Lesions of the Long Head of the Biceps Tendon Concomitant with Rotator Cuff Tears: Tenotomy or Subpectoral Mini-open Tenodesis? A Comparative Short to Mid-term Follow-up Study.

OBJECTIVE: To compare the clinical and radiological outcomes of patients who underwent rotator cuff repair (RCR) concomitant with long head of the biceps tendon (LHBT) tenotomy or subpectoral mini-open tenodesis. METHODS: Prospectively collected data was reviewed on 154 patients, who underwent a LHBT procedure (tenotomy or tenodesis) concomitant with RCR between January 2010 and January 2017. The exclusion criteria were irreparable massive rotator cuff tear, rotator cuff partial tear, subscapular tendon tear, glenohumeral arthritis, and prior shoulder surgery. The two patient groups are as follows: RCR + Tenotomy (Group A) and RCR + Subpectoral mini-open tenodesis (Group B). The visual analog scale (VAS) for pain, Constant Score scale, American Shoulder and Elbow Surgeons (ASES) scores, and the Disabilities of the Arm, Shoulder and Hand (DASH) scores preoperatively and 1 month, 3 months, 6 months, 1 year postoperatively and the latest out-patient clinic were compared between the two groups. RESULTS: Ninety-two patients in Group A and 62 patients in Group B completed the follow-up, with a median follow-up time of 27 and 42 months respectively. At the final follow-up, the VAS, Constant, ASES, and DASH scores in Group A were 0.1 ± 0.2, 87.0 ± 12.8, 96.4 ± 4.3 and 6.6 ± 4.8 respectively, and the VAS, Constant, ASES, and DASH scores in Group B were 0.1 ± 0.3, 92.5 ± 3.9, 96.3 ± 3.6 and 2.9 ± 1.3 respectively. Clinical evaluation scales showed satisfactory results in both groups, and there were no statistically significant differences between the two groups at the same follow-up time. Popeye sign was detected in one case of Group A (1.1%) and in one case of Group B (1.6%, P > 0.05). CONCLUSION: Both tenotomy and subpectoral mini-open tenodesis are effective for concomitant lesions of the LHBT in patients with reparable rotator cuff tears, and subpectoral mini-open tenodesis of the LHBT does not provide any significant clinical or functional improvement than isolated tenotomy.

[Tenotomy fixed on distal trochlea under arthroscopy for long head of biceps tendon and rotator cuff tear].

OBJECTIVE: To explore operative technique and clinical efficacy of tenotomy fixed on distal trochlea under arthroscopy for long head of biceps tendon and rotator cuff tear. METHODS: From June 2015 to November 2016, 23 patients with long head of biceps tendon and rotator cuff tear were treated with tenotomy fixed on distal trochlea under arthroscopy and rotator cuff repair. Among them, including 9 males and 14 females aged from 44 to 71 years old with an average of(56.38±5.74) years old, 3 patients on left shoulder injury, and the other 20 patients on right shoulder injury. Constant-Murley shoulder score, VAS score and improvement of shoulder ROM were assessed before operation, 3 months, 6 months and 12 months after operation. RESULTS: All patients were followed up from 12 to 18 months with an average of (15.37±4.82) months. Ipsilateral shoulder had no obvious pain, and ROM and muscle power almost returned to the level of patients' uninjured shoulder. Postoperative Constant-Murley score at 3 months was 67.47±12.19, 74.82±13.26 at 6 months after operation and 93.47±10.19 at 12 months after operation, which were better than that of 39.62±12.39 before operation. According to Constant-Murley score, 18 patients got excellent results, 4 good and 1 poor. There was statistical significance in VAS score before operation 6.85±2.14 and 0.36±0.54 at 12 months after operation. Anteflexion of shoulder joint and abduction at 12 months after operation were (163.55±15.24)°, (164.37±14.46)°, and improved more than before operation (75.52±6.31)°, (84.36±13.36)°. CONCLUSIONS: Clinical effects of tenotomy fixed on distal trochlea under arthroscopy for long head of biceps tendon and rotator cuff tear were satisfied, solving pains of shoulder joint, recovering shoulder joint functions without damaging appearance and muscle strength of musculus biceps brachii.

