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Pelvic discontinuity (PD) has been a considerable challenge for the hip revision arthroplasty surgeon. However, not all PDs are the same. Some occur during primary cup insertion, resembling a fresh periprosthetic fracture that separates the superior and inferior portions of the pelvis, while others are chronic as a result of gradual acetabular bone loss due to osteolysis and/or acetabular implant loosening. In the past, ORIF, various types of cages, bone grafts and bone cement were utilized with little success. Today, the biomechanics and biology of PD as well as new diagnostic tools and especially a variety of new implants and techniques are available to hip revision surgeons. Ultraporous cups and augments, cup-cage constructs and custom triflange components have revolutionized the treatment of PD when used in various combinations with ORIF and bone grafts. For chronic PD the cup-cage construct is the most popular method of reconstruction with good medium-term results. Dislocation continues to be the leading cause of failure in all situations, followed by infection. Ultimately, surgeons today have a big enough armamentarium to select the best treatment approach. Case individualization, personal experience and improvisation are the best assets to drive treatment decisions and strategies.Cite this article: EFORT Open Rev 2021;6:459-471. DOI: 10.1302/2058-5241.6.210022

Objectives To investigate the impact of the body mass index (BMI) change on risk of falling in postmenopausal women with osteopenia or osteoporosis. Also, we aimed to evaluate and associate the individuals' functionality, mobility and balance with the risk of falling. Methods This one-year prospective observational study assessed 498 postmenopausal Greek women over the 50th year of age suffering from either osteoporosis or osteopenia. Parameters such as the height, weight and BMI were documented. Furthermore, the subjects were asked whether they experienced a fall the preceding year. Balance was evaluated using the Berg Balance Scale, the Timed-Up-And-Go test, and the 30 Seconds Sit-to-Stand test. Hand-grip strength was assessed with the Jamar Hydraulic Hand Dynamometer. Results The observed one-year BMI change was associated with falls in postmenopausal osteopenic and osteoporotic women over the age of 70. Additionally, there were statistically significant changes in the BBS, TUG, 30CST and the hand-grip strength on both hands at the one-year follow-up but there were not associated with an increased fall risk. Conclusion The one-year change in BMI was associated with the risk of falling in postmenopausal osteopenic and osteoporotic women over the 70th year of age. Whereas, the one-year change in balance, mobility and grip strength were not linked to an increased risk of falling.

Aims: Modular-neck femoral implants are used to enable more variability in femoral neck version, offset and length. It has been reported that these implants carry a higher rate of revision. The aim of this review was to assess the overall and cause-specific revision rate of titanium-titanium alloy modular-neck implants in primary total hip arthroplasty (THA). Methods: A systematic review was conducted following PRISMA guidelines and utilising multiple databases. All results were screened for eligibility. Studies published from 2000 onwards, using a current-generation, titanium-titanium, modular-neck implant were included. Overall and cause-specific revision rates were analysed, comparing to fixed-neck prostheses where applicable. Results: 920 studies were screened. After applying exclusion criteria, 23 were assessed in full and 14 included. These consisted of 12 case series and 2 joint registry analyses. 21,841 patients underwent a modular-neck implant with a weighted mean follow-up of 5.7 years, mean age of 62.4 years, and average body mass index (BMI) of 28.4kg/m2. The overall revision rate was 3.95% and 2.98% for modular and fixed-neck prostheses, respectively. For studies with >5 years follow-up the mean revision rate was 3.08%. There was no difference in cause-specific revision rates by implant design. Mean improvement in Harris Hip Score was 41.9. Conclusions: At medium-term, revision rates for titanium-titanium primary modular-neck THA are acceptable. These prostheses are a sensible management option in patients with considerable anatomical hip deformity not amenable to correction with standard fixed-neck implants. Patients of male gender, high BMI and requiring prostheses with a larger neck, offset or head are at higher risk of implant failure.

We aimed to evaluate the quantity and quality of current evidence concerning the outcomes of use of plastinated specimens in anatomy education. We performed a narrative literature review, searching for papers dealing with the use of plastination in anatomy education. PubMed, Scopus, ERIC, Cochrane, Web of Science and CINAHL complete electronic databases were searched. The following data were extracted: author(s), year of publication, type of study (comparative or not), number of participants, evaluation of statistical significance, educational outcomes and their level according to Kirkpatrick hierarchy. Six studies were eligible for analysis. Five of them evaluated only students’ reactions about plastination and one study also assessed their examinations results. There were four non-comparative and two comparative studies. Only a study evaluated statistical significance (p

Objectives: To examine the influence of the annual change in kyphosis on the risk of falling in postmenopausal osteopenic and osteoporotic women. Methods: This prospective observational study included 498 postmenopausal Greek women over the age of 50, suffering from either osteoporosis or osteopenia. Data on age, height, weight, and self-reported falls were collected. Additionally, we evaluated the degree of the kyphosis angle, the balance, the mobility, the functionality and the handgrip strength on both hands of each subject using the Debrunner kyphometer, the Berg Balance Scale, the Timed-Up-and-Go test, the 30 Seconds Sit-to-Stand test and the Jamar Hydraulic Hand Dynamometer, respectively. All the above data were recorded at the baseline visit and the 12-month follow-up visit for each participant. Results: All examined variables presented a statistically significant change at the 12-month follow-up visit. Nevertheless, the annual change in kyphosis did not show any association with the risk of falling. Conclusion: No association was shown between the annual change in kyphosis and the risk of falling in postmenopausal osteopenic and osteoporotic women, nor bears any substantial prognostic value for future falls.

