Immune and stem cell compartments of acetabular and femoral bone marrow in hip osteoarthritis patients.

OBJECTIVE: Hip osteoarthritis (OA) affects all components of the osteochondral unit, leading to bone marrow (BM) lesions, and unknown consequences on BM cell functionality. We analyzed the cellular composition in OA-affected acetabula compared to proximal femur shafts obtained of hip OA patients to reveal yet not explored immune and stem cell compartments. DESIGN: Combining flow cytometry, cellular assays and transcription analyses, we performed extensive ex vivo phenotyping of acetabular BM cells from 18 hip OA patients, comparing them with their counterparts from patient-matched femoral shaft BM samples. Findings were related to differences in skeletal sites and age. RESULTS: Acetabular BM had a greater frequency of T-lymphocytes, non-hematopoietic cells and colony-forming units fibroblastic potential than femoral BM. The incidence of acetabular CD45+CD3+ T-lymphocytes increased (95% CI: 0.1770 to 0.0.8416), while clonogenic hematopoietic progenitors declined (95% CI: -0.9023 to -0.2399) with age of patients. On the other side, in femoral BM, we observed higher B-lymphocyte, myeloid and erythroid cell frequencies. Acetabular mesenchymal stromal cells (MSCs) showed a senescent profile associated with the expression of survival and inflammation-related genes. Efficient osteogenic and chondrogenic differentiation was detected in acetabular MSCs, while adipogenesis was more pronounced in their femoral counterparts. CONCLUSION: Our results suggest that distinctions in BM cellular compartments and MSCs may be due to the influence of the OA-stressed microenvironment, but also acetabular vs femoral shaft-specific peculiarities cannot be excluded. These results bring new knowledge on acetabular BM cell populations and may be addressed as novel pathogenic mechanisms and therapeutic targets in OA.

[Mega-prostheses in revision knee arthroplasty]. / Megaprothesen in der Knierevision.

BACKGROUND: Due to a predicted increase in primary total knee arthroplasty (TKA), revision TKA will gain importance over the following years. Because the average age of patients receiving a TKA is decreasing the possible need for multiple revisions might increase as well. Despite efforts to minimize bone and soft tissue damage, the resulting bone and soft-tissue loss increases with each revision and will make the use of megaprostheses indispensable in the future. COMPLICATIONS: The implantation of a mega-prosthesis must be carefully considered and planned, since mega-prostheses in particular are associated with an increased risk of infection and loosening. Mechanical complications, patient-specific problems and periprosthetic infections can be either the cause for or the result of revision surgery of a mega-prosthesis. In the case of a complication, only a salvage procedure, namely an arthrodesis, amputation or-if necessary-the installation of a permanent fistula is commonly recommended.

[Diagnosis of periprosthetic joint infection : Development of an evidence-based algorithm by the work group of implant-associated infection of the AE-(German Society for Arthroplasty)]. / Diagnostik der periprothetischen Infektion : Entwicklung eines evidenzbasierten Algorithmus der Arbeitsgruppe implantatassoziierte Infektion der Arbeitsgemeinschaft Endoprothetik.

BACKGROUND: Prosthetic joint infections (PPI) will challenge orthopaedic surgeons and the health care system in the coming years. Evidence-based and reliable preoperative diagnostics are necessary for success in the field of revision arthroplasty. Especially the preoperative detection of PPI is important with respect to the treatment strategy. AIM: The aim of this study was to develop a detailed and structured standard operating procedure (SOP) to detect PPI preoperatively. METHODS: A systematic literature research was performed and relevant articles identified. After extracting the data, statistical calculations of sensitivity, specificity, positive/negative predictive value and positive/negative likelihood ratio were performed. The results were discussed and evaluated in four meetings analogously to standard Delphi rounds by the workgroup of implant-associated infections of the German AE (Arbeitsgemeinschaft Endoprothetik). An algorithm for the diagnostic approach according to ISO 5807 was made. RESULTS: The standardized algorithm combines a sequence of evidence-based procedures with detailed and structured main and additional criteria to every critical step in the diagnostic approach. CONCLUSION: The detection of PPI is of tremendous importance prior to revision arthroplasty and determines its success or failure. The diagnosis "prosthetic joint infection" requires a substantial change with respect to treatment concepts. The algorithm summarizes current literature and specialized expert opinions in a modern standardized format for a transparent diagnostic approach.