Case report: A 10 years follow-up of periprosthetic femoral fracture after total hip arthroplasty in osteopetrosis.

Osteopetrosis is an inherited disorder characterized by increased bone density and brittle bone quality. Degenerative changes often occur after the age of 40 in patients with osteopetrosis. Operative intervention is the primary treatment option if the clinical manifestation of secondary osteoarthritis is severe. A 44-year-old male suffering autosomal dominant osteopetrosis and progressive unilateral hip osteoarthritis required a total hip arthroplasty. However, there were several technical challenges associated with this procedure including creating a femoral medullary canal and developing a Vancouver type B2 periprosthetic femoral fracture postoperatively. To afford some experience for the management of similar cases, we here present our technical solutions to these problems.

Physical regulation of stem cells differentiation into teno-lineage: current strategies and future direction.

Tendon injuries are commonly encountered in the clinic, disrupting the patient's normal work/life routine and damaging the career life of athletes. Currently, there is still no effective treatment for tendon injury. Tendon tissue engineering appears to be a promising route for tendon repair and regeneration. However, current strategies utilized in research are still far away from clinical applications due to unsuccessful cellular differentiation to tendon/tenocytes. In this review, we focus on the current physical strategies (mechanical stimulation and extracellular matrix topography) and evaluate their roles in precise and stepwise tendon differentiation. A systematic comprehension of normal tendon development process by structure, gene profile and physical microenvironment analysis is likely suggestive for stepwise tenocyte differentiation.

[Medium-term follow-up outcomes of total hip arthroplasty for patients with ankylosing spondylitis].

OBJECTIVE: To retrospectively study medium-term follow-up outcomes of total hip arthroplasty (THA) for patients with ankylosing spondylitis (AS). METHODS: From January 2000 to December 2008, 67 patients (88 hip joints) with AS were treated with all ceramic interface THA. And 55 patients (74 hips) were finally followed up. Among them, there were 30 males and 25 females, with an average age of 32.6 (ranged 19 to 58) years old. Sixty-one hips were treated with biological prosthesis and 13 hips were treated with hybrid prosthesis. Fifty-five patients were followed up at least 5 years, with an average of (75.2 +/- 8.6) months. Clinical symptoms and radiography information were evaluated after follow-up. RESULTS: Harris hip score were significantly improved from 30.8 +/- 7.0 preoperatively to 85.2 +/- 5.5 at the last follow-up (P<0.01). The hip movement range increased from (21.2 +/- 8.5) degrees preoperatively to (142.0 +/- 10.2) degrees postoperatively (P<0.01). The 5-year survival of prosthesis was 95.9%. One patient were renovated because of internal wall broken caused by injury, 1 was renovated for infection, 1 was renovated for fracture arround femoral stem prostheses, and 1 was treated with conservative treatment by dislocation. Three cases with abnormal sound were cured with non-operation. 7 cases with heterotopic ossification were not treated, 2 cases with thigh pain received conservative treatment. Bone dissolve around prosthesis, loose and sink of femur and acetabulum prosthesis were occurred in other cases. CONCLUSION: THA for the treatment of AS is a reliable method, which has a satisfied medium-term follow-up outcomes.

Reconstruction of segmental bone defects in the rabbit ulna using periosteum encapsulated mesenchymal stem cells-loaded poly (lactic-co-glycolic acid) scaffolds.

