Two-Year Follow-Up and Remodeling Kinetics of ChonDux Hydrogel for Full-Thickness Cartilage Defect Repair in the Knee.

OBJECTIVE: To determine performance and repair kinetics of the ChonDux hydrogel scaffold for treating focal articular cartilage defects in the knee over 24 months. DESIGN: This assessor-blinded trial evaluates ChonDux hydrogel scaffold implantation in combination with microfracture in 18 patients across 6 sites. Male and female patients 18 to 65 years of age with full-thickness femoral condyle defects 2 to 4 cm2 in area were enrolled. Eligible patients received ChonDux treatment followed by rehabilitation. Defect volume fill was evaluated after 3, 6 (primary outcome), 12, 18, and 24 months by assessor blinded magnetic resonance imaging (MRI) analysis. Secondary outcomes were T2-weighted MRI relaxation time and patient surveys via visual analogue scale (VAS) pain and International Knee Documentation Committee (IKDC) knee function scoring. RESULTS: ChonDux maintained durable tissue restoration over 24 months with final defect percent fill of 94.2% ± 16.3% and no significant loss of fill volume at any time points. Tissues treated with ChonDux maintained T2 relaxation times similar to uninjured cartilage between 12 and 24 months. VAS pain scoring decreased between 1 and 6 weeks, and IKDC knee function scores improved by approximately 30.1 with ChonDux over 24 months. CONCLUSION: ChonDux treatment is a safe adjunct to microfracture therapy and promotes stable restoration of full thickness articular cartilage defects for at least 24 months.

Mobile-bearing total knee arthroplasty: More rotation is evident during more demanding tasks.

BACKGROUND: Some reports showed few but significant more axial femorotibial rotation in favor of mobile-bearing (MB) versus fixed-bearing (FB) total knee arthroplasty (TKA), mostly during knee bend fluoroscopic studies. The goal of the current study was to submit MB and FB groups of TKA patients to a turning activity, in which additional rotation was to be expected. METHODS: Two consecutive cohorts of patients after TKA (10 FB and 11 MB knees in a total of 18 patients) were assessed using motion analysis five year postoperatively, while performing gait and sit-to-walk (STW) movements with and without turning steps. RESULTS: Mean range of rotation in the FB group increased from 9.7° during gait, to 11.7° during STW straight, and to 14.3° during STW turning. Mean range of rotation in the MB group increased from 13.4° during gait to 21.0° during STW straight, and stayed at 21.1° during STW turning. CONCLUSIONS: Too many uncontrolled variables in the current study hinder a meaningful discrimination of MB from FB TKA rotation. However, the study does illustrate how more demanding task loads could be helpful in exploring the geometric constraints of TKA variants. LEVEL OF EVIDENCE: Level III, therapeutic study.

Early loosening of a press-fit cup with ceramic-on-ceramic articulation: our early results.

INTRODUCTION: In this study, we present the short-term results of the Selexys TH+ cup with the Ceramys inlay which is a press-fit cup with a ceramic-on-ceramic articulation. (Mathys, Bettlach, Switzerland). We compared the results with a retrospective-matched control group with a Delta PF cup (Lima, Udine, Italy), which is also a press-fit cup with a ceramic-on-ceramic articulation. MATERIALS AND METHODS: 257 elective hip arthroplasties with the Selexys TH+ cup in 250 patients placed in 2009 and 2010 were analyzed and compared with a control group retrospective analysis of the uncemented Delta PF cup (Lima, Udine, Italy) placed in 2007 and 2008 in 208 patients (222 hips). Surgical technique and surgeons were identical in both groups. RESULTS: During a follow-up period of 3-21 months, 19 aseptic loosenings (7.4 %) were found for the Selexys TH+ cup. The survival plotted by a Kaplan-Meier curve shows a 1-year survival of 87.4 %. The Lima Delta PF cup showed a 1-year survival of 99.5 %. Failure analysis showed no clear explanation for this early loosening. CONCLUSION: The Selexys TH+ cup combined with the Ceramys ceramic-on-ceramic inlay coupling show an unacceptable high early revision rate. Therefore, we advice against using this combination.

Treatment of an osteoporotic vertebral compression fracture with the StaXx FX system resulting in intrathoracic wafers: a serious complication.

