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A Clinical Prediction Rule to Identify Patients With Low Back Pain Who Are Likely to
Experience Short-Term Success Following Lumbar Stabilization Exercises: A Randomized
Controlled Validation Study
21 Nov 2013 10:40 pm
Journal of Orthopaedic & Sports Physical Therapy, Volume 0, Issue 0, Page 1-70, Ahead of Print.
A Special Thanks to 2013 JOSPT Contributors
01 Dec 2013 06:09 am
Journal of Orthopaedic & Sports Physical Therapy, Volume 43, Issue 12, Page 860-863, December 2013.
A rat tail temporary static compression model reproduces different stages of intervertebral
disc degeneration with decreased notochordal cell phenotype
28 Nov 2013 04:45 am
The intervertebral disc nucleus pulposus (NP) has two phenotypically distinct cell types—notochordal cells
(NCs) and non-notochordal chondrocyte-like cells. In human discs, NCs are lost during adolescence, which
is also when discs begin to show degenerative signs. However, little evidence exists regarding the link
between NC disappearance and the pathogenesis of disc degeneration. To clarify this, a rat tail disc
degeneration model induced by static compression at 1.3 MPa for 0, 1, or 7 days was designed and
assessed for up to 56 postoperative days. Radiography, MRI, and histomorphology showed degenerative
disc findings in response to the compression period. Immunofluorescence displayed that the number of
DAPI-positive NP cells decreased with compression; particularly, the decrease was notable in larger,
vacuolated, cytokeratin-8- and galectin-3-co-positive cells, identified as NCs. The proportion of TUNELpositive cells, which predominantly comprised non-NCs, increased with compression. Quantitative PCR
demonstrated isolated mRNA up-regulation of ADAMTS-5 in the 1-day loaded group and MMP-3 in the 7day loaded group. Aggrecan-1 and collagen type 2α-1 mRNA levels were down-regulated in both groups.
This rat tail temporary static compression model, which exhibits decreased NC phenotype, increased
apoptotic cell death, and imbalanced catabolic and anabolic gene expression, reproduces different stages
of intervertebral disc degeneration. © 2013 Orthopaedic Research Society. Published by Wiley Periodicals,
Inc. J Orthop Res
Accuracy of Patient Recall of Hand and Elbow Disability on the QuickDASH Questionnaire
Over a Two-Year Period
20 Nov 2013 12:00 am
Background:
Patient self-reporting questionnaires such as the QuickDASH, a shortened version of the Disabilities of the
Arm, Shoulder and Hand (DASH) outcome measure, are critical to current orthopaedic outcomes research.
The use of these questionnaires could introduce recall bias in retrospective, case-control, and crosssectional studies if no preoperative data has been collected prior to study inception. The purpose of this
study was to quantify recall accuracy on the QuickDASH questionnaire as a function of the duration of the
recall interval.
Methods:
This cross-sectional study enrolled 140 patients with nontraumatic hand and elbow diseases. Patients were
stratified into groups of thirty-five based on the time since their initial office visit (three months, six months,
twelve months, or twenty-four months). All patients had completed the QuickDASH as part of a standard
intake form at the time of the initial office visit (actual baseline score). Patients were contacted by phone
and asked to recall their upper extremity disability from the time of the initial office visit with use of the
QuickDASH questionnaire. Patients also completed the QuickDASH to rate their current disability. Actual
and recalled QuickDASH scores for each group were statistically compared. Kruskal-Wallis analysis was
used to determine any differences in recall accuracy between the groups. Pearson correlation coefficients
quantified relations between recall accuracy and patient age and current function (absolute QuickDASH
scores).
Results:
Mean differences between recalled QuickDASH scores and actual scores were all less than the
QuickDASH minimal clinically important difference (MCID) of 13 points at different time points: three months
(–7.1, p < 0.01), six months (0.8, p = 0.79), twelve months (–2.3, p = 0.43), and twenty-four months (–2.8, p
= 0.26). There were no significant differences in recall accuracy across the four groups (p = 0.77). Recalled
QuickDASH scores were highly correlated with actual baseline values (rp ≥ 0.74). Recall accuracy was
neither correlated with patient age nor current QuickDASH scores (rp ≤ 0.04).
Conclusions:
Patients with a nontraumatic hand or elbow diagnosis are able to recall prior level of function accurately for
up to two years with the QuickDASH questionnaire. Although data collected prospectively remain optimal,
our data suggest that research conducted with use of recalled QuickDASH scores produces reliable
assessment of disability from common upper extremity diagnoses with acceptable recall bias.
Level of Evidence:
Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Acute Exertional Rhabdomyolysis
01 Dec 2013 06:10 am
Journal of Orthopaedic & Sports Physical Therapy, Volume 43, Issue 12, Page 932, December 2013.
Acute neck pain caused by arthritis of the lateral atlanto-axial joint - Accepted Manuscript
21 Nov 2013 12:00 am
Abstract: Background context: Many diseases can cause acute neck pain in elderly individuals. We
conducted the present prospective study based on the hypothesis that arthritis of the lateral atlanto-axial
joint may be involved in acute neck pain in elderly patients with limited neck rotation.Purpose: To clarify
whether the lateral atlanto-axial joint is involved in acute neck pain among elderly individuals by conducting
lateral atlanto-axial joint puncture.Study design: A prospective study.Patient sample: A total of 27 patients
(13 men, 14 women) ≥50 years old who provided consent for atlanto-axial joint puncture and met the
following four inclusion criteria: 1) acute neck pain with limited cervical rotation less than 20° as the chief
complaint; 2) visual analog scale (VAS) pain score ≥70 mm at initial visit; 3) tenderness in the paraspinal
muscle of upper cervical vertebrae; and 4) serum C-reactive protein level ≥0.5 mg/dl.Outcome measures:
VAS pain score and radiological findings.Methods: Patients underwent puncture of the lateral atlanto-axial
joint and were evaluated clinically and radiologically.Results: Computed tomography (CT) obtained before
puncture showed calcification of the transverse ligament of the atlas in the posterior dens in 22 patients
(81.5%), calcification in the longus colli in 2 patients (7.4%), and no calcification in 3 patients (11.1%). Of
the 27 patients who underwent lateral atlanto-axial joint puncture, joint fluid was collected from 16 patients
(59.3%), and calcium pyrophosphate dihydrate (CPPD) crystals were identified in 10 patients (62.5%). For
the entire patient population, mean VAS score before puncture was 81.9±16.3 mm, significantly improving
to 35.6±24.4 mm by 30 min after puncture (p<0.001).Conclusions: The results of this study suggest that
crystal-induced arthritis (pseudogout) of the lateral atlanto-axial joint may be closely involved with acute
neck pain in the elderly.
Age and obesity alter the relationship between femoral articular cartilage thickness and
ambulatory loads in individuals without osteoarthritis
26 Nov 2013 09:32 am
Articular cartilage is sensitive to mechanical loading, so increased risk of osteoarthritis in older or obese
individuals may be linked to changes in the relationship between cartilage properties and extrinsic joint
loads. A positive relationship has been reported between ambulatory loads and cartilage thickness in young
individuals, but whether this relationship exists in individuals who are older or obese is unknown. This study
examined the relationship between femoral cartilage thickness and load, measured by weight × height and
the peak adduction moment, in young normal-weight (28 subjects, age: 28.0 ± 3.8 years, BMI:
21.9 ± 1.9 kg/m2), middle-aged normal-weight (27 subjects, 47.0 ± 6.5 years, 22.7 ± 1.7 kg/m2), young
overweight/obese (27 subjects, 28.4 ± 3.6 years, 33.3 ± 4.6 kg/m2), and middle-aged overweight/obese (27
subjects, 45.8 ± 7.2 years, 31.9 ± 4.4 kg/m2) individuals. On the lateral condyle, cartilage thickness was
positively correlated with weight × height for all groups (R2 = 0.26–0.20) except the middle-aged
overweight/obese. On the medial condyle, weight × height was significantly correlated only in young normalweight subjects (R2 = 0.19), as was the case for the correlation between adduction moment and medial–
lateral thickness ratio (R2 = 0.20). These results suggest that aging and obesity are both associated with a
loss of the positive relationship between cartilage thickness and ambulatory loads, and that the relationship
is dependent on the compartment and whether the load is generated by body size or subject-specific gait
mechanics. © 2013 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res
Aging Changes in Lumbar Discs and Vertebrae and Their Interaction A 15-year Follow-up
Study - Accepted Manuscript
21 Nov 2013 12:00 am
Abstract: Background Context: Many studies have focused on either the intervertebral disc, as a culprit in
back pain problems, or the vertebral body, but very few studies have examined both structures and their
relation.Purpose: The goals were to measure the concordant changes in morphology of the discs and
vertebrae during 5, 10 and 15-year follow-ups.Study Design: Longitudinal study.Patient Sample: Among a
general population sample of 232 men that had been scanned in 1992-1993, 105 men were re-examined in
1997-1998 and 2007-2008. Mean age at 15-year follow-up was 63 years. A confirmatory sample with 10year follow-up was also included.Methods: 1.5 Tesla scanners with surface coils were used at baseline and
follow-up. Image analysing software was used to measure distances and areas of interest of mid-sagittal
and mid-axial spine images.Results: The disc heights decreased at 5 years by 3.4% (0.4 mm) and 3.3 %
(0.4 mm) and at 15 years 8.7 % (1.0 mm) and 11.3 % (1.3 mm) in the upper and the lower discs
respectively (p<0.001). While not clear after 5years, vertebra heights increased in mean by 3.1 % (0.8 mm)
in the upper lumbar levels and by 4.7 % (1.1 mm) in the lower vertebrae after 15 years (p<0.001). Vertebra
height increases were associated with disc narrowing (P=0.001). The mean annual shortening of the lumbar
spine L1-S1 block was 0.13 mm/year, which was in line with the mean standing height, which decreased
little (174.7 cm at baseline and 174.4 cm at follow-up).CONCLUSIONS: Discs and vertebrae degenerate or
remodel in concert: decreases in disc height appear to be compensated, in part, by accompanying
increases in adjacent vertebra heights. The mechanism behind this novel finding and its implications require
further study.
