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Background The ultrasonic Harmonic Blade cuts and coagulates soft tissue at temperatures lower than conventional electrosurgery. This study investigated whether improved hemostatic control and reduced collateral damage in skeletal muscle incisions translates into improved myofiber regeneration, reduced fibrosis and faster muscle recovery. Materials and Methods Transections in the left gastrocnemius muscles of mice were made with the Harmonic Blade, and contralaterally, with either cold steel scissors or electrosurgery. Histology up to 8 wk after surgery was performed to evaluate myofiber regeneration and fibrosis. Tissue inflammation (Gr1+ neutrophils) and vascularization (CD31+ capillaries) were assessed immunohistochemically at 1 wk . Results Overall the Harmonic Blade showed significantly higher level of muscle regeneration than cold steel. Fibrosis for both the Harmonic Blade and cold steel decreased three-fold over the 8 wk period, while electrosurgery yielded significantly increasing fibrosis through wk 4 before declining. At 1 wk post-surgery the Harmonic Blade induced less inflammation than electrosurgery, and higher vascularization than electrosurgery and cold steel. Conclusions Harmonic Blade-incised tissue showed accelerated vascularization, slight reduction of inflammation, enhanced muscle regeneration and decreased scarring, demonstrating a more effective healing process than electrosurgery.

Large meniscal defects are a common problem for which treatment options are limited. Successful meniscal regeneration has been achieved by using grafts of small intestinal submucosa in posterior, vascular meniscal defects in a dog model. This study investigates the long-term effects of a tibial tunnel fixation technique and a clinically based meniscectomy defect on meniscal regeneration using this model. Eight mongrel dogs underwent medial arthrotomy and partial meniscectomy. The dogs were divided into groups based on defect treatment: small intestinal submucosa (n = 4) or meniscectomy (n = 4). Dogs were scored for lameness by subjective scoring postoperatively, sacrificed at 6 months, and assessed for articular cartilage damage, gross and histologic appearance of the operated meniscus, amount of new tissue in the defect, and relative compressive stiffness of articular cartilage. Dogs in the meniscectomy group were significantly (P = .002) more lame than dogs treated with small intestinal submucosa. Small intestinal submucosa-treated joints had significantly (P = .01) less articular cartilage damage than meniscectomy joints. Small intestinal submucosa meniscal implants resulted in production of meniscal-like replacement tissue, which was consistently superior to meniscectomy in amount, type, and integration of new tissue, chondroprotection, and limb function during the study period. Small intestinal submucosa implants may be useful for treatment of large posterior vascular meniscal defects in humans. The tibial tunnel technique used for fixation may have clinical advantages and therefore warrants further investigation.

Background Large meniscal defects are a common problem for which current treatment options are limited. Hypothesis Treatment of posterior medial meniscal defects in dogs with small intestinal submucosa is superior to partial meniscectomy in terms of clinical limb function, chondroprotection, and amount and type of new tissue in the defect. Study Design Controlled laboratory study. Methods A total of 51 mongrel dogs underwent medial arthrotomy with creation of standardized meniscal defects. The dogs were divided into groups based on defect treatment: small intestinal submucosa meniscal implant (n = 29) or meniscectomy (n = 22). The dogs were assessed for lameness by subjective scoring after surgery and sacrificed at 3, 6, or 12 months and assessed for articular cartilage damage, gross and histologic appearance of the operated meniscus, amount of new tissue in the defect, equilibrium compressive modulus of meniscal tissue, and relative compressive stiffness of articular cartilage. Results Dogs in the meniscectomy groups were significantly (P Conclusion Small intestinal submucosa scaffolds placed in large meniscal defects resulted in production of meniscus-like replacement tissue, which was consistently superior to meniscectomy in amount, type, and integration of new tissue; chondroprotection; and limb function in the long term. Clinical Relevance Small intestinal submucosa implants might be useful for treatment of large posterior vascular meniscal defects in humans.