PURPOSE: To report a serious complication of the StaXx FX system used to stabilize an osteoporotic vertebral fracture. CASE REPORT: A 76-year-old woman presented with a painful vertebral fracture. Treatment by means of a PEEK wafer kyphoplasty was complicated by malposition of the wafers. The patient recovered fully after removal of the wafers by means of a thoracotomy. CONCLUSIONS: New treatment modalities have their own pitfalls and possible complications, as demonstrated in this case report. Caution regarding implementation of new treatment modalities should be practiced.

A randomised controlled trial for the effectiveness of intra-articular Ropivacaine and Bupivacaine on pain after knee arthroscopy: the DUPRA (DUtch Pain Relief after Arthroscopy)-trial.

PURPOSE: In this double-blinded, randomised clinical trial, the aim was to compare the analgesic effects of low doses of intra-articular Bupivacaine and Ropivacaine against placebo after knee arthroscopy performed under general anaesthesia. METHODS: A total of 282 patients were randomised to 10 cc NaCl 0.9%, 10 cc Bupivacaine 0.5% or 10 cc Ropivacaine 0.75%. Patients received the assigned therapy by intra-articular injection after closure of the portal. Pain and satisfaction were measured at one, 4 h and 5-7 days after arthroscopy with Numerical Rating Scale (NRS) -scores. NSAID consumption was also recorded. RESULTS: One-h NRS-scores at rest were higher in the NaCl group compared with the Bupivacaine group (P < 0.01), 1 h NRS-scores in flexion were higher in the NaCl group compared with the Bupivacaine (P < 0.01) and Ropivacaine (P < 0.01) groups. NRS-satisfaction at 4 h was higher for the Bupivacaine group compared with the NaCl group (P = 0.01). Differences in NRS-scores were significant but low in magnitude. NSAID consumption was lower in the Bupivacaine group compared with the NaCl group (P < 0.01). CONCLUSIONS: The results of this randomised clinical trial demonstrate improved analgesia after administration of low doses of intra-articular Bupivacaine and Ropivacaine after arthroscopy of the knee. Considering reports of Bupivacaine and Ropivacaine being chondrotoxic agents and the relatively small improvement on patient comfort found in this trial, it is advised to use systemic anaesthetic instead of intra-articular Bupivacaine or Ropivacaine for pain relief after knee arthroscopy.

Obesity in total hip arthroplasty--does it really matter? A meta-analysis.

BACKGROUND AND PURPOSE: Discussion persists as to whether obesity negatively influences the outcome of hip arthroplasty. We performed a meta-analysis with the primary research question of whether obesity has a negative effect on short- and long-term outcome of total hip arthroplasty. METHODS: We searched the literature and included studies comparing the outcome of hip arthroplasty in different weight groups. The methodology of the studies included was scored according to the Cochrane guidelines. We extracted and pooled the data. For continuous data, we calculated a weighted mean difference and for dichotomous variables we calculated a weighted odds ratio (OR). Heterogeneity was calculated using I(2) statistics. RESULTS: 15 studies were eligible for data extraction. In obese patients, dislocation of the hip (OR = 0.54, 95% CI: 0.38-0.75) (10 studies, n = 8,634), aseptic loosening (OR = 0.64, CI: 0.43-0.96) (6 studies, n = 5,137), infection (OR = 0.3, CI: 0.19-0.49) (10 studies, n = 7,500), and venous thromboembolism (OR = 0.56, CI: 0.32-0.98) (7 studies, n = 3,716) occurred more often. Concerning septic loosening and intraoperative fractures, no statistically significant differences were found, possibly due to low power. Subjective outcome measurements did not allow pooling because of high heterogeneity (I(2) = 68%). INTERPRETATION: Obesity appears to have a negative influence on the outcome of total hip replacement.

Complications after tomofix medial opening wedge high tibial osteotomy.

This article describes the complications after medial opening wedge high tibial osteotomy (HTO) with the TomoFix plate. Between June 2003 and July 2005, 40 TomoFix medial opening wedge HTOs were performed. On average, radiological consolidation was reached after 10.4 months. Nonunions were not recorded. In 4 cases (10%), a superficial infection was found. Between operation and consolidation of the osteotomy, an average loss of correction of 0.3 degrees was observed. Loss of correction after removal of the implant was not observed. Excluding the breakage of 1 screw during extraction of the implant, failure did not occur. The fixation of the TomoFix with locking-head screws for the opening wedge HTO, as described in this study, is stable. The planned correction could be reached with high exactitude during the operation.