Aims The aim of this study was to investigate the hypothesis that a single dose of tranexamic acid (TXA) would reduce blood loss and transfusion rates in elderly patients undergoing surgery for a subcapital or intertrochanteric (IT) fracture of the hip. Methods In this single-centre, randomized controlled trial, elderly patients undergoing surgery for a hip fracture, either hemiarthroplasty for a subcapital fracture or intramedullary nailing for an IT fracture, were screened for inclusion. Patients were randomly allocated to a study group using a sealed envelope. The TXA group consisted of 77 patients, (35 with a subcapital fracture and 42 with an IT fracture), and the control group consisted of 88 patients (29 with a subcapital fracture and 59 with an IT fracture). One dose of 15 mg/kg of intravenous (IV) TXA diluted in 100 ml normal saline (NS,) or one dose of IV placebo 100 ml NS were administered before the incision was made. The haemoglobin (Hb) concentration was measured before surgery and daily until the fourth postoperative day. The primary outcomes were the total blood loss and the rate of transfusion from the time of surgery to the fourth postoperative day. Results Homogeneity with respect to baseline characteristics was ensured between groups. The mean total blood loss was significantly lower in patients who received TXA (902.4 ml (-279.9 to 2,156.9) vs 1,226.3 ml (-269.7 to 3,429.7); p = 0.003), while the likelihood of requiring a transfusion of at least one unit of red blood cells was reduced by 22%. Subgroup analysis showed that these differences were larger in patients who had an IT fracture compared with those who had a subcapital fracture. Conclusion Elderly patients who undergo intramedullary nailing for an IT fracture can benefit from a single dose of 15 mg/kg TXA before the onset of surgery. A similar tendency was identified in patients undergoing hemiarthroplasty for a subcapital fracture but not to a statistically significant level. Cite this article: Bone Joint J 2021;103-B(3):442–448.

Summary Osteoarthritis affects over 300 million people worldwide. Here, we conduct a genome-wide association study meta-analysis across 826,690 individuals (177,517 with osteoarthritis) and identify 100 independently associated risk variants across 11 osteoarthritis phenotypes, 52 of which have not been associated with the disease before. We report thumb and spine osteoarthritis risk variants and identify differences in genetic effects between weight-bearing and non-weight-bearing joints. We identify sex-specific and early age-at-onset osteoarthritis risk loci. We integrate functional genomics data from primary patient tissues (including articular cartilage, subchondral bone, and osteophytic cartilage) and identify high-confidence effector genes. We provide evidence for genetic correlation with phenotypes related to pain, the main disease symptom, and identify likely causal genes linked to neuronal processes. Our results provide insights into key molecular players in disease processes and highlight attractive drug targets to accelerate translation., Graphical abstract, Highlights • A multicohort study identifies 52 previously unknown osteoarthritis genetic risk variants • Similarities and differences in osteoarthritis genetic risk depend on joint sites • Osteoarthritis genetic components are associated with pain-related phenotypes • High-confidence effector genes highlight potential targets for drug intervention, A multicohort genome-wide association meta-analysis of osteoarthritis highlights the impact of joint site types on the features of genetic risk variants and the link between osteoarthritis genetics and pain-related phenotypes, pointing toward potential targets for therapeutic intervention.

Place: United States

There have been several studies published comparing the ultrasound-guided with the "blind" infiltrations in the shoulder's area. On the contrary, there is only very limited data regarding the necessity of ultrasound guidance in lateral epicondylitis.A prospective, randomized, blinded at initial and follow-up evaluation, comparative clinical trial was conducted, involving 44 patients with a history of chronic persistent epicondylopathy. The patients were randomly divided into 2 groups of 22 people each. Group A patients underwent three ultrasound-guided betamethazone injections, while group B included those who underwent three "blind" injections, centered at the palpable point of maximum pain. The evaluation was done before and after (4 and 12 weeks) the injections using the Visual Analogue Scale for pain (VAS, 0-10) and the RolesMaudsley score.There was not any significant statistical difference between the two groups as for mean VAS at 4 weeks (p = 0.150, t-test) and mean VAS at 12 weeks (p = 0.286, t-test). Furthermore, the final success rate, as measured by the RolesMaudsley score, was slightly superior in group B (67 % of the patients with excellent or good results) when compared with group A (46 % of the patients), but without any statistical difference (p = 0.161, chi-square).Our trial proved that an ultrasound-guided injection is not superior than a palpation-guided injection of corticosteroids in the treatment of lateral epicondylopathy.In mehreren Studien wurden ultraschallgesteuerte mit „blinden“ Infiltrationen im Schulterbereich verglichen. Im Gegensatz dazu gibt es nur sehr begrenzte Daten bezüglich der ultraschallkontrollierten Infiltrationstherapie bei einer Epikondylitis humeri lateralis.In die prospektive, randomisierte, verblindete Studie wurden 44 Patienten mit chronischer, therapieresistenter Epikondylitis humeri lateralis eingeschlossen. Die Patienten wurden nach dem Zufallsprinzip in 2 Gruppen von jeweils 22 Patienten eingeteilt. Patienten der Gruppe A erhielten drei ultraschallgesteuerte Betamethazon-Injektionen, Patienten der Gruppe B drei „blinde“ (= palpationsgesteuerte) Injektionen am Ort ihrer maximalen Schmerzen. Vor sowie 4 und 12 Wochen nach der letzten Injektion wurden die Schmerzen mittels der Visuellen Analogskala (VAS, 0–10) und der RolesMaudsley-Score erfasst.Weder 4 noch 12 Wochen nach Injektionsbehandlung fand sich ein statistisch signifikanter Unterschied punkto Schmerzen (p = 0,150; p = 0,286). Bzgl. der endgültiger Erfolgsrate (RolesMaudsley-Score) zeigte sich Gruppe B mit 67 % exzellenten oder guten Ergebnissen der Gruppe A mit 46% exzellenten oder guten Ergebnissen leicht überlegen, ohne dass dies statistisch signifikant war.Die Studie zeigt, dass eine ultraschallgesteuerte Injektionsbehandlung der Epikondylitis humeri lateralis der palpationsgesteuerten nicht überlegen ist.

