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A successful osseointegration relies on the interplay of implant surface and surrounding bone marrow cells. This study was undertaken to investigate the impact of age and gender on the bone marrow composition.Bone marrow aspirates were obtained from the discarded metaphysis region of the femoral head in 24 patients with total hip replacement. Flow cytometry was used to measure the expression of Stro-1(+) cells and BMP receptors (BMPRs)-expressing cells. ELISA was used to measure bone marrow aspirate bone morphology protein7 (BMP7) concentration.Our data demonstrates that there are diverse bone marrow profiles (Stro-1(+) cell and BMPRs(+) cells). There are no differences of Stro-1(+) cells, BMPRs(+) cells, and BMP7 concentration between male and female patients. Though there are slight increases in the number of Stro-1(+) cells and BMPRs(+) cells in younger patients (70 years old) than those of old patients (≥ 70 years old), the difference is not statistically significant. However, we found a close association between the Stro-1(+) cells, BMPR1a cells and BMP7 concentration. In addition, a correlation exists between the number of Stro-1(+) cells and BMIs of these patients.Our data suggests that the age and gender of THR patients have little impact on their bone marrow osteogenic potential. The significance of the number of the Stro-1(+) with BMPRs expression on the implant fixation and osseointegration warrants further investigation.

The study was carried out to report the results of wide resection in sacral chordoma using a posterior approach and gauze packing technique.The study was carried out between 1990 and 2002; there were 21 patients who underwent the operation. Fourteen patients were male and seven were female. Their ages ranged between 29 and 75 years. Most of the patients presented with sacral mass, pain and neurological deficit. Total sacrectomy and bone reconstruction were carried out in 12 patients. Subtotal sacrectomy was carried out in the remaining nine patients. All patients were followed up for at least seven years.All survived after the operation. Operative time ranged between five and ten hours. All patients needed blood transfusion which ranged between four and 11 units. After the operation, all patients had a certain degree of bowel and bladder dysfunction. Five patients had local complications including infection in three patients with wound disruption and two patients with a seroma. During the follow-up, three patients (14%) had tumour recurrence and one of the patients expired. The remaining 18 patients were still tumour-free at the seven-year follow-up.Wide resection via the posterior approach and gauze packing technique could be used for management of sacral chordoma with acceptable results.

The purpose of this study was to evaluate clinical outcomes following one-stage anterior radical debridement, interbody fusion, and sacral rod fixation for the treatment of lumbosacral segment tuberculosis.From March 2004 to November 2008, 11 patients diagnosed with spinal tuberculosis received antituberculosis medications for two to three weeks before anterior radical debridement, autologous iliac bone grafting, and internal sacral rod fixation. Surgery was performed when the toxic symptoms of tuberculosis were controlled and erythrocyte sedimentation rates (ESR) decreased to 37.2 ± 9.6 mm/h (25-54 mm/h). Lumbosacral angle, visual analogue scale (VAS) pain, ESR, and neurological performance were assessed before and after surgery.All surgical procedures were performed successfully without intra or postoperative complication. There were no instances of spinal tuberculosis recurrence. Patients were followed-up for a mean of 19.6 months. The mean lumbosacral angle was significantly increased from the mean preoperative angle (12.9 ± 5.0°) both postoperatively (21.5 ± 6.1°) and at final follow-up (20.1 ± 5.2°) (both P0.001). The mean VAS scores and ESR were significantly decreased from preoperative levels (7.3 ± 1.2 and 37.2 ± 9.6 mm/h, respectively) both postoperatively (1.5 ± 0.5 at month six and 10.4 ± 4.5 mm/h at month three, respectively) and at final follow-up (0.6 ± 0.5 and 10.5 ± 2.3 mm/h, respectively) (all P0.001). Bone fusion occurred in all patients at a mean of nine months (range six to 12 months) after surgery. Three patients who had impaired neurological performance before surgery had normal neurological performance after surgery.Our findings suggest that anterior radical debridement, interbody fusion, and sacral rod fixation can be an effective treatment option for lumbosacral segment tuberculosis.

Assessment of patient function after TKA often focuses on implant alignment and daily activity capabilities, but the functional results and kinematics of the TKA are not easily predicted by some of these parameters during surgery.We asked whether differences in implant alignment in the transverse plane may affect fluorokinematics and be one of the many variables that help explain the discrepancies in fluorokinematic results.We utilized a computer model (LifeMOD™/KneeSIM; LifeModeler, Inc, San Clemente, CA, USA) to show variability in polyethylene contact patterns. We imported components of a cruciate-retaining TKA into the model and subjected the systems to a simulated lunge. We modeled five different combinations of implant positioning in the transverse plane of both the femoral and tibial components in internal or external rotation and compared the resulting changes in joint rotations and displacements of these five variations to those for published fluorokinematic observations using the same modeled lunge-type maneuver for five patients.We observed variations in AP translation of the lateral and medial femoral condyles resembling several of those in the literature for individual patients with the same cruciate-retaining knee implant. The largest AP translational changes were seen with the tibia internally rotated 5°. Using the five different implant transverse plane alignment scenarios resulted in a coefficient of determination of 0.6 for the linear regression when compared to five subjects from a published fluorokinematic study.Variations in implant positioning may be responsible for variations in fluorokinematics reported for individual subjects with the same implant design.

One of the most commonly used local anesthetic techniques in dentistry is the Fischer’s technique for the inferior alveolar nerve block. Incidentally this technique also suffers the maximum failure rate of approximately 35–45%. We studied a method of inferior alveolar nerve block by injecting a local anesthetic solution into the pterygomandibular space by arching and changing the approach angle of the conventional technique and estimated its efficacy. The needle after the initial insertion is arched and inserted in a manner that it approaches the medial surface of the ramus at an angle almost perpendicular to it. The technique was applied to 100 patients for mandibular molar extraction and the anesthetic effects were assessed. A success rate of 98% was obtained.

Ptosis occurs when the muscles that raise the upper eyelid (levator and Muller’s muscle) get damaged. There are lot of ptosis correction surgery reported in the journals of oculoplastic surgery and opthalmic surgery. Most of these surgeries are cosmetic correction. Rarely ptosis can be seen as a complication following orbitozygomatic complex injuries. Cause of traumatic ptosis most often is levator detachment from the superior tarsal plate. Lacerations of the lid may sever the levator tendon leading to scarring and secondary mechanical ptosis. Challenge in surgical management lies in identification of Levator aponeurosis, posterior to orbital septum and preaponeuratic fat. Once the levator muscle is freed from scar tissue it should be reapproximated to tarsal plate.

Labial and nasal deformities have always been a fundamental problem in the treatment of cleft lip, alveolus and palate patients. The primary surgical treatment of nasolabial area is of paramount importance in order to obtain both an esthetical correction of the deformity and a progressive and a balanced development of mid-face. In this study the nasal deformities in patients with cleft lip, alveolus and palate (CLAP) were analyzed and the relevant role of the perinasal, perioral muscular balance and the inborn dislocation of the alar cartilages are presented.50 CLAP patients were analyzed, 40 UCLP and 10BCLP. The lip repair was done by modification of Millard's technique. The severity of the cleft appearance was evaluated pre and post operatively, according to a pre-agreed visual rating scale. There are 4° of severity of the deformity pre operatively (mild, moderate, severe and very severe) and post operatively 5 categories of outcome (excellent,very good, good, satisfactory and poor), depending on the scores obtained by summing up the points corresponding to different types of deformity. This scale is closely related to the American Cleft Palate classification of clefts.In the 40 UCLP patients, 8 excellent, 10 very good, 16 good and 6 satisfactory results were obtained following primary cheiloplasty. In 10 BCLP patients 1 very good, 7 good, 1 satisfactory and 1 poor result were obtained.During the primary repair, it is important to correct the abnormal position of ala nasi, the nasal floor and the base of the columella. Abnormalities in the insertion of the nasolabial muscles with their abnormal function contribute to the cleft nose deformities. Therefore the reconstruction not only the orbicularis muscle but also of the paranasal muscles is therefore important for a symmetrical growth of the nose. Separate suture of intrinsic orbicularis oris provide a better shape to the vermillion. The position of the alar cartilage plays an important role for the symmetry of the nose. It is necessary to place the alar base symmetrically in three dimensions.

