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The Papers Presented at the Annual Meetings of the Knee Society Symposium includes selected papers read at the 2007 Annual Interim Meeting of the Knee Society held in Sienna, Italy in September 2007, and the 2008 Open Scientific Meeting of the Knee Society, held in San Francisco in March 2008. The wide range and high quality of the scientific material presented here is a credit to the excellent work of the Knee Society education committee and particularly to its Program Chair, Gil Scuderi, MD. Each of these papers is focused, concise and highly readable, which is a credit to the outstanding work of the staff at CORR in providing clear and consistent guidelines for each of the authors whose work was accepted for publication. The 2008 Ranawat Award was authored by Dr. Patricia Franklin and colleagues for their work on patient-specific attributes that affect the functional outcome after total knee replacement. While considerable interest in patient outcomes research has been present for some time now, we are still uncovering the hidden power, and the hidden pitfalls, of such evaluation tools in orthopaedics. Dr. Franklin and colleagues effectively demonstrate the substantial influence of specific patient characteristics in determining the ultimate functional outcome after knee replacement. These data are useful for surgeons and patients alike as part of the preoperative discussion so that expectations can be managed more appropriately. Further, this paper provides some insight into additional strategies that might be employed prior to knee replacement to affect some patient attributes that adversely impact outcome. The 2008 Coventry Award paper was authored by D’Lima, Colwell, and colleagues from the Scripps Clinic for their innovative report that directly measured the in vivo forces that the knee experiences after total knee arthroplasty. In an outstanding collaboration between basic science researchers, engineers, and clinicians, Dr. Colwell’s group designed and implanted in three patients an instrumented tibial component that allowed the direct measurement of both knee forces and moments in vivo. These results begin to give us a true glimpse of the forces that are seen by total knee bearing surfaces and fixation interfaces thus providing us with a more scientific approach to what have otherwise been empiric recommendations regarding physical activities after total knee arthroplasty. The 2008 John Insall Award paper was authored by Dr. Steven MacDonald and colleagues from London, Ontario and addressed the specific impact of gender on the clinical outcome after total knee arthroplasty. The introduction into the marketplace of so-called gender-specific total knee components has been met with a competing mix of interest and skepticism among surgeons, while among patients curiosity might be the most appropriate descriptor. This scientific work again highlights the powerful relationship between preoperative variables and postoperative outcomes. These authors rightly highlight the importance of focusing on the change or improvement in preoperative to postoperative outcomes measures and balance that against the absolute scores. Female gender was associated with lower preoperative scores with these outcomes tools so perhaps it is not surprising some of the postoperative scores remain lower than those observed in males. The change or improvement from preoperative to postoperative, however, appears to be similar between males and females after total knee arthroplasty. The remaining papers in this symposium are grouped to include new information regarding total knee surgical technique, gender-related issues in technique and outcome, computer navigation, patellar resurfacing, total knee materials and design issues and revision total knee concerns. As surgeons we have specific interest in improving our intraoperative skills. In this symposium there is information on a method to determine rotational position of total knee components, data on the impact of a ligament balancing technique on the rate of lateral retinacular release, and the introduction of an extramedullary femoral referencing system to facilitate less invasive surgery. Gender-related issues are addressed in a series of papers that look at both documenting physical measurement differences in knee anatomy and then measuring outcomes differences. While little doubt exists that gender-associated differences can be measured, what remains to be determined is the clinical importance of such findings, and in that area we collectively still have work to do. While it appears that the initial wave of enthusiasm for computer navigation in total knee arthroplasty has crested, we are now at a point where more definitive scientific data are emerging regarding the benefits and drawbacks to this particular technology. Two of the implicit promises of computer navigation have been that it may make the occasional knee surgeon more like the expert surgeon, and that a navigation system can be the eye that facilitates accurate minimally invasive surgery. In this symposium there are scientific data that cast some doubt on promise number two, and all of us in the scientific community continue to look for evidence that navigation is reproducibly accurate when used by the occasional knee surgeon. The added costs of this technology is an issue yet to be addressed. Revision TKA is an area of ascending importance as the demographics of our population point to a growing need in this area. In this Symposium there are useful data on the outcomes differences between primary and revision TKA, comparative data on in-hospital complications between primary and revision TKA, isolated patellar revision, patellar bone loss problems and the use of stems in conjunction with constrained condylar knee designs. The Knee Society remains committed to advancing scientific knowledge and educating clinicians worldwide regarding surgery of the knee. We hope that our readers find this Symposium to be intellectually rigorous and clinically useful.

The authors present a case of a spondylolisthesis with obvious foraminal stenosis on both sides as shown on the preoperative MRI. A proper operative technique in this case would include a restoration of disc height and the (partial) reduction of the slip. This technique would widen both foramina and no complication like opposite nerve root compression would occur. If reduction or disc height restoration cannot be achieved, decompression of both foramina should be performed. In mild cases a simple posterior distraction may be enough. In their paper the authors agree to this point as they write “decompression of the opposite side has not been judged necessary in the past as it has been commonly assumed that the TLIF spacer increases the disc space height and the foraminal height in the opposite foramen of the TLIF approach.” However, it seems that in the current case the authors failed to achieve restoration of disc height. Figure 7 shows differences between the preoperative and the postoperative CT scan of 1 mm (4 vs. 5 mm) and 1.5 mm (6.5 vs. 8 mm), respectively. The same is true for the “decrease” of foraminal height of 2 mm. I think that these measurements are not reliable since there is no calibration and no matching between the slices. Hence no obvious increase in disc height or decrease in foraminal height can be measured accurately. Anyway, the clinical significance of 1 or 2 mm of reduced foraminal height, if really present, seems to be questionable.

The work, "Ricardo M. The effect of ultrasound on the healing of muscle-pediculated bone graft in scaphoid non-union. Int Orthop. 2006 Apr;30(2):123–127", published by the prestigious journal International Orthopaedics, contains some misprints. In the paper it is reported that the ultrasound intensity emitted by the equipment employed in the study, a Theramed 101B, was 30 mW/cm2. Actually, the reported intensity should have been 50mW/cm2. The error could have come about since initially in the Department of Orthopedics and Traumatology of the Manuel Fajardo Teaching Hospital, a preliminary study was conducted for the stimulation of bone repair that indeed used 30mW/cm2. The first results of this preliminary study were published in the following reference, "O. Rodriguez, R. Monreal. Acceleration of Osseous Fracture Repair by Low-intensity Pulsed Ultrasound Therapy: A Preliminary Study", Proceedings of the II Latin-American Congress on Biomedical Engineering (ISBN 959-7132-57-5), Havana, Cuba, Cod. 265, (2001). Nevertheless after that preliminary study and since the beginning of 2000, the Theramed 101B equipment was modified for an emmision of 50 mW/cm2. Therefore, the year for the beginning of the study described by author should be 2000 and not 1999, and the reported intensity must be 50 mW/cm2, and not 30 mW/cm2. Sincerely yours, Orlando R. Rodriguez Rua (MD), Researcher of the “Instituto de Cibernetica, Matematica y Fisica”, La Habana Cuba. Chief of the project PRI/1/1 of the “Agencia Cubana de Energia Nuclear y Tecnologias de Avanzadas” under which the Theramed 101B was Developer with the collaboration of the “Departamento de Ingenieria Electrica y Electronica, Instituto Tecnologico y de Estudios Superiores de Monterrey, Campus Estado de Mexico, Mexico” and the “Seccion de Bioelectronica, Departamento de Ingenieria Electrica, Centro de Investigacion y de Estudios Avanzados del Instituto Politecnico Nacional, Mexico DF, Mexico”.