BACKGROUND: Repair of large bone defects remains a challenge for clinicians. The present study investigated the ability of mesenchymal stem cells (MSCs) and/or periosteum-loaded poly (lactic-co-glycolic acid) (PLGA) to promote new bone formation within rabbit ulnar segmental bone defects. METHODS: Rabbit bone marrow-derived MSCs (passage 3) were seeded onto porous PLGA scaffolds. Forty segmental bone defects, each 15 mm in length, were created in the rabbit ulna, from which periosteum was obtained. Bone defects were treated with either PLGA alone (group A), PLGA + MSCs (group B), periosteum-wrapped PLGA (group C) or periosteum-wrapped PLGA/MSCs (group D). At 6 and 12 weeks post-surgery, samples were detected by gross observation, radiological examination (X-ray and micro-CT) and histological analyses. RESULTS: Group D, comprising both periosteum and MSCs, showed better bone quality, higher X-ray scores and a greater amount of bone volume compared with the other three groups at each time point (P < 0.05). No significant differences in radiological scores and amount of bone volume were found between groups B and C (P > 0.05), both of which were significantly higher than group A (P < 0.05). CONCLUSIONS: Implanted MSCs combined with periosteum have a synergistic effect on segmental bone regeneration and that periosteum plays a critical role in the process. Fabrication of angiogenic and osteogenic cellular constructs or tissue-engineered periosteum will have broad applications in bone tissue engineering.

Matrix-induced autologous chondrocyte implantation addressing focal chondral defect in adolescent knee.

BACKGROUND: Matrix-induced autologous chondrocyte implantation (MACI) is the third generation tissue-engineering technique for the treatment of full-thickness articular cartilage defects. The aim of this study was to describe this new technique and the postoperative findings in adolescent knee with focal chondral defect. METHODS: The MACI consists of diagnostic arthroscopy and cartilage harvest, chondrocyte culture and seeding in tissue-engineering collagenous membrane, and implantation of the scaffold. Clinical outcome at minimum 1-year follow-up was assessed in seven patients (mean age (16.6 ± 1.5) years; 14 - 19 years) with full-thickness cartilage defects, with International Knee Documentation Committee (IKDC) score, the International Cartilage Repair Society (ICRS) score and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Besides, MR imaging was performed with T1 and T2-weighted imaging and three-dimensional spoiled gradient-recalled (3D-SPGR) MR imaging. RESULTS: Clinical evaluation showed significant improvement and MRI analysis showed that the structure was homogeneous and the implant surface was regular and intact in six patients, but irregular in one. Of all the seven patients, the cartilage defect site was nearly totally covered by the implanted scaffold. CONCLUSIONS: These results indicated that MACI technique is an option for cartilage defect in adolescent knee joint, especially large defect of over 2 cm(2). Long-term assessment is necessary to determine the true value of this technique.

Anatomic double-bundle anterior cruciate ligament reconstruction.

OBJECTIVE: To retrospectively evaluate the early results of anatomic double-bundle anterior cruciate ligament (ACL) reconstruction and compare with the results of native ACL of the contralateral knee. METHODS: The results of a consecutive series of 118 patients receiving arthroscopic ACL reconstruction were evaluated. Eight patients were lost to the latest follow-up, leaving a total of 110 patients available for study within at least 3 years'clinical follow-up. Among them, 63 patients underwent postoperative MRI and CT scan, as well as clinical evaluation. RESULTS: After reconstruction, the knees were stable and pain-free. Mean postoperative Lysholm score was 95.54 in 110 patients after 3 years. CT and MRI assessment showed that the reconstruction centered in the femoral footprint of ACL (n equal to 63). The sagittal ACL angle in the reconstructed ACL (52.16 degree+/-2.45 degree was much close to that in the contralateral intact ACL (51.31 degree +/-2.18 degree, P larger than 0.05). By ACL-Blumensaat line angle analysis, there was no difference between double-bundle reconstructed knees and their contralateral normal knees (4.67 degree+/-0.43 degree vs. 4.62 degree+/-0.60degree, P larger than 0.05). CONCLUSION: Anatomic double-bundle ACL reconstruction can place grafts more precisely in the anatomic footprint of the ACL and better restore knee kinematics.

[Intermediate outcomes of alumina-on-alumina bearing total hip arthroplasty].