An Expression of Concern
20 Nov 2013 12:00 am
A letter to our readers:
An Injection of Platelet-Rich Plasma, Glucocorticoid, or Saline Solution Produced Similar
Pain and Disability Results in Lateral Epicondylitis
20 Nov 2013 12:00 am
Anatomic Predisposition to Ligamentous Lisfranc Injury: A Matched Case-Control Study
20 Nov 2013 12:00 am
Background:
Subtle, or ligamentous, Lisfranc injuries occur following low-energy trauma to the midfoot and can be
debilitating. Since they are ligamentous, they may not heal, requiring arthrodesis in some cases. Certain
mortise anatomic characteristics on radiographs have been shown to be associated with a predisposition to
the ligamentous subtype of Lisfranc injuries. It is not known whether there are other morphometric
characteristics, such as arch height or the relative length of the second metatarsal, that can similarly
influence the predisposition to these injuries.
Methods:
The present retrospective matched case-control study involved fifty-two control subjects and twenty-six
patients with ligamentous Lisfranc injuries treated from 2006 to 2010 at two institutions. Clinical and
radiographic data (second metatarsal length relative to foot length, first intermetatarsal angle, navicularcuboid overlap relative to cuboid vertical height, first metatarsal-talus angle, and calcaneal pitch angle) were
examined for the existence of significant differences between control and Lisfranc subjects. Logistic
regression analysis was then performed to evaluate potential risk for injury on the basis of these anatomic
variables.
Results:
Compared with matched controls, patients with a ligamentous Lisfranc injury were found to have a
significantly smaller ratio of second metatarsal length to foot length (p < 0.001) on weight-bearing
radiographs.
Conclusions:
Occurrence of a ligamentous Lisfranc injury was shown to be associated with a smaller ratio of second
metatarsal length to foot length; >50% of patients in the injury group had a ratio of <29%.
Level of Evidence:
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Anterior Talocrural Joint Laxity: Diagnostic Accuracy of the Anterior Drawer Test of the
Ankle
01 Dec 2013 06:09 am
Journal of Orthopaedic & Sports Physical Therapy, Volume 43, Issue 12, Page 911-919, December 2013.
Anti-Glucosaminidase IgG in Sera as a Biomarker of Host Immunity Against
Staphylococcus aureus in Orthopaedic Surgery Patients
20 Nov 2013 12:00 am
Background:
Staphylococcus aureus infections remain a major complication of orthopaedic surgery. Although serum Creactive protein is useful for diagnosis, there are no specific tests for host immunity that can assess a
patient’s risk for serious infection. On the basis of the identification of glucosaminidase as a potentially
protective antigen in animal models, we tested the hypotheses that anti-glucosaminidase IgG
(immunoglobulin G) levels vary in sera of mice and orthopaedic patients with Staphylococcus
aureus infections and that physical and neutralizing titers correlate.
Methods:
In vitro ELISAs (enzyme-linked immunosorbent assays) were developed to quantify binding (physical) and
enzyme-neutralizing (functional) anti-glucosaminidase IgG titers. The assays were validated with use of
sera from naive, Staphylococcus aureus-challenged, and glucosaminidase-immunized mice. The physical,
functional, and isotype titers of anti-glucosaminidase IgG were measured in sera from twenty-four patients
with a confirmed Staphylococcus aureus infection following orthopaedic surgery and in sera from twenty
noninfected patients. The specificity of the anti-glucosaminidase assay was evaluated by means of linear
regression and receiver-operator characteristic curve analysis.
Results:
In mice, the analytic range of the physical titer assay for anti-glucosaminidase IgG was determined to be 1
ng/mL to 1 μg/mL, and physical titers correlated with functional titers (p < 0.002). Although all patients had
measurable anti-glucosaminidase IgG, the physical titers in the infected patients were significantly higher by
a factor of two compared with those in the healthy controls (p = 0.015). The physical titers were significantly
correlated with the functional titers (p < 0.0001). Receiver-operator characteristic curve analysis
demonstrated a diagnostic specificity of 0.72 (p = 0.014) for the assay. The anti-glucosaminidase titer in
almost every patient was dominated by the IgG1 isotype.
Conclusions:
Humoral immunity against glucosaminidase varied in mammals with Staphylococcus aureus osteomyelitis.
Anti-glucosaminidase titers in sera were a potential biomarker of infection and have the potential to assess
the quality of host immunity againstStaphylococcus aureus.
Clinical Relevance:
Staphylococcus aureus infections can be challenging to diagnose, and there is no diagnostic test for host
immunity. We demonstrated a cost-effective assay for determining the anti-glucosaminidase titer, which can
be readily combined with conventional serology to improve diagnosis and to assess host immunity
againstStaphylococcus aureus.
Arthritis Self-Efficacy Scale Scores in Knee Osteoarthritis: A Systematic Review and Metaanalysis Comparing Arthritis Self-Management Education With or Without Exercise
01 Dec 2013 06:10 am
Journal of Orthopaedic & Sports Physical Therapy, Volume 43, Issue 12, Page 895-910, December 2013.
Arthroscopic Partial Meniscectomy Was Not More Effective Than Physical Therapy for
Meniscal Tear and Knee Osteoarthritis
20 Nov 2013 12:00 am
Assessing Competence of Orthopaedic Residents: The Reliability and Validity of an
Objective Structured Clinical Examination After a Sports Medicine Rotation
20 Nov 2013 12:00 am
The traditional method of orthopaedic training in Canada utilizes a time-based system, combined with a
formal exit examination. Increasing interest in competency-based curriculum has raised the issue of how to
test in-training competence. Currently, the most commonly used method is the In-Training Evaluation
Report (ITER), which is known to be relatively subjective in nature; the true establishment of competence
would likely benefit from the addition of an objective assessment1,2.
Association Between Centralization and Directional Preference and Functional and Pain
Outcomes in Patients With Neck Pain
21 Nov 2013 10:40 pm
Journal of Orthopaedic & Sports Physical Therapy, Volume 0, Issue 0, Page 1-30, Ahead of Print.
Capitellum excision: Mechanical implications and clinical consequences
20 Nov 2013 04:14 am
Controversy exists regarding the optimal treatment of isolated fractures of the capitellum that are not
amenable to open reduction and internal fixation. Excision of the capitellum could result in instability of the
elbow, though only limited the clinical or laboratory evidence exists to support this outcome. The aim of our
study was to determine if capitellum excision leads to significant instability by measuring the relative change
in varus–valgus displacement of the elbow. The varus–valgus displacement was recorded in 11 cadaveric
elbows before and after isolated excision of the capitellum. Specimens were testing in varus-loaded and
valgus-loaded positions with and without a 1 kg weight on the forearm. The varus–valgus displacement at
the elbow was measured using a 3D motion capture system. Capitellum excision did not significantly
change varus–valgus displacements in either the adducted, varus, or valgus position of the elbow (p = 0.80,
p = 0.28, p = 0.51). Furthermore, the addition of the 1 kg external functional load to the forearm did not
produce a significant change in the varus and valgus loaded positions (p = 0.16, p = 0.36). Our results
demonstrate that excision of the capitellum in the setting of intact ligamentous structures does not result in
significant instability in either the adducted varus loaded or valgus loaded positions of the elbow. © 2013
Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res
Cement augmentation of hip implants in osteoporotic bone: How much cement is needed
and where should it go?
20 Nov 2013 09:10 am
Several studies proved the beneficial effect of cement augmentation of proximal femoral nail antirotation
(PFNA) blades on implant purchase in osteoporotic bone. We investigated the effect of different
localizations and amounts of bone cement. Polyurethane foam specimens were instrumented with a PFNA
blade and subsequently augmented with PMMA bone cement. Eight study groups were formed based on
localization and amount of cement volume related to the blade. All specimens underwent cyclic loading with
physiological orientation of the force vector until construct failure. Foam groups were compared between
each other and to a cadaveric control group. The experiments revealed a significant dependency of implant
purchase on localization and amount of cement. Biomechanically favorable cement positions were found at
the implant tip and at the cranial side. However, none of the tested augmentation patterns performed
significantly inferior to the cadaveric benchmark. These findings will allow surgeons to further reduce the
amount of injected PMMA, decreasing the risk of cement leakage or cartilage damage. © 2013 Orthopaedic
Research Society. Published by Wiley Periodicals, Inc. J Orthop Res
Cervical Tuberculosis Associated with Cervical Pain and Neurological Deficit: a Case
Report and Literature Review - Accepted Manuscript
21 Nov 2013 12:00 am
Abstract: Background Context: Isolated tuberculosis (TB) of posterior elements of the cervical spine is
extremely rare. Only few cases are reported in literature but none described isolated spinous process and
laminae involvement without TB in any other part of the body.Purpose: The authors report a case of isolated
TB involvement of the spinous process and right laminae of C2 combined with atlantoaxial luxation.Study
design: A case report of isolated spinous process and right laminae TB of C2 combined with atlantoaxial
luxation.Patient Sample: a 20-year-old male peasant complained about a 2-month history of aggravating
neck pain, of a 1-month history of a slowly growing lump at the back of neck, and of numbness and
weakness of the right arm, which had gradually progressed to involve all the limbs for 2 weeks before
presentation.Outcome Measures: X-ray and CT of cervical spine and Frankel grading of neural function are
included to evaluate the therapeutic efficiency.Methods: CT scans showed flake-like bony destruction
located in the spinous process and at right laminae of C2. MRI showed a large swelling lump posterior to
C2 and atlantoaxial luxation induced distinct compression of the spinal cord. The patient underwent 2weeks of skull traction and quadruple anti-TB treatment before surgery.Results: The patient underwent
surgical treatment which included posterior radical debridement, decompression, internal fixation with a
screw-rod system from C1 to C4, autologous bone grafting and fusion. The patient gained normal neural
function and returned to work one year after surgery.Conclusions: TB of the posterior elements of the upper
cervical spine is very rare and potentially dangerous. CT and MRI are very useful and important for making
a correct diagnosis. Prompt medical and surgical treatment may avert potential catastrophic event in these
cases.
