelita Albert EinsteinOrthopaedic and Trauma DepartmentSão PauloBrazil
| | - Marcel Jun Tamaoki
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyRua Borges Lagoa, 783 ‐ 5th FloorSão PauloBrazil04038‐032
| | - Robert A Magnussen
- The Ohio State University Medical CenterOrthopaedic Surgery2050 Kenny RdColumbusUSA43221
| | - Flávio Faloppa
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyRua Borges Lagoa, 783 ‐ 5th FloorSão PauloBrazil04038‐032
| | - João Carlos Belloti
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyRua Borges Lagoa, 783 ‐ 5th FloorSão PauloBrazil04038‐032
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Barth J, Akritopoulos P, Graveleau N, Barthelemy R, Toanen C, Saffarini M. Efficacy of Osteoconductive Ceramics in Bioresorbable Screws for Anterior Cruciate Ligament Reconstruction: A Prospective Intrapatient Comparative Study. Orthop J Sports Med 2016; 4:2325967116647724. [PMID: 27294168 PMCID: PMC4892430 DOI: 10.1177/2325967116647724] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background: Osteoconductive additives are used in resorbable interference screws for anterior cruciate ligament (ACL) reconstruction to improve graft incorporation and mitigate adverse effects. There are no published studies that compare biological performances of bioresorbable and biocomposite screws without artifacts due to different follow-up times and intrinsic patient characteristics. Purpose/Hypothesis: The purpose of this study was to evaluate the efficacy of osteoconductive agents in bioresorbable screws for ACL reconstruction at minimum follow-up of 2 years by intrapatient comparison. The hypothesis was that osteoconductive ceramics would result in slower resorption, improved ossification, and less tunnel widening. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 28 ACL reconstructions at 2 centers were randomly assigned into 2 comparable groups: (1) the graft was fixed in the tibia using standard bioresorbable screws and in the femur using biocomposite screws with osteoconductive agents (biphasic calcium phosphate), and (2) the graft was fixed in the femur using a standard bioresorbable screw and in the tibia using a biocomposite screw with osteoconductive agents. Results: Twenty-seven patients completed evaluations at 29.9 ± 4.0 months. Resorption was complete for more bioresorbable (81%) than biocomposite (37%) screws (P = .0029), whereas satisfactory ossification was observed in more biocomposite (52%) than bioresorbable (15%) screws (P = .0216). The tunnel shape was normal in more biocomposite (81%) than bioresorbable (48%) screws (P = .0126), and marked cortical formation was twice more frequent for biocomposite (78%) than bioresorbable (37%) screws (P = .0012). Bioresorbable screws exhibited faster resorption in the femur (P = .0202) but not in the tibia (not significant). Conversely, biocomposite screws demonstrated better ossification, less tunnel widening, and more cortical formation in the tibia (P < .0001, P = .0227, and P < .0001, respectively) but not in the femur (not significant for all). Conclusion: Osteoconductive additives can reduce the extent of resorption while improving ossification, reducing tunnel widening, and increasing cortical formation. Clinical Relevance: The benefits of osteoconductive agents justify their associated costs for ACL reconstruction, particularly in the tibia.
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Affiliation(s)
- Johannes Barth
- Department of Orthopaedic Surgery, Centre Osteoarticulaire des Cèdres, Grenoble, France
| | | | - Nicolas Graveleau
- Department of Orthopaedic Surgery, Centre Médico Chirurgical Paris V, Paris, France
| | | | - Cécile Toanen
- Department of Orthopaedic Surgery, Centre Médico Chirurgical Paris V, Paris, France
| | - Mo Saffarini
- Department of Medical Technology, Accelerate Innovation Management SA, Geneva, Switzerland.; Department of Medical Research, Alliance Scientifique SAS, Lyon, France
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Ntagiopoulos PG, Demey G, Tavernier T, Dejour D. Comparison of resorption and remodeling of bioabsorbable interference screws in anterior cruciate ligament reconstruction. INTERNATIONAL ORTHOPAEDICS 2014; 39:697-706. [DOI: 10.1007/s00264-014-2530-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 09/04/2014] [Indexed: 11/24/2022]
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15
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Ramsingh V, Prasad N, Lewis M. Pre-tibial reaction to biointerference screw in anterior cruciate ligament reconstruction. Knee 2014; 21:91-4. [PMID: 23993273 DOI: 10.1016/j.knee.2013.07.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 07/22/2013] [Accepted: 07/25/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND We aim to report a series of cases that presented as pre-tibial swelling and pain following anterior cruciate ligament (ACL) reconstruction using bioabsorbable fixation devices. METHODS All ACL reconstructions done between 2007 and 2010 were reviewed retrospectively to identify complications related to bioabsorbable fixation devices. We performed 273 ACL reconstructions over a period of three years from 2007 to 2010 using a bioabsorbable screw for tibial fixation of the quadrupled hamstring autograft. RESULTS Fourteen patients (5%) at mean age of 30 (range 16-47) years, presented to us at a mean post-operative period of 26 months (range 12-39) with pre-tibial pain and swelling over the tibial screw site. All of them had normal inflammatory markers. All of these patients underwent surgical debridement, which revealed remnants of screw and reactive material. There was no evidence of infection in the intra-operative specimen cultures. Histopathology revealed a reactive appearance and surrounding myxoid changes. Removal of screw debris and curettage of the tunnel resulted in complete recovery of all patients at a mean follow up of 12 (range 8-16) months. CONCLUSIONS Pre-tibial cyst along with other adverse biological response should be considered as a possible complication in ACL reconstruction. We report an incidence of 5% of pre-tibial reaction in patients undergoing ACL reconstruction with bio-absorbable interference screw fixation for the proximal tibia.
