Using the patient's perspective to develop function short forms specific to total hip and knee replacement based on WOMAC function items.

Although the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index was originally developed for the assessment of non-operative treatment, it is commonly used to evaluate patients undergoing either total hip (THR) or total knee replacement (TKR). We assessed the importance of the 17 WOMAC function items from the perspective of 1198 patients who underwent either THR (n = 704) or TKR (n = 494) in order to develop joint-specific short forms. After these patients were administered the WOMAC pre-operatively and at three, six, 12 and 24 months' follow-up, they were asked to nominate an item of the function scale that was most important to them. The items chosen were significantly different between patients undergoing THR and those undergoing TKR (p < 0.001), and there was a shift in the priorities after surgery in both groups. Setting a threshold for prioritised items of ≥ 5% across all follow-up, eight items were selected for THR and seven for TKR, of which six items were common to both. The items comprising specific WOMAC-THR and TKR function short forms were found to be equally responsive compared with the original WOMAC function form.

Migration pattern, morphology and viability of cells suspended in or sealed with fibrin glue: a histomorphologic study.

INTRODUCTION: We studied the migration pattern, morphology and viability of cells suspended in five different fibrin glues. Besides this, the behaviour of chondrocytes seeded on porous matrices comprising different collagen types sealed with fibrin glue was investigated. MATERIAL AND METHODS: In an experiment A, cell suspension (0.5x10(6) cells) was incubated with different fibrin glues. Experiment B was set up to evaluate chondrocytes migration either through a collagen I/III (Chondro-Gide, Geistlich Biomaterials, Switzerland) or collagen II matrix sealed with different fibrin glues in a perfusion chamber system. Analysis were performed by lightmicroscopy (Mayer's hematoxylin-eosin; Masson-Goldner; TUNEL test) and by transmission and scanning electron microscopy. All fibrin glues were measured for TGF-beta 1 and 2 with a specific ELISA. RESULTS: After incubation of cell suspension in autologous fibrin glue, the morphology of cells is chondrocyte-like. Spindly, process-bearing cells were seen in commercial fibrin glue. Cells suspended in commercial fibrin glue revealed a significant higher percentage of TUNEL positive cells compared to fibrin tissue adhesives mixed with autologous serum (p=0.006). The TGF-beta 1 and 2 concentration was significantly higher in partial autologous fibrin sealant (PAF) compared to their commercial counterparts (p=0.001). Cells seeded on the collagen I/III matrix retained their chondrocytic morphology, while in the type II collagen matrix the chondrocytes displayed a fibroblastic phenotype. The ratio of TUNEL positive cells for the collagen I/III matrix was significantly surpassed by the values, when a collagen II matrix was used (p=0.008). No ingrowth of cells was seen in any of the experimental conditions. CONCLUSION: Partial autologous fibrin glue and collagen I/III matrices are favourable in respect to migration pattern, morphology and viability, but definitive conclusions can only be drawn after in vivo studies. This will be addressed in future animal studies.

Matrix testing for urothelial tissue engineering.

INTRODUCTION: Surgical reconstruction of the bladder is associated with many well-known complications. Tissue engineering is under discussion as a potential therapeutic strategy and many of the proposed benefits are of special interest for children. Biomaterials play a key role in tissue engineering. Many materials have been proposed for the experimental reconstruction of the bladder and urethra. They determine the biological and mechanical characteristics of the reconstructed tissues. Most publications focus on a single material. In order to identify the most suitable biomaterial it was the aim of this study to compare biological and mechanical features of different biomaterials seeded with urothelial cells in vitro. MATERIALS AND METHODS: Commercially available biomaterials (Biogide, Ethisorb, Lyoplant, SIS, Vicryl, Xenoderm) of biologic or synthetic origin were seeded with urothelial cells. Cell-matrix constructs were cultured and investigated by scanning electron microscopy for surface structure and cell morphology. They were also subjected to extension until failure and the force required was reported as f (max). Values obtained and curve shape were compared to specimens of bladder mucosa and submucosa. RESULTS: Cell adhesion and morphology showed marked differences between materials. Cell shape varied from single spherical cells to confluent layers of flat urothelium. f (max) ranged from 0.02 N to 48.86 N for tested materials and 1.19 N for native bladder mucosa/submucosa. DISCUSSION: The materials showed marked differences in biological and mechanical features in vitro. Cells cultured on biogenic matrices were more similar to native urothelium. Most of the tested materials showed different curve shapes and higher f (max) values than native bladder mucosa.

