Bilateral Slipped Capital Femoral Epiphysis in a Young Girl Treated With Chemotherapy: A Case Report.

CASE: A 1-year-old girl was treated with chemotherapy and hematopoietic stem cell transplantation because of CD40 ligand deficiency. Four years later, she presented with pain in her right leg, diagnosed as atypical acute slipped capital femoral epiphysis, without a clear cause, besides chemotherapy possibly. She was treated with fixation of the epiphysis with a cannulated screw. Two years later, the same diagnosis was made for the left hip and the same surgery was applied. After the 2-year follow-up, clinical outcomes were good. CONCLUSION: Chemotherapy may be a risk factor for atypical slipped capital femoral epiphysis, even without the combination with radiotherapy.

Male-female differences in thoracic aortic diameters at presentation of acute type A aortic dissection.

Background: Acute type A aortic dissection (ATAAD) is a highly lethal event, associated with aortic dilatation. It is not well known if patient height, weight or sex impact the thoracic aortic diameter (TAA) at ATAAD. The study aim was to identify male-female differences in TAA at ATAAD presentation. Methods: This retrospective cross-sectional study analysed all adult patients who presented with ATAAD between 2007 and 2017 in two tertiary care centres and underwent contrast enhanced computed tomography (CTA) before surgery. Absolute aortic diameters were measured at the sinus of Valsalva (SoV), ascending (AA) and descending thoracic aorta (DA) using double oblique reconstruction, and indexed for body surface area (ASI) and height (AHI). Z-scores were calculated using the Campens formula. Results: In total, 59 % (181/308) of ATAAD patients had CT-scans eligible for measurements, with 82 female and 99 male patients. Females were significantly older than males (65.5 ± 12.4 years versus 60.3 ± 2.3, p = 0.024). Female patients had larger absolute AA diameters than male patients (51.0 mm [47.0-57.0] versus 49.0 mm [45.0-53.0], p = 0.023), and larger ASI and AHI at all three levels. Z-scores for the SoV and AA were significantly higher for female patients (2.99 ± 1.66 versus 1.34 ± 1.77, p < 0.001 and 5.27 [4.38-6.26] versus 4.06 [3.14-5.02], p < 0.001). After adjustment for important clinical factors, female sex remained associated with greater maximal TAA (p = 0.019). Conclusion: Female ATAAD patients had larger absolute ascending aortic diameters than males, implying a distinct timing in disease presentation or selection bias. Translational studies on the aortic wall and studies on growth patterns should further elucidate these sex differences.

Listing criteria for heart transplantation in the Netherlands.

The updated listing criteria for heart transplantation are presented on behalf of the three heart transplant centres in the Netherlands. Given the shortage of donor hearts, selection of those patients who may expect to have the greatest benefit from a scarce societal resource in terms of life expectancy and quality of life is inevitable. The indication for heart transplantation includes end-stage heart disease not remediable by more conservative measures, accompanied by severe physical limitation while on optimal medical therapy, including ICD/CRT­D. Assessment of this condition requires cardiopulmonary stress testing, prognostic stratification and invasive haemodynamic measurements. Timely referral to a tertiary centre is essential for an optimal outcome. Chronic mechanical circulatory support is being used more and more as an alternative to heart transplantation and to bridge the progressively longer waiting time for heart transplantation and, thus, has become an important treatment option for patients with advanced heart failure.

Uncemented total hip arthroplasty; increased risk of early periprosthetic fracture requiring revision surgery in elderly females.