Cisplatin inhibits bone healing during distraction osteogenesis
20 Nov 2013 09:24 am
Osteosarcoma (OS) is the most common malignant bone tumor affecting children and adolescents. Many
patients are treated with a combination of chemotherapy, resection, and limb salvage protocols. Surgical
reconstructions after tumor resection include structural allografts, non-cemented endoprostheses, and
distraction osteogenesis (DO), which require direct bone formation. Although cisplatin (CDP) is extensively
used for OS chemotherapy, the effects on bone regeneration are not well studied. The effects of CDP on
direct bone formation in DO were compared using two dosing regimens and both C57BL/6 (B6) and tumor
necrosis factor receptor 1 knockout (TNFR1KO) mice, as CDP toxicity is associated with elevated TNF
levels. Detailed evaluation of the five-dose CDP regimen (2 mg/kg/day), demonstrated significant decreases
in new bone formation in the DO gaps of CDP treated versus vehicle treated mice (p < 0.001). Further, no
significant inhibitory effects from the five-dose CDP regimen were observed in TNFR1KO mice. The twodose regimen significantly inhibited new bone formation in B6 mice. These results demonstrate that CDP
has profound short term negative effects on the process of bone repair in DO. These data provide the
mechanistic basis for modeling peri-operative chemotherapy doses and schedules and may provide new
opportunities to identify molecules that spare normal cells from the inhibitory effects of CDP. © 2013
Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res
Clinical outcomes, radiologic kinematics, and effects on sagittal balance of the 6-degreesof-freedom LP-ESP® lumbar disc prosthesis - Accepted Manuscript
21 Nov 2013 12:00 am
Abstract: Background Context: Surgical treatment of degenerative disc disease remains a controversial
subject. Lumbar fusion has been associated with a potential risk of segmental junctional disease and
sagittal balance misalignment. Motion preservation devices have been developed as an alternative to
fusion. The LP-ESP® disc is a one-piece deformable device achieving 6 degrees of freedom, including
shock absorption and elastic return. This is the first clinical report on its use.Purpose: To assess clinical
outcomes and radiological kinematics in the first two years after implantation.Study Design: Prospective
cohort of patients with LP-ESP total disc replacement at the lumbar spine.Patient sample: 46 consecutive
patientsOutcome measures: Clinical outcomes were the visual scale for pain (VAS), the Oswestry disability
index (ODI), and the GHQ28 psychological score. Radiologic data were the range of motion (ROM), sagittal
balance parameters, and mean center of rotation (MCR).Methods: Patients had single-level total disc
replacement at L4L5 or L5S1. Outcomes were prospectively recorded for two years (before and at 3, 6, 12,
and 24 months after surgery). The spineview software was used for computed analysis of the radiographic
data. Paired t-tests were used for statistical comparisons.Results: No intraoperative complication occurred.
All clinical scores improved significantly at 24 months: the back pain visual analog scales by a mean of 4.1
points and the Oswestry disability index by 33 points. The average range of motion of the instrumented
level was 5.4° ± 4.8° at 2 years and more than 2° for 76% of prostheses. The mean center rotation was in a
physiological area in 73% of cases. The sagittal balance (pelvic tilt, sacral slope, and segmental lordosis)
did not change significantly at any point of follow-up.Conclusions: Results from the 2-year follow-up indicate
that LP-ESP® prosthesis recreates lumbar spine function similar to that of the healthy disc in terms of range
of motion, quality of movement, effect on sagittal balance, and (absence of modification in the) kinematics
of the upper adjacent level.
Comparative analysis of international standards for the fatigue testing of posterior spinal
fixation systems - Corrected Proof
22 Nov 2013 12:00 am
Abstract: Background context: Preclinical evaluation of the long-term reliability of devices for lumbar fixation
is a mandatory activity before they are put into market. The experimental setups are described in two
different standards edited by the International Organization for Standardization (ISO) and the American
Society for Testing Materials (ASTM), but the evaluation of the suitability of such tests to simulate the actual
loading with in vivo situations has never been performed.Purpose: To calculate through finite element (FE)
simulations the stress in the rods of the fixator when subjected to ASTM and ISO standards. To compare
the calculated stresses arising in the same fixator once it has been virtually mounted in a physiological
environment and loaded with physiological forces and moments.Study design: FE simulations and
validation experimental tests.Methods: FE models of the ISO and ASTM setups were created to conduct
simulations of the tests prescribed by standards and calculate stresses in the rods. Validation of the
simulations were performed through experimental tests; the same fixator was virtually mounted in an L2-L4
FE model of the lumbar spine and stresses in the rods were calculated when the spine was subjected to
physiological forces and moments.Results: The comparison between FE simulations and experimental tests
showed good agreement between results obtained using the two methodologies, thus confirming the
suitability of the FE method to evaluate stresses in the device in different loading situations. The usage of a
physiological load with ASTM standard is impossible due to the extreme severity of the ASTM configuration;
in this circumstance, the presence of an anterior support is suggested. Also, ISO prescriptions, although the
choice of the setup correctly simulates the mechanical contribution of the discs, seem to overstress the
device as compared with a physiological loading condition. Some daily activities, other than walking, can
induce a further state of stress in the device that should be taken into account in setting up new
experimental procedures.Conclusions: ISO standard loading prescriptions seems to be more severe than
the expected physiological ones. The ASTM standard should be completed by including some anterior
supporting device and declaring the value of the load to be imposed. Moreover, a further enhancement of
standards would be simulating other movements representative of daily activities different from walking.
Comparison of Hemiarthroplasty and Reverse Shoulder Arthroplasty for the Treatment of
Proximal Humeral Fractures in Elderly Patients
20 Nov 2013 12:00 am
Background:
Treatment of complex three and four-part proximal humeral fractures with hemiarthroplasty in elderly
patients has yielded mixed clinical results. Reverse shoulder arthroplasty has emerged as a treatment
option for comminuted proximal humeral fractures for these patients. The purpose of the study was to
perform a prospective evaluation of patient outcomes comparing hemiarthroplasty and reverse shoulder
arthroplasty for the treatment of comminuted proximal humeral fractures in elderly patients.
Methods:
Fifty-three consecutive elderly patients (average age, 74.4 years) underwent an arthroplasty for a complex
proximal humeral fracture. Indications for arthroplasty were four-part fractures, three-part fractures with
severe comminution of the greater tuberosity, and fractures that involved an articular split of the humeral
head. Twenty-six patients underwent hemiarthroplasty (the HA group), followed by twenty-seven patients
who underwent reverse shoulder arthroplasty (the RSA group). A total of forty-seven patients (twenty-three
in the HA group and twenty-four in the RSA group) were available for follow-up at a minimum of two years.
Results:
Final average outcome scores were lower in the HA group than in the RSA group (American Shoulder and
Elbow Surgeons [ASES] score of 62 versus 77 [p = 0.0001] and Simple Shoulder Test [SST] of 5.8 versus
7.4 [p = 0.0062]), and patient-reported satisfaction was lower in the HA group than in the RSA group (61%
versus 91%; p = 0.038). Radiographic healing of the tuberosities occurred in 61% of the patients in the HA
group compared with 83% of the patients in the RSA group (p = 0.17). Forward elevation of the arm was
higher in the RSA group (139°) than in the HA group (100°) (p = 0.0002), but no significant differences were
observed for shoulder external rotation or internal rotation. Complication rates in both groups were similar.
Three patients (13%) in the HA group elected revision to reverse shoulder arthroplasty because of failed
tuberosity healing and resultant shoulder pseudoparesis.
Conclusions:
In this series, reverse shoulder arthroplasty resulted in better clinical outcomes and a similar complication
rate compared with hemiarthroplasty for the treatment of comminuted proximal humeral fractures in the
elderly.
Level of Evidence:
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Comparison of Native Anatomy with Recommended Safe Component Orientation in Total
Hip Arthroplasty for Primary Osteoarthritis
20 Nov 2013 12:00 am
Background:
The adverse consequences of impingement, dislocation, and implant wear have stimulated increasing
interest in accurate component orientation in total hip arthroplasty and hip resurfacing. The aims of the
present study were to define femoral and acetabular orientation in a cohort of patients with primary hip
osteoarthritis and to determine whether the orientation of their native hip joints corresponded with
established recommendations for implantation of prosthetic components.
Methods:
We retrospectively evaluated a consecutive series of 131 preoperative computed tomography (CT) scans of
patients with primary end-stage hip osteoarthritis (fifty-seven male and seventy-four female patients; mean
age, sixty years). Patients were positioned according to a standardized protocol. Accounting for pelvic tilt,
three-dimensional acetabular orientation was determined in the anatomical reference frame. Moreover,
three-dimensional femoral version was measured. Differences in native anatomy between male and female
patients were assessed with use of nonparametric tests. Native anatomy was evaluated with reference to
the “safe zone” as described by Lewinnek et al. and to a “safe” combined anteversion of 20° to 40°.
Results:
In the entire cohort, the mean femoral anteversion was 13° and the mean acetabular anteversion was 19°.
No significant differences in femoral, acetabular, or combined (femoral and acetabular) anteversion were
observed between male and female patients. The mean acetabular inclination was 62°. There was no
significant difference in acetabular inclination between female and male patients. We did not observe a
correlation among acetabular inclination, acetabular anteversion, and femoral anteversion. Ninety-five
percent (125) of the native acetabula were classified as being within the safe anteversion zone, whereas
only 15% (nineteen) were classified as being within the safe inclination zone. Combined anteversion was
within the safe limits in 63% (eighty-three) of the patients. However, only 8% (ten) of the cases in the
present cohort met the criteria of both “safe zone” definitions (that of Lewinnek et al. and combined
anteversion).
Conclusions:
Acetabular anteversion of the osteoarthritic hip as defined by the native acetabular rim typically matches the
recommended component “targets” for cup insertion. There was no specific relationship among native
acetabular inclination, acetabular anteversion, and femoral anteversion. Neither native acetabular
inclination nor native combined anteversion appears to be related to current implant insertion targets.
Clinical Relevance:
The present findings of native acetabular and femoral orientation in patients with primary hip osteoarthritis
support intraoperative component positioning for total hip arthroplasty.
