Long-term Follow-up Results of Femoral Revision Hip Arthroplasty Using Impaction Bone Grafting and Standard Cemented Polished Stem.

Background: To report the long-term clinical and radiologic results of impaction bone grafting and standard cemented polished stem for femoral revision arthroplasty in patients with extensive bone deficiency. Methods: We retrospectively reviewed 47 hips that underwent femoral revision hip arthroplasty using an impaction-morselized allograft with a standard cemented polished stem. The average age at the time of revision hip arthroplasty was 55 years (range, 39-75 years). The modified Harris hip score (HHS) was used for clinical evaluation. The radiologic evaluation focused on stem subsidence, stem position, progressive radiolucent lines, bone remodeling, and the incorporation of allografts. Results: The modified HHS improved from an average of 55.04 (range, 25-79.5) preoperatively to 90.1 (range, 81-93.2) at the last follow-up. The mean follow-up duration was 13.5 years (10.9-17.8 years). The radiographic analysis revealed stable stems. Femoral stems showed an average subsidence of 3.2 mm (range, 2-8 mm) in the cement mantle. However, there was no mechanical failure or subsidence of the cement mantle in the femurs. The stem position was neutral or varus less than 5°. No progressive radiolucent line or osteolysis was observed. Evidence of cortical and trabecular remodeling was observed in all cases. There were four cases of intraoperative cracks and four cases of distal femur splitting. Conclusions: Initial stem stability using impaction bone grafting and a standard cemented polished stem in femoral revision arthroplasty resulted in good outcome. Delicate impaction grafting techniques and intraoperative crack and splitting fixation are the points that need attention for successful long-term results.

Allogenic umbilical cord blood-derived mesenchymal stromal cell implantation was superior to bone marrow aspirate concentrate augmentation for cartilage regeneration despite similar clinical outcomes.

PURPOSE: The aim of this study was to compare clinical and second-look arthroscopic outcomes between bone marrow aspirate concentrate (BMAC) augmentation and human umbilical cord blood-derived mesenchymal stromal cell (hUCB-MSC) implantation in high tibial osteotomy (HTO) for medial compartmental knee osteoarthritis and identify the relationship between articular cartilage regeneration and HTO outcomes. METHODS: A total of 176 patients who underwent HTO combined with a BMAC or hUCB-MSC procedure for medial compartment osteoarthritis (Kellgren-Lawrence grade 3) between June 2014 and September 2018 with a minimum follow-up of 2 years were reviewed. After HTO, multiple holes were drilled at cartilage defect sites of the medial femoral condyle (MFC), and then prepared BMAC or hUCB-MSCs in combination with scaffolds were implanted in the MFC lesions. After propensity score matching based on sex, age, body mass index, and lesion size, 55 patients in each of the BMAC and hUCB-MSC groups were successfully matched. Second-look arthroscopic findings were assessed according to the International Cartilage Repair Society (ICRS) Cartilage Repair Assessment (CRA) grading system and Koshino staging system. Clinical outcomes were evaluated using the International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Short-Form 36 (SF-36), and Tegner activity scores. RESULTS: At a mean follow-up of 33 months, clinical outcomes including IKDC, KOOS, SF-36, and Tegner activity scores were significantly improved in both groups (p < 0.001); however, there were no differences between the two groups. Second-look arthroscopy showed better healing of regenerated cartilage in the hUCB-MSC group (Grade I [4 cases, 9.1%]; Grade II [30 cases, 68.2%]; Grade III [11 cases, 22.7%]) than in the BMAC group (Grade I [1 case, 2.7%]; Grade II [20 cases, 54.1%]; Grade III [11 cases, 29.7%]; Grade IV [5 cases, 13.5%]) according to the ICRS CRA grading system (p = 0.040). There was no significant intergroup difference in terms of defect coverage based on the Koshino staging system (p = 0.057). Moreover, ICRS CRA grades at second-look arthroscopy were significantly correlated with clinical outcomes (r = - 0.337; p = 0.002). CONCLUSION: There were no significant differences in the clinical outcomes between the two groups. Both treatments provided similar, reliable outcomes in terms of pain relief, functional scores, and quality of life at a mean follow-up of 33 months. However, hUCB-MSC implantation was more effective than BMAC augmentation for articular cartilage regeneration.

