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Mann KA, Miller MA, Gandhi SA, Kusler JE, Tatusko ME, Biggs AE, Oest ME. Peri-operative zoledronic acid attenuates peri-prosthetic osteolysis in a rat model of cemented knee replacement. J Orthop Res 2024. [PMID: 39032112 DOI: 10.1002/jor.25941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/23/2024] [Accepted: 06/28/2024] [Indexed: 07/22/2024]
Abstract
Progressive osteolysis can occur at the cement-bone interface of joint replacements and the associated loss of fixation can lead to clinical loosening. We previously developed a rat hemiarthroplasty model that exhibited progressive loss of fixation with the development of cement-bone gaps under the tibial tray that mimicked patterns found in human arthroplasty retrievals. Here we explored the ability of a bisphosphonate (zoledronic acid, ZA) to attenuate cement-bone osteolysis and maintain implant stability. Sprague-Dawley rats (n = 59) received a poly(methylmethacrylate) cemented tibial component and were followed for up to 12 weeks. Treatment groups included peri-operative administration of ZA (ZA group), administration of ZA at 6 weeks postop (late ZA group), or vehicle (Veh group). There was a 60% reduction in the rate of cement-bone gap formation for the ZA group (0.15 mm3/week) compared to Veh group (0.38 mm3/week, p = 0.016). Late ZA prevented further progression of gap formation but did not reverse bone loss to the level achieved in the ZA group. Micromotion from five times body weight toggle loading was positively correlated with cement-bone gap volume (p = 0.009) and negatively correlated with the amount of cement in the metaphysis (p = 0.005). Reduced new bone formation and enduring nonviable bone in the epiphysis for the ZA group were found. This suggests that low bone turnover in the epiphysis may suppress the early catabolic response due to implantation, thereby maintaining better fixation in the epiphysis. This preclinical model presents compelling supporting data documenting improved maintenance of the cement-bone fixation with the use of peri-operative bisphosphonates.
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Affiliation(s)
- Kenneth A Mann
- Department of Orthopedic Surgery, Institute for Human Performance, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Mark A Miller
- Department of Orthopedic Surgery, Institute for Human Performance, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Sachin A Gandhi
- Department of Orthopedic Surgery, Institute for Human Performance, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Jace E Kusler
- Department of Orthopedic Surgery, Institute for Human Performance, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Megan E Tatusko
- Department of Orthopedic Surgery, Institute for Human Performance, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Amy E Biggs
- Department of Orthopedic Surgery, Institute for Human Performance, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Megan E Oest
- Department of Orthopedic Surgery, Institute for Human Performance, SUNY Upstate Medical University, Syracuse, New York, USA
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2
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Thomson AL, Suhardi VJ, Niu Y, Oktarina A, Döring K, Chao C, Greenblatt MB, Ivashkiv LB, Bostrom MPG, Yang X. A translational murine model of aseptic loosening with osseointegration failure. J Orthop Res 2024. [PMID: 38899517 DOI: 10.1002/jor.25915] [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: 03/24/2024] [Revised: 05/19/2024] [Accepted: 05/25/2024] [Indexed: 06/21/2024]
Abstract
An in vivo animal model of a weight-bearing intra-articular implant is crucial to the study of implant osseointegration and aseptic loosening caused by osseointegration failure. Osseointegration, defined as a direct structural and functional attachment between living bone tissue and the surface of a load-carrying implant, is essential for implant stability and considered a prerequisite for the long-term clinical success of implants in total joint arthroplasty. Compared to large animal models, murine models offer extensive genetic tools for tracing cell differentiation and proliferation. The 18- to 22-week-old C57BL/6J background mice underwent either press-fitted or loose implantation of a titanium implant, achieving osseointegration or fibrous integration. A protocol was developed for both versions of the procedure, including a description of the relevant anatomy. Samples were subjected to microcomputed tomography and underwent biomechanical testing to access osseointegration. Lastly, samples were fixed and embedded for histological evaluation. The absence of mineralized tissue and weakened maximum pull-out force in loose implantation samples indicated that these implants were less mechanically stable compared to the control at 4 weeks postoperation. Histological analysis demonstrated extensive fibrotic tissue in the peri-implant area of loose implantation samples and excellent implant osseointegration in press-fitted samples at 4 weeks. Both mechanically stable and unstable hemiarthroplasty models with either osseous ingrowth or a robust periprosthetic fibrosis were achieved in mice. We hope that this model can help address current limitations for in vivo study of aseptic loosening and lead to necessary translational benefits.
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Affiliation(s)
- Andrew L Thomson
- Research Institute, Hospital for Special Surgery, New York, New York, USA
| | - Vincentius J Suhardi
- Research Institute, Hospital for Special Surgery, New York, New York, USA
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Yingzhen Niu
- Research Institute, Hospital for Special Surgery, New York, New York, USA
- Department of Joint Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, People's Republic of China
| | - Anastasia Oktarina
- Research Institute, Hospital for Special Surgery, New York, New York, USA
| | - Kevin Döring
- Research Institute, Hospital for Special Surgery, New York, New York, USA
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Christina Chao
- Research Institute, Hospital for Special Surgery, New York, New York, USA
| | - Matthew B Greenblatt
- Research Institute, Hospital for Special Surgery, New York, New York, USA
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Lionel B Ivashkiv
- Research Institute, Hospital for Special Surgery, New York, New York, USA
| | - Mathias P G Bostrom
- Research Institute, Hospital for Special Surgery, New York, New York, USA
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Department of Orthopedic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Xu Yang
- Research Institute, Hospital for Special Surgery, New York, New York, USA
- Department of Orthopedic Surgery, Weill Cornell Medicine, New York, New York, USA
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3
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Ferrao PNF, Saragas NP, Naude JJ. Outcomes of Total Ankle Arthroplasty After Periprosthetic Cyst Curettage and Bone Grafting. Foot Ankle Clin 2024; 29:123-143. [PMID: 38309797 DOI: 10.1016/j.fcl.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2024]
Abstract
Total ankle arthroplasty (TAA) has become a popular management option for ankle arthritis. Periprosthetic osteolysis is one of the most common causes for reoperation in TAA. A CT scan should be done in all suspected osteolysis cases to confirm location, quantify size and aid in surgical planning. These patients are often asymptomatic with limited evidence regarding appropriate management. Smaller lesions should be monitored for progression in size. Periprosthetic cysts measuring 10-15mm in all three axes should be considered for debridment and curettage with autogenous bone grafting. The authors believe that bone grafting of large asymptomatic periprosthetic cysts could prevent implant failure.
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Affiliation(s)
- Paulo N F Ferrao
- The Orthopaedic Foot & Ankle Unit, Netcare Linksfield Hospital, 303 Linksfield Medical Centre, 24 12th Avenue, Linksfield West, 2192, South Africa; Department of Orthopaedic Surgery, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa.
| | - Nikiforos P Saragas
- The Orthopaedic Foot & Ankle Unit, Netcare Linksfield Hospital, 303 Linksfield Medical Centre, 24 12th Avenue, Linksfield West, 2192, South Africa; Department of Orthopaedic Surgery, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
| | - Jaco J Naude
- The Orthopaedic Foot & Ankle Unit, Netcare Linksfield Hospital, 303 Linksfield Medical Centre, 24 12th Avenue, Linksfield West, 2192, South Africa; Life Wilgers Hospital, Denneboom road, Wilgers ext 14, Pretoria, 0040, South Africa
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4
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Bratengeier C, Johansson L, Liszka A, Bakker AD, Hallbeck M, Fahlgren A. Mechanical loading intensities affect the release of extracellular vesicles from mouse bone marrow-derived hematopoietic progenitor cells and change their osteoclast-modulating effect. FASEB J 2024; 38:e23323. [PMID: 38015031 DOI: 10.1096/fj.202301520r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/19/2023] [Accepted: 11/07/2023] [Indexed: 11/29/2023]
Abstract
Low-intensity loading maintains or increases bone mass, whereas lack of mechanical loading and high-intensity loading decreases bone mass, possibly via the release of extracellular vesicles by mechanosensitive bone cells. How different loading intensities alter the biological effect of these vesicles is not fully understood. Dynamic fluid shear stress at low intensity (0.7 ± 0.3 Pa, 5 Hz) or high intensity (2.9 ± 0.2 Pa, 1 Hz) was used on mouse hematopoietic progenitor cells for 2 min in the presence or absence of chemical compounds that inhibit release or biogenesis of extracellular vesicles. We used a Receptor activator of nuclear factor kappa-Β ligand-induced osteoclastogenesis assay to evaluate the biological effect of different fractions of extracellular vesicles obtained through centrifugation of medium from hematopoietic stem cells. Osteoclast formation was reduced by microvesicles (10 000× g) obtained after low-intensity loading and induced by exosomes (100 000× g) obtained after high-intensity loading. These osteoclast-modulating effects could be diminished or eliminated by depletion of extracellular vesicles from the conditioned medium, inhibition of general extracellular vesicle release, inhibition of microvesicle biogenesis (low intensity), inhibition of ESCRT-independent exosome biogenesis (high intensity), as well as by inhibition of dynamin-dependent vesicle uptake in osteoclast progenitor cells. Taken together, the intensity of mechanical loading affects the release of extracellular vesicles and change their osteoclast-modulating effect.
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Affiliation(s)
- C Bratengeier
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - L Johansson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Clinical Pathology, Linköping University, Linköping, Sweden
| | - A Liszka
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - A D Bakker
- Department of Oral Cell Biology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - M Hallbeck
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Clinical Pathology, Linköping University, Linköping, Sweden
| | - A Fahlgren
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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5
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Panez-Toro I, Heymann D, Gouin F, Amiaud J, Heymann MF, Córdova LA. Roles of inflammatory cell infiltrate in periprosthetic osteolysis. Front Immunol 2023; 14:1310262. [PMID: 38106424 PMCID: PMC10722268 DOI: 10.3389/fimmu.2023.1310262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/13/2023] [Indexed: 12/19/2023] Open
Abstract
Classically, particle-induced periprosthetic osteolysis at the implant-bone interface has explained the aseptic loosening of joint replacement. This response is preceded by triggering both the innate and acquired immune response with subsequent activation of osteoclasts, the bone-resorbing cells. Although particle-induced periprosthetic osteolysis has been considered a foreign body chronic inflammation mediated by myelomonocytic-derived cells, current reports describe wide heterogeneous inflammatory cells infiltrating the periprosthetic tissues. This review aims to discuss the role of those non-myelomonocytic cells in periprosthetic tissues exposed to wear particles by showing original data. Specifically, we discuss the role of T cells (CD3+, CD4+, and CD8+) and B cells (CD20+) coexisting with CD68+/TRAP- multinucleated giant cells associated with both polyethylene and metallic particles infiltrating retrieved periprosthetic membranes. This review contributes valuable insight to support the complex cell and molecular mechanisms behind the aseptic loosening theories of orthopedic implants.
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Affiliation(s)
- Isidora Panez-Toro
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Chile, Independencia, Santiago, Chile
- Nantes Université, Centre National de Recherche Scientifique (CNRS), UMR6286, US2B, Nantes, France
- Institut de Cancérologie de l’Ouest, Tumor Heterogeneity and Precision Medicine Laboratory, Saint-Herblain, France
| | - Dominique Heymann
- Nantes Université, Centre National de Recherche Scientifique (CNRS), UMR6286, US2B, Nantes, France
- Institut de Cancérologie de l’Ouest, Tumor Heterogeneity and Precision Medicine Laboratory, Saint-Herblain, France
- Nantes Université, Laboratory of Histology and Embryology, Medical School, Nantes, France
- The University of Sheffield, Dept of Oncology and Metabolism, Sheffield, United Kingdom
| | - François Gouin
- Department of Surgical Oncology, Centre Léon Bérard, Lyon, France
| | - Jérôme Amiaud
- Nantes Université, Laboratory of Histology and Embryology, Medical School, Nantes, France
| | - Marie-Françoise Heymann
- Nantes Université, Centre National de Recherche Scientifique (CNRS), UMR6286, US2B, Nantes, France
- Institut de Cancérologie de l’Ouest, Tumor Heterogeneity and Precision Medicine Laboratory, Saint-Herblain, France
| | - Luis A. Córdova
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Chile, Independencia, Santiago, Chile
- IMPACT, Center of Interventional Medicine for Precision and Advanced Cellular Therapy, Santiago, Chile
- Oral and Maxillofacial Surgery, Clínica MEDS, Santiago, Chile
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6
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Jabbal M, Simpson AHR, Walmsley P. Mechanisms of bone loss in revision total knee arthroplasty and current treatment options. Orthop Rev (Pavia) 2023; 15:75359. [PMID: 37405274 PMCID: PMC10317505 DOI: 10.52965/001c.75359] [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] [Indexed: 07/06/2023] Open
Abstract
Purpose Primary total knee arthroplasty (TKA) is an effective treatment which is increasing in use for both elderly and younger patients. With the overall increasing life span of the general population, the rate of revision TKA is projected to increase significantly over the coming decades. Analyses from the national joint registry of England and Wales support this prediction with an increase in primary TKA of 117% and an increase in revision TKA of 332% being forecast by 2030. Bone loss presents a challenge in revision TKA so an understanding of the aetiology and principles behind this is essential for the surgeon undertaking revision. The purpose of this article is to review the causes of bone loss in revision TKA, discuss the mechanisms of each cause and discuss the possible treatment options. Methods The Anderson Orthopaedic Research Institute (AORI) classification and zonal classification of bone loss are commonly used in assessing bone loss in pre-operative planning and will be used in this review. The recent literature was searched to find advantages and limitations of each commonly used method to address bone loss at revision TKA. Studies with the highest number or patients and longest follow-up period were selected as significant. Search terms were: "aetiology of bone loss", "revision total knee arthroplasty", "management of bone loss". Results Methods for managing bone loss have traditionally been cement augmentation, impaction bone grafting, bulk structural bone graft and stemmed implants with metal augments. No single technique was found to be superior. Megaprostheses have a role as a salvage procedure when the bone loss is deemed to be too significant for reconstruction. Metaphyseal cones and sleeves are a newer treatments with promising medium to long term outcomes. Conclusion Bone loss encountered at revision TKA presents a significant challenge. No single technique currently has clear superiority treatment should be based on a sound understanding of the underlying principles.