The critical literature review investigates the extent to which the current evidence supports that three-dimensional printing (3DP) could play an important role in human anatomy education. PubMed, ERIC, and Cochrane databases were searched for papers dealing with the outcomes of 3DP implementation in human undergraduate anatomy education. The following data were extracted from each paper: authors, year of publication, type of study (comparative or not), number of participants, level of outcome according to Kirkpatrick hierarchy, influence of 3DP on acquisition of anatomical knowledge and skills, as well as perceptions about the 3DP use in anatomy teaching. Eight papers were eligible for analysis. All of them comprised comparison of 3DP with other anatomy teaching tools. Two papers evaluated only students’ perceptions about 3DP, while six papers explored its impact on students’ knowledge. The 3DP was statistically significantly superior to two-dimensional images in terms of the investigated parameters. However, comparison between 3DP and cadavers’ dissection by students did not take place in any study. The 3DP implementation in anatomy education showed promising outcomes. However, the lack of studies which compared the educational effectiveness of 3DP with that of cadavers’ dissection is highlighted. It seems that 3DP could certainly be used as an adjunct to cadavers’ dissection. Further research could clarify if 3DP could obtain a more prominent role in anatomy pedagogy compared to other anatomy teaching modalities.

Background The outcomes of the implementation of augmented reality (AR) in anatomical education have not been reviewed so far. We performed a narrative review of the literature concerning these outcomes. Methods We searched in the databases PubMed, Scopus, Cochrane, ERIC, CINAHL plus and Web of Science for papers with the aim to explore the outcomes of the implementation of AR in anatomical education. From each paper, we extracted the following data: authors, year of publication, type of study (comparative or not), number of participants, level of outcome according to Kirkpatrick hierarchy, acceptability of AR, impact on examinations performance, ability to facilitate understanding of spatial organization of structures and to motivate students to learn anatomy. Results Seven papers were eligible for analysis. There were five comparative and two non-comparative studies. Three studies evaluated only students’ perceptions about AR, while four papers assessed their examinations performance after the application of AR. Generally, AR was proved a highly acceptable and enjoyable anatomy teaching tool. It had remarkable efficacy in terms of helping students understand three-dimensional organization of structures and achieve satisfactory examinations results. Conclusions Although the research concerning the implementation of AR in anatomical education is relatively limited, there are promising results regarding the teaching potential of AR. These results could encourage anatomy educators to include this tool in their teaching methods. Randomized controlled studies are needed to prove if AR could effectively replace or supplement other anatomy pedagogy methods.

Reconstruction of the interosseous membrane has the potential to re-establish a normal loading pattern through the forearm and enhance stability after an Essex-Lopresti lesion. The aim of our study was to assess the capacity of three different techniques, which all use a regionally harvested autograft, to restore longitudinal stability. Simulation of the Essex-Lopresti lesion was done by excising the radial head and sectioning the interosseous membrane in seven cadaveric specimens. Each technique was used in each specimen consecutively, using the pronator teres, the brachioradialis and the flexor carpi radialis tendons, respectively. The specimens were submitted to mechanical testing by applying proximally migratory forces to the radius and radioulnar displacement was assessed fluroscopically at wrist level. The pronator teres tendon achieved the greatest reduction (94% correction with respect to the intact interosseous membrane/radial head out state, followed by brachioradialis (92%) and flexor carpi radialis (85%). However, no statistically significant differences in displacement data or strength were detected between the techniques.

We present the second implementation of a fracture liaison service (FLS) at a national level in Greece. This was a multicenter prospective study, organized by the Hellenic Society for the Study of Bone Metabolism, aiming to investigate the tracking and outcome of patients with low-trauma fractures visiting four university orthopedic departments across the country. The primary endpoint was the participation rate of eligible patients with low-trauma fractures in the program within a time frame of 1 year. Secondary outcomes included the percentage of patients initiating osteoporosis treatment, adherence to treatment, and the percentage of patients experiencing subsequent fractures. A major difference with previous reports was the designed implication of the orthopedic surgeon managing the fracture. Among the 1350 eligible patients with major osteoporotic fractures, only 396 (29.3%; mean age 78.1 ± 11.6 years; female/male ratio: 4.4) agreed to participate, nearly all of the latter (n = 392) completing the study. With the exception of seven patients, all participants were receiving anti-osteoporotic treatment at the end of the study. Twelve new fractures were recorded at completion of the 12-month follow-up, which were all sustained in patients who either declined to receive anti-osteoporotic treatment or who discontinued treatment despite advice to the contrary. The participation rate remains low and needs improvement. However, we report herein that whenever the treating physician is involved in the FLS structure, patients are more easily convinced to complete the program, to receive anti-osteoporotic treatment, and to stay connected throughout with the outpatient clinic.

