Aims

A growing number of fractures progress to delayed or nonunion, causing significant morbidity and socioeconomic impact. Localized delivery of stem cells and subcutaneous parathyroid hormone (PTH) has been shown individually to accelerate bony regeneration. This study aimed to combine the therapies with the aim of upregulating fracture healing.

Aims

This study investigates the effects of intra-articular injection of adipose-derived mesenchymal stem cells (AdMSCs) and platelet-rich plasma (PRP) on lameness, pain, and quality of life in osteoarthritic canine patients.

Aims

Minimally manipulated cells, such as autologous bone marrow concentrates (BMC), have been investigated in orthopaedics as both a primary therapeutic and augmentation to existing restoration procedures. However, the efficacy of BMC in combination with tissue engineering is still unclear. In this study, we aimed to determine whether the addition of BMC to an osteochondral scaffold is safe and can improve the repair of large osteochondral defects when compared to the scaffold alone.

Aims

Periprosthetic joint infection (PJI) is a debilitating condition with a substantial socioeconomic burden. A novel autologous blood glue (ABG) has been developed, which can be prepared during surgery and sprayed onto prostheses at the time of implantation. The ABG can potentially provide an antimicrobial coating which will be effective in preventing PJI, not only by providing a physical barrier but also by eluting a well-known antibiotic. Hence, this study aimed to assess the antimicrobial effectiveness of ABG when impregnated with gentamicin and stem cells.

Aims

For cementless implants, stability is initially attained by an interference fit into the bone and osteo-integration may be encouraged by coating the implant with bioactive substances. Blood based autologous glue provides an easy, cost-effective way of obtaining high concentrations of growth factors for tissue healing and regeneration with the intention of spraying it onto the implant surface during surgery. The aim of this study was to incorporate nucleated cells from autologous bone marrow (BM) aspirate into gels made from the patient’s own blood, and to investigate the effects of incorporating three different concentrations of platelet rich plasma (PRP) on the proliferation and viability of the cells in the gel.

Aims

Limb salvage in bone tumour patients replaces the bone with massive segmental prostheses where achieving bone integration at the shoulder of the implant through extracortical bone growth has been shown to prevent loosening. This study investigates the effect of multidrug chemotherapy on extracortical bone growth and early radiological signs of aseptic loosening in patients with massive distal femoral prostheses.

Aims

To evaluate graft healing of decellularized porcine superflexor tendon (pSFT) xenograft in an ovine anterior cruciate ligament (ACL) reconstruction model using two femoral fixation devices. Also, to determine if pSFT allows functional recovery of gait as compared with the preoperative measurements.

Objectives

Mesenchymal stem cells (MSCs) are of growing interest in terms of bone regeneration. Most preclinical trials utilize bone-marrow-derived mesenchymal stem cells (bMSCs), although this is not without isolation and expansion difficulties. The aim of this study was: to compare the characteristics of bMSCs and adipose-derived mesenchymal stem cells (AdMSCs) from juvenile, adult, and ovarectomized (OVX) rats; and to assess the effect of human parathyroid hormone (hPTH) 1-34 on their osteogenic potential and migration to stromal cell-derived factor-1 (SDF-1).

During remodelling, osteoclasts produce discrete bone cavities filled with bone and this is associated with the dimensions of the cavity. The aim of this study is to investigate the effect of pores of similar size to those produced by osteoclasts on the morphology, proliferation and osteogenic differentiation of bone marrow mesenchymal stem cells (BMSCs) in vitro. The hypothesis is that a porous surface similar in morphology to a bone surface prepared by osteoclasts will increase cell proliferation and osteogenic differentiation of MSCs.

Sheep BMSCs were seeded onto plain titanium surfaces and 100µm, 250µm and 500µm discrete pores surfaces. Cell metabolic activity was investigated using Presto Blue on days 3, 7 and 10. Bone mineralisation was quantified by Alizarin red staining at days 3, 7 and 14. Cell morphology was observed by scanning electron microscopy (SEM). Data was statistically analysed using one-way analysis of variance and a Bonferroni correction method.

Cells on porous discs had a three dimensional phenotype and aligned on the circumference of each pore. Metabolic activity was significantly higher by day 10 on plain discs compared to all porous discs. Bone mineralization was significantly higher on 100µm pores by day 3 (0.545mM±0.66; p=0.047) than plain discs and significantly higher on both 100µm and 250µm pores by day 7(p=0.000 and p=0.005) than plain discs. Substantial mineralised bone matrix was found on 100µm discs without being treated with osteogenic supplements, compared to other control disc types (p=0.043, p=0.003, p=0.000).

The different topographies altered cell behaviour and migration.100µm pores demonstrated earlier and enhanced bone mineralisation even in the absence of osteogenic supplements. This pore size is aligned to the size of individual resorption bays that osteoclasts produce on bone surfaces and is considerably lower than the pore sizes used to enhance osteo-integration of implant surfaces.

Intraosseous Transcutaneous Amputation Prosthesis (ITAP) is a new generation of limb replacements that can provide to amputees, an alternative solution to the main problems caused by the most common used external prosthesis such as pressure sores, infections and unnatural gait. ITAP is designed as one pylon osteointegrated into the bone and protruding through the skin, allowing both the mechanical forces to be directly transferred to the skeleton and the external skin being free from frictions and infections. The skin attachment to the implant is fundamental for the success of the ITAP, as it prevents the implant to move and consequently fail.

In this study we wanted to test if cell viability and attachment was improved using TiO2 nanotubes.

Human keratinocytes and human dermal fibroblasts were seeded for three days on TiO2 nanotubes with different sizes (18–30nm, 40–60nm and 60–110nm), compared with controls (smooth titanium) and tested for viability and attachment. A Mann-Whitney U test was used to compare groups where p values < 0.05 were considered significant. The results showed that the viability and cell attachment for keratinocytes were significantly higher after three days on controls comparing with all nanotubes (p=0.02), while attachment was higher on bigger nanotubes and controls. Cell viability for fibroblasts was significantly higher on nanotubes between 40 and 110nm comparing with smaller size and controls (p=0.03), while investigation of cell attachment is ongoing.

From these early results, we can say that TiO2 nanotubes can improve the soft tissue attachment on ITAP. Further in-vitro and ex-vivo experiments on cell attachment will be carried out.

A significant number of fractures develop non-union. Stem cell therapy may be beneficial in their treatment, however this requires acquisition, culture and delivery of stem cells. Stem cell homing and migration is regulated through SDF-1 and its receptor CXCR4. Studies have demonstrated endogenous mobilisation of different populations of stem and progenitor cells by administering growth factors with a pharmacological antagonist of CXCR4, AMD3100. This may therefore be a means to improve compromised fracture healing. A 1.5mm femoral osteotomy in adult female Wistar rats was stabilised with an external skeletal fixator. After osteotomy, saline/PBS (P) VEGF (V), IGF-1 (I) or GCSF (G) (100ug/kg, 0.5ml/100g i.p.), were administered daily for 4 days. On day 5, a single 5mg/kg i.p. dose of AMD3100 was given. Control group (C) did not receive growth factors or AMD 3100. At 5 weeks, the femur was retrieved and microCT scanned. Compared to group C (n=7), group P (n=5) had a significant increase in bone volume (P=0.01) 8.9±2.2um∧3 (control 4.3±3.1um∧3) and trabecular thickness (P=0.03). Group I (n=6) also had a significant increase in bone volume (P=0.035) 5.1±4.2um∧3 and trabecular thickness 0.062±0.008um (control 0.042±0.01um) (P=0.01). Group V (n=8), showed a non-significant increase in bone volume; 5.22±1.7um∧3 and trabecular thickness 0.048±0.007um. Group G (n=5) showed a significant decrease in bone volume (2.5±2.6um∧3) (P=0.048). AMD3100 alone and IgF1-AMD3100, showed the greatest increase in bone formation, presumably through mobilisation of beneficial combinations of stem and progenitor cells. GCSF-AMD3100, which is expected to mobilise hematopoietic progenitors inhibited bone healing.