Customised bi-compartmental knee arthroplasty shows encouraging 3-year results: findings of a prospective, multicenter study.

PURPOSE: The purpose of this study was to assess the clinical and patient-reported outcomes of a customised, individually made (CIM) bi-compartmental knee arthroplasty (BKA). METHODS: A prospectively recruited cohort of 79 patients was implanted with a CIM-BKA (patello-femoral plus either medial or lateral tibio-femoral, iDuo G2 system, Conformis, Billerica MA) at eight centres in the US and Germany. Patients were assessed for the 2011 KSS, KOOS, and ROM pre-operatively and at 2 weeks, 6 weeks, 12 weeks, 1 year, and 2 years post-operatively. RESULTS: The objective KSS score significantly improved from 69 at the pre-operative visit, to 94 at the 2-year post-operative time-point. Similar improvements were observed for the KSS function and satisfaction domains. Significant improvements from pre-operative levels were observed across all five domains of the KOOS. Two patients have undergone surgery to revise their CIM-BKA implant to total knees, resulting in a survivorship rate of 97.5% at an average follow-up of 2.6 years. CONCLUSIONS: CIM-BKA compares favourably to published scores as well as revision rates for previously available monolithic OTS-BKA implants. CIM-BKA implants provide surgeons with a viable and patient-specific monolithic implant solution as an option for patients presenting with bi-compartmental disease, who might, otherwise, be treated by performing uni-condylar + patello-femoral joint or bicruciate sparing TKA surgeries. Longer follow-up and higher numbers have to be awaited for further validation of these encouraging early results. LEVEL OF EVIDENCE: 3b (individual case-controlled study).

Achilles Tension Mitigates Fibular Malalignment Measured in Cadaveric Studies of Syndesmotic Clamping.

BACKGROUND:: Fibular malreduction is becoming a commonly recognized complication of surgical repair of the syndesmosis when a reduction clamp is used. The goal of this work was to determine the interdependent effects of transsyndesmotic reduction clamp position and applied compression force on fibular alignment in a realistic cadaveric preparation of complete syndesmotic injury. METHODS:: Six through-the-knee cadaveric specimens were CT scanned intact, with the distal syndesmosis fully destabilized, and with 53, 102, and 160 N clamping forces each applied along an anteriorly, centrally, and posteriorly directed transsyndesmotic axis. Testing was repeated incorporating 178 N of Achilles tendon tension using all 3 clamping forces applied along the centrally directed axis. Fibular reduction was automatically quantified from CT scan-generated bony surfaces as rotation of the fibula around the tibia, rotation of the fibula within the incisura, medial/lateral fibular displacement, and anterior/posterior fibular displacement. RESULTS:: Transsyndesmotic clamping along the anteriorly directed axis resulted in the best reduction quality by all 4 quantified measures. Along the centrally and posteriorly directed axes, progressively greater forces caused significantly greater sagittal plane fibular malreduction. Addition of Achilles tension reduced the magnitude of fibular malreduction and overcompression. CONCLUSION:: Placing the medial tine of a transsyndesmotic reduction clamp on the anterior medial tibia resulted in the most accurate syndesmotic reduction and provided some protection against overcompression with large reduction clamp forces. Achilles tension appeared to contribute to reduction, decreasing the magnitude of measured malreduction from clamping. CLINICAL RELEVANCE:: Previous studies estimating fibular malpositioning in cadaveric models that lacked passive muscle tension may have overestimated expected magnitudes of malalignment in patients treated with syndesmotic clamping. However, syndesmotic malreduction, particularly in the sagittal plane, was a real complication of syndesmotic clamping that was reduced by using an anterior position of the medial tine on the tibia.

Screw fixation of the syndesmosis alters joint contact characteristics in an axially loaded cadaveric model.