Gait analysis is a significant diagnostic procedure for the clinicians who manage musculoskeletal disorders. Surface electromyography (sEMG) combined with kinematic and kinetic data is a useful tool for decision making of the appropriate method needed to treat such patients. sEMG has been used for decades to evaluate neuromuscular responses during a range of activities and develop rehabilitation protocols. The sEMG methodology followed by researchers assessed the issues of noise control, wave frequency, cross talk, low signal reception, muscle co-contraction, electrode placement protocol and procedure as well as EMG signal timing, intensity and normalisation so as to collect accurate, adequate and meaningful data. Further research should be done to provide more information related to the muscle activity recorded by sEMG and the force produced by the corresponding muscle during gait analysis.

The purpose of this study was to illustrate the usefulness of ultrasound in the early diagnosis of occult scaphoid fractures. Forty-eight patients with clinical symptoms of scaphoid fracture and negative initial X-rays were examined. All patients underwent ultrasonography in the emergency room (ER). After 14 days, a computed tomography (CT) scan was performed, which confirmed or not the initial suspicion of fracture. Twenty-two patients were found with subperiosteal hematoma, while six also had cortical discontinuity. The sensitivity of ultrasound in the diagnosis of occult scaphoid fractures was 90% and the specificity was 85.7%. The positive prognostic value was 81.8%. The authors support the use of the scaphoid ultrasound only under strict circumstances. If subperiosteal hematoma or cortical discontinuity is present, there is a high likelihood of scaphoid fracture. On the contrary, if the ultrasound is negative and symptoms persist, the patient will require a CT scan or magnetic resonance imaging for definitive diagnosis. (Journal of Surgical Orthopaedic Advances 28(1):1-9, 2019).

Reconstruction of the central band of the interosseous membrane is an emerging procedure implemented in the treatment of longitudinal radioulnar dissociation (LRUD), usually in its chronic setting, after Essex-Lopresti injuries of the forearm. There are no sufficient clinical data to support reconstruction of the central band of the interosseous membrane in acute LRUD injuries. Clinical and cadaveric studies comparing autografts (palmaris longus, flexor carpi radialis and bone-patellar-bone), allografts (Achilles tendon) and synthetic ligaments have not shown superiority of one technique versus another; however, they have shown special concerns with respect to the use of synthetic grafts. Latrogenic fracture, decrease of rotational range of movement, iatrogenic nerve injury (superficial radial and median nerve), donor site morbidity with autografts and recurrent instability are the complications reported in literature after interosseous membrane reconstruction. Cite this article: EFORT Open Rev 2019;4:143-150. DOI: 10.1302/2058-5241.4.180072

Longitudinal stability of the forearm is mainly provided by three structures: the radiocapitellar contact, which acts as the primary stabilizer, the central band of the interosseous ligamentous complex (IOLC) and the intact triangular fibrocartilage complex (TFCC). In an Essex-Lopresti lesion the forearm becomes fully destabilized, since all of these three components are injured. Fixation or replacement of the radial head with a metallic prosthesis along with repair of the TFCC and stabilization of the distal radioulnar joint (DRUJ) are well-established treatment goals. However the reconstruction of the central band of the IOLC remains to some extent controversial. The authors believe that the reconstruction of the central band, particularly in active patients, is crucial in order to restore normal load distribution through the forearm, thus ensuring both transverse and longitudinal stability. In this article, we present a case with an Essex-Lopresti lesion, which was effectively treated acutely with restoration of all three components of the injury (radial head prosthesis, DRUJ repair and reconstruction of the central band of the IOLC). A novel technique by rerouting the brachioradialis tendon is described in detail.

Background Total knee arthroplasties (TKAs) using well-designed, fixed bearing prostheses, such as medial pivot (MP), have produced good long-term results. Rotating-platform, posterior-stabilized (RP-PS) mobile bearing implants were designed to decrease polyethylene wear. Sagittal and coronal plane TKA biomechanics are well examined and correlated to polyethylene wear. However, limited research findings describe this relationship in transverse plane. We assumed that although axial plane biomechanics might not be the most destructive parameters on polyethylene wear, it is important to clarify their role because both joint kinematics and kinetics in all 3 planes are important input parameters for TKA wear testing (International Organization for Standardization 14243-1 and 14343-3). Our hypothesis was that transverse plane overall range of motion (ROM) and/or peak moment show differences that reflect on wear advantages when compared RP-PS implants to MP designs. Methods Two groups (MPs = 24 and RP-PSs = 22 subjects) were examined by using 3D gait analysis. The variables were total internal-external rotation (IER) ROM and peak IER moments. Results No statistically significant difference was demonstrated between the 2 groups in kinetics ( P = .389) or kinematics ( P = .275). Conclusion In the present study, no wear advantages were found between 2 TKAs. Both designs showed identical kinetics at the transverse plane in level-ground walking. Kinematic analysis could not illustrate any statistically significant difference in terms of overall IER ROM. Nevertheless, kinematic gait pattern differences observed possibly reflect different patterns of joint surface motion or abnormal gait patterns. Thus, wear testing with various input waveforms combined with functional data analysis will be necessary to identify the actual effects of gait variability on polyethylene wear.