Aim

To quantify the micro-motion at the fracture gap in a tibial fracture model stabilised with an external fixator.

Introduction

Numerous studies have reported on clinically significant volumes of material loss and corrosion at the head-stem junction of metal-on-metal (MOM) hips; less is understood about metal-on-polyethylene (MOP) hips. We compared the effect of bearing type (MOM vs MOP) on taper material loss for a hip system of a single design (DePuy Pinnacle).

Objectives

This study aimed to assess the effect of age and osteoporosis on the proliferative and differentiating capacity of bone-marrow-derived mesenchymal stem cells (MSCs) in female rats. We also discuss the role of these factors on expression and migration of cells along the C-X-C chemokine receptor type 4 (CXCR-4) / stromal derived factor 1 (SDF-1) axis.

Increasing innovation in rapid prototyping (RP) and additive manufacturing (AM), also known as 3D printing, is bringing about major changes in translational surgical research.

This review describes the current position in the use of additive manufacturing in orthopaedic surgery.

Cite this article: Bone Joint J 2018;100-B:455-60.

Aims

The success of anterior cruciate ligament reconstruction (ACLR) depends on osseointegration at the graft-tunnel interface and intra-articular ligamentization. Our aim was to conduct a systematic review of clinical and preclinical studies that evaluated biological augmentation of graft healing in ACLR.

Objectives

Cellular movement and relocalisation are important for many physiologic properties. Local mesenchymal stem cells (MSCs) from injured tissues and circulating MSCs aid in fracture healing. Cytokines and chemokines such as Stromal cell-derived factor 1(SDF-1) and its receptor chemokine receptor type 4 (CXCR4) play important roles in maintaining mobilisation, trafficking and homing of stem cells from bone marrow to the site of injury. We investigated the differences in migration of MSCs from the femurs of young, adult and ovariectomised (OVX) rats and the effect of CXCR4 over-expression on their migration.

Background

Children suffering from primary bone cancer necessitating resection of growth plates, may suffer progressive leg length discrepancy, which can be attenuated with extendable prostheses. A serious complication is catastrophic implant failure. Over time, bone will remodel, altering the stress pattern in the implant. By using finite element analysis we can model different bone remodeling conditions to ascertain the effect that this will have on stress distribution and magnitude.

A finite element analysis was performed. Simplified computer generated models were designed of a cemented femoral Stanmore growing massive endoprosthesis. Three scenarios were designed, modelled on post-operative radiographs. Scenario 1 had a gap between the end of the femur and the implant collar, scenario 2 had no gap, but with no bone attachment into the collar, and scenario 3 had growth of the bone over the length of the collar with attachment. Physiological loading conditions were applied. The resultant stress in the implant for each scenario was measured, and compared to the strength of the material. Peak stresses were recorded at the stem-collar junction.

The maximum stress recorded in the implant in scenario 1 was 3104.2Mpa, compared to 1054.4Mpa in scenario 2, and 321.2Mpa in scenario 3.

Background

Stress shielding and wear induced aseptic loosening cause failure in arthroplasty surgery. To improve survivorship, the use of a low modulus, low wearing biomaterial may be a suitable alternative to hard bearing prostheses, such as cobalt chromium (CoCr). There has been considerable research interest in the use of polyetheretherketone (PEEK) based on observed clinical success especially in spinal surgery. This study investigated the wear performance of PEEK, carbon reinforced PEEK (CFR-PEEK) and acetal as bearing materials in an all polymer total knee arthroplasty (TKA) using a unidirectional pin on plate test.

Background

Re-attachment of tendon to bone is challenging with surgical repair failing in up to 90% of cases. Poor biological healing is common and characterised by the formation of weak scar tissue. Previous work has demonstrated that decellularised allogenic demineralised bone matrix (DBM) regenerates a physiologic enthesis. Xenografts offer a more cost-effective option but concerns over their immunogenicity have been raised. We hypothesised that augmentation of a healing tendon-bone interface with DBM incorporated with autologous mesenchymal stem cells (MSCs) would result in improved function, and restoration of the native enthesis, with no difference between xenogenic and allogenic scaffolds.

Background

Osteoporosis and bone fractures lead to immobility, chronic pain and high patient care costs. Mesenchymal stem cells (MSCs) from postmenopausal women have a slower growth rate and osteogenic differentiation ability causing lower bone density and reduced fracture healing capacity compared to MSCs from premenopausal women. Cellular movement and relocalisation are necessary for many physiologic properties. Local MSCs from injured tissues and circulating MSCs are involved in fracture healing. Cytokines and chemokines such as SDF-1 and its receptor CXCR4 play important roles in maintaining mobilisation, trafficking and homing of stem cells from bone marrow to the site of injury. This study investigated the effect of CXCR4 over-expression on the migration of MSCs from ovariectomised, normal and young rats.

Aims

The Intraosseous Transcutaneous Amputation Prosthesis (ITAP) may improve quality of life for amputees by avoiding soft-tissue complications associated with socket prostheses and by improving sensory feedback and function. It relies on the formation of a seal between the soft tissues and the implant and currently has a flange with drilled holes to promote dermal attachment. Despite this, infection remains a significant risk. This study explored alternative strategies to enhance soft-tissue integration.

Background

Complications of metal-on-metal hip resurfacing, leading to implant failure, include femoral notching, neck fracture, and avascular necrosis. Revision arthroplasty options include femoral-only revision with a head, however mis-matching radial clearance could accelerate metal ion release. Alternatively, revision of a well-fixed acetabular component could lead to further bone loss, complicating revision surgery. We have developed a ceramic hip resurfacing system with a titanium-ceramic taper junction; taking advantage of the low frictional torque and wear rates that ceramic affords. Taking a revision scenario into account, the ceramic head has a deep female taper for the resurfacing stem, but also a superficial tapered rim. Should revision to this resurfacing be required, any femoral stem with a 12/14 taper can be implanted, onto which a dual taper adaptor is attached. The outer diameter of the taper adaptor then becomes the male taper for the superficial taper of the ceramic head; ultimately allowing retention of the acetabular component. In an in-vitro model, we have compared the fretting corrosion of this taper adaptor to existing revision taper options: a titanium-cobalt chrome (Ti-CoCr) taper junction, and a titanium-titanium sleeve-ceramic (Ti-Ti-Cer) taper junction.

Background

Hip resurfacing has advantages for the young active patient with arthritis; maintaining a large range of motion, preserving bone stock, and reduced dislocation risk. However high serum metal ion levels with metal-on-metal resurfacing, and their clinical implications, has led to a decline in the use of hip resurfacing. Ceramic bearing surfaces display the lowest frictional torque and excellent wear rates. Recent developments have enabled large, strong ceramic materials to be used as resurfacing components. Any wear debris that is generated from these articulations is inert. However an all-ceramic hip resurfacing could be at risk of fracture at the head-stem junction. A new ceramic hip resurfacing system with a titanium-ceramic modular taper junction has been developed. The introduction of a taper introduces the potential for fretting corrosion; we sought to determine the extent of this in an in-vitro model, and compared this prosthesis to the conventional 12/14 titanium-cobalt chrome (Ti6Al4V-CoCr) taper junction.

Aims

Massive endoprostheses rely on extra-cortical bone bridging (ECBB) to enhance fixation. The aim of this study was to investigate the role of selective laser sintered (SLS) porous collars in augmenting the osseointegration of these prostheses.

DVC allowed measurements of displacement and strain distribution in bone through the comparison of two, or more, 3D images. Hence, it has a potential as a diagnostic tool in combination with clinical CT. Currently, traditional computed tomography (CT) allows for a detailed 3D analysis of hard tissues, but imaging in a weight-bearing condition is still limited. PedCAT-CT (Curvebeam, USA) emerged as a novel technology allowing, for the first time, 3D imaging under full-weight bearing (Richter, Zech et al. 2015). Specifically, a PedCAT-CT based DVC was employed to establish its reliability through the strain uncertainties produced on bone structure targets, preliminarily to any further clinical studies. In addition, a reverse engineering FE modeling was used to predict possible force associated to displacement errors from DVC.