Comparison of spinal fusion and nonoperative treatment in patients with chronic low back
pain: long-term follow-up of three randomized controlled trials
06 Nov 2013 12:00 am
Abstract: Background context: Chronic low back pain (cLBP) represents a major challenge to our health
care systems. The relative efficacy of surgery over nonoperative treatment for the treatment of cLBP
remains controversial, and little is known of the long-term comparative outcomes.Purpose: To compare the
clinical outcome at long-term follow-up (LTFU) of patients who were randomized with either spinal fusion or
multidisciplinary cognitive-behavioral and exercise rehabilitation for cLBP.Study design/setting: Long-term
clinical follow-up of three multicenter randomized controlled trials (RCTs) of surgery (instrumented or
noninstrumented fusion, stabilization) versus nonoperative treatment (multidisciplinary cognitive-behavioral
and exercise rehabilitation) in Norway and the United Kingdom.Patient sample: A total of 473 patients with
cLBP of at least 1 year's duration who were all considered candidates for spinal fusion.Outcome measures:
The primary outcome was the Oswestry Disability Index (ODIv2.1a for the United Kingdom and ODIv1 for
Norway) score measured at LTFU. Secondary outcomes included visual analog scale (VAS) pain intensity,
pain frequency, pain medication use, work status, EuroQol VAS for health-related quality of life, satisfaction
with care, and global treatment outcome at LTFU.Methods: Patients who consented to LTFU (average 11.4
[range 8–15] years after the initial treatment) completed the outcome questionnaires.Results: Of 473
enrolled patients, 261 (55%) completed LTFU, 140/242 patients randomized to receive surgery and 121/231
randomized to receive multidisciplinary cognitive-behavioral and exercise rehabilitation. The intention-totreat analysis showed no statistically or clinically significant differences between treatment groups for ODI
scores at LTFU (adjusted for baseline ODI, previous surgery, duration of LBP, sex, age, and smoking
habit): the mean adjusted treatment effect of fusion was −0.7 points on the 0–100 ODI scale (95%
confidence interval [CI], −5.5 to 4.2). An as-treated analysis similarly demonstrated no advantage of surgery
(treatment effect, −0.8 points on the ODI (95% CI, −5.9 to 4.3). The results for the secondary outcomes
were largely consistent with those of the ODI, showing no relevant group differences.Conclusions: After an
average of 11 years follow-up, there was no difference in patient self-rated outcomes between fusion and
multidisciplinary cognitive-behavioral and exercise rehabilitation for cLBP. The results suggest that, given
the increased risks of surgery and the lack of deterioration in nonoperative outcomes over time, the use of
lumbar fusion in cLBP patients should not be favored in health care systems where multidisciplinary
cognitive-behavioral and exercise rehabilitation programmes are available.
Correlation Between Femoral Tunnel Length and Tunnel Position in ACL Reconstruction
20 Nov 2013 12:00 am
Background:
The position of the femoral tunnel affects the osseous geometry available for drilling during anterior cruciate
ligament (ACL) reconstruction. The length of the tunnel changes with changes in the tunnel position and
may have implications for femoral fixation.
Methods:
Forty-seven patients with a single-bundle ACL reconstruction underwent computed tomography (CT)
evaluation to generate three-dimensional (3D) CT bone models. With use of a previously described
anatomic coordinate system, the center of the femoral tunnel was quantified in the posterior-anterior and
proximal-distal dimensions on 3D CT. Tunnel length was defined as the distance between the centers of the
intra-articular and extra-articular tunnel apertures. The reconstructed knees were dichotomized by anatomy
and technique into anatomic (n = 20) and nonanatomic (n = 27) groups as well as according to whether they
had undergone medial portal drilling (n = 20) or transtibial drilling (n = 27) for analysis. In addition, a review
of the literature on the relationship between tunnel length and tendon-to-bone healing was performed.
Results:
Femoral tunnels drilled with nonanatomic footprints were longer (mean [and standard deviation], 43.6 ± 8.5
mm; range, 28.2 to 60.7 mm) than tunnels drilled with anatomic footprints (31.0 ± 6.3 mm; 21.2 to 42.5 mm)
(p < 0.001). Tunnels drilled transtibially (44.4 ± 7.6 mm; 32.5 to 60.7 mm) were significantly longer than
tunnels drilled through the medial portal (29.8 ± 5.0 mm; 21.2 to 40.3 mm) (p < 0.001). There was a strong
correlation between tunnel length and posterior-anterior femoral tunnel position (r = 0.78, p < 0.05), with
more anterior tunnel positioning associated with greater tunnel length. There was no correlation between
posterior-distal femoral tunnel position and tunnel length (r = −0.05; p = 0.74). There was no consensus in
the literature regarding adequate tunnel length for biologic fixation.
Conclusions:
Femoral tunnels drilled with anatomic footprints had sufficient length for adequate femoral fixation. Femoral
tunnels positioned anterior to the native insertion of the ACL were longer than those in anatomic position.
Clinical Relevance:
The results of this study can help the surgeon to consider the relationship between tunnel position and
subsequent tunnel length in ACL reconstruction.
Cytotoxicity of local anesthetics and nonionic contrast agents on bovine intervertebral disc
cells cultured in a three-dimensional culture system - Corrected Proof
18 Nov 2013 12:00 am
Abstract: Background context: Carragee et al. reported an accelerated progression of lumbar intervertebral
disc (IVD) degeneration after discography in a human trial. Local anesthetics and contrast agents have
exhibited toxicity to cardiac, renal, and neuronal cells. We hypothesize that local anesthetics or contrast
agents commonly injected into the disc space during discography may result in cytotoxicity in vitro. In this
study, we compared the cytotoxicity of these agents, alone or in combination, using nucleus pulposus (NP)
and annulus fibrosus (AF) cells in a three-dimensional (3D) culture system.Purpose: The purpose of this
study was to examine the effects of local anesthetics and contrast agents on IVD cells to help guide their
usage in future clinical practices.Study design: Ours was an in vitro study to assess the cytotoxicity of local
anesthetics and contrast agents commonly used in discography, using bovine NP and AF cells cultured in a
3D system.Methods: Bovine NP and AF cells were isolated and encapsulated in alginate beads and
cultured in media completed with serum and ascorbic acid. Beads were transferred to a 24-well plate and
treated with local anesthetics, nonionic contrast agents, or with saline as a control for 2, 6, and 16 hours.
Three different concentrations of local anesthetics, lidocaine and bupivacaine, were tested: 0.25%, 0.125%,
and 0.0625%. Two different dilutions (1:2 or 1:4) of nonionic contras agents, iohexol and iopamidol, were
tested. In a parallel study, beads were incubated with a combination of local anesthetics at equipotent
concentrations and contrast agents for 6 hours. Cells were then examined with the LIVE/DEAD cell assay.
Live cells (fluorescing green) and dead cells (fluorescing red) were visualized using fluorescent microscopy.
The percentage of live cells after treatment was determined.Results: More cell death was observed when
NP and AF cells were incubated with anesthetics than contrast agents at the concentrations tested. When
tested at equipotent concentrations, 0.125% bupivacaine (N=8) resulted in significantly more cell death than
0.5% lidocaine (N=6) in NP cells (p<.05). In these studies, cell death caused by bupivacaine was both dose
and time dependent. When tested at the same dilutions, iopamidol diluted 1:2 caused slightly more cell
death than iohexol. When incubating the cells with a combination of contrast and anesthetic agent, the
cytotoxic effects of the anesthetics and contrast agent were not synergistic. In this culture system, AF cells
were more sensitive to some of the agents than NP cells.Conclusions: Cell death was observed when AF
and NP cells were incubated in a dose- and time-dependent manner with local anesthetics and contrast
agents commonly used for discography. Relative toxicity of these compounds was noted in the order of
bupivacaine, lidocaine, iopamidol, and iohexol. Future studies of the effects of these agents in organ culture
or animal models are indicated to predict what happens in vivo.
December 2013 Letter to the Editor-in-Chief
01 Dec 2013 06:09 am
Journal of Orthopaedic & Sports Physical Therapy, Volume 43, Issue 12, Page 934-936, December 2013.
December 2013 New Products
01 Dec 2013 06:09 am
Journal of Orthopaedic & Sports Physical Therapy, Volume 43, Issue 12, Page 937-938, December 2013.
Decreased posterior cruciate and altered collateral ligament loading following ACL
transection: A longitudinal study in the ovine model
26 Nov 2013 05:58 am
Although ACL deficiency is shown to lead to joint degeneration, few quantitative data are reported on its
effect on soft tissue structures surrounding the knee joint, specifically, the posterior cruciate and collateral
ligaments. The kinematics of the stifle joint of sheep (N = 5) were measured during “normal” gait, as well as
4 and 20 weeks after ACL transection. These motions were reproduced using a unique robotic manipulator
and the loads borne by PCL, MCL, and LCL during gait were determined. Our results demonstrated a
significant decrease in mean PCL loads 20 weeks post-ACL injury, at hoof-strike (0% of gait, p = 0.034),
hoof-off (66% of gait, p = 0.006), peak-swing (85% of gait, p = 0.026), and extension-before-hoof-strike (95%
of gait, p = 0.028). Mean MCL loads did not significantly increase following ACL transection, maybe due to
large between-animal variation. Finally, mean LCL loads indicated a significant decrease (p < 0.047) at 20
weeks across the entire gait cycle. From a clinical perspective, the load redistributions observed in cruciate
and collateral ligaments following ACL injury indicate that these tissues can carry/adapt to the altered
mechanical environment of the joint. The considerable variability in the magnitudes of change following ACL
injury among animals also simulates clinical variability in humans after trauma. © 2013 Orthopaedic
Research Society. Published by Wiley Periodicals, Inc. J Orthop Res
Differences in Neuromuscular Control and Quadriceps Morphology Between Potential
Copers and Noncopers Following ACL Injury
21 Nov 2013 10:41 pm
Journal of Orthopaedic & Sports Physical Therapy, Volume 0, Issue 0, Page 1-26, Ahead of Print.
Discoid Meniscus: The Troublemaker in the Knee Commentary on an article by Seung-Ju
Kim, MD, et al.: “Does Torn Discoid Meniscus Have Effects on Limb Alignment and Arthritic
Change in Middle-Aged Patients?”
20 Nov 2013 12:00 am
Does Torn Discoid Meniscus Have Effects on Limb Alignment and Arthritic Change in
Middle-Aged Patients?
20 Nov 2013 12:00 am
Background:
The purpose of the present study was to evaluate the characteristics of the discoid lateral meniscus in
patients more than forty years of age. We studied whether a torn discoid lateral meniscus that has no
treatment until middle age would increase the tendency of the knee to develop a varus deformity and
investigated the correlation between torn discoid lateral meniscus and osteoarthritis.
Methods:
We retrospectively reviewed the records for 164 knees in 158 patients who were more than forty years old
and who underwent a knee arthroscopic procedure from 1992 to 2007. The mean age at the time of surgery
was fifty-two years. Comparative evaluation of the clinical and radiographic differences between the eightyfour patients with torn discoid lateral meniscus (Group A) and the seventy-four patients with a torn normally
shaped lateral meniscus (Group B) was carried out.
