Implantation of Culture-Expanded Bone Marrow Derived Mesenchymal Stromal Cells for Treatment of Osteonecrosis of the Femoral Head.

BACKGROUND: Although core decompression (CD) with stem cell for the treatment of osteonecrosis of the femoral head (ONFH) showed promising results in many reports, the efficacy remains uncertain. We aimed to evaluate the efficacy of CD with culture-expanded autologous bone marrow-derived mesenchymal stem cell (BM-MSC) implantation in early stage ONFH. METHODS: A total of 18 patients (22 hips) with ONFH who underwent CD with culture-expanded BM-MSC implantation from September 2013 to July 2020 were retrospectively reviewed. The median age was 35.0 years [interquartile range (IQR), 28.5-42.0], and the median follow-up period was 4.0 years (IQR, 2.0-5.3). The median number of MSCs was 1.06 × 108. To evaluate radiographic and clinical outcomes, Association Research Circulation Osseous (ARCO) classifications, Japanese Investigation Committee classification, combined necrotic angle (CNA) visual analogue scale (VAS) and Harris Hip Score (HHS) were checked at each follow-up. RESULTS: The preoperative stage of ONFH was ARCO 2 in 14 hips and ARCO 3a in 8 hips. The ARCO staging was maintained in 7 hips in ARCO 2 and 4 hips in ARCO 3a. The radiographic failure rate of ARCO 2 and 3a was 14.3 and 50%, respectively. Furthermore, CNA decreased to more than 20° in 6 hips (four were ARCO 2 and two were ARCO 3a).There was no significant difference in the VAS and HHS (P = 0.052 and P = 0.535, respectively). Total hip arthroplasty was performed in 4 hips. CONCLUSION: CD with culture-expanded autologous BM-MSCs showed promising results for the treatment of early stage ONFH.

Occipitocervical inclination: new radiographic parameter of neutral occipitocervical position.

PURPOSE: To describe occipitocervical inclination (OCI), a new parameter that could compensate for defects in existing radiographic parameters, and to define occipitocervical neutral position. METHODS: Neutral, flexion, and extension lateral cervical spine radiographs of 200 patients (100 male and 100 female patients) judged to be normal were analyzed. The mean age was 45.19 years (range 11-74; 42.84 for male and 47.53 for female patients). For OCI, the angle formed by the line connecting the posterior border of the C4 vertebral body and McGregor's line was measured. Occipitocervical angle (OCA) and occipitocervical distance (OCD) were measured and compared with OCI. RESULTS: OCI on standard, neutral lateral cervical radiographs was 102.51° ± 8.87°. There was no significant gender difference in neutral OCI 102.81° ± 7.93° for male and 102.21° ± 9.74° for female patients (P = 0.631). The mean neutral OCA was 38.69° ± 9.23°, and the mean neutral OCD was 22.98 ± 5.10 mm. Pearson's correlation coefficient for the value of the cervical lordosis angle and that of neutral OCI was r = 0.274 (P < 0.001). Intraclass correlation coefficient values for inter- and intraobserver reliability for OCI were significantly higher than those for OCA (P < 0.001) and tended to be higher than those for OCD (P = 0.087). CONCLUSIONS: OCI is a very useful parameter for the determination of neutral position during occipitocervical fusion for patients with altered C0-C2 anatomy.

Malalignment after minimally invasive plate osteosynthesis in distal femoral fractures.