We observed a substantial increase in the incidence of pulmonary embolism (PE) after total joint arthroplasty (TJA) when multidetector computerized tomography (MDCT) replaced ventilation-perfusion (V/Q) scans as the diagnostic modality of choice. We questioned whether this resulted from the detection of clinically unimportant PE with the more sensitive MDCT and in 2007 instituted a hypoxia protocol to enhance the detection of PE.We determined whether this new hypoxia protocol increased the specificity of our workups for suspected clinically important PE in the immediate postoperative period without affecting patient morbidity and mortality.We compared the frequency of MDCT, V/Q scan and total investigations, incidence of PE, and overall mortality rates in the 3 years prior (January 2003 to December 2006) and 2 years after (January 2007 to November 2009) the implementation of the algorithm.After instituting the protocol, we observed a trend toward a decrease in the number of patients worked up for PE (4.6 to 4.0 per 100 TJAs, 13.5% decrease). At the same time, there was an increase in the percent of positive findings of PE per workup for PE (23-33 positive PEs per 100 patients, 40.5% increase). All-cause mortality rates decreased for the 30-day period (3.1 to 1.4 per 1000 TJAs, 53.5% decrease) and the 90-day period (5.0 to 2.6 per 1000 TJAs, 48.3% decrease).With the implementation of this algorithm, the specificity of our management of postoperative hypoxia and suspected clinically important PE improved without affecting patient morbidity or mortality.

This study sought to determine the efficacy of cortical tibial bone graft for nasal augmentation. Nine cases of augmentation rhinoplasty with cortical tibial bone graft are presented.This prospective study evaluated the postoperative results of nine patients who underwent augmentation rhinoplasty using cortical tibial bone graft. There were six males and three females aged between 21 and 36 years (mean age 29). All the nine cases were treated through closed rhinoplasty incisions.Nine patients were operated on and the average follow up was 18 months. The results were favorable. The aesthetic results were gratifying; with good nasal projection in every case without any significant postoperative effects or complications requiring surgery were noted during the follow up.The findings of this study support the use of cortical tibial bone graft for nasal augmentation although further studies with more sample size are required.

There is relatively little information available about the long-term results of total knee arthroplasty (TKA) following high tibial osteotomy. The aim of our study was to share our experiences and long-term results of TKA after a previous closing wedge high tibial osteotomy according to Wagner.In a retrospective study we identified 48 consecutive patients who had undergone TKA after a previous closing wedge high tibial osteotomy according to Wagner with a follow-up of over ten years. The average duration of follow-up after the TKA was 13.3 years (min 10.0, max 15.5). X-rays were taken in two planes before TKA, one week after TKA and at the latest follow-up. Tibio-femoral alignment was measured on weightbearing long-leg anteroposterior radiographs. Radiolucent lines at the latest follow-up were documented. Functional evaluations were performed preoperatively and postoperatively (at the time of latest follow-up).The mean Knee Society function score increased from 63.1 points preoperatively to 90.0 points postoperatively. The mean overall Knee Society score increased from 93.2 points preoperatively to 160.8 points postoperatively. The mean average femoro-tibial angle was corrected from varus 0.8° (varus 14°-valgus 8.0°) preoperatively to valgus 7.6° (valgus 2-9°) at the last follow-up.The closing wedge high tibial osteotomy according to Wagner does not compromise subsequent total knee replacement and leads to good clinical and radiological results.

While short-stem design is not a new concept, interest has surged with increasing utilization of less invasive techniques. Short stems are easier to insert through small incisions. Reliable long-term results including functional improvement, pain relief, and implant survival have been reported with standard tapered stems, but will a short taper perform as well?We compared short, flat-wedge, tapered, broach-only femoral stems to standard-length, double-tapered, ream and broach femoral stems in terms of intraoperative complications, short-term survivorship, and pain and function scores.We retrospectively reviewed the records of 606 patients who had 658 THAs using a less invasive direct lateral approach from January 2006 to March 2008. Three hundred sixty patients (389 hips) had standard-length stems and 246 (269 hips) had short stems. Age averaged 63 years, and body mass index averaged 30.7 kg/m(2). We recorded complications and pain and function scores and computed short-term survival. Minimum followup was 0.8 months (mean, 29.2 months; range, 0.8-62.2 months).We observed a higher rate of intraoperative complications with the standard-length stems (3.1%; three trochanteric avulsions, nine femoral fractures) compared with the shorter stems (0.4%; one femoral fracture) and managed all complications with application of one or more cerclage cables. There were no differences in implant survival, Harris hip score, and Lower Extremity Activity Scale score between groups.Fewer intraoperative complications occurred with the short stems, attesting to the easier insertion of these devices. While longer followup is required, our early results suggest shortened stems can be used with low complication rates and do not compromise the survival and functional outcome of cementless THA.Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Revision of failed two-stage revision TKA for infection is challenging, and amputation often is the only alternative.We asked whether reinfection after two-stage revision for infection could be controlled with an aggressive revision protocol and intraarticular antibiotic infusion.We retrospectively reviewed 18 patients (12 women, six men) who underwent revision for failed reimplantation between January 1999 and January 2008. Mean time from revision for infection to rerevision for reinfection was 5 months (range, 1-18 months). All knees were treated with an individualized protocol that included aggressive exposure, extensive débridement, uncemented components, closure with muscle flaps (seven knees) and other plastic surgery procedures (three knees), and direct antibiotic infusion through Hickman catheters for 6 weeks. Ten knees had one-stage revision; five had débridement, cement spacer, and revision surgery 3 to 4 months later; and three had extensive soft tissue reconstruction before revision surgery. The minimum followup was 2.3 years (mean, 6.1 years; range, 2.3-12.0 years).The mean Knee Society scores improved from 33 preoperatively to 76. Seventeen of the 18 had control of infection and achieved durable fixation and a closed wound. One patient had recurrent infection 13 months after one-stage revision, was revised, and remained asymptomatic 28 months postoperatively after redébridement and vancomycin infusion for 6 weeks. In one patient, soft tissue closure was not obtained and the patient required amputation.Extensile exposure, débridement, and soft tissue flaps for closure combined with uncemented fixation of revision implants and antibiotic infusion into the knee controlled reinfection after revision TKA.