Purpose To compare the efficacy and safety of TDR to that of the fusion for the treatment of lumbar degenerative disc disease (LDDD). Methods Randomized controlled trials comparing TDR with any other intervention for LDDD were acquired by a comprehensive search in PubMedCentral, MEDLINE, EMBASE, BIOSIS, ClinicalTrials.gov, and the FDA trials register. Methodologic quality was assessed and relevant data were retrieved, and appropriate meta-analysis was performed. Two review authors independently selected studies, extracted data, and assessed risk of bias. Results and upper bounds of confidence intervals were compared with predefined clinically relevant differences. Results Six relevant randomized controlled trials (RCTs) involving 1,603 patients were identified and reported two year follow-up results. Patients in TDR group compared with lumbar fusion group demonstrated significant improvements in ODI, VAS scores and complication rates at the two year follow-up. Meanwhile, except for operating time in anterior group, intra-operative blood loss, operating time in posterior group, and reoperation rate were without clinical significance between the two groups. In addition, the range of motion (ROM) was maintained within normal ranges after TDR. Conclusions The results showed the TDR has significant safety and efficacy comparable to lumbar fusion at two year follow-up. Although superiority compared to fusion could not be proved, by comparing clinical symptoms relieved, motion preserved, and the low reoperation rate during long-term follow-up on TDR, TDR was considered safe and effective. Therefore, the authors suggest adopting TDR on a large scale; with failure of TDR, interbody fusion would be performed.

The aim of this health economic analysis was to compare the cost-effectiveness of ticagrelor versus clopidogrel within the German health care system. A two-part decision model was adapted to compare treatment with ticagrelor or clopidogrel in a low-dose acetylsalicylic acid (ASA) cohort (≤150 mg) for all ACS patients and subtypes NSTEMI/IA and STEMI. A decision-tree approach was chosen for the first year after initial hospitalization based on trial observations from a subgroup of the PLATO study. Subsequent years were estimated by a Markov model. Following a macro-costing approach, costs were based on official tariffs and published literature. Extensive sensitivity analyses were performed to test the robustness of the model. One-year treatment with ticagrelor is associated with an estimated 0.1796 life-years gained (LYG) and gained 0.1570 quality-adjusted life-years (QALY), respectively, over the lifetime horizon. Overall average cost with ticagrelor is estimated to be EUR 11,815 vs. EUR 11,387 with generic clopidogrel over a lifetime horizon. The incremental cost-effectiveness ratio (ICER) was EUR 2,385 per LYG (EUR 2,728 per QALY). Comparing ticagrelor with Plavix® or the lowest priced generic clopidogrel, ICER ranges from dominant to EUR 3,118 per LYG (EUR 3,567 per QALY). These findings are robust under various additional sensitivity analyses. Hence, 12 months of ACS treatment using ticagrelor/ASA instead of clopidogrel/ASA may offer a cost-effective therapeutic option, even when the generic price for clopidogrel is employed. Electronic supplementary material The online version of this article (doi:10.1007/s00392-013-0552-7) contains supplementary material, which is available to authorized users.

Purpose The aim of the study was to assess bone graft incorporation after revision hip arthroplasty in patients with rheumatoid arthritis (RA). Methods We report an acetabular reconstruction using impacted, morselized, frozen, radiation sterilized bone allografts in 71 patients suffering from RA. There were sixty-six women and five men at a mean age of 57.5 years. Reconstruction was performed in 78 revision total hip arthroplasties (THAs) for aseptic loosening of acetabular component. The mean follow-up was five years and four months. In 38 cases, a revision was done with use of reinforcement devices. Results In four revised hips (10 %) without reinforcement implants, resorption of the allografts was noticed. All Mueller rings and 50 % of unscrews cages (Link, Howmedica) were revised because of aseptic loosening and bone graft resorption. In all of 17 hips with the Burch-Schneider cage, no measurable migration or bone allografts resorption occurred. There were no major general complications. Conclusions Acetabular reconstruction with use of morselized, frozen, radiation sterilized bone allografts and the Burch-Schneider cage can be highly successful in managing massive deficiency of acetabular bone stock in revision hip arthroplasty in RA patients.

Purpose Recurrences and deaths are known to occur, even if less frequently, in small, node-negative breast cancer patients, and decision on adjuvant treatments remains controversial. In the present analysis, we evaluate recurrence risk in patients with pT1 a, b, c, node-negative, breast cancer, accordingly with some prognostic biological factors. Methods We retrospectively evaluated 900 node-negative patients (pT1a, b, c) surgery treated between 2000 and 2009 in four Italian oncologic centers. We defined 3 different cohorts: ER positive (ER+); Her-2 positive (Her-2+); and triple negative (TN). Results pT1a was seen in 7.6% of patients, 37.7 % pT1b, 54.8 % pT1c. Concerning the 3 different cohorts, 58.2 % were ER+; 10.8 % were Her-2+; 8.2 % were TN. Overall, chemotherapy was given to 3.0 %, 27.2 %, 69.8 % of pT1a, b, c, respectively, and to 22.7 %, 58.8 %, 68.9 % of ER+, Her-2+, TN subgroups. At a median follow-up of 67 months, 5-year DFS was 96.3 %, 89.2 %, 89.4 % in pT1a, b, c, respectively (100 %, 93.6 %, 89.8 % in ER+; 100 %, 78.7 %, 85.0 % in Her-2+; 100 %, 76.8 %, 85.2 % in TN) (p = ns). At multivariate analysis, histologic grade and Ki-67 resulted independent prognostic factors. Overall, 5-year OS was 98 %, without differences among pT1a, b, c, or among the 3 cohorts. Conclusions Overall, 5-year DFS was very favorable in this series of small, node-negative breast cancers, but Her-2+ and TN cohorts have a higher recurrence rate than ER+ cohort (p

The aim of this study was to evaluate the clinical effectiveness of covered Niti-S stent placement under multidetector CT and fluoroscopy guidance for the palliation of dysphagia in patients with cervical esophageal cancer. Under radiological imaging guidance using axial and sagittal CT scans, and fluoroscopy, Niti-S esophageal stents were placed in ten consecutive patients with complete obstruction caused by cervical esophageal cancer (9 men and 1 woman; age range = 54–79 years; mean age = 68.1 years) between February 2010 and December 2011. The procedure time and technical success rate were evaluated. Swallowing improvement was assessed by the following items: ability to eat and/or swallow (graded as follows: 3 = ability to eat normal diet, 2 = ability to eat semisolids, 1 = ability to swallow liquids, 0 = complete obstruction). Procedural and post-procedural complications were also evaluated. Survival (mean ± SD) was examined. The mean (±SD) procedure time was 40 ± 19 min (range = 21–69 min). Stent placement was technically successful in all patients; inadequate stent deployment did not occur in any case. Ability to eat and/or swallow was improved and scored 2.4 (score 3 in 5 cases, score 2 in 4 cases, score 1 in 1 case, and score 0 in no case) after stent placement. No major or post-procedural complications were encountered. The mean survival time was 131 ± 77 days (range = 31–259 days). Niti-S stents appeared to be a safe and effective device for the palliation of dysphagia caused by advanced cervical esophageal cancer. Multidetector CT and fluoroscopy image guidance helped the operators accurately place the stents in the cervical esophagus.