The anterior glenohumeral joint capsule: macroscopic and MRI anatomy of the fasciculus obliquus or so-called ligamentum glenohumerale spirale.

The purpose of this study was to demonstrate the macroscopic and MRI anatomy of the fasciculus obliquus, otherwise known as the ligamentum glenohumerale spirale or spiral GHL of the anterior shoulder joint capsule. Conventional and MR arthrography (1.5-T device Somatom Symphony, Siemens with shoulder coil) images in standard planes were compared with gross anatomic dissection findings in six fresh shoulder specimens from three cadavers. The MR imaging protocol included T1, PD and DESS 3D WI sequences. The macroscopically recognisable band-the spiral GHL-was identified by anatomic dissection and MRI in all the specimens. It was best visualised by MR arthrography on axial and oblique sagittal planes (T1; PD WI) and appeared as a low signal intensity stripe within the superficial layer of the anterior joint capsule. The absence of the variable middle glenohumeral ligament did not influence the anatomic properties and the MR imaging of the spiral GHL. Diagnostic visualisation of the normal anatomic structures is a prerequisite to distinguish between normal and pathologic conditions. Anatomy of the spiral GHL can be used by radiologists for more detailed interpretation of the anterior shoulder joint capsule ligaments on MR images.

Investigating the effects of bone cement, cyanoacrylate glue and marine mussel adhesive protein from Mytilus edulis on human osteoblasts and fibroblasts in vitro.

Bone cement is a widely used standard fixation substance in Orthopaedic Surgery. Cyanoacrylate glue is available for wound closure to supplement suturing. The mussel adhesive protein extracted from Mytilus edulis (Cell-Tak, BD Biosciences, Heidelberg, Germany) is an experimental fixation device used for in vitro purposes of cell adhesion. The aim of this study is to introduce a cell culture model investigating the effects of commonly applied and experimental glues on human fibroblasts and osteoblasts in vitro. Cells cultured without additives served as a control group. Microscopic examination was performed to evaluate the morphologic changes. An apoptosis test (Apo-Tag, Chemicon International, Temecula, CA, U. S. A.) was applied to determine the rate of natural cell death at the end of the study. It could be demonstrated that morphological changes in bone cement are different in fibroblasts and osteoblasts. Osteoblasts seem to grow on bone cement and develop an orderly formation. Fibroblasts grow in a confluent monolayer around bone cement but do not adhere to the cement itself. This is a desirable effect since most Orthopaedic applications aim at osteointegration as opposed to fibrous tissue overgrowth. Apoptosis attributed to bone cement is comparable to the respective natural rate of apoptosis. Cyanoacrylate glue and the mussel adhesive protein lead to an almost complete apoptosis in the investigated cells. Their routine application should be avoided. The developed cell culture model seems appropriate for performing further investigations.

[Biomechanical properties of cartilage repair tissue after different cartilage repair procedures in sheep]. / Biomechanische Eigenschaften von Knorpelersatzgewebe nach verschiedenen Methoden der Knorpeldefektbehandlung beim Schaf.