This comparative study compares the primary and secondary healing after surgical removal of impacted mandibular third molars, evaluating and monitoring the extent of swelling and severity of pain and trismus.60 patients (37 females, 23 males; age range 18-40 years) were included in the series. The patients were randomly subdivided into 2 groups of 30 each. All the patients were operated by the same operator under same clinical conditions. Group 1 had 30 patients who underwent primary closure. Group 2 had 30 patients who underwent secondary closure. Pain, swelling and trismus were evaluated for 1st, 3rd and 7th days after surgery with a VAS scale.An analysis of immediate findings showed that the patients with primary closure experienced significantly greater pain, swelling and trismus than that was experienced by patients with secondary closure. When the subsequent findings were analyzed there was statistically significant difference in pain, swelling and trismus experienced between both the groups.The findings of this study suggest that the procedure of choice after removal of impacted mandibular third molars is a secondary closure and healing by secondary intention. A secondary closure appears to minimize the postoperative edema, pain and trismus and thus contributes to enhanced patient comfort.

Deep infections are devastating complications of TKA often treated with component explantation, intravenous antibiotics, and antibiotic-impregnated cement spacers. Historically, the spacers have been static, which may limit patients' ROM and ability to walk. Several recent reports describe dynamic spacers, which may allow for improved ROM and make later reimplantation easier. However, because of several dynamic spacer problems noted at our institution, we wanted to assess their associated failures, reinfection rates, and functionality.We therefore asked whether there were differences between static and dynamic spacers in (1) reinfection rates, (2) complications directly related to the spacer, and (3) final patient functionality as measured by Knee Society objective scores and ROM.We retrospectively identified 111 patients (115 knees) with 34 dynamic spacers (30%) and 81 static spacers (70%). Reinfection rates, complications requiring additional surgery, and final Knee Society scores and ROM were collected for all patients.Reinfection rates were comparable between groups. In the dynamic spacer cohort, there were four complications; however, these could all be explained by surgical technical errors or patient weightbearing compliance. All patients with failed results eventually underwent successful two-stage exchange arthroplasty. Final Knee Society scores and ROM were also similar between groups.Reinfection rates, Knee Society scores, and ROM were comparable between the static and dynamic spacer groups. Meticulous surgical technique and proper patient selection should be used to avoid any complications with any spacers.

Treatment of acute subcutaneous Achilles tendon rupture remains challenging. Whereas the results of conservative and operative treatment are inconsistent, early mobilisation treatment seems to be beneficial. Besides suture repair, operative treatment using adhesives reveals promising results. Our hypothesis was that a gluing technique provides initial stability comparable to sutures.In a biomechanical study, 18 fresh frozen sheep Achilles tendons were used to compare the biomechanical properties of suture repair using PDS® II and Bunnell's technique to tendon gluing using BioGlue® and Tissucol®. Load to failure testing was performed.Ultimate failure loads of sutures (146.2 ± 30.8 N) are significantly superior to the techniques using BioGlue® (38.4 ± 18.3 N; p0.0001) or Tissucol® (4.7 ± 2.5 N; p0.0001). Interestingly, no significant differences in stiffness were found between the application of BioGlue® and PDS® II.Suture repair provides significantly superior biomechanical properties compared to the use of both tested adhesives BioGlue® and Tissucol®. Based on the presented data we recommend the use of suture material for open Achilles tendon repair.

Dear Editor, We would like to raise some concerns regarding the article “Regenerative medicine for the treatment of musculoskeletal overuse injuries in competition horses” by Torricelli et al [1]. Although, the main objective of the authors was to evaluate the clinical benefit of administering a combination of autologous platelet rich plasma (PRP) and freshly isolated bone marrow mononucleated cells (BMMNCs) to competition horses affected by overuse musculoskeletal injuries that are refractory to other therapies, some assumptions expressed by them could incite the use of this combined biological therapy without sufficient scientific basis. Our opinion is based on the following points: The authors did not include a control group or at least one group only receiving PRP. It is irresponsible to recommend the use of this combined biological treatment without having an adequate study design. BMMNCs are very sensitive to high calcium concentrations. It is likely that the 10% calcium chloride solution used to activate PRP produced death or metabolic impairment of the BMMNCs (and the subset of multipotent cells in it), and would explain why the concentration of these cells was not related to clinical benefit in this study. It is possible that the unique clinical effect of this treatment is related to the use of PRP per se and not to the BMMNCs. In this sense, the morbidity associated with bone marrow aspiration in the patients and the associated costs for the owners could be unnecessary. We hope that you consider our letter to be of importance for the correct use of regenerative therapies in horses with musculoskeletal overuse injuries.

The aim of this investigation was to study patient-reported long-term clinical outcome, instrumental stablitity and prevalence of radiological osteoarthritis (OA) a minimum of ten years after isolated anterior cruciate ligament (ACL) reconstruction. An average of 13.5 years after ACL reconstruction with bone–patellar tendon–bone (BTB) autograft, 73 patients were evaluated. Inclusion criteria consisted of an isolated ACL rupture and reconstruction with BPTB graft with no associated intra-articular lesions, in particular, cartilage alterations or meniscal lesions. Clinical assessment was performed using the International Knee Documentation Committee (IKDC) and Tegner and Lysholm scores. Instrumental anterior laxity testing was carried out with the KT–1000™ arthrometer. Degree of degenerative changes and prevalence of OA were determined using the Kellgren- Lawrence scale. Mean follow-up was 13.5 years. Mean age was 43.8 years. About 75% of patients were graded A or B according to the IKDC score. The Lysholm score was 90.2 ± 4.8. Radiological assessment reported degenerative changes of grade II OA in 54.2% of patients. Prevalence of grades III or IV OA was found in 20%. The incidence of OA was significantly correlated with stability and function at long-term follow-up. Arthroscopic ACL reconstruction using BPTB autograft resulted in a high degree of patient satisfaction and good clinical results on long-term follow-up. A higher degree of OA developed in 20% of patients and was significantly correlated with increased anterior laxity at long-term follow-up.

Wear is a major contributor to osteolysis and aseptic loosening of total hip replacements (THR). Both alumina (Al(2)O(3)) and cobalt-chrome (CoCr) femoral heads are commonly used. We investigated wear comparing alumina heads to cobalt-chrome heads against conventional cemented polyethylene (PE) cups for up to ten years.Linear wear was measured with radiostereometry (RSA). Our material was derived from two prospective randomised trials that investigated fixation of femoral stems, not wear, and was evaluated retrospectively (Level III).The mean (95% CI) proximal head penetration was 0.96 mm (0.68-1.23) in the cobalt-chrome group and 0.42 mm (0.30-0.53) in the alumina group at ten years (P = 0.001). The mean (95% CI) 3D penetration was 1.07 mm (0.79-1.35) and 0.53 mm (0.38-0.63), respectively, at ten years (P = 0.001).Alumina heads performed better than cobalt-chrome heads in this study after ten-year follow-up.

Routine patellar resurfacing performed at the time of knee arthroplasty is controversial, with some evidence of utility in both TKA (tricompartmental) and bicompartmental knee arthroplasty. However, whether one approach results in better implant survival remains unclear.We asked whether (1) routine patellar resurfacing in TKAs resulted in lower cumulative revision rates compared to bicompartmental knee arthroplasties, (2) patella-friendly implants resulted in lower cumulative revision rates than earlier designs, and (3) bicompartmental knee arthroplasties revised to TKAs had higher cumulative revision rates than primary TKAs.From a community-based joint registry, we identified 8135 patients treated with 9530 cemented, all-polyethylene patella TKAs and 627 bicompartmental knee arthroplasties without patellar resurfacing. We compared age, gender, year of index procedure, diagnosis, cruciate status, revision, and revision reason.TKAs had a lower cumulative revision rate for patella-only revision than bicompartmental knee arthroplasties (0.8% versus 4.8%). Adjusting for age, bicompartmental knee arthroplasties were 6.9 times more likely to undergo patellar revision than TKAs. There was no difference in the cumulative revision rate for patella-only revisions between patella-friendly and earlier designs. The cumulative revision rate for any second revision after a patella-only revision was 12.7% for bicompartmental knee arthroplasties while that for primary TKAs was 6.3%.Bicompartmental knee arthroplasties had higher revision rates than TKAs. Femoral component design did not influence the cumulative revision rate. Secondary patella resurfacing in a bicompartmental knee arthroplasty carried an increased revision risk compared to resurfacing at the time of index TKA. To reduce the probability of reoperation for patellofemoral problems, our data suggest the patella should be resurfaced at the time of index surgery.