Background Drug-coated balloons (DCBs) have been developed for the percutaneous treatment of coronary artery disease. An initial focus has been the management of in-stent restenosis (ISR) but randomised controlled trials (RCTs) have been small and powered only for angiographic endpoints. Objective The aim of the work was to assess the clinical and angiographic outcomes of patients treated for ISR with DCB versus control (balloon angioplasty or drug-eluting stents) by a meta-analysis of RCTs. Methods A comprehensive search was performed of RCTs where patients with ISR were randomly assigned to either DCB or alternative coronary intervention. Outcome measurements were death, myocardial infarction (MI), target lesion revascularisation (TLR), binary definition of restenosis and in-lesion late luminal loss (LLL). Results Four studies were identified that fulfilled the inclusion criteria. Pooled odds ratios (ORs) were calculated for patients treated for ISR (n = 399). Mean follow-up duration was 14.5 months. DCBs were associated with lower rates of TLR [8.8 vs. 29.7 % OR (95 % confidence interval, CI) 0.20 (0.11–0.36), p

Purpose Surgical treatment of an acute Achilles tendon rupture can effectively reduce the risk of re-rupture, but it increases the probability of surgical complications. We postulated that a minimally invasive surgical treatment might reduce the number of complications related to open surgery and improve the functional results. Method We enrolled 47 patients with acute Achilles tendon ruptures in a prospective, randomised trial to compare clinical results and complications between a minimally invasive procedure with the Achillon® device and traditional open surgery with Krackow-type sutures. The average patient age was 46 years. The follow up time was 24 months. Results No Achilles tendon re-rupture or nerve injury occurred in treated patients. There were two cases of wound infections in the open surgery group, and one superficial wound infection occurred in the minimally invasive group. The groups were not significantly different in the amount of pain, range of ankle movements, the single heel-rise test, calf circumference, or time to return to work and sports. Conclusion After a two year follow-up period, we found no significant differences in clinical outcomes between groups treated with traditional open surgery or minimally invasive surgery.

Objective We tested whether bedside testing for H-FABP is, alone or integrated in combination models, useful for rapid risk stratification of non-high-risk PE. Methods We prospectively studied 136 normotensive patients with confirmed PE. H-FABP was determined using a qualitative bedside-test showing a positive result for plasma concentration >7 ng/ml. Results Overall, 11 patients (8.1 %) had an adverse 30-day outcome. Of 58 patients (42.6 %) with a positive H-FABP bedside-test, 9 (15.5 %) had an unfavourable course compared to 2 of 78 patients (2.6 %) with a negative test result (p = 0.009). Logistic regression analysis indicated a sevenfold increased risk for an adverse outcome (95 % CI, 1.45–33.67; p = 0.016) for patients with a positive H-FABP bedside-test. Additive prognostic information were obtained by a novel score including the H-FABP bedside-test (1.5 points), tachycardia (2 points), and syncope (1.5 points) (OR 11.57 [2.38–56.24]; p = 0.002 for ≥3 points). Increasing points were associated with a continuous exponential increase in the rate of an adverse 30-day outcome (0 % for patients with 0 points and 44.4 % for ≥5 points). Notably, this simple score provided similar prognostic value as the combination of the H-FABP bedside-test with echocardiographic signs of right ventricular dysfunction (OR 12.73 [2.51–64.43]; p = 0.002). Conclusions Bedside testing for H-FABP appears a useful tool for immediate risk stratification of non-high-risk patients with acute PE, who may be at increased risk of an adverse outcome, in particular if integrated in a novel score without the need of echocardiographic examination.

Purpose Whilst excellent long-term results with contemporary uncemented stems have been reported for total hip arthroplasty in young patients, the survival rates for the whole reconstruction are often compromised by high failure rates on the acetabular site due to peri-acetabular osteolysis and accelerated wear. Methods In patients 60 years old or younger, we retrospectively reviewed the results at a minimum of ten years of 89 consecutive uncemented total hip replacements in 88 patients using the press-fit Fitmore acetabular component in combination with the CLS Spotorno stem and a 28-mm Metasul metal-on-metal articulation or a 28-mm alumina ceramic on conventional polyethylene bearing. The mean age at the time of surgery was 49 years (range, 25–60). The mean clinical and radiological follow-up was 12 years (range, 10–15). Results Six patients (six hips) died and two patients (two hips) were lost to follow-up. Five hips were revised: one for deep infection, one for peri-prosthetic femoral fracture, and one for aseptic stem loosening. In two hips an isolated revision of the acetabular liner was performed (one for recurrent dislocation and one for unexplained pain). No revision was performed for accelerated wear, osteolysis or aseptic loosening of the acetabular shell. We could not detect peri-acetabular osteolysis visible on plain radiographs in those hips evaluated radiographically. The Kaplan-Meier survival with revision for any reason as the endpoint was 94% (95% confidence interval, 86–97) at 12 years. Conclusions The survival rates and the radiological outcomes with this implant combination in this young and active patient group are encouraging when compared to the results reported for other uncemented cups in this age group.

PURPOSE: There is renewed interest in the all-polyethylene tibial component in total knee arthroplasty (TKA). Long-term results of this prosthesis in rheumatoid arthritis (RA) patients, however, are limited. Therefore, we studied 104 primary cemented all-polyethylene tibial TKA in 80 consecutive RA patients for up to 25 years to determine the long-term survival of all-polyethylene tibial components in patients suffering from end stage RA. METHODS: We estimated revision rates according the revision rate per 100 observed component years used in national joint registries. Kaplan-Meier was used to estimate survival curves. RESULTS: During the 25-year follow-up, three revisions for tibial component loosening were performed. The mean revision rate of all-polyethylene tibial components with revision for aseptic loosening as the endpoint was 0.09 per 100 observed component years. This corresponds to a revision rate of 0.9% after ten years and 2.25% after 25 years. Survivorship according to Kaplan-Meier was 100% at ten years and 87.5% at 25 years [95% confidence interval (CI) 64.6-100)]. CONCLUSION: This study shows good long-term results of all-polyethylene tibial TKA in patients with RA. RA patients with multiple-joint inflammation may be less physically active than osteoarthritis patients, resulting in a lower demand on the prosthesis, and these patients may, indeed, be good candidates for all-polyethylene tibial TKA. Our results suggest that all-polyethylene tibial TKA could be a successful and cost-saving treatment for end-stage knee arthritis in RA patients.

Background Studies have demonstrated sex differences in femoral shape and quadriceps angle raising a question of whether implant design should be sex-specific. Much of this research has addressed shape differences within the Caucasian population and little is known about differences among ethnic groups. Questions/purposes We therefore asked: Do shape differences in the distal femur and proximal tibia exist among different ethnic groups and between the sexes in each ethnic population? And if ethnic differences exist, do they have a clinical impact on current TKA design? Subjects and Methods We analyzed 1000 normal adult knees (80 African American, 80 East Asian, and 860 Caucasian). Three-dimensional surface models were created for each bone and added to three-dimensional statistical bone atlases. Statistical shape analysis was conducted with a process combining principal components and multiple discriminate analyses. Eleven femoral and nine tibial measurements were calculated. Results We found differences in mean measurements between the sexes and ethnicities. Males had larger knees, with a mean 5-mm-larger anteroposterior dimension than females in all ethnicities. African American females had a 7.4-mm-deeper patellar groove, 2.3-mm-smaller tibial mediolateral dimension, and 2.5-mm-larger tibial anteroposterior dimension than Caucasian females. African American males had a 4.3-mm-larger femoral anteroposterior dimension, 10.1-mm-larger tibial mediolateral dimension, and 6-mm-larger tibial anteroposterior dimension than Asian males. Conclusions We identified differences in three-dimensional knee morphology among Caucasian, African American, and East Asian populations. Clinical studies will be required to determine whether these differences are important for implant design.

Purpose The value of intraoperative neurophysiological monitoring (IONM) with surgical detethering in dysraphic patients has been questioned. A retrospective analysis of our series of 65 patients is presented with special focus on technical set-up and outcome. Methods All patients were diagnosed with a tethered cord (TC) due to spinal dysraphism. A high-risk group (HRG) was determined consisting of 40 patients with a lipomyelomeningocele and/or a split cord malformation sometimes in combination with a tight filum terminale. The surgical procedure was a detethering operation in all cases performed by a single surgeon during a 9-year period (1999–2008). A standard set-up of IONM was used in all patients consisting of motor-evoked potentials (MEP) evoked by transcranial electrical stimulation (TES) and electrical nerve root stimulation. In young patients, conditioning stimulation was applied in order to improve absent or weak MEPs. Results IONM responses could be obtained in all patients. Postoperative deterioration of symptoms was found in two patients of whom one patient belonged to the HRG. Mean maximal follow-up of all 65 patients was 4.6 years (median 4.1 years). Long-term deterioration of symptoms was found in 6 of 65 patients with a mean follow-up of 5 years (median 5.3 years). Conclusion The use of IONM is feasible in all TC patients. The identification of functional nervous structures and continuous guarding of the integrity of sacral motor roots by IONM may contribute to the safety of surgical detethering.