AIM: The purpose of this study was to evaluate the biomechanical quality of cartilage and repair tissue in a sheep's knee. 4 standardized 7 mm defects were created on the medial femoral condyle and on the patellar groove (n = 22). These were treated with 4 different cartilage repair procedures and examined 1 year later. MATERIAL AND METHODS: The different groups were: (1) a cell-seeded collagen type-I/III-membrane (Chondro Gide(R)) glued into the defect; (2) a collagen type-I/III-membrane, sutured and cells injected underneath; (3) an engineered, cell-seeded collagen type-II-membrane, glued; (4) periosteum sutured and cells injected underneath; (5) CONTROLS: healthy contra-lateral knees. Indentation tests were performed to reveal the biomechanical capacity. From creep indentation over 35 s a "25-s creep index" was calculated. A high creep index means that the cartilage can undergo greater and faster compression. RESULTS: The repair tissue was significantly thinner than the normal cartilage. The mean creep index of all repair tissues was measured at 111 and 125, respectively (p < 0.05). There were no significant differences among the treated groups. CONCLUSION: In this animal study, none of the induced repair tissues was biomechanically comparable to genuine articular cartilage.

Total knee arthroplasty infection due to Abiotrophia defectiva.

The first documented case of knee alloarthroplasty infection due to Abiotrophia defectiva, formerly known as nutritionally variant streptococci (NVS) and Streptococcus defectivus, is presented. The microbiology of this bacterium is discussed and clinical features of previously reported cases of infections by NVS are reviewed briefly.

A cell-seeded biocomposite for cartilage repair.

Chondrocytes in monolayer cultures lose their phenotype and capability to express type-II collagen, they dedifferentiate into a fibroblastic cell type. Using three-dimensional culture systems a redifferentiation of these cells may occur. In the present study we investigated the morphology and biosynthetic activity of human articular chondrocytes seeded on porous matrices of type I/III collagen (Chondrogide, Geistlich Biomaterials, Wolhusen, Switzerland). Microscopical examinations showed that chondrocytes adhere firmly to a collagen-I/III-membrane exhibiting their characteristic spherical cell shape. Cell numbers after enzymatic digestion of the membrane showed a 93% recovery of seeded cells. Immunohistological examination revealed positive staining for type-II collagen in some areas. The generated biocomposite withstands mechanical stress, keeps its size and design and does not shrink in culture. It is therefore easy to handle, can be sutured, glued or fixed with pins. This study shows, that in vitro production of autologous cartilage-like tissue could be established using a bilayer collagen type I/III fleece. This biocomposite carries active chondrocytes and is currently being evaluated in vivo in a sheep model as well as in a clinical trial for the repair of localized cartilage defects in the knee.

[Iliopsoas impingement after cementless total hip arthroplasty. Case reports]. / Iliopsoaskontaktphänomen nach zementfreier Hüfttotalendoprothese. Eine Fallbeschreibung.

Postoperative pain after total hip arthroplasty can be caused by several conditions. We describe two cases of postoperative persistent iliopsoas impingement after cementless implantation of the acetabular component. The groin pain was relieved after revision with a more anteverted acetabular component. We describe the diagnostic methods as well as the principles of the revision.

Comparison of three sedation regimes for spinal anesthesia in sheep.

The authors considered three protocols for spinal anesthesia using sheep as a model. An appropriate spinal anesthesia method would obviate the need for general anesthesia in certain surgical approaches.

Effects of hyaluronic acid on the morphology and proliferation of human chondrocytes in primary cell culture.