Three porcine thoracic vertebrae were used as bone benchmark for the DVC (Palanca, Tozzi et al. 2016, Tozzi, Dall'Ara et al. 2016). The choice of using porcine vertebrae (in a CT designed for foot/ankle) was driven by availability, as well as similar dimensions to the calcaneus. Each vertebra was immersed in saline solution and scanned twice without any repositioning (zero-strain-test) with a pedCAT-CT (Curvebeam, USA) obtaining an isotropic voxel size of 370 micrometers. Volumes of interest of 35 voxel were cropped inside the vertebrae. Displacement and strains were evaluated using DVC (DaVis-DC, LaVision, Germany), with different spatial resolution. The displacement maps were used to predict the force uncertainties via FE (Ansys Mechanical v.14, Ansys Inc, Canonsburg, PA). Each element was assigned a linear elastic isotropic constitutive law (Young modulus: 8 GPa, Poisson's ratio: 0.3, as in (Follet, Peyrin et al. 2007)). Overall, the precision error of strain measurement was evaluated as the average of the standard deviation of the absolute value of the different component of strain (Liu and Morgan 2007).

The force uncertainties obtained with the FE analysis produced magnitudes ranging from 231 to 2376 N. No clear trend on the force was observed in relation to the spatial resolution. Precision errors were smaller than 1000 microstrain in all cases, with the lowest ranging from 83 microstrain for the largest spatial resolution. Full-field strain on the bone tissue did not seem to highlight a preferential distribution of error in the volume.

The precision errors showed that the pedCAT-CT based DVC can be sufficient to investigate the bone tissue failure (7000–10000 microstrain) or, physiological deformation if well-optimized. FE analysis produced important force uncertainties up to 2376 N. However, this is a preliminary investigation. Further investigation will give a clearer indication on DVC based PedCAT-CT, as well as force uncertainties predicted. So far, the DVC showed its ability to measure displacement and strain with reasonable reliability with clinical-CT as well.

Intermittent parathyroid hormone 1–34 (teriparatide) is the N-fragment terminal of the intact hormone, currently in clinical use to treat osteoporosis. Unlike anti-catabolic agents such as bisphosphonates, PTH 1–34 not only affects the osteoclast, but also up regulates bone formation via both modelling and remodelling mechanisms. The actions of iPTH on mesenchymal stem cell differentiation (MSCs) may underpin a further method in the treatment of osteoporosis specifically, and for fracture healing in general. Stem cells from older female osteoporotic animals have reduced activity and poorer osteogenic potential; additionally, their migration to and retention at sites of increased bone turnover are reduced in comparison to cells from younger animals. The aim of this study was to isolate bone marrow derived MSCs from both young Wild Type (WT) and ovarectomized senile (OVX) rats, then to investigate and compare the effect of pulsatile and continuous PTH administration on migration to SDF-1, proliferation and osteogenic differentiation.

MSCs were harvested from the femora of 6–9week Wistar rats, and from 10–13month ovarectomized rats with established osteopenia. Cells were cultured with 25, 50 and 100nmMol of PTH 1–34 added to osteogenic media either continuously or in a pulsatile fashion for 6 hours in every 72hour cycle. ALP and Alizarin Red were used to assess the optimal concentration of PTH for osteogenic differentiation. Subsequently, proliferation was assessed with Alamar Blue and cells were seeded in a Boyden chamber to quantify the migration to SDF-1. As the data was parametric a student t-test was used to analyse results, and a p value < 0.05 was considered significant.

ALP and Alizarin Red parameters were significantly increased for both WT and OVX groups at 50nmMol of pulsatile PTH in comparison to groups cultured in 25 or 100nmMol. Continuous administration at all concentrations led to reduced calcium phosphate deposition by day 21 in all groups. Interestingly, in comparison to cells cultured in osteogenic media, 50nmMol of pulsatile PTH lead to statistically significant higher ALP and Alizarin Red measurements up to day 10 and 14 respectively in WT cells, and days 10 and 21 in OVX cells. The proliferation rate normalised against DNA was similar for both OVX and WT rats at all-time points. PTH administration did not effect cell proliferation in any group. WT MSCs not only had improved osteogenic differentiation, but also showed increased migration to SDF-1 in comparison to OVX groups. Pulsatile PTH led to further increases in migration of both OVX and WT cells.

Intermittent PTH increases the osteogenic diffrentiation and migration of MSCs from both young and ovarectomised rats, though importantly this effect is not dose dependent. Ultimately, the role of PTH 1–34 on MSCs may lead to improved bone formation and cell homing capacity-particularly in the context of osteoporosis.

Osteoporosis is characterised by an uncoupling of bone formation and resorption resulting in a net reduction in bone density. Stem cells derived from bone marrow in osteoporotic patients typically contain more adipocytes,. Intermittent Parathyroid hormone (iPTH), has been shown to cause the preferential differentiation of mesenchymal stem cells (MSCs) to osteoblasts. We isolated rat bone marrow derived MSCs, investigating the effect of iPTH on adipocyte differentiation.

MSCs were harvested from the femora of 6–10week oldWT rats and cultured to induce adipogenesis for 21 days. Subsequently, cells were continually cultured in adipogenic media, osteogenic media or in osteogenic media supplemented with PTH 1–34 either continuously or intermittently for 6hours in every 72hour cycle. ALP and Alizarin Red assessed osteogenic differentiation, and Oil Red O used to assess intracellular microdroplet formation. A student t-test was used to analyse results, and a p value<0.05 considered significant.

Quantitatively measurements of Alizarin Red staining significantly increased in all adipocytes grown in osteogenic media compared to the cells continually cultured in adipogenic media. Calcium phosphate deposition continued to increase significantly in these groups up to day 14. At day 14, Alizarin Red staining from cells cultured in iPTH were significantly higher than osteogenic media alone. ALP expression was significantly higher for cells cultured in osteogenic media and iPTH compared to adipogenic media at days 3–14. Expression peaked at day 7, at this timepoint cells cultured in iPTH expressed significantly more ALP than other groups. Oil Red O measurements were significantly reduced from days 7–14 for all osteogenic groups, this significance was greatest for the iPTH group at day 7.

iPTH increased the transdifferentiation of adipocytes derived from MSCs into osteoblasts, this effect was most significant after 7 days. Ultimately, the role of iPTH on adipocytes may lead to improved bone formation with many orthopaedic applications.

The current treatment for osteoporosis such as bisphosphonates inhibits the catabolic activity of osteoclasts and subsequent bone resorption, but does not increase bone formation. There is therefore interest in using anabolic factors such as stem cells to augment fracture repair. The poor bone formation in postmenopausal women could be due to poor retention and function of Mesenchymal stem cells (MSCs) resulting into delayed unions. Another factor associated with fracture healing is the retention and migration of stem cells to the site of injury (1–3). The aim of this study was to isolate stem cells from osteopenic rats and investigate and compare the CD marker expression, proliferation, migration, osteogenic and adipogenic differentiation. The hypothesis of this study is that the migration of MSCs from young, adult and ovariectomised (OVX) rats will have different proliferation, differentiation and migratory abilities.

Ovariectomy was performed in 6–9 month old Wistar rats and osteopenia developed over a 4 month post-op period. MSCs were harvested from the femora of young, adult and osteopenic Wistar rats. Proliferation of the these MSCs from the three group of rats was measured using Alamar blue, osteogenic differentiation was measured using ALP expression at day 0, 7, 14 and 21 and alizarin red at day 21. Adipogenic differentiation was measured at day 7, 14 and 21 using Oil red O. Cells were incubated in Boyden chambers to quantify their migration towards SDF1. For analysis, the number of cells migrating across the membrane was expressed as a percentage of the cells remaining on the upper membrane surface. Data was analysed using a Student t-test where p values < 0.05 were considered significant.