Total Hip Arthroplasty (THA) is an effective treatment for severe hip arthritis, with patients reporting high rates of satisfactory results postoperatively. There are a variety of choices regarding THA implant designs. Ceramic on Ceramic and Ceramic on Highly Cross-Linked Polyethylene (XLPE) THAs are the materials of choice nowadays. The purpose of this study is to review the effect of kinematics and kinetics on wear (in vivo and in vitro testing) that affect wear in Ceramic on Ceramic and Ceramic on XLPE total hip arthroplasties and identify possible advantages amongst them. The study hypothesis was that THA kinematics and/or kinetics, since they directly affect THA wear, could provide data for possible advantages between the examined implant designs. A systematic review of the literature identified no significant evidence for biomechanical advantages between these two prostheses in terms of wear. Further research is proposed with the use of gait analysis systems combined with surface electromyography to further investigate THA biomechanics at a laboratory set up. Wearable sensors technology could also identify detailed biomechanical parameters in more complex daily activities.

Low back pain affects an estimated half a billion people at any time worldwide. Although several noninvasive treatment strategies have been developed, in many cases, they cannot relief patients’ symptoms, thus low back discectomy is the appropriate treatment of choice. It is widely accepted that surgery alters the biomechanics of the functional motion segment and results in additional disc herniation at the adjacent level or the opposite side, more commonly than expected. After the discectomy, changes in vertebral load properties and kinetics could occur. As a result, biomechanical stress on the affected level as well as cyclic loads can cause lumbar disc reherniation (rLDH). Since the rate of recurrent disc herniation is about 5%-15%, further research should be done so as to quantify the postoperative lumbar spine kinematic pattern, with the use of wearable sensors technology, that could be a potential biomechanical factor causing rLDH.

Background There are conflicting reports regarding the therapeutic effect of platelet-rich plasma (PRP) versus autologous whole-blood (platelet poor plasma, PPP) injections for plantar fasciitis. Therefore, this study was conducted to compare the effectiveness of a single ultrasound (US)-guided PRP versus PPP injection in patients with chronic plantar fasciitis. Materials and methods 36 patients were recruited with clinical and sonographic evidence of chronic (>6 months) plantar fasciitis, refractory to analgesics and physical therapy in a double-blinded, randomized, prospective study. The patients were randomly allocated into two groups with a sealed envelope method. Group A included 18 patients who underwent a single US-guided PRP injection and group B included another 18 patients who underwent PPP injection with the same technique. Follow-up was set at 3 and 6 months; no patient was lost to follow-up. Pain, function and satisfaction were assessed using visual analogue scales, and occurrence of complications. Results All scores statistically significantly improved for both groups from baseline at the 3- and 6-month follow-up evaluation, without, however, any statistically significant differences between the two groups with respect to pain, function and satisfaction scores. Complications were not observed. Conclusions A single US-guided PRP injection yields similar results with PPP injection in patients with chronic plantar fasciitis. Both treatments provide significant improvement at 3 and 6-month follow-up after the injection.

Background: Given that apoptosis of chondrocytes is one of the most important factors related to the pathogenesis of osteoarthritis (OA), the recent research interest adds progress not only to the knowledge of the molecular signals that mediate apoptosis but also to find new therapeutic targets. This study attempts to investigate the differential expression of BCL2 family genes in the articular cartilage of an experimental animal model of OA. Methods: In total, 26 New Zealand white rabbits underwent an anterior cruciate ligament transaction, 26 more were subjected to a placebo surgery and 18 specimens constituted the control non-operated group. Thirteen weeks later, samples of cartilage from the osteoarthritic and non-osteoarthritic knees were collected and subjected to analysis of the BCL2, BAX and BCL2L12 gene expression at the mRNA level. Results: Installed osteoarthritic alterations of varied intensity and of grade 1 up to grade 5, were confirmed according to the OARSI system. Contrary to the physiologically healthy samples, in the osteoarthritic samples the mRNA expression levels of BAX and BCL2L12 genes were found significantly upregulated by signals which can activate apoptosis. However, the difference between BCL2 mRNA expression levels in healthy and osteoarthritic samples was not supported statistically. Conclusions: Since apoptosis is the main feature of the cartilage degeneration in OA, the effective inhibition of apoptosis of chondrocytes can provide novel and interesting therapeutic strategies for the treatment of OA. Therefore, BAX and BCL2L12 are highlighted as potential therapeutic targets in OA.

A series of clinical trials focused on the use of ultrasound-guided platelet-rich plasma (PRP) infusions for the treatment of patients with carpal tunnel syndrome (CTS) were published over the last few years. However, the role of PRP for CTS remains unclear. We performed a systematic review according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Two reviewers independently conducted the search using multiple databases: MEDLINE/PubMed, SCOPUS, Cochrane Database, and Web of Science. These databases were searched using terms "platelet" AND "rich" AND "plasma" AND "carpal" AND "tunnel". To maximize the search, backward chaining of references from retrieved papers was also undertaken. From the initial 19 studies, only five met our eligibility criteria. These articles included one randomized controlled double-blind study, one randomized controlled single-blind study, one randomized controlled non-blind study, one case-control study, and one case report. The vast majority of the included studies supported that PRP infusion improved the clinical condition of the patients and that PRP infusion was beneficial for patients with mild-to-moderate CTS. Therefore, PRP seems to be an interesting alternative for the treatment of mild-to-moderate CTS which, still, has not been thoroughly investigated. However, despite the promising results of the present studies, PRP has to be further tested before we reach to a definite conclusion regarding its therapeutic value.