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Miller MA, Hardy WR, Oest ME, Mann KA. Potential for supraphysiologic fluid shear stresses in a rat cemented knee replacement model. J Orthop Res 2023; 41:94-103. [PMID: 35332943 PMCID: PMC9509496 DOI: 10.1002/jor.25326] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 02/02/2022] [Accepted: 03/13/2022] [Indexed: 02/04/2023]
Abstract
The mechano-biologic environment associated with aseptic loosening of cemented joint replacements is not fully understood. The goal of this study was to use a preclinical rat knee arthroplasty model to explore the changes in cement-bone morphology and micromotion that occur with in vivo service. Narrow gaps between cement and bone under the tibial tray were present at early time points, and with even small magnitude micromotion, resulted in large micromotion-to-gap width ratios. These data were then used to develop models of fluid flow in the cement-bone gaps to estimate potential for high fluid shear stress (FSS). Modeling results revealed supraphysiologic (>4 Pa) FSS were possible, particularly for cases in which eccentric loading applied to the implant and if the fluid in the gap consisted of marrow or synovial fluid. The early, high FSS environment, could cause fluid-induced periprosthetic osteolysis locally, resulting in progressive loss of cement-bone fixation.
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Affiliation(s)
- Mark A Miller
- SUNY Upstate Medical University, Syracuse, New York, USA
| | | | - Megan E Oest
- SUNY Upstate Medical University, Syracuse, New York, USA
| | - Kenneth A Mann
- SUNY Upstate Medical University, Syracuse, New York, USA
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8
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Bratengeier C, Bakker AD, Liszka A, Schilcher J, Fahlgren A. The release of osteoclast-stimulating factors on supraphysiological loading by osteoprogenitors coincides with expression of genes associated with inflammation and cytoskeletal arrangement. Sci Rep 2022; 12:21578. [PMID: 36517534 PMCID: PMC9751069 DOI: 10.1038/s41598-022-25567-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 12/01/2022] [Indexed: 12/15/2022] Open
Abstract
Supraphysiological loading induced by unstable orthopedic implants initiates osteoclast formation, which results in bone degradation. We aimed to investigate which mechanosensitive cells in the peri-implant environment produce osteoclast-stimulating factors and how the production of these factors is stimulated by supraphysiological loading. The release of osteoclast-stimulating factors by different types of isolated bone marrow-derived hematopoietic and mesenchymal stem cells from six osteoarthritic patients was analyzed after one hour of supraphysiological loading (3.0 ± 0.2 Pa, 1 Hz) by adding their conditioned medium to osteoclast precursors. Monocytes produced factors that enhanced osteoclastogenesis by 1.6 ± 0.07-fold and mesenchymal stem cells by 1.4 ± 0.07-fold. Medium from osteoprogenitors and pre-osteoblasts enhanced osteoclastogenesis by 1.3 ± 0.09-fold and 1.4 ± 0.03-fold, respectively, where medium from four patients elicited a response and two did not. Next generation sequencing analysis of osteoprogenitors revealed that genes encoding for inflammation-related pathways and cytoskeletal rearrangements were regulated differently between responders and non-responders. Our data suggest that released osteoclast-stimulating soluble factors by progenitor cells in the bone marrow after supraphysiological loading may be related to cytoskeletal arrangement in an inflammatory environment. This connection could be relevant to better understand the aseptic loosening process of orthopedic implants.
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Affiliation(s)
- Cornelia Bratengeier
- grid.5640.70000 0001 2162 9922Department of Biomedical and Clinical Sciences, Division of Cell Biology, Linköping University, Linköping, Sweden
| | - Astrid D. Bakker
- grid.7177.60000000084992262Department of Oral Cell Biology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Aneta Liszka
- grid.5640.70000 0001 2162 9922Department of Biomedical and Clinical Sciences, Division of Cell Biology, Linköping University, Linköping, Sweden
| | - Jörg Schilcher
- grid.5640.70000 0001 2162 9922Department of Orthopedics and Department of Biomedical and Clinical Sciences, Faculty of Health Sciences and the Wallenberg Centre for Molecular Medicine, Linköping University, Linköping, Sweden
| | - Anna Fahlgren
- grid.5640.70000 0001 2162 9922Department of Biomedical and Clinical Sciences, Division of Cell Biology, Linköping University, Linköping, Sweden
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9
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Mjöberg B. Hip prosthetic loosening and periprosthetic osteolysis: A commentary. World J Orthop 2022; 13:574-577. [PMID: 35949708 PMCID: PMC9244959 DOI: 10.5312/wjo.v13.i6.574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/02/2022] [Accepted: 06/14/2022] [Indexed: 02/06/2023] Open
Abstract
Prosthetic loosening and periprosthetic osteolysis have been debated for decades, both in terms of the timing and nature of the triggering events. The hypothesis of wear-particle-induced loosening states that wear particles cause a foreign-body response leading to periprosthetic osteolysis and ultimately to late prosthetic loosening, i.e., that the osteolysis precedes the loosening. The theory of early loosening, on the other hand, postulates that the loosening is already initiated during or shortly after surgery, i.e., that the osteolysis is secondary to the loosening. This commentary focuses on the causal relationship between prosthetic loosening and periprosthetic osteolysis.
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Affiliation(s)
- Bengt Mjöberg
- Department of Orthopedics, Lund University, Lund SE-221 00, Sweden
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10
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Naude JJ, Saragas NP, Ferrao PNF. CT Scan Assessment and Functional Outcome of Periprosthetic Bone Grafting After Total Ankle Arthroplasty at Medium-term Follow-up. Foot Ankle Int 2022; 43:609-619. [PMID: 35073771 DOI: 10.1177/10711007211064612] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Periprosthetic cysts can occur in up to 95% of total ankle arthroplasties (TAA) and have been correlated with implant failure. The aim of this study was to determine the clinical and radiologic outcomes, using computed tomographic (CT) scan, after periprosthetic cyst bone grafting and assess for the minimum cyst size that should be grafted. METHODS A retrospective review was performed of all TAA procedures performed between 2007 and 2014 (n=93). A CT scan was done to assess cyst size and operative planning. Eight patients with 9 periprosthetic cysts larger than 1.75 cm3 were grafted and specimens sent for histology. The mean time to bone grafting was 7.3 (3.8-9.5) years. Functional outcome was assessed using the American Orthopaedic Foot & Ankle Society ankle score, visual analog scale, and Self-reported Foot and Ankle Score. A CT scan was performed at follow-up to assess graft incorporation and cyst size progression. The mean time to CT scan post grafting was 3.0 (0.7-4.7) years. RESULTS There was no implant malalignment identified and no differences in the pre- and postoperative functional scores. Preoperatively cysts had a mean volume of 8.16 (2.04-14.03) cm3. The mean percentage incorporation was 89% (69%-100%). Eight of the grafted cysts were considered successful on CT, with the ninth having 69% incorporation. Five cysts were not grafted, as they were below 1.75 cm3, and remained the same size or had minimal enlargement. CONCLUSION The satisfactory results in this small cohort suggests that prophylactic bone grafting may extend implant survival. We recommend that periprosthetic cysts greater than 1.75 cm3 be prophylactically bone grafted, and that cysts smaller than 1.75 cm3 be monitored for progression in size. LEVEL OF EVIDENCE Level IV, Case Series.
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Affiliation(s)
- Jaco J Naude
- The Orthopaedic Foot and Ankle Unit, Netcare Linksfield Hospital, Johannesburg, Gauteng, South Africa.,Department of Orthopaedic Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Nikiforos P Saragas
- The Orthopaedic Foot and Ankle Unit, Netcare Linksfield Hospital, Johannesburg, Gauteng, South Africa.,Department of Orthopaedic Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Paulo N F Ferrao
- The Orthopaedic Foot and Ankle Unit, Netcare Linksfield Hospital, Johannesburg, Gauteng, South Africa.,Department of Orthopaedic Surgery, University of the Witwatersrand, Johannesburg, South Africa
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11
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Mjöberg B. Hip prosthetic loosening: A very personal review. World J Orthop 2021; 12:629-639. [PMID: 34631447 PMCID: PMC8472441 DOI: 10.5312/wjo.v12.i9.629] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/03/2021] [Accepted: 08/03/2021] [Indexed: 02/06/2023] Open
Abstract
Hip prosthetic loosening is often difficult to detect at an early stage, and there has been uncertainty for a long time as to when the loosening occurs and thus to the basic causes. By comparing different diagnostic methods, we found that loosening is best defined as prosthetic migration and measured by radiostereometric analysis. Convincing evidence indicates that poor interlock, poor bone quality, and resorption of a necrotic bone bed may initiate loosening during or shortly after surgery; this forms the basis of the theory of early loosening. Biomechanical factors do affect the subsequent progression of loosening, which may increase subclinically during a long period of time. Eventually, the loosening may be detected on standard radiographs and may be interpreted as late loosening but should to be interpreted as late detection of loosening. The theory of early loosening explains the rapid early migration, the development of periprosthetic osteolysis and granulomas, the causality between wear and loosening, and largely the epidemiology of clinical failure of hip prostheses. Aspects discussed are definition of loosening, the pattern of early migration, the choice of migration threshold, the current understanding of loosening, a less exothermic bone cement, cemented taper-slip stems, a new exciting computed tomography-based technique for simpler implant migration studies, and research suggestions.
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Affiliation(s)
- Bengt Mjöberg
- Department of Orthopedics, Lund University, Lund SE-221 00, Sweden
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12
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Kiuttu J, Lehenkari P, Leskelä HV, Yrjämä O, Ohtonen P, Valkealahti M. Intra-operative Clodronate Rinsing Improves the Integration of the Femoral Stem in a Prospective, Double-blinded, Randomized, Placebo-controlled Clinical RSA-study. Open Orthop J 2021. [DOI: 10.2174/1874325002115010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Background:
Periprosthetic bone loss after Total Hip Arthroplasty (THA), detected as an early migration of the prosthesis may predict later loosening of the implant.
Objective:
We hypothesized that intra-operative bisphosphonate rinsing would reduce bone resorption after THA. It might therefore be possible to achieve better early fixation of the implant.
Methods:
Nineteen patients suffering from arthrosis were recruited in a prospective, double-blinded, randomized, placebo-controlled clinical pilot trial. Patients were operated with an uncemented Bimetric stem using tantalum markers. The femoral proximal intramedullary canal was rinsed with 1mM clodronate in nine patients and with saline in 10 patients. These patients were followed for two years using radiostereometric analysis (RSA), dual energy x-ray absorptiometry (DXA) and the Harris Hip Score (HHS).
Results:
We did not found any significant differences between the study groups with regards to the primary output measures (maximum total point motion, MTPM). However, there was evidence that clodronate could affect periprosthetic bone quality; a beneficial effect in BMD in Gruen zone 3 during the two-year follow-up was observed, BMD decreased less in the clodronate group (p = 0.02). The maximal x-translation of the stem at 3-24 months was significantly two-fold, being higher in the placebo group (p = 0.02). The baseline BMD and the maximal total point motion (MTPM) at 3-24 months showed a positive correlation in the clodronate group and a negative correlation in the placebo group.