Background Malar mounds may be accentuated by chronic lid edema, with the development from malar edema to malar mounds and finally to malar festoons. Because standard techniques do not seem effective and not specifically proposed for the treatment of malar festoons, subperiosteal vertical upper-midface lift associated with lower blepharoplasty overcomes these shortcomings. Methods Twelve patients (3 males and 9 females, age = 47 ± 6 years) underwent video-assisted endoscopic subperiosteal vertical upper-midface lift (SUM-lift) in conjunction with a lower blepharoplasty between 2006 and 2007 for treatment of malar festoons. This includes simultaneous lower blepharoplasties and video-assisted transtemporal subperiosteal and sub-SMAS tissue release. Results All patients healed uneventfully without any major postoperative problems. The surgical outcome was evaluated according to the analysis of photographs obtained before and after surgery and the analysis of pre- and postoperative measurements. The technique we used (SUM-lift) achieved a significant rejuvenation of the midface and the malar festoons. Conclusion Subperiosteal vertical midface lift resuspends and redrapes the facial network that originates at the level of the orbital rim. It seems to improve the permeability characteristics of the malar septum in the treatment of malar festoons and malar mounds by freeing the cheek tissue from underlying bone and redraping the malar septum. It is a reliable technique to improve malar mounds, palpebral bags, or festoons.

The survival of acetabular components depends on several factors: wear, osteolysis and septic or aseptic loosening. Osteolysis seems to be the main cause for concern in cementless arthroplasties. Acetabular osteolysis results from particle debris and segmental unloading of acetabular bone by rigid sockets. We investigated a cementless elastic monoblock socket with regard to acetabular osteolysis and aseptic loosening in a cohort of young patients. We evaluated 158 hip arthroplasties with a minimum follow-up of ten years (ten to 18) and a mean age of 42 years (18–50). The overall revision rate at 14 years was 80% with a 98% survival rate for aseptic loosening. The mean polyethylene wear rate was 0.11 mm/year. Progressive acetabular osteolysis was seen in 3% of patients evaluated. In conclusion, we found low pelvic osteolysis rates, acceptable overall wear rates, satisfactory overall survival and excellent survival rates for aseptic loosening of a cementless elastic monoblock socket in patients younger than 50 years. Ongoing tribology developments and knowledge about acetabular bone adaptations behind acetabular implants will further lower wear and osteolysis rates and optimise survival rates of cementless sockets.

The purpose of this study was to evaluate concentrated autologous bone marrow aspirate transplantation (CABMAT) treatment for corticosteroid-induced osteonecrosis of the femoral head (ONFH) in systemic lupus erythematosus (SLE). Bone marrow was aspirated from iliac crests, concentrated on a conventional manual blood bag centrifugation technique that is used to extract buffy coats and then injected into nine hips with drilling. The mean number of nucleated cells for transplantation was 5.32 × 10(7) cells/ml. This cell concentration was significantly higher after concentration, and the mean concentration ratio was 5.5. At follow-up (minimum: three years), significant improvement in pain and Harris Hip Score was observed. For eight of nine hips, we successfully preserved the femoral head. However, one hip required total hip arthroplasty 45 months after the operation. CABMAT using our centrifugation technique is an effective, safe and low-cost procedure of therapeutic osteogenesis for corticosteroid-induced ONFH in SLE.

Purpose Untreated complete obstetric brachial plexus injury (COBPI) usually results in limited spontaneous recovery of shoulder function. Older methods used to treat COBPI have had questionable success, with very few studies being published. The purpose of the current study was to examine the results of triangle tilt surgery on shoulder function and development in COBPI individuals. Methods This study was conducted as a retrospective chart review. Inclusion criteria were COBPI patients that had undergone the triangle tilt procedure from 2005 to 2009 and were between the ages of 9 months and 12 years. COBPI was defined as permanent injury to all five nerve roots (C5–T1), with significant degradation in development and function of the hand. Twenty-five patients with a mean age of 5 (0.75–12) years were followed up clinically for more than 2 years. Results The triangle tilt procedure resulted in demonstrable clinical enhancements with appreciable improvements in shoulder function, glenoid version, and humeral head congruity. There was a significant increase in the overall Mallet score (2.4 points, p

Objective It is well known that 10–15% of hydrocephalus cases at childhood and 40–50% in premature infants, occur following Germinal matrix hemorrhage (GMH). Such hemorrhages are reported to arise due to the rupture of germinal matrix (GM) vessels as a result of cerebral blod flow changes among infants with

Background Bevacizumab is frequently combined with 5-fluorouracil-based chemotherapy for patients with metastatic colorectal cancer (mCRC). The relative benefit of bevacizumab in older patients has not been widely studied and is of interest. Patients and methods This retrospective analysis used data from three first-line randomized controlled studies and one second-line randomized controlled study of bevacizumab plus chemotherapy in medically fit (Eastern Cooperative Oncology Group performance status 0 or 1) patients with mCRC. Overall survival (OS) and on-treatment progression-free survival (PFS) were assessed in patients aged

This biographical sketch on Virgil Pendelton Gibney corresponds to the historic text, The Classic: Chapter XVIII. Operative Treatment in Chronic Articular Ostitis, available at DOI 10.1007/s11999-009-1165-3 .

The Baumann angle of the humerus has been commonly used as an outcome measure for supracondylar fractures in children. However, there is limited or no information about the reliability of this measurement. The purpose of this study was to determine the inter-observer reliability (IEOR) and intra-observer reliability (IAOR) of the Baumann angle of the humerus. The Baumann angle of the humerus was measured by five observers on the anteroposterior radiographs of 35 children’s elbows, all of which had sustained a nondisplaced supracondylar humeral fracture. The values of IEOR and IAOR were calculated using a Pearson coefficient of correlation. Ranges of differences in the measurement of the Baumann angle of the humerus were established, and the percentage of agreement between observers was then calculated using those ranges. The Baumann angle of the humerus is a simple, repeatable and reliable measurement that can be used for the determination of the outcome of supracondylar humeral fractures in the paediatric population. An excellent IEOR was found for the measurement of the Baumann angle (r = 0.78, p = 0.0001). When the difference between observers in the reported measurement of the Baumann’s angle was calculated to be within seven degrees of each other, at least four of the five observers agreed 100% of the time. Similarly, excellent values of IAOR were found for the measurement of the Baumann’s angle (r = 0.80, p = 0.0001). Level of evidence for this study was III.

We evaluated the influence of CT-free or CT-based computer assisted orthopaedic surgery (CAOS) on the alignment of total knee prostheses (TK) and micromotion of tibial components. This randomised study compared 19 CT-free, 17 CT-based CAOS TK, and a matched control group of 21 conventionally placed TK. Using Roentgen stereophotogrammetric analysis (RSA) the migration was measured. The alignment and component positions were measured on radiographs. No significant difference in leg and tibial component alignment was present between the three groups. A significant difference was found for micromotion in subsidence, with the conventional group having a mean of 0.16 mm, compared to the CT-free group at 0.01 mm and the CT-based group at −0.05 mm. No clinical significant difference in alignment was found between CAOS and conventionally operated TK. More subsidence of the tibial component was seen in the conventional group compared to both CAOS groups at two year follow-up.