Results:
Preoperative standing anteroposterior radiographs, which were made for all patients, showed that varus
deformity was more common in Group A than in Group B and that osteoarthritic changes in both the medial
and lateral compartments were also more common in Group A. With regard to chondral injury, Outerbridge
grade-3 or 4 involvement was identified in 46% of the knees in Group A and 18% of the knees in Group B.
Conclusions:
In the present study of middle-aged patients, those with a torn discoid lateral meniscus had a higher
prevalence of varus knee deformity and a higher prevalence of osteoarthritis. Knees with a discoid lateral
meniscus that have diminished valgus alignment should be monitored carefully with long-term follow-up
because a discoid lateral meniscus may increase the risk for progression to degenerative knee
osteoarthritis.
Level of Evidence:
Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Does Tranexamic Acid Reduce Blood Loss in Total Knee Arthroplasty? Commentary on an
article by X. Aguilera, MD, et al.:“Efficacy and Safety of Fibrin Glue and Tranexamic Acid to
Prevent Postoperative Blood Loss in Total Knee Arthroplasty. A Randomized Controlled
Clinical Trial”
20 Nov 2013 12:00 am
Does the presence of the fibronectin-aggrecan complex predict outcomes from lumbar
discectomy for disc herniation? - Corrected Proof
18 Nov 2013 12:00 am
Abstract: Background context: Protein biomarkers associated with lumbar disc disease have been studied
as diagnostic indicators and therapeutic targets. Recently, a cartilage degradation product, the fibronectinaggrecan complex (FAC) identified in the epidural space, has been shown to predict response to lumbar
epidural steroid injection in patients with radiculopathy from herniated nucleus pulposus (HNP).Purpose:
Determine the ability of FAC to predict response to microdiscectomy for patients with radiculopathy due to
lumbar disc herniationStudy design/setting: Single-center prospective consecutive cohort study.Patient
sample: Patients with radiculopathy from HNP with concordant symptoms to MRI who underwent
microdiscectomy.Outcomes measures: Oswestry disability index (ODI) and visual analog scores (VAS)
were noted at baseline and at 3-month follow-up. Primary outcome of clinical improvement was defined as
patients with both a decrease in VAS of at least 3 points and ODI >20 points.Methods: Intraoperative
sampling was done via lavage of the excised fragment by ELISA for presence of FAC. Funding for the
ELISA was provided by Cytonics, Inc.Results: Seventy-five patients had full complement of data and were
included in this analysis. At 3-month follow-up, 57 (76%) patents were “better.” There was a statistically
significant association of the presence of FAC and clinical improvement (p=.017) with an 85% positive
predictive value. Receiver-operating-characteristic (ROC) curve plotting association of FAC and clinical
improvement demonstrates an area under the curve (AUC) of 0.66±0.08 (p=.037). Subset analysis of those
with weakness on physical examination (n=48) plotting the association of FAC and improvement shows
AUC on ROC of 0.81±0.067 (p=.002).Conclusions: Patients who are “FAC+” are more likely to demonstrate
clinical improvement following microdiscectomy. The data suggest that the inflammatory milieu plays a
significant role regarding improvement in patients undergoing discectomy for radiculopathy in lumbar HNP,
even in those with preoperative weakness. The FAC represents a potential target for treatment in HNP.
Down-regulation of collagen synthesis and matrix metalloproteinase expression in
myofibroblasts from dupuytren nodule using adenovirus-mediated relaxin gene therapy
30 Nov 2013 02:35 pm
Dupuytren's disease is a fibroproliferative connective tissue disorder characterized by contracture of the
palmer fascia of the hand. Relaxin (RLN) is a multifunctional factor which contributes to the remodeling of
the pelvic ligament by inhibiting fibrosis and inflammatory activities. The aim of this study was to investigate
the effect of the RLN gene on the inhibition of fibrosis in myofibroblastic cells. Myofibroblast cells with
adenovirus LacZ (Ad-LacZ) as a marker gene or adenovirus relaxin (Ad-RLN) as therapeutic gene showed
transgene expressions in beta-galactosidase assay and Western blot analysis. Myofibroblastic cells with
Ad-RLN demonstrated a 22% and 48% reduction in collagen I and III mRNA expressions respectively, a
50% decrease in MMP-1, 70% decrease in MMP-2, 80% decrease in MMP-9, and a 15% reduction in MMP13 protein expression compared with cultures with viral control and saline control. In addition,
myofibroblastic cells with Ad-RLN showed a 40% decrease in TIMP 1 and a 15% increase in TIMP 3 protein
expression at 48 h compared to cultures with viral control and saline control. Also, myofibroblastic cell with
Ad-RLN demonstrated a 74% inhibition of fibronectin and a 52% decrease in total collagen synthesis at 48 h
compared with cultures with viral control and saline control. In conclusion, the RLN gene render
antifibrogenic effect on myofibroblastic cells from Dupuytren's nodule via direct inhibition of collagen
synthesis not through collagenolytic pathway such as MMP-1, -13, TIMP 1, and 3. Therefore relaxin can be
an alternative therapeutic strategy in initial stage of Dupuytren's disease by its antifibrogenic effect. © 2013
Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res
Effectiveness of the Alfredson’s Protocol Compared With a Lower Repetition Volume
Protocol for Mid-portion Achilles Tendinopathy: A Randomized Controlled Trial
21 Nov 2013 10:40 pm
Journal of Orthopaedic & Sports Physical Therapy, Volume 0, Issue 0, Page 1-36, Ahead of Print.
Efficacy and Safety of Fibrin Glue and Tranexamic Acid to Prevent Postoperative Blood
Loss in Total Knee Arthroplasty A Randomized Controlled Clinical Trial
20 Nov 2013 12:00 am
Background:
Postoperative blood loss in patients after total knee arthroplasty may cause local and systemic
complications and influence clinical outcome. The aim of this study was to assess whether fibrin glue or
tranexamic acid reduced blood loss compared with routine hemostasis in patients undergoing total knee
arthroplasty.
Methods:
A randomized, single-center, parallel, open clinical trial was performed in adult patients undergoing primary
total knee arthroplasty. Patients were divided into four groups. Group 1 received fibrin glue manufactured by
the Blood and Tissue Bank of Catalonia, Group 2 received Tissucol (fibrinogen and thrombin), Group 3
received intravenous tranexamic acid, and Group 4 (control) had no treatment other than routine
hemostasis. The primary outcome was total blood loss collected in drains after surgery. Secondary
outcomes were the calculated hidden blood loss, transfusion rate, preoperative and postoperative
hemoglobin, number of blood units transfused, adverse events, and mortality.
Results:
One hundred and seventy-two patients were included. The mean total blood loss (and standard deviation)
collected in drains was 553.9 ± 321.5 mL for Group 1, 567.8 ± 299.3 mL for Group 2, 244.1 ± 223.4 mL for
Group 3, and 563.5 ± 269.7 mL for Group 4. In comparison with the control group, Group 3 had significantly
lower total blood loss (p < 0.001), but it was not significantly lower in Groups 1 and 2. The overall rate of
patients who had a blood transfusion was 21.1% (thirty-five of 166 patients analyzed per protocol). Two
patients required transfusion in Group 3 compared with twelve patients in Group 4 (p = 0.015). No
significant difference was observed between the two fibrin glue groups and the control group with regard to
the need for transfusion. There was no difference between groups with regard to the percentage of adverse
events.
Conclusions:
Neither type of fibrin glue was more effective than routine hemostasis in reducing postoperative bleeding
and transfusion requirements, and we no longer use them. However, this trial supports findings from
previous studies showing that intravenous tranexamic acid can decrease postoperative blood loss.
Level of Evidence:
Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Efficacy of a sclerostin antibody compared to a low dose of PTH on metaphyseal bone
healing
14 Nov 2013 10:07 am
We compared the effect of a sclerostin antibody to that of a clinically relevant dose of parathyroid hormone
(PTH) in a rat model for metaphyseal bone healing. Screws of steel or poly methyl methacrylate (PMMA)
were inserted bilaterally into the proximal tibia of young male rats. During 4 weeks the animals then
received injections of either phosphate buffered saline (control), sclerostin antibody (25 mg/kg, twice weekly)
or PTH (5 µg/kg, daily). The healing response around the screws was then assessed by mechanical testing
and X-ray microtomography (µCT). To distinguish between effects on healing and general effects on the
skeleton, other untraumatized bone sites and serum biomarkers were also assessed. After 4 weeks of
treatment, PTH yielded a 48% increase in screw pull-out force compared to control (p = 0.03), while the
antibody had no significant effect. In contrast, the antibody increased femoral cortical and vertebral strength
where PTH had no significant effect. µCT showed only slight changes that were statistically significant for
the antibody mainly at cortical sites. The results suggest that a relatively low dose of PTH stimulates
metaphyseal repair (screw fixation) specifically, whereas the sclerostin antibody has wide-spread effects,
mainly on cortical bone, with less influence on metaphyseal healing. © 2013 Orthopaedic Research Society.
Published by Wiley Periodicals, Inc. J Orthop Res
Enhanced spinal fusion using a biodegradable porous mesh container in a rat posterolateral
spinal fusion model - Corrected Proof
22 Nov 2013 12:00 am
Abstract: Background context: Posterolateral fusion (PLF) with an autogenous iliac bone graft is the most
common procedure for treating various lumbar spinal diseases. However, the limited success and
associated morbidity from an iliac crest graft demands new biologically competent graft enhancers or
substitutes.Purpose: To investigate the feasibility of tubular mesh container made of bioabsorbable sutures
(poly-1,4-dioxane-2-one, PDO) for spinal fusion.Study design: Experimental animal study.Methods: A
biodegradable PDO tubular mesh container was used to contain small pieces of bone grafts. Twenty
Sprague-Dawley male rats underwent PLF between L4 and L5 transverse processes with bilateral iliac
grafts. Experimental animals were assigned into two different groups: autograft-only group (N=10) that
underwent PLF with autograft-only or mesh container group (N=10) that underwent PLF with tubular mesh
container filled with autogenous bone grafts. The rats were sacrificed at 8 weeks postoperatively, and the
lumbar spines were removed. Spinal fusion was evaluated by manual palpation, microcomputed
tomography, three-point bending test, and histological examination.Results: Solid fusion was achieved in all
cases of the mesh container group, whereas the autograft-only group showed 60% of solid fusion. New
bone mass was higher and more solidly fused in the mesh container group than the autograft-only group
(p<.01). Volume of fusion mass and density of bone were significantly higher in the mesh container group
(p<.05). In all cases, inflammatory response was minimal.Conclusions: This study demonstrated that a
tubular mesh container made of bioabsorbable suture is useful to hold small pieces of bone grafts and to
enhance spinal fusion.