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Affiliation(s)
- V Ramsingh
- Royal Gwent Hospital, Newport NP20 4FW, UK.
| | - N Prasad
- Royal Gwent Hospital, Newport NP20 4FW, UK
| | - M Lewis
- Royal Gwent Hospital, Newport NP20 4FW, UK
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Revolutionizing orthopaedic biomaterials: The potential of biodegradable and bioresorbable magnesium-based materials for functional tissue engineering. J Biomech 2013; 47:1979-86. [PMID: 24373510 DOI: 10.1016/j.jbiomech.2013.12.003] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 11/18/2013] [Accepted: 12/01/2013] [Indexed: 02/08/2023]
Abstract
In recent years, there has been a surge of interest in magnesium (Mg) and its alloys as biomaterials for orthopaedic applications, as they possess desirable mechanical properties, good biocompatibility, and biodegradability. Also shown to be osteoinductive, Mg-based materials could be particularly advantageous in functional tissue engineering to improve healing and serve as scaffolds for delivery of drugs, cells, and cytokines. In this paper, we will present two examples of Mg-based orthopaedic devices: an interference screw to accelerate ACL graft healing and a ring to aid in the healing of an injured ACL. In vitro tests using a robotic/UFS testing system showed that both devices could restore function of the goat stifle joint. Under a 67-N anterior tibial load, both the ACL graft fixed with the Mg-based interference screw and the Mg-based ring-repaired ACL could restore anterior tibial translation (ATT) to within 2mm and 5mm, respectively, of the intact joint at 30°, 60°, and 90° of flexion. In-situ forces in the replacement graft and Mg-based ring-repaired ACL were also similar to those of the intact ACL. Further, early in vivo data using the Mg-based interference screw showed that after 12 weeks, it was non-toxic and the joint stability and graft function reached similar levels as published data. Following these positive results, we will move forward in incorporating bioactive molecules and ECM bioscaffolds to these Mg-based biomaterials to test their potential for functional tissue engineering of musculoskeletal and other tissues.
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17
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Migration of "bioabsorbable" screws in ACL repair. How much do we know? A systematic review. Knee Surg Sports Traumatol Arthrosc 2013; 21:986-94. [PMID: 23377842 DOI: 10.1007/s00167-013-2414-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 01/17/2013] [Indexed: 01/02/2023]
Abstract
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.
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18
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Adhesion and proliferation of human osteoblast-like cells on different biodegradable implant materials used for graft fixation in ACL-reconstruction. Arch Orthop Trauma Surg 2012; 132:1637-45. [PMID: 22864871 DOI: 10.1007/s00402-012-1592-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Indexed: 01/10/2023]
Abstract
INTRODUCTION This study investigates the adhesion and proliferation behaviour of human osteoblast-like cells over time when incubated on surfaces of biodegradable screws and pins used for graft fixation in ACL reconstruction. MATERIALS AND METHODS 2 mm-sized-wedges of four bioresorbable implants [1. poly-L-lactide acid (PLLA) screw, 2. PLLA/β-tricalciumphosphate (PLLA/TCP) (70 %/30 %) screw, 3. poly-L-lactide-co-glycolic acid/β-tricalciumphosphate (PLGA/TCP) (70 %/30 %) screw and 4. PLLA pin] were incubated with human osteoblast-like cells. All probes were evaluated after 3,7,14 and 21 days by cell number count, determination of cell proliferation, observation of cell adhesion of human osteoblast-like cells under an environmental scanning electron microscope (ESEM), and by a live-dead assay. RESULTS Cell numbers were lower at all stages in both PLLA groups compared to the composite materials (PLLA/TCP and PLGA/TCP). A significant difference in cell proliferation was found after 21 days. The cells on both composite screws (PLLA/TCP and PLGA/TCP) maintained more contact points with the screw surface compared to the cells on PLLA screws under ESEM. No cytotoxicity could be observed in the live-dead assay. DISCUSSION Mainly, β-TCP as part of a composite implant seems to offer good ultrastructural properties for cell adhesion according to our in vitro study. Cell numbers seem to be influenced by the degradation behaviour with higher cell numbers in the composite groups.
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Sprowson AP, Aldridge SE, Noakes J, Read JW, Wood DG. Bio-interference screw cyst formation in anterior cruciate ligament reconstruction--10-year follow up. Knee 2012; 19:644-7. [PMID: 22341197 DOI: 10.1016/j.knee.2012.01.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Revised: 01/13/2012] [Accepted: 01/16/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE This study used serial MRI to assess the absorption of a poly l-lactide Bioabsorbable interference screw used in the anterior cruciate ligament reconstruction with a 4-strand hamstring technique. METHODS A consecutive series of ten patients undergoing anterior cruciate ligament reconstruction a 4-strand hamstring technique were assessed with magnetic resonance imaging (MRI) scans at 1, 2, 4, 7 and 10 years postoperatively. RESULTS No resorption had occurred after 4 years in any of the patients. By 7 years screw absorption was complete in seven patients and had progressed in three. New cyst formation occurred in 3 patients between 5 and 7 years. Half the patients displayed small fluid collections within the tibial tunnels. At 10 years all screws were fully absorbed; however cyst formation was common, including the development of a new cyst in the period between 7 and 10 years in one patient. None of the patients had instability, persistent effusions, or clinically detectable adverse reactions to the screws. CONCLUSIONS This study has shown that poly l-lactide bioabsorbable screws take longer to resorb than initial in vitro data suggested. It is unclear whether ganglion formation within the tibial tunnel is related to screw resorption or the hamstring graft. The theoretical advantages of bioabsorbable screws must be weighed against these findings.