PURPOSE: The preferred method of stem fixation in total hip arthroplasty (THA) remains debatable. Uncemented THA favors a lower rate of aseptic loosening but has an increased risk of early periprosthetic fractures (EPF). We hypothesize that routine placement of uncemented THA by experienced surgeons diminishes this EPF-risk. The purpose of this study is to investigate the effect of age, gender, ASA classification and BMI of THA performed by experienced surgeons on the risk of EPF. METHODS: A retrospective cohort study including all primary THAs and revision surgeries performed between 2012 and 2018. Possible predictive factors included are age, gender, BMI, ASA classification, presence of osteoporosis, Dorr classification, revision surgery type and clinical outcome. A number needed to treat (NNT) analysis was conducted assuming that cementing THA prevents EPF. RESULTS: 2635 primary THAs were performed. Indications for 70 revisions included 18 EPF in uncemented THA female patients. Periprosthetic fractures without a relevant trauma occurred within six weeks in 16 patients. There was a statistically significant correlation between EPF-risk and age (P = 0.032), female gender (P = 0.001) and ASA classification (P = 0.015). For age ≥75, there was an increase in EPF (P = 0.047). With the assumption that cementing would prevent EPF, the NNT is 48. No statistically significant correlation was found between EPF and BMI, osteoporosis or Dorr classification. CONCLUSION: Female patients aged ≥75 have an increased EPF-risk after uncemented THA and would therefore benefit from treatment with a cemented stem. An ASA score of III-IV is an independent risk factor for EPF after uncemented THA.

Care for the organ transplant recipient on the intensive care unit.

All transplant recipients receive tacrolimus, mycophenolate and glucocorticoids and these drugs have many side-effects and drug-drug interactions. Common complications include surgical complications, infections, rejection and acute kidney injury. Infections as CMV and PJP can be prevented with prophylactic treatment. Given the complexity of organ transplant recipients a multi-disciplinary team of intensivists, surgeons, pharmacists and transplant specialists is essential. After heart transplantation a temporary pacemaker is required until the conduction system recovers. Stiffening of the heart and increased cardiac markers indicate rejection. An endomyocardial biopsy is performed via the right jugular vein, necessitating its preservation. For lung transplant patients, early intervention for aspiration is warranted to prevent chronic rejection. Risk of any infection is high, requiring active surveillance and intensive treatment, mainly of fungal infections. The liver is immunotolerant requiring lower immunosuppression. Transplantation surgery is often accompanied by massive blood loss and coagulopathy. Other complications include portal vein or hepatic artery thrombosis and biliary leakage or stenosis. Kidney transplant recipients have a high risk of cardiovascular disease and posttransplant anemia should be treated liberally. After postmortal transplantation, delayed graft function is common and dialysis is continued. Ureteral anastomosis complications can be diagnosed with ultrasound.

Heterotopic ossification in primary total hip arthroplasty using the posterolateral compared to the direct lateral approach.

PURPOSE: Total hip arthroplasty (THA) is a successful procedure. However, in time, heterotopic ossification (HO) can form due to, amongst others, soft tissue damage. This can lead to pain and impairment. This study compares the formations of HO between patients who underwent either THA with the posterolateral approach (PA) or with the direct lateral approach (DLA). Our hypothesis is that patients who underwent THA with a PA form less HO compared to THA patients who underwent DLA. METHODS: In this prospective cohort study, 296 consecutive patients were included who underwent THA. A total of 127 patients underwent THA with the PA and 169 with the DLA. This was dependent on the surgeon's preference and experience. More than 95% of patients had primary osteoarthritis as the primary diagnosis. Clinical outcomes were scored using the Numeric Rating Scale (NRS) and Harris Hip Score (HHS), radiological HO were scored using the Brooker classification. Follow-up was performed at 1 and 6 years postoperatively. RESULTS: Two hundred and fifty-eight patients (87%) completed the 6-year follow-up. HO formation occurred more in patients who underwent DLA, compared to PA (43(30%) vs. 21(18%), p = 0.024) after 6 years. However, the presence of severe HO (Brooker 3-4) was equal between the DLA and PA (7 vs. 5, p = 0.551). After 6 years the HHS and NRS for patient satisfaction were statistically significant higher after the PA (95.2 and 8.9, respectively) compared to the DLA (91.6 and 8.5, respectively) (p < 0.001 and p = 0.003, respectively). The NRS for load pain was statistically significant lower in the PA group (0.5) compared to the DLA group (1.2) (p = 0.004). The NRS for rest pain was equal: 0.3 in the PA group and 0.5 in the DLA group. CONCLUSION: THA with the PA causes less HO formation than the DLA. TRIAL REGISTRATION: Registrated as HipVit trial, NL 32832.100.10, R-10.17D/HIPVIT 1. Central Commission Human-Related research (CCMO) Registry.