Evaluation of a bipolar-cooled radiofrequency device for ablation of bone metastases:
preclinical assessment in porcine vertebrae - Corrected Proof
25 Nov 2013 12:00 am
Abstract: Background context: Cancer spread to the spine affects bone stability and can lead to pathologic
fracture and neurologic impairment. Radiofrequency ablation (RFA) recently has gained popularity in
treating skeletal tumors. Conventional RFA devices use a monopolar design, which limits the ability to
comprehensively treat large tumors in bony tissues and may pose risks to adjacent critical normal
neurologic tissues when applied to vertebrae. New bipolar-cooled radiofrequency (BCRF) may generate
larger controlled lesions without the same degree of risk to adjacent structures.Purpose: The purpose of this
study was to evaluate the feasibility, efficacy, and safety of RFA with the use of a new bone-specific, BCRF
probe in a porcine vertebral model and to evaluate the ability of magnetic resonance (MR) imaging to
represent histologic outcomes of RFA treatment.Study design: Basic science: preclinical in vivo
study.Methods: RFA was evaluated in three noncontiguous lumbar vertebrae in six Yorkshire pigs (25–30
kg). Via a transpedicular approach for probe placement, two vertebrae received BCRF treatment and one
vertebrae served as a sham control. MR imaging and neurological assessments were conducted pre- and
posttreatment as well as immediately before animal sacrifice (n=3 at day 0, n=3 at day 14). MR ablation
zones were compared with hematoxylin and eosin–stained histological sections.Results: With BCRF, large
reproducible zones of ablation were achieved, confined within the vertebrae, without damage to adjacent
tissues or the spinal cord. All animals demonstrated normal consistent neurologic behavior pre- and
posttreatment. External tissue temperatures around targeted vertebrae were not increased. MR imaging
after 14 days was more effective in demonstrating ablation effects than images on day 0, with radiologic
findings most apparent on T2-weighted sequences. Histologic analysis of samples corresponded well to the
zones of ablation observed on MR images (R=0.9, p<.01).Conclusions: The study demonstrated feasibility,
safety, and effectiveness of BCRF ablation of vertebral bone. This motivates ongoing preclinical evaluation
in diseased models to further explore the potential for its use in clinical treatment of metastatic vertebrae.
Feasibility and biomechanical performance of a novel transdiscal screw system for one
level in non-spondylolisthetic lumbar fusion: an in vitro investigation - Corrected Proof
22 Nov 2013 12:00 am
Abstract: Background context: The bilateral pedicle screw system (BPSS) is currently the “gold standard”
fusion technique for spinal instability. A new stabilization system that provides the same level of stability
through a less invasive procedure will have a high impact on clinical practice. A new transdiscal screw
system is investigated as a promising minimally invasive device.Purpose: To evaluate the feasibility of a
novel transdiscal screw in spinal fixation as an alternative to BPSS, with and without an interbody cage, in
non-spondylolisthesis cases.Study design: An in vitro biomechanical study in lumbar cadaveric
spines.Methods: Twelve lumbar cadaveric segments (L4–S1) were tested under flexion-extension (FE),
lateral bending (LB), and axial rotation (AR). Six treatments were simulated as follows: (1) intact, (2)
bilateral facetectomy at L4–L5, (3) transdiscal screw system, (4) BPSS, (5) BPSS with transforaminal
lumbar interbody cage, and (6) transdiscal screws with transforaminal interbody cage. Specimens were
randomly divided into two testing groups: Group 1 (n=6) was tested under the first five conditions, in the
order presented, whereas Group 2 (n=6) was tested under the first, second, third, fourth, and sixth
conditions, with the fourth condition preceding the third. Range of motion (ROM) and neutral zone stiffness
(NZS) were estimated and normalized with respect to the intact condition to explore statistical differences
among treatments using non-parametric approaches.Results: Significant differences in FE ROM were
observed in the pedicle screws-cage condition with respect to the facetectomy (p<.01), the pedicle screw
(p=.03), and the transdiscal screw (p<.02) conditions. All fixation constructs significantly restricted LB and
AR ROM (p<.01) with respect to facetectomy. In terms of stiffness, the pedicle screw and the transdiscal
screw systems increased (p<.01) LB and AR NZS with respect to facetectomy. The pedicle screws-cage
condition significantly increased flexion and extension stiffness with respect to all other conditions (p<.05).
However, LB NZS for the pedicle screws-cage and the transdiscal screws-cage condition could not be
explored due to a testing order bias effect. There was not enough evidence to state any difference between
the pedicle and transdiscal screw conditions in terms of ROM or NZS.Conclusions: Transdiscal and pedicle
screw systems showed comparable in vitro biomechanical performance in the immediate stabilization of a
complete bilateral facetectomy. The pedicle screws-cage condition was the most stable in FE motion;
however, comparison with respect to the transdiscal screws-cage condition could not be investigated.
Finite element investigation of the effect of a bifid arch on loading of the vertebral isthmus Corrected Proof
22 Nov 2013 12:00 am
Abstract: Background: The biomechanical effect of a bifid arch as seen in spina bifida occulta and following
a midline laminectomy is poorly understood.Purpose: To test the hypothesis that fatigue failure limits will be
exceeded in the case of a bifid arch, but not in the intact case, when the segment is subjected to complex
loading corresponding to normal sporting activities.Study design: Finite element analysis.Methods: Finite
element model of an intact L4-S1 human lumbar motion segment including ligaments was used. A section
of the L5 vertebral arch and spinous process was removed to create the model with a midline defect. The
models were loaded axially to 1 kN and then combined with axial rotation of 3°. Bilateral stresses,
alternating stresses, and shear fatigue failure on both models were assessed and compared.Results: Under
1 kN axial load, the von Mises stresses observed in midline defect case and in the intact case were very
similar (differences <5 MPa) having a maximum at the ventral end of the isthmus that decreases
monotonically to the dorsal end. However, under 1 kN axial load and rotation, the maximum von Mises
stresses observed in the ipsilateral L5 isthmus in the midline defect case (31 MPa) was much higher than
the intact case (24.2 MPa), indicating a lack of load sharing across the vertebral arch in the midline defect
case. When assessing the equivalent alternating shear stress amplitude, this was found to be 22.6 MPa for
the midline defect case and 13.6 MPa for the intact case. From this, it is estimated that shear fatigue failure
will occur in less than 70,000 cycles, under repetitive axial load and rotation conditions in the midline defect
case, whereas for the intact case, fatigue failure will occur only after more than 10 million
cycles.Conclusions: A bifid arch predisposes the isthmus to early fatigue fracture by generating increased
stresses across the inferior isthmus of the inferior articular process, specifically in combined axial rotation
and anteroposterior shear.
Fracture of the Lateral Femoral Condyle
01 Dec 2013 06:09 am
Journal of Orthopaedic & Sports Physical Therapy, Volume 43, Issue 12, Page 933, December 2013.
Gabapentin Did Not Reduce Morphine Consumption, Pain, or Opioid-Related Side Effects
in Total Knee Arthroplasty
20 Nov 2013 12:00 am
Guiding Femoral Rotational Growth in an Animal Model
20 Nov 2013 12:00 am
Background:
Guided growth is most commonly utilized about the knee and ankle for the correction of coronal-plane
deformities by the use of plates positioned perpendicular to the physis. Sagittal-plane deformity correction
has been described as well. The purpose of our study was to examine the ability to affect axial-rotational
growth. Our hypothesis was that placement of plates in an oblique orientation relative to the physis can
induce rotational growth deformity.
Methods:
Our hypothesis was tested with use of a mathematical model and a bone model and subsequently in a
rabbit model. Thirteen six-week-old rabbits underwent a rotational guided growth procedure involving the
distal aspect of the right femur, with a sham procedure performed on the left side. Two plates were
positioned in an oblique orientation relative to the physis, medially and laterally, to guide either internal or
external rotational growth. After the rabbits were killed six weeks after the surgery, the femoral rotational
profile was assessed by computed tomography scans of the dissected femora and the growth plates were
examined histologically.
Results:
A significant effect on the rotational profile was found in the treated femora. When the plates were
positioned to guide external rotation, the rotational profile was significantly greater in the treated femora
(29.0° compared with 11.3° in the sham femora; p = 0.008). There was a positive linear correlation between
the right-left difference in rotational profile and the change in inter-plate angle (R2 = 0.72, p = 0.001). Every
1° of inter-plate angle change induced 0.367° of rotational profile difference (p = 0.001). Histologically, a
swirling effect of the physeal cell columns was seen in the treated femora.
Conclusions:
Guided growth using plates was demonstrated to alter axial-rotational growth in a predictable fashion in a
rabbit model.
Clinical Relevance:
Guided growth using plates may be effective for correction of rotational and multiplanar deformities.
How many different types of femora are there in primary hip osteoarthritis? An active shape
modeling study
19 Nov 2013 05:55 am
We assessed the variation in proximal femoral canal shape and its association with geometric and
demographic parameters in primary hip OA. In a retrospective cohort study, the joint geometry of the
proximal femur was evaluated on radiographs and corresponding CT scans of 345 consecutive patients
with end-stage hip OA. Active shape modeling (ASM) was performed to assess the variation in endosteal
shape of the proximal femur. To identify natural groupings of patients, hierarchical cluster analysis of the
shape modes was used. ASM identified 10 independent shape modes accounting for >96% of the variation
in proximal femoral canal shape within the dataset. Cluster analysis revealed 10 specific shape clusters.
Significant differences in geometric and demographic parameters between the clusters were observed.
ASM and subsequent cluster analysis have the potential to identify specific morphological patterns of the
proximal femur despite the variability in proximal femoral anatomy. The study identified patterns of proximal
femoral canal shape in hip OA that allow a comprehensive classification of variation in shape and its
association with joint geometry. Our data may improve future stem designs that will optimize stem fit and
simultaneously allow individual restoration of hip biomechanics. © 2013 Orthopaedic Research Society.