Summary The present study estimated the 10-year probability using the Japanese version of WHO fracture risk assessment tool (FRAX™) in order to determine fracture probabilities that correspond to intervention thresholds currently used in Japan and to resolve some issues for its use in Japan. Introduction The objective of the present study was to evaluate a Japanese version of the WHO fracture risk assessment (FRAX™) tool to compute 10-year probabilities of osteoporotic fracture in Japanese men and women. Since lumbar spine bone mineral density (BMD) is used preferentially as a site for assessment, and densitometers use Japanese reference data, a second aim was to investigate the suitability and impact of this practice in Japan. Methods Fracture probabilities were computed from published data on the fracture and death hazards in Japan. Probabilities took account of age, sex, the presence of clinical risk factors and femoral neck BMD. Fracture probabilities were determined that were equivalent to intervention thresholds currently used in Japan. The difference between T-scores derived from international reference data and that using Japanese-specific normal ranges was estimated from published sources. The gradient of risk of BMD for fracture in Japan was compared to that for BMD at the lumbar spine in the Hiroshima cohort. Results The 10-year probabilities of a major osteoporosis-related fracture that corresponded to current intervention thresholds ranged from approximately 5% at the age of 50 years to more than 20% at the age of 80 years. The use of femoral neck BMD predicts fracture as well as or better than BMD tests at the lumbar spine. There were small differences in T-scores between those used for the model and those derived from a Japanese reference population. Conclusions The FRAX™ tool has been used to determine possible thresholds for therapeutic intervention, based on equivalence of risk with current guidelines. The approach will need to be supported by appropriate health economic analyses. Femoral neck BMD is suitable for the prediction of fracture risk among Japanese. However, when applying the FRAX™ model to Japan, T-scores and Z-scores should be converted to those derived from the international reference.

Extracorporeal shock wave lithotripsy (ESWL) is a non-invasive procedure that allows urinary stones to be fragmented using acoustic shock waves. The impact of the shock waves causes transient stinging pain at the entry site as well as deep visceral discomfort, requiring analgesia during the procedure. The objective of this study was to compare the clinical efficacy of Entonox and pethidine for pain relief during outpatient ESWL. We randomized 150 outpatients undergoing elective ESWL into three groups of 50 patients, each group receiving inhalational Entonox, intravenous pethidine, or inhalational compressed air during ESWL. Quantitative evaluation of pain was performed according to a visual analogue scale (VAS), before and after the intervention. Analysis of variance (ANOVA) and paired t tests were used to compare VAS scores in the three groups, before and after the intervention. Entonox and pethidine decreased the pain score significantly, while compressed air did not. There was no significant difference between pain relief by Entonox and pethidine. This study demonstrates for the first time that inhalational Entonox is an effective analgesic regimen for ESWL. Entonox can be regarded as an appropriate alternative to analgesics like opioids in relieving pain during ESWL.

The treatment of severe foot deformities in children or adolescents is complex and demanding to the surgeon. This paper describes the technical strategy of using a Taylor spatial frame and reports on the functional outcome.The Taylor spatial frame was used by a single surgeon in patients with severe foot deformities. Seven patients with eight severe deformities were treated. Mean patient age at surgery was 15.1 (9-29) years. A double Taylor spatial frame reconstruction was mounted to the limb. All patients had a midtarsal osteotomy and an additional inverse dome-shaped calcaneus osteotomy. Assessed measures were pre- and postoperative deformity and associated complications and clinical results according to Ferreira et al.Mean follow-up was 576.5 (359-987) days. The final functional outcome according to Ferreira was good in seven cases, fair in none, and poor in one. Early complications included pin-tract infection, temporary hypoesthesia, and temporary shortening of the tendon of the M. flexor digitorum. At follow-up there was no deformity recurrence.In children or adolescents, the innovative treatment using the Taylor spatial frame and a double osteotomy allows joint-preserving correction of severe foot deformities. However, the complication rate is relatively high due to the severely deformed feet. Furthermore, the Taylor spatial frame is expensive. Thus, this treatment is only recommended for severe foot deformities and should be handled by experienced orthopedic surgeons.

The renewed popularity of resurfacing hip arthroplasty in the last 10 years has generated a remarkable quantity of scientific contributions based on mid- and short-term follow-up. More than one paper has reported a consistent early revision rate as a consequence of biological or biomechanical failure. Two major complications are commonly described with resurfacing implants: avascular necrosis and femoral-neck fracture. A close relationship between these two events has been suggested, but not firmly demonstrated, whereas cementing technique seems to be better understood as potential cause of failure.We performed an in vitro study in which four different resurfacing implants were evaluated with a simulated femoral head, two types of cement, (low and high viscosity) and two cementing techniques: direct (cement apposition directly on the femoral head) and indirect (cement poured into the femoral component).High-viscosity cement showed homogeneous distribution over the entire femoral head. Low-viscosity cement showed a massive polar concentration with insufficient, if not absent, distribution in the equatorial zone.Polar cement concentration could be a risk factor for early implant failure due to two effects on the femoral head: biological (excessive local exothermic reaction could cause osteocyte necrosis) and biomechanical (which could lead to uneven load distribution on the femoral head).

Chronic lateral ankle instability causes significant problems in physical activity and accelerates development of osteoarthritic changes. The results of treatment for chronic ankle instability are often meets controversial. A surgical reconstruction of ATFL as described in this paper was performed during the period 1997–2005 on 47 patients (26 male, 21 female), with a mean age of 29.3 years. The average follow-up period was 46.2 months. All patients had clinical examination, X-ray and MRI. The mean values of the Good score improved from an average 3.32 prior to surgery to 1.19 one year after the operation. Paired t-tests showed improvements of great significance (p

A series of 49 pilon fractures in a tertiary referral centre treated definitively by open reduction and internal fixation have been assessed and the complications of such injuries examined. A retrospective analysis of case notes, radiographs and computerised tomographs over a seven-year period from 1999–2006 was performed. Infection was the most common postoperative problem. There were seven cases of superficial infection. There was a single case of deep infection requiring intravenous antibiotics and removal of metalwork. Other notable complications were those of secondary osteoarthritis (three cases) and malunion (one case). The key finding of this paper is the 2% incidence of deep infection following the direct operative approach to these fractures. The traditional operative approach to such injuries (initially advocated by Ruedi and Allgower in Injury 2:92–99, 1969) consisted of extensive soft tissue dissection to gain access to the distal tibia. Our preferred method is to access the tibia via the “direct approach” which involves direct access to the fracture site with minimal disturbance of the soft tissue envelope. We therefore believe that open reduction and internal fixation of pilon fractures via the direct approach to be a safe technique in the treatment of such devastating injuries.

Since its inauguration by Gerber in 1988, the latissimus dorsi transfer has become an established surgical option for non-reconstructable, massive posterosuperior rotator cuff tears. We describe 26 consecutive patients, all of whom underwent a latissimus dorsi transfer using a modified single incision mini-invasive Herzberg transfer. The primary focus of this paper was to compare the applied clinical results of this new technique with the published results of the Gerber technique. Following transfer of the latissimus dorsi to restore external rotation, 26 patients were evaluated. The mean age was 60 +/- 18 years. The patients were examined after surgery at an average of 24 months (range: 12-41). The unweighted Constant score rose from 20 (range: 13-34) to 56 (range: 63-81). The acromiohumeral distance remained statistically unchanged from an initial value of 4.7 mm (1-9 mm) to a postoperative value of 4.8 (2-11 mm). In the Hamada classification the level of rotator cuff defect arthropathy increased from 1.7 (1-3) to 1.8 (1-3). On the basis of its low morbidity rate, the latissimus dorsi transfer in Herzberg's modified technique is a sensible alternative to the technique initially described by Gerber, especially when the initial situation exhibits pre-existing weakness of the deltoid muscle.