OBJECTIVE: To explore the intermediate outcomes of third-generation alumina-on-alumina total hip arthroplasty (THA). METHODS: A consecutive series of 165 primary alumina-on-alumina total hip arthroplasties were performed in 135 patients. Three patients died and 13 patients lost follow-up so that a total of 119 patients (146 hips) were available for study. The mean patient age was 53.4 ± 11.0 years old (range: 26 - 79). Hydroxyapatite. (HA)-coated press-fit acetabular cups were used in all cases. At femoral side, 123 cases were implanted with HA-coated uncemented stems and 23 cases implanted with high polished double taped cemented stems. All patients were evaluated clinically and radiographically after a minimal follow-up duration of 60 months. RESULTS: The preoperative mean Harris hip score of 49.6 ± 7.9 points improved to 91.7 ± 3.0 points at the last follow-up (P < 0.05). The 5-year survival for any reason lead to revision was 96.6%. Five hips were under revision, 1 for acetabular shell loosening and migration, 1 for Vancouver B2 periprosthetic fracture, 1 for fracture of pure alumina liner and 2 for infections. All other prostheses demonstrated no radiographic evidence of loosening. No periprosthetic osteolysis was found. There were 2 cases of dislocations and 2 patients presented postoperatively with "squeaking-like" hips. CONCLUSION: The clinical and radiographic outcomes after primary THA with third-generation ceramic-on-ceramic bearing surfaces are favorable after a minimal follow-up duration of 5 years. The modified alumina-on-alumina bearing implants offer a better option for younger and active patients.

Combined use of extensively porous coated femoral components with onlay cortical strut allografts in revision of Vancouver B2 and B3 periprosthetic femoral fractures.

BACKGROUND: Periprosthetic femoral fractures following total hip arthroplasty are getting more prevalent. The aim of this study was to evaluate the clinical results of combined use of uncemented extensively porous coated femoral components with onlay cortical strut allografts in revision of Vancouver type B2 and B3 periprosthetic femoral fractures. METHODS: Thirteen hips after total hip arthroplasty in 13 patients who suffered a Vancouver B2 or B3 periprosthetic fracture were treated with an uncemented extensively porous coated femoral component combined with onlay cortical strut allografts. Each patient was assigned a Harris hip score, and a visual analog scale (VAS) score for pain and satisfaction. Radiographs were examined for component stability, fracture site and allograft-host union and allograft reconstruction. RESULTS: At an average of 5.3-year follow-up, no patient required repeat revision. The average Harris hip score was (71.8 +/- 6.3) points, the pain VAS score was (16.6 +/- 4.3) points, and the patient satisfaction VAS score was (81.5 +/- 5.7) points. Radiographic examination showed no detectable loosening of the prostheses, and 12 cases were presented fixation by osseointegration and the other one was stable fibrous ingrown fixation. All fractures united for (5.2 +/- 1.4) months in average. And all onlay strut allografts united to host bone for about (11.5 +/- 2.6) months. CONCLUSIONS: Combined use of uncemented, long stemmed, extensively porous coated implant with cortical onlay strut allografts can achieve good clinic results and high rate of union for both fracture site and allograft-host bone junction. This technique could be used routinely to augment fixation and healing of Vancouver B2 and B3 periprosthetic fractures.

Use of mid-vastus approach in less invasive primary total knee arthroplasty.

BACKGROUND: Total knee arthroplasties (TKR) combined with the concept of reduced trauma to tissue has been performed by many doctors. The aim of this study was to retrospectively assess the early results of a group of TKR with a mid-vastus approach, which was characterized as no patellar eversion, no disruption of suprapatellar pouch and extensor mechanism, and to compare the outcome with conventional operative techniques. METHODS: A total of 59 patients (67 knees) were followed. All patients received the same prosthesis of Genesis II posterior-stabilized total knees. Of them, 29 consecutive patients (34 knees) had a mid-vastus approach and were operated on with less invasive instruments and techniques. The mean follow-up duration was 11.6 months. Clinical evaluations were performed according to the Hospital for Special Surgery scores; radiographic assessment followed the guidelines of the Knee Society. Postoperative recovery of quadriceps strength and the extensor mechanism was also evaluated. RESULTS: No prosthetic loosening or anterior knee pain was found at the latest follow-up; 1 patient had a superficial infection and postoperative stiffness of the knee who undertook a debridement and manipulation several months later. The angulations of tibial osteotomy were within normal range. The average preoperative and postoperative Hospital for Special Surgery scores were 57.9 points and 86.1 points respectively. The mean postoperative range of motion was 113.5 degrees . Most patients regained their quadriceps strength at the third or fourth month postoperatively. CONCLUSIONS: The overall early results from using the mid-vastus approach were comparable with that of using a standard approach, and the exposure did not affect the accuracy of the tibial cut. The muscle maximal contraction strength recovered gradually after operation. The approach was safe and patients of this group obtained satisfactory outcomes.