Published by Wiley Periodicals, Inc. J Orthop Res
Hyperemia in Plantar Fasciitis Determined by Power Doppler Ultrasound
01 Dec 2013 06:09 am
Journal of Orthopaedic & Sports Physical Therapy, Volume 43, Issue 12, Page 875-880, December 2013.
In vivo diagnostics of human knee cartilage lesions using delayed CBCT arthrography
19 Nov 2013 05:50 am
The aim of this study was to investigate the feasibility of delayed cone beam (CBCT) arthrography for
clinical diagnostics of knee cartilage lesions. Knee joints with cartilage lesions were imaged using native
radiography, MRI, and delayed CBCT arthrography techniques in vivo. The joints were imaged three times
with CBCT, just before, immediately after (arthrography) and 45 min after the intra-articular injection of
contrast agent. The arthrographic images enabled sensitive detection of the cartilage lesions. Use of
arthrographic and delayed images together with their subtraction image enabled also detection of cartilage
with inferior integrity. The contrast agent partition in intact cartilage (ICRS grade 0) was lower (p < 0.05) than
that of cartilage surrounding the ICRS grade I–IV lesions. Delayed CBCT arthrography provides a novel
method for diagnostics of cartilage lesions. Potentially, it can also be used in diagnostics of cartilage
degeneration. Due to shorter imaging times, higher resolution, and lower costs of CT over MRI, this
technique could provide an alternative for diagnostics of knee pathologies. However, for comprehensive
evaluation of the clinical potential of the technique a further clinical study with a large pool of patients having
a wide range of cartilage pathologies needs to be conducted. © 2013 Orthopaedic Research Society.
Published by Wiley Periodicals, Inc. J Orthop Res
Influence of biochemical composition on endplate cartilage tensile properties in the human
lumbar spine
23 Nov 2013 03:28 am
Endplate cartilage integrity is critical to spine health and is presumably impaired by deterioration in
biochemical composition. Yet, quantitative relationships between endplate biochemical composition and
biomechanical properties are unavailable. Using endplate cartilage harvested from human lumbar spines
(six donors, ages 51–67 years) we showed that endplate biochemical composition has a significant
influence on its equilibrium tensile properties and that the presence of endplate damage associates with a
diminished composition–function relationship. We found that the equilibrium tensile modulus (5.9 ± 5.7 MPa)
correlated significantly with collagen content (559 ± 147 µg/mg dry weight, r2 = 0.35) and with the
collagen/GAG ratio (6.0 ± 2.1, r2 = 0.58). Accounting for the damage status of the adjacent cartilage
improved the latter correlation (r2 = 0.77) and indicated that samples with adjacent damage such as fissures
and avulsions had a diminished modulus–collagen/GAG relationship (p = 0.02). Quasi-linear viscoelastic
relaxation properties (C, τ1, and τ2) did not correlate with biochemical composition. We conclude that
reduced matrix quantity decreases the equilibrium tensile modulus of human endplate cartilage and that
characteristics of biochemical composition that are independent of matrix quantity, that is, characteristics
related to matrix quality, may also be important. © 2013 Orthopaedic Research Society. Published by Wiley
Periodicals, Inc. J Orthop Res
Influence of implant rod curvature on sagittal correction of scoliosis deformity - Corrected
Proof
25 Nov 2013 12:00 am
Abstract: Background context: Deformation of in vivo–implanted rods could alter the scoliosis sagittal
correction. To our knowledge, no previous authors have investigated the influence of implanted-rod
deformation on the sagittal deformity correction during scoliosis surgery.Purpose: To analyze the changes
of the implant rod's angle of curvature during surgery and establish its influence on sagittal correction of
scoliosis deformity.Study design: A retrospective analysis of the preoperative and postoperative implant rod
geometry and angle of curvature was conducted.Patient sample: Twenty adolescent idiopathic scoliosis
patients underwent surgery. Average age at the time of operation was 14 years.Outcome measures: The
preoperative and postoperative implant rod angle of curvature expressed in degrees was obtained for each
patient.Methods: Two implant rods were attached to the concave and convex side of the spinal deformity.
The preoperative implant rod geometry was measured before surgical implantation. The postoperative
implant rod geometry after surgery was measured by computed tomography. The implant rod angle of
curvature at the sagittal plane was obtained from the implant rod geometry. The angle of curvature between
the implant rod extreme ends was measured before implantation and after surgery. The sagittal curvature
between the corresponding spinal levels of healthy adolescents obtained by previous studies was
compared with the implant rod angle of curvature to evaluate the sagittal curve correction. The difference
between the postoperative implant rod angle of curvature and normal spine sagittal curvature of the
corresponding instrumented level was used to evaluate over or under correction of the sagittal
deformity.Results: The implant rods at the concave side of deformity of all patients were significantly
deformed after surgery. The average degree of rod deformation Δθ at the concave and convex sides was
15.8° and 1.6°, respectively. The average preoperative and postoperative implant rod angle of curvature at
the concave side was 33.6° and 17.8°, respectively. The average preoperative and postoperative implant
rod angle of curvature at the convex side was 25.5° and 23.9°, respectively. A significant relationship was
found between the degree of rod deformation and preoperative implant rod angle of curvature (r=0.60,
p<.005). The implant rods at the convex side of all patients did not have significant deformation. The results
indicate that the postoperative sagittal outcome could be predicted from the initial rod shape.Conclusions:
Changes in implant rod angle of curvature may lead to over- or undercorrection of the sagittal curve. Rod
deformation at the concave side suggests that corrective forces acting on that side are greater than the
convex side.
Inhibition of cell-matrix adhesions prevents cartilage chondrocyte death following impact
injury
19 Nov 2013 06:30 am
Focal adhesions are transmembrane protein complexes that attach chondrocytes to the pericellular
cartilage matrix and in turn, are linked to intracellular organelles via cytoskeleton. We previously found that
excessive compression of articular cartilage leads to cytoskeleton-dependent chondrocyte death. Here we
tested the hypothesis that this process also requires integrin activation and signaling via focal adhesion
kinase (FAK) and Src family kinase (SFK). Osteochondral explants were treated with FAK and SFK
inhibitors (FAKi, SFKi, respectively) for 2 h and then subjected to a death-inducing impact load. Chondrocyte
viability was assessed by confocal microscopy immediately and at 24 h post-impact. With no treatment
immediate post-impact viability was 59%. Treatment with 10 µM SFKi, 10 μM, or 100 µM FAKi improved
viability to 80%, 77%, and 82%, respectively (p < 0.05). After 24 h viability declined to 34% in controls, 48%
with 10 µM SFKi, 45% with 10 µM FAKi, and 56% with 100 µM FAKi (p < 0.01) treatment. These results
confirmed that most of the acute chondrocyte mortality was FAK- and SFK-dependent, which implicates
integrin-cytoskeleton interactions in the death signaling pathway. Together with previous findings, these
data support the hypothesis that the excessive tissue strains accompanying impact loading induce death via
a pathway initiated by strain on cell adhesion receptors. © 2013 Orthopaedic Research Society. Published
by Wiley Periodicals, Inc. J Orthop Res
Injury and lumbar reposition sense in cricket pace bowlers in neutral and pace bowling
specific body positions - Corrected Proof
25 Nov 2013 12:00 am
Abstract: Background and context: The cricket pace bowling action consists of a complex sequence of
forceful actions, involving practiced, particular movements of the lumbar spine. The nature and repetition of
the pace bowling action is known to be associated with a high incidence of low back injuries.Purpose: This
study aimed to establish whether lumbar proprioception (as measured by joint position sense) in the neutral
lumbar spine position as well as lumbar positions corresponding to those at front foot placement and ball
release positions of the cricket pace bowling action were related to previous injury and injury sustained
during the cricket season under review. Injuries specifically sustained during the bowling action and those
specific to the low back were explicitly investigated.Study setting: Longitudinal study with participants tested
at the start and monitored over the duration of a cricket season.Participant sample: Seventeen male cricket
pace bowlers between the ages of 18 and 26 years participated in this study.Outcome measures:
Physiological outcome measures were used. Lumbar position sense was established using
electrogoniometry.Methods: Lumbar reposition error was measured in three positions (neutral lumbar spine,
front foot placement, and ball release bowling positions). In each position, lumbar orientation was
determined in the sagittal (flexion-extension) and coronal (left-right lateral flexion) planes. Wilcoxon
matched-pairs ranks and Kruskal-Wallis tests were used to establish the relationship between
variables.Results: Reposition error was associated with general injuries sustained in the past and during the
cricket season under review, low back injuries, as well as injuries sustained during the bowling action
(p<.05).Conclusion: Lumbar position sense, as a measure of proprioception, was related to injury in
general, injuries sustained during the bowling action, and, especially, low back injury sustained in the past.
Low back injury prevention methods are particularly needed because of the high load nature of the pace
bowling action. If the proprioception of the lumbar spine is improved in pace bowlers, their risk of lumbar
injury can potentially be reduced.
Inpatient Pulmonary Embolism After Elective Primary Total Hip and Knee Arthroplasty in the
United States
20 Nov 2013 12:00 am
Background:
The incidence of inpatient pulmonary embolism in patients who have elective primary hip and knee
arthroplasty in the United States is unknown. Prior studies have included patients with cancer, trauma, or
revisions. The goal of this study was to determine the incidence and risks of inpatient pulmonary embolism
after elective arthroplasty by type of procedure.
Methods:
We used the 1998 to 2009 Healthcare Cost and Utilization Project Nationwide Inpatient Sample for this
retrospective cohort study. Patients who were sixty years of age or older and underwent elective primary
total hip or knee arthroplasty were included. The study variable was the type of arthroplasty: total hip, total
knee, or two joints. Inpatient pulmonary embolism was the primary outcome; mortality was secondary.
Logistic regression determined the adjusted odds ratios of inpatient pulmonary embolism by procedure,
adjusting for age, sex, Charlson Comorbidity Index, atrial fibrillation, and surgical indication.
Results:
Records represented 5,044,403 hospital discharges after primary total hip or knee arthroplasty. Total knee
arthroplasty comprised 66% of the admissions. Less than 5% of patients had two joint procedures. The
overall incidence of pulmonary embolism was 0.358% (95% confidence interval [CI], 0.338, 0.378). The
incidence of pulmonary embolism differed by procedure and was highest among patients who had two-joint
arthroplasty (0.777%; 95% CI, 0.677, 0.876), was lowest in recipients of total hip arthroplasty (0.201%; 95%
CI, 0.179, 0.223), and was intermediate in patients who had total knee arthroplasty (0.400%; 95% CI, 0.377,
0.423). The adjusted odds ratios of pulmonary embolism in patients who had two joint procedures were
3.89 times higher than among patients who had total hip arthroplasty, controlling for other factors.