Classical ballet is an art form requiring extraordinary physical activity, characterised by rigorous training. These can lead to many overuse injuries arising from repetitive minor trauma. The purpose of this paper is to report our experience in the diagnosis and treatment of stress fractures at the base of the second and third metatarsal bones in young ballet dancers. We considered 150 trainee ballet dancers from the Ballet Schools of "Teatro Alla Scala" of Milan from 2005 to 2007. Nineteen of them presented with stress fractures of the base of the metatarsal bones. We treated 18 dancers with external shockwave therapy (ESWT) and one with pulsed electromagnetic fields (EMF) and low-intensity ultrasound (US); all patients were recommended rest. In all cases good results were obtained. The best approach to metatarsal stress fractures is to diagnose them early through clinical examination and then through X-ray and MRI. ESWT gave good results, with a relatively short time of rest from the patients’ activities and a return to dancing without pain.

The objective of this paper was to assess the efficacy of cementation of the femoral head in stage III glucocorticoid-induced osteonecrosis. Ten hips (nine patients) were treated by the injection of low-viscosity cement to reduce the collapse. The follow up included clinical and radiological assessments preoperatively and at 3, 6 and 12 months after surgery. The visual analogue scale (VAS) score, the Lequesne index and the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) score did not show any significant improvement. Eight of the ten hips showed a worsening of the collapse and required total hip arthroplasty during follow up. The mean time before total hip replacement was 8.6 +/- 7 months. The other two hips did not show any relapse of collapse nor functional worsening at the maximum follow up of 5 years. Our results suggest that cement injection is not a treatment that should be proposed for glucocorticoid-induced osteonecrosis.

This biographical sketch on Ernest Amory Codman corresponds to the historic text, The Classic: The Registry of Bone Sarcomas as an Example of the End-Result Idea in Hospital Organization, available at DOI 10.1007/s11999-009-1048-7 and The Classic: Registry of Bone Sarcoma: Part I.-Twenty-Five Criteria for Establishing the Diagnosis of Osteogenic Sarcoma. Part II.-Thirteen Registered Cases of "Five Year Cures" Analyzed According to These Criteria, available at DOI 10.1007/s11999-009-1049-6 .

The purpose of this paper was to evaluate the results of acetabular revisions with the use of an oblong revision cup that is designed with its longitudinal diameter elongated relative to its transverse diameter. Between 1996 and 2001, 62 hips in 60 patients underwent an acetabular revision with the insertion of a LOR acetabular component. Seven hips were lost to follow-up or the patients died; the remaining 55 hips (53 patients) remained in follow-up for an average of 7.2 years (range: 5.0–10.1 years). One socket was revised for aseptic loosening, and another was operated on for a late polyethylene liner dissociation. The average Harris hip score (HHS) improved from 34 to 79. Results were rated as excellent in 16 hips, good in 28, fair in six and poor in three. Radiographic analysis demonstrated an improvement in the average vertical displacement of the hip centre: 49 hips had a well-fixed, bone-ingrown cup and four had a stable fibrous union. For large superolateral acetabular bone deficiencies, this implant facilitated a complex reconstruction without the need for bulk structural acetabular bone grafts, provided good clinical results and showed satisfactory stability at the midterm follow-up.

Purpose: Along with the increase in primary total knee arthroplasty, there has been an increase in the number of revisions. The aim of this study was to propose a selection algorithm for the knee revision constraint according to the state of ligaments and to the bone defects Anderson Orthopaedic Research Institute Classification [AORI] classification. The hypothesis was that this algorithm would facilitate the appropriate choice of prosthesis constraint, thus providing stable components and a good long-term survivorship of the knee revisions. Methods: Sixty consecutive revision knee arthroplasties in 57 patients were prospectively evaluated. Prostheses implanted at revision included postero-stabilised, condylar constrained and rotating hinged, relative to the state of the ligaments and of the bone loss around the knee. The median follow-up was nine years (range, 4-12). Results: The median IKS knee and function scores and HSS score were 41 (15-62), 21.5 (12-43) and 34 (23-65) points, respectively, before the operation, and 81 (48-97), 79 (56-92) and 83.5 (62-98) points (p < 0.001) at the latest follow-up evaluation. The median ROM increased from 74 (29-110) preoperatively to 121 (98-132) (p < 0.01) at the final follow-up. Re-revision was necessary in five (8.3 %) patients. Conclusions: A selection algorithm for the revision implant constraint based on the state of ligaments and the bone loss AORI classification could provide stable knee reconstructions and long-term success of knee revisions. © 2013 Springer-Verlag Berlin Heidelberg.

Hip perforation is a major complication in proximal femoral nailing. For biaxial nails, knowledge of their biomechanics is limited. Besides re-evaluation of accepted risk factors like the tip-apex distance (TAD), we analysed the influence of anti-rotational pin length.We compared 22 hip perforation cases to 50 randomly chosen controls. TAD, lag-screw position, angle between lag-screw and femoral neck axis, lag-screw gliding capacity, displacement and anti-rotational pin length were investigated.Hip perforation was associated with a higher angle of deviation between lag-screw and femoral neck axis (p = 0.001), a lower telescoping capacity of the lag screw (p = 0.02), and higher TAD (p = 0.048). If the anti-rotational pin exceeded a line connecting the tip of the nail and the lag screw (NS line), hip perforation incidence was increased (p = 0.009). Inadequate pin length resulted in an odds ratio of 10.8 for hip perforation (p = 0.001).In biaxial nails anti-rotational element positioning is underestimated, however, crucial.

Three-dimensional computerised tomography (3DCT) can provide comprehensive patho-anatomy of complex bone on a single image. Though important, the key articular quadrilateral [Q] surface has not been a part of the systems developed for classifying acetabulum fractures. The purpose of the study was to simplify the complexity of classification by the direct sign of the broken Q surface which lies opposite the entire floor of the acetabulum.The study reviewed 84 acetabular fractures using 3DCT images of the interior lateral view (IL) taken between June 2002 to December 2009. Fractures were traditionally classified using the anatomical disruption, plane of the fracture line breaking through or not through the bone column described by Judet and Letournel.The 3D images clearly show the primary site of impaction acting on the acetabulum and the whole course of fracture. The image could not illustrate disruption of the lips of acetabulum and congruity of hip joints in 20 cases of wall (W) fracture. There were 30 transverse (T) fractures classified when the acetabulum was divided horizontally from front to back into upper and lower parts and 34 cases of column (C) fracture when the main vertical lines run and collide along the anterior and posterior column.This study showed that the well-known complex fractures can be satisfactorily classified with the broad flat inner plane of the Q surface.

Pigmented villonodular synovitis (PVNS) is a relatively rare, benign proliferation lesion of the synovium of large joints, but there is not much information available about the disease's aetiology, clinical history, differential diagnosis, treatment, and long-term effects. We conducted a study to analyse these aspects of PVNS.We reviewed all clinical data for 75 patients with PVNS (81 joints) who were treated either by synovectomy alone or synovectomy plus arthroplasty.In all cases, the diagnosis of PVNS was confirmed by pathological examination. The ratio of males to females was 27:48, and the average age of patients was 46 years (range, 15-80 years). Lesions were located in the knee, hip, or ankle, and pain and swelling were the main symptoms. Of 75 patients, 42 had a history of trauma to the involved joint. Forty-one patients (43 joints) underwent synovectomy alone, and 34 patients (38 joints) underwent synovectomy and arthroplasty together. Of the 75 patients, 61 had full follow-up data. Twelve patients had recurrent legions detected by pathological examinations; four patients had more than two recurrences. Moreover, five patients developed PVNS after arthroplasty.PVNS occurs most often in middle-aged women and most frequently involves the knee, followed by the hip and ankle. The disease's etiology is varied and unclear. Surgical excision alone or with arthroplasty is an effective treatment, but there is a high rate of recurrence.

