rhBMP-2-Conjugated Three-Dimensional-Printed Poly(L-lactide) Scaffold is an Effective Bone Substitute

BACKGROUND@#Bone growth factors, particularly bone morphogenic protein-2 (BMP-2), are required for effective treatment of significant bone loss. Despite the extensive development of bone substitutes, much remains to be desired for wider application in clinical settings. The currently available bone substitutes cannot sustain prolonged BMP-2 release and are inconvenient to use. In this study, we developed a ready-to-use bone substitute by sequential conjugation of BMP to a three-dimensional (3D) poly(L-lactide) (PLLA) scaffold using novel molecular adhesive materials that reduced the operation time and sustained prolonged BMP release. @*METHODS@#A 3D PLLA scaffold was printed and BMP-2 was conjugated with alginate-catechol and collagen. PLLA scaffolds were conjugated with different concentrations of BMP-2 and evaluated for bone regeneration in vitro and in vivo using a mouse calvarial model. The BMP-2 release kinetics were analyzed using ELISA. Histological analysis and microCT image analysis were performed to evaluate new bone formation. @*RESULTS@#The 3D structure of the PLLA scaffold had a pore size of 400 lm and grid thickness of 187–230 lm. BMP-2 was released in an initial burst, followed by a sustained release for 14 days. Released BMP-2 maintained osteoinductivity in vitro and in vivo. Micro-computed tomography and histological findings demonstrate that the PLLA scaffold conjugated with 2 lg/ml of BMP-2 induced optimal bone regeneration. @*CONCLUSION@#The 3D-printed PLLA scaffold conjugated with BMP-2 enhanced bone regeneration, demonstrating its potential as a novel bone substitute.

Increased interleukin-6 and TP53 levels in rotator cuff tendon repair patients with hypercholesterolemia

Background@#A previous study reported that hyperlipidemia increases the incidence of tears in the rotator cuff tendon and affects healing after repair. The aim of our study was to compare the gene and protein expression of torn rotator cuff tendons in patients both with and without hypercholesterolemia. @*Methods@#Thirty patients who provided rotator cuff tendon samples were classified into either a non-hypercholesterolemia group (n=19, serum total cholesterol [TC] <200 mg/dL) and hypercholesterolemia group (n=11, serum TC ≥240 mg/dL) based on their concentrations of serum TC. The expression of various genes of interest, including COL1A1, IGF1, IL-6, MMP2, MMP3, MMP9, MMP13, TNMD, and TP53, was analyzed by real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR). In addition, Western blot analysis was performed on the proteins encoded by interleukin (IL)-6 and TP53 that showed significantly different expression levels in real-time qRT-PCR. @*Results@#Except for IGF1, the gene expression levels of IL-6, MMP2, MMP9, and TP53 were significantly higher in the hypercholesterolemic group than in the non-hypercholesterolemia group. Western blot analysis confirmed significantly higher protein levels of IL-6 and TP53 in the hypercholesterolemic group (p<0.05). @*Conclusions@#We observed an increase in inflammatory cytokine and matrix metalloproteinase (MMP) levels in hypercholesterolemic patients with rotator cuff tears. Increased levels of IL-6 and TP53 were observed at both the mRNA and protein levels. We suggest that the overexpression of IL-6 and TP53 may be a specific feature in rotator cuff disease patients with hypercholesterolemia.

Extra-Articular Chondrolipoma of the Knee / 대한정형외과학회잡지

Chondrolipoma is a rare benign mesenchymoma containing mature cartilage and adipose tissues. Chondrolipoma has been encountered mainly in the oral cavity and breast; however, this type of mesenchymoma occurs extremely rarely in the knee area. This paper reports a case of a 60-year-old woman who presented with a two-year history of a palpable mass lesion at the anterior side of the left knee. Magnetic resonance imaging showed a mass lesion adjacent to the medial side of the patellar tendon. The mass had a heterogenous nature, consisting of fat components and calcification. Surgical excision was performed. The size of the excised mass was approximately 4.5 cm×3 cm×4 cm, and it had a round shape and was encapsulated. The posterior part of the mass had a mixed pattern comprised of fat and cartilage tissues. A pathological examination showed that the chondrolipoma was composed of mature adipose and hyaline cartilage tissues.