The stem cells from all 3 groups of rats expressed on average the same amount of CD29 (>90%), CD90 (>96%), CD34 (<5%) and CD45 (approx 10%). The proliferation rate measured by Alamar blue normalised against DNA was also similar at day 3, 7, 10 and 14. However, interestingly the migration and differentiation ability was significantly different between the MSCs from the 3 groups of rats. The young MSCs were not only better at differentiating into bone and fat as well, but they also migrated significantly more towards SDF1. The migration of SDF-1 doubled with young rats compared to the adult rats (p = 0.023) and it was four times higher when compared to cells isolated from OVX rats (p = 0.013).

MSCs from OVX rats are similar to MSCs from young rats. However when induced to turn into bone, fat and migrate towards SDF1, young MSCs are significantly more responsive than MSCs from OVX and adult control rats. The poor homing ability and differentiation of the stem cells and their retention may result in a reduction in bone formation leading to delayed union in fractures of osteoporotic patients(4).

Mesenchymal stem cells (MSCs) are believed to be immune-privileged due to lack of antigen-presenting-cell related markers, however, evidence suggests that MSCs are immunogenic and are attacked by the immune system. Our research investigates the hypothesis that there are differences between MSC clones from the same individual in terms of their morphology, proliferation, differentiation and immune profile. Our goal is to discover immune-privileged stem cells, which can act as a universal allogenic mesenchymal stem cell donor to facilitate bone ingrowth for osteosarcoma patients status post tumor excision and prosthesis implantation.

Serial dilutions of bone-marrow derived (BMMSCs) and adipose derived mesenchymal stem cells (ADMSCs) from same animal were carried out in order to isolate single-cell clones. From a single animal we obtained 3 clones from BMMSCs and 3 from ADMSCs. This procedure was repeated for another other 2 animals. The proliferation rate and cell doubling time of each clonal culture was measured. The proliferation rate of mixed clonal cultures was also measured. The tri-differentiation potential of the clonal cultures was compared and a comparison was also made with the original isolates from bone marrow and fat. The immune-privileged properties were measured by flow cytometry and immuno-staining for the major histocompatibility complex (MHC) antigens. To measure the immune response a mixed leucocyte reaction was used but where leucocytes from a different individual were mixed with the clonal MSC cells.

All isolates were able to differentiate into osteoblasts, chondrocytes and adipocytes. All clonal cultures revealed significantly different proliferation rates and doubling times when compared with each other and with mixed cultures. All clonal cultures showed different surface marker presentations, which included differences in the expression of MHC antigens. One clone isolated from ADMSCs showed lack of MHCI and MHCII. Our mixed leucocyte reaction and MHC staining showed variety of immune-modulation and this was related to the expression of the MHC antigens.

All clones tri-differentiated and therefore show a degree of ‘stemness’. MSCs are generally are believed not to express MHC II and to be immune-privileged. However, this study shows that the expression of these antigens in clones isolated from bone marrow and from fat is variable. A heterogeneous result indicates individual differences between MSCs, even from same origin. The immune response elicited by MSCs is complicated. MSCs have been shown to release interleukin 10, which could inhibit the immune response but on the other hand interferon-gamma could enhance MHCII presentation in some MSCs. Our results confirmed our hypothesis because clonal cultures isolated from different sources of MSCs in the same animal showed significant differences in proliferation rate, morphology and surface marker presentation. Mesenchymal stem cells are not immunogenic or immune-privileged. Individual differences highlighted through single-cell clonal cultures may be the key to finding a universal immune-privileged MSCs for allogeneic transplantation.

Intermittently administered parathyroid hormone (PTH 1-34) has been shown to promote bone formation in both human and animal studies. The hormone and its analogues stimulate both bone formation and resorption, and as such at low doses are now in clinical use for the treatment of severe osteoporosis. By varying the duration of exposure, parathyroid hormone can modulate genes leading to increased bone formation within a so-called ‘anabolic window’. The osteogenic mechanisms involved are multiple, affecting the stimulation of osteoprogenitor cells, osteoblasts, osteocytes and the stem cell niche, and ultimately leading to increased osteoblast activation, reduced osteoblast apoptosis, upregulation of Wnt/β-catenin signalling, increased stem cell mobilisation, and mediation of the RANKL/OPG pathway. Ongoing investigation into their effect on bone formation through ‘coupled’ and ‘uncoupled’ mechanisms further underlines the impact of intermittent PTH on both cortical and cancellous bone. Given the principally catabolic actions of continuous PTH, this article reviews the skeletal actions of intermittent PTH 1-34 and the mechanisms underlying its effect.

Cite this article: L. Osagie-Clouard, A. Sanghani, M. Coathup, T. Briggs, M. Bostrom, G. Blunn. Parathyroid hormone 1-34 and skeletal anabolic action: The use of parathyroid hormone in bone formation. Bone Joint Res 2017;6:14–21. DOI: 10.1302/2046-3758.61.BJR-2016-0085.R1.

Aim

Photodynamic therapy (PDT) requires a photosensitiser, a light source of an appropriate wavelength, and the presence of molecular oxygen. Once stimulated to its excited phase by the light, the photosensitiser reacts with oxygen to form free radicals of ‘singlet oxygen’ which is cytotoxic to microorganisms.

We aim to demonstrate the effectiveness of PDT as an in-vitro antimicrobial technique against Staphylococcus aureus, Methicillin resistant Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa and Acinetobacter bauminii. This will form the scientific basis for further animal and human studies assessing PDT for treatment of periprosthetic infections, septic arthritis, and open fractures.

Osteoporosis is characterised by an uncoupling of bone formation and resorption resulting in net resorption. Stem cells derived from bone marrow in osteoporotic patients typically contain more adipocytes. Intermittent Parathyroid hormone (iPTH), has been shown to cause the preferential differentiation of mesenchymal stem cells (MSCs) to osteoblasts. We isolated rat bone marrow derived MSCs, investigating the effect of iPTH on adipocyte differentiation.

MSCs were harvested from the femora of 6–10week oldWT rats and cultured to induce adipogenesis for 21 days. Subsequently, cells were continually cultured in adipogenic media, osteogenic media or in osteogenic media supplemented with PTH 1–34 either continuously or intermittently for 6hours in every 72hour cycle. ALP and Alizarin Red assessed osteogenic differentiation, and Oil Red O used to assess intracellular microdroplet formation. A student t-test was used to analyse results, and a p value<0.05 considered significant.

Quantitatively measurements of Alizarin Red staining significantly increased in all adipocytes grown in osteogenic media compared to the cells continually cultured in adipogenic media. Calcium phosphate deposition continued to increase significantly in these groups up to day 14. At day 14, Alizarin Red staining from cells cultured in iPTH were significantly higher than osteogenic media alone.

ALP expression was significantly higher for cells cultured in osteogenic media and iPTH compared to adipogenic media at days 3–14. Expression peaked at day 7, at this timepoint cells cultured in iPTH expressed significantly more ALP than other groups (Figure 2). Oil Red O measurements were significantly reduced from days 7–14 for all osteogenic groups, this significance was greatest for the iPTH group at day 7.

iPTH increased the transdifferentiation of adipocytes derived from MSCs into osteoblasts, this effect was most significant after 7 days. Ultimately, the role of iPTH on adipocytes may lead to improved bone formation with many orthopaedic applications.

Mesenchymal stem cells (MSCs) are usually believed to be immune-privileged. However, immunogenic MSCs were also reported. We hypothesize that there are differences between MSC clones from the same individual in terms of their morphology, proliferation, differentiation and immunogenicity. Our goal is to discover immune-privileged stem cells for universal allogenic MSCs transplantation.