Although proteoglycan (PG) is one of the major components of cartilage matrices, its biological function is not fully elucidated.The objectives of this study were to investigate the proliferation and differentiation of chondrocytes embedded in atelocollagen gel with exogenous cartilage PG (PG-atelocollagen gel) in vitro, and also to evaluate the repair of cartilage defects by PG-atelocollagen gel in vivo. In the in vitro study, rabbit chondrocytes were cultured in the PG-atelocollagen gel. Cell proliferation and mRNA expression levels were measured, and gels were histologically evaluated. In the in vivo study, cultured PG-atelocollagen gel containing chondrocytes were transplanted into full-thickness articular cartilage defects in rabbit knees, and evaluated macroscopically and histologically.For the in vitro study, chondrocyte proliferation in 5.0 mg/ml PG-atelocollagen gel was enhanced, and the gene expression of Col2a1 and Aggrecan were decreased. In contrast, chondrocyte proliferation in 0.1 and 1.0 mg/ml PG-atelocollagen gel was not enhanced. The gene expression of Aggrecan in 0.1 and 1.0 mg/ml PG-atelocollagen gel was increased. For the in vivo study, the histological average total score of the 0.1 mg/ml PG-atelocollagen gel was significantly better than that of the group without PG.Although the appropriate concentration of PG has not been defined, this study suggests the efficacy of PG for cartilage repair.

The purpose of the study was to evaluate the efficacy of three dimensional titanium miniplates as treatment modality for the stabilization of the fractured or osteotomized bone fragments in maxillofacial region.24 patients with maxillofacial trauma and one patient who underwent orthognathic surgery constituted the sample of the study. All the patients with maxillofacial injuries required open reduction internal fixation of the fractures and the orthognathic surgery patient required stabilization of the osteotomized segments.Three dimensional plates provide good stability of bone fragments due to closed quadrangular geometric shape, and the ease of contouring and adapting. Because of better inter fragmentary stability; supplemental fixation is not necessary, thereby enhancing the overall comfort, convenience and well being of the patient.

Coronal malalignment occurs frequently in TKA and may affect implant durability and knee function. Designed to improve alignment accuracy and precision, the patient-specific positioning guide is predicated on restoration of the overall mechanical axis and is a multifaceted new tool in achieving traditional goals of TKA. We compared the effectiveness of patient-specific positioning guides to manual instrumentation with intramedullary femoral and extramedullary tibial guides in restoring the mechanical axis of the extremity and achieving neutral coronal alignment of the femoral and tibial components. We retrospectively reviewed 569 TKAs performed with patient-specific positioning guides and 155 with manual instrumentation by two surgeons using postoperative long-leg radiographs. For all patients, we assessed the zone in which the overall mechanical axis passed through the knee, and for one surgeon’s cases (105 patient-specific positioning guide, 55 manual instrumentation), we also measured the hip-knee-ankle angle and the individual component angles with respect to their mechanical axes. The overall mechanical axis passed through the central third of the knee more often with patient-specific positioning guides (88%) than with manual instrumentation (78%). The overall mean hip-knee-ankle angle for patient-specific positioning guides (180.6°) was similar to manual instrumentation (181.1°), but there were fewer ± 3° hip-knee-ankle angle outliers with patient-specific positioning guides (9%) than with manual instrumentation (22%). The overall mean tibial (89.9° versus 90.4°) and femoral (90.7° versus 91.3°) component angles were closer to neutral with patient-specific positioning guides than with manual instrumentation, but the rate of ± 2° outliers was similar for both the tibia (10% versus 7%) and femur (22% versus 18%). Patient-specific positioning guides can assist in achieving a neutral mechanical axis with reduction in outliers. Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Hip replacement using a hemiarthroplasty (HA) is a common surgical procedure in elderly patients with fractures of the femoral neck. Data from the Swedish Hip Arthroplasty Register suggest that there is a higher risk for revision surgery with the bipolar HA compared with the unipolar HA.In this study we analysed the reoperation and the dislocation rates for Exeter HAs in patients with a displaced femoral neck fracture, comparing the unipolar and bipolar prosthetic designs. Additionally, we compared the outcome for HAs performed as a primary intervention with those performed secondary to failed internal fixation.We studied 830 consecutive Exeter HAs (427 unipolar and 403 bipolar) performed either as a primary operation for a displaced fracture of the femoral neck or as a secondary procedure after failed internal fixation of a fracture of the femoral neck. Cox regression analyses were performed to evaluate factors associated with reoperation and prosthetic dislocation. Age, gender, the surgeon's experience, indication for surgery (primary or secondary) and type of HA (unipolar or bipolar) were tested as independent variables in the model.The prosthetic design (uni- or bipolar) had no influence on the risk for reoperation or dislocation, nor had the age, gender or the surgeon's experience. The secondary HAs were associated with a significantly increased risk for reoperation (HR 2.6, CI 1.5-4.5) or dislocation (HR 3.3, CI 1.4-7.3) compared to the primary HAs. We found no difference in the risk for reoperation or dislocation when comparing Exeter unipolar and bipolar HAs, but special attention is called for to reduce the risk of prosthesis dislocation and reoperation after a secondary HA.

Background With contemporary canal-filling press-fit stems, there is no adjustability of stem position in the canal and therefore the canal anatomy determines stem version. Stem version will affect head/neck impingement, polyethylene wear from edge loading, and hip stability, but despite this, the postoperative version of a canal-filling press-fit stem is unclear.

The objective of this study was to determine the role of β-catenin in normal postnatal articular cartilage growth and degeneration.We investigated β-catenin gene and protein expression in hip cartilage cells of normal Wistar rats at two, four, six and eight weeks of age by using reverse transcriptase polymerase chain reaction (RT-PCR) and immunohistochemistry. Primary articular chondrocytes from eight week old rats were cultured and treated with LiCl for activation of β-catenin. Collagen X and matrix metalloproteinase 13 (MMP-13) were detected by quantitative RT-PCR and immunofluorescence. A disintegrin and metalloproteinase with thrombospondin motifs (ADAMTS)-4 and 5 were detected by quantitative RT-PCR, and terminal deoxynucleotidyl transferase dUTP nick end labelling (TUNEL) was used for detecting cell apoptosis.The highest levels of β-catenin expressions were detected in two week old rats, after which a steady decline was observed over the remaining period of observation (p 0.05). When primary articular chondrocytes from eight week old rats were treated with LiCl, β-catenin mRNA and protein were induced (p 0.05). Moreover, LiCl-activated β-catenin in chondrocytes was associated with significant concomitant increases in mRNA expression of collagen X and the MMP-13 encoding collagenase 3. Significantly increased mRNA expression of ADAMTS-5 was also seen in primary chondrocytes from eight week old rats after LiCl treatment (p 0.05). The effect was specific to ADAMTS-5 since ADAMTS-4, which has similar proteolytic activity but different aggrecanase activity, was unaffected. Finally, TUNEL staining revealed that LiCl-activated β-catenin signalling led to increased cell apoptotic events in chondrocytes (p 0.05).Our findings suggest that normal spatiotemporal patterns and degrees of Wnt/β-catenin signalling are needed to maintain postnatal articular cartilage growth and function. In the early stages of cartilage development, activation of β-catenin signalling is necessary for articular cartilage growth, while in adult cartilage it leads to degeneration and osteoarthritic-like chondrocytes.