The purpose of this study was to investigate kinematic factors affecting postoperative knee flexion after cruciate-retaining (CR) total knee arthroplasty (TKA) by analysing pre- and postoperative knee kinematics.We retrospectively analysed 58 patients with osteoarthritis who received the same implant series. Pre- and postoperative kinematics were measured intraoperatively using a navigation system. As a clinical outcome, we measured the knee flexion angle before and one year after surgery. Correlations among pre- and postoperative kinematics and postoperative flexion were analysed using simple linear regression analyses.Preoperative knee kinematics, including tibial internal rotation and anterior translation (R = 0.87, P 0.001; R = 0.53, P 0.001, respectively), were significantly correlated with postoperative kinematics. Preoperative varus-valgus movements improved significantly postoperatively; however, tibial internal rotation remained unchanged. Furthermore, postoperative knee flexion angle was significantly correlated with postoperative tibial internal rotation (R = 0.45, P 0.001).Preoperative knee kinematics were unchanged even after CR-TKA. Postoperative tibial internal rotation is one of the most important factors affecting postoperative knee flexion.

Although the resumption of low-impact sports activities is compatible with total hip arthroplasty (THA), participation in high-impact sports seems problematic, and there is no consensus as to whether it is advisable. The purpose of this article is to evaluate the quality and possibility of resuming high-impact physical activities after hip resurfacing.The study was performed in an on-going, single-surgeon, prospective series of 215 resurfacing arthroplasties (RSA). Mean follow-up was 44.1 months (range, 39.1-54.5). Clinical evaluation included the Postel-Merle d'Aubigné (PMA) score, the Oxford hip score, the Harris hip score (HHS), Devane score, and UCLA activity score. A specific questionnaire analysing sports activities was administered to each patient to assess the number and level of physical activities performed (both before the operation and at final follow-up).In the series of 202 consecutive patients (215 RSA), 50 patients (55 RSA) engaged regularly in at least one high-impact activity before their operation and the onset of pain, 102 patients practised at least one intermediate-impact activity, and the 50 remaining patients undertook only low-impact activities. Harris hip score increased from 44.8 (range, 23-68) before the operation to 97.8 (range, 85-100) at the last follow-up. Mean time to sports resumption after surgery was 14.6 weeks (range, 7-29). The resumption rate was 98 % for sports of any impact level and 82 % for high-impact activities. No osteolysis or implant loosening was observed at follow-up. No revision was performed.In 2012, no consensus recommendations yet exist for the resumption of sports activities after RSA. Existing recommendations concern only conventional THA. We believe that RSA allows younger and more active patients to resume physical and sports activities without restriction. The rate of return to sports after RSA appears to be excellent and unequalled by conventional hip prostheses. High-impact sports seem to be compatible with hip resurfacing, although no long-term studies have analysed the impact of these activities on wear and/or aseptic loosening.

The haematoma at a fracture site plays an important role in fracture healing. Previously, we demonstrated that a fracture haematoma contains multilineage mesenchymal progenitor cells. We postulated that the haematoma provided a source of chondrogenic cells for endochondral ossification during fracture healing and preservation of the cells contributed to biological fracture healing. In this study, we investigated whether haematoma-derived cells (HCs) could differentiate into hypertrophic chondrocytes and finally induce calcification of the extracellular matrix in vitro.Fracture haematomas were obtained from four patients. HCs were cultured for five weeks under conditions that induce chondrogenic differentiation, followed by two weeks of hypertrophic induction using a pellet culture system. The pellets were analysed histologically and immunohistochemically. The gene expression levels of chondrogenic, hypertrophic, osteogenic, and angiogenic markers were measured by real-time PCR.The histological and immunohistochemical analyses revealed that HCs differentiated into chondrocytes and hypertrophic chondrocytes, followed by calcification of the extracellular matrix. This sequential differentiation was also reflected in the gene expression profiles. After chondrogenic induction, expression of osteogenic and angiogenic markers was not significantly upregulated. However, the expression of these markers was significantly upregulated following hypertrophic induction. These in vitro observations mimicked the process of endochondral ossification during fracture healing.Our results suggest that the fracture haematoma may offer a source of cells with chondrogenic potential that play key roles in endochondral ossification during fracture healing. These findings support the opinion that the haematoma should be preserved for biological fracture healing.

Post arthroplasty gait analysis has up till now been performed on subjects walking slowly on flat ground rather than challenging them at faster speeds or walking uphill. We therefore asked: (1) Is there a measurable difference in the performance of hip resurfacing arthroplasty (HRA) and total hip arthroplasty (THA) limbs at patients' self-determined fastest walking speeds and steepest inclines? and (2) Is there a relationship between the observed differences between the gait of HRA and THA implanted limbs and patient walking speeds and inclines.In an ethically approved study we recruited patients with bilateral hip arthroplasties: one HRA and one THA. Nine subjects were assessed using an instrumented treadmill at a range of speeds and inclines by a blinded observer. The ground reaction forces of subjects were recorded and an age, sex and BMI matched control group was used for comparison.Increasing walking speed correlated strongly with between leg differences in weight acceptance (r = 0.9, p = 0.000) and push-off force (r = 0.79, p = 0.002). HRA implanted limbs accepted significantly more weight at top walking speeds (1208 N ± 320 versus 1279 N ± 370, p = 0.026) and pushed off with greater force when walking uphill (818 N ± 163 versus 855 ± 166, p = 0.012). HRA limbs more closely approximated to the gait of the normal control group.Arthroplasty implants do have an impact on the gait characteristics of patients. Differences in gait are more likely to be evident when assessment is made at fast speeds and walking uphill. This study suggests that HRA may enable a more normal gait.

The purpose of this study was to examine retrospectively the effectiveness of Sugioka's transtrochanteric valgus osteotomy (TVO) combined with the shelf procedure for patients who had advanced osteoarthritis (OA) of the hip with severe acetabular dysplasia.Sixty-two hips in 61 patients were reviewed retrospectively between April 1993 and March 2009. Of these hips, 25 hips with the pre-operative acetabular head index (AHI) ≥ 60 % (single group) underwent a TVO, whereas the other 37 with AHI60 % (combined group) underwent a TVO combined with the shelf procedure.Using conversion to total hip arthroplasty as the endpoint, the Kaplan-Meier survival rates at ten years were calculated to be 85.5 % for the single group and 100 % for the combined group; there was a significant difference between the two groups (p 0.05, log-rank test). Similarly, calculated using progressive OA as the endpoint, survival rates at ten years were 69.5 % and 89.3 % respectively; there was also a significant difference between the two groups (p0.05, log-rank test). In the single group, the latest radiographic evaluations of the patients with the pre-operative AHI ≥ 70 % were significantly better than those of the patients with the pre-operative AHI70 % (P 0.05).More satisfactory ten year results of TVO were obtained in cases that had a pre-operative AHI of ≥70 %, or where the shelf procedure was added. It is desirable that acetabuloplasty be added for patients with pre-operative AHI70 %.

Individual physiological knee kinematics are highly variable in normal knees and are altered following cruciate-substituting (PS) and cruciate-retaining (CR) total knee arthroplasty (TKA). We wanted to know whether knee kinematics are different choosing two different knee designs, CR and PS TKA, during surgery using computer navigation.For this purpose, 60 consecutive TKA were randomised, receiving either CR (37 patients) or PS TKA (23 patients). All patients underwent computer navigation, and kinematics were assessed prior to making any cuts or releases and after implantation. Outcome measures were relative rotation between femur and tibia, measured medial and lateral gaps and medial and lateral condylar lift-off.We were not able to demonstrate a significant difference in femoral external rotation between either group prior to implantation (7.9° CR vs. 7.4° PS) or after implantation (9.0° CR vs. 11.3° PS), both groups showed femoral roll-back. It significantly increased pre- to postoperatively in PS TKA. In the CR group both gaps increased, the change of the medial gap was significantly attributable to medial release. In the PS group both gaps increased and the change of the medial and of the lateral gap was significant. Condylar lift-off was observed in the CR group during 20° and 60° of flexion.This study did not reveal significant differences in navigation-based knee kinematics between CR and PS implants. Femoral roll-back was observed in both implant designs, but significantly increased pre- to postoperatively in PS TKA. A slight midflexion instability was observed in CR TKA. Intra-operative computer navigation can measure knee kinematics during surgery before and after TKR implantation and may assist surgeons to optimise knee kinematics or identify abnormal knee kinematics that could be corrected with ligament releases to improve the functional result of a TKR, whether it is a CR or PS design. Our intra-operative finding needs to be confirmed using fluoroscopic or radiographic 3D matching after complete recovery from surgery.