There is growing evidence that a hydrodynamic environment is beneficial for growing cartilage tissue-engineered constructs; however, the mechanisms by which fluid shear provides for a better construct are not well understood. In this study, we investigated one possible mechanism by which constructs grow faster under fluid shear: fluid shear upregulates chondrocyte proliferation. Further, we investigated if this effect is mediated by TGF-beta1, a known mediator of fluid shear effects in other cell types and a mitogen for chondrocytes. To test the hypotheses, primary bovine articular chondrocytes were cultured in monolayers (approximately 40,000 cells/cm(2)) to 80-85% confluency. After 24 h of growth arrest, cells were exposed to 3.5 Pa fluid shear stress for 96 h. Total DNA was compared between flow and static culture slides. Total TGF-beta1 was quantified in flow-conditioned media (CM) and static culture-CM. Mitogenic capacity of the CM, with or without anti-TGF-beta1 or anti-TbetaRII (TGF beta receptor type II) antibodies, was also assessed. Results show that fluid shear significantly up-regulates chondrocyte proliferation (p < 0.02). Further, total TGF-beta1 in the flow-CM was more than 3.5-fold higher (p < 0.03) and its mitogenicity significantly higher (p < 0.007) as compared to static culture-CM. Adding excess anti-TGF-beta1 or anti-TbetaRII antibodies partially, but significantly depressed mitogenicity (approximately 20% decrease) of the flow-CM. These results show that fluid shear stress upregulates chondrocyte proliferation and that this effect is partially mediated by TGF-beta1.

While the risks associated with the use of electrosurgery near nerves are well known, few studies have examined the neurophysiologic effects of application of the Harmonic Blade, an ultrasonic scalpel, in the vicinity of nerve fibres. This study sought to compare the sub-acute neurophysiologic effects of the Harmonic Blade and electrosurgery after incisions close to the sciatic nerve.Incisions were made in rats with the Harmonic Blade and electrosurgery at distances of 1, 2, 3 and 4 mm from the sciatic nerve. Sham surgery was also performed. The compound action potential, conduction velocity and calibrated nylon filament (von Frey hair, VFH) stimulating force were monitored for up to 3 hours after surgery. The sciatic nerve was assessed for inflammation via HE staining and impaired axonal transport by β-APP immunohistochemistry.Electrosurgery incisions produced a significantly greater decrease in compound action potential and conduction velocity, and increase in the VFH force than the Harmonic Blade over all time points and distances from the sciatic nerve. The Harmonic Blade was similar to sham surgery for the compound action potential and VFH force. Electrosurgery yielded significantly greater leukocyte infiltration than the Harmonic Blade and produced the highest levels of β-APP immunoreactive swellings.Incisions with electrosurgery in the range of 1-4 mm of the sciatic nerve caused substantial changes in neurophysiologic functioning and inflammation. In contrast, the Harmonic Blade was similar to sham surgery in the vicinity of the nerve, producing little observable acute trauma.

Orthopedic joint procedures frequently require extensive dissection of skeletal muscles resulting in tissue injury, formation of scar tissue, pain, and potentially, functional impairment. The authors hypothesized that using a low-temperature ultrasonic cutting and coagulating device (Harmonic Blade, Ethicon Endo-Surgery, Cincinnati, OH) would result in reduction in tissue trauma in terms of reducing acute and chronic inflammation during healing. Bilateral longitudinal incisions were made into the tibialis cranialis muscles of rabbits with either a Harmonic Blade or a standard monopolar electrosurgical scalpel. At 3, 7, and 21 days postoperatively, necropsy and histological evaluations indicated a significant attenuation of acute inflammation ( P = .011) for the Harmonic incisions compared with electrosurgery. No significant differences were observed for chronic inflammation, necrosis, or fibrosis. Use of a Harmonic scalpel during dissection of skeletal muscle in orthopedic surgery may result in reduced influx of neutrophils, reducing acute inflammation, and potentially aid in reducing postoperative pain and functional impairment.