BACKGROUND: The purpose of this study was to quantify the effects of rigid syndesmotic fixation on functional talar position and cartilage contact mechanics. METHODS: Twelve below-knee cadaveric specimens with an intact distal syndesmosis were mechanically loaded in four flexion positions (20° plantar flexion, 10° plantar flexion, neutral, 10° dorsiflexion) with zero, one, or two 3.5-mm syndesmotic screws. Rigid clusters of reflective markers were used to track bony movement and ankle-specific pressure sensors were used to measure talar dome and medial/lateral gutter contact mechanics. RESULTS: Screw fixation caused negligible anterior and inferior shifts of the talus within the mortise. Relative to no fixation, mean peak contact pressure decreased by 6%-32% on the talar dome and increased 2.4- to 6.6-fold in the medial and lateral gutters, respectively, depending on ankle position and number of screws. CONCLUSIONS: Two-way ANOVA indicated syndesmotic screw fixation significantly increased contact pressure in the medial/lateral gutters and decreased talar dome contact pressure while minimally altering talar position.

Extensor hallucis longus-transfer for tibialis anterior tendon rupture repair.

OBJECTIVE: Restore the function of the tibialis anterior muscle, which is responsible for dorsiflexion and inversion of the foot. INDICATIONS: Spontaneous or traumatic rupture of the tibialis anterior tendon. CONTRAINDICATIONS: Patients with multimorbidity or lack of functional demands. SURGICAL TECHNIQUE: Direct repair of the tibialis anterior tendon with fiber-wire suture and augmentation with extensor hallucis longus tendon, potentially in combination with reinsertion of the tibialis anterior tendon in the medial cuneiform. POSTOPERATIVE MANAGEMENT: Six weeks of non-weight-bearing: 3 weeks of cast immobilization with ankle in 10° dorsiflexion, followed by 3 weeks of splint immobilization and passive mobilization. Then stepwise increase in weight-bearing over a period of 2-3 weeks. RESULTS: In 8 patients postoperative results with a mean follow-up of 13.5 months were available. One patient showed a rerupture of the augmented tendon. The mean American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was 81.0 (range 67-88). The median ankle dorsiflexion muscle strength was 67% (range 29.3-85.5%) compared to the nonoperated leg. All patients, except the one that experienced rerupture, were very satisfied or satisfied with the result.

Periprosthetic infection is the major indication for TKA revision - experiences from a university referral arthroplasty center.

BACKGROUND: We hypothesized, that periprosthetic joint infection (PJI) accounts for the major proportion of first (primary) and repeated (secondary) Total Knee Arthroplasty revisions at our university referral arthroplasty center. METHODS: One thousand one hundred forty-three revisions, performed between 2008 and 2016 were grouped into primary (55%) and secondary (45%) revisions. The rate of revision indications was calculated and indications were categorized by time after index operation. The odds ratios of the indications for primary versus secondary revision were calculated. RESULTS: In the primary revision group PJI accounted for 22.3%, instability for 20.0%, aseptic loosening for 14.9% and retropatellar arthrosis for 14.2%. PJI (25.6%) was the most common indication up to 1 year after implantation, retropatellar arthrosis (26.8%) 1-3 years and aseptic loosening (25.6%) more than 3 years after implantation. In the secondary revision group PJI accounted for 39.7%, aseptic loosening for 16.2% and instability for 13.2%. PJI was the most common indication at any time of revision with 43.8% up to one, 35.4% 1-3 years and 39.4% more the 3 years after index operation. The odds ratios in repeated revision were 2.32 times higher (p = 0.000) for PJI. For instability and retropatellar arthrosis the odds ratios were 0.60 times (p = 0.006) and 0.22 times (p = 0.000) lower. CONCLUSIONS: PJI is the most common indication for secondary TKA revision and within one year after primary TKA. Aseptical failures such as instability, retropatellar arthrosis and aseptical loosening are the predominant reasons for revision more than one year after primary TKA.

Biomechanical Comparison of Syndesmotic Repair Techniques During External Rotation Stress.