The Value of SPECT/CT for Knee Osteoarthritis: A Systematic Review.

BACKGROUND: Single photon emission computed tomography (SPECT/CT) is a diagnostic option for knee osteoarthritis patients without osteoarthritic features on X-ray; however, the added value of SPECT/CT remains debatable in the diagnostic algorithm. OBJECTIVE: To review the added value of SPECT/CT in the diagnostic algorithm of knee osteoarthritis. STUDY DESIGN: Systematic review. METHODS: A systematic search was carried out in the databases EMBASE, MEDLINE, and the Cochrane collaboration. The retrieved articles were screened for relevance on title and abstract. This was followed by a full-text study quality appraisal of the remaining articles. Finally, a total of 9 trials were included. RESULTS: The use of SPECT/CT might objectify some clinical knee osteoarthritis symptoms. It could correlate with findings on plain radiography and magnetic resonance imaging. Furthermore, there is some evidence SPECT/CT gives additional information compared with these imaging modalities; however, superiority is not proven. The uptake on SPECT could predict the intraoperative macroscopic findings. Yet the clinical relevance remains unclear. CONCLUSION: There is no strong evidence SPECT/CT should play a role in the diagnosing and decision-making processes of knee osteoarthritis. Yet there is evidence suggesting SPECT/CT might give additional information in the diagnosing process. More research would be of added value to answer this research question.

Waiting list mortality and the potential of donation after circulatory death heart transplantations in the Netherlands.

BACKGROUND: With more patients qualifying for heart transplantation (HT) and fewer hearts being transplanted, it is vital to look for other options. To date, only organs from brain-dead donors have been used for HT in the Netherlands. We investigated waiting list mortality in all Dutch HT centres and the potential of donation after circulatory death (DCD) HT in the Netherlands. METHODS: Two different cohorts were evaluated. One cohort was defined as patients who were newly listed or were already on the waiting list for HT between January 2013 and December 2017. Follow-up continued until September 2018 and waiting list mortality was calculated. A second cohort of all DCD donors in the Netherlands (lung, liver, kidney and pancreas) between January 2013 and December 2017 was used to calculate the potential of DCD HT. RESULTS: Out of 395 patients on the waiting list for HT, 196 (50%) received transplants after a median waiting time of 2.6 years. In total, 15% died while on the waiting list before a suitable donor heart became available. We identified 1006 DCD donors. After applying exclusion criteria and an age limit of 50 years, 122 potential heart donors remained. This number increased to 220 when the age limit was extended to 57 years. CONCLUSION: Waiting list mortality in the Netherlands is high. HT using organs from DCD donors has great potential in the Netherlands and could lead to a reduction in waiting list mortality. Cardiac screening will eventually determine the true potential.

[A woman with a painful right knee]. / Een vrouw met persisterende kniepijn.

This case concerns a 62-year-old lady with persistent right knee pain. A conventional radiograph and additional MRI scan showed Hydroxyapatite crystal deposition disease (HADD) of the medial head of the gastrocnemius muscle. This was treated with a course of NSAIDs and functional weight-bearing mobilisation.

Osteochondral lesion depth on MRI can help predict the need for a sandwich procedure.