Hyaline articular cartilage is a specialised connective tissue with weight bearing and adsorbing functions. Injury or loss of which often leads to impaired joint function and severe pain. Since the self-renewing abilities of hyaline articular cartilage are limited, there is major interest in the development of bioengineered cartilaginous implants. A cell-matrix-biocomposite composed of a collagen I/III scaffold seeded with autologous chondrocytes is currently being used in clinical trials; however, in order to optimise culture conditions, we cultured human condrocytes and seeded them on type I/III collagen membranes and on Thermanox plastic coverslips with media containing 0 to 500 microg/ml Hyaluronic Acid. After 4 days, the cells were either fixed or BrdU incorporation procedures begun. HE staining clearly demonstrated that cells grown in HA form three dimensional clusters and produce secretory vesicles as opposed to the monolayer control cells with noticeably fewer secretory vesicles. BrdU incorporation revealed a noticeable increase in cell proliferation in cells grown in 100 microg/ml; however, no comparable increase in 500 micorg/ml but rather a slight depression in proliferation. Immunohistochemistry for collagen II and aggrecan revealed an obvious increase in deposition of these two substances with increased HA administration as compared to the control; however, again, the higher concentration of HA, 500 microg/ml, did not result in a further increase in production. These results suggest that HA at 100 microg/ml not only influences chondrocytes to differentiate and produce more Collagen II and aggrecan, but also increases proliferation. We, therefore, propose that the addition of HA at low to middle dosages in condrocyte culturing might help improve condrocyte redifferentation and thus, the bioengineered cartilage.

Anatomical composition of the anterior shoulder joint capsule. A cadaver study on 12 glenohumeral joints.

Twelve right cadaver shoulder joints were investigated after alcohol-formalin-glycerol fixation. The tendons of the "rotator cuff" were separated from the joint capsule. The capsulo-ligamentous structures: Lig. coracohumerale, Lig. coracoglenoidale and Ligg. glenohumeralia were dissected. In addition to the Ligg. glenohumerale superius, medium et inferius, an "unknown glenohumeral ligament" coursed in the midline of the superficial layer of the anterior shoulder joint capsule. It arose from the axillary part of the Lig. glenohumerale inferius and the insertion tendon of the Caput longum m. tricipitis brachii, coursed upwards laterally and fused with the Lig. glenohumerale medium. Between the Ligg. glenohumerale medium et inferius it was connected with the shoulder joint capsule by loose connective tissue. Craniolaterally it melted into the superior portion of the M. subscapularis and inserted together with its tendon to the Tuberculum minus of the Humerus. The ascending fibres of the "unknown glenohumeral ligament" and the oblique, descending fibres of the Ligg. glenohumeralia medium et inferius crossed twice and formed X-shape connections between the ligaments. In external rotation and abduction or anteversion the course of fibres of the "unknown glenohumeral ligament" was spiral. According to the shape and anatomical position of the "unknown glenohumeral ligament" we propose to name it "Lig. glenohumerale spirale".

Anatomy of the coracohumeral and coracoglenoidal ligaments.

The Ligg. coracohumerale and coracoglenoidale are constant anatomical structures, represented in all the 34preparations investigated. The Lig. coracoglenoidale is a strong band of dense connective tissue, running from the Processus coracoideus to the Tuberculum supraglenoidale. In 27 specimens out of 34 it was the continuation of the M. pectoralis minor tendon. The Lig. coracohumerale consists of two separate parts. The "inferior part" originates from the Processus coracoideus and the Lig. coracoglenoidale, which separates it from the base of the coracoid process. It is composed of the joint capsule anteriorly and a remnant of the M. pectoralis minor tendon posteriorly. The "superior part" arises from the medio-posterior surface of the Processus coracoideus, just below the Lig. coracoacromiale. Both parts of the Lig. coracohumerale run into the shoulder joint capsule under the M. supraspinatus tendon and insert into a capsular semicircular band. According to the shape and course of fibres between the greater and lesser tubercles of the Humerus, we propose to name it the "Lig. semicirculare humeri". None of the two parts of the Lig. coracohumerale begins from the base of the Processus coracoideus, and fibres of the Lig. coracohumerale do not reach the Tuberculum majus et minus directly.

Characteristics of human chondrocytes, osteoblasts and fibroblasts seeded onto a type I/III collagen sponge under different culture conditions. A light, scanning and transmission electron microscopy study.