The diagnosis of periprosthetic joint infection (PJI) continues to pose a challenge. While many diagnostic criteria have been proposed, a gold standard for diagnosis is lacking. Use of multiple diagnostic criteria within the joint arthroplasty community raises concerns in patient treatment and comparison of research pertaining to PJI.We (1) determined the variation in existing diagnostic criteria, (2) compared the existing criteria to a proposed new set of criteria that incorporates aspirate cell count analysis, and (3) investigated the variations between the existing criteria and the proposed criteria.We retrospectively identified 182 patients undergoing 192 revision knee arthroplasties who had a preoperative joint aspiration analysis at our institution between April 2002 and November 2009. We excluded 20 cases due to insufficient laboratory parameters, leaving 172 cases for analysis. We applied six previously published sets of diagnostic criteria for PJI to determine the variation in its incidence using each set of criteria. We then compared these diagnostic criteria to our proposed new criteria and investigated cases where disagreement occurred.We identified 41 cases (24%) in which at least one established criteria set classified the case as infected while at least one other criteria set classified the case as uninfected. With our proposed criteria, the infected/uninfected ratio was 92/80. The proposed criteria had a large variance in sensitivity (54%-100%), specificity (39%-100%), and accuracy (53%-100%) when using each of the established criteria sets as the reference standard.The discrepancy between definitions of infection complicates interpretation of the literature and the treatment of failed TKAs owing to PJI. Based on our findings, we suggest establishing a common set of diagnostic criteria utilizing aspirate analysis to improve the treatment of PJI and facilitate interpretation of the literature.Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Posttraumatic arthritis secondary to lateral tibial plateau fracture malunion causes pain and limited function for patients. It is sometimes technically challenging to correct malalignment in these patients with advanced arthritis using osteotomies. Lateral unicompartmental knee arthroplasty (UKA) may be an option to treat such patients.We asked whether UKA for lateral posttraumatic osteoarthritis (1) reliably alleviates pain and improve function, (2) restores lower limb alignment, and (3) is as durable as UKA for primary lateral osteoarthritis.We retrospectively reviewed 13 patients with lateral cemented UKA (mean age at surgery, 50.1 years) treated at two institutions between 1985 and 2007. We obtained Knee Society scores and evaluated radiographs for evidence of implant loosening or progression of arthritis in the medial compartment. Minimum followup was 3 years (mean, 10.2 years; range, 3-22.1 years).Mean Knee Society knee score improved from 51 points (range, 29-75 points) preoperatively to 88 points (range, 65-100 points) at last followup, suggesting the procedure relieved pain. Mean function score improved from 51 points (range, 10-89 points) preoperatively to 87 points (range, 35-100 points) at last followup. The mean hip-knee-ankle angle was 188° preoperatively (range, 184°-193º) and 185° (range, 183°-188°) at last followup. Prosthesis survivorship was 100% at 5 and 10 years and 80% at 15 years.Despite the limited number of indications and technical considerations, our observations suggest lateral UKA is a reasonable option for treating lateral arthritis secondary to malunited fractures.

In the United States, the obese population has increased markedly over the last four decades, and this trend continues. High patient weight places additional stress on TKA components, which may lead to increased polyethylene wear, osteolysis, radiolucencies, and clinical failure. Metal-backed tibial components and all-polyethylene tibial components in the general population have comparable osteolysis and failure, but it is unclear whether these components yield similar osteolysis and failure in obese patients.We therefore determined the (1) function, (2) occurrence of osteolysis, and (3) complications in a cohort of obese patients receiving all-polyethylene tibial components.Between September 17, 1996, and December 19, 2002, we implanted all-polyethylene tibial components in 90 obese patients (125 knees); 24 patients (33 knees) died and 13 patients (17 knees) were lost to followup, leaving 53 patients (59%) with 75 knees. All surgeries were cruciate-retaining, tricompartmental TKAs. We evaluated patients with Knee Society Scores and serial radiographs. Minimum followup was 7 years (mean, 10.4 years; range, 7-14 years).At latest followup, mean Knee Society Score was 92 points. There were five tibial radiolucencies, all less than 1 mm and characterized as nonprogressive. We observed minimal, nonprogressive osteolysis in one knee. One patient required reoperation after a traumatic event. There were no implant-related failures and no implants at risk of failure.At an average 10-year followup, all-polyethylene tibial components were functioning well in this obese group. These findings confirm the effectiveness of all-polyethylene tibial components in obese patients.

Soft tissue augmentation by hyaluronic acid filler injections has become the most commonly done cosmetic procedure in the last 10 years. These are now being widely used for improvement of the nasolabial folds. The present study was done to evaluate the patient satisfaction after these injections. The study was conducted on 10 consenting patients. Hyaluronic acid filler (22.5 ml cross linked), 1 ml on each groove was injected under an infraorbital block. Patient satisfaction was evaluated at 0, 14, 30, and 180 days. Photographic record was maintained. Any side effects experienced by the patients were recorded. All the patients were satisfied immediately after the procedure. More than 50% were not happy at 14 days. Majority of the patients were happy at 30 days and the satisfaction was maintained at 6 months. Fillers are a very safe and effective modality for improving the nasolabial fold. This could prove to be a very useful tool in dental practice. Setting the patient expectations before the procedure is performed can lead to satisfied and happy patients.

Both the antero-posterior and anterior approaches have been used for treating L5-S1 vertebral tuberculosis. However, no studies have compared the efficacy of the two methods in treating the disease.The antero-posterior (AP group, 14 cases) and anterior (A group, 13 cases) approaches were performed on L5-S1 vertebral tuberculosis cases who were followed up for average of 25 months. Clinical and radiographic data were obtained from and compared between groups.Average operative time, blood loss and pre-operative, post-operative and last follow-up of lumbo-sacral angles for groups AP and A were 497 min vs 190 min, 980 ml vs 410 ml, 22.3° vs 20.6°, 29.8° vs 25.7° and 28.3° vs 23.6°, respectively. Averaged visual analogue scale (VAS) scores in groups AP and A, respectively, were 6.5 vs 6.0 points before surgery and 3.0 vs 2.8 points after surgery. Mean ODI scores were 60.2 vs 63.0 points before and 30.0 vs 28.5 points after the operation for groups AP and A, respectively. Six cases in the AP group and five in the A group who exhibited neurological symptoms recovered to American Spinal Injury Association (ASIA) grade E. The average hospitalisations of groups AP and A lasted for 21 and 15 days, respectively. Bony fusion was achieved in both groups, with an average fusion time of five and four months, respectively.Both the antero-posterior and anterior approaches can effectively heal L5-S1 vertebral tuberculosis, but the average surgical time, blood loss and hospital stay following the anterior approach are prominently less than those following the antero-posterior approach.