PURPOSE: Autologous subchondral bone grafting in combination with autologous chondrocyte implantation (ACI) (sandwich procedure) is a well-accepted procedure for the treatment of osteochondral lesions of the knee. This requires a different surgical technique and preoperative planning compared to ACI alone. In addition, pain from bone marrow donor site locations can be expected and should be part of patient consent and expectations. This study evaluates whether the MRI made as part of the standard preoperative cartilage patient work up has the diagnostic accuracy to predict the need for a sandwich procedure. METHODS AND MATERIALS: Retrospectively, 185 preoperative MRI scans (PD and T2 sequences) of patients planned for ACI were included. The integrity of the subchondral bone and lamina was scored by four different observers (3 radiologists, and 1 orthopaedic resident). The depth of the defect was measured perpendicular from articulating surface to the bottom of the bony lesion. The area under the curve (AUC) for subchondral defect on MRI (i.e. lamina or bone defect or expert impression), depth measurements and eventual sandwich procedure were calculated. Also inter-observer Kappa values were determined. RESULTS: The AUCs for lamina (0.74-0.80) and bone defect (0.73-0.79) were fair and inter-observer Kappas ranged from 0.49 to 0.76, indicating a moderate-good inter-observer agreement and moderate prediction of the need for a sandwich procedure based on the presence of lamina and or subchondral bone defect on MRI. However, depth measurements resulted in an AUC of 0.90 (95% CI: 0.84-0.95,) with an optimal cut-off point at 6.5mm depth of the lesion (90% sensitivity, 80% specificity) to predict the need for a sandwich procedure. CONCLUSION: Ours is the first study examining MRI as a diagnostic tool in predicting the need for a sandwich procedure. Our results show that the integrity of the subchondral layer on MRI has a moderate role in predicting the need for an eventual autologous bone graft to augment ACI whereas in our cohort a depth of the lesion above 6.5mm accurately predicts the need for a sandwich procedure. This can aid in optimising the preoperative planning and patient consent.

A Multicenter Study on Long-Term Outcomes After Lung Transplantation Comparing Donation After Circulatory Death and Donation After Brain Death.

The implementation of donation after circulatory death category 3 (DCD3) was one of the attempts to reduce the gap between supply and demand of donor lungs. In the Netherlands, the total number of potential lung donors was greatly increased by the availability of DCD3 lungs in addition to the initial standard use of donation after brain death (DBD) lungs. From the three lung transplant centers in the Netherlands, 130 DCD3 recipients were one-to-one nearest neighbor propensity score matched with 130 DBD recipients. The primary end points were primary graft dysfunction (PGD), posttransplant lung function, freedom from chronic lung allograft dysfunction (CLAD), and overall survival. PGD did not differ between the groups. Posttransplant lung function was comparable after bilateral lung transplantation, but seemed worse after DCD3 single lung transplantation. The incidence of CLAD (p = 0.17) nor the freedom from CLAD (p = 0.36) nor the overall survival (p = 0.40) were significantly different between both groups. The presented multicenter results are derived from a national context where one third of the lung transplantations are performed with DCD3 lungs. We conclude that the long-term outcome after lung transplantation with DCD3 donors is similar to that of DBD donors and that DCD3 donation can substantially enlarge the donor pool.

The value of arterial pressure waveform cardiac output measurements in the radial and femoral artery in major cardiac surgery patients.