Fractures of modern cementless stems are almost extinct. However, extra small stems used for cases of developmental dysplasia of the hip (DDH) are still at risk for this complication. We review the fracture of a small size 11, custom-made Wagner cone prosthesis in a 70 year old female patient. The patient had a body-mass index (BMI) of 22.2, 7 yrs after undergoing a total hip arthroplasty. The procedure was undertaken to correct extreme high-riding congenital hip dysplasia. She presented with sudden pain due to a non-traumatic fracture of the stem, just below the proximal third region. At revision, it was apparent that the stem had a concrete distal fixation, whereas the proximal part was loose and probably failed due to cantilever bending fatigue, although the patient had small stature and a low BMI. We trephined out the distal portion, and the patient was successfully revised with a cemented DDH Co-Cr stem. It is our belief that care should be taken when choosing extra small, cementless implants with distal fixation. Cemented prostheses may offer a safe alternative in such cases.

Gait analysis using external skin markers provides scope for the study of kinematic and kinetic parameters shown on different total knee arthroplasties (TKA). Thus an appropriate methodology is of great importance for the collection and correlation of valid data. Calibration of equipment is of great importance before measurements, to assure accuracy. Force plates should be calibrated to 1080 Hz and optoelectronic cameras should use 120 Hz frequency, because of the nature of gait activity. Davis model which accurately defines the position of the markers is widely accepted and cited, for the gait analysis of TKA's. To ensure the reproducibility of the measurement, a static trial at the anatomical position must be captured. Following, all acquisitions of dynamic data must be checked for consistency in walking speed, and abnormal gait style because of fatigue or distraction. To establish the repeatability of the measurement, this procedure must be repeated at a pre-defined number of 3-5 gait cycles. Anthropometric measurements should be combined with three-dimensional marker data from the static trial to provide positions of the joint's center and define anatomical axes of total knee arthroplasty. Kinetic data should be normalized to bodyweight (BW) and percentage of BW and height depending on the study. External moments should also be calculated by using inverse dynamics and amplitude-normalized to body mass (Nm/kg). Gait analysis using external skin markers provides scope for the study of biomechanical parameters shown on different TKAs. Thus a standard gait analysis methodology when measuring TKA biomechanical parameters is necessary for the collection and correlation of accurate, adequate, valid and reproducible data. Further research should be done to clarify if the development of a specific kinematic model is appropriate for a more accurate definition of total knee implant joint center in measurements concerning 3D gait analysis.

Background: Radiographic fracture classification helps with research on prognosis and treatment. AO/OTA classification into fracture type has shown to be reliable, but further classification of fractures into subgroups reduces the interobserver agreement and takes a considerable amount of practice and experience in order to master. Questions/purposes: We assessed: (1) differences between more and less experienced trauma surgeons based on hip fractures treated per year, years of experience, and the percentage of their time dedicated to trauma, (2) differences in the interobserver agreement between classification into fracture type, group, and subgroup, and (3) differences in the interobserver agreement when assessing fracture stability compared to classifying fractures into type, group and subgroup. Methods: This study used the Science of Variation Group to measure factors associated with variation in interobserver agreement on classification of proximal femur fractures according to the AO/OTA classification on radiographs. We selected 30 anteroposterior radiographs from 1061 patients aged 55 years or older with an isolated fracture of the proximal femur, with a spectrum of fracture types proportional to the full database. To measure the interobserver agreement the Fleiss’ kappa was determined and bootstrapping (resamples = 1000) was used to calculate the standard error, z statistic, and 95% confidence intervals. We compared the Kappa values of surgeons with more experience to less experienced surgeons. Results: There were no statistically significant differences in the Kappa values on each classification level (type, group, subgroup) between more and less experienced surgeons. When all surgeons were combined into one group, the interobserver reliability was the greatest for classifying the fractures into type (kappa, 0.90; 95% CI, 0.83 to 0.97; p < 0.001), reflecting almost perfect agreement. When comparing the kappa values between classes (type, group, subgroup), we found statistically significant differences between each class. Substantial agreement was found in the clinically relevant groups stable/unstable trochanteric, displaced/non-displaced femoral neck, and femoral head fractures (kappa, 0.60; 95% CI, 0.53 to 0.67, p < 0.001). Conclusions: This study adds to a growing body of evidence that relatively simple distinctions are more reliable and that this is independent of surgeon experience.

Both in vitro and in vivo experiments have confirmed that platelet-rich plasma has therapeutic effects on many neuropathies, but its effects on carpal tunnel syndrome remain poorly understood. We aimed to investigate whether single injection of platelet-rich plasma can improve the clinical symptoms of carpal tunnel syndrome. Fourteen patients presenting with median nerve injury who had suffered from mild carpal tunnel syndrome for over 3 months were included in this study. Under ultrasound guidance, 1-2 mL of platelet-rich plasma was injected into the region around the median nerve at the proximal edge of the carpal tunnel. At 1 month after single injection of platelet-rich plasma, Visual Analogue Scale results showed that pain almost disappeared in eight patients and it was obviously alleviated in three patients. Simultaneously, the disabilities of the arm, shoulder and hand questionnaire showed that upper limb function was obviously improved. In addition, no ultrasonographic manifestation of the carpal tunnel syndrome was found in five patients during ultrasonographic measurement of the width of the median nerve. During 3-month follow-up, the pain was not greatly alleviated in three patients. These findings show very encouraging mid-term outcomes regarding use of platelet-rich plasma for the treatment of carpal tunnel syndrome.