Effect of delayed pulsed-wave ultrasound on local pharmacokinetics and pharmacodynamics of vancomycin-loaded acrylic bone cement in vivo.

This study sought to investigate the effect of delayed pulsed-wave ultrasound with low frequency on drug release from and the antimicrobial efficacy of vancomycin-loaded acrylic bone cement in vivo and the possible mechanism of this effect. After the implantation of cement and the inoculation of Staphylococcus aureus into the bilateral hips of rabbits, ultrasound (average intensity, 300 mW/cm(2); frequency, 46.5 kHz; on/off ratio, 20 min/10 min) was applied to animals in the normal ultrasound group (UG(0-12)) from 0 through 12 h after surgery and to those in the delayed-ultrasound group (UG(12-24)) from 12 through 24 h after surgery. The control group (CG) was not exposed to ultrasound. Based on vancomycin concentrations in left hip cavities at projected time intervals, the amount of time during which the local drug concentration exceeded the MIC (T(>MIC)) in UG(12-24) was significantly prolonged compared with that in either CG or UG(0-12), and the ratios between the areas under the concentration-time curves over 24 h and the MIC for UG(0-12) and UG(12-24) were both increased compared with that for CG. The greatest reductions in bacterial densities in both right hip aspirates and right femoral tissues at 48 h were achieved with UG(12-24). Local hemorrhage in rabbits of UG(0-12) during the 12-h insonation was more severe than that in rabbits of UG(12-24). Of four variables, the T(>MIC) and the bioacoustic effect were both identified as parameters predictive of the enhancement of the antimicrobial efficacy of cement by ultrasound. Sustained concentrations above the MIC replaced early high maximum concentrations and long-term subtherapeutic release of the drug, provided that ultrasound was not applied until local hemorrhage was relieved. The enhancement of the antimicrobial efficacy of cement by ultrasound may be attributed to the prolonged T(>MIC) and the bioacoustic effect caused by ultrasound.

Position of the prosthesis and the incidence of dislocation following total hip replacement.

BACKGROUND: Dislocation is the second most common complication of hip replacement surgery, and impact of the prosthesis is believed to be the fundamental reason. The present study employed Solidworks 2003 and MSC-Nastran software to analyze the three dimensional variables in order to investigate how to prevent dislocation following hip replacement surgery. METHODS: Computed tomography (CT) imaging was used to collect femoral outline data and Solidworks 2003 software was used to construct the cup model with variabilities. Nastran software was used to evaluate dislocation at different prosthesis positions and different geometrical shapes. Three dimensional movement and results from finite element method were analyzed and the values of dislocation resistance index (DRI), range of motion to impingement (ROM-I), range of motion to dislocation (ROM-D) and peak resisting moment (PRM) were determined. Computer simulation was used to evaluate the range of motion of the hip joint at different prosthesis positions. RESULTS: Finite element analysis showed: (1) Increasing the ratio of head/neck increased the ROM-I values and moderately increased ROM-D and PRM values. Increasing the head size significantly increased PRM and to some extent ROM-I and ROM-D values, which suggested that there would be a greater likelihood of dislocation. (2) Increasing the anteversion angle increased the ROM-I, ROM-D, PRM, energy required for dislocation (ENERGY-D) and DRI values, which would increase the stability of the joint. (3) As the chamber angle was increased, ROM-I, ROM-D, PRM, Energy-D and DRI values were increased, resulting in improved joint stability. Chamber angles exceeding 55 degrees resulted in increases in ROM-I and ROM-D values, but decreases in PRM, Energy-D, and DRI values, which, in turn, increased the likelihood of dislocation. (4) The cup, which was reduced posteriorly, reduced ROM-I values (2.1 -- 5.3 degrees ) and increased the DRI value (0.073). This suggested that the posterior high side had the effect of 10 degrees anteversion angle. CONCLUSIONS: Increasing the head/neck ratio increases joint stability. Posterior high side reduced the range of motion of the joint but increased joint stability; Increasing the anteversion angle increases DRI values and thus improve joint stability; Increasing the chamber angle increases DRI values and improves joint stability. However, at angles exceeding 55 degrees , further increases in the chamber angle result in decreased DRI values and reduce the stability of the joint.