To investigate the curative efficacy of osteonecrosis of the femoral head (ONFH) in a hip-preserving operative approach, by grafting a vascularized greater trochanter flap combined with a free iliac flap, in an attempt to seek an innovative approach for patients who suffered middle to late stage ONFH without total hip arthroplasty (THA) surgery.Our research included a total of 60 patients (66 hips) who accepted hip-preserving surgery by grafting a vascularized greater trochanter flap combined with a free iliac flap which was tightly filled by hammering because of ONFH (most were Association Research Circulation Osseous (ARCO) stage III patients) from January, 2006 to December, 2010. A Harris Hip Score was obtained during follow-ups, evaluating the clinical efficacy, X-rays were taken regularly for image assessing, and the SF-36 scale was used for estimating quality of life. Terminal observation time was considered when patients had symptom-dependant indications for performing another hip-preserving surgery or THA surgery.Fifty-eight patients (64 hips) were eventually contacted by telephone for an out-patient clinic return visit, with a mean follow-up time of 35.8 months (varied from 12 months to 60 months), but two patients lost contact for various reasons. The demographic data were as follows: there were 16 ARCO IIIA cases, 22 ARCO IIIB cases, and 26 ARCO IIIC cases, respectively. Postoperative X-rays revealed a well-repaired necrotic area of the femoral head and improvement of femoral-acetabulum coverage. The last follow-up mean Harris Hip Score was 86.56 ± 7.38 (excellent results reached 87.50%), which were greatly improved compared to 50.95 ± 6.86 pre-operatively. Also the postoperative mean scores of all dimensions of the SF-36 scale were improved to some extent. Additionally the physical component summary (PSC) scores were enhanced from 42 ± 13 pre-operatively to 78 ± 11, while the postoperative mental component summary (MCS) scores (76 ± 11) largely increased in contrast to pre-operative scores (51 ± 10), with both target indices having statistical significance (p = 0.005, p = 0.01), signifying hugely improvement of the quality of life of the patients. A correlation was found between Harris Hip Score and all dimensions of SF-36 scale (r = 0.32-0.72), especially closely correlated with physical functioning (PF), role-physical (RP) and bodily pain (BP) in PCS aspect (r = 0.72, p 0.01; r = 0.58, p 0.01; r = 0.65, p 0.01, respectively).There is definite curative efficacy for the treatment of ONFH with an hip-preserving operative approach by grafting a vascularized greater trochanter flap combined with a free iliac flap which was tightly filled by hammering. This kind of operative approach reconstructs the biological stability of femoral head, which promotes repair of necrotic areas and indirectly preserves the femoral head of patients and a majority of hip function. It possesses vast clinical as well as practical significance, because the long-term efficacy can satisfy fundamental life requirements, especially for those young and middle-aged patients who suffer ONFH to avoid or put off the time of total hip arthroplasty (THA) surgery.

The aim of this study was to investigate the expression of insulin-like growth factor (IGF)-1 and programmed cell death 5 (PDCD5) in osteoarthritis chondrocytes, and to explore the potential correlation between them in the apoptosis process of osteoarthritis chondrocytes.Patients with knee osteoarthritis were placed into four categories according to radiological staging. The mRNA and protein levels of IGF-1 and PDCD5 in osteoarthritis chondrocytes were respectively detected by quantitative reverse transcriptase polymerase chain reaction (qPCR) and western blotting. In addition, IGF-1 and PDCD5 protein expression in chondrocytes were also measured by immunohistochemistry. Apoptotic cells were measured by TUNEL staining.Both the mRNA and protein levels of IGF-1 were down-regulated, while the levels of PDCD5 were up-regulated, and the mRNA and protein levels of IGF-1 were negatively correlated with those of PDCD5, respectively. The apoptotic cell was significantly increased in osteoarthritis chondrocytes compared with control. Importantly, the apoptosis rate was positively correlated with PDCD5 protein expression and negatively correlated with IGF-1 protein expressionWe concluded that IGF-1 may down-regulate the expression of PDCD5 and thus inhibit the apoptosis of osteoarthritis chondrocytes.

The functional results after reconstruction of the proximal humerus in tumour surgery are poor. Therefore, a reversed proximal humerus replacement was developed in our institution (MUTARS humerus inverse). A low degree of wear on the polyethylene is required because of the patients' youth and demands on shoulder function. A special type of polyethylene with shock-absorbing properties has been developed to minimise polyethylene wear in the MUTARS inverse proximal humerus replacement. We compared the tribological properties of an anatomical shoulder prosthesis (CAPICA) with the new reversed proximal humerus replacement (MUTARS humerus inverse).Both prostheses were tested up to 5 × 10(6) cycles. Every millionth cycle the surface was inspected and a gravimetric measurement was performed. A measurement of surface roughness was done before testing and after 5 × 10(6) cycles.In both prostheses after 5 × 10(6) cycles there were no major defects, such as delamination, observed. In the reversed proximal humerus replacement abrasion of 28 mg/10(6) cycles was detected. The mean abrasion of the anatomical prosthesis was 9.28 mg/ 10(6) cycles.The glenoid component of the first reversed humerus replacement (MUTARS humerus inverse) has wear properties comparable to those of normal reversed shoulder prostheses. This is important, as this type of prosthesis is used in young patients after resection of bone tumours, with a good functional outcome. It can, therefore, be expected that the revision rate due to wear will be as high as in patients with normal reversed shoulder prostheses.

Purpose The aim of this study was to investigate the biomechanics of the pelvis reconstructed with a modular hemipelvic prosthesis using finite element (FE) analysis.

Based on biomechanical cadaver studies, anatomical double-bundle reconstruction of the anterior cruciate ligament (ACL) was introduced to achieve better stability in the knee, particularly in respect of rotatory loads. Previously, the success of ACL reconstruction was believed to be mainly dependent on correct positioning of the graft, irrespective of the number of bundles for which computer-assisted surgery was developed to avoid malpositioning of the tunnel. The aim of this study was to compare rotational and translational stability after computer-navigated standard single-bundle and anatomical double-bundle ACL reconstruction.The authors investigated 42 consecutive patients who had undergone the single-bundle or double-bundle ACL reconstruction procedure using autogenous hamstring tendon grafts and ENDOBUTTON fixation in patients who had been followed up for a minimum of 24 months. Post-operative anteroposterior and rotational laxity was measured with the KT3000 and compared between groups.Both surgical procedures significantly improve rotational and translational stability compared to the preoperative ACL-deficient knee (P0.05). No significant differences were registered between groups with regard to anteroposterior displacement of the tibia. The International Knee Documentation Committee (IKDC) and Lysholm scores were significantly higher in the double-bundle group. However, the results were excellent in both groups.The use of computer-assisted ACL reconstruction, which is a highly accurate method of graft placement, could be useful for inexperienced surgeons to avoid malposition. Long-term results of at least five years are needed to determine whether double-bundle ACL reconstruction, which was associated with improved rotational laxity and significantly better IKDC and Lysholm scores compared to the standard single-bundle ACL reconstruction procedure, exerts an influence in terms of avoiding osteoarthritis or meniscus degeneration.