Conclusion:
In conclusion, further studies with larger patient groups and longer follow-up periods are needed to estimate the clinical importance of these findings and further to prove if an intraoperative clodronate rinsing prior to application of femoral stem during THA can prevent periprosthetic bone loss.
Clinical Trial Registration No.: NCT03803839
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Stigbrand H, Brown K, Olivecrona H, Ullmark G. Implant migration and bone mineral density measured simultaneously by low-dose CT scans: a 2-year study on 17 acetabular revisions with impaction bone grafting. Acta Orthop 2020; 91:571-575. [PMID: 32452289 PMCID: PMC8023911 DOI: 10.1080/17453674.2020.1769295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Early postoperative implant migration predicts failure of joint replacements. Bone mineral density reflects bone quality and bone-graft incorporation. Implant migration and bone densitometry analysis usually require special equipment. We investigated cup migration and bone mineral density changes simultaneously with low-dose CT scans after acetabular revision hip arthroplasty using impaction bone grafting.Patients and methods - We performed a low-dose CT postoperatively, after 6 weeks, and after 2 years in 17 patients, all revised using impaction bone grafting and a graft-compressing titanium shell in the acetabulum. 6 patients had combined segmental and cavitary acetabular defects. Cup migration was analyzed using CT-based micromotion analysis (CTMA). Bone mineral density was determined in the graft and in surrounding native bone using volumetric quantitative computed tomography (QCT). The bone graft volume was calculated from 3D reconstructions.Results - At 2 years, the translations were 1.5 (95% CI 0.4-2.6) mm in proximal direction, -0.6 (CI -1.6 to 0.4) in the medial direction and 0.3 (CI 0.0-0.6) in the anterior direction. The mean volume of impacted bone graft was 40 cm³ (CI 28-52). In the graft bone mineral density increased 14% after 6 weeks and 23% after 2 years. There was 1 mechanical failure.Interpretation - Proximal migration of the acetabular component was low and comparable to previous reports. There was a rapid increase of bone mineral density in the bone graft. Low-dose CT scans make migration analysis and bone densitometry measurements possible in the same setting, offering great diagnostic potential for hip arthroplasty patients.
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Affiliation(s)
- Hampus Stigbrand
- Department of Orthopedics Gävle Hospital, Center for Research & Development, Uppsala University/County Council of Gävleborg, Sweden; ,Department of Surgical Sciences/Orthopedics, Uppsala University, Sweden; ,Correspondence:
| | | | - Henrik Olivecrona
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Gösta Ullmark
- Department of Orthopedics Gävle Hospital, Center for Research & Development, Uppsala University/County Council of Gävleborg, Sweden; ,Department of Surgical Sciences/Orthopedics, Uppsala University, Sweden;
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Abstract
Prosthetic loosening has been debated for decades, both in terms of the timing and nature of the triggering events. Multiple radiostereometric studies of hip prostheses have now shown that early migration poses a risk of future clinical failure, but is this enough to explain late clinical loosening?To answer this question, the progression of loosening from initiation to radiographic detection is described; and the need for explanations other than early prosthetic loosening is analysed, such as stress-shielding, particle disease, and metal sensitivity.Much evidence indicates that prosthetic loosening has already been initiated during or shortly after the surgery, and that the subsequent progression of loosening is affected by biomechanical factors, fluid pressure fluctuations and inflammatory responses to necrotic cells and cell fragments, i.e. the concept of late loosening appears to be a misinterpretation of late-detected loosening.Clinical implications: atraumatic surgery and initial prosthetic stability are crucial in ensuring low risk of prosthetic loosening. Cite this article: EFORT Open Rev 2020;5:113-117. DOI: 10.1302/2058-5241.5.190014.
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Affiliation(s)
- Bengt Mjöberg
- Department of Orthopaedics, Lund University, Lund, Sweden
- Bengt Mjöberg, Västra Vallgatan 29, SE-27135 Ystad, Sweden.
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15
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Bratengeier C, Liszka A, Hoffman J, Bakker AD, Fahlgren A. High shear stress amplitude in combination with prolonged stimulus duration determine induction of osteoclast formation by hematopoietic progenitor cells. FASEB J 2020; 34:3755-3772. [PMID: 31957079 DOI: 10.1096/fj.201901458r] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 12/04/2019] [Accepted: 12/19/2019] [Indexed: 12/15/2022]
Abstract
To date, it is unclear how fluid dynamics stimulate mechanosensory cells to induce an osteoprotective or osteodestructive response. We investigated how murine hematopoietic progenitor cells respond to 2 minutes of dynamic fluid flow stimulation with a precisely controlled sequence of fluid shear stresses. The response was quantified by measuring extracellular adenosine triphosphate (ATP), immunocytochemistry of Piezo1, and sarcoplasmic/endoplasmic Ca2+ reticulum ATPase 2 (SERCA2), and by the ability of soluble factors produced by mechanically stimulated cells to modulate osteoclast differentiation. We rejected our initial hypothesis that peak wall shear stress rate determines the response of hematopoietic progenitor cells to dynamic fluid shear stress, as it had only a minor correlation with the abovementioned parameters. Low stimulus amplitudes corresponded to activation of Piezo1, SERCA2, low concentrations of extracellular ATP, and inhibition of osteoclastogenesis and resorption area, while high amplitudes generally corresponded to osteodestructive responses. At a given amplitude (3 Pa) and waveform (square), the duration of individual stimuli (duty cycle) showed a strong correlation with the release of ATP and osteoclast number and resorption area. Collectively, our data suggest that hematopoietic progenitor cells respond in a viscoelastic manner to loading, since a combination of high shear stress amplitude and prolonged duty cycle is needed to trigger an osteodestructive response. PLAIN LANGUAGE SUMMARY: In case of painful joints or missing teeth, the current intervention is to replace them with an implant to keep a high-quality lifestyle. When exercising or chewing, the cells in the bone around the implant experience mechanical loading. This loading generally supports bone formation to strengthen the bone and prevent breaking, but can also stimulate bone loss when the mechanical loading becomes too high around orthopedic and dental implants. We still do not fully understand how cells in the bone can distinguish between mechanical loading that strengthens or weakens the bone. We cultured cells derived from the bone marrow in the laboratory to test whether the bone loss response depends on (i) how fast a mechanical load is applied (rate), (ii) how intense the mechanical load is (amplitude), or (iii) how long each individual loading stimulus is applied (duration). We mimicked mechanical loading as it occurs in the body, by applying very precisely controlled flow of fluid over the cells. We found that a mechanosensitive receptor Piezo1 was activated by a low amplitude stimulus, which usually strengthens the bone. The potential inhibitor of Piezo1, namely SERCA2, was only activated by a low amplitude stimulus. This happened regardless of the rate of application. At a constant high amplitude, a longer duration of the stimulus enhanced the bone-weakening response. Based on these results we deduce that a high loading amplitude tends to be bone weakening, and the longer this high amplitude persists, the worse it is for the bone.
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Affiliation(s)
- Cornelia Bratengeier
- Department of Clinical and Experimental Medicine, Division of Cell Biology, Linköping University, Linköping, Sweden
| | - Aneta Liszka
- Department of Clinical and Experimental Medicine, Division of Cell Biology, Linköping University, Linköping, Sweden
| | - Johan Hoffman
- Department of Computational Science and Technology, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Astrid D Bakker
- Department of Oral Cell Biology, ACTA-University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Anna Fahlgren
- Department of Clinical and Experimental Medicine, Division of Cell Biology, Linköping University, Linköping, Sweden
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16
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Periprosthetic Osteolysis: Mechanisms, Prevention and Treatment. J Clin Med 2019; 8:jcm8122091. [PMID: 31805704 PMCID: PMC6947309 DOI: 10.3390/jcm8122091] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 11/28/2019] [Accepted: 11/29/2019] [Indexed: 02/06/2023] Open
Abstract
Clinical studies, as well as in vitro and in vivo experiments have demonstrated that byproducts from joint replacements induce an inflammatory reaction that can result in periprosthetic osteolysis (PPOL) and aseptic loosening (AL). Particle-stimulated macrophages and other cells release cytokines, chemokines, and other pro-inflammatory substances that perpetuate chronic inflammation, induce osteoclastic bone resorption and suppress bone formation. Differentiation, maturation, activation, and survival of osteoclasts at the bone-implant interface are under the control of the receptor activator of nuclear factor kappa-Β ligand (RANKL)-dependent pathways, and the transcription factors like nuclear factor κB (NF-κB) and activator protein-1 (AP-1). Mechanical factors such as prosthetic micromotion and oscillations in fluid pressures also contribute to PPOL. The treatment for progressive PPOL is only surgical. In order to mitigate ongoing loss of host bone, a number of non-operative approaches have been proposed. However, except for the use of bisphosphonates in selected cases, none are evidence based. To date, the most successful and effective approach to preventing PPOL is usage of wear-resistant bearing couples in combination with advanced implant designs, reducing the load of metallic and polymer particles. These innovations have significantly decreased the revision rate due to AL and PPOL in the last decade.
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Madsen RV, Nam D, Schilcher J, Dvorzhinskiy A, Sutherland JP, Bostrom FM, Fahlgren A. Mechanical instability induces osteoclast differentiation independent of the presence of a fibrous tissue interface and osteocyte apoptosis in a rat model for aseptic loosening. Acta Orthop 2019; 91:115-120. [PMID: 31762353 PMCID: PMC7006729 DOI: 10.1080/17453674.2019.1695351] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Insufficient initial fixation or early micromotion of an implant is associated with a thin layer of fibrous tissue at the peri-implant interface. It is unknown if bone loss is induced by the fibrous tissue interface acting as an active biological membrane, or as a membrane that will produce supraphysiologic fluid flow conditions during gait, which activates the mechanosensitive osteocytes to mediate osteoclast differentiation. We investigated whether mechanically induced osteolysis is dependent on the fibrous tissue interface as a biologically active scaffold, or if it merely acts as a conduit for fluid flow, affecting the mechanosensitive osteocytes in the peri-prosthetic bone.Methods - Using a rat model of mechanically instability-induced aseptic loosening, we assessed whether the induction of osteoclast differentiation was dependent on the presence of a peri-implant fibrous interface. We analyzed the amount of osteoclast differentiation, osteocyte apoptosis, pro-resorptive cytokine expression and bone loss using immunohistochemistry, mRNA expression and micro-CT.Results - Osteoclast differentiation and bone loss were induced by mechanical instability but were not affected by the presence of the fibrous tissue membrane or associated with osteocyte apoptosis. There was no increased mRNA expression of any of the cytokines in the fibrous tissue membrane compared with the peri-implant bone.Interpretation - Our data show that the fibrous tissue membrane in the interface plays a minor role in inducing bone loss. This indicates that the peri-implant bone adjacent to loose bone implants might play an important role for osteoclast differentiation.
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Affiliation(s)
- Rune Vinther Madsen
- Hospital for Special Surgery, New York, USA; ,Department of Orthopaedic Surgery, Zealand University Hospital, Køge, Denmark;
| | - Denis Nam
- Rush University Medical Center, Chicago, USA;
| | - Jörg Schilcher
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; ,Department of Orthopedic Surgery, University Hospital Linköping, Sweden
| | | | | | | | - Anna Fahlgren
- Hospital for Special Surgery, New York, USA; ,Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; ,Correspondence:
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18
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McArthur BA, Scully R, Patrick Ross F, Bostrom MPG, Falghren A. Mechanically Induced Periprosthetic Osteolysis: A Systematic Review. HSS J 2019; 15:286-296. [PMID: 31624485 PMCID: PMC6778158 DOI: 10.1007/s11420-018-9641-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 09/25/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Peri-prosthetic bone loss can result from chemical, biological, and mechanical factors. Mechanical stimulation via fluid pressure and flow at the bone-implant interface may be a significant cause. Evidence supporting mechanically induced osteolysis continues to grow, but there is no synthesis of published clinical and basic science data. QUESTIONS/PURPOSES We sought to review the literature on two questions: (1) What published evidence supports the concept of mechanically induced osteolysis? (2) What is the proposed mechanism of mechanically induced osteolysis, and does it differ from that of particle-induced osteolysis? METHODS A systematic review was performed of the PubMed and Web of Science databases. Additional relevant articles were recommended by the senior authors based on their expert opinion. Abstracts were reviewed and the manuscripts pertaining to the study questions were read in full. Studies showing support of mechanically induced osteolysis were quantified and findings summarized. RESULTS We identified 49 articles of experimental design supporting the hypothesis that mechanical stimulation of peri-prosthetic bone from fluid pressure and flow can induce osteolysis. While the molecular mechanisms may overlap with those implicated in particle-induced osteolysis, mechanically induced osteolysis appears to be mediated by distinct and parallel pathways. CONCLUSIONS The role of mechanical stimuli is increasingly recognized in the pathogenesis of peri-prosthetic osteolysis. Current research aims to elucidate the molecular mechanisms to better target therapeutic interventions.