Serial dilutions of bone-marrow derived (BMMSCs) and adipose derived mesenchymal stem cells (ADMSCs) from same animal were carried out to isolate single-cell clones. From a single animal we obtained 3 clones from BMMSCs and 3 from ADMSCs. The proliferation rate of each clonal culture and mixed clonal culture were measured. The tri-differentiation potential of the clonal cultures was compared, as well as with the original isolates from bone marrow and fat. The immune-privileged properties were measured by flow cytometry and immuno-staining for the major histocompatibility complex (MHC) antigens. Mixed leucocyte reaction (MLR) were also performed to investigate immunogenicity.

Tri-differentiation was confirmed in all isolates. All clonal cultures revealed significant different morphology and proliferation rates, compared with each other and mixed cultures. All clonal cultures showed different surface markers, inclusive of MHC antigens. One clone from ADMSCs showed lack of MHC antigens. Our MLR and MHC staining disclosed variety of immune properties.

All clones tri-differentiated which indicated a degree of ‘stemness’. MSCs are generally believed not to express MHC II, resulting in immune-privileged. Our results confirmed our hypothesis because clonal cultures isolated from different origins of same animal show differences in morphology, proliferation rate, and surface marker presentation. Individual immune differences highlighted through single-cell clonal cultures may be crucial to find universal immune-privileged MSCs as universal allogeneic donor.

Intermittent parathyroid hormone (iPTH 1–34) increases bone formation via modelling and remodelling mechanisms and as such is used to treat osteoporosis. The actions of iPTH on mesenchymal stem cell (MSCs) may underpin a further treatment option.

We isolated bone marrow derived MSCs from young (WT) and ovarectomized senile (OVX) rats, investigating the effect of intermittent and continuous PTH administration on migration to SDF-1, proliferation and osteogenic differentiation.

MSCs were harvested from the femora of 6–10week old WT rats and 10–13month old OVX rats. Cells were cultured with 25,50 and 100nmMol of PTH 1–34 added to osteogenic media either continuously or intermittently for 6hours in every 72hour cycle. ALP and Alizarin Red assessed osteogenic differentiation, and Alamar Blue- proliferation. Cells were seeded in a Boyden chamber to quantify SDF-1 migration. A student t-test was used to analyse results, and a p value<0.05 considered significant.

ALP and Alizarin Red were significantly increased for WT and OVX groups at 50nmMol of iPTH. Continuous administration at all concentrations reduced calcium phosphate deposition by day 21 in all groups.

In comparison to cells cultured in osteogenic media, 50nmMol of iPTH led to significantly higher ALP and Alizarin Red measurements up to days 10 and 7 respectively (figure 1). There was no change in proliferation between the groups, and PTH had no effect (figure 2.)

WT MSCs not only had improved osteogenic differentiation, but also showed increased migration to SDF-1 in comparison to OVX groups. iPTH led to further increases in migration of both OVX and WT cells.

iPTH increases the osteogenic differentiation and migration of MSCs from both young and ovarectomised rats, though this effect is not dose dependent. Ultimately, the role of iPTH on MSCs may lead to improved bone formation and cell homing capacity-particularly in the context of osteoporosis.

There is increasing interest in using anabolic factors such as stem cells to augment fragility fracture repair. One of the factors associated with fracture healing is the retention and migration of stem cells to the site of injury (1–3). The aim of this study was to isolate stem cells from osteopenic rats and investigate and compare the CD marker expression, proliferation, migration, osteogenic and adipogenic differentiation. The hypothesis of this study is that the migration of MSCs from young, adult and ovariectomised (OVX) rats will have different proliferation, differentiation and migratory abilities.

CD marker expression of MSCs from young, adult and osteopenic rats was measured using flow cytometry. Proliferation, osteogenic differentiation and adipogenic differentiation was measured using Alamar Blue, ALP expression and Alizari n Red and quantitative Oil red O respectively. Cells were incubated in Boyden chambers to quantify their migration towards SDF1. Data was analysed using a Student t-test where p values < 0.05 were considered significant.

MSCs from all 3 groups of rats had similar proliferation and expression of CD29(>90%), CD90(>96%), CD34(<5%) and CD45(approx 10%). The proliferation rate was also similar. However, interestingly the migration and differentiation ability was significantly different between the MSCs from the 3 groups of rats. The young MSCs were not only better at differentiating into bone and fat, but they also migrated significantly more towards SDF1. MSCs from OVX rats are similar to MSCs from young rats. However when induced to turn into bone, fat and migrate towards SDF1, young MSCs are significantly more responsive than MSCs from OVX and adult control rats. The poor homing ability and differentiation of the stem cells and their retention may result in a reduction in bone formation leading to delayed union in fractures of osteoporotic patients(4).

Introduction

The Primoris® femoral stem was designed to preserve bone and maintain normal stress to the proximal femur, thereby minimizing stress-shielding. The implant is anchored in the femoral neck and metaphysis without diaphysial involvement and differs from other neck prothesis by: a) Elliptical shape to fit the inner neck dimensions. b) On top of Ti– porous-coating electrochemically deposited hydroxy apatite (Bonemaster®) c) The surgical technique aims to enhance initial implant stability by compaction of neck and metaphyseal cancellous bone.

Introduction

Stress shielding and wear induced aseptic loosening cause failure in total joint arthroplasty. To improve long-term outcomes in total knee arthroplasty (TKA), the use of a low modulus, low wearing biomaterial may be a suitable alternative to cobalt chromium (CoCr) femoral components. Based on its favorable mechanical properties and observed clinical success especially in spinal surgery, polyetheretherketone (PEEK) is investigated as a candidate material for a metal free TKA. An all polymer TKA has several theoretical advantages, these include a more physiological stress in the distal femur, elimination of biological reaction to metal, better radiographic visualisation of the bone implant interface especially with CT and MRI. In addition, polymers afford a cheaper option for the manufacture of prostheses.

Background

Polyetheretherketone (PEEK) may be advantageous as an alternative material to metal alloys in some orthopaedic applications. However, it is bioinert and does not osseointegrate1. A novel accelerated neutral atom beam technique (ANAB) has been developed to improve the bioactivity of PEEK where the surface is modified to a depth of 5 nm without affecting the integrity of the underlying PEEK structure2.

There is increasing global awareness of adverse reactions to metal debris and elevated serum metal ion concentrations following the use of second generation metal-on-metal total hip arthroplasties. The high incidence of these complications can be largely attributed to corrosion at the head-neck interface. Severe corrosion of the taper is identified most commonly in association with larger diameter femoral heads. However, there is emerging evidence of varying levels of corrosion observed in retrieved components with smaller diameter femoral heads. This same mechanism of galvanic and mechanically-assisted crevice corrosion has been observed in metal-on-polyethylene and ceramic components, suggesting an inherent biomechanical problem with current designs of the head-neck interface.

We provide a review of the fundamental questions and answers clinicians and researchers must understand regarding corrosion of the taper, and its relevance to current orthopaedic practice.

Cite this article: Bone Joint J 2016;98-B:579–84.

Introduction

Recent studies on large diameter femoral head hip replacements have implicated the modular taper junction as one of the significant sources of wear and corrosion products and this has been attributed to increased torque and bending on the taper interface. The aim of this study was to assess the effect of frictional torque and bending moment on fretting corrosion at the taper junction and to investigate whether different material combinations also had an effect.

The aim of this study was to assess the effect of frictional torque and bending moment on fretting corrosion at the taper interface of a modular femoral component and to investigate whether different combinations of material also had an effect. The combinations we examined were 1) cobalt–chromium (CoCr) heads on CoCr stems 2) CoCr heads on titanium alloy (Ti) stems and 3) ceramic heads on CoCr stems.

In test 1 increasing torque was imposed by offsetting the stem in the anteroposterior plane in increments of 0 mm, 4 mm, 6 mm and 8 mm when the torque generated was equivalent to 0 Nm, 9 Nm, 14 Nm and 18 Nm.