Low-intensity pulsed ultrasound affects human articular chondrocytes in vitro.

We investigated whether low-intensity pulsed ultrasound (LIPUS) stimulates chondrocyte proliferation and matrix production in explants of human articular cartilage obtained from donors suffering from unicompartimental osteoarthritis of the knee, as well as in isolated human chondrocytes in vitro. Chondrocytes and explants were exposed to LIPUS (30 mW/cm(2); 20 min/day, 6 days). Stimulation of [35S]-sulphate incorporation into proteoglycans by LIPUS was 1.3-fold higher in degenerative than in collateral monolayers as assessed biochemically and 1.9-fold higher in explants as assessed by autoradiography. LIPUS decreased the number of cell nests containing 1-3 chondrocytes by 1.5 fold in collateral and by 1.6 fold in degenerative explants. LIPUS increased the number of nests containing 4-6 chondrocytes by 4.8 fold in collateral and by 3.9 fold in degenerative explants. This suggests that LIPUS stimulates chondrocyte proliferation and matrix production in chondrocytes of human articular cartilage in vitro. LIPUS might provide a feasible tool for cartilage tissue repair in osteoarthritic patients, since it stimulates chondrocyte proliferation and matrix production.

Early complications after high tibial osteotomy: a comparison of two techniques.

This prospective cohort study compared opening wedge high tibial osteotomy with use of the Puddu plate and the Vitoss synthetic cancellous bone versus closing wedge high tibial osteotomy with use of the AO/ASIF L-plate, focusing on complications (nonunions, infections, loss of correction, reoperations) and patient satisfaction (visual linear analog scale). During a 10-month period, we performed high tibial osteotomy for 40 patients experiencing medial knee osteoarthritis and a varus deformity. The average follow-up was 11 months. The complication rate in patients treated with the opening wedge technique was significantly higher regarding tibial nonunion, loss of correction, and material failure. Patients in the closing wedge group were more satisfied with the postoperative result. This study found that the Puddu plate, despite 6 weeks of non-weight bearing facilitating the osseous consolidation with Vitoss cement, was not able to maintain the correction during the time required for bone healing.

Arthroscopic debridement for grade III and IV chondromalacia of the knee in patients older than 60 years.

Arthroscopic debridement has been used to treat patients with degenerative knee osteoarthritis, although there is sometimes conflicting evidence documenting its efficacy. This study evaluates the success of arthroscopic debridement in elderly patients with grade III and IV chondromalacia of the knee as measured by patient satisfaction and the need for additional surgery. From December 1998 to August 2001, a total of 102 consecutive cases of knee arthroscopy in 99 patients > 60 years were performed. Average follow-up was 34 months (range: 7-104 months). Patients were asked about their satisfaction using a visual analog scale, and the presence of meniscal lesions during arthroscopy and the treatment for these lesions were evaluated. Knees also were assessed for articular surface degeneration using Outerbridge's classification for chondromalacia. The need for and type of additional surgery was evaluated. During arthroscopy, meniscal lesions requiring a partial meniscectomy were found in 95 knees. Chondromalacia was found in 92 knees; 53 knees had grade I or II chondromalacia and 39 knees had grade III or IV chondromalacia. Additional surgery was performed in 17 knees. Mean patient satisfaction score was 73 (range: 50-100) in the 39 knees with grade III or IV chondromalacia after arthroscopic debridement was performed. These findings suggest arthroscopic debridement in elderly patients has a place in the treatment algorithm for grade III or IV chondromalacia of the knee.

Long term results of surgical intervention for osteoarthritis of the trapeziometacarpal joint : comparison of resection arthroplasty, trapeziectomy with tendon interposition and trapezio-metacarpal arthrodesis.