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Affiliation(s)
- Andrew P Sprowson
- North Sydney Orthopaedic and Sports Medicine Centre (NSOSMC), 286 Pacific Highway, NSW 2065, Australia.
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20
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Tibor LM, Long JL, Schilling PL, Lilly RJ, Carpenter JE, Miller BS. Clinical outcomes after anterior cruciate ligament reconstruction: a meta-analysis of autograft versus allograft tissue. Sports Health 2012; 2:56-72. [PMID: 23015924 PMCID: PMC3438864 DOI: 10.1177/1941738109347984] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Clinical outcomes of autograft and allograft anterior cruciate ligament (ACL) reconstructions are mixed, with some reports of excellent to good outcomes and other reports of early graft failure or significant donor site morbidity. OBJECTIVE To determine if there is a difference in functional outcomes, failure rates, and stability between autograft and allograft ACL reconstructions. DATA SOURCES Medline, Cochrane Central Register of Controlled Trials (Evidence Based Medicine Reviews Collection), Cochrane Database of Systematic Reviews, Web of Science, CINAHL, and SPORTDiscus were searched for articles on ACL reconstruction. Abstracts from annual meetings of the American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America were searched for relevant studies. STUDY SELECTION INCLUSION CRITERIA FOR STUDIES WERE AS FOLLOWS: primary unilateral ACL injuries, mean patient age less than 41 years, and follow-up for at least 24 months postreconstruction. Exclusion criteria for studies included the following: skeletally immature patients, multiligament injuries, and publication dates before 1990. DATA EXTRACTION Joint stability measures included Lachman test, pivot-shift test, KT-1000 arthrometer assessment, and frequency of graft failures. Functional outcome measures included Tegner activity scores, Cincinnati knee scores, Lysholm scores, and IKDC (International Knee Documentation Committee) total scores. RESULTS More than 5000 studies were identified. After full text review of 576 studies, 56 were included, of which only 1 directly compared autograft and allograft reconstruction. Allograft ACL reconstructions were more lax when assessed by the KT-1000 arthrometer. For all other outcome measures, there was no statistically significant difference between autograft and allograft ACL reconstruction. For all outcome measures, there was strong evidence of statistical heterogeneity between studies. The sample size necessary for a randomized clinical trial to detect a difference between autograft and allograft reconstruction varied, depending on the outcome. CONCLUSIONS With the current literature, only KT-1000 arthrometer assessment demonstrated more laxity with allograft reconstruction. A randomized clinical trial directly comparing allograft to autograft ACL reconstruction is warranted, but a multicenter study would be required to obtain an adequate sample size.
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Affiliation(s)
| | - Joy L. Long
- Lancaster Orthopaedic Group, Lancaster, Pennsylvania
| | | | | | | | - Bruce S. Miller
- University of Michigan, Ann Arbor, Michigan
- Address correspondence to Bruce S. Miller, MD, MS, MedSport, Department of Orthopaedic Surgery, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106 (e-mail: )
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Abstract
With the rising number of anterior cruciate ligament (ACL) reconstructions performed, revision ACL reconstruction is increasingly common nowadays. A broad variety of primary and revision ACL reconstruction techniques have been described in the literature. Recurrent instability after primary ACL surgery is often due to non-anatomical ACL graft reconstruction and altered biomechanics. Anatomical reconstruction must be the primary goal of this challenging revision procedure. Recently, revision ACL reconstruction has been described using double bundle hamstring graft. Successful revision ACL reconstruction requires an exact understanding of the causes of failure and technical or diagnostic errors. The purpose of this article is to review the causes of failure, preoperative evaluation, graft selection and types of fixation, tunnel placement, various types of surgical techniques and clinical outcome of revision ACL reconstruction.
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Johnston M, Morse A, Arrington J, Pliner M, Gasser S. Resorption and remodeling of hydroxyapatite-poly-L-lactic acid composite anterior cruciate ligament interference screws. Arthroscopy 2011; 27:1671-8. [PMID: 21978431 DOI: 10.1016/j.arthro.2011.06.036] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Revised: 06/27/2011] [Accepted: 06/28/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the progression of hydroxyapatite-poly-L-lactic acid (HA-PLLA) interference screw resorption and remodeling in patients after anterior cruciate ligament (ACL) reconstruction. METHODS Sixty-five patients undergoing ACL reconstruction with patellar tendon autograft or allograft fixed at both the femur and tibia with HA-PLLA screws were evaluated. We evaluated 10 patients each at 2, 3, and 4 years postoperatively, whereas 35 patients were evaluated at 5 years postoperatively. In all patients a physical examination was performed and functional outcome scores and computed tomography (CT) analysis were obtained at follow-up. RESULTS Screw tract densities determined by CT at 5 years postoperatively were higher than muscle and were similar to the surrounding bone. At 4 years, 80% to 90% of screws were completely resorbed. At 5-year follow-up, 29% of patients showed complete ossification of the screw tract in the femur versus 34% in the tibia. There was no tunnel widening or sclerosis noted. Subjective and objective clinical results remained high throughout the study period. CONCLUSIONS The HA-PLLA interference screws are slowly resorbed over time, and the majority are completely resorbed between 3 and 4 years after ACL reconstruction with patellar tendon autograft or allograft. Osteoconductivity and remodeling were confirmed by CT scans, and no tunnel widening, sclerosis, cysts, or inflammatory changes were noted. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Matt Johnston
- Celebration Orthopaedic & Sports Medicine Institute, Florida, USA
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23