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Affiliation(s)
- Benjamin A. McArthur
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas, Texas Orthopedics Sports and Rehabilitation Associates, 4215 Benner Road, Ste. 300, Kyle, TX 78640 USA
| | - Ryan Scully
- Department of Orthopedic Surgery, George Washington University, 2300 M Street, NW, Washington, DC, 20037 USA
| | - F. Patrick Ross
- Hospital for Special Surgery, 535 E. 70th Street, New York, NY 10021 USA
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19
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Mohammadkhah M, Marinkovic D, Zehn M, Checa S. A review on computer modeling of bone piezoelectricity and its application to bone adaptation and regeneration. Bone 2019; 127:544-555. [PMID: 31356890 DOI: 10.1016/j.bone.2019.07.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 07/17/2019] [Accepted: 07/20/2019] [Indexed: 02/07/2023]
Abstract
Bone is a hierarchical, multiphasic and anisotropic structure which in addition possess piezoelectric properties. The generation of piezoelectricity in bone is a complex process which has been shown to play a key role both in bone adaptation and regeneration. In order to understand the complex biological, mechanical and electrical interactions that take place during these processes, several computer models have been developed and used to test hypothesis on potential mechanisms behind experimental observations. This paper aims to review the available literature on computer modeling of bone piezoelectricity and its application to bone adaptation and healing. We first provide a brief overview of the fundamentals of piezoelectricity and bone piezoelectric effects. We then review how these properties have been used in computational models of bone adaptation and electromechanical behaviour of bone. In addition, in the last section, we summarize current limitations and potential directions for future work.
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Affiliation(s)
- Melika Mohammadkhah
- Department of Structural Mechanics, Berlin Institute of Technology, Fakultät V - Institut für Mechanik, FG Strukturmechanik und Strukturberechnung, Sekr. C 8-3, Geb. M Str. des 17, Juni 135, D-10623 Berlin, Germany.
| | - Dragan Marinkovic
- Department of Structural Mechanics, Berlin Institute of Technology, Fakultät V - Institut für Mechanik, FG Strukturmechanik und Strukturberechnung, Sekr. C 8-3, Geb. M Str. des 17, Juni 135, D-10623 Berlin, Germany; Faculty of Mechanical Engineering, University of Nis, Aleksandra Medvedeva 14, 18000 Nis, Serbia.
| | - Manfred Zehn
- Department of Structural Mechanics, Berlin Institute of Technology, Fakultät V - Institut für Mechanik, FG Strukturmechanik und Strukturberechnung, Sekr. C 8-3, Geb. M Str. des 17, Juni 135, D-10623 Berlin, Germany.
| | - Sara Checa
- Department of Structural Mechanics, Berlin Institute of Technology, Fakultät V - Institut für Mechanik, FG Strukturmechanik und Strukturberechnung, Sekr. C 8-3, Geb. M Str. des 17, Juni 135, D-10623 Berlin, Germany; Julius Wolff Institute, Charité - Universitätsmedizin Berlin, Föhrer Str. 15, 13353 Berlin, Germany.
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20
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Dyskova T, Kriegova E, Slobodova Z, Zehnalova S, Kudelka M, Schneiderova P, Fillerova R, Gallo J. Inflammation time-axis in aseptic loosening of total knee arthroplasty: A preliminary study. PLoS One 2019; 14:e0221056. [PMID: 31469844 PMCID: PMC6716666 DOI: 10.1371/journal.pone.0221056] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 07/29/2019] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Aseptic loosening (AL) is the most frequent long-term reason for revision of total knee arthroplasty (TKA) affecting about 15-20% patients within 20 years after the surgery. Although there is a solid body of evidence about the crucial role of inflammation in the AL pathogenesis, scared information on inflammation signature and its time-axis in tissues around TKA exists. DESIGN The inflammation protein signatures in pseudosynovial tissues collected at revision surgery from patients with AL (AL, n = 12) and those with no clinical/radiographic signs of AL (non-AL, n = 9) were investigated by Proximity Extension Assay (PEA)-Immunoassay and immunohistochemistry. RESULTS AL tissues had elevated levels of TNF-family members sTNFR2, TNFSF14, sFasL, sBAFF, cytokines/chemokines IL8, CCL2, IL1RA/IL36, sIL6R, and growth factors sAREG, CSF1, comparing to non-AL. High interindividual variability in protein levels was evident particularly in non-AL. Levels of sTNFR2, sBAFF, IL8, sIL6R, and MPO discriminated between AL and non-AL and were associated with the time from index surgery, suggesting the cumulative character of inflammatory osteolytic response to prosthetic byproducts. The source of elevated inflammatory molecules was macrophages and multinucleated osteoclast-like cells in AL and histiocytes and osteoclast-like cells in non-AL tissues, respectively. All proteins were present in higher levels in osteoclast-like cells than in macrophages. CONCLUSIONS Our study revealed a differential inflammation signature between AL and non-AL stages of TKA. It also highlighted the unique patient's response to TKA in non-AL stages. Further confirmation of our preliminary results on a larger cohort is needed. Analysis of the time-axis of processes ongoing around TKA implantation may help to understand the mechanisms driving periprosthetic bone resorption needed for diagnostic/preventative strategies.
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Affiliation(s)
- Tereza Dyskova
- Department of Immunology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Eva Kriegova
- Department of Immunology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Zuzana Slobodova
- Department of Clinical and Molecular Pathology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Sarka Zehnalova
- Department of Computer Science, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, Ostrava, Czech Republic
| | - Milos Kudelka
- Department of Computer Science, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, Ostrava, Czech Republic
| | - Petra Schneiderova
- Department of Immunology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Regina Fillerova
- Department of Immunology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Jiri Gallo
- Department of Orthopaedics, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
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21
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Arcângelo J, Guerra-Pinto F, Pinto A, Grenho A, Navarro A, Martin Oliva X. Peri-prosthetic bone cysts after total ankle replacement. A systematic review and meta-analysis. Foot Ankle Surg 2019; 25:96-105. [PMID: 29409184 DOI: 10.1016/j.fas.2017.11.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 11/01/2017] [Accepted: 11/15/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Periprosthetic cystic osteolysis is a well-known complication of total ankle replacement. Several theories have been proposed for its aetiology, based on individual biomechanical, radiological, histopathology and outcome studies. METHODS Studies that met predefined inclusion/exclusion criteria were analysed to identify literature describing the presence of peri-prosthetic ankle cystic osteolysis. Quantitative data from the selected articles were combined and statistically tested in order to analyse possible relations between ankle peri-prosthetic bone cysts and specific implant characteristics. RESULTS Twenty-one articles were elected, totalizing 2430 total ankle replacements, where 430 developed peri-prosthetic cystic osteolysis. A statistically significant association (P<.001) was found between the presence of bone cysts and non-anatomic implant configuration, hydroxyapatite-coating, mobile-bearing and non tibial-stemmed implants. No significant association existed between the type of constraining and the presence of cysts (P>.05). CONCLUSIONS Non-anatomic, mobile-bearing, hydroxyapatite-coated and non tibial-stemmed total ankle replacements are positively associated with more periprosthetic bone cysts.
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Affiliation(s)
- Joana Arcângelo
- Orthopedic Surgery Department, Hospital Curry Cabral - Centro Hospitalar Lisboa Central, Lisboa, Portugal.
| | | | - André Pinto
- Orthopedic Surgery Department, Centro Hospitalar de Coimbra, Coimbra, Portugal.
| | - André Grenho
- Orthopedic Surgery Department, Hospital Curry Cabral - Centro Hospitalar Lisboa Central, Lisboa, Portugal.
| | - Alfons Navarro
- Human Anatomy and Embryology Unit, School of Medicine, University of Barcelona, Spain.
| | - Xavier Martin Oliva
- Human anatomy Unit, School of Medicine, University of Barcelona, Foot and Ankle Unit, Clinica del Remei, Barcelona, Spain.
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22
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Knowles NK, Langohr GDG, Athwal GS, Ferreira LM. Polyethylene glenoid component fixation geometry influences stability in total shoulder arthroplasty. Comput Methods Biomech Biomed Engin 2018; 22:271-279. [PMID: 30596527 DOI: 10.1080/10255842.2018.1551526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Glenoid component stability is essential to ensure successful long-term survivability following total shoulder arthroplasty. As such, this computational study assessed the stability of five all-polyethylene glenoid components (Keel, Central-Finned 4-Peg, Peripheral 4-Peg, Cross-Keel, and Inverted-Y), using simulated joint loading in an osteoarthritic patient cohort. Stability was assessed on the basis of component micromotion in the tangential and normal directions. Maximum tangential micromotion occurred in the Cross-Keel (146 ± 46 µm), which was significantly greater (p < .001) than the other components. Maximum normal micromotion occurred in the Inverted-Y (109 ± 43 µm), which was significantly greater (p ≤ .002) than the other four components. In general, the Central-Finned 4-Peg exhibited the least normal and tangential micromotion, while the keeled components shown the highest normal and tangential micromotion. This study suggests that modifications to keeled designs do not improve component stability under the conditions tested, and pegged components show superior computational stability.
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Affiliation(s)
- Nikolas K Knowles
- a School of Biomedical Engineering , The University of Western Ontario , London , ON, Canada.,b Roth
- McFarlane Hand and Upper Limb Centre , London , ON, Canada.,c Collaborative Training Program in Musculoskeletal Health Research, and Bone and Joint Institute , The University of Western Ontario , London , ON, Canada
| | - G Daniel G Langohr
- a School of Biomedical Engineering , The University of Western Ontario , London , ON, Canada.,b Roth
- McFarlane Hand and Upper Limb Centre , London , ON, Canada.,c Collaborative Training Program in Musculoskeletal Health Research, and Bone and Joint Institute , The University of Western Ontario , London , ON, Canada.,d Department of Mechanical and Materials Engineering , The University of Western Ontario , London , ON, Canada
| | - George S Athwal
- b Roth
- McFarlane Hand and Upper Limb Centre , London , ON, Canada.,c Collaborative Training Program in Musculoskeletal Health Research, and Bone and Joint Institute , The University of Western Ontario , London , ON, Canada
| | - Louis M Ferreira
- a School of Biomedical Engineering , The University of Western Ontario , London , ON, Canada.,b Roth
- McFarlane Hand and Upper Limb Centre , London , ON, Canada.,c Collaborative Training Program in Musculoskeletal Health Research, and Bone and Joint Institute , The University of Western Ontario , London , ON, Canada.,d Department of Mechanical and Materials Engineering , The University of Western Ontario , London , ON, Canada
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23
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Bratengeier C, Bakker AD, Fahlgren A. Mechanical loading releases osteoclastogenesis-modulating factors through stimulation of the P2X7 receptor in hematopoietic progenitor cells. J Cell Physiol 2018; 234:13057-13067. [PMID: 30536959 DOI: 10.1002/jcp.27976] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 11/20/2018] [Indexed: 01/20/2023]
Abstract
Mechanical instability of bone implants stimulate osteoclast differentiation and peri-implant bone loss, leading to prosthetic loosening. It is unclear which cells at the periprosthetic interface transduce mechanical signals into a biochemical response, and subsequently facilitate bone loss. We hypothesized that mechanical overloading of hematopoietic bone marrow progenitor cells, which are located near to the inserted bone implants, stimulates the release of osteoclast-inducing soluble factors. Using a novel in vitro model to apply mechanical overloading, we found that hematopoietic progenitor cells released adenosine triphosphate (ATP) after only 2 min of mechanical loading. The released ATP interacts with its specific receptor P2X7 to stimulate the release of unknown soluble factors that inhibit (physiological loading) or promote (supraphysiological loading) the differentiation of multinucleated osteoclasts derived from bone marrow cultures. Inhibition of ATP-receptor P2X7 by Brilliant Blue G completely abolished the overloading-induced stimulation of osteoclast formation. Likewise, stimulation of P2X7 receptor on hematopoietic cells by BzATP enhanced the release of osteoclastogenesis-stimulating signaling molecules to a similar extent as supraphysiological loading. Supraphysiological loading affected neither gene expression of inflammatory markers involved in aseptic implant loosening (e.g., interleukin-1β (IL-1β), IL-6, tumor necrosis factor-α, and PTGES2) nor expression of the osteoclast modulators receptor activator of nuclear factor κ-Β ligand and osteoprotegerin. Our findings suggest that murine hematopoietic progenitor cells are a potential key player in local mechanical loading-induced bone implant loosening via the ATP/P2X7-axis. Our approach identifies potential therapeutic targets to prevent prosthetic loosening.