Purpose To demonstrate whether and to what extent a single injection of Platelet-Rich Plasma (PRP), under ultrasound guidance, can improve the clinical symptoms of patients with a mild to moderate carpal tunnel syndrome (CTS). Methods We conducted a prospective, randomized, clinical study including 50 patients suffering from mild to moderate CTS for a minimum duration of 3-months. Patients were randomly divided into two groups: A (26 patients) received an ultrasound-guided PRP injection into the carpal tunnel, whereas Group B (24 patients) was injected with placebo (0.9% normal saline, N/S). The short and mid-term outcomes were determined with the use of the Q-DASH questionnaire and the pain scale VAS administered at 0, 4, 12 weeks follow-up. The success ratio was determined by the difference in the Q-DASH obtained pre-injection minus the final Q-DASH obtained after 12 weeks follow-up. Success was defined as a difference more than 25%. Results Group A patients demonstrated a 76.9% success as determined by the difference Q-DASH, while group B patients demonstrated 33.3% success, which was significantly less than group A (Χ2, p=0.011). Conclusion The findings of the present study suggest that a single PRP ultrasound-guided injection has positive effects in patients with carpal tunnel syndrome.

Osteoarthritis is a common complex disease with huge public health burden. Here we perform a genome-wide association study for osteoarthritis using data across 16.5 million variants from the UK Biobank resource. Following replication and meta-analysis in up to 30,727 cases and 297,191 controls, we report 9 new osteoarthritis loci, in all of which the most likely causal variant is non-coding. For three loci, we detect association with biologically-relevant radiographic endophenotypes, and in five signals we identify genes that are differentially expressed in degraded compared to intact articular cartilage from osteoarthritis patients. We establish causal effects for higher body mass index, but not for triglyceride levels or type 2 diabetes liability, on osteoarthritis.

Osteoarthritis is a common complex disease imposing a large public-health burden. Here, we performed a genome-wide association study for osteoarthritis, using data across 16.5 million variants from the UK Biobank resource. After performing replication and meta-analysis in up to 30,727 cases and 297,191 controls, we identified nine new osteoarthritis loci, in all of which the most likely causal variant was noncoding. For three loci, we detected association with biologically relevant radiographic endophenotypes, and in five signals we identified genes that were differentially expressed in degraded compared with intact articular cartilage from patients with osteoarthritis. We established causal effects on osteoarthritis for higher body mass index but not for triglyceride levels or genetic predisposition to type 2 diabetes.

A 70-year-old woman had a primary cemented total arthroplasty of her right hip performed elsewhere in 1967 for developmental hip dysplasia. The arthroplasty failed in 1977, due to aseptic loosening and since then the patient has undergone 3 revision procedures including 2 acetabular cup revisions. In 2006, a porous tantalum acetabular augment (PTAA) (Zimmer, Warsaw, IN) was used to support a hemispherical cementless acetabular centroid Hilock cup (SYMBIOS Orthopedie, Yverdon-les-Bains, Switzerland) made of titanium alloy (Ti6Al4V) with a porous titanium and hydroxyapatite dual coating. At that time, no cement was interpositioned between the cup and augment—as instructed by the manufacturers. 6 years later, the patient was unable to walk and suffered severe pain, and she was referred to us for an additional revision. The preoperative radiographs showed a peculiar “halo formation” surrounding the acetabular component (Figure 1). Extensive metallosis of this surrounding tissue was found intraoperatively. Black pigmentation was also found in the overlying skin (Figure 2). Following the removal of the loose Hilock cup, the tantalum augment was found to be non-osseointegrated, severely worn, and broken (Figure 3). Debridement and synovectomy was performed and a modified cup-cage construct technique was used to address the existing pelvic discontinuity. Figure 1. Pre-revision radiograph. An unexplained “hallo formation” can be seen surrounding the acetabular components. Figure 2. Skin pigmentation immediately after revision. Figure 3. Intraoperative findings. Extensive periprosthetic metallosis and wear of the tantalum augment and the adjacent porous titanium and hydroxyapatite-coated acetabular SYMBIOS cup. Ta particles were embedded in the polyethylene surface (black stains). 2 peripheral blood samples were taken just before the revision operation and periprosthetic tissue samples were taken intraoperatively using a standardized technique for minimizing any potential risk of contamination during collection or handling. Quantitative determination of metal levels in serum and tissue samples was performed after the dissolution of the samples. The serum samples were diluted 10-fold with 0.14 M high-purity nitric acid in double-distilled water, and the tissue samples were digested in a temperature-controlled microwave oven (Milestone START D) (Rodushkin et al. 2004). Due to the very low concentrations of tantalum in serum reported in the literature (in the nanogram-per-liter range), the Ta content of the solutions was determined by inductively coupled plasma-mass spectrometry (ICP-MS) for the 181Ta isotope using the Agilent 7700 ICP-MS spectrometer with an octopole reaction system to eliminate possible interferences (Rodushkin et al. 2004). For study of the morphology of the tissue surface, and for semi-quantitative analysis (FEI company), a Quanta 200 scanning electron microscope (SEM) equipped with an EDX-Genesis 400 energy-dispersive X-ray fluorescence spectrometer (EDX) was used under low vacuum, without any pretreatment of the samples. The SEM image showed an alteration on the surface of the largest part of the tissue (Figure 4). The semi-quantitative EDX analysis of area A revealed a composition with Ta as the predominant element, accompanied by Cr and Co (Ta: 76.2%; Co: 6%; Cr: 2.9%; C: 6.3%; O: 7.3%; S: 0.7%; and Ti: 0.6%). Figure 4. SEM image and results of EDX analysis of areas A, B, C, and D revealing the predominance of Ta. Spot analyses of areas B and C showed almost pure pieces of Ta (88% and 75%, respectively) laid on the tissue. Area C showed a small increase in the titanium concentration (1%). EDX analysis of area D, considered to be rather free of depositions, showed a composition of C: 31%; N: 18%; O: 32%; Na: 0.5%; S: 1%; Ca: 0.4%; Ta: 18%; and Ti: 0.3%) with a reduced content of Ta in comparison to the previous examined spots B and C. The Ti level was close to the detection limit. The actual values of tantalum serum levels determined in both preoperative serum samples were 20 (SD 2) μg/L. These values were approximately 2,000 times higher than what has been reported in the literature, which is in the 0.008–0.010 μg/L range for normal serum samples (Rodushkin et al. 2004). The total concentrations of Ta and Ti in the investigated tissue sample were 35% and 0.6% respectively. No clinical signs of systemic ion toxicity were identified, and markers of liver and kidney function were within the normal range. At re-revision, as there was pelvic discontinuity we used a modified cup-cage concept using a jumbo Ta acetabular cup and distal augment, which were protected by a Ti Burch Schneider-type reconstruction ring—Contour (Smith and Nephew, Memphis TN)—with Palacos cement in all implant interfaces. 6 months after revision, the serum tantalum levels were 15 μg/L, a decrease of 25% compared to the levels found in the serum just before revision operation. The patient had no pain (Figure 5). Figure 5. 6 months after re-revision of the acetabular components. A modified jumbo Ta cup-Ti cage construct and peripheral Ta augment were used due to pelvic discontinuity. The patient had no pain at the latest follow-up.