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Barber FA, Dockery WD, Hrnack SA. Long-term degradation of a poly-lactide co-glycolide/β-tricalcium phosphate biocomposite interference screw. Arthroscopy 2011; 27:637-43. [PMID: 21429700 DOI: 10.1016/j.arthro.2010.11.056] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2010] [Revised: 11/12/2010] [Accepted: 11/16/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the long-term in vivo degradation of biodegradable interference screws made of poly-L-lactide co-glycolide (poly-L-lactic acid [PLLA]/polyglycolic acid [PGA]) and β-tricalcium phosphate (β-TCP). METHODS To study in vivo the biological behavior of a PLLA/PGA/β-TCP biocomposite screw (Milagro; DePuy Mitek, Raynham, MA), an institutional review board-approved program using anterior cruciate ligament (ACL) interference fixation screws was initiated in 2005. Thirteen patients who had bone-patellar tendon-bone ACL reconstruction fixed at both the femur and tibia with PLLA/PGA/β-TCP screws at least 24 months earlier were evaluated by physical, radiographic, and computed tomography (CT) evaluations. Lysholm, Tegner, Cincinnati, and International Knee Documentation Committee scores were also obtained. Radiographs and CT scans of the operated knee were obtained. CT scan data measured in Hounsfield units (HU) evaluated the material density at the screw and bone plug sites. Soft-tissue and cancellous and cortical bone site readings were also taken. Osteoconductivity scores were determined at the screw sites by use of an ossification quality score (range, 1 to 4). RESULTS Eleven men and two women were evaluated at a mean of 38 months after surgery (range, 24 to 49 months). CT scans and radiographs showed the bone plug fused to the tunnel wall with no PLLA/PGA/β-TCP screw remaining. The screws were replaced with material that was calcified and non-trabecular. Osteoconductivity was present in 21 of 26 tunnels (81%) and complete (type 4 ossification) in 5 of 26 (19%). Mean screw site densities (femoral, 159 HU; tibial, 157 HU) were not different from the mean cancellous bone density (femoral, 146 HU; tibial, 140 HU). No positive pivot-shift tests were found. Lysholm, Tegner, and Cincinnati scores improved from 44, 3.7, and 37 preoperatively to 93, 6, and 87 at follow-up, respectively. The mean KT arthrometer (MEDmetric, San Diego, CA) difference was 0.8 mm. CONCLUSIONS The PLLA/PGA/β-TCP interference screw completely degraded, and no remnant was present 3 years after implantation for a bone-patellar tendon-bone graft ACL reconstruction. Osteoconductivity was confirmed in 21 of 26 screw sites (81%) and completely filled the site in 5 of 26 (19%). The PLLA/PGA/β-TCP biocomposite interference screw is osteoconductive. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- F Alan Barber
- Plano Orthopedic Sports Medicine and Spine Center, Plano, Texas 75093, USA
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24
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Drogset JO, Straume LG, Bjørkmo I, Myhr G. A prospective randomized study of ACL-reconstructions using bone-patellar tendon-bone grafts fixed with bioabsorbable or metal interference screws. Knee Surg Sports Traumatol Arthrosc 2011; 19:753-9. [PMID: 21234545 PMCID: PMC3076560 DOI: 10.1007/s00167-010-1353-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2009] [Accepted: 11/30/2010] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Bioabsorbable screws are, at the expense of metal screws, increasingly used as fixation device in ACL-reconstructions. The possible advantages with bioabsorbable screws are better postoperative MRI evaluations and easier revision surgery. PURPOSE The aim of this study was to compare the clinical outcome after ACL-reconstructions with BPTB-grafts fixed with metal interference screws or bioabsorbable screws 7 years postoperatively. The resorption of the bioabsorbable screws was also analyzed. METHODS Between 2000 and 2001, 41 patients with ACL deficient knees were randomized for the use of BPTB-graft fixed with either metal interference screws or bioabsorbable poly-L: -lactic acid screws. This is a 7-year follow-up with clinical examinations of both groups and, MRI of the patients with bioabsorbable screws. RESULTS The clinical and functional results were satisfactory in both groups. There were no significant differences between the groups in any parameter measured, except for better Pivot shift results in the bioscrew group (P = 0.04). The MRI evaluation showed degradation of the bioscrews. A residual screw tract which appeared threaded was seen in the tibia in 11 of the 16 patients. There was no sign of bony ingrowth in the previous screw site in the tibia in any of the patients. CONCLUSION The potential advantages of using PLLA-screws compared to metal screws are not sufficient to warrant the routine use of PLLA-screws in ACL-reconstructions. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Jon Olav Drogset
- Trondheim University Hospital, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Ingrid Bjørkmo
- Norwegian University of Science and Technology, Trondheim, Norway
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Wijdicks CA, Brand EJ, Nuckley DJ, Johansen S, LaPrade RF, Engebretsen L. Biomechanical evaluation of a medial knee reconstruction with comparison of bioabsorbable interference screw constructs and optimization with a cortical button. Knee Surg Sports Traumatol Arthrosc 2010; 18:1532-41. [PMID: 20563561 DOI: 10.1007/s00167-010-1127-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Accepted: 03/11/2010] [Indexed: 10/19/2022]
Abstract
Current fixation techniques in medial knee reconstructions predominantly utilize interference screws alone for soft tissue graft fixation. The use of concurrent fixation techniques as part of a hybrid fixation technique has also been suggested to strengthen soft tissue fixation, although these hybrid fixation techniques have not been biomechanically validated. The purpose was to biomechanically evaluate two distal tibial superficial MCL graft fixation techniques that consisted of an interference screw alone and in combination with a cortical button. Furthermore, the aim was to compare interference screws of different constructs. Twenty-four porcine tibias (average bone mineral density of 1.3 ± 0.2 g/cm(2); range, 1.0-1.6 g/cm(2), measured by DEXA scan) were divided into 4 groups of six specimens each. Group Ia consisted of a 7 × 23-mm poly-L-lactide (PLLA) interference screw. Group Ib utilized a PLLA interference screw in combination with a cortical button. Group IIa consisted of a 7 × 23-mm composite 70% poly(L-lactide-co-D, L-lactide) and 30% biphasic calcium phosphate (BCP) interference screw. Group IIb also utilized a composite interference screw in combination with a cortical button. The specimens were biomechanically tested with cyclic (500 cycles, 50-250 N, 1 Hz) and load-to-failure (20 mm/min) parameters. During cyclic loading, a significant increase in stiffness was seen for the PLLA hybrid 29.6 (±6.9) N/mm fixation compared to the PLLA screw-only 21.2 (±3.8) N/mm group (P < 0.05). Failure loads were 407.8 (±77.9) N for the composite screw, 445 (±72.2) N for the PLLA screw-only, 473.9 (±69.6) N for the composite hybrid fixation, and 511.0 (±78.5) N for the PLLA hybrid fixation. The PLLA screw alone was found to provide adequate fixation for a superficial MCL reconstruction, and the use of a cortical suture button combined with the PLLA screw resulted in a stiffer fixation during cyclic loading. The current reconstruction superficial MCL graft fixation technique utilizing a PLLA interference screw alone serves as an adequate recreation of the native tibial superficial MCL strength. In addition, a hybrid fixation with a cortical button which lends additional cyclic stiffness to its fixation would be advisable for use in suboptimal fixation cases.