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Affiliation(s)
- Cornelia Bratengeier
- Department of Clinical and Experimental Medicine, Division of Cell Biology, Linköping University, Linköping, Sweden
| | - Astrid D Bakker
- Department of Oral Cell Biology, ACTA, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Anna Fahlgren
- Department of Clinical and Experimental Medicine, Division of Cell Biology, Linköping University, Linköping, Sweden
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24
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Fahlgren A, Bratengeier C, Semeins CM, Klein-Nulend J, Bakker AD. Supraphysiological loading induces osteocyte-mediated osteoclastogenesis in a novel in vitro model for bone implant loosening. J Orthop Res 2018; 36:1425-1434. [PMID: 29068483 DOI: 10.1002/jor.23780] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 10/13/2017] [Indexed: 02/04/2023]
Abstract
We aimed to develop an in vitro model for bone implant loosening, allowing analysis of biophysical and biological parameters contributing to mechanical instability-induced osteoclast differentiation and peri-implant bone loss. MLO-Y4-osteocytes were mechanically stimulated for 1 h by fluid shear stress using regimes simulating: (i) supraphysiological loading in the peri-prosthetic interface (2.9 ± 2.9 Pa, 1 Hz, square wave); (ii) physiologic loading in the cortical bone (0.7 ± 0.7 Pa, 5 Hz, sinusoidal wave); and (iii) stress shielding. Cellular morphological parameters, membrane-bound RANKL expression, gene expression influencing osteoclast differentiation, nitric oxide release and caspase 3/7-activity were determined. Either Mouse bone marrow cells were cultured on top of loaded osteocytes or osteocyte-conditioned medium was added to bone marrow cells. Osteoclast differentiation was assessed after 6 days. We found that osteocytes subjected to supraphysiological loading showed similar morphology and caspase 3/7-activity compared to simulated physiological loading or stress shielding. Supraphysiological stimulation of osteocytes enhanced osteoclast differentiation by 1.9-fold compared to physiological loading when cell-to-cell contact was permitted. In addition, it enhanced the number of osteoclasts using conditioned medium by 1.7-fold, membrane-bound RANKL by 3.3-fold, and nitric oxide production by 3.2-fold. The stimulatory effect of supraphysiological loading on membrane-bound RANKL and nitric oxide production was higher than that achieved by stress shielding. In conclusion, the in vitro model developed recapitulated the catabolic biological situation in the peri-prosthetic interface during instability that is associated with osteoclast differentiation and enhanced RANKL expression. The model thus provides a platform for pre-clinical testing of pharmacological interventions with potential to stop instability-induced bone implant loosening. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1425-1434, 2018.
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Affiliation(s)
- Anna Fahlgren
- Department of Clinical and Experimental Medicine, Division of Cell Biology, Linköping University, Linköping, Sweden
| | - Cornelia Bratengeier
- Department of Clinical and Experimental Medicine, Division of Cell Biology, Linköping University, Linköping, Sweden
| | - Cornelis M Semeins
- Department of Oral Cell Biology, ACTA-University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Jenneke Klein-Nulend
- Department of Oral Cell Biology, ACTA-University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Astrid D Bakker
- Department of Oral Cell Biology, ACTA-University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
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Mjöberg B. Is the proximal bone resorption around the femoral stem after hip arthroplasty really caused by reduced stress? Acta Orthop 2018; 89:128-129. [PMID: 28942699 PMCID: PMC5810821 DOI: 10.1080/17453674.2017.1373492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
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Goodheart JR, Miller MA, Oest ME, Mann KA. Trabecular resorption patterns of cement-bone interlock regions in total knee replacements. J Orthop Res 2017; 35:2773-2780. [PMID: 28452065 PMCID: PMC5659954 DOI: 10.1002/jor.23586] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 04/24/2017] [Indexed: 02/04/2023]
Abstract
UNLABELLED With in vivo service, there is loss of mechanical interlock between trabeculae and PMMA cement in total knee replacements. The mechanisms responsible for the loss of interlock are not known, but loss of interlock results in weaker cement-bone interfaces. The goal of this study was to determine the pattern of resorption of interdigitated bone using a series of 20 postmortem retrieved knee replacements with a wide range of time in service (3-22 years). MicroCT scans were obtained of a segment of the cement-bone interface below the tibial tray for each implant. Image processing methods were used to determine interface morphology and to identify supporting, interdigitated, resorbed, and isolated bone as a function of axial position. Overall, the amount of remaining interdigitated bone decreased with time in service (p = 0.0114). The distance from the cement border (at the extent of cement penetration into the bone bed) to 50% of the interdigitated volume decreased with time in service (p = 0.039). Isolated bone, when present, was located deep in the cement layer. Overall, resorption appears to start at the cement border and progresses into the cement layer. Initiation of trabecular resorption near the cement border may be a consequence of proximity to osteoclastic cells in the adjacent marrow space. CLINICAL SIGNIFICANCE Aseptic loosening of joint replacements remains an important clinical problem. This work explores the process and pattern of trabecular bone resorption responsible for loss of interface fixation. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2773-2780, 2017.
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Affiliation(s)
- Jacklyn R. Goodheart
- Department of Orthopedic Surgery, State University of New York, Upstate Medical University, 3216 IHP, 750 East Adams Street, Syracuse, NY, 13210, USA
| | - Mark A. Miller
- Department of Orthopedic Surgery, State University of New York, Upstate Medical University, 3216 IHP, 750 East Adams Street, Syracuse, NY, 13210, USA
| | - Megan E. Oest
- Department of Orthopedic Surgery, State University of New York, Upstate Medical University, 3216 IHP, 750 East Adams Street, Syracuse, NY, 13210, USA
| | - Kenneth A. Mann
- Department of Orthopedic Surgery, State University of New York, Upstate Medical University, 3216 IHP, 750 East Adams Street, Syracuse, NY, 13210, USA
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Amirhosseini M, Madsen RV, Escott KJ, Bostrom MP, Ross FP, Fahlgren A. GSK-3β inhibition suppresses instability-induced osteolysis by a dual action on osteoblast and osteoclast differentiation. J Cell Physiol 2017; 233:2398-2408. [PMID: 28731198 DOI: 10.1002/jcp.26111] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 07/20/2017] [Indexed: 01/17/2023]
Abstract
Currently, there are no medications available to treat aseptic loosening of orthopedic implants. Using osteoprotegerin fusion protein (OPG-Fc), we previously blocked instability-induced osteoclast differentiation and peri-prosthetic osteolysis. Wnt/β-catenin signaling, which regulates OPG secretion from osteoblasts, also modulates the bone tissue response to mechanical loading. We hypothesized that activating Wnt/β-catenin signaling by inhibiting glycogen synthase kinase-3β (GSK-3β) would reduce instability-induced bone loss through regulation of both osteoblast and osteoclast differentiation. We examined effects of GSK-3β inhibition on regulation of RANKL and OPG in a rat model of mechanical instability-induced peri-implant osteolysis. The rats were treated daily with a GSK-3β inhibitor, AR28 (20 mg/kg bw), for up to 5 days. Bone tissue and blood serum were assessed by qRT-PCR, immunohistochemistry, and ELISA on days 3 and 5, and by micro-CT on day 5. After 3 days of treatment with AR28, mRNA levels of β-catenin, Runx2, Osterix, Col1α1, and ALP were increased leading to higher osteoblast numbers compared to vehicle-treated animals. BMP-2 and Wnt16 mRNA levels were downregulated by mechanical instability and this was rescued by GSK-3β inhibition. Osteoclast numbers were decreased significantly after 3 days of GSK-3β inhibition, which correlated with enhanced OPG mRNA expression. This was accompanied by decreased serum levels of TRAP5b on days 3 and 5. Treatment with AR28 upregulated osteoblast differentiation, while osteoclastogenesis was blunted, leading to increased bone mass by day 5. These data suggest that GSK-3β inactivation suppresses osteolysis through regulating both osteoblast and osteoclast differentiation in a rat model of instability-induced osteolysis.
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Affiliation(s)
- Mehdi Amirhosseini
- Division of Cell Biology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Rune V Madsen
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - K Jane Escott
- Scientific Partnering & Alliances, Innovative Medicines and Early Development Biotech Unit, AstraZeneca, Melbourn, UK
| | - Mathias P Bostrom
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - F Patrick Ross
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Anna Fahlgren
- Division of Cell Biology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Amirhosseini M, Andersson G, Aspenberg P, Fahlgren A. Mechanical instability and titanium particles induce similar transcriptomic changes in a rat model for periprosthetic osteolysis and aseptic loosening. Bone Rep 2017; 7:17-25. [PMID: 28795083 PMCID: PMC5544474 DOI: 10.1016/j.bonr.2017.07.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 07/24/2017] [Accepted: 07/26/2017] [Indexed: 01/30/2023] Open
Abstract
Wear debris particles released from prosthetic bearing surfaces and mechanical instability of implants are two main causes of periprosthetic osteolysis. While particle-induced loosening has been studied extensively, mechanisms through which mechanical factors lead to implant loosening have been less investigated. This study compares the transcriptional profiles associated with osteolysis in a rat model for aseptic loosening, induced by either mechanical instability or titanium particles. Rats were exposed to mechanical instability or titanium particles. After 15 min, 3, 48 or 120 h from start of the stimulation, gene expression changes in periprosthetic bone tissue was determined by microarray analysis. Microarray data were analyzed by PANTHER Gene List Analysis tool and Ingenuity Pathway Analysis (IPA). Both types of osteolytic stimulation led to gene regulation in comparison to unstimulated controls after 3, 48 or 120 h. However, when mechanical instability was compared to titanium particles, no gene showed a statistically significant difference (fold change ≥ ± 1.5 and adjusted p-value ≤ 0.05) at any time point. There was a remarkable similarity in numbers and functional classification of regulated genes. Pathway analysis showed several inflammatory pathways activated by both stimuli, including Acute Phase Response signaling, IL-6 signaling and Oncostatin M signaling. Quantitative PCR confirmed the changes in expression of key genes involved in osteolysis observed by global transcriptomics. Inflammatory mediators including interleukin (IL)-6, IL-1β, chemokine (C-C motif) ligand (CCL)2, prostaglandin-endoperoxide synthase (Ptgs)2 and leukemia inhibitory factor (LIF) showed strong upregulation, as assessed by both microarray and qPCR. By investigating genome-wide expression changes we show that, despite the different nature of mechanical implant instability and titanium particles, osteolysis seems to be induced through similar biological and signaling pathways in this rat model for aseptic loosening. Pathways associated to the innate inflammatory response appear to be a major driver for osteolysis. Our findings implicate early restriction of inflammation to be critical to prevent or mitigate osteolysis and aseptic loosening of orthopedic implants.
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Affiliation(s)
- Mehdi Amirhosseini
- Division of Cell Biology, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
- Corresponding author.
| | - Göran Andersson
- Division of Pathology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
| | - Per Aspenberg
- Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Anna Fahlgren
- Division of Cell Biology, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
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Cyndari KI, Goodheart JR, Miller MA, Oest ME, Damron TA, Mann KA. Peri-Implant Distribution of Polyethylene Debris in Postmortem-Retrieved Knee Arthroplasties: Can Polyethylene Debris Explain Loss of Cement-Bone Interlock in Successful Total Knee Arthroplasties? J Arthroplasty 2017; 32:2289-2300. [PMID: 28285038 PMCID: PMC5469692 DOI: 10.1016/j.arth.2017.01.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 01/06/2017] [Accepted: 01/25/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Loss of mechanical interlock between cement and bone with in vivo service has been recently quantified for functioning, nonrevised, cemented total knee arthroplasties (TKAs). The cause of interlocking trabecular resorption is not known. The goal of this study is to quantify the distribution of PE debris at the cement-bone interface and determine if polyethylene (PE) debris is locally associated with loss of interlock. METHODS Fresh, nonrevised, postmortem-retrieved TKAs (n = 8) were obtained en bloc. Laboratory-prepared constructs (n = 2) served as negative controls. The intact cement-bone interface of each proximal tibia was embedded in Spurr's resin, sectioned, and imaged under polarized light to identify birefringent PE particles. PE wear particle number density was quantified at the cement-bone interface and distal to the interface, and then compared with local loss of cement-bone interlock. RESULTS The average PE particle number density for postmortem-retrieved TKAs ranged from 8.6 (1.3) to 24.9 (3.1) particles/mm2 (standard error) but was weakly correlated with years in service. The average particle number density was twice as high as distal (>5mm) to the interface compared to at the interface. The local loss of interlock at the interface was not related to the presence, absence, or particle density of PE. CONCLUSION PE debris can migrate extensively along the cement-bone interface of well-fixed tibial components. However, the amount of local bone loss at the cement-bone interface was not correlated with the amount of PE debris at the interface, suggesting that the observed loss of trabecular interlock in these well-fixed TKAs may be due to alternative factors.