Dentigerous cyst develops in the follicular tissue surrounding the impacted lower third molar. A study was carried out to know the incidence of Association of Dentigerous cyst with radiographically normal impacted lower third molars and to draw the attention of the Oral Surgeons towards the prophylactic removal of impacted third molars.A prospective study was done on 30 patients with impacted lower third molars which were indicated for extraction. The follicle tissue surrounding the impacted tooth was subjected for histopathologic investigations. Only those teeth with a radiographic finding of pericoronal space of less than 2.5 mm were considered. Two Oral Pathologists reviewed the slides for any changes suggestive of cystic pathology.Pathologic changes suggestive of Dentigerous cyst was found in 7 of the 30 follicular tissue sent for histopathologic testing. It was found to be statistically significant (P 0.001).This study shows statistically high incidence of Dentigerous cyst association with radiographically normal impacted lower third molar teeth. Hence the Oral and Maxillofacial surgeons should consider histopathologic evaluation and radiographic diagnosis in the management of impacted lower third molars. Prophylactic extractions of normal impacted lower third molars should be considered as a treatment option.

The purpose of this study was to determine the clinical results of patients with late onset upper thoracic sharp Pott's kyphosis and to predict the prognosis for Pott's paraplegics.The study included five patients who developed late onset upper thoracic (T1-T4) sharp Pott's kyphosis/kyphoscoliosis within a period from 19 to 37 years after the active disease was healed. The kyphosis angle of the patients ranged from 95° to 105°. Among them, three patients suffered onset of paraplegia ranging from 26 to 31 years after spinal tuberculosis was healed. The duration of neurological deterioration before surgery ranged from four to five years. All patients underwent decompressive surgery with an attempt to correct the curve. Neurological status was evaluated using the ASIA impairment classification and the motor score.Postoperatively, kyphosis correction ranged from 20° to 30° for five patients. No neurological deficit occurred in two patients with normal neurological status. Two ASIA D paraplegics remained unchanged after surgery and no further improvement was found at one year follow-up. One ASIA C paralysis deteriorated neurologically to ASIA B after surgery and persisted to a deterioration of neurological status at one year follow-up.Upper thoracic sharp Pott's kyphosis and neurological deficits occur progressively. The neurological recovery or improvement of Pott's paraplegics with upper thoracic severe sharp kyphosis results in poor prognosis after decompressive surgery.

The aim of the study was to investigate whether a bioactive glass (BG) coating on the polyethylene terephthalate (PET) artificial ligament could enhance graft osseointegration by promoting bone regeneration at the interface between PET graft and bone tunnel.Thirty New Zealand white rabbits underwent artificial ligament graft transplantation in proximal tibial tunnels bilaterally. One limb was implanted with a 58S BG-coated PET graft, and the contralateral limb was implanted with a non-BG-coated PET graft as a control. The rabbits were randomly sacrificed at three, six and 12 weeks after surgery for biomechanical and histological examinations.The maximum load to failures of the BG-coated experimental group were significantly higher than those of the control group at 12 weeks (p = 0.0051). Histologically, at 12 weeks, the BG-coated PET graft induced great new bone formation between graft and host bone, and the average graft-bone interface width of the BG group became significantly lower than that of the control group. Furthermore, the BG coating on the ligament graft surface also stimulated greater expression of bone morphogenetic protein 2 (BMP-2) and vascular endothelial growth factor (VEGF) around the graft in vivo compared to the control group at three weeks (p0.05).This study has shown that a BG coating on the PET artificial ligament surface has a positive effect in the induction of artificial ligament osseointegration within the bone tunnel.

The present study was designed to address whether osteoblasts play a synergistic role in promoting mesenchymal stem cell (MSC) osteogenesis in a direct cell-cell contact co-culture model.Murine C3H10T1/2 and MC3T3-E1 cell lines were mixed and plated onto 12-well culture plates and co-cultured at various ratios of initial cell densities. To compare the possible improvement on osteogenic differentiation, co-culture cells were served with or without osteogenic supplements in culture medium.Weak osteogenesis was induced in MSCs co-cultured in an untreated medium with different ratios of osteoblasts. An osteoblast-dependent increase in osteogenic gene expression of Runx2, type I collagen, and osteocalcin was observed over time. Moreover, both alkaline phosphatase (ALP) activity and calcium deposition were distinctly enhanced at levels that were proportional to the quantity of osteoblasts in the culture. The increases in mRNA expression and ALP activity were greater in co-cultures treated with osteogenic supplements than in untreated cultures. However, the production of ALP activity followed by a distinct matrix mineralization was lower in osteogenic-treated cultures containing greater numbers of osteoblasts. This suggests that a higher density of osteoblasts may lead to weak osteogenesis of MSCs by direct cell-cell contact co-culture in an untreated environment. Furthermore, additional osteogenic supplements may act synergistically with osteoblasts to accelerate matrix mineralization by reducing the process of osteogenic differentiation in osteogenic treated co-cultures.The present work may improve the understanding of MSC osteogenesis and may provide benefits for regenerative medicine.

The purpose of this study was to compare images of a newly developed high-frequency ultrasound imaging system (HFUIS) and scanning acoustic microscope (SAM) and to calculate their Pearson product moment correlations with a view to applying HFUIS for clinical use.Cylindrical cartilage-bone complexes from adult male Sprague-Dawley rats were obtained. The specimens were immersed in normal saline and scanned by HFUIS. Intensity by HFUIS was normalised by reflection from a steel plate at the same distance. After the scanning, specimens were fixed with paraformaldehyde, decalcified and embedded in paraffin. Thinly sliced tissues were prepared for SAM evaluation. After the scanning, three layers of articular cartilage (superficial, middle and deep) were independently evaluated and their relationships calculated.The superficial and deep layers indicated high relative intensity, whereas the middle layer showed nonhomogeneous relative intensity by HFUIS. A high relative intensity by HFUIS and high sound speed area by SAM had strong correlations (Pearson product moment correlation, superficial layer 0.704, middle layer 0.731).HFUIS produced high-resolution images of the articular cartilage and its intensity was strongly correlated with sound speed by SAM.

To reports ten Japanese surgical cases of verrucous carcinoma (VC) of the oral cavity.The author reviewed histopathology of 10 cases of oral VC.Ten cases of oral VC were found in our pathology department in the last 10 years. During the 10 years, a total of 187 cases of oral malignancy were recognized. Therefore, the frequency of VC was 5.3% of all oral malignancies. The patients consisted of six women and four men. The age ranged from 52 to 84 years with a median of 68 years. The locations of VC were buccal mucosa in two cases, gingiva in three cases, hard palate in one case, tongue in three cases, and soft palate in one case. The presenting symptoms were oral discomfort in two cases and tumors in eight cases. All cases underwent surgical resection. Frozen sections were performed in three cases for margin check. Grossly, all cases showed verrucous lesions. The size ranged from 0.8 to 3.2 cm with a median of 1.3 cm. Histologically, tumor cells proliferated with verrucous or papillary features. The tumor cells had acidophilic, ample cytoplasm, and nuclear atypia was minimal. Individual keratinization, koilocytosis, basal cell mild atypia, and squamous pearl formation were recognized in all cases. Three cases showed microinvasion. One case had focal ordinary squamous cell carcinoma within the VC. Epithelial dysplasia in the mucosa was recognized in the vicinity of VC in two cases. One case showed multiple tumors of VC; the number was five. Lymphocytic infiltration in the dermis was recognized in seven cases. Immunohistochemically, p53 protein was positive in all the ten cases. Its location was accentuated near the basal cells and microinvasive parts. Ki-67 positive cells were also seen mainly in the basal cells and in the microinvasive areas, and the KI-67 labeling index ranged from 12 to 21%. Two patients recurred, and additional operations were performed. None show metastatic lesions. One patient died of other disease, and nine patients are now alive without tumors.Clinicopathologic features of ten cases of oral VC were described.