Conclusions:
Elective total knee arthroplasty is associated with a higher incidence and odds of inpatient pulmonary
embolism than is total hip arthroplasty; multiple procedures pose the highest risk for pulmonary embolism
and associated mortality.
Level of Evidence:
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Interesting Case of Subependymoma of the Spinal Cord - Accepted Manuscript
21 Nov 2013 12:00 am
Abstract: Background Context: Subependymomas are rare, slow-growing, usually non-invasive/ nonaggressive WHO Grade I tumors which tend to occur in the ventricles. Their most common site of
occurrence is the fourth ventricle followed by the lateral ventricles. Spinal cord subependymomas typically
manifest as cervical and cervico-thoracic intramedullary or, rarely, extramedullary mass lesions. They often
present clinically with pain and neurological symptoms including motor, sensory, urinary, and sexual
dysfunction. Histologically, there are hypocellular areas with occasional clusters of cells and frequent
microcystic changes, calcifications and hemorrhage. Radiologically, subependymomas generally manifest
as eccentric well circumscribed nodular lesions with mild to moderate enhancement.Purpose: To highlight
an interesting and rare presentation for subependymoma of the spinal cord.Study Design/ Setting: This is a
case report of a single patient for whom a subependymoma was resected from his cervical spinal cord with
return to normal functioning.Methods: Clinical examination, MRI evaluation, surgical resection, and
histological analysis were performed for diagnosis and treatment of this patient.Results: The patient
experiencing myelopathy symptoms underwent surgical resection of a cervical spinal cord
subependymoma, which resulted in return to normal function.Conclusions: Subependymoma should be
included in the differential diagnosis of atypical presentations for myelopathy as discrete surgical resection
can result in good outcome.
Intervention timing of strontium treatment on estrogen depletion-induced osteoporosis in
rats: Bone microstructure and mechanics
14 Nov 2013 10:07 am
Purpose To evaluate the effect of intervention timing of Sr treatment on trabecular bone microstructure and
mechanics. Methods Ninety female rats were randomly divided into three batches with three groups in each
batch. Each group was divided according to the initiation timing of vehicle or strontium compound (SrC),
which was at week 0 (early), 4 (mid-term) and 8 (late) after the ovariectomy, respectively. The treatment
lasted for 12 weeks. The trabecular bone biomechanical properties, trabecular bone tissue mechanical
properties, trabecular bone microstructure, and bone remodeling were analyzed with mechanical testing,
nanoindentation, microCT, and histomorphometry, respectively. The osteoblast and osteoclast phenotypic
genes were analyzed with real-time polymerase chain reaction (PCR). Results Early and mid-term Sr
treatment significantly increased biomechanical properties of trabecular bone, which was associated with
increased microarchitecture parameters, increased bone formation parameters and up-regulation of
osteoblast-related gene expression. Late Sr treatment failed to exert a beneficial effect on any of those
parameters. Conclusions The beneficial effect of Sr was dependent on the intervention timing in
ovariectomized rats. © 2013 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop
Res
Intervertebral discs from spinal nondeformity and deformity patients have different
mechanical and matrix properties - Corrected Proof
18 Nov 2013 12:00 am
Abstract: Background context: It is well-established that disc mechanical properties degrade with
degeneration. However, prior studies utilized cadaveric tissues from donors with undefined back pain
history. Disc degeneration may present with pain at the affected motion segment, or it may be present in the
absence of back pain. The mechanical properties and matrix quantity of discs removed and diagnosed for
degeneration with patient chronic pain may be distinct from those with other diagnoses, such as spinal
deformity.Purpose: To test the hypothesis that discs from nondeformity segments have inferior mechanical
properties than deformity discs owing to differences in matrix quality.Study design/setting: In vitro study
comparing the mechanical and matrix properties of discs from surgery patients with spinal nondeformity and
deformity.Methods: We analyzed nucleus and annulus samples (8–11 specimens per group) from surgical
discectomy patients as part of a fusion or disc replacement procedure. Tissues were divided into two
cohorts: nondeformity and deformity. Dynamic indentation tests were used to determine energy dissipation,
indentation modulus, and viscoelasticity. Tissue hydration at a physiologic pressure was assessed by
equilibrium dialysis. Proteoglycan, collagen, and collagen cross-link content were quantified. Matrix
structure was assessed by histology.Results: We observed that energy dissipation was significantly higher
in the nondeformity nucleus than in the deformity nucleus. Equilibrium dialysis experiments showed that
annulus swelling was significantly lower in the nondeformity group. Consistent with this, we observed that
the nondeformity annulus had lower proteoglycan and higher collagen contents.Conclusions: Our data
suggest that discs from nondeformity discs have subtle differences in mechanical properties compared with
deformity discs. These differences were partially explained by matrix biochemical composition for the
annulus, but not for the nucleus. The results of this study suggest that compromised matrix quality and
diminished mechanical properties are features that potentially accompany discs of patients undergoing
segmental fusion or disc replacement for disc degeneration and chronic back pain. These features have
previously been implicated in pain via instability or reduced motion segment stiffness.
Key role for the transcriptional factor, osterix, in spine development - Corrected Proof
22 Nov 2013 12:00 am
Abstract: Background context: Osterix (Osx) is an important transcriptional factor for bone formation;
however, its role in spine development has not been determined.Purpose: The goal of the present study is
to observe the role of Osx in spine development.Study design/setting: Deletion and overexpression of Osx
were achieved in Osx knockout and transgenic mice, respectively, to determine the effect of Osx on spine
development.Methods: With 2.3-kb type I collagen as a promoter, Osx were deleted in mice, and
overexpression of Osx was obtained in Osx transgenic mice. Video, X-ray radiology, histology, tartrateresistant acid phosphatase staining, Safranin O staining, and immunohistochemistry were used to assess
the effect of Osx deletion and overexpression on spine development. This study was supported by National
Science Foundation of China (81271935) and Foundation of State Key Laboratory of Trauma, Burns and
combined injury (SKLZZ SKLZZ201124). No potential conflict of interest to disclose.Results:
Overexpression of Osx did not have an obvious effect on spine development, whereas deletion of Osx led
to severe spine deformities that included wedged vertebrae, spinal stenosis, and congenital scoliosis. Also,
Osx deactivation resulted in shortened vertebrae and excessive bone volume in the vertebrae. TRAP
staining showed that activity of osteoclasts decreased in Osx-null mice, and examination with TdT-mediated
dUTP nick end labeling revealed that the apoptosis rate at the growth plate decreased significantly in Osxnull mice. Excessive formation of bone was positive for Safranin O staining.Conclusions: Osx plays an
important role in spine development, and its deactivation leads to severe spine deformities.
Long-term clinical outcome of sacral chondrosarcoma treated by total en bloc sacrectomy
and reconstruction of lumbosacral and pelvic ring using intraoperative extracorporeal
irradiated autologous tumor-bearing sacrum A case report with ten years follow-up Accepted Manuscript
21 Nov 2013 12:00 am
Abstract: Background Context: Primary malignant tumors of the sacrum are rare. Chondrosarcoma is one of
the common malignant tumors arising from the sacrum. Chondrosarcoma is often invasive and there is a
high propensity for local recurrence. Surgical resection is often the only effective treatment; however, the
treatment of malignant sacral tumors can be challenging, both because of the anatomy of the spinopelvic
complex and the frequently large tumor size.Purpose: We report a case of sacral chondrosarcoma, which
was successfully treated by total en bloc sacrectomy and reconstruction of lumbosacral and pelvic ring
using intraoperative extracorporeal irradiated autologous tumor-bearing sacrumStudy Design: A case report
with ten years follow-up.Methods: A 51-year-old male presented with right lower leg pain. Plain radiographs
and computed tomography (CT) showed an osteolytic lesion at the sacrum, which extended to the sacroiliac
joint. Magnetic resonance imaging (MRI) demonstrated that the tumor mass was localized from S1 to S2
with epidural lesion at L5-S1 disc level. Histopathological evaluation by open biopsy revealed that the lesion
was chondrosarcoma. Total en bloc sacrectomy of the tumor-bearing sacrum was performed. The removed
tumor-bearing sacrum was extracorporeally irradiated at 200 Gy during the operation, and returned to the
original position as a bone graft and fixed with instruments thereafter.Results: We needed two revision
surgeries during the first three years because of the implant failures, however, ten years after the initial
surgery, CT revealed that the irradiated sacrum had remodeled by living bone and integrated with
surrounding iliac bone without radiological evidence of the tumor recurrence. The patient ambulates without
any support and there was no clinical and radiological evidence of tumor recurrence.Conclusions: The
advantages of our method include the following: availability of high dose of radiation because of
extracorporeal irradiation, excellent fit between graft and host bone, reduction of the dead space, no
immunological rejection, no need for a bone bank, availability of the sacrum not only for the augmentation of
the large defect but also for the scaffold for the other bone grafts. Our report is only one case; however, we
consider that it could be one option for the treatment of sacral malignant bone tumors such as
chondrosarcoma.
Long-term hip simulator testing of the artificial hip joint bearing surface grafted with
biocompatible phospholipid polymer
19 Nov 2013 06:32 am
To prevent periprosthetic osteolysis and subsequent aseptic loosening of artificial hip joints, we recently
developed a novel acetabular highly cross-linked polyethylene (CLPE) liner with graft polymerization of 2methacryloyloxyethyl phosphorylcholine (MPC) on its surface. We investigated the wear resistance of the
poly(MPC) (PMPC)-grafted CLPE liner during 20 million cycles in a hip joint simulator. We extended the
simulator test of one liner to 70 million cycles to investigate the long-term durability of the grafting.
Gravimetric, surface, and wear particle analyses revealed that PMPC grafting onto the CLPE liner surface
markedly decreased the production of wear particles and showed that the effect of PMPC grafting was
maintained through 70 million cycles. We believe that PMPC grafting can significantly improve the wear
resistance of artificial hip joints. © 2013 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
J Orthop Res
Major trauma
24 Jun 2015 01:00 am
This is the clinical guideline in development on using Major trauma.
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