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Affiliation(s)
- Karen I Cyndari
- Department of Orthopaedic Surgery, State University of New York Upstate Medical University, Syracuse, New York
| | - Jacklyn R Goodheart
- Department of Orthopaedic Surgery, State University of New York Upstate Medical University, Syracuse, New York
| | - Mark A Miller
- Department of Orthopaedic Surgery, State University of New York Upstate Medical University, Syracuse, New York
| | - Megan E Oest
- Department of Orthopaedic Surgery, State University of New York Upstate Medical University, Syracuse, New York
| | - Timothy A Damron
- Department of Orthopaedic Surgery, State University of New York Upstate Medical University, Syracuse, New York
| | - Kenneth A Mann
- Department of Orthopaedic Surgery, State University of New York Upstate Medical University, Syracuse, New York
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The implication of the osteolysis threshold and interfacial gaps on periprosthetic osteolysis in cementless total hip replacement. J Biomech 2017; 58:1-10. [PMID: 28511839 DOI: 10.1016/j.jbiomech.2017.03.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 02/10/2017] [Accepted: 03/31/2017] [Indexed: 11/20/2022]
Abstract
Osteolysis around joint replacements may develop due to migration of wear particles from the joint space into gaps between the interface bone and the implant where they can accumulate in high concentrations to cause tissue damage. Osteolysis may appear in various postoperative times and morphological shapes which can be generalized into linear and focal. However, there are no clear explanations on the causes of such variations. Patients' degree of sensitivity to polyethylene particles (osteolysis thresholds), the local particle concentration and the access route provided by the interface gaps have been described as determining factors. To study their effects, a 2D computational fluid dynamics model of the hip joint capsule in communication with an interfacial gap and the surrounding bone was employed. Particles were presented using a discrete phase model (DPM). High capsular fluid pressure was considered as the driving force for particle migration. Simulations were run for different osteolysis thresholds ranging from 5×108 to 1×1012 particle number per gram of tissue and fibrous tissue generation in osteolytic lesion due to particles was simulated for the equivalent of ten postoperative years. In patients less sensitive to polyethylene particles (higher threshold), osteolysis may be linear and occur along an interfacial gap in less than 5% of the interfacial tissue. Focal osteolysis is more likely to develop in patients with higher sensitivity to polyethylene particles at distal regions to an interfacial gaps where up to 80% of the interfacial tissue may be replaced by fibrous tissue. In these patients, signs of osteolysis may also develop earlier (third postoperative year) than those with less sensitivity who may show very minor signs even after ten years. This study shows the importance of patient sensitivity to wear particles, the role of interfacial gaps in relation to morphology and the onset of osteolysis. Consequently, it may explain the clinically observed variation in osteolysis development.
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Strauß V, Scheer AC, Andermahr J. Pathogenese von Knochenzysten nach Sprunggelenksendoprothesen. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.fuspru.2017.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Schilcher J, Palm L, Ivarsson I, Aspenberg P. Local bisphosphonate reduces migration and formation of radiolucent lines adjacent to cemented acetabular components. Bone Joint J 2017; 99-B:317-324. [PMID: 28249970 DOI: 10.1302/0301-620x.99b3.bjj-2016-0531.r1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 10/06/2016] [Indexed: 12/13/2022]
Abstract
AIMS Post-operative migration of cemented acetabular components as measured by radiostereometric analysis (RSA) has a strong predictive power for late, aseptic loosening. Also, radiolucent lines predict late loosening. Migration has been reduced by systemic bisphosphonate treatment in randomised trials of hip and knee arthroplasty. Used as a local treatment, a higher local dose of bisphosphonate can be achieved without systemic exposure. We wished to see if this principle could be applied usefully in total hip arthroplasty (THA). PATIENTS AND METHODS In this randomised placebo-controlled, double-blinded trial with 60 participants, we compressed gauze soaked in bisphosphonate solution (ibandronate) or saline against the acetabular bone bed immediately before cementing the acetabular component. RSA, classification of radiolucent lines, the Harris Hip Score (HHS) and the Western Ontario McMasters Universities Osteoarthritis Index (WOMAC) were carried out at three-, six-, 12-, and 24-month follow-up. RESULTS Migration of the cemented acetabular component relative to the pelvis was reduced by movement almost half in the ibandronate group, when measured as maximum total point or as movement of the femoral head (p = 0.001 and 0.004, respectively). Radiolucent lines after one year were classified as absent, partial or complete, and correlated with treatment (rho 0.37; p = 0.004). Only three of 30 patients in the ibandronate group had complete lines, compared with 13 of 28 in the placebo group (p = 0.002). There were no significant effects on HHS or WOMAC score. CONCLUSION Considering the power of RSA to predict loosening of cemented acetabular components, and the likelihood that radiolucent lines indicate risk of loosening, these data suggest that local treatment with a bisphosphonate can reduce the risk of late aseptic loosening. Cite this article: Bone Joint J 2017;99-B:317-24.
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Affiliation(s)
| | - L Palm
- Linköping University, Linköping, Sweden
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Malfroy Camine V, Terrier A, Pioletti DP. Micromotion-induced peri-prosthetic fluid flow around a cementless femoral stem. Comput Methods Biomech Biomed Engin 2017; 20:730-736. [PMID: 28271719 DOI: 10.1080/10255842.2017.1296954] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Micromotion-induced interstitial fluid flow at the bone-implant interface has been proposed to play an important role in aseptic loosening of cementless implants. High fluid velocities are thought to promote aseptic loosening through activation of osteoclasts, shear stress induced control of mesenchymal stem cells differentiation, or transport of molecules. In this study, our objectives were to characterize and quantify micromotion-induced fluid flow around a cementless femoral stem using finite element modeling. With a 2D model of the bone-implant interface and full-factorial design, we first evaluated the relative influence of material properties, and bone-implant micromotion and gap on fluid velocity. Transverse sections around a femoral stem were built from computed tomography images, while boundary conditions were obtained from experimental measurements on the same femur. In a second step, a 3D model was built from the same data-set to estimate the shear stress experienced by cells hosted in the peri-implant tissues. The full-factorial design analysis showed that local micromotion had the most influence on peak fluid velocity at the interface. Remarkable variations in fluid velocity were observed in the macrostructures at the surface of the implant in the 2D transverse sections of the stem. The 3D model predicted peak fluid velocities extending up to 2.2 mm/s in the granulation tissue and to 3.9 mm/s in the trabecular bone. Peak shear stresses on the cells hosted in these tissues ranged from 0.1 to 12.5 Pa. These results offer insight into mechanical stimuli encountered at the bone-implant interface.
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Affiliation(s)
- Valérie Malfroy Camine
- a Laboratory of Biomechanical Orthopedics , Ecole Polytechnique Fédérale de Lausanne , Lausanne , Switzerland
| | - Alexandre Terrier
- a Laboratory of Biomechanical Orthopedics , Ecole Polytechnique Fédérale de Lausanne , Lausanne , Switzerland
| | - Dominique P Pioletti
- a Laboratory of Biomechanical Orthopedics , Ecole Polytechnique Fédérale de Lausanne , Lausanne , Switzerland
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Pakvis DFM, Heesterbeek PJC, Severens M, Spruit M. Cancellous and cortical bone mineral density around an elastic press-fit socket in total hip arthroplasty. Acta Orthop 2016; 87:583-588. [PMID: 27659074 PMCID: PMC5119440 DOI: 10.1080/17453674.2016.1237439] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The acetabular component has remained the weakest link in hip arthroplasty for achievement of long-term survival. One of the possible explanatory factors for acetabular failure has been acetabular stress shielding. For this, we investigated the effects of a cementless elastic socket on acetabular bone mineral density (BMD). Patients and methods - During 2008-2009, we performed a single-center prospective cohort trial on 25 patients (mean age 64 (SD 4), 18 females) in whom we implanted a cementless elastic press-fit socket. Using quantitative BMD measurements on CT, we determined the change in BMD surrounding the acetabular component over a 2-year follow-up period. Results - We found a statistically significant decrease in cancellous BMD (-14% to -35%) and a stable level of cortical BMD (5% to -5%) surrounding the elastic press-fit cup during the follow-up period. The main decrease was seen during the first 6 months after implantation. During the second year, cancellous BMD showed a further decrease in the medial and lower acetabular regions. Interpretation - We found no evidence that an elastic press-fit socket would prevent acetabular stress shielding during a 2-year follow-up.
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Affiliation(s)
- Dean F M Pakvis
- Department of Orthopaedic surgery, Sint Maartenskliniek;,Correspondence:
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Strain shielding in trabecular bone at the tibial cement-bone interface. J Mech Behav Biomed Mater 2016; 66:181-186. [PMID: 27889526 DOI: 10.1016/j.jmbbm.2016.11.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 10/12/2016] [Accepted: 11/01/2016] [Indexed: 11/21/2022]
Abstract
Aseptic loosening of the tibial component remains the leading cause for revision surgery in total knee arthroplasty (TKA). Understanding the mechanisms leading to loss of fixation can offer insight into preventative measures to ensure a longer survival rate. In cemented TKA, loosening occurs at the cement-trabecular interface probably due to a stress-shielding effect of the stiffer implant material in comparison with bone. Using finite element models of lab-prepared tibial cement-trabeculae interface specimens (n=4) based on micro-CT images, this study aims to investigate the micromechanics of the interlock between cement and trabecular bone. Finite element micromotion between cement and trabeculae and bone strain were compared in the interdigitated trabeculae as well as strain in the bone distal to the interface. Lab-prepared specimens and their FE models were assumed to represent the immediate post-operative situation. The cement layer was removed in the FE models while retaining the loading conditions, which resulted in FE models that represented the pre-operative situation. Results showed that micromotion and bone strain decrease when interdigitation depth increases. Bone-cement micromotion and bone strain at the distal interdigitated region showed a dependence on bone volume fraction. Comparing the immediate post-operative and pre-operative situations, trabeculae embedded deep within the cement generally showed the highest level of strain-shielding. Strain shielding of interdigitated bone, in terms of reduction in compressive strains, was found to be between 35 and 61 % for the four specimens. Strain adaptive remodeling could thus be a plausible mechanism responsible for loss of interdigitated bone.
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Jeuken RM, Roth AK, Peters RJRW, Van Donkelaar CC, Thies JC, Van Rhijn LW, Emans PJ. Polymers in Cartilage Defect Repair of the Knee: Current Status and Future Prospects. Polymers (Basel) 2016; 8:E219. [PMID: 30979313 PMCID: PMC6432241 DOI: 10.3390/polym8060219] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 05/26/2016] [Accepted: 05/31/2016] [Indexed: 02/06/2023] Open
Abstract
Cartilage defects in the knee are often seen in young and active patients. There is a need for effective joint preserving treatments in patients suffering from cartilage defects, as untreated defects often lead to osteoarthritis. Within the last two decades, tissue engineering based techniques using a wide variety of polymers, cell sources, and signaling molecules have been evaluated. We start this review with basic background information on cartilage structure, its intrinsic repair, and an overview of the cartilage repair treatments from a historical perspective. Next, we thoroughly discuss polymer construct components and their current use in commercially available constructs. Finally, we provide an in-depth discussion about construct considerations such as degradation rates, cell sources, mechanical properties, joint homeostasis, and non-degradable/hybrid resurfacing techniques. As future prospects in cartilage repair, we foresee developments in three areas: first, further optimization of degradable scaffolds towards more biomimetic grafts and improved joint environment. Second, we predict that patient-specific non-degradable resurfacing implants will become increasingly applied and will provide a feasible treatment for older patients or failed regenerative treatments. Third, we foresee an increase of interest in hybrid construct, which combines degradable with non-degradable materials.