Second-look arthroscopic cartilage status is related to intermediate-term outcomes after medial opening-wedge high tibial osteotomy.

AIMS: To determine the relationship between articular cartilage status and clinical outcomes after medial opening-wedge high tibial osteotomy (MOHTO) for medial compartmental knee osteoarthritis at intermediate follow-up. METHODS: We reviewed 155 patients (155 knees) who underwent MOHTO from January 2008 to December 2016 followed by second-look arthroscopy with a mean 5.3-year follow-up (2.0 to 11.7). Arthroscopic findings were assessed according to the International Cartilage Repair Society (ICRS) Cartilage Repair Assessment (CRA) grading system. Patients were divided into two groups based on the presence of normal or nearly normal quality cartilage in the medial femoral condyle: good (second-look arthroscopic) status (ICRS grade I or II; n = 70), and poor (second-look arthroscopic) status (ICRS grade III or IV; n = 85) groups at the time of second-look arthroscopy. Clinical outcomes were assessed using the International Knee Documentation Committee (IKDC) score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and 36-Item Short Form survey. RESULTS: Significant improvements in all clinical outcome categories were found between the preoperative and second-look arthroscopic assessments in both groups (p < 0.001). At the latest follow-up, the mean IKDC and WOMAC scores in the good status group further improved compared with those at the time of second-look arthroscopic surgery (p < 0.001), which was not shown in the poor status group. The mean IKDC (good status, 72.8 (SD 12.5); poor status, 64.7 (SD 12.1); p = 0.002) and mean WOMAC scores (good status, 15.7 (SD 10.8); poor status, 21.8 (SD 13.6); p = 0.004) significantly differed between both groups at the latest follow-up. Moreover, significant correlations were observed between ICRS CRA grades and IKDC scores (negative correlation; p < 0.001) and WOMAC scores (positive correlation; p < 0.001) at the latest follow-up. Good cartilage status was found more frequently in knees with the desired range of 2° to 6° valgus correction than in those with corrections outside this range (p = 0.019). CONCLUSION: Second-look arthroscopic cartilage status correlated with clinical outcomes after MOHTO at intermediate-term follow-up, despite the relatively small clinical differences between groups. Cite this article: Bone Joint J 2021;103-B(11):1686-1694.

Plasma-assisted multiscale topographic scaffolds for soft and hard tissue regeneration.

The design of transplantable scaffolds for tissue regeneration requires gaining precise control of topographical properties. Here, we propose a methodology to fabricate hierarchical multiscale scaffolds with controlled hydrophilic and hydrophobic properties by employing capillary force lithography in combination with plasma modification. Using our method, we fabricated biodegradable biomaterial (i.e., polycaprolactone (PCL))-based nitrogen gas (N-FN) and oxygen gas plasma-assisted flexible multiscale nanotopographic (O-FMN) patches with natural extracellular matrix-like hierarchical structures along with flexible and controlled hydrophilic properties. In response to multiscale nanotopographic and chemically modified surface cues, the proliferation and osteogenic mineralization of cells were significantly promoted. Furthermore, the O-FMN patch enhanced regeneration of the mineralized fibrocartilage tissue of the tendon-bone interface and the calvarial bone tissue in vivo in rat models. Overall, the PCL-based O-FMN patches could accelerate soft- and hard-tissue regeneration. Thus, our proposed methodology was confirmed as an efficient approach for the design and manipulation of scaffolds having a multiscale topography with controlled hydrophilic property.

Allogeneic umbilical cord blood-derived mesenchymal stem cells combined with high tibial osteotomy: a retrospective study on safety and early results.