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Affiliation(s)
- Coen A Wijdicks
- Biomechanics Research Department, Steadman Philippon Reasearch Institute, 181 West Meadow Drive, Vail, CO 81657, USA
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Willis-Owen CA, Hearn TC, Keene GC, Costi JJ. Biomechanical testing of implant free wedge shaped bone block fixation for bone patellar tendon bone anterior cruciate ligament reconstruction in a bovine model. J Orthop Surg Res 2010; 5:66. [PMID: 20813059 PMCID: PMC2939630 DOI: 10.1186/1749-799x-5-66] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 09/02/2010] [Indexed: 12/14/2022] Open
Abstract
Background The use of an interference fit wedged bone plug to provide fixation in the tibial tunnel when using bone-patellar tendon-bone autograft for anterior cruciate ligament reconstruction offers many theoretic advantages including the potential to offer a more economical and biological alternative to screw fixation. This technique has not been subjected to biomechanical testing. We hypothesised that a wedged bone plug fixation technique provides equivalent tensile load to failure as titanium interference screw fixation. Methods In a controlled laboratory setting, anterior cruciate ligament reconstruction was performed in 36 bovine knees using bone-patella-bone autograft. In 20 knees tibial fixation relied upon a standard cuboid bone block and interference screw. In eight knees a wedge shaped bone block with an 11 mm by 10 mm base without a screw was used. In a further eight knees a similar wedge with a 13 mm by 10 mm base was used. Each specimen used a standard 10 mm tibial tunnel. The reconstructions were tested biomechanically in a physiological environment using an Instron machine to compare ultimate failure loads and modes of failure. Results Statistical analysis revealed no significant difference between wedge fixation and screw fixation (p = 0.16), or between individual groups (interference screw versus 11 mm versus 13 mm wedge fixation) (P = 0.35). Conclusions Tibial tunnel fixation using an impacted wedge shaped bone block in anterior cruciate ligament reconstruction has comparable ultimate tensile strength to titanium interference screw fixation.
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Efe T, Bauer J, Herdrich S, Gotzen L, El-Zayat BF, Schmitt J, Schofer MD. Comparison between bovine bone and titanium interference screws for implant fixation in ACL reconstruction: a biomechanical study. Arch Orthop Trauma Surg 2010; 130:993-9. [PMID: 20066430 DOI: 10.1007/s00402-010-1052-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Indexed: 01/10/2023]
Abstract
INTRODUCTION The application of interference screws for the fixation of bone-patellar tendon-bone (BPTB) grafts is a well-established technique in anterior-cruciate ligament reconstruction. Interference screws derived from bovine compact bone are a biological alternative to metallic or biodegradable polymer interference screws. MATERIALS AND METHODS In 60 porcine specimens, the tibial part of an anterior-cruciate ligament reconstruction was performed using a BPTB graft. To secure the graft, either an 8-mm titanium interference screw or a self-made bovine interference screw (BC), or a commercial bovine compact bone screw (Tutofix) was used. The maximum failure load was determined by means of a universal testing machine with computer interface at a testing speed of 50 mm/min. In a second test series, cyclic sub-maximal load was applied to the test specimen from 40 to 400 N with a number of 1,000 load cycles and a frequency of 1 Hz. Subsequently, the maximum failure load was determined. The stiffness of the test specimen was investigated in both test series. Each type of interference screw was tested 10 times. RESULTS A secure fixation of the grafts was achieved with all interference screws. In the experiments on the maximum load to failures, the titanium screws showed significantly higher failure loads than the Tutofix screws (P = 0.005). The stiffness of the grafts fixed with BC screws was significantly higher as compared to the fixation with Tutofix screws (P = 0.005). After cyclic sub-maximal loading, the maximum failure load of the titanium screws was significantly higher than that of the Tutofix screws (P = 0.033). The fixation of the BC screws showed a significantly higher failure load (P = 0.021) and stiffness (P = 0.032) than the Tutofix screw fixation. Except for two screw head fractures and two intra-tendinous graft ruptures, the failure mode was slippage in the interface between interference screw and bone plug. CONCLUSION Interference screws derived from bovine compact bone show similar good results as the titanium interference screws. Therefore, the safety and in vivo performance of products derived from xenogenic bone should be the focus of further investigations.