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Affiliation(s)
- Ralph M Jeuken
- Department of Orthopaedic Surgery, Maastricht University Medical Center, P. Debyelaan 25, Maastricht 6229 HX, The Netherlands.
| | - Alex K Roth
- Department of Orthopaedic Surgery, Maastricht University Medical Center, P. Debyelaan 25, Maastricht 6229 HX, The Netherlands.
| | | | - Corrinus C Van Donkelaar
- Department of Biomedical Engineering, Eindhoven University of Technology, P.O. Box 513, Eindhoven 5600 MB, The Netherlands.
| | - Jens C Thies
- DSM Biomedical, Koestraat 1, Geleen 6167 RA, The Netherlands.
| | - Lodewijk W Van Rhijn
- Department of Orthopaedic Surgery, Maastricht University Medical Center, P. Debyelaan 25, Maastricht 6229 HX, The Netherlands.
| | - Pieter J Emans
- Department of Orthopaedic Surgery, Maastricht University Medical Center, P. Debyelaan 25, Maastricht 6229 HX, The Netherlands.
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Miller MA, Goodheart JR, Khechen B, Janssen D, Mann KA. Changes in microgaps, micromotion, and trabecular strain from interlocked cement-trabecular bone interfaces in total knee replacements with in vivo service. J Orthop Res 2016; 34:1019-25. [PMID: 26595084 PMCID: PMC4877298 DOI: 10.1002/jor.23109] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 11/20/2015] [Indexed: 02/04/2023]
Abstract
The initial fixation of cemented Total Knee Replacements (TKRs) relies on mechanical interlock between cement and bone, but loss of interlock occurs with in vivo service. In this study, cement-trabeculae gap morphology and micromechanics were measured for lab prepared (representing post-operative state) and postmortem retrieval (with in vivo remodeling) TKRs to determine how changes in fixation affect local micromechanics. Small specimens taken from beneath the tibial tray were loaded with 1 MPa axial compression and the local micromechanics of the trabeculae-cement interface was quantified using digital image correlation. Lab prepared trabeculae that initially interlock with cement had small gaps (ave:14 μm) and limited micromotion (ave:1 μm) which were larger near the cement border. Trabecular resorption was prevalent following in vivo service; interface gaps became larger (ave:40 μm) and micromotion increased (ave:6 μm), particularly near the cement border. Interlocked trabeculae from lab prepared specimens exhibited strains that were 20% of the supporting bone strain, indicating the trabeculae were initially strain shielded. The spatial and temporal progression of gaps, micromotion, and bone strain was complex and much more variable for post-mortem retrievals compared to the lab prepared specimens. From a clinical perspective, attaining more initial interlock results in cement-bone interfaces that are better fixed with less micromotion. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1019-1025, 2016.
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Affiliation(s)
- Mark A. Miller
- Department of Orthopedic Surgery, State University of New York, Upstate Medical University, 3216 IHP, 750 East Adams Street, Syracuse, New York, 13210, USA
| | - Jacklyn R. Goodheart
- Department of Orthopedic Surgery, State University of New York, Upstate Medical University, 3216 IHP, 750 East Adams Street, Syracuse, New York, 13210, USA
| | - Benjamin Khechen
- Department of Orthopedic Surgery, State University of New York, Upstate Medical University, 3216 IHP, 750 East Adams Street, Syracuse, New York, 13210, USA
| | - Dennis Janssen
- Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Kenneth A. Mann
- Department of Orthopedic Surgery, State University of New York, Upstate Medical University, 3216 IHP, 750 East Adams Street, Syracuse, New York, 13210, USA
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Zimmerman WF, Miller MA, Cleary RJ, Izant TH, Mann KA. Damage in total knee replacements from mechanical overload. J Biomech 2016; 49:2068-2075. [PMID: 27237382 DOI: 10.1016/j.jbiomech.2016.05.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 04/05/2016] [Accepted: 05/15/2016] [Indexed: 01/16/2023]
Abstract
The mechanical loads acting across the knee joint following total knee replacements (TKR) during activities of daily living have recently been measured using instrumented TKRs. Using a series of postmortem retrieved TKR constructs we investigated whether these mechanical loads could result in damage to the implant bone interface or supporting bone in the tibia. Eighteen cemented en bloc tibial components (0 to 22 years in service) were loaded under axial compression in increments from 1 to 10 times body weight and digital image correlation was used to measure bone strain and interface micromotion during loading and unloading. Failure was considered to occur when micromotion exceeded 150µm or compressive bone strain exceeded 7300με. The results show that all retrieved specimens had sufficient bone strength to support most activities of daily living, but ~40% would be at risk under larger physiologic loads that might occur secondary to a higher impacts such as jogging or a stumble. The tray-bone micromotion (regression model R(2)=0.48, p=0.025) was greater for donors with lower age at implantation (p=0.0092). Proximal bone strain (model R(2)=0.46, p=0.03) was greater for donors with longer time in service (p=0.021). Distal bone strain (model R(2)=0.58, p=0.005) was greater for donors with more time in service (p=0.0054) and lower peri-implant BMD (p=0.049). High mechanical overload of a single or repetitive nature may be an initiating factor in aseptic loosening of total joint arthroplasties and should be avoided in order to prolong the life of the implant.
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Affiliation(s)
- William F Zimmerman
- Department of Orthopedic Surgery, State University of New York, Upstate Medical University, 3216 IHP, 750 East Adams Street, Syracuse, NY 13210, USA.
| | - Mark A Miller
- Department of Orthopedic Surgery, State University of New York, Upstate Medical University, 3216 IHP, 750 East Adams Street, Syracuse, NY 13210, USA.
| | - Richard J Cleary
- Department of Statistics and Mathematics, Babson College, Wellesley, MA, USA
| | | | - Kenneth A Mann
- Department of Orthopedic Surgery, State University of New York, Upstate Medical University, 3216 IHP, 750 East Adams Street, Syracuse, NY 13210, USA.
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Srinivasan P, Miller MA, Verdonschot N, Mann KA, Janssen D. Experimental and computational micromechanics at the tibial cement-trabeculae interface. J Biomech 2016; 49:1641-1648. [PMID: 27079621 DOI: 10.1016/j.jbiomech.2016.03.054] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 03/11/2016] [Accepted: 03/28/2016] [Indexed: 02/05/2023]
Abstract
Aseptic loosening of the tibial component in cemented total knee arthroplasty remains a major concern. We hypothesize that micromotion between the cement and trabeculae leads to increased circulation of interstitial fluid which in turn causes fluid-induced resorption of the trabeculae. Another mechanism for implant loosening is trabecular strain shielding. Using a newly developed experimental setup and digital image correlation (DIC) methods we were able to measure micromotion and strains in lab-prepared cement-trabeculae interface specimens (n=4). Finite element (FE) models of these specimens were developed to determine whether differences in micromotion and strain in morphologically varying specimens could be simulated accurately. Results showed that the measured micromotion and strains correlated well with FE model predictions (r(2)=0.59-0.85; r(2)=0.66-0.90). Global specimen strains measured axially matched well with the FE model strains (r(2)=0.87). FE model cement strains showed an increasing trend with distance from the cement border. The influence of loss of trabecular connectivity at the specimen edges was studied using our FE model results. Micromotion values at the outer edge of the specimens were higher than the specimen interior when considering a very thin outer edge (0.1mm). When the outer edge thickness was increased to about one trabecular length (0.8mm), there was a drop in the median and peak values. Using the experimental and modelling approach outlined in this study, we can further study the mechanisms that lead to loss of interlock between cement and trabeculae at the tibial interface.
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Affiliation(s)
- Priyanka Srinivasan
- Radboud university medical center, Radboud Institute for Health Sciences, Orthopaedic Research Laboratory, Nijmegen, The Netherlands.
| | - Mark A Miller
- Department of Orthopedic Surgery, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Nico Verdonschot
- Radboud university medical center, Radboud Institute for Health Sciences, Orthopaedic Research Laboratory, Nijmegen, The Netherlands; University of Twente, Laboratory for Biomechanical Engineering, Faculty of Engineering Technology, Enschede, The Netherlands
| | - Kenneth A Mann
- Department of Orthopedic Surgery, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Dennis Janssen
- Radboud university medical center, Radboud Institute for Health Sciences, Orthopaedic Research Laboratory, Nijmegen, The Netherlands
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Green CJ, Beck A, Wood D, Zheng MH. The biology and clinical evidence of microfracture in hip preservation surgery. J Hip Preserv Surg 2016; 3:108-23. [PMID: 27583147 PMCID: PMC5005050 DOI: 10.1093/jhps/hnw007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 01/11/2016] [Indexed: 01/01/2023] Open
Abstract
The use of microfracture in hip arthroscopy is increasing dramatically. However, recent reports raise concerns not only about the lack of evidence to support the clinical use of microfracture, but also about the potential harm caused by violation of the subchondral bone plate. The biology and pathology of the microfracture technique were described based on observations in translational models and the clinical evidence for hip microfracture was reviewed systematically. The clinical outcomes in patients undergoing microfracture were the same as those not undergoing microfracture. However, the overall clinical evidence quality is poor in hips. This review identified only one study with Level III evidence, while most studies were Level IV. There were no randomized trials available for review. Repair tissue is primarily of fibrocartilaginous nature. Reconstitution of the subchondral bone is often incomplete and associated with poor quality repair tissue and faster degeneration. Subchondral bone cyst formation is associated with microfracture, likely secondary to subchondral bone plate disruption and a combination of pressurized synovial fluid and inflammatory mediators moving from the joint into the bone. There is a lack of clinical efficacy evidence for patients undergoing microfracture. There is evidence of bone cyst formation following microfracture in animal studies, which may accelerate joint degeneration. Bone cyst formation following microfracture has not been studied adequately in humans.
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Affiliation(s)
- Chadwick John Green
- Department of Orthopaedic Surgery, Royal Perth Hospital, Perth 6000, Australia and
| | - Aswin Beck
- Centre for Orthopaedic Research, School of Surgery, University of Western Australia, Nedlands 6009, Australia
| | - David Wood
- Centre for Orthopaedic Research, School of Surgery, University of Western Australia, Nedlands 6009, Australia
| | - Ming H Zheng
- Centre for Orthopaedic Research, School of Surgery, University of Western Australia, Nedlands 6009, Australia
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Jakobsen T, Kold S, Baas J, Søballe K, Rahbek O. Sheep Hip Arthroplasty Model of Failed Implant Osseointegration. Open Orthop J 2015; 9:525-9. [PMID: 26664497 PMCID: PMC4671224 DOI: 10.2174/1874325001509010525] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 08/26/2015] [Accepted: 09/03/2015] [Indexed: 12/13/2022] Open
Abstract
Early secure stability of an implant is important for long-term survival. We examined whether micromotion of implants consistently would induce bone resorption and formation of a fibrous membrane and thereby prevent osseointegration. One micromotion implant was inserted into one of the medial femoral condyles in ten sheep. The micromotion device consists of an anchor bearing a PMMA implant and a PE plug. During each gait cycle the PE plug will make the PMMA implant axially piston 0.5 mm. After 12 weeks of observation the bone specimens were harvested and a post-mortem control implant was inserted into the contra-lateral medial femoral condyle. Histomorphometrical evaluation showed that the surface on the implant observed for 12 weeks was covered by fibrous tissue. The control implants were covered by lamellar bone. No difference was found with respect to the volume fraction of lamellar bone in a 1 mm zone around the implants. This study indicates that implant micromotion is sufficient to induce bone resorption and formation of a fibrous membrane.
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Affiliation(s)
- Thomas Jakobsen
- Orthopaedic Research Laboratory, Department of Orthopaedics, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Kold
- Aalborg University Hospital, Department of Orthopaedics, Aalborg, Denmark
| | - Jørgen Baas
- Orthopaedic Research Laboratory, Department of Orthopaedics, Aarhus University Hospital, Aarhus, Denmark
| | - Kjeld Søballe
- Orthopaedic Research Laboratory, Department of Orthopaedics, Aarhus University Hospital, Aarhus, Denmark
| | - Ole Rahbek
- Orthopaedic Research Laboratory, Department of Orthopaedics, Aarhus University Hospital, Aarhus, Denmark
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Gallo J, Raska M, Konttinen YT, Nich C, Goodman SB. Innate immunity sensors participating in pathophysiology of joint diseases: a brief overview. J Long Term Eff Med Implants 2015; 24:297-317. [PMID: 25747032 DOI: 10.1615/jlongtermeffmedimplants.2014010825] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The innate immune system consists of functionally specialized "modules" that are activated in response to a particular set of stimuli via sensors located on the surface or inside the tissue cells. These cells screen tissues for a wide range of exogenous and endogenous danger/damage-induced signals with the aim to reject or tolerate them and maintain tissue integrity. In this line of thinking, inflammation evolved as an adaptive tool for restoring tissue homeostasis. A number of diseases are mediated by a maladaptation of the innate immune response, perpetuating chronic inflammation and tissue damage. Here, we review recent evidence on the cross talk between innate immune sensors and development of rheumatoid arthritis, osteoarthritis, and aseptic loosening of total joint replacements. In relation to the latter topic, there is a growing body of evidence that aseptic loosening and periprosthetic osteolysis results from long-term maladaptation of periprosthetic tissues to the presence of by-products continuously released from an artificial joint.