Results and Factors Affecting Clinical Efficacy of Medial Patellofemoral Ligament Reconstruction Using a Gracilis Tendon Suture Technique

Background@#This study evaluated the outcomes of medial patellofemoral ligament (MPFL) reconstruction using a gracilis tendon suture technique for patients with patellar instability. Potential factors affecting clinical efficacy were also evaluated. @*Methods@#This study included 22 patients diagnosed with patellar instability, who underwent MPFL reconstruction using a gracilis tendon. Their mean age was 21.5 years (range, 15–48 years), and the mean follow-up period was 26.8 months (range, 12–66 months). Clinical evaluation included the determination of Kujala, Lysholm, and Tegner scores. Radiographic evaluation included changes in congruence angle and arthritic changes in the patellofemoral joint. Additionally, patients were examined for any complications, including recurrent dislocation. Factors affecting clinical efficacy were also evaluated. @*Results@#All clinical scores improved at final follow-up. The mean congruence angle improved from 23.6° before surgery to –6.5° at final follow-up. Two of 15 patients developed osteoarthritic changes in the patellofemoral joint. Dislocation recurred in 2 patients with type C trochlear dysplasia, which showed a statistically significant association with recurrent dislocation when compared to type A and B dysplasia (p = 0.026). Kujala scores were significantly lower among patients with abnormal patellar tilts (p = 0.038), and Lysholm scores were significantly lower among patients with femoral internal rotation deformity (p = 0.024). @*Conclusions@#Satisfactory results were obtained after MPFL reconstruction using a gracilis tendon suture technique for patients with patellar instability. However, dislocation recurred in patients with type C trochlear dysplasia, and clinical efficacy was lower among patients with femoral internal rotation and patellar tilt.

Treatment of Malunion / 대한정형외과학회잡지

Although current surgical techniques have reduced the incidence of malunion, it is still observed because of the complexity of the fracture or associated injuries. Osteotomy is needed when the amount of malunion is expected to result in an overload of cartilage and instability of the joint. Preoperative planning is essential when performing an osteotomy for malunion. Inadequate planning can result in serious complications, such as iatrogenic malalignment, intraoperative fracture, postoperative recurrence of deformity, or soft tissue injuries. In addition, a poor functional result can occur secondary to poor patient selection. This review article includes the surgical indications and planning to correct malunion. Various methods of corrective osteotomy are described according to the kinds of plane and fixation implants.

Can medial stability be preserved after open wedge high tibial osteotomy?

Purpose@#This study evaluated the medial joint stability after high tibial osteotomy (HTO) releasing the superficial medial collateral ligament (sMCL) without cutting and repairing. @*Methods@#Twenty-one patients who performed HTO were enrolled. After an L-shaped incision was made in the pes anserinus, the sMCL was released from the distal portion during surgery. After plate fixation, the sMCL was reattached and the pes anserinus was repaired underneath the plate. Plate removal was performed after 31.1 ± 14.2 months. Before HTO, a valgus force of 40 N was exerted at extension for reference values. Before and after plate removal, a valgus force of 40 N was exerted at extension and at a flexion position of 20°. Medial stability was evaluated by measuring the joint line convergence angle (JLCA). @*Results@#The JLCAs in the extension state before HTO and plate removal were 1.64° ± 1.15° and 1.83° ± 1.36°, respectively; there was no significant difference (p = 0.198). There was also no significant difference in JLCA before HTO and after plate removal (p = 0.835). There was also no significant difference in JLCA before and after plate removal both at a knee extension and flexion position of 20° (p = 0.348 and p = 0.456, respectively). @*Conclusions@#Releasing the sMCL without cutting and repairing the pes anserinus underneath the plate during medial open wedge HTO could facilitate the maintenance of medial joint stability.

Concomitant Coracoid Process Fracture with Bony Bankart Lesion Treated with the Latarjet Procedure

Bony lesions of the glenoid and Hill-Sachs lesions are the most common injuries after a first-time traumatic shoulder dislocation. However, fracture of the coracoid process after traumatic shoulder dislocation is rare. A single, open surgical procedure could be performed by a Latarjet procedure using a fractured fragment of the coracoid process. If a fracture of the coracoid process is associated with a traumatic anterior shoulder dislocation, the Latarjet procedure may be the most appropriate surgical option.

Can medial stability be preserved after open wedge high tibial osteotomy?