BACKGROUND: The purpose of this study was to compare mechanical behavior of conventional syndesmosis fixation devices with new anatomic repair techniques incorporating various repair augmentations to determine which approach would return rotational ankle mechanics closer to those of an intact ankle. METHODS: Ten pairs of fresh-frozen through-the-knee cadaveric lower limbs were subjected to 7.5 Nm of external rotation torque while under 750 N of axial compression. After testing specimens intact and with the deltoid and syndesmotic ligament complexes completely destabilized, specimens underwent syndesmotic fixation using a screw, a suture button construct, a prototype structurally augmented flexible trans-syndesmotic fixation device, or the prototype device plus suture repairs of the anterior-inferior tibiofibular ligament and deep deltoid ligament. Syndesmotic repair devices were exchanged between tests so that each specimen was tested with 2 different fixation techniques. Whole-foot rotation angles at 7.5 Nm of applied torque were measured for comparison of the different repair strategies, and reflective markers mounted on the tibia, fibula, and talus were used to track translations and rotations of the talus and the fibula relative to the tibia during testing. RESULTS: Syndesmotic destabilization significantly ( P < .001) increased whole-foot, talus, and fibula rotation in an axial plane and posterior fibula translation under 7.5 Nm of torque. Neither the suture button nor the augmented flexible trans-syndesmotic fixation device reduced those increases. Screw fixation or addition of anatomic ligament repairs to the augmented flexible fixation device successfully reduced axial plane rotations and sagittal plane translations to near intact levels. CONCLUSION: Flexible trans-syndesmotic fixation alone was found to be insufficient for restoring rotational stability to the ankle/talus or preventing sagittal plane displacement of the fibula. CLINICAL RELEVANCE: Repairs to simulate anatomic structures disrupted during a syndesmosis injury were required to restore rotational stability to the foot when using flexible trans-syndesmotic fixation that may have clinical applicability.

[Osteotomies of the distal tibia]. / Distale Tibiaosteotomien.

OBJECTIVE: Restoration of physiological alignment of the distal tibia and thereby restoration of physiological loading of the ankle joint; joint preservation in asymmetric degenerative arthritis of the ankle. INDICATIONS: Congenital deformities of the distal tibia; acquired deformities of the distal tibia; asymmetric degenerative arthritis with partially preserved cartilage. CONTRAINDICATIONS: Absolute contraindications comprise severe nicotine abuse, Charcot arthropathy, peripheral polyneuropathy, relevant peripheral arterial vessel disease, poor local soft tissue condition, acute infection and extensive cartilage damage grade 3-4 in the Outerbridge classification in the complete joint. SURGICAL TECHNIQUE: Medial and lateral open and closed wedge osteotomies and dome osteotomies of the distal tibia are used, and shortening, lengthening and derotating osteotomies of the fibula. POSTOPERATIVE MANAGEMENT: For 6 weeks, 15-20 kg partial weight-bearing in a below knee cast or a walker orthosis; full weight-bearing depending on osseous healing after 9-12 weeks postoperatively. RESULTS: Between July 2012 and May 2017, 15 patients (10 men, 5 women) underwent a supramalleor osteotomy. Average age was 41.8 years (range 17-63 years) and the retrospective average follow-up was 28.7 months (range 3-47 months). Mean preoperative AOFAS (American Orthopaedic Foot and Ankle Society) hindfoot score was 54.3 (range 26-86) and postoperatively a mean of 74.2 (44-100). Preoperatively, 9 patients had varus malalignment and 6 patients valgus malalignment; overall, 4 patients developed complications requiring surgical intervention (26.7%). Osteosynthetic material was removed in 60% of the patients.

Discrete element analysis is a valid method for computing joint contact stress in the hip before and after acetabular fracture.

Evaluation of abnormalities in joint contact stress that develop after inaccurate reduction of an acetabular fracture may provide a potential means for predicting the risk of developing post-traumatic osteoarthritis. Discrete element analysis (DEA) is a computational technique for calculating intra-articular contact stress distributions in a fraction of the time required to obtain the same information using the more commonly employed finite element analysis technique. The goal of this work was to validate the accuracy of DEA-computed contact stress against physical measurements of contact stress made in cadaveric hips using Tekscan sensors. Four static loading tests in a variety of poses from heel-strike to toe-off were performed in two different cadaveric hip specimens with the acetabulum intact and again with an intentionally malreduced posterior wall acetabular fracture. DEA-computed contact stress was compared on a point-by-point basis to stress measured from the physical experiments. There was good agreement between computed and measured contact stress over the entire contact area (correlation coefficients ranged from 0.88 to 0.99). DEA-computed peak contact stress was within an average of 0.5 MPa (range 0.2-0.8 MPa) of the Tekscan peak stress for intact hips, and within an average of 0.6 MPa (range 0-1.6 MPa) for fractured cases. DEA-computed contact areas were within an average of 33% of the Tekscan-measured areas (range: 1.4-60%). These results indicate that the DEA methodology is a valid method for accurately estimating contact stress in both intact and fractured hips.