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Affiliation(s)
- Jiri Gallo
- Department of Orthopedics, University Hospital and Faculty of Medicine and Dentistry, Palacky University, Olomouc 775 20, Czech Republic
| | - Milan Raska
- Department of Immunology, Faculty of Medicine & Dentistry, Palacky University, Hnevotinska 3, 775 15 Olomouc, Czech Republic
| | - Yrjo T Konttinen
- Department of Clinical Medicine, University of Helsinki and ORTON Orthopaedic Hospital of the Invalid Foundation, Helsinki, Finland
| | - Christophe Nich
- Laboratoire de Biomecanique et Biomateriaux Osteo-Articulaires - UMR CNRS 7052, Faculte de Medecine - Universite Paris 7, Paris, France; Department of Orthopaedic Surgery, European Teaching Hospital, Assistance Publique - Hopitaux de Paris
| | - Stuart B Goodman
- Department of Orthopaedic Surgery Stanford University Medical Center Redwood City, CA
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Yang X, Ricciardi BF, Dvorzhinskiy A, Brial C, Lane Z, Bhimani S, Burket JC, Hu B, Sarkisian AM, Ross FP, van der Meulen MCH, Bostrom MPG. Intermittent Parathyroid Hormone Enhances Cancellous Osseointegration of a Novel Murine Tibial Implant. J Bone Joint Surg Am 2015; 97:1074-83. [PMID: 26135074 PMCID: PMC4574908 DOI: 10.2106/jbjs.n.01052] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Long-term fixation of uncemented joint implants requires early mechanical stability and implant osseointegration. To date, osseointegration has been unreliable and remains a major challenge in cementless total knee arthroplasty. We developed a murine model in which an intra-articular proximal tibial titanium implant with a roughened stem can be loaded through the knee joint. Using this model, we tested the hypothesis that intermittent injection of parathyroid hormone (iPTH) would increase proximal tibial cancellous osseointegration. METHODS Ten-week-old female C57BL/6 mice received a subcutaneous injection of PTH (40 μg/kg/day) or a vehicle (n = 45 per treatment group) five days per week for six weeks, at which time the baseline group was killed (n = 6 per treatment group) and an implant was inserted into the proximal part of the tibiae of the remaining mice. Injections were continued until the animals were killed at one week (n = 7 per treatment group), two weeks (n = 14 per treatment group), or four weeks (n = 17 per treatment group) after implantation. Outcomes included peri-implant bone morphology as analyzed with micro-computed tomography (microCT), osseointegration percentage and bone area fraction as shown with backscattered electron microscopy, cellular composition as demonstrated by immunohistochemical analysis, and pullout strength as measured with mechanical testing. RESULTS Preimplantation iPTH increased the epiphyseal bone volume fraction by 31.6%. When the data at post-implantation weeks 1, 2, and 4 were averaged for the iPTH-treated mice, the bone volume fraction was 74.5% higher in the peri-implant region and 168% higher distal to the implant compared with the bone volume fractions in the same regions in the vehicle-treated mice. Additionally, the trabecular number was 84.8% greater in the peri-implant region and 74.3% greater distal to the implant. Metaphyseal osseointegration and bone area fraction were 28.1% and 70.1% higher, respectively, in the iPTH-treated mice than in the vehicle-treated mice, and the maximum implant pullout strength was 30.9% greater. iPTH also increased osteoblast and osteoclast density by 65.2% and 47.0%, respectively, relative to the values in the vehicle group, when the data at post-implantation weeks 1 and 2 were averaged. CONCLUSIONS iPTH increased osseointegration, cancellous mass, and the strength of the bone-implant interface. CLINICAL RELEVANCE Our murine model is an excellent platform on which to study biological enhancement of cancellous osseointegration.
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Affiliation(s)
- Xu Yang
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for X. Yang:
| | - Benjamin F Ricciardi
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for X. Yang:
| | - Aleksey Dvorzhinskiy
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for X. Yang:
| | - Caroline Brial
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for X. Yang:
| | - Zachary Lane
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for X. Yang:
| | - Samrath Bhimani
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for X. Yang:
| | - Jayme C Burket
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for X. Yang:
| | - Bin Hu
- Department of Biomaterials and Biomimetics, New York University College of Dentistry, 345 East 24th Street, New York, NY 10010
| | - Alexander M Sarkisian
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for X. Yang:
| | - F Patrick Ross
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for X. Yang:
| | | | - Mathias P G Bostrom
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for X. Yang:
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Liu C, Li S, Ji B, Huo B. Flow-Induced Migration of Osteoclasts and Regulations of Calcium Signaling Pathways. Cell Mol Bioeng 2014. [DOI: 10.1007/s12195-014-0372-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Comparison of periprosthetic tissues in knee and hip joints: differential expression of CCL3 and DC-STAMP in total knee and hip arthroplasty and similar cytokine profiles in primary knee and hip osteoarthritis. Osteoarthritis Cartilage 2014; 22:1851-60. [PMID: 25151085 DOI: 10.1016/j.joca.2014.08.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 07/11/2014] [Accepted: 08/03/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To identify expression profiles (EP) associated with aseptic loosening of total knee arthroplasty (TKA) and to compare them with EP observed in total hip arthroplasty (THA), and primary knee and hip osteoarthritis (OA). DESIGN Gene EP of TNF, IL-6, IL-8, CHIT1, BMP4, CCL3, CCL18, MMP9, RANKL, OPG, DC-STAMP and SOCS3 were assessed using quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR) on tissues retrieved from patients with aseptically failed TKA (n = 21), THA (n = 41) and primary knee (n = 20) and hip (n = 17) OA. Immunohistochemistry was applied to localize the proteins. RESULTS When compared to knee OA, the pseudosynovial tissue in TKA exhibit (1) elevation of alternative macrophage activation marker (CHIT1), chemokine (IL-8), and a proteolytic enzyme (MMP9); (2) downregulation of pro-inflammatory cytokine (TNF), osteoclastic regulator (OPG) and a stimulator of bone formation (BMP4); (3) no difference in IL-6, CCL3, CCL18, RANKL, DC-STAMP and SOCS3. The EP in TKA differed from EP in aseptically failed THA by lower CCL3 and DC-STAMP mRNA and protein expression. EP of all studied inflammatory and osteoclastogenic molecules were similar in knee and hip OA. CONCLUSIONS Comparing to OA, aseptic loosening of TKA is associated with upregulated expression of CHIT1, IL-8 and MMP9, dysregulated RANKL:OPG ratio and low levels of inflammatory cytokines. Similar cytokine profiles were associated with primary knee and hip OA. Further research is required to explain the differences in CCL3 and DC-STAMP expression between failed TKA and THA.
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47
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Li P, Liu C, Hu M, Long M, Zhang D, Huo B. Fluid flow-induced calcium response in osteoclasts: signaling pathways. Ann Biomed Eng 2014; 42:1250-60. [PMID: 24710796 DOI: 10.1007/s10439-014-0984-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 01/25/2014] [Indexed: 01/07/2023]
Abstract
Intracellular calcium oscillation and its downstream signaling in osteoclasts is believed to play critical roles in regulating bone resorption. Our previous study demonstrated that fluid shear stress (FSS) induced more calcium responsive peaks in the late differentiated osteoclasts than the early ones. In this paper, the signaling pathways of FSS-induced calcium response for the osteoclasts in different differentiation stages were studied. RAW264.7 macrophage cells were induced to differentiate into osteoclasts with the conditioned medium from MC3T3-E1 osteoblasts. Furthermore pharmacological agents were added to block the specific signaling pathways. Finally the cells were exposed to FSS at different levels (1 or 10 dyne/cm(2)) after being induced for 4 or 8 days. The results showed that the mechanosensitive, cation-selective channels, phospholipase C (PLC) and endoplasmic reticulum constituted the major signaling pathway for mechanical stimulation-induced calcium response in osteoclasts. Extracellular calcium or ATP involved with calcium oscillation in a FSS magnitude-dependent manner. This pathway study may help to give insight into the molecular mechanism of mechanical stimulation-regulated bone remodeling.
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Affiliation(s)
- Ping Li
- Department of Mechanics, School of Aerospace Engineering, Beijing Institute of Technology, No. 5 South Zhongguancun Street, Beijing, 100081, People's Republic of China
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48
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Periprosthetic wear particle migration and distribution modelling and the implication for osteolysis in cementless total hip replacement. J Mech Behav Biomed Mater 2014; 32:225-244. [DOI: 10.1016/j.jmbbm.2014.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 01/03/2014] [Accepted: 01/08/2014] [Indexed: 11/19/2022]
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49
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Mann KA, Miller MA, Goodheart JR, Izant TH, Cleary RJ. Peri-implant bone strains and micro-motion following in vivo service: a postmortem retrieval study of 22 tibial components from total knee replacements. J Orthop Res 2014; 32:355-61. [PMID: 24277230 PMCID: PMC4100998 DOI: 10.1002/jor.22534] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 11/07/2013] [Indexed: 02/04/2023]
Abstract
Biological adaptation following placement of a total knee replacements (TKRs) affects peri-implant bone mineral density (BMD) and implant fixation. We quantified the proximal tibial bone strain and implant-bone micro-motion for functioning postmortem retrieved TKRs and assessed the strain/micro-motion relationships with chronological (donor age and time in service) and patient (body weight and BMD) factors. Twenty-two tibial constructs were functionally loaded to one body weight (60% medial/40% lateral), and the bone strains and tray/bone micro-motions were measured using a digital image correlation system. Donors with more time in service had higher bone strains (p = 0.044), but there was not a significant (p = 0.333) contribution from donor age. Donors with lower peri-implant BMD (p = 0.0039) and higher body weight (p = 0.0286) had higher bone strains. Long term implants (>11 years) had proximal bone strains 900 µϵ that were almost twice as high as short term (<5 years) implants 570 µϵ. Micro-motion was greater for younger donors (p = 0.0161) and longer time in service (p = 0.0008). Increased bone strain with long term in vivo service could contribute to loosening of TKRs by failure of the tibial peri-implant bone.
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Affiliation(s)
- Kenneth A Mann
- Department of Orthopaedic Surgery, SUNY Upstate Medical University, Syracuse, New York
| | - Mark A Miller
- Department of Orthopaedic Surgery, SUNY Upstate Medical University, Syracuse, New York
| | - Jacklyn R Goodheart
- Department of Orthopaedic Surgery, SUNY Upstate Medical University, Syracuse, New York
| | | | - Richard J Cleary
- Department of Statistics and Mathematics, Babson College, Wellesley, Massachusetts
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Oest ME, Miller MA, Howard KI, Mann KA. A novel in vitro loading system to produce supraphysiologic oscillatory fluid shear stress. J Biomech 2013; 47:518-25. [PMID: 24275439 DOI: 10.1016/j.jbiomech.2013.10.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 08/21/2013] [Accepted: 10/26/2013] [Indexed: 01/01/2023]
Abstract
A multi-well fluid loading (MFL) system was developed to deliver oscillatory subphysiologic to supraphysiologic fluid shear stresses to cell monolayers in vitro using standard multi-well culture plates. Computational fluid dynamics modeling with fluid-structure interactions was used to quantify the squeeze film fluid flow between an axially displaced piston and the well plate surface. Adjusting the cone angle of the piston base modulated the fluid pressure, velocity, and shear stress magnitudes. Modeling results showed that there was near uniform fluid shear stress across the well with a linear drop in pressure across the radius of the well. Using the MFL system, RAW 264.7 osteoclastic cells were exposed to oscillatory fluid shear stresses of 0, 0.5, 1.5, 4, 6, and 17 Pa. Cells were loaded 1 h per day at 1 Hz for two days. Compared to sub-physiologic and physiologic levels, supraphysiologic oscillatory fluid shear induced upregulation of osteoclastic activity as measured by tartrate-resistant acid phosphatase activity and formation of mineral resorption pits. Cell number remained constant across all treatment groups.
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Affiliation(s)
- Megan E Oest
- Department of Orthopedic Surgery, SUNY Upstate Medical University, Syracuse, NY 13210, United States.
| | - Mark A Miller
- Department of Orthopedic Surgery, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Karen I Howard
- Department of Orthopedic Surgery, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Kenneth A Mann
- Department of Orthopedic Surgery, SUNY Upstate Medical University, Syracuse, NY 13210, United States
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