In test 2 we investigated the effect of increasing the bending moment by offsetting the application of axial load from the midline in the mediolateral plane. Increments of offset equivalent to head + 0 mm, head + 7 mm and head + 14 mm were used.

Significantly higher currents and amplitudes were seen with increasing torque for all combinations of material. However, Ti stems showed the highest corrosion currents. Increased bending moments associated with using larger offset heads produced more corrosion: Ti stems generally performed worse than CoCr stems. Using ceramic heads did not prevent corrosion, but reduced it significantly in all loading configurations.

Cite this article: Bone Joint J 2015;97-B:463–72.

Arthroplasty registries are important for the surveillance of joint replacements and the evaluation of outcome. Independent validation of registry data ensures high quality. The ability for orthopaedic implant retrieval centres to validate registry data is not known. We analysed data from the National Joint Registry for England, Wales and Northern Ireland (NJR) for primary metal-on-metal hip arthroplasties performed between 2003 and 2013. Records were linked to the London Implant Retrieval Centre (RC) for validation. A total of 67 045 procedures on the NJR and 782 revised pairs of components from the RC were included. We were able to link 476 procedures (60.9%) recorded with the RC to the NJR successfully. However, 306 procedures (39.1%) could not be linked. The outcome recorded by the NJR (as either revised, unrevised or death) for a primary procedure was incorrect in 79 linked cases (16.6%). The rate of registry-retrieval linkage and correct assignment of outcome code improved over time. The rates of error for component reference numbers on the NJR were as follows: femoral head category number 14/229 (5.0%); femoral head batch number 13/232 (5.3%); acetabular component category number 2/293 (0.7%) and acetabular component batch number 24/347 (6.5%).

Registry-retrieval linkage provided a novel means for the validation of data, particularly for component fields. This study suggests that NJR reports may underestimate rates of revision for many types of metal-on-metal hip replacement. This is topical given the increasing scope for NJR data. We recommend a system for continuous independent evaluation of the quality and validity of NJR data.

Cite this article: Bone Joint J 2015;97-B:10–18.

Summary

Our results prove that Demineralised Cortical Bone (DCB) can be used as biological tendon graft substitute, combined with correct surgical technique and the use of suture bone anchor early mobilisation can be achieved.

Summary Statement

Proximal femoral bony deficits present a surgical and biomechanical challenge to implant longevity in revision hip arthroplasty. This work finds comparable primary stability when a distally fixing tapered fluted stem was compared with a conical design in cadaveric tests.

Summary

Our study shows that a tendon rupture can be successfully augmented with Demineralised Cortical Bone (DCB) giving initial appropriate mechanical strength suitable for in vivo use providing the biological reactions to the graft are favourable.

Summary

Osseointegrated Amputation Prostheses can be functionalised by both biological augmentation and structural augmentation. These augmentation techniques may aid the formation of a stable skin-implant interface.

Aim:

The aim of this study was test the amount of corrosion occurring at the (Ti) /cobalt chrome (CoCr) interface comparing this with Ti and Ti interfaces. This was compared with retrieved metal work visualised under a scanning electron microscope (SEM).

Introduction:

Due to absence of fusion in guided-growth devices for EOS (growing rods, Shilla, LSZ) movement of the rods against their attachment is possible resulting in wear debris formation. It is important to understand the wear resistance of materials used in these devices under appropriate conditions.

Introduction:

There has been widespread concern regarding the adverse tissue reactions after metal-on-metal (MoM) total hip replacements (THR). Concerns have also been expressed with mechanical wear from micromotion and fretting corrosion at the head/stem taper junction in total hip replacements. In order to understand the interface mechanism a study was undertaken in order to investigate the effect of surface finish and contact area associated with modular tapers in total hip replacements with a single combination of materials of modular tapers.

Introduction

Revision hip arthroplasty is a technically challenging operation as proximal bony deficits preclude the use of standard implants. Longer distally fixing stems are therefore required to achieve primary stability.

Introduction:

High failure rates with large diameter, metal on metal hip replacements have highlighted a potential issue with the head/stem taper junction as one of the significant sources of metal ion release. Postulated reasons as to why this may be such a problem with large head metal on metal hip replacements is due to the increased torque achieved by the larger head size. This may be responsible for applying greater micromotion between the head and stem taper and consequently greater amounts of fretting corrosion. The aim of this study was to perform short term in vitro electrochemical tests to assess the effect of increasing head diameter and torque on the fretting corrosion susceptibility of the head/stem taper interface and to investigate its effect on different material combinations.

Introduction

It has been suggested that corrosion and fretting at the taper junctions of stemmed metal-on-metal hip replacements may contribute to their high failure rates. A peer-reviewed semi-quantitative scoring system [Goldberg et al., 2002] has been used to visually assess the severity of corrosion and fretting of the taper junction but has not been validated using multiple examiners. The aim of this study was to assess the inter-observer variability of this method.

Following the recall of modular neck hip stems in July 2012, research into femoral modularity will intensify over the next few years. This review aims to provide surgeons with an up-to-date summary of the clinically relevant evidence. The development of femoral modularity, and a classification system, is described. The theoretical rationale for modularity is summarised and the clinical outcomes are explored. The review also examines the clinically relevant problems reported following the use of femoral stems with a modular neck.

Joint replacement registries in the United Kingdom and Australia have provided data on the failure rates of modular devices but cannot identify the mechanism of failure. This information is needed to determine whether modular neck femoral stems will be used in the future, and how we should monitor patients who already have them implanted.

Cite this article: Bone Joint J 2013;95-B:1011–21.

Introduction

Bone-anchored devices have been used as skin-crossing conduits to record neuromuscular signals in sedated animals. Long-term recordings from cognisant subjects must be assessed. Hypothesis A bone-anchored device is suitable as a conduit for epimysial EMG (Electromyogram) recordings and is reliable in the long-term.

Material loss at the head-stem taper junction may contribute to the high early failure rates of stemmed large head metal-on-metal (LH-MOM) hip replacements. We sought to quantify both wear and corrosion and by doing so determine the main mechanism of material loss at the taper. This was a retrospective study of 78 patients having undergone revision of a LH-MOM hip replacement. All relevant clinical data was recorded. Corrosion was assessed using light microscopy and scanning electron microscopy, and graded according to a well-published classification system. We then measured the volumetric wear of the bearing and taper surfaces. Evidence of at least mild taper corrosion was seen in 90% cases, with 46% severely corroded. SEM confirmed the presence of corrosion debris, pits and fretting damage. However, volumetric wear of the taper surfaces was significantly lower than that of the bearing surfaces (p = 0.015). Our study supports corrosion as the predominant mechanism of material loss at the taper junction of LH-MOM hip replacements. Although the volume of material loss is low, the ionic products may be more biologically active compared to the particulate debris arising from the bearing surfaces.

It has been speculated that high wear at the head-stem taper may contribute to the high failure rates reported for stemmed large head metal-on-metal (LH-MOM) hips. In this study of 53 retrieved LH-MOM hip replacements, we sought to determine the relative contributions of the bearing and taper surfaces to the total wear volume. Prior to revision, we recorded the relevant clinical variables, including whole blood cobalt and chromium levels. Volumetric wear of the bearing surfaces was measured using a coordinate measuring machine and of the taper surfaces using a roundness measuring machine. The mean taper wear volume was lower than the combined bearing surface wear volume (p = 0.015). On average the taper contributed 32.9% of the total wear volume, and in only 28% cases was the taper wear volume greater than the bearing surface wear volume. Despite contributing less to the total material loss than the bearing surfaces, the head-stem taper junction remains an important source of implant-derived wear debris. Furthermore, material loss at the taper is likely to involve corrosion and it is possible that the material released may be more biologically active than that from the bearing surface.