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Affiliation(s)
- Turgay Efe
- Department of Orthopaedics and Rheumatology, University Hospital Marburg, Germany.
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Suchenski M, McCarthy MB, Chowaniec D, Hansen D, McKinnon W, Apostolakos J, Arciero R, Mazzocca AD. Material properties and composition of soft-tissue fixation. Arthroscopy 2010; 26:821-31. [PMID: 20511042 DOI: 10.1016/j.arthro.2009.12.026] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Revised: 12/18/2009] [Accepted: 12/21/2009] [Indexed: 02/02/2023]
Abstract
Surgical interference screws and suture anchors for attaching soft tissue, such as ligaments and tendons, to bone are routinely used in arthroscopic surgery and sports medicine. Interference screw fixation provides a press fit between bone, graft/tendon, and screw and is frequently used to attach replacement ligaments in tunnels drilled for anterior and posterior cruciate ligament reconstruction. Suture anchors are used in surgical procedures wherein it is necessary for a surgeon to attach (tie) tissue to the surface of the bone, for example, during joint reconstruction and ligament repair or replacement. The composition of these implants ranges from metals to polymers and composites. Typically, because of the relatively large amount of torque that must be applied during insertion, these screws are constructed from metal. However, interference screws and suture anchors have also been constructed from bioabsorbable polymers and composites. The ideal material would (1) provide adequate mechanical fixation, (2) completely degrade once no longer needed, and (3) be completely replaced by bone. Because no material has been shown to be superior for all applications, the surgeon must weigh the advantages and disadvantages of each to evaluate the optimum material for a given application and patient. The purpose of this article is to present a comprehensive review of the commercially available interference screws and suture anchors, with an emphasis on implant composition, interaction, and design. This article provides the orthopaedic surgeon with a background on biomaterials, specifically those used in interference screws and suture anchors. Because there is no material that is perfect for all surgical situations, this review can be used to make educated decisions on a case-by-case basis.
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Affiliation(s)
- Maureen Suchenski
- Department of Orthopaedic Surgery, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06030, U.S.A
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Bauer J, Efe T, Herdrich S, Gotzen L, El-Zayat BF, Schmitt J, Timmesfeld N, Schofer MD. Torsional stability of interference screws derived from bovine bone--a biomechanical study. BMC Musculoskelet Disord 2010; 11:82. [PMID: 20433761 PMCID: PMC2881015 DOI: 10.1186/1471-2474-11-82] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2009] [Accepted: 05/01/2010] [Indexed: 01/10/2023] Open
Abstract
Background In the present biomechanical study, the torsional stability of different interference screws, made of bovine bone, was tested. Interference screws derived from bovine bone are a possible biological alternative to conventional metallic or bioabsorbable polymer interference screws. Methods In the first part of the study we compared the torsional stability of self-made 8 mm Interference screws (BC) and a commercial 8 mm interference screw (Tutofix®). Furthermore, we compared the torsional strength of BC screws with different diameters. For screwing in, a hexagon head and an octagon head were tested. Maximum breaking torques in polymethyl methacrylate resin were recorded by means of an electronic torque screw driver. In the second part of the study the tibial part of a bone-patellar tendon-bone graft was fixed in porcine test specimens using an 8 mm BC screw and the maximum insertion torques were recorded. Each interference screw type was tested 5 times. Results There was no statistically significant difference between the different 8 mm interference screws (p = 0.121). Pairwise comparisons did not reveal statistically significant differences, either. It was demonstrated for the BC screws, that a larger screw diameter significantly leads to higher torsional stability (p = 9.779 × 10-5). Pairwise comparisons showed a significantly lower torsional stability for the 7 mm BC screw than for the 8 mm BC screw (p = 0.0079) and the 9 mm BC screw (p = 0.0079). Statistically significant differences between the 8 mm and the 9 mm BC screw could not be found (p = 0.15). During screwing into the tibial graft channel of the porcine specimens, insertion torques between 0.5 Nm and 3.2 Nm were recorded. In one case the hexagon head of a BC screw broke off during the last turn. Conclusions The BC screws show comparable torsional stability to Tutofix® interference screws. As expected the torsional strength of the screws increases significantly with the diameter. The safety and in vivo performance of products derived from xenogeneic bone should be the focus of further investigations.
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Affiliation(s)
- Joscha Bauer
- Department of Orthopaedics and Rheumatology, University Hospital Marburg, Baldingerstrasse, 35043 Marburg, Germany
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Lind M, Feller J, Webster KE. Tibial bone tunnel widening is reduced by polylactate/hydroxyapatite interference screws compared to metal screws after ACL reconstruction with hamstring grafts. Knee 2009; 16:447-51. [PMID: 19423351 DOI: 10.1016/j.knee.2009.04.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Revised: 03/30/2009] [Accepted: 04/07/2009] [Indexed: 02/02/2023]
Abstract
Composite interference screws containing calcium phosphate for anterior cruciate ligament graft fixation could improve implant/bone integration and thereby reduced tunnelwidening and graft slippage. The present study investigated the effect of polylactate/hydroxyapatite interference screw (HA/PLLA) screw used for tibial graft fixation on tunnel widening and clinical outcomes compared with a metal interference screw. We hypothesized less tibial tunnelwidening with HA/PLLA screws compared to metal screws. Hundred patients with HA/PLLA screw tibial fixation was compared with 100 patients with metal screw tibial fixation. Tibial tunnel widening was measured on AP and lateral radiographs taken at 12 months follow-up. Clinical outcome was assessed by objective and subjective international Knee Documentation Committee (IKDC) scores, Noyes Sports Activity and Occupational Rating scores and KT-1000 knee laxity measurements. Tibial tunnel widening at the level of the metal screw group was 36% and 38% on AP and lateral radiographs respectively. Tunnel widening was lower in the HA/PLLA group with mean tunnel widening of 30% and 32% (p=0.012 and 0.018) on AP and lateral radiographs respectively. No differences were found for any of the clinical scores or for anterior knee laxity. The use of a polylactate/hydroxyapatite interference screw resulted in less tibial tunnel widening than a metal screw around the screw but did not affect clinical outcome or objective knee laxity.