BackgroundThere is no consensus regarding the extent of meniscectomy leading to deleterious effects on tibiofemoral contact mechanics.HypothesisThe meniscus aids in optimizing tibiofemoral contact mechanics, increasing contact area, and decreasing contact stress.Study DesignControlled laboratory study.MethodsTwelve fresh-frozen human cadaveric knees each underwent 15 separate testing conditions—5 serial 20-mm posterior medial meniscectomy conditions (intact, 50% radial width, 75% radial width, segmental, and total meniscectomy) at 3 flexion angles (0°, 30°, and 60°)—under an 1800-N axial load. Tekscan sensors were used to measure total force and medial force, contact area, mean contact stress, and peak contact stress.ResultsAll posterior medial meniscectomy conditions resulted in significantly decreased contact areas and increased mean and peak contact stresses compared with the intact state (P < .05). The changes in contact mechanics after segmental and total posterior medial meniscectomies were not statistically different (P > .05). Incremental changes in contact area and mean contact stress increased as more peripheral portions of the medial meniscus were removed, whereas peak contact stresses exhibited similar incremental changes throughout all meniscectomy conditions.ConclusionsThe meniscus is a crucial load-bearing structure, optimizing contact area and minimizing contact stress. Loss of hoop tension (ie, segmental meniscectomy) is equivalent to total meniscectomy in load-bearing terms. The peripheral portion of the medial meniscus provides a greater contribution to increasing contact areas and decreasing mean contact stresses than does the central portion, whereas peak contact stresses increase proportionally to the amount of meniscus removed.Clinical RelevanceBecause the degree of meniscectomy leading to clinically significant outcomes is unknown, a prudent strategy is to preserve the greatest amount of meniscus possible.

Naturally occurring biomaterials, such as small intestine submucosa (SIS), are attractive as potential scaffolds for engineering various tissue types. The aim of this study was to determine whether acellular SIS scaffolds can support cell attachment and ingrowth in a diarthroadial joint without significant intraarticular hemorrhage. Disks of porcine SIS were arthoscopically implanted freely within a randomized knee joint of 21 dogs and harvested 1, 2, 3, and 6 weeks postoperatively. Harvested disks were assessed for gross and histologic appearance, cellular infiltration, and immunoreactivity of collagenase and collagen types I and II. Knee synovium and synovial fluid were also evaluated. All disks were thickened and opacified at harvest. Eleven disks (52%) had adhered to intraarticular tissues and cellular infiltration into the disks was positively correlated with tissue adherence. Further, tissue adherence was positively correlated with duration of intraarticular implantation. Five disks (24%) contained focal areas of homogeneous extracellular matrix. A trend toward more collagenase immunoreactivity was noted in the 3-week disks. Collagen type I was present in remaining SIS and extracellular matrix associated with infiltrated cells. Placed freely within a joint, acellular SIS disks underwent cellular and extracellular matrix modification resulting in fibrocartilage-like tissue. Utilization of SIS as a scaffold for intraarticular tissue-engineering applications is supported as cytoconductivity, appropriate residence time, and absence of untoward effects of implantation are desirable criteria for a tissue-engineering biomaterial.

Articular cartilage responds to its mechanical environment through altered cell metabolism and matrix synthesis. In this study, isolated articular chondrocytes were cultured in collagen type I gels and exposed to uniaxial static compression of 0%, 25%, or 50% of original thickness for 0.5, 4, and 24 h, and to oscillatory (25 +/- 4%, 1 Hz) compression for 24 h. The cellular response was assessed through competitive and real-time RT-PCR to quantify expression of genes for collagen type I, collagen type II, and aggrecan core protein, and through radiolabelled proline and sulfate incorporation to quantify protein and proteoglycan synthesis rates. Static compression for 24 h inhibited expression of collagen I and II mRNAs and inhibited 3H-proline and 35S-sulfate incorporation. The mRNA expression exhibited transient fluctuations at intermediate time points. Oscillatory compression had no effect upon mRNA expression, and 24 h after release from static compression, there was no difference in collagen II or aggrecan mRNA, while there was an inhibition of collagen I. We conclude that the chondrocytes maintained some aspects of their ability to sense and respond to static compression, despite a biochemical and mechanical environment which is different from that in tissue. This suggests that mechanical stimuli may be useful in modulating chondrocyte metabolism in tissue engineering systems using fibrillar protein scaffolds.