Purpose@#This study evaluated the medial joint stability after high tibial osteotomy (HTO) releasing the superficial medial collateral ligament (sMCL) without cutting and repairing. @*Methods@#Twenty-one patients who performed HTO were enrolled. After an L-shaped incision was made in the pes anserinus, the sMCL was released from the distal portion during surgery. After plate fixation, the sMCL was reattached and the pes anserinus was repaired underneath the plate. Plate removal was performed after 31.1 ± 14.2 months. Before HTO, a valgus force of 40 N was exerted at extension for reference values. Before and after plate removal, a valgus force of 40 N was exerted at extension and at a flexion position of 20°. Medial stability was evaluated by measuring the joint line convergence angle (JLCA). @*Results@#The JLCAs in the extension state before HTO and plate removal were 1.64° ± 1.15° and 1.83° ± 1.36°, respectively; there was no significant difference (p = 0.198). There was also no significant difference in JLCA before HTO and after plate removal (p = 0.835). There was also no significant difference in JLCA before and after plate removal both at a knee extension and flexion position of 20° (p = 0.348 and p = 0.456, respectively). @*Conclusions@#Releasing the sMCL without cutting and repairing the pes anserinus underneath the plate during medial open wedge HTO could facilitate the maintenance of medial joint stability.

Biological Enhancement of Healing with Kartogenin Injection at the Tendon-to-Bone Interface in a Rat Rotator Cuff Tear Model / 대한스포츠의학회지

Purpose@#The purpose of this study was to investigate the effects of kartogenin (KGN) on the tendon-bone interface in a rat rotator cuff tear model. @*Methods@#Twenty male rats were divided into two equal groups; group 1 (repair only) and group 2 (KGN single injection). A rat rotator cuff rupture model was prepared, and KGN (500 μM) was injected into the repair site. The specimens were collected after 8 weeks, and biomechanical and histological analyses were performed. We assessed the healing quality of the tendon-to-bone repair site using six aspects of tendon tissue. The histological findings were classified semiquantitatively into four grades (grade 0, the poorest appearance; grade 1, poorer; grade 2, better; and grade 3, marked regeneration). @*Results@#Group 2 showed a higher mean ultimate load to failure than the control group (group 1: 25.78±31.38 N, group 2: 55.64±36.02 N; p=0.011). On histological analysis, group 2 exhibited a significantly greater total score (group 1: 7.20±2.14, group 2: 9.50±1.84; p=0.019), collagen fiber continuity (group 1: 1.20±0.42, group 2: 1.70±0.48; p=0.024), and collagen fiber density (group 1: 1.50±0.52, group 2: 2.20±0.63; p=0.080). Metachromasia were more intense in group 2 than in the control group. @*Conclusion@#A single injection of KGN reinforces biomechanical strength and the formation of collagen and fibrocartilage at the tendon-to-bone interface in a rat rotator cuff tear model.

Comparison of Magnetic Resonance Imaging and Operation Waiting Times in Patients Having Traumatic Cervical Spinal Cord Injury; with or without Bony Lesions

PURPOSE@#To compare the time intervals to magnetic resonance imaging (MRI) and surgical treatment in patients having traumatic cervical spinal cord injury (SCI) with and without bony lesions.@*METHODS@#Retrospectively analyzed adult patients visited Kyungpook National University Hospital and underwent surgical treatment for cervical SCI within 24 hours. The patients who were suspected of having cervical SCI underwent plain radiography and computed tomography (CT) upon arrival. After the initial evaluation, we evaluated the MRI findings to determine surgical treatment. Waiting times for MRI and surgery were evaluated.@*RESULTS@#Thirty-four patients were included. Patients' mean age was 57 (range, 23–80) years. Patients with definite bony lesions were classified into group A, and 10 cases were identified (fracture-dislocation, seven; fracture alone, three). Patients without bony lesions were classified into group B, and 24 cases were identified (ossification of the posterior longitudinal ligament, 16; cervical spondylotic myelopathy, eight). Mean intervals between emergency room arrival and start of MRI were 93.60 (±60.08) minutes in group A and 313.75 (±264.89) minutes in group B, and the interval was significantly shorter in group A than in group B (p=0.01). The mean times to surgery were 248.4 (±76.03) minutes in group A and 560.5 (±372.56) minutes in group B, and the difference was statistically significant (p=0.001). The American Spinal Injury Association scale at the time of arrival showed that group A had a relatively severe neurologic deficit compared with group B (p=0.046). There was no statistical significance, but it seems to be good neurological recovery, if we start treatment sooner among patients treated within 24 hours (p=0.198).@*CONCLUSIONS@#If fracture or dislocation is detected by CT, cervical SCI can be easily predicted resulting in MRI and surgical treatment being performed more rapidly. Additionally, fracture or dislocation tends to cause more severe neurological damage, so it is assumed that rapid diagnosis and treatment are possible.