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Affiliation(s)
- Martin Lind
- Division of Sportstrauma, Orthopaedic Department, Aarhus University Hospital, Tage Hansensgade 2, 8000 Aarhus C, Denmark.
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Mayr HO, Dietrich M, Fraedrich F, Hube R, Nerlich A, von Eisenhart-Rothe R, Hein W, Bernstein A. Microporous pure beta-tricalcium phosphate implants for press-fit fixation of anterior cruciate ligament grafts: strength and healing in a sheep model. Arthroscopy 2009; 25:996-1005. [PMID: 19732638 DOI: 10.1016/j.arthro.2009.02.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2008] [Revised: 02/21/2009] [Accepted: 02/25/2009] [Indexed: 02/02/2023]
Abstract
PURPOSE A sheep study was conducted to test a press-fit technique using microporous pure beta-tricalcium phosphate (beta-TCP) dowels for fixation of the anterior cruciate ligament (ACL) graft. METHODS Microporous (5 mum) cylindrical plugs of beta-TCP (diameter, 7 mm; length, 25 mm) with interconnecting pores were used. The material featured a novel configuration of structure and surface geometry. Implants were tested by use of press-fit fixation of ACL grafts with and without bone blocks in 42 sheep over a period of 24 weeks. Biomechanical, radiologic, histologic, and immunohistochemical evaluations were performed. RESULTS In load-to-failure tests at 6, 12, and 24 weeks after surgery, the intra-articular graft always failed, not the fixation. Grafts showed bony fixation in the tunnel at 6 weeks and primary healing at the junction of the tunnel and joint after 24 weeks. Tricalcium phosphate was resorbed and simultaneously replaced by bone. Remodeling was still incomplete at 24 weeks. CONCLUSIONS In the sheep model microporous beta-TCP implants used with press-fit fixation of ACL grafts permit early functional rehabilitation. After 6 weeks, the graft is fixed by woven bone or bony integration. Implanted microporous tricalcium phosphate is resorbed and replaced by bone. CLINICAL RELEVANCE In a sheep model we showed that primary healing of ACL grafts with resorption and bony replacement of the fixating implant can be achieved by means of press-fit fixation with pure beta-TCP.
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Affiliation(s)
- Hermann O Mayr
- Clinic for Orthopedic Surgery, Martin Luther University, Halle, Germany.
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Frosch KH, Sawallich T, Schütze G, Losch A, Walde T, Balcarek P, Konietschke F, Stürmer KM. Magnetic resonance imaging analysis of the bioabsorbable Milagro interference screw for graft fixation in anterior cruciate ligament reconstruction. Strategies Trauma Limb Reconstr 2009; 4:73-9. [PMID: 19697105 PMCID: PMC2746274 DOI: 10.1007/s11751-009-0063-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2008] [Accepted: 08/04/2009] [Indexed: 02/03/2023] Open
Abstract
Ligament graft fixation with bioabsorbable interference screws is a standard procedure in cruciate ligament replacement. Previous screw designs may resorb incompletely, and can cause osteolysis and sterile cysts despite being implanted for several years. The aim of this study was to examine the in vivo degradation and biocompatibility of the new Milagro™ interference screw (Mitek, Norderstedt, Germany). The Milagro™ interference screw is made of 30% ß-TCP (TriCalcium phosphate) and 70% PLGA (Poly-lactic-co-glycolic acid). In the period between June 2005 and February 2006, 38 patients underwent graft fixation with Milagro™ screws in our hospital. Arthroscopic ACL reconstruction was performed using hamstring tendon grafts in all the patients. MR imaging was performed on 12 randomly selected patients out of the total of 38 at 3, 6 and 12 months after surgery. During the examination, the volume loss of the screw, tunnel enlargement, presence of osteolysis, fluid lines, edema and postoperative screw replacement by bone tissue were evaluated. There was no edema or signs of inflammation around the bone tunnels. At 3, 6 and 12 months, the tibial screws showed an average volume loss of 0, 8.1% (±7.9%) and 82.6% (±17.2%, P < 0.05), respectively. The femoral screws showed volume losses of 2.5% (±2.1%), 31.3% (±21.6%) and 92.02% (±6.3%, P < 0.05), respectively. The femoral tunnel enlargement was 47.4% (±43.8%) of the original bone tunnel volume after 12 months, and the mean tunnel volume of the tibial tunnel was −9.5% (±58.1%) compared to the original tunnel. Bone ingrowth was observed in all the patients. In conclusion, the resorption behaviour of the Milagro™ screw is closely linked to the graft healing process. The screws were rapidly resorbed after 6 months and, at 12 months, only the screw remnants were detectable. Moreover, the Milagro™ screw is biocompatible and osteoconductive, promoting bone ingrowth during resorption. Tunnel enlargement is not prevented in the first months but is reduced by bone ingrowth after 12 months.