BACKGROUND: Cartilage repair performed as a single-stage procedure is an important advancement in the treatment of full-thickness cartilage injury and has potential for widespread clinical use. PURPOSE: To investigate the short-term outcomes and cartilage regeneration after implantation of allogeneic human umbilical cord blood-derived mesenchymal stem cells (hUCB-MSCs) in patients who received high tibial osteotomy (HTO) for symptomatic medial knee osteoarthritis. METHODS: Patients underwent treatment of full-thickness chondral injury in the osteoarthritic knee with HTO and implantation of hUCB-MSCs and were followed prospectively for a minimum of one year. Ninety-three patients were followed for a mean 1.7 years (range, 1.0-3.5). Median cartilage lesion size was 6.5 cm2 (range, 2.0-12.8). Clinical outcomes were examined with patient-reported scoring instruments that consisted of the International Knee Documentation Committee (IKDC) subjective score, Western Ontario and McMaster University Osteoarthritis Index (WOMAC) score, Knee Society Score (KSS), and Hospital for Special Surgery (HSS) score. Cartilage regeneration was evaluated using the International Cartilage Repair Society (ICRS) cartilage repair assessment grading (CRA) system and the Koshino regeneration staging system in 49 patients who underwent second look arthroscopic assessment when their HTO plates were removed. RESULTS: At final follow-up, the median IKDC subjective score had significantly improved from 39.0 to 71.3; the WOMAC score from 44.5 to 11.0; the KSS pain and function scores from 29.8 to 43.2 and 61.0 to 81.2, respectively; and the HSS from 61.6 to 82.7 (p < 0.05). Pre-operative examination showed ICRS grade IV cartilage injury in all knees, and cartilage regeneration at 2nd look arthroscopy showed improvements (8.2% of patients improved to ICRS grade I, 69.3% to grade II, and 22.5% to grade III). Moreover, Koshino stage was B in 24.5% and C in 75.5% of patients (p < 0.05). CONCLUSION: Allogeneic hUCB-MSC implantation combined with HTO for medial knee osteoarthritis was safe and showed signs of cartilage status improvement. Furthermore, randomized controlled studies with a control group are necessary to determine the real effectiveness and indications of this new combined procedure for patients with osteoarthritis.

The Influence of Preoperative Tibial Bone Marrow Edema on Outcomes After Medial Opening-Wedge High Tibial Osteotomy.

BACKGROUND: The relationship between preoperative subchondral bone marrow edema (BME) in the osteoarthritic knee and pain has been established. However, little is known about the influence of preoperative BME on outcomes after medial opening-wedge high tibial osteotomy (MOHTO). The purpose of this study was to clarify the association between preoperative BME severity and clinical outcomes after MOHTO at intermediate follow-up. METHODS: We reviewed the cases of 105 consecutive patients who underwent MOHTO for osteoarthritis of the knee with preoperative subchondral BME in the medial aspect of the tibia between January 2005 and December 2015. BME was evaluated using magnetic resonance imaging (MRI). The sizes of the BME lesions were determined on the basis of the maximum diameter and were classified as small (<1 cm), medium (<2 cm), large (<4 cm), or very large (diffuse; >4 cm). Associations between preoperative BME severity and postoperative outcomes at a mean follow-up of 6.2 years (range, 2.0 to 14.3 years) were evaluated according to a Spearman correlation matrix with each reviewer's grades. Functional outcomes were assessed using the Hospital for Special Surgery (HSS) score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Society Score (KSS), and Short Form-12 (SF-12) questionnaire. Survival rate and complications were also evaluated. RESULTS: The degree of preoperative BME was not significantly correlated with postoperative outcomes (p > 0.05). There were significant improvements between the preoperative and latest follow-up assessments in all functional outcome categories (p < 0.001). Patients demonstrated marked improvements with respect to pain, function, and quality of life. The overall survival rate was 95.2%, with a mean follow-up of 6.2 years. Six major complications were identified in 5.7% of the patients, and these resulted in 5 patients (4.8%) who had conversion to total knee arthroplasty. CONCLUSIONS: We did not find any correlation between preoperative subchondral BME severity and postoperative outcomes. MOHTO showed good functional outcomes, a low major complication rate, and an excellent survival rate with a mean follow-up of 6.2 years, regardless of the degree of preoperative BME. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Coronal malalignment of lower legs depending on the locations of the exostoses in patients with multiple hereditary exostoses.