Femoral component revision using extensively porous-coated cementless stem.

OBJECTIVE: To evaluate the clinical and radiographic results of extensively porous-coated femoral stem in revision of total hip arthroplasty (THA). METHODS: From January 1999 to December 2003, fifteen hips of fifteen cases received revision of THA with extensively porous-coated femoral stem. There were six males and nine females. The average age was 66 years (ranging 58-82 years). The reason for the revision was aseptic loosening in 10 cases, septic loosening in 2, femoral shaft fracture around loose implant in 2, and femoral revision for malposition of the femoral component in 1. All the patients were clinically evaluated using Harris hip score and radiographically evaluated both preoperatively and postoperatively at regular follow-up intervals. RESULTS: No patients were lost for follow-up. The average length of follow-up was 2.3 years (range, 1-5 years). The average preoperative Harris hip score was 42 points, which was improved to 89 points at latest follow-up. The latest follow-up showed that bone in-growth occurred in fourteen stems and solid fibrous fixation in one. Complications consisted of femoral shaft fracture in two cases (1 undisplaced distal femur fracture and 1 cortical perforation at the tip of the prosthesis), and postoperative dislocation in one. There was no mechanical failure of the stem in this study. CONCLUSIONS: Satisfactory results of short-term clinical and radiographic follow-up have been achieved in using extensively porous-coated femoral stem for revision of THA. It should be noticed that the straight, 203 mm stem should be used with caution in short people.

Total hip arthroplasty with cementless cups and femoral head autografts for patients with hip dysplasia and osteoarthritis.

OBJECTIVE: To evaluate the outcome of total hip arthroplasty (THA) with cementless cups and femoral head autografts for patients with hip dysplasia and osteoarthritis. METHODS: Between 1995 and 2002, we implanted 23 cementless cups and femoral head autografts in 20 patients with hip dysplasia and osteoarthritis. In this study, a retrospective study was made on 21 hips in 20 patients (18 females and 2 males, aged 50 years on an average) with developmental hip dysplasia treated by THA with a cementless cup and femoral head autograft. The acetabular cup was placed at the level of the true acetabulum and all the patients required autogenous femoral head grafts due to acetabular deficiency. The average rate of the acetabular cup covered by the femoral head autograft was 31% (ranging from 10% to 45%). Eight hips had less than 25% cup coverage and thirteen between 25% and 50%. The average follow-up period was 4.7 years (range, 1-8 years). The replacing outcome was evaluated by modified Harris hip score. Preoperative and follow-up radiographs were made. RESULTS: All the autografts were united to the host bones. No autograft was collapsed or no component from the hip was loosed in all the patients. According to the modified Harris hip score, the average hip score increased from 46 before operation to 89 at the final review. Before operation, the leg-length discrepancy was greater than 2 cm in all the patients except one with bilateral hip dysplasia. After operation, only 2 out of 20 patients had a leg-length discrepancy greater than 1 cm. Three hips showed minor bone resorption in the lateral portion of the graft, which did not support the cup. Three hips developed Grade 1 Brooker heterotopic ossification and one developed Grade 2. CONCLUSIONS: THA with a cementless cup and a femoral head autograft for patients with osteoarthritis resulted from hip dysplasia can result in favorable outcomes. This method can provide reliable acetabular fixation and restore the acetabular bone stock in patients with developmental hip dysplasia when the cementless cup covered by the graft does not exceed 50%.