Repair of tendon injuries aims to restore length, mechanical strength and function. We hypothesise that Demineralised Cortical Bone (DCB) present in biological tendon environment will result in remodelling of the DCB into ligament tissue. A cadaveric study was carried out to optimize the technique. The distal 1cm of the patellar tendon was excised and DCB was used to bridge the defect. 4 models were examined, Model-1: one anchor, Model-2: 2 anchors, Model-3: 2 anchors with double looped off-loading thread, Model-4: 2 anchors with 3 threads off-loading loop. 6 mature sheep undergone surgical resection of the distal 1cm of the right patellar tendon. Repair was done using DCB with 2 anchors. Immediate mobilisation was allowed, animals were sacrificed at 12 weeks. Force plate assessments were done at weeks 3, 6, 9 and 12. Radiographs were taken and pQCT scan was done prior to histological analysis. In the cadaveric study, the median failure force for the 4 models; 250N, 290N, 767N and 934N respectively. In the animal study, none of the specimens showed evidence of ossification of the DCB. One animal failed to show satisfactory progress, X-rays showed patella alta, on specimen retrieval there was no damage to the DCB and sutures and no evidence of anchor pullout. Functional weight bearing was 79% at week12. Histological analysis proved remodelling of the collagen leading to ligamentisation of the DCB. Results prove that DCB can be used as biological tendon substitute, combined with the use of suture bone anchor early mobilisation can be achieved.

Treatment of tendon and ligament injuries remains challenging; the aim is to find a biocompatible substance with mechanical and structural properties that replicate those of normal tendon and ligament. We examined the mechanical properties of Demineralised Cortical Bone (DCB) after gamma irradiation (GI) and freeze drying (FD). We also used different techniques for repairing bone-tendon-bone with DCB in order to measure the mechanical performance of the construct. DCB specimens were allocated into 4 groups; FD, GI, combination of both or none. The maximum tensile forces and stresses were measured. 4 cadaveric models of repair of 1cm patellar tendon defect using DCB were designed; model-1 using one bone anchor, Model-2 using 2 bone anchors, Model-3 off-loading by continuous thread looped twice through bony tunnels, Model-4 off-loading with 3 hand braided threads. Force to failure and mode were recorded for each sample. FD groups results were statistically higher (p=<0.05) compared to non-FD groups, while there was no statistical difference between GI and non-GI groups. The median failure force for model-1: 250N, model-2: 290N, model-3: 767N and model-4: 934N. There was no statistical significance between model-1 and model-2 (p=0.249), however statistical significance was found between other models (p=<0.006). GI has no significant effect on mechanical strength of the CDB while FD may have positive effect on its mechanical strength. Our study shows that a tendon rupture can be successfully augmented with CDB giving initial appropriate mechanical strength suitable for in vivo use providing the biological reactions to the graft are favourable.

Introduction

Tendon injuries remain challenging, secondary healing and prolonged immobilisation result in suboptimal outcome. Previous study by our group showed that demineralised bone matrix (DBM) can result in faster healing of a tendon enthesis. The aim of this study is to test different ways augmenting tendon with DBM to enhance tendon repair and regeneration.

Introduction

Demineralised Bone Matrix (DBM) is widely used in Orthopaedics and dentistry as a bone graft substitute and may be used to augment bone formation in load bearing applications.

In this study we examine the effect of gamma irradiation and freeze drying on the tensile strength of Demineralised Cortical Bone (DCB).

Introduction

Intraosseous transcutaneous amputation prostheses (ITAP) provide an alternative means of attaching artificial limbs for amputees. Conventional stump-socket devices are associated with soft tissue complications including; pressure sores and tissue necrosis. ITAP resolves these problems by attaching the exo-prosthesis transcutaneously to the skeleton. The aim of this study is to increase the attachment of dermal fibroblasts to titanium alloy in vitro. Fibronectin (Fn) and laminin 332 (Ln) enhance early cell growth and adhesion. We hypothesize that silanized dual coatings of fibronectin and laminin (SiFnLn) will be more durable when compared with adsorbed dual coating (AdFnLn), and will enhance early fibroblast growth and adhesion compared to single coatings.

Introduction

Following amputation, residual stumps used to attach the external prostheses can be associated with sores, infection and skin necrosis. These problems could be overcome by off loading the soft tissues. Intraosseous transcutaneous amputation prostheses (ITAP) attach external implants directly to residual bone reducing these complications. However, a tight seal at the skin implant interface is crucial in preventing epithelial down-growth and infection. Fibronectin (Fn) and laminin 332 (Ln), enhance early cell growth and adhesion of keratinocytes. Silanization to titanium alloy (Ti) allows these proteins to bond to the metal directly. We hypothesize that silanized dual coatings of fibronectin and laminin (SiFnLn) will be more durable than absorbed proteins and that keratinocyte adhesion will be increased compared with Ti controls and single silanized proteins.

INTRODUCTION

Autologous bone grafts are considered gold standard in the repair of bone defects. However they are limited in supply and are associated with donor site morbidity. This has led to the development of synthetic bone graft substitute (BGS) materials, many of which have been reported as being osteoinductive. The structure of the BGS is important and bone formation has been observed in scaffolds with a macroporous morphology. Smaller pores termed ‘strut porosity’ may also be important for osteoinduction. The aim of this study was to compare the osteoinductive ability of one silicate-substituted calcium phosphate (SiCaP) with differing strut porosities in an ectopic ovine model. Our hypothesis was that SiCaP with greater strut porosity would be more osteoinductive.

Background

Extendable proximal femoral replacements(PFR) are used in children with bone tumours in proximity to the proximal femoral physis, previously treated by hip disarticulation. Long-axis growth is preserved, allowing limb salvage. Since 1986, survival outcomes after limb salvage and amputation have been known to be equal.

Background

Extendable partial femoral replacements (EPFR) permit limb salvage in children with bone tumours in proximity to the physis. Older designs were extended through large incisions or minimally invasive surgery. Modern EPFR are lengthened non-invasively. Lengthening improves functional score (Futani, 2006) but has been associated with complications including infection (Jeys, 2005). This study is the first to look specifically at the relationship between EPFR lengthening and complications.

Background/Aims

The development of extendable prostheses has permitted limb salvage surgery in paediatric patients with bone tumours in proximity to the physis. Prostheses are extended to offset limb length discrepancy as the child grows. Aseptic loosening (AL) is a recognised complication. The implant stem must fit the narrow paediatric medullary canal and remain fixed while withstanding growth and increasing physical demands. Novel designs incorporate a hydroxyapatite (HA) coated collar that manufacturers claim improves bony ongrowth and stability, providing even stress distribution in stem and shoulder regions and providing a bone-implant seal, resulting in decreased AL and prolonged survival. This study aims to assess whether there is a relationship between bony ongrowth onto a HA collar and AL. Hypothesis: Bone ongrowth onto the HA collar of extendable prostheses is associated with more stable fixation and less AL despite patient growth.

Introduction

A new conservative hip stem has been designed to address the complex problem of total hip arthroplasty in the younger population.

Synthetic bone grafts are used in several major dental and orthopaedic procedures. Strontium, in the form of strontium ranelate, has been shown to reduce fracture risk when used to treat osteoporosis. The aim of the study was to compare bone repair in femoral condyle defects filled with either a 10% strontium substituted bioactive glass (StronBoneTM) or a TCP-CaSO4 graft. We hypothesise that strontium substituted bioactive glass increases the rate of bone ingrowth into a bone defect when compared to a TCP-CaSO4 ceramic graft.

A critical size defect was created in the medial femoral condyle of 24 sheep; half were treated with a Sr-bioactive glass (StronBoneTM), and in the other animals defects were filled TCP-CaSO4. Two time points of 90 and 180 days were selected. The samples were examined with regard to: bone mineral density (BMD) from peripheral quantitative CT (pQCT), mechanical properties through indentation testing, and bony ingrowth and graft resorption through histomorphometry.