Trapeziometacarpal osteoarthritis is a common entity, often bilateral and predominantly affecting postmenopausal women. In the case of failure of conservative treatment, surgery is a good option. The aim of this study was to compare three surgical procedures. 63 patients (74 thumbs) with osteoarthritis of the trapezio-metacarpal joint were surgically treated; 54 patients were seen for follow-up, 7 had died and 2 were lost to follow-up. The patients were stratified according to treatment; resection arthroplasty (the joint surface's of the metacarpal and the trapezium are resected) (18 thumbs), trapeziectomy with tendon interposition (17 thumbs) or trapezio-metacarpal arthrodesis (28 thumbs). Baseline characteristics were comparable in the three groups for mean age at operation, Eaton classification, left right distribution and dominant hands operated. The average follow-up was 13 years for the resection group, 8 years for the trapeziectomy group and 9 years for the arthrodesis group. No statistically significant difference between the three groups was found for the visual analogue pain and satisfaction scale, pain frequency nor DASH score. Patients in the trapeziectomy group had significantly less pain compared to the arthrodesis group (p=0.025). Statistically, radial abduction was significantly better after trapeziectomy compared to resection arthroplasty (p<0.01) or arthrodesis (p=0.01). There was no difference among the three groups in grip and tip pinch strength nor in pain on palpation. None of the patients in the trapeziectomy group needed a re-operation, one patient in the resection arthroplasty group had a re-operation, and 22 patients in the arthrodesis group had one or more re-operations for hardware removal or because of a complication. This study shows that the resection arthroplasty has equally good long term results compared to trapeziectomy combined with tendon interposition or arthrodesis. Resection arthroplasty is performed through a single incision and is technically simple. In our clinic resection arthroplasty is therefore the preferred technique for the treatment of osteoarthritis of the trapeziometacarpal joint.

Different responsiveness to mechanical stress of bone cells from osteoporotic versus osteoarthritic donors.

INTRODUCTION: Osteoporosis (OP) and osteoarthritis (OA) are both common diseases in the elderly, but remarkably seldom coexist. The bone defects that are related to both diseases develop with increasing age, which suggests that they are related to some form of imperfect bone remodeling. Current opinion holds that the bone remodeling process is supervised by bone cells that respond to mechanical stimuli. An imperfect response of bone cells to mechanical stimuli might thus relate to imperfect bone remodeling, which could eventually lead to a lack bone mass and strength, such as in OP patients. MATERIALS: To investigate whether the cellular response to mechanical stress differs between OP and OA patients, we compared the response of bone cells from both groups to fluid shear stress of increasing magnitude. Bone cells from 9 female OP donors (age 60-90 year) and 9 female age-matched OA donors were subjected to pulsating fluid flow (PFF) of low (0.4+/-0.1 Pa at 3 Hz), medium (0.6+/-0.3 Pa at 5 Hz), or high shear stress (1.2+/-0.4 at 9Hz), or were kept under static culture conditions. RESULTS: We found subtle differences in the shear-stress response of the two groups, measured as nitric oxide (NO) and prostaglandin E2 (PGE2) production. The NO-response to shear stress was higher in the OP than the OA cells, while the PGE2-response was higher in the OA cells. CONCLUSIONS: Assuming that NO and PGE2 play a role in cell-cell communication during remodeling, these results suggest that slight differences in mechanotransduction might relate to the opposite bone defects in osteoporosis and osteoarthritis.

Additive effects of estrogen and mechanical stress on nitric oxide and prostaglandin E2 production by bone cells from osteoporotic donors.

Mechanical loading is thought to provoke a cellular response via loading-induced flow of interstitial fluid through the lacuno-canalicular network of osteocytes. This response supposedly leads to an adaptation of local bone mass and architecture. It has been suggested that loss of estrogen during menopause alters the sensitivity of bone tissue to mechanical load, thereby contributing to the rapid loss of bone. The present study aimed to determine whether estrogen modulates the mechanoresponsiveness of bone cells from osteoporotic women. Bone cell cultures from nine osteoporotic women (aged 62-90 years) were pre-cultured for 24 h with 10(-11) mol/l 17beta-estradiol (E2) or vehicle, and subjected to 1 h of pulsating fluid flow (PFF) or static culture. E2 alone enhanced prostaglandin E(2) (PGE(2)) and nitric oxide (NO) production by 2.8-fold and 2.0-fold, respectively, and stimulated endothelial nitric oxide synthase protein expression by 2.5-fold. PFF, in the absence of E2, stimulated PGE(2) production by 3.1-fold and NO production by 3.9-fold. Combined treatment with E2 and PFF increased PGE(2) and NO production in an additive manner. When expressed as PFF-treatment-over-control ratio, the response to fluid shear stress was similar in the absence or presence of E2. These results suggest that E2 does not affect the early response to stress in bone cells. Rather, E2 and shear stress both promote the production of paracrine factors such as NO and PGE(2) in an additive manner.