Technical feasibility of personalized articulating knee joint distraction for treatment of tibiofemoral osteoarthritis.

BACKGROUND: Knee osteoarthritis is a highly prevalent degenerative joint disorder characterized by joint tissue damage and pain. Knee joint distraction has been introduced as a joint preserving surgical procedure to postpone knee arthroplasty. An often used standard externally fixation device for distraction poses a burden to patients due to the absence of joint flexion during the 6weeks treatment. Therefore, a personalized articulating distraction device was developed. The aim of this study was to test technical feasibility of this device. METHODS: Based on an often applied rigid device, using equal bone pin positions and connectors, a hinge mechanism was developed consisting of a cam-following system for reproducing the complex joint-specific knee kinematics. In support, a device was developed for capturing the joint-specific sagittal plane articulation. The obtained kinematic data were translated into joint-specific cam shapes that were installed bilaterally in the hinge mechanism of the distraction device, as such providing personalized knee motion. Distraction of 5mm was performed within a range of motion of 30deg. joint flexion. Pre-clinical evaluation of the working principle was performed on human cadaveric legs and system stiffness characteristics were biomechanically evaluated. FINDINGS: The desired range of motion was obtained and distraction was maintained under physiologically representative loading. Moreover, the joint-specific approach demonstrated tolerance of deviations from anatomical and alignment origin during initial placement of the developed distraction device. INTERPRETATION: Articulation during knee distraction is considered technically feasible and has potential to decrease burden and improve acceptance of distraction therapy. Testing of clinical feasibility is warranted.

[Scaffold-based Bone Tissue Engineering]. / Gerüstträgerbasiertes Knochen-Tissue-Engineering.

Tissue engineering provides the possibility of regenerating damaged or lost osseous structures without the need for permanent implants. Within this context, biodegradable and bioresorbable scaffolds can provide structural and biomechanical stability until the body's own tissue can take over their function. Additive biomanufacturing makes it possible to design the scaffold's architectural characteristics to specifically guide tissue formation and regeneration. Its nano-, micro-, and macro-architectural properties can be tailored to ensure vascularization, oxygenation, nutrient supply, waste exchange, and eventually ossification not only in its periphery but also in its center, which is not in direct contact with osteogenic elements of the surrounding healthy tissue. In this article we provide an overview about our conceptual design and process of the clinical translation of scaffold-based bone tissue engineering applications.

[Refixation of the biceps tendon onto the radial tuberosity using two suture anchors]. / Refixation der distalen Bizepssehne an der Tuberositas radii mit zwei Spreizankern.

OBJECTIVE: Reinsertion of the distal biceps tendon onto the radial tuberosity restoring full force of flexion and supination. INDICATIONS: Distal biceps tendon avulsion from the radial tuberosity. Acute and chronic tears with a tendon stump, which can be mobilized and reduced to the radial tuberosity in flexion and supination. CONTRAINDICATIONS: Tears of the musculotendinous junction. Chronic distal biceps tendon tears with wide retraction and the need for tendon graft augmentation. Severe atrophy of the biceps muscle. SURGICAL TECHNIQUE: In supination, the skin is incised longitudinally for 4 cm, centered over the medial border of the radial tuberosity. Incision starts 2 cm distal from the humeroradial joint line. Bluntly the distal biceps tendon stump is found and mobilized. Preparation and debriding of the radial tuberosity sparing neurovascular structures. Crossing vessel branches are ligated, if needed. Positioning of two spreading anchors into the radial tuberosity and reinsertion of the tendon stump. POSTOPERATIVE MANAGEMENT: Adjustable elbow movement orthosis adapted to tendon quality and tissue tension for 6 weeks without active flexion or supination. Degree of extension is gradually increased by 20° every 2 weeks. After orthosis treatment is finished after 6 weeks, flexion and supination with weights is not allowed for another 6 weeks. RESULTS: In a retrospective study of 30 patients with a mean follow-up of 45 months (range 15-80 months), the clinical outcome was good or excellent in 99% of cases. On average, a Mayo Elbow Performance Score of 93 points (range 65-100 points) and a QuickDash of 5 points (range 0-39 points) were achieved.