Total knee arthroplasty (TKA) as a treatment for end-stage osteoarthritis of the knee shows good results in terms of patient satisfaction. For the assessment of outcome and revision rate after total joint arthroplasty, there are two major data sources: clinical studies and national arthroplasty registers. The purpose of this study was to analyse the outcome of Anatomic Graduated Component (AGC) TKA reported in clinical studies and to perform a comparison with the outcome reported by national arthroplasty registers.A systematic literature review was performed using standardised methodology in order to determine the outcome and revision rate of AGC TKA. In a comprehensive meta-analysis of clinical studies and worldwide register results we examined the quality of the basic data and the occurrence and influence of potential bias factors. Confidence intervals were calculated to determine the statistical significance of differences.We found significant differences as regards the revision rate measured in revisions per 100 observed component years. Compared to worldwide register data it turned out to be significantly lower in clinical studies published by the implant development team. Actually, they reported a revision rate of 0.18 revisions per 100 observed component years, whereas annual reports of national arthroplasty registers report 0.74 revisions per 100 observed component years. A comparison of the results from national arthroplasty registers of different countries revealed a significantly higher revision rate for Denmark in relation to worldwide register data.A conventional meta-analysis of clinical studies is affected by the influence of the development team and therefore subject to bias. For the assessment of outcome arthroplasty register data should be rated as superior and, being used as reference data for the detection of potential bias factors in the clinical literature, could make an essential contribution to the quality of scientific meta-analysis.

The purpose of this study was to compare clinical outcomes between a primary dislocation group (group P) and a recurrent dislocation group (group R) with combined lesion of Bankart and type II SLAP lesions (type V SLAP lesion) and to evaluate incidence of type V SLAP lesion. In addition, the authors evaluated clinical outcomes of these patients by dividing two groups according to the sequence for Bankart and SLAP lesion suture. From May 2000 to May 2005, 310 patients who gave informed consent, underwent the diagnostic arthroscopy and magnetic resonance arthrography (MRA). One hundred and ten patients met the following criteria: (1) post-traumatic primary or recurrent anterior shoulder instability, (2) a normal contralateral shoulder, (3) a type V SLAP lesion, and (4) minimum follow-up of two years. Group P included 42 patients, and group R, 68 patients. Among all patients, 58 patients who had Bankart lesions sutured first were included in group B, and 52 who had their SLAP lesions sutured beforehand, group S. Visual analogue scale, range of motion, Rowe and Constant score were used to compare results between group P and group R, also group B and group S. The incidence rates of type V SLAP lesion were 42.8% in group P and 32.0% in group R. The overall treatment results in our study were good. Even if the difference between the two groups was statistically insignificant, group P showed greater recovery of range of motion than group R in external rotation. No significant difference was found between the two different operative methods according to suture sequence. The incidence rates of type V SLAP lesion were 42.8% in the primary dislocation group and 32.0% in the recurrent dislocation group. The overall treatment results in our study were good. Although there was no statistical significance in surgical time between the two groups, when both SLAP and Bankart lesions are present, the Bankart lesion must be sutured first to reduce surgical time.

This is a randomised controlled trial to examine whether intra-articular injection of tranexamic acid (TXA) decreases blood loss, as well as reducing leg swelling after total knee arthroplasty (TKA).We performed 100 TKA in osteoarthritis patients. At closure, a total of 2,000 mg/20 ml TXA was injected into the knee joint through a closed suction drain (TXA group). For the control group, the same volume of physiological saline was injected. The pre-operative condition of the patients, post-operative haemoglobin (Hb) levels, discharge volumes from drain, D-dimer and needs for transfusion were compared between these two groups. Furthermore, leg diameters (thigh, suprapatellar portion and calf girth) were measured pre- and post-operatively to investigate whether TXA has an influence on leg swelling after surgery.The results revealed that post-operative decrease in Hb level was significantly reduced in the TXA group. Furthermore, knee joint swelling after operation was significantly suppressed in the TXA group compared to the control group.The results revealed intra-articular administration of TXA decreased not only blood loss, but also knee joint swelling after TKA.

Improved staging of cartilage degeneration is required, particularly during the early stages. We correlated mechanical properties with histological and macroscopic findings.One hundred and twenty cartilage samples were obtained during total knee arthroplasty. Two adjacent plugs were harvested--one for histological classification and one for macroscopic and biomechanical purposes. Dynamic impact testing was performed; normal stress, dissipated energy (∆E), tangent modulus and stiffness were evaluated.Samples were classified according to six categories of the ICRS histological scale. Mechanical characteristics revealing significant differences between the groups (p0.01) were specific damping and related absolute ∆E. A significant correlation was found between the macroscopic score and specific damping, as well as absolute and relative ∆E (p0.01). A strong relation was revealed between relative ∆E and cartilage thickness (p0.001; R (2) = 0.69).Only ∆E correlated with the condition of the cartilage--the value increased with decreasing quality-and is the most suitable characteristic. This change appears substantial in initial stages of cartilage deterioration.

The history of metal-on-metal bearing began with K. Mc Kee. Several "episodes" have marked the history of metal-on-metal articulations, and each has contributed to a better understanding of this type of tribology. But to date the indications for this bearing are debated and are subject to reservations because of the existence of permanently elevated levels of circulating metal ions. It therefore appears that the monitoring of our patients, the documentation of our revisions and the collaboration with our industry partners as well as communicating with our biology and pathology colleagues is necessary to help us solve these problems.

"Thoracic outlet syndrome is an often misdiagnosed syndrome which consists of a neurovascular compression at the upper thoracic outlet. The clinical presentation can be variable, ranging from mild symptoms to venous thrombosis and muscle atrophy. Many aetiologies, both congenital and acquired, related either to bony or soft tissue anomalies, have been associated with this syndrome. As a consequence, the diagnosis is often challenging and sometimes it can be obtained only with surgical exploration. Additionally, no specific clinical test is considered diagnostic of thoracic outlet syndrome. However, the recent advances in imaging techniques together with a careful clinical evaluation give the surgeon the chance to recognize the constricting anatomy before surgery in many cases. No standard surgical procedure has been identified; however, in literature the largest series have been treated with transaxillary first rib resection. Here we report our experience in the surgical treatment of this syndrome with a minimum follow-up of three years. Our approach consists of performing a supraclavicular decompression without routine first rib resection. This allows for identifying and removing the constricting anatomy in most cases, with satisfactory results in 96.9% of patients and a low complication rate."