Stimulation of bone cell differentiation by low-intensity ultrasound--a histomorphometric in vitro study.

Several investigations have established a stimulatory effect of low-intensity ultrasound treatment on osteogenesis and fracture healing. The objective of this study was to examine whether the stimulatory effect of low-intensity ultrasound results in increased bone cell activity and/or proliferation. Twenty-four paired triplets of metatarsal bone rudiments of twelve 17-days-old fetal mice were dissected and divided into two groups. One group of bone rudiments was treated with pulsating low-intensity ultrasound (30 mW/cm(2); 1.5 MHz) for 20 min/day for a period of 3 or 6 days. The other group served as controls. After culture, the metatarsal bone rudiments were prepared for computer aided light microscopy. The following histomorphometric parameters were determined: length, width and volume of the calcified cartilage and of the bone collar, and cell number. GLM analysis demonstrated that bone collar volume and calcified cartilage percentage were significantly higher in the ultrasound-stimulated rudiments compared to untreated controls. Further, the calcified cartilage volume bordering the hypertrophic zone was significantly higher than in the center of the bone rudiment. Ultrasound treatment did not change the number of the cells. These results suggest that the stimulatory effect of low-intensity ultrasound on endochondral ossification is likely due to stimulation of bone cell differentiation and calcified matrix production, but not to changed cell proliferation.

Trochanteric reduction osteotomy as a treatment for refractory trochanteric bursitis.

We describe a new operative procedure for patients with chronic trochanteric bursitis. Between March 1994 and May 2000, a trochanteric reduction osteotomy was performed on ten patients (12 hips). All had received conservative treatment for at least one year. Previous surgical treatment with a longitudinal release of the iliotibial band combined with excision of the trochanteric bursa had been performed on five hips. None had responded to these treatments. The mean follow-up was 23.5 months (6 to 77). The mean Merle d'Aubigné and Postel score improved from 15.8 (8 to 20) before to 27.5 (18 to 30) after operation, six patients showing very great improvement, five great improvement and one fair improvement. We conclude that trochanteric reduction osteotomy is a safe and effective procedure for patients with refractory trochanteric bursitis who do not respond to conservative treatment.

[Effects of low-intensity ultrasound on bone. Perspectives for dentistry?]. / Effecten van lage-intensiteit ultrageluid op bot. Perspectieven voor de tandheelkunde?

Low-intensity ultrasound is frequently used for non-invasive diagnostic purposes. However, low intensity ultrasound can also be used as a therapeutical agent. It has been concluded from animal experiments that it significantly stimulates the growth of bone. In clinical trials an accelerated healing of fracture has been found. Future research has to define the role in dentistry and the final therapeutical value of low intensity ultrasound.

Low-intensity pulsed ultrasound in the treatment of nonunions.

BACKGROUND: Low-intensity ultrasound has demonstrated an acceleration of bone healing and more profound callus formation in animal and human clinical experiments. In this study, the effect of pulsed, low-intensity ultrasound was determined in established nonunion cases. METHODS: The enrolled cases were reviewed for the time from their last surgical procedure and evidence of no healing or progression of healing during the 3 or more months before the start of low-intensity ultrasound therapy to determine whether the cases were established nonunions. Twenty-nine cases, located in the tibia, femur, radius/ulna, scaphoid, humerus, metatarsal, and clavicle, met the criteria for established nonunions. On average, the postfracture period before the start of ultrasound treatment was 61 weeks. Initial fracture treatment was conservative in 8 cases and operative in 21 cases. Additional treatments including bone grafting, reosteosynthesis, and other surgical procedures were performed an average of 52 weeks before the start of ultrasound treatment. Daily, 20-minute applications of low-intensity ultrasound at the site of the nonunion were performed by the patients at home. RESULTS: Twenty-five of the 29 nonunion cases (86%) healed in an average treatment time of 22 weeks (median, 17 weeks). Stratification of the healed and failed outcome for age, gender, concomitant disease, bone location, fracture age, prior last surgery interval, nonunion type, smoking habits, and fixation before and during treatment showed a significant difference only in the smoking habit strata. CONCLUSION: Noninvasive ultrasound therapy can be useful in the treatment of challenging, established nonunions.