BACKGROUND: A relatively new uncalibrated arterial pressure waveform cardiac output (CO) measurement technique is the Pulsioflex-ProAQT® system. Aim of this study was to validate this system in cardiac surgery patients with a specific focus on the evaluation of a difference in the radial versus the femoral arterial access, the value of the auto-calibration modus and the ability to show fluid-induced changes. METHODS: In twenty-five patients scheduled for ascending aorta, aortic arch replacement, or both we measured CO simultaneously by transpulmonary thermodilution (COtd) and by using the ProAQT® system connected to the radial (COpR), as well as the femoral artery catheter (COpF). Hemodynamic data were assessed at predefined time points; from incision until 16 h after ICU admission. RESULTS: In total 175 (radial) and 179 (femoral) pairs of CO measurement were collected. The accuracy of COpR/COpF was evaluated showing a mean bias of -0.31 L/min (±2.9 L/min) and -0.57 L/min (± 2.8 L/min) with percentage errors of 49 and 46% respectively. Trending ability of the ProAQT® device was evaluated; the four quadrant concordance rates in the radial and femoral artery were 74 and 75% and improved to 77 and 85% after auto-calibration. The mean angular biases in the radial and femoral artery were 6.4° and 6.0° and improved to 5° and 3.3° after auto-calibration. The polar concordance rates in the radial and femoral artery were 65 and 70% and improved to 76 and 84% after auto-calibration. Considering the fluid-induced changes in stroke volume(SV), the coefficient of correlation between the changes in SVtd and SVp was 0.57 (p < 0.01) in the radial artery and 0.60 (p < 0.01) in the femoral artery. CONCLUSIONS: The ProAQT® system can be of additional value if the clinician wants to determine fluid responsiveness in cardiac surgery patients. However, the ProAQT® system provided inaccurate CO measurements compared to transpulmonary thermodilution. The trending ability was poor for COpR but moderate for COpF. Auto-calibration of the system did not improve accuracy of CO measurements nor did it improve the prediction of fluid responsiveness. However, the trending ability was improved by auto-calibration, possibly by correcting a drift over a longer time period.

The fixation of a collagen type I/III membrane in the distal radioulnar joint of a human cadaver model.

Damage to the cartilage of the distal radioulnar joint frequently leads to pain and limitation of movement, therefore repair of this joint cartilage would be highly desirable. The purpose of this study was to investigate the fixation of scaffold in cartilage defects of this joint as part of matrix-assisted regenerative autologous cartilage techniques. Two techniques of fixation of collagen scaffolds, one involving fibrin glue alone and one with fibrin glue and sutures, were compared in artificially created cartilage defects of the distal radioulnar joint in a human cadaver. After being subjected to continuous passive rotation, the methods of fixation were evaluated for cover of the defect and pull out force. No statistically significant differences were found between the two techniques for either cover of the defect or integrity of the scaffold. However, a significantly increased mean pull out force was found for the combined procedure, 0.665 N (0.150 to 1.160) versus 0.242 N (0.060 to 0.730) for glue fixation (p = 0.001). This suggests that although successful fixation of a collagen type I/III scaffold in a distal radioulnar joint cartilage defect is feasible with both forms of fixation, fixation with glue and sutures is preferable.

A validated new histological classification for intervertebral disc degeneration.

UNLABELLED: Histology is an important outcome variable in basic science and pre-clinical studies regarding intervertebral disc degeneration (IVD). Nevertheless, an adequately validated histological classification for IVD degeneration is still lacking and the existing classifications are difficult to use for inexperienced observers. OBJECTIVE: Therefore the aim of this study was to develop and to validate a new histological classification for IVD degeneration. Moreover, the new classification was compared to the frequently used non-validated classification. METHODS: The new classification was applied to human IVD sections. The sections were scored twice by two independent inexperienced observers, twice by two experienced IVD researchers and once by a pathologist. For comparison, the sections were also scored according to the classification described by Boos et al. by two experienced IVD researchers. Macroscopic grading according Thompson et al., glycosaminoglycan (GAG) content and age were used for validation. RESULTS: The new classification had an excellent intra- and a good inter-observer reliability. Intraclass Correlation Coefficients (ICC) were 0.83 and 0.74, respectively. Intra- and inter-observer reliability were comparable for experienced and inexperienced observers. Statistically significant correlations were found between the new classification, macroscopic score, GAG content in the nucleus pulposus (NP) and age; Correlation coefficient (CC) 0.79, -0.62 and 0.68, respectively. The CCs of the Boos classification were all lower compared to the new classification. CONCLUSION: the new histological classification for IVD degeneration is a valid instrument for evaluating IVD degeneration in human IVD sections and is suitable for inexperienced and experienced researchers.