Etiology and Management of Nonunion / 대한정형외과학회잡지

Nonunion is caused by various factors related to fracture characteristics, patient characteristics, treatment, and infection. Aseptic nonunion, is divided into three categories in accordance with the biological activity of the fracture: atrophic nonunion, oligotrophic nonunion, and hypertrophic nonunion. Treatment of nonunion depends on the cause and classification. Here, we report our experiences and review the various causes of nonunion and treatment methods available.

Pelvis/Acetabular Fractures in the Elderly: When and How to Fix?

Owing to the increase in life expectancy, the incidence of osteoporotic fracture of the pelvis and acetabulum is increasing. Fractures in the elderly population is different from those in younger patients. Pelvic ring and acetabular fractures in geriatric patients are more likely the result of low-energy trauma, but the outcomes are generally poorer than those of the younger population. Multiple management options are available, but no intervention has become the standard of care for these fractures in the elderly. A treatment strategy should be established depending on the state of the individual patient. Regardless of whether nonsurgical or surgical treatment is selected, early ambulation should be considered to avoid the complications associated with prolonged immobilization.

An Irreducible Hip Dislocation with Femoral Head Fracture

Urgent reduction is required in cases of traumatic hip dislocation to reduce the risk of avascular necrosis of the femoral head. However, in cases of femoral head fractures, the dislocated hip cannot be reduced easily, and in some cases, it can even be irreducible. This irreducibility may provoke further incidental iatrogenic fractures of the femoral neck. In an irreducible hip dislocation, without further attempting for closed reduction, an immediate open reduction is recommended. This can prevent iatrogenic femoral neck fracture or avascular necrosis of the femoral head, and save the natural hip joint.

A Correction of Malunion or Deformity in the Lower Extremity

The incidence of malunion in the long bone with has been reduced because of the advancements in surgical technique. However, nonunion or malunion are still observed in mechanical axis deformation of the lower limb, resulting in the overload of cartilage and instability of the joint, requiring surgical correction. Preoperative planning for malunion is very important, and accurate evaluation of the deformity is essential. Herein, we describe the indications of corrective osteotomy, choice of patients, and various surgical methods for the treatment of malunion of the long bone.

A Correction of Malunion or Deformity in the Lower Extremity

The incidence of malunion in the long bone with has been reduced because of the advancements in surgical technique. However, nonunion or malunion are still observed in mechanical axis deformation of the lower limb, resulting in the overload of cartilage and instability of the joint, requiring surgical correction. Preoperative planning for malunion is very important, and accurate evaluation of the deformity is essential. Herein, we describe the indications of corrective osteotomy, choice of patients, and various surgical methods for the treatment of malunion of the long bone.

Two Case Reports of Calcified Spinal Meningioma and a Literature Review

STUDY DESIGN: Case Report. OBJECTIVES: The aim of this study was to report 2 cases of calcified spinal meningioma that displayed differences in appearance during resection, and to review the current literature on calcified and ossified spinal meningiomas. SUMMARY OF LITERATURE REVIEW: Calcified and ossified spinal meningiomas are rare, and tumor calcification is a risk factor for poor neurological outcomes resulting from the additional manipulations required to dissect the tumor. MATERIALS AND METHODS: We describe the clinical course and intraoperative findings of 2 female patients who presented with symptoms of myelopathy. Magnetic resonance imaging showed calcified spinal meningiomas of the thoracic spine. The type of tumor resection performed was dependent on the solidity and texture of the individual tumors. RESULTS: Pathologic evaluation revealed psammoma bodies, which suggested calcified meningioma. The patients' neurologic symptoms resolved with no neurologic sequelae. CONCLUSIONS: Although there are a few pathologic differences regarding the main type and pathogenesis of ossified and calcified meningioma, both are thought to have a poor prognosis. For these tumors, adequately accounting for the expected poor prognosis and performing a wide laminectomy in order to ensure an adequate surgical margin are important factors for achieving a favorable outcome.