Hyaline cartilage has only a limited capacity of regeneration, thus, lesions of articular cartilage can lead to early osteoarthrosis. Current concepts in conservative orthopedic therapy do not always lead to satisfying results. As one new attempt to facilitate cartilage repair, autologous transplantation of articular chondrocytes is investigated in different assays. This study was designed to create a resistible and stable cell-matrix-biocomposite with viable and biosynthetically active human chondrocytes, osteoblasts or fibroblasts. This biocomposite might serve as an implant to treat deep osteochondral defects in the knee. We collected cartilage, spongiosa and skin probes from healthy patients undergoing hip-surgery and enzymatically liberated the chondrocytes, seeded them into culture flasks and cultured them until confluent. The spongiosa and the skin samples were also placed in culture flasks and cells cultured until confluent. After 4-6 weeks, cells were trypsinized and grown on a type I/III collagen matrix (Chondrogide, Geistlich Biomaterials, Wolhusen, Switzerland) for 7 days in standard Petri dishes and in a special perfusion chamber culture system. As controls, cells were seeded onto plastic surfaces. Then scaffolds were fixed and embedded for light microscopy and electron microscopy by routine methods. Light microscopically, chondrocytes grown on the surface of the scaffold form clusters or a dense layer of sometimes rather fibroblast-like and sometimes roundish, chondrocyte-like cells. Only a few cells grow deeper into the matrix. In transmission electron microscopy, the cells have a rather chondrocyte-like morphology which emphasizes the matrix-induced redifferentiation after dedifferentiation of chondrocytes in monolayer-culture in culture flasks. Chondrocytes on plastic surfaces have a spinocellular aspect with little signs of differentiation. Grown on Chondrogide, cells are more roundish and adhere firmly to the collagen fibrils of the scaffold. Osteoblasts grown on the collagen scaffold and examined by light microscopy form a thin cell-layer on the surface of the matrix with a reticular layer of dendritic cells underneath this sheet. Transmission electron micrographs show spinocellular and flat cells on the collagen fibrils. Scanning electron micrographs show large dendritic osteoblasts on plastic and a confluent layer of flattened, dendritic cells on the collagen scaffold. Fibroblasts form a thick multi-layer of typical spinocellular cells on the collagen matrix. Fibroblasts grown on plastic surfaces and examined by scanning electron microscopy also show a dense layer of fibroblast-like cells. For all three different types of cells no morphological differences could be seen when comparing cultivation in the perfusion culture system to cultivation in standard Petri dishes, although mechanical stress is believed to induce differentiation of chondrocytes. Especially the observed partially differentiated chondrocyte-matrix biocomposite might serve as an implant to treat deep cartilage defects, whereas osteoblasts and fibroblasts seem to be less suited.

Development of a biocomposite to fill out articular cartilage lesions. Light, scanning and transmission electron microscopy of sheep chondrocytes cultured on a collagen I/III sponge.

The regenerative capacity of hyaline articular cartilage is limited. Thus, lesions of this tissue are a proarthrotic factor, and up to now the conservative treatment of cartilage lesions and arthrosis does not yield satisfying results. Therefore, autologous transplantation of articular chondrocytes is being investigated in a variety of different assays. The aim of our study was to create a mechanically stable cell-matrix implant with viable and active chondrocytes which could serve to fill out articular lesions created in the knees of sheep. For this purpose, articular cartilage was collected from knee lesions, chondrocytes were liberated enzymatically and seeded in culture flasks and cultured till confluency. Cells were then trypsinized and grown on a type I/III collagen matrix (Chondro-Gide, Geistlich Biomaterials, Wolhusen, Switzerland) for 3, 6 and 10 days before being fixed and embedded for electron microscopy by routine methods. Scanning electron microscopy was performed after dehydration in acetone, critical point drying and sputter-coating with gold-paladium. Light microscopically, clusters of chondrocytes can be seen on the surface of the matrix with a few cells growing into the matrix. Transmission electron microscopic photographs yield a rather differentiated chondrocyte-like appearance, which is evidence of a matrix-induced redifferentiation after dedifferentiation during the growth period in the culture flasks. Scanning electron microscopic results show large, flattened chondrocytes without signs of differentiation on plastic, whereas chondrocytes grown on the Chondro-Gide sponge show a more roundish aspect wrapping firmly around the collagen fibrils, exhibiting numerous contacts with the matrix. This cell-matrix biocomposite can now serve to fill out articular cartilage lesions created in the knees of sheep.