Lower-extremity angular deformities are among the most common non-traumatic conditions in children being referred to pediatric orthopedists. Understanding of this abnormality and knowledge of current treatment is essential for pediatricians and primary caregivers. A development in the surgical management of these problems has improved the quality of care of affected children and adolescents. Traditionally, angular deformities are treated by means of osteotomy. In patients who are skeletally immature, this major intervention can be avoided by influencing or guiding the growth of the affected physis using hemiepiphysiodesis techniques. Recently, alternative surgical techniques and implants have been described for improved control of the guided growth.

MM is frequently associated with the development of osteolytic bone lesions, osteoporosis and pathological fractures. Bone destruction in MM is caused by osteoclasts recruited in areas adjacent to myeloma plasma cells; their contact triggers both cell types to secrete soluble factors sustaining one each other’s activation and proliferation. Osteoclasts differentiate and maturate upon binding of the receptor activator of NF-kappaB ligand (RANKL), secreted by bone marrow microenvironmental cells, to its receptor (RANK) on osteoclast progenitors, while osteoprotegerin (OPG), a natural decoy receptor, can block the aforementioned ligation. At the same time osteoblasts are inactivated by the Wnt/β-catenin signaling pathway inhibitor, Dickkopf-1 protein (DKK-1), secreted by malignant plasma cells. Furthermore, DKK-1 deregulates the OPG/RANKL equilibrium, promoting osteoclastogenesis. Myeloma bone disease (MBD) can be treated with myeloma-directed chemotherapy and agents inhibiting bone resorption such as aminobisphosphonates, although new promising biology driven monoclonal antibodies targeting osteoclastogenesis mechanisms are emerging. Palliative MBD treatment includes analgesics, orthotics, radiation therapy, vertebroplasty and kyphoplasty. In case of spinal cord compression, radiation therapy or surgical decompression, should be instantly performed, along with steroid administration. Surgery may also be an option especially in case of weight-bearing bone fractures. MBD is a morbid complication and should be carefully managed because it deteriorates patients’ quality of life and worsens disease outcome.

Liaison: Paul Lichstein MD, MSLeaders: Thorsten Gehrke MD (International), Adolph Lombardi MD, FACS (US), Carlo RomanoMD (International), Ian Stockley MB, ChB, MD, FRCS (International)Delegates: George Babis MD, Jerzy Bialecki MD, La´szlo´ Bucsi MD, Xu Cai MD, Li Cao MD, Briande Beaubien MD, Johannes Erhardt MD, Stuart Goodman MD, PhD, FRCSC, FACS, FBSE,William Jiranek MD, Peter Keogh, David Lewallen MD, MS, Paul Manner MD, WojciechMarczynski MD, J. Bohannon Mason MD, Kevin Mulhall MB, MCh, FRCSI, Wayne PaproskyMD, Preetesh Patel MD, Francisco Piccaluga MD, Gregory Polkowski MD, Luis Pulido MD, IanStockley MBBS, ChB, FRCS, Juan Suarez MD, Fritz Thorey MD, Rashid Tikhilov MD, JobDiego Velazquez MD, Heinz Winkler MD

This study presents the clinical outcomes of 35 hands with Dupuytren's Disease treated with the McCash technique between 1990 and 2009. Of the 31 patients (28 males and three females, mean age 53 yrs), four patients had bilateral involvement (12.9%). Thirty hands had no previous medical or surgical treatment for the disease, while the remaining five hands had been operated on at least once. The mean contracture of metacarpophalangeal (MCP) joint improved from 42.14° to 1.83°, while that of the proximal interphalangeal (PIP) joint improved from 62.60° to 7.09°. All wounds healed within a mean 9.8 weeks. Sensory evaluation revealed no permanent numbness. With realistic expectations, clear documentation, meticulous surgical technique and implementation of a demanding post-operative rehabilitation program, an acceptable outcome may be achieved with the McCash technique for Dupuytren's disease.