INTRODUCTION: Although minimally invasive plate osteosynthesis (MIPO) is a preferred operative treatment for fractures of the distal femur, malalignment is a significant concern because of indirect reduction of the fracture. The purpose of this study, therefore, was to evaluate radiologic alignment after MIPO for distal femoral fractures. PATIENTS AND METHODS: Of the 138 patients with fracture of the distal femur who underwent MIPO, we enrolled 51 patients in whom bilateral rotational alignment could be assessed by postoperative computed tomography (CT). The patients included 32 men and 19 women, with a mean age of 54.3 years. Thirteen patients had femoral shaft fractures (according to the AO/OTA classification: 32-A, n=2; 32-B, n=6; 32-C, n=5), whereas 38 patients had distal femoral fractures (33-A, n=7; 33-C, n=31). Coronal and sagittal alignments were assessed using simple radiography, whereas rotational alignment was assessed using CT. According to the difference between the affected and unaffected sides, we divided the patients into satisfactory and unsatisfactory groups (reference point of 8°, using Handolin's classification). Thereafter, we determined which factors can lead to malalignment, including fracture location (distal femoral shaft fracture or metaphyseal fracture), fracture pattern (simple fracture, n=15; complex fractures, n=36 patients), coronal and sagittal alignments, and combined ipsilateral long bone fractures. RESULTS: Coronal and sagittal alignment were satisfactory in 96.2% (average, 2.8°) and 98% (average, 2.2°), respectively, whereas the rotational alignment was satisfactory in 56.9% of patients. Leg length discrepancy was satisfactory in 92.3% of the patients (average, 10.9mm). Concerning rotational malalignment, an unsatisfactory result was obtained in 48.6% of subjects with complex fractures and 26.7% of subjects with simple fractures (p=0.114). No significant correlation was noted between the angular deformity in the coronal and sagittal planes and the degree of rotational alignment (p=0.607 and 0.774, respectively). CONCLUSIONS: Regardless of the fracture pattern, rotational malalignment may occur at an extremely high rate after MIPO for fractures of the distal femur.

Comparison of Cable Method and Miniaci Method Using Picture Archiving and Communication System in Preoperative Planning for Open Wedge High Tibial Osteotomy.

PURPOSE: The purpose was to compare the accuracy of Miniaci method using picture archiving and communication system (PACS) with a cable method in high tibial osteotomy (HTO). MATERIALS AND METHODS: This study analyzed 47 patients (52 knees) with varus deformity and medial osteoarthritis. From 2007 to 2013, patients underwent HTO using either a cable method (20 knees) or Miniaci method based on a PACS image (32 knees). In the cable method, the 62.5% point of the mediolateral tibial plateau width was located using an electrocautery cord under fluoroscopy (cable group). The Miniaci method used preoperative radiographs to shift the weight bearing axis (PACS group). Full-length lower limb radiographs obtained preoperatively and at the sixth postoperative week were used to compare the percentage of crossing point of the weight bearing line on the tibial plateau with respect to the medial border. RESULTS: The weight bearing line on the tibial plateau was corrected from a preoperative 11.0±7.0% to a postoperative 47.2±7.4% in the cable group and from 12.7±4.9% to 59.5±5.3% in the PACS group. The mechanical femorotibial angle was corrected from varus 8.9±3.7° to valgus 0.3±4.0° in the cable group and from varus 9.0±3.3° to valgus 2.9±2.6° in the PACS group. CONCLUSIONS: In HTO, correction based on the Miniaci method using a PACS was more accurate than correction using the cable method.

The incidence of and factors affecting iliosacral screw loosening in pelvic ring injury.

INTRODUCTION: Iliosacral screw fixation has been commonly used for stabilization of the posterior ring in unstable pelvic fractures. However, loosening of the screw may develop with or without redisplacement of the fracture. This study was undertaken to evaluate the incidence of iliosacral screw loosening and to identify its predictive factors. MATERIALS AND METHODS: In total, 110 patients whose posterior pelvic ring was stabilized with iliosacral screws were enrolled. These included 9 cases of anteroposterior compression, 64 cases of lateral compression, and 37 cases of vertical shear (VS) injuries. Among those with posterior pelvic ring injuries, 95 had sacral fractures (zone I: 52, zone II: 43) and 15 had sacroiliac joint dislocations. The screws were fixed to the anterior one-third region of the first sacral (S1) body in 46 cases, and to the middle one-third region in the remaining 64 cases. If loosening of the iliosacral screw influenced the pelvic ring stability, it was considered a failure. The relationship between iliosacral screw loosening and the possible influencing factors were analyzed. RESULTS: Nineteen patients (17.3 %) were found to have loosening of the iliosacral screw at a mean 25.3 days postoperatively. Of these, 13 patients (11.8 %) had failure of the screws. The incidence of iliosacral screw loosening was significantly higher in those with VS injury (29.7 %, p = 0.014), in those with screw fixed to the middle one-third region of the S1 body (23.4 %, p = 0.044), and in those with VS injury combined with zone II sacral fracture (43.5 %, p = 0.019). With respect to failure of the iliosacral screw, patients with VS injury also had a higher incidence of failure (21.6 %, p = 0.036). CONCLUSIONS: Our findings demonstrate that cases with VS injuries are prone to screw loosening, especially when combined with zone II sacral fracture. Accordingly, alternative fixation methods should be considered in such cases.