[New therapy procedure for localized cartilage defects. Encouraging results with autologous chondrocyte implantation]. / Neues Therapieverfahren für lokalisierte Knorpeldefekte. Ermutigende Resultate mit der autologen Chondrozytenimplantation.

Owing to the poor regenerative capacity of cartilage, cartilaginous defects are considered to represent pre-arthrotic factors. In addition to autologous and allogenic osteochondral fragments, proliferative tissue, such as periosteum and perichondrium are increasingly being used as graft material. The aim of treatment is to eliminate the defect and to restore the load-bearing capacity and function of the affected joint. A new, recently introduced, approach aims to stimulate the formation of new cartilage via autologous cultured chondrocyte implantation (ACI). The rationale for this treatment is the restoration of loadable hyaline or hyaline-like articular cartilage. Although long-term results are not yet available, clinical follow-up data obtained so far are encouraging. In addition to existing methods of treating cartilaginous defects, this article describes a modified method of transplantation of autologous chondrocytes. With this method the periosteal flap used to cover a defect is replaced by an absorbable collagenl/III membrane (Chondrogide, Geistlich Wolhusen, Switzerland) that is used as a carrier for the patient's own chondrocytes. After placement in the defect, the membrane is fixed in place with fibrin glue (MACI).

Erythrocytes and proinflammatory mediators in wound drainage.

BACKGROUND AND OBJECTIVES: Retransfusion of shed blood collected after operation has become popular, but recent reports of side effects led to a search for possible causes. MATERIALS AND METHODS: In a randomized study of 28 patients undergoing total hip arthroplasty, shed blood was collected in Solcotrans, Orth-Evac, and ordinary Redon drainage. Osmotic fragility was measured and electron-microscopic pictures of erythrocytes from selective samples were taken. Serotonin, prostaglandin E2 (PGE2), and histamine were measured with enzyme-linked immunosorbent assays. RESULTS: Higher osmotic fragility of erythrocytes collected with Solcotrans appeared to be due to ACD which was used only with that system. Serotonin concentrations did not differ significantly. However, there was a great increase in histamine (Solcotrans 477.7, Orth-Evac 344.0, Redon drainage 453.1 nmol/ml) and PGE2 (Solcotrans 1,908.3, Orth-Evac 1,225.0, Redon drainage 2,666.7 microgram/ml) in shed blood compared with venous blood (histamine 9.5 nmol/l, PGE2 4.2 microgram/ml). CONCLUSION: Unwashed wound drainage blood collected after operation contains levels of proinflammatory mediators that can account for the reported side effects.

HLA-dependent heterogeneous T cell response to Mycoplasma arthritidis-derived superantigen (MAS).

Mycoplasma arthritidis induces a chronic arthritis in rodents. The role of M. arthritidis-derived superantigen (MAS) in the arthritis is still a subject of controversy. MAS stimulates mouse and human T cells in a V beta-restricted manner with the subsequent liberation of cytokines. The presence of the major histocompatibility complex class II molecule is required for such a stimulation. In this study we assessed MAS-induced cytokine production in peripheral blood from patients with different rheumatic diseases and controls using an enzyme-linked immunosorbent assay. Statistically significant differences in cytokine production in response to MAS stimulation allowed the distinction of high responders and low responders within groups of patients and controls. Higher cytokine induction was statistically correlated with the HLA-DR specificities DR4, DR7 and DR12. To confirm these results, murine V beta 8.1 cytotoxic T lymphocytes (CTL) were stimulated with MAS in the presence of different HLA-DR lymphoblastoid B cells. CTL proliferation was only observed in presence of DR4 and DR7. In conclusion, MAS T cell stimulation and its subsequently cytokine production depends on the presence of certain HLA-DR specificities.