Mesenchymal stem cells (MSCs) were isolated from bone marrow of 18 adult New Zealand White rabbits. These cells were culture expanded, suspended in type I collagen gel, and implanted into a surgically induced defect in the donor s right patellar tendon. A cell-free collagen gel was implanted into an identical control defect in the left patellar tendon. Repair tissues were evaluated biomechanically (n = 13) and histomorphometrically (n = 5) at 4 weeks after surgery. Compared to their matched controls, the MSC-mediated repair tissue demonstrated significant increases of 26% (p < 0.001), 18% (p < 0. 01), and 33% (p < 0.02) in maximum stress, modulus, and strain energy density, respectively. Qualitatively, there appeared to be minor improvements in the histological appearance of some of the MSC- mediated repairs, including increased number of tenocytes and larger and more mature-looking collagen fiber bundles. Morphometrically, however, there were no significant left-right differences in nuclear aspect ratio (shape) or nuclear alignment (orientation). Therefore, delivering a large number of mesenchymal stem cells to a wound site can significantly improve its biomechanical properties by only 4 weeks but produce no visible improvement in its microstructure.

Purpose of study: To develop an experimental model of degenerative disc disease without direct intervention of the intervertebral disc (IVD). Our hypothesis was that inducing vertebral body damage at sites adjacent to the IVD would modify nutrient transport through the end plates and thus initiate degeneration in a manner relevant to degenerative disc disease in humans. Methods used: Vertebral body defects were created in lumbar motion segments of minipigs (10 experimental and 7 control levels, n=3). A high-speed drill with a diamond burr (3 to 5 mm diameter) was used to remove bone adjacent to the inferior and superior end plates of the experimental IVDs. A resorbable calcium phosphate bone cement was then packed into the defects. Spines were harvested at 3, 6 and 9 months and imaged in the sagittal plane with high-resolution magnetic resonance imaging (MRI; 7.1 T). Four blinded observers graded MRI appearance with the scheme of Thompson and coworkers (1990; 1 = nondegenerate, 5 = severely degenerate). In addition, MRI data sets were analyzed to determine changes in disc height and signal intensity for regions corresponding to the nucleus pulposus (NP) and anterior and posterior anulus fibrosus (AF). After imaging, individual motion segments were processed for routine histology (toluidine blue, hemotoxylin and eosin) and immunohistochemistry to detect matrix proteins including type II collagen and decorin. of findings: Higher MRI grades of degeneration were observed in all experimental IVD regions at 9 months after surgery. Reviewer grades were significantly higher for both NP (average of four graders = 1.8 vs. 3.8, control vs. experimental) and AF at 9 months after surgery (1.7 vs. 3.4). There was some evidence of end plate changes beginning at 3 months after surgery (1.5 vs. 2.3, control vs. experimental), which became quite dramatic at 9 months (1.4 vs. 4.5). No differences were noted in disc height between control and experimental IVDs at any region. However, decreases in MRI signal intensity (normalized to maximum values) were noted in experimental IVDs, particularly in the anterior AF (mean, 39%) and NP at 9 months (15%). Decreased signal intensity is a hallmark of IVD degeneration in the human, suggesting loss of hydration. Upon histological examination, there was evidence of inward bulging of the inner AF, end plate damage and decreased NP staining. Immunostaining demonstrated increased collagen type II in the experimental sections compared with controls, although few consistent changes were noted in the expression of decorin. Increases in the levels of both collagen type II and decorin have been demonstrated in other animal models of IVD degeneration and in human disease. Relationship between findings and existing knowledge: Overall, the changes observed in this experimental model confirm some key features of human IVD degeneration, including increased radiographic grade of degeneration, decreased MRI intensity and morphological and histological changes, such as increased staining for collagen type II and decreased staining of the NP. Holm and coworkers (1999) demonstrated that a controlled vertebral end plate defect will induce compositional and morphological evidence of disc degeneration in an animal model. Findings of the current study demonstrate that disruption of the vertebral body alone, without controlled violation of the end plate, may serve to initiate disc degeneration without direct, surgical injury of the IVD. Overall significance of findings: The mechanism for the onset of degeneration is not known but may relate to a role of vertebral body damage in altering nutrient transport across the end plate. Disclosures: No disclosures. Conflict of interest: William J. Richardson, grant research support, DePuy Orthobiologics.