Two-Stage Revision for Infected Total Knee Arthroplasty: Based on Autoclaving the Recycled Femoral Component and Intraoperative Molding Using Antibiotic-Impregnated Cement on the Tibial Side.

BACKGROUND: The purpose of this study was to determine the degree of infection control and postoperative function for new articulating metal-on-cement spacer. METHODS: A retrospective study of 19 patients (20 cases), who underwent a two-stage revision arthroplasty using mobile cement prosthesis, were followed for a minimum of 2 years. This series consisted of 16 women and 3 men, having an overall mean age of 71 years. During the first stage of revision, the femoral implant and all the adherent cement was removed, after which it was autoclaved before replacement. The tibial component was removed and a doughy state, antibiotic-impregnated cement was inserted on the tibial side. To achieve joint congruency, intraoperative molding was performed by flexing and extending the knee joint. Each patient was evaluated clinically and radiologically. The clinical assessments included range of motion, and the patients were scored as per the Hospital for Special Surgery (HSS) and Knee Society (KS) criteria. RESULTS: The mean range of knee joint motion was 70° prior to the first stage operation and 72° prior to the second stage revision arthroplasty; following revision arthroplasty, it was 113° at the final follow-up. The mean HSS score and KS knee and function scores were 86, 82, and 54, respectively, at the final follow-up. The success rate in terms of infection eradication was 95% (19/20 knees). No patient experienced soft tissue contracture requiring a quadriceps snip. CONCLUSIONS: This novel technique provides excellent radiological and clinical outcomes. It offers a high surface area of antibiotic-impregnated cement, a good range of motion between first and second stage revision surgery for the treatment of chronic infection after total knee arthroplasty, and is of a reasonable cost.

Biplanar Open Wedge High Tibial Osteotomy in the Medial Compartment Osteoarthritis of the Knee Joint: Comparison between the Aescula and TomoFix Plate.

BACKGROUND: The purpose of this study was to compare the results of Aescula and TomoFix plates used for biplanar open wedge high tibial osteotomy in medial osteoarthritis of the knee joint with varus deformity. METHODS: A consecutive series of 50 cases of biplanar open wedge high tibial osteotomy were evaluated retrospectively. Group A contained 25 cases treated by using the Aescula plate, and group T contained 25 cases treated by using the TomoFix plate. Full weight-bearing was permitted at 6 weeks after surgery in group A and at 2 weeks in group T. Clinical evaluations were performed at the final follow-up by using postoperative knee scores and functional scores. Radiographic analysis included postoperative mechanical femur-tibia angle, change in posterior tibial slope angle, and complications related to implants. The mean follow-up periods were 30 months in group A and 26 months in group T. RESULTS: The knee and functional scores were improved at the final follow-up in both groups (p < 0.05), but no differences were observed between the two groups (p > 0.05). An acceptable correction angle was obtained in 52% of group A and in 84% of group T (p = 0.015). Change in posterior tibial slope angle was larger in group A than in group T (p < 0.001), showing better maintenance of posterior tibial slope in group T. In group A, there were 3 cases of screw loosening and 4 cases of delayed union. In addition, there were residual varus deformities in 7 cases (6 in group A and 1 in group T). CONCLUSIONS: This study shows that firm fixation using a TomoFix plate for open wedge high tibial osteotomy produces better radiologic results and a low complication rate than those of the Aescula spacer plate.