Biomechanical analysis of an interference screw and a novel twist lock screw design for bone graft fixation.

BACKGROUND: Malpositioning of an anterior cruciate ligament graft during reconstruction can occur during screw fixation. The purpose of this study is to compare the fixation biomechanics of a conventional interference screw with a novel Twist Lock Screw, a rectangular shaped locking screw that is designed to address limitations of graft positioning and tensioning. METHODS: Synthetic bone (10, 15, 20lb per cubic foot) were used simulating soft, moderate, and dense cancellous bone. Screw push-out and graft push-out tests were performed using conventional and twist lock screws. Maximum load and torque of insertion were measured. FINDINGS: Max load measured in screw push out with twist lock screw was 64%, 60%, 57% of that measured with conventional screw in soft, moderate and dense material, respectively. Twist lock max load was 78% and 82% of that with conventional screw in soft and moderate densities. In the highest bone density, max loads were comparable in the two systems. Torque of insertion with twist lock was significantly lower than with conventional interference screw. INTERPRETATION: Based on geometric consideration, the twist lock screw is expected to have 35% the holding power of a cylindrical screw. Yet, results indicate that holding power was greater than theoretical consideration, possibly due to lower friction and lower preloaded force. During graft push out in the densest material, comparable max loads were achieved with both systems, suggesting that fixation of higher density bone, which is observed in young athletes that require reconstruction, can be achieved with the twist lock screw.

Systemic corticosteroids inhibit bone healing in a rabbit ulnar osteotomy model.

Prolonged systemic administration of corticosteroids causes osteoporosis and increased risk of fracture. Despite this well documented side effect of systemic corticosteroids, the effect of these compounds on fracture healing is not well defined. The goal of this study was to test the hypothesis that systemic corticosteroid therapy adversely affects fracture healing in a rabbit ulnar osteotomy model. Non-critical sized (1 mm) defects were created bilaterally in 18 adult female New Zealand White rabbits. Starting 2 months before operative intervention and continuing for 6 weeks during healing of the osteotomies, a subcutaneous dose of either sterile saline or prednisone (0.15 mg/kg) was administered daily. Serial radiographs of the forelimb were taken immediately postoperatively and weekly beginning the second week postoperatively. After killing at 6 weeks, only 3 of 20 limbs from animals treated with prednisone achieved radiographic union while 13 of 16 control limbs achieved union. The radiographic density of bone in the defect as well as callus size were greater in the control limbs than in the limbs from prednisone-treated animals. DEXA confirmed that the bone mineral content was lower in the ulnae of prednisone-treated rabbits both within the defect and in adjacent ulnar bone. Mechanical data indicated that osteotomies from rabbits chronically treated with prednisone were weaker than in controls. In this rabbit ulnar osteotomy model, chronic prednisone treatment clearly inhibited bone healing.

Parathyroid hormone-related protein analog RS-66271 is an effective therapy for impaired bone healing in rabbits on corticosteroid therapy.

A new class of parathyroid hormone-related protein (PTHrP) analogs has been developed that causes a rapid gain in both trabecular and cortical bone in models of osteopenia. This study investigates the efficacy of the PTHrP analog, RS-66271 ([MAP(1-10)]22-31 hPTHrP(1-34)-NH(2)), as systemic therapy for impaired bone healing in corticosteroid-treated rabbits. A 1 mm defect was created bilaterally in the ulnae of 30 rabbits. Delayed healing was induced by daily injections of prednisone (0.15 mg/kg) beginning 2 months prior to surgery and continuing until killing. Rabbits in the experimental group received daily subcutaneous injections of PTHrP analog RS-66271 (0.01 mg/kg) starting 1 day after surgery. Control animals received subcutaneous normal saline. At the 6 week timepoint, nine of ten ulnae from PTHrP-treated rabbits achieved radiographic union, whereas only two of ten limbs achieved union in control rabbits (p < 0.01). In a separate part of the study, 20 animals (10 control, 10 RS-66271-treated) were killed when radiographic union was achieved bilaterally. In this portion of the study, all limbs in animals treated with PTHrP achieved union by 6 weeks. In the control animals that were allowed to heal for 10 weeks, only 20% of the limbs achieved radiographic union. In addition, ulnae in the PTHrP-analog-treated rabbits showed greater radiographic intensity (20%-40%), larger callus area (209% anteroposterior view, 417% lateral view) (mean area on AP radiographs: control, = 387 +/- 276 mm(2); PTHrP analog, 1195 +/- 408 mm(2)), and greater stiffness (64%) and torque (87%) when compared with controls. RS-66271 was shown to be an effective therapy for preventing impaired bone healing caused by prednisone in a rabbit model.

Transforming growth factor beta in fracture repair.

Transforming growth factor betas are a group of polypeptide growth factors that have a wide range of activities in the musculoskeletal and immunological systems. They are thought to play an important role in the development, induction, and repair of bone. This family of closely related genes includes the five known transforming growth factor betas and also the bone morphogenetic proteins. With the development of new techniques to analyze gene expression, the broad range of cellular activities regulated by transforming growth factor beta is beginning to be understood. The critical role that transforming growth factor beta plays in the regulation and stimulation of mesenchymal precursor cells for chondrocytes, osteoblasts, and osteoclasts is now emerging based on a series of in vitro studies. Although transforming growth factor betas appear to stimulate proliferation of precursor cells, it appears that transforming growth factor betas have an inhibitory effect on mature cell lines. In vivo studies indicate the presence of transforming growth factor beta protein and transforming growth factor beta gene expression in normal fracture healing, whereas exogenous transforming growth factor beta administration stimulates the recruitment and proliferation of osteoblasts in fracture healing. Although the cascade of events that leads to bone formation and repair is not completely understood, transforming growth factor beta's central role in the regulation of fracture healing is not disputed.

Short crank cycle ergometry.

The change in knee angle during cycling was mathematically analyzed. It was determined that if the crank length of the cycle ergometer was shortened, the arc of knee motion necessary to cycle could be reduced. A computer program was written to represent the above mathematical model utilizing a patient's lower limb lengths to generate an individualized, range of motion profile. A custom cycle ergometer was built with interchangeable crank lengths of 80 mm, 110 mm, 140 mm, and 170 mm. This device can be adjusted to achieve a desired range of motion for a specific patient. The above custom cycle ergometer can be used on early postoperative knee patients who are unable to ride a conventional cycle ergometer because of a lack of knee motion or on patients who require a limited arc of motion in their postoperative therapy protocol. J Orthop Sports Phys Ther 1991;13(2):95-100.