Revision total hip arthroplasty in the setting of a large proximal femoral deficiency or a peri-prosthetic fracture remains a challenging problem. We describe the development, surgical technique and the use of cementless revision stems with distal inter-locking screws to provide immediate stability of the femoral implant. Results were assessed in a large multicentre French study conducted with the french hip and knee surgery society (SFHG). We retrospectively reviewed 725 revisions using interlocking stems from 14 French orthopaedic departments. Seven different stems were used in this series. In-patient records were retrieved, and in addition to demographic data the indication for revision, the preoperative and postoperative PMA and Harris hip scores were documented. The bone deficiency was classified on the basis of the French National Orthopaedic Meeting (SOFCOT) classification. Intraoperative complications and problems if any were retrieved from operative notes. Clinical status and radiographs at the final follow-up were evaluated, paying special attention to the metaphyseal filling index. Average follow-up was 4.5 years. As for the clinical results, the mean Harris hip score at last follow-up was 81. Therefore, it increased by an average of 31 points. Bone reconstruction was assessed on the cortico-medullary index in the metaphyseal area and at mid-shaft increasing from 36 to 45 and 54 to 63, respectively. Radiologically, 637 implants were stable, and 40 demonstrated subsidence. Forty-eight implants have been revised. We found a significant relation between the metaphyseal filling index, the stability of the stem and the quality of bone reconstruction. Results were analysed with respect to three groups of stems: group 1 was a straight, partially HA-coated implant; group 2 was a curved, fully HA-coated implant; and group 3 was a curved, partially-coated implant. Group 1 showed a significantly higher rate of failure when compared with the others types of implants. Group 2 had better functional results than group 3, which in turn reported better results than group 1. With regard to implant fixation, group 2 had significantly better results. Both groups 2 and 3 induced less thigh pain than group 1. The distal interlocking stem has shown promising results for femoral revisions. The advantages are initial axial and rotational stability and consistent bony in-growth owing to hydroxyapatite coating. Distal locked stems are mainly indicated to treat complex femoral revision with severe bone loss and peri-prosthetic fractures.

Current approaches for segmental bone defect reconstruction are restricted to autografts and allografts which possess osteoconductive, osteoinductive and osteogenic properties, but face significant disadvantages. The objective of this study was to compare the regenerative potential of scaffolds with different material composition but similar mechanical properties to autologous bone graft from the iliac crest in an ovine segmental defect model. After 12 weeks, in vivo specimens were analysed by X-ray imaging, torsion testing, micro-computed tomography and histology to assess amount, strength and structure of the newly formed bone. The highest amounts of bone neoformation with highest torsional moment values were observed in the autograft group and the lowest in the medical grade polycaprolactone and tricalcium phosphate composite group. The study results suggest that scaffolds based on aliphatic polyesters and ceramics, which are considered biologically inactive materials, induce only limited new bone formation but could be an equivalent alternative to autologous bone when combined with a biologically active stimulus such as bone morphogenetic proteins.

To analyze gender differences in cleft pattern by the clinical statistical study of Japanese patients with cleft lip and/or cleft palate.Cleft pattern modeling was used to analyze 782 patients with cleft lip and/or cleft palate (417 males and 365 females) who had been examined at the Cleft Lip and Palate Center, Aichi-Gakuin University Hospital, and whose details could be confirmed. Relationships between gender and cleft type were analyzed with chi-squared test.A comparison of gender differences by cleft type revealed that a greater percentage of males had milder cleft lip, cleft lip and palate, or cleft palate, whereas the percentage of females tended to be greater as cleft severity increased.Modeling of cleft patterns enables more detailed classification of cleft lip and palate, and can lead to a greater understanding of pathology.

Acetabular osteolysis associated with socket loosening is one of the main long-term complications of total hip arthroplasty. In case of major bone loss, where

The osteonecrosis of the femoral head implies significant disability partly due to pain. After conventional core decompression using a 10-mm drill, patients normally are requested to be non-weight bearing for several weeks due to the risk of fracture. After core decompression using multiple small drillings, patients were allowed 50% weight bearing. The alternative of simultaneous implantation of a tantalum implant has the supposed advantage of unrestricted load bearing postoperatively. However, these recommendations are mainly based on clinical experience. The aim of this study was to perform a finite element analysis and confirm the results by clinical data after core decompression and after treatment using a tantalum implant. Postoperatively, the risk of fracture is lower after core decompression using multiple small drillings and after the implantation of a tantalum rod according to finite element analysis compared to core decompression of one 10-mm drill hole. According to the results of this study, a risk of fracture exists only during extreme loading. The long-term results reveal a superior performance for core decompression presumably due to the lack of complete bone ingrowth of the tantalum implant. In conclusion, core decompression using small drill holes seems to be superior compared to the tantalum implant and to conventional core decompression.

The wide surgical tumour resection is the only effective treatment in chondrosarcoma. However, a major problem remains the high rate of local recurrences and metastases due to the lack of adjuvant therapies. In this study the cytotoxic effect of the bisphosphonate clodronate (0.1–1000 μM) and zoledronate (0.1–1000 μM) in different concentrations on two chondrosarcoma cell lines (HTB-94 and CAL-78) has been investigated. After an incubation period of 48, 72 and 96 hours the chondrosarcoma cell viability was measured as the MTT-proliferation rate. In concentrations of >1 μm zoledronate the cell activity was reduced by up to 95% for the CAL-78 cells. Further, zoledronate has been more effective in lower concentrations than clodronate in the reduction of cell viability for both cell lines. However, clodronate showed significant cytotoxic effects in high concentrations and after longer incubation periods. Further research is necessary, but in the light of these results bisphosphonates may also play a role in the treatment of chondrosarcomas.

While acetabular structural allografts provide an important alternative for reconstructions, concerns remain with long-term graft resorption, collapse, and failure. Midterm studies of minor column (shelf) allograft suggest reasonable survival but long-term survival is unknown.We therefore assessed long-term graft/cup survivorship, functional scores, radiographic resorption, and complications associated with minor column allograft.We retrospectively reviewed 74 patients (85 hips) with a mean age of 54 years (range, 28-83 years) undergoing acetabular cup revision using a minor column allograft. A minor column allograft was used in uncontained acetabular bone defects sized between 30% and 50% of the acetabulum. Graft failure was considered to occur when the graft required revision with another graft, metal augment, reconstruction cage, or excision arthroplasty. The minimum followup was 5 years (mean, 16 years; range, 5.3-25 years).Twenty-three patients (27 hips) had rerevision for all causes at a mean time to rerevision of 6.9 years (range, 0.1-23). Fifteen grafts failed at a mean time-to-rerevision of 6.1 years (range, 0.5-23.2). The 15- and 20-year Kaplan-Meier survivorships were 61% and 55% for cups and 78% for grafts with rerevision for all causes as end point. With rerevision for aseptic loosening as end point, survivorships were 67% and 61% for cups and 81% for grafts. The mean modified Harris hip scores were 41 (range, 20-60) preoperatively, 73 (range, 40-95) at 1 year postoperatively and 73 (range, 26-93) at last followup.The data may provide a long-term benchmark by which future treatments for Type III defects can be measured.

Postthrombotic syndrome (PTS) is a chronic condition in the lower extremity that develops after deep vein thrombosis (DVT). The incidence of PTS after total hip arthroplasty (THA) is not well established.We (1) determined the incidence of PTS after DVT in patients undergoing primary THA for osteoarthritis; and (2) determined whether the incidence of PTS was greater in patients with DVT than without.We retrospectively reviewed records of all 1037 patients who underwent primary THA for osteoarthritis during a 4-year period. All patients underwent postoperative screening ultrasound. We identified 21 (2%) patients with a DVT by ultrasound of whom 14 had a minimum 1-year followup (mean, 3.4 years; range, 1.0-6.0 years). PTS was diagnosed if any two of the six clinical signs were documented.Three of 14 patients with DVT had at least two signs consistent with PTS; two of these had a DVT proximal to the soleal arch. Three of 91 randomly matched patients undergoing THA without DVT had at least two signs of PTS. The incidence of developing PTS after THA appeared higher in patients with DVT than in patients without DVT.While we observed a difference between the incidence of PTS after THA in patients with and without DVT, that incidence was based on only three of 1037 patients with DVT after THA. PTS does not appear to be a major complication after DVT in patients undergoing THA.Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.