One-stage focal cartilage defect treatment with bone marrow mononuclear cells and chondrocytes leads to better macroscopic cartilage regeneration compared to microfracture in goats.

OBJECTIVE: The combination of chondrocytes and mononuclear fraction (MNF) cells might solve the expansion induced dedifferentiation problem of reimplanted cells in autologous chondrocytes implantation as sufficient cells would be available for direct, one-stage, implantation. Earlier in vitro work already showed a positive stimulation of cartilage specific matrix production when chondrocytes and MNF cells were combined. Therefore, this study aimed to evaluate cartilage regeneration using a one-stage procedure combining MNF cells and primary chondrocytes for the treatment of focal cartilage lesions in goats compared to microfracture treatment. DESIGN: Freshly created focal cartilage defects were treated with either a combination of chondrocytes and MNF cells embedded in fibrin glue or microfracture treatment. After 6 months follow-up local regeneration as well as the general joint cartilage health were evaluated using validated scores and biochemical assays. RESULTS: Macroscopic (P = 0.015) scores for the cartilage surface at the treated defect were, after 6 months, significantly higher for the chondrocyteMNF treatment compared to microfracture-treated defects, but microscopic scores were not (P = 0.067). The articulating cartilage showed more (P = 0.005) degeneration following microfracture treatment compared to chondrocyteMNF treatment. Biochemical glycosaminoglycans (GAG) evaluation did not reveal differences between the treatments. Both treatments had resulted in a slight to moderate cartilage degeneration at other locations in the joint. CONCLUSION: In conclusion, treatment of focal articular cartilage lesions in goats using a combination of MNF cells from bone marrow and unexpanded chondrocytes leads to better macroscopic regeneration compared to microfracture, however needs further fine-tuning to decrease the negative influence on other joint compartments.

Delayed gadolinium enhanced MRI of cartilage (dGEMRIC) can be effectively applied for longitudinal cohort evaluation of articular cartilage regeneration.

OBJECTIVE: Delayed gadolinium enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC) facilitates non-invasive evaluation of the glycosaminoglycan content in articular cartilage. The primary aim of this study was to show that the dGEMRIC technique is able to monitor cartilage repair following regenerative cartilage treatment. DESIGN: Thirty-one patients with a focal cartilage lesion underwent a dGEMRIC scan prior to cartilage repair surgery and at 3 and 12 months follow-up. At similar time points clinical improvement was monitored using the Knee injury and Osteoarthritis Outcome Score (KOOS) and Lysholm questionnaires. Per MRI scan several regions-of-interest (ROIs) were defined for different locations in the joint. The dGEMRIC index (T1gd) was calculated for each ROI. Repeated-measures analysis of variance (RMANOVA) analysis was used to evaluate improvement in clinical scores and MRI T1gd over time. Also regression analysis was performed to show the influence of local repair on cartilage quality at distant locations in the knee. RESULTS: Clinical scores and the dGEMRIC T1gd per ROI showed a statistically significant improvement (P < 0.01), from baseline, at 12 months follow-up. Also, improvement from baseline in T1gd of the ROI defining the treated cartilage defect showed a direct relationship (P < 0.007) to the improvement of the T1gd of ROI at other locations in the joint. CONCLUSIONS: The dGEMRIC MRI protocol is a useful method to evaluate cartilage repair. In addition, local cartilage repair influenced the cartilage quality at other location in the joint. These findings validate the use of dGEMRIC for non-invasive evaluation of the effects of cartilage regeneration.

Cartilage Repair in Football (Soccer) Athletes: What Evidence Leads to Which Treatment? A Critical Review of the Literature.