BACKGROUNDS: Though malalignment of lower legs is a common pathologic phenomenon in multiple hereditary exostoses (MHE), relationship between locations of exostoses and malalignment of lower legs remains unclear. This study examined radiographs of MHE patients in an attempt to evaluate the tendency of coronal malalignment of lower legs with different location of exostoses on lower legs consisting of two parallel long bones. METHODS: Between 2000 and 2017, we retrospectively reviewed the anteroposterior films of the teleo-roentgenographics of 63 patients with MHE. The patients were classified into four different groups depending on the locations of the exostosis, which occurred on both proximal and distal tibiofibular joints (A), proximal tibiofibular joint (B), distal tibiofibular joint (C), and not for the tibiofibular joint area (D). To evaluate the influence of the location of exostoses on coronal malalignment of lower legs, medial proximal tibia angle (MPTA), lateral distal tibia angle (LDTA), and fibular shortening were analyzed for each group. RESULTS: Significant difference was observed in multiple comparative analyses for each of the four groups. On MPTA radiologic analysis, group A showed greatest value with significant difference compared with groups C and D (vs. (B): p = 0.215; vs. distal joints (C): p = 0.004; vs. (D): p = 0.001). Group B showed significant difference only with group D (vs. distal joints (C): p = 0.388; vs. (D): p = 0.002), but for group C and D showed no significant difference. For LDTA, only group A showed significant difference compared to other groups (p < 0.001). With regard to tibiofibular ratio for evaluation of fibular shortening, group A showed the lowest ratio (vs. (B): p = 0.004; vs. (C): p = 0.655; vs. (D): p < 0.001). Group C also presented the significant lower ratio than group D (p = 0.002). CONCLUSIONS: For evaluation of the coronal malalignment of lower legs in MHE patients, not only ankle around the distal tibiofibular joint but also proximal tibiofibular joint should be examined, in that, lower limb deformity occurred by two parallel long bone which has self-contained joint. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

C-Peptide-Based Index Is More Related to Incident Type 2 Diabetes in Non-Diabetic Subjects than Insulin-Based Index.

BACKGROUND: Diabetes can be efficiently prevented by life style modification and medical therapy. So, identification for high risk subjects for incident type 2 diabetes is important. The aim of this study is to identify the best ß-cell function index to identify high risk subjects in non-diabetic Koreans. METHODS: This is a retrospective longitudinal study. Total 140 non-diabetic subjects who underwent standard 2-hour 75 g oral glucose tolerance test from January 2007 to February 2007 at Kangbuk Samsung Hospital and followed up for more than 1 year were analyzed (mean follow-up, 54.9±16.4 months). The subjects were consist of subjects with normal glucose tolerance (n=44) and subjects with prediabetes (n=97) who were 20 years of age or older. Samples for insulin and C-peptide levels were obtained at 0 and 30 minutes at baseline. RESULTS: Thirty subjects out of 140 subjects (21.4%) developed type 2 diabetes. When insulin-based index and C-peptide-based index are compared between progressor and non-progressor to diabetes, all C-peptide-based indices were statistically different between two groups, but only insulinogenic index and disposition index among insulin-based index were statistically different. C-peptide-based index had higher value of area under receiver operating characteristic curve (AROC) value than that of insulin-based index. "C-peptidogenic" index had highest AROC value among indices (AROC, 0.850; 95% confidence interval, 0.761 to 0.915). C-peptidogenic index had significantly higher AROC than insulinogenic index (0.850 vs. 0.731 respectively; P=0.014). CONCLUSION: C-peptide-based index was more closely related to incident type 2 diabetes in non-diabetic subjects than insulin-based index.