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Affiliation(s)
- K-H Frosch
- Department of Trauma Surgery, Plastic and Reconstructive Surgery, Georg-August-University Goettingen, Robert-Koch-Str. 40, 37075, Goettingen, Germany,
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Konan S, Haddad FS. A clinical review of bioabsorbable interference screws and their adverse effects in anterior cruciate ligament reconstruction surgery. Knee 2009; 16:6-13. [PMID: 18639461 DOI: 10.1016/j.knee.2008.06.001] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2008] [Revised: 05/27/2008] [Accepted: 06/09/2008] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- S Konan
- University College Hospital, London, UK.
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Graft choices and fixation types in anterior cruciate ligament reconstruction. CURRENT ORTHOPAEDIC PRACTICE 2008. [DOI: 10.1097/bco.0b013e32830136db] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Barber FA, Dockery WD. Long-term absorption of beta-tricalcium phosphate poly-L-lactic acid interference screws. Arthroscopy 2008; 24:441-7. [PMID: 18375277 DOI: 10.1016/j.arthro.2007.10.004] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2007] [Revised: 09/24/2007] [Accepted: 10/07/2007] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the long-term in vivo degradation of biodegradable interference screws made of poly-L-lactic acid (PLLA) and beta-tricalcium phosphate (beta-TCP). METHODS Twenty patients undergoing patellar tendon autograft anterior cruciate ligament reconstruction fixed at both the femur and tibia with beta-TCP-PLLA screws at least 44 months earlier were evaluated by physical, radiographic, and computed tomography (CT) evaluations. This study was approved by the institutional review board. Lysholm, Tegner, Cincinnati, and International Knee Documentation Committee scores were also obtained. CT data were measured in Hounsfield units. RESULTS We evaluated 13 male and 7 female patients at a mean of 50 months after surgery (range, 44 to 56 months). CT scans and radiographs showed the bone plug fused to the tunnel wall with no beta-TCP-PLLA screw remaining. The screws were replaced with clearly calcified non-trabecular material, denser than soft tissue. Osteoconductivity was present in 75% of the tunnels and complete in 10%. No positive pivot-shift tests were found. Lysholm, Tegner, and Cincinnati scores improved from 60.4, 3.7, and 53.3, respectively, preoperatively to 90.8, 5.8, and 86.4, respectively, at follow-up. The mean side-to-side difference determined by use of the KT arthrometer (MEDmetric, San Diego, CA) was 0.4 mm. CONCLUSIONS The beta-TCP-PLLA interference screw (Bilok; ArthroCare, Sunnyvale, CA) completely degraded, and no remnant was present 4 years after insertion. Osteoconductivity was confirmed by CT scans at 75% of the screw sites and completely filled the site in 10%. The addition of beta-TCP to PLLA results in a biocomposite interference screw that is osteoconductive. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- F Alan Barber
- Plano Orthopedic and Sports Medicine Center, Plano, Texas 75093, USA
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Anterior cruciate ligament reconstruction using allograft: single tunnel technique. Sports Med Arthrosc Rev 2007; 15:191-8. [PMID: 18004218 DOI: 10.1097/jsa.0b013e3181595bd2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The author presents his current technique for reconstructing an isolated anterior cruciate ligament rupture using an allograft. The specific positioning and surgical steps are presented. Dangers to be avoided are included, which have led to this current technique. The step-by-step technique should enable the surgeon to reconstruct the ligament with little difficulty. The postoperative course including rehabilitation is discussed from postoperative day 1 to full restoration of activity.
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Barber FA, Boothby MH. Bilok interference screws for anterior cruciate ligament reconstruction: clinical and radiographic outcomes. Arthroscopy 2007; 23:476-81. [PMID: 17478277 DOI: 10.1016/j.arthro.2006.12.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2006] [Revised: 12/11/2006] [Accepted: 12/21/2006] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the clinical effectiveness and radiographic response of a poly-L-lactide (PLLA)/beta-tricalcium phosphate (TCP) interference screw for anterior cruciate ligament (ACL) reconstruction. METHODS In a consecutive series of patellar tendon autograft ACL reconstructions, all patients had both ends fixed with PLLA/beta-TCP screws. Inclusion criteria were positive Lachman and pivot-shift tests and closed or nearly closed growth plates. Exclusionary criteria were posterior cruciate ligament tears and bilateral ACL or multiple ligament injuries. Tegner, Lysholm, Cincinnati, and International Knee Documentation Committee activity scores; Lachman and pivot-shift data; radiographic examinations; and KT measurements (MEDmetric, San Diego, CA) were obtained. RESULTS In this study 41 patients met the criteria (31 male and 10 female patients), at a mean follow-up of 34 months (range, 24 to 44 months). Of these patients, 40 were available for follow-up (1 had died). Postoperatively, the mean Cincinnati score was 83 (64 preoperatively), the mean Tegner score was 5.5 (3.2 preoperatively), the mean Lysholm score was 88 (59 preoperatively), and the mean International Knee Documentation Committee activity score was 3.0 out of 4 (1.8 preoperatively). No patients had positive postoperative Lachman or pivot-shift tests. The maximum difference based on KT manual examinations 3 mm or less. Adverse events included screw breakage during insertion. Postoperative radiographs showed rapid bone plug incorporation. Radiographic tunnel obliteration with bony ingrowth was shown at 2 and 3 years' follow-up. CONCLUSIONS The PLLA/beta-TCP interference screw performed well clinically based on both subjective and objective results. Radiographic screw incorporation into the adjacent bone was apparent at 3 years. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- F Alan Barber
- Plano Orthopedic and Sports Medicine Center, Plano, Texas 75093, USA
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