The prevalence of focal articular cartilage lesions among athletes is higher than in the general population. Treatment goals differ considerably between the professional and recreational athlete. High financial stakes and the short duration of a professional career influence the treatment selection for the professional athlete, while such parameters weigh differently in recreational sports. This article describes our investigation of the relation between sports and a high prevalence of focal cartilage lesions. In addition, we provide a critical review of the best available evidence for cartilage surgery and treatment selection, evaluate specific patient profiles for professional and recreational athletes, and propose a treatment algorithm for the treatment of focal cartilage lesions in football (soccer) players.

Aortic root reoperations after pulmonary autograft implantation.

OBJECTIVE: To report the results of aortic root reoperations after pulmonary autograft implantation. METHODS: All consecutive patients in our prospective Ross research database were selected for analysis, and additional information for patients requiring reoperation was obtained from the hospital records. RESULTS: From 1988 to 2009, 155 pulmonary autograft operations were performed. During this period, 41 patients required reoperation for aortic root dilatation and/or autograft valve insufficiency, in 8 patients combined with pulmonary allograft dysfunction. The freedom from autograft reoperation rate was 86% (standard error, 3.3%) after 10 years and 52% (standard error, 6.6%) after 15 years. The median interval to reoperation was 15.3 years. During reoperation, 39 patients underwent aortic root replacement (mechanical conduit, 31; stentless root, 2; allograft, 3; and valve sparing, 3), and 2 patients underwent valve replacement. In 8 patients this was combined with pulmonary allograft replacement. The technical difficulties encountered included bleeding at the sternal re-entry in 5 patients. No 30-day mortality occurred. The postoperative complications included reexploration for persistent blood loss in 3 patients and cerebrovascular accident in 3 patients. Two patients died during the follow-up period. The survival rate after reoperation was 94% (standard error, 4.1%) at 5 years. CONCLUSIONS: An increasing number of patients requires reoperation after pulmonary autograft implantation. These reoperations can be done with very low mortality and morbidity and excellent follow-up results.

Quality of scaffold fixation in a human cadaver knee model.

OBJECTIVE: Newly developed regenerative cartilage interventions based on the application of 3D-scaffolds require a further evaluation of the surgical techniques involved. The present study compared four different scaffold fixation techniques [fibrin glue (FG), transosseous (TS) fixation, biodegradable pin (BP) fixation and continuous cartilage sutures (CS)] to implant a custom-printed porous PEOT/PBT1000/70/30 scaffold in a human cadaver knee model. METHODS: After implantation, the knees were subjected to a vertically oriented loaded continuous passive motion (CPM) protocol. The fixation techniques were evaluated after 60 and a subsequent 150 motion cycles, focusing on area coverage, outline attachment and scaffold integrity. After the total of 210 cycles, also an endpoint fixation test was performed. RESULTS: The fixation techniques revealed marginal differences for area coverage and outline attachment after 60 and 150 cycles. The FG scored higher on scaffold integrity compared to TS (P<0.05) and CS (P=0.01). Endpoint fixation was highest for the CS, whereas FG showed a weak final fixation strength (P=0.01). CONCLUSIONS: This study showed that optimal fixation cannot be combined always with high scaffold integrity. Special attention devoted to scaffold properties in relation to the fixation technique may result in an improvement of scaffold fixation, and thus clinical cartilage regenerative approaches involving these scaffolds.

Diagnostic Modalities for Diseased Articular Cartilage-From Defect to Degeneration: A Review.

The progression of cartilage matrix damage to generalized degeneration is associated with specific pathophysiological and clinical aspects. Reliable detection of stage-related characteristics of cartilage disease serves both a therapeutic and prognostic goal. Over the past years, several (pre)clinical diagnostic modalities for cartilage pathologies have been advocated. Each modality focuses on different aspects of the disease. Early diagnosis, before irreversible damage has occurred, opens up the possibility for better treatment and improves the patients' prognosis. This article gives an overview of the diagnostic modalities available for monitoring cartilage pathology and focuses on reliability, clinical value, current status, and possible applications.