Changes in Joint Contact Mechanics in a Large Quadrupedal Animal Model After Partial Meniscectomy and a Focal Cartilage Injury.

Acute mechanical damage and the resulting joint contact abnormalities are central to the initiation and progression of post-traumatic osteoarthritis (PTOA). Study of PTOA is typically performed in vivo with replicate animals using artificially induced injury features. The goal of this work was to measure changes in a joint contact stress in the knee of a large quadruped after creation of a clinically realistic overload injury and a focal cartilage defect. Whole-joint overload was achieved by excising a 5-mm wedge of the anterior medial meniscus. Focal cartilage defects were created using a custom pneumatic impact gun specifically developed and mechanically characterized for this work. To evaluate the effect of these injuries on joint contact mechanics, Tekscan (Tekscan, Inc., South Boston, MA) measurements were obtained pre-operatively, postmeniscectomy, and postimpact (1.2-J) in a nonrandomized group of axially loaded cadaveric sheep knees. Postmeniscectomy, peak contact stress in the medial compartment is increased by 71% (p = 0.03) and contact area is decreased by 35% (p = 0.001); the center of pressure (CoP) shifted toward the cruciate ligaments in both the medial (p = 0.004) and lateral (p = 0.03) compartments. The creation of a cartilage defect did not significantly change any aspect of contact mechanics measured in the meniscectomized knee. This work characterizes the mechanical environment present in a quadrupedal animal knee joint after two methods to reproducibly induce joint injury features that lead to PTOA.

Bicompartmental individualized knee replacement : Use of patient-specific implants and instruments (iDuo™).

OBJECTIVE: Bicompartmental knee replacement in patients with combined osteoarthritis (OA) of the medial or lateral and patellofemoral compartment. Patient-specific instruments and implants (ConforMIS iDuo™) with a planning protocol for optimal implant fit. INDICATIONS: Bicompartmental OA of the knee (Kellgren & Lawrence stage IV) affecting both the medial or lateral and patellofemoral compartment after unsuccessful conservative or joint-preserving surgery. CONTRAINDICATIONS: Tricompartmental OA, knee ligament instabilities, knee deformities >15° (varus, valgus, extension deficit). Relative contraindication: body mass index >40; prior unicompartmental knee replacement or osteotomies. SURGICAL TECHNIQUE: Midline or parapatellar medial skin incision, medial arthrotomy; identify mechanical contact zone of the intact femoral condyle (linea terminalis); remove remaining cartilage and all osteophytes that may interfere with the correct placement of the individually designed instruments. Balance knee in extension with patient-specific balancing chips. Resection of proximal tibia with an individual cutting block; confirm axial alignment using an extramedullary alignment guide, balance flexion gap using spacer blocks in 90° flexion. Final femur preparation with resection of the anterior trochlea. After balancing and identification of insert heights, final tibial preparation is performed. Implant is cemented in 45° of knee flexion. Remove excess cement and final irrigation, followed by closure. POSTOPERATIVE MANAGEMENT: Sterile wound dressing; compressive bandage. No limitation of active/passive range of motion (ROM). Partial weight bearing the first 2 weeks, then transition to full weight bearing. Follow-up directly after surgery, at 12 and 52 weeks, then every 1-2 years. RESULTS: In all, 44 patients with bicompartmental OA of the medial and patellofemoral compartment were treated. Mean age 59 years. Minimum follow-up 12 months. Implant converted to TKA due to tibial loosening (1 patient); patella resurfacing (3 patients). No further revisions or complications. Radiographic analyses demonstrated ideal fit of the implant with less than 2 mm subsidence or overhang. KSS pain scores improved from preoperatively 5.7 to 1.7 postoperatively with level walking, and from 7.3 preoperatively to 2.8 postoperatively with climbing stairs or inclines. The WOMAC score improved from preoperatively 43 to 79 postoperatively.