Low-intensity ultrasound stimulates endochondral ossification in vitro.

Animal and clinical studies have shown an acceleration of bone healing by the application of low-intensity ultrasound. The objective of this study was to examine in vitro the influence of low-intensity ultrasound on endochondral ossification of 17-day-old fetal mouse metatarsal rudiments. Forty-six triplets of paired metatarsal rudiments were resected 'en block' and cultured for 7 days with and without low-intensity ultrasound stimulation (30 mw/cm2). At days 1, 3, 5, and 7, the total length of the metatarsal rudiments, as well as the length of the calcified diaphysis were measured. Histology of the tissue was performed to examine its vitality. The increase in length of the calcified diaphysis during 7 days of culture was significantly higher in the ultrasound-treated rudiments compared to the untreated controls (P = 0.006). The growth of the control diaphysis was 180 +/- 30 microm (mean +/- SEM), while the growth of the ultrasound-treated diaphysis was 530 +/- 120 microm. The total length of the metatarsal rudiments was not affected by ultrasound treatment. Histology revealed a healthy condition of both ultrasound-treated and control rudiments. In conclusion, low-intensity ultrasound treatment stimulated endochondral ossification of fetal mouse metatarsal rudiments. This might be due to stimulation of activity and/or differentiation of osteoblasts and hypertrophic chondrocytes. Our results support the hypothesis that low-intensity ultrasound activates ossification via a direct effect on osteoblasts and ossifying cartilage.

The influence of subtalar and triple arthrodesis on the tibiotalar joint. A long-term follow-up study.

From 1975 to 1990 we performed subtalar or triple arthrodesis on 54 patients; 48 of them were reviewed after a mean follow-up of 10 years (6 to 15). There were 17 subtalar fusions in 14 patients and 37 triple arthrodeses in 28 patients. We assessed tibiotalar ankle function using the criteria of Mazur which gives a points score of a maximum of 100. Radiological evidence of degenerative change was graded on a scale of 0 to 4. The mean Mazur score was 85 for the subtalar fusions and 78 for the triple arthrodeses. The radiological score showed no degenerative changes in 36 feet (24 triple and 12 subtalar arthrodeses) and an increase of one grade in 14 feet (10 triple and 4 subtalar), of two grades in three feet (all triple arthrodeses) and of three grades in one foot after a subtalar arthrodesis. We found no statistically significant difference in the radiological score in unilateral fusions between feet with subtalar and triple arthrodeses and the contralateral foot. In all four feet which showed an increase in degenerative changes of two or more grades, there was an abnormality of the tibiotalar joint before the fusion operation. Of the 14 feet which showed an increase of one grade, there was a similar increase on the contralateral side in nine. Our findings show that subtalar or triple arthrodesis has little adverse influence on the function of the tibiotalar joint, even after many years.

Distal tibiofibular synostosis after ankle fracture. A 14-year follow-up study.

Over an eight-year period up to 1983, a total of 322 consecutive patients had operations for ankle fractures; 176 were Weber type B and 128 type C. We were able to review 230 of these patients after a mean follow-up of six years (1 to 11) including 128 with Weber B and 102 with Weber C fractures. We used an ankle score which combined symptoms and clinical and radiological findings, with a maximum score of 100 points. The mean score for all 230 was 92 (68 to 100). Fifteen of these patients had developed a distal synostosis between the tibia and fibula, three after a Weber B and 12 after a Weber C fracture. In 13 of these 15 ankles the synostosis had been visible radiologically within three months of the operation. In the other two there had been radiologically visible calcification at the three-month follow-up. In 1993, we were able to review nine of the 15 patients with synostosis using the same scoring system. At a mean follow-up of 14 years (12 to 18) the mean score for those with synostosis was 91 (71 to 100), much the same as this group's previous score and the mean score of the whole group of operated patients. We conclude that distal tibiofibular synostosis after ankle fracture usually causes few symptoms and does not generally require any treatment.