The radiological density of Sr-bioactive glass in the defect is significantly higher than that of the TCP-CaSO4-filled defect at 90 and 180 days, (p=0.035 and p=0.000). At 90 days, the stiffness of the defect containing Sr-bioactive glass and is higher than that of the TCP-CaSO4 filled defect, (p=0.023). At 6 months there is no significant difference between the two materials. Histomorphometry showed no significant difference in bone ingrowth at any time point, however significantly more of the graft is retained for the StronBoneTM treatment group than the TCP-CaSO4 group at both 0 days (p=0.004) and 180 days (p=0.000). The amount of soft tissue within the defect was significantly less in the StronBoneTM group than for the TCP-CaSO4 group at 90 days (p=0.006) and 180 days (p=0.000)

The data shows the mechanical stability of the defect site is regained at a faster rate with the strontium substituted bioglass than the TCP-CaSO4 alternative. Histomorphmetry shows this is not due to increased bone ingrowth but may be due to the incorporation of stiff graft particles into the trabeculae. Sr-bioactive glass produces a stronger repair of a femoral condyle defect at 3 months compared with TCP-CaSO4.

Introduction

The National Joint Registry has recently identified failure of large head metal on metal hip replacements. This failure is associated with the high torque at the interface of standard modular taper junction leading to fretting and corrosion. A number of manufacturers produce mini spigots, which in theory, provide a greater range of motion as the neck head junction is reduced. However, the relative torque to interface ratio at this junction is also increased. In this study we investigated hypothesis that the use of small spigots (minispigots) will increase wear and corrosion on modular tapers.

Introduction

A modified anodisation technique where a titanium surface releases bactericidal concentrations of silver was developed and called Agluna. Our hypothesis was that silver incorporation was bactericidal and had no effects on the viability of fibroblasts and osteoblasts, would have no negative effect on interfacial shear strength and bone contact in an in vivo trans-cortical implant ovine model.

Introduction

This study investigated the binding agent Calcium/Sodium Alginate fibre gel and the addition of autogenic bone marrow aspirate (BMA) on bone growth into a porous HA scaffold implanted in an ovine femoral condyle critical-sized defect. Our hypothesis was that Alginate fibre gel would have no negative effect on bone formation and osteoconduction within the scaffold and that BMA would augment the incorporation of the graft with the surrounding bone at 6 and 12 weeks post implantation.

Impaction allograft using cement is commonly used in revision surgery for filling bone defects and provides a load bearing interface. However, the variable regeneration of new bone within the defect makes clinical results inconsistent. Previous studies showed that addition of mesenchymal stem cells (MSCs) seeded on allograft can enhance bone formation in the defect site. The purpose of this study is to test the hypothesis that heat generated during cement polymerization will not affect viability of the human MSCs.

The temperatures and durations were taken from previous studies that recorded the maximum temperature generated at the bone-cement interface. Temperatures of below 30 degrees Celsius to over 70 degrees Celsius have been detected and the duration of elevated temperature varies from 30 seconds to 5 minutes. In this study the viability of MSCs cultured at different temperatures was assessed. Ten groups were studied with three repeats (Table 1). A control group in which cells were cultures normally was used.

Culture medium was heated to the required temperature and added to the cells for the required duration. The metabolism of MSCs was measured using the alamar Blue assay, cell viability was analysed using Trypan Blue and cell apoptosis and necrosis were tested using Annexin V and Propidium Iodide staining.

Results showed that cell metabolism was not affected with temperatures up to 48 degrees Celsius for periods of 150s, while cells in the 58 degrees Celsius group eventually died (Fig. 1). Similar results were shown in Trypan Blue analysis (Fig. 2). When comparing the group of cells heated to 48 degrees Celsius for 150s with the control group for apoptosis and necrosis, no significant difference was observed.

The study suggests that human MSCs seeded to allograft can be exposed to temperatures up to 48 degrees Celsius for 150s, which covers many of the situations when cement is used. This indicates that the addition of mesenchymal stem cells to cemented impaction grafting can be carried out without detrimental effects on the cells and that this may increase osteointegration.

Infection is the primary failure modality for transcutaneous implants because the skin breach provides a route for pathogens to enter the body. Intraosseous transcutaneous amputation prostheses (ITAP) are being developed to overcome this problem by creating a seal at the skin-implant interface to prevent bacterial invasion. Oral gingival epithelial cell adhesion creates an infection free seal around dental implants; however this has yet to be demonstrated outside the oral environment. All epithelial cells attach via hemidesmosomes (HD) and focal adhesions (FA) and their expression is an indicator of adhesion efficiency. The aim of this study was to compare epidermal keratinocyte with oral gingival epithelial cell adhesion on titanium alloy in vitro to determine whether these two cell types differ in their speed and strength of adhesion. It was hypothesised that oral gingival epithelial cells attach to titanium alloy earlier than epidermal keratinocytes; with greater expression of hemidesmosomes and focal adhesions.

Human oral gingival epithelial cell (HGEP) and primary human epidermal keratinocyte (HPEK) adhesion to titanium alloy, was assessed at 4, 24, 48 and 72 hrs. Adhesion was measured by the number of FAs per unit cell area and expression of HDs using a semi-quantitative scale.

At 4 and 24hrs, there was a significant increase in vinculin marker expression per unit cell area of 4.3 and 4.7 times in HGEP compared with HPEK (p=0.000). At 48 and 72hrs there were no significant differences.

HD expression was significantly greater in HGEP at 4 and 24hrs (p=0.002) compared with HPEK. Up-regulation of HD expression in HPEK lagged that of HGEP until 48hrs, after which no significant differences were observed.

This study has demonstrated that oral gingival cells up-regulate both focal adhesion and hemidesmosome expression at earlier time points compared with epidermal keratinocytes. Expression of hemidesmosomes lags that of focal adhesions, suggesting that focal adhesion formation is a prerequisite for hemidesmosome assembly. We postulate that early attachment of oral gingival epithelial cells to dental implant biomaterials may be responsible for the formation of an infection-free seal.

Introduction

Following bone tumour resection, lower limb reconstruction results in leg-length discrepancy in skeletally immature patients. Previously, minimally invasive endoprostheses have been associated with a high risk of complications including joint stiffness, nerve injury, aseptic loosening and infection. The purpose of this study was to examine the outcome of the Stanmore non-invasive extendible endoprostheses used in our institution between 2002 and 2009 and compare them with implants used in the past.

Introduction

Primary bone tumours of the distal radius are rare, while it remains the third commonest site for primary lesions and recurrences of Giant Cell Tumours (GCT). The functional demands on the hand make reconstruction of the wrist joint following the excision of distal radius, particularly challenging.

Non-invasive expandable prostheses for limb salvage tumour surgery were first used in 2002. These implants allow ongoing lengthening of the operated limb to maintain limb-length equality and function while avoiding unnecessary repeat surgeries and the phenomenon of anniversary operations.

A large series of skeletally immature patients have been treated with these implants at the two leading orthopaedic oncology centres in England (Royal National Orthopaedic Hospital, Stanmore, and Royal Orthopaedic Hospital, Birmingham).

An up to date review of these patients has been made, documenting the relevant diagnoses, sites of tumour and types of implant used. 87 patients were assessed, with an age range of 5 to 17 years and follow up range of up to 88 months.

Primary diagnosis was osteosarcoma, followed by Ewing's sarcoma. We implanted distal femoral, proximal femoral, total femoral and proximal tibial prostheses. All implants involving the knee joint used a rotating hinge knee. 6 implants reached maximum length and were revised. 8 implants had issues with lengthening but only 4 of these were identified as being due to failure of the lengthening mechanism and were revised successfully. Deep infection was limited to 5% of patients.

Overall satisfaction was high with the patients avoiding operative lengthening and tolerating the non-invasive lengthenings well. Combined with satisfactory survivorship and functional outcome, we commend its use in the immature population of long bone tumour cases.

Infected mega-endoprostheses are difficult to treat with systemic antibiotics due to encapsulation of the implant by fibrous tissue, formation of biofilms and antibiotic resistant bacteria. Modifying the implant surface by incorporating a bactericidal agent may reduce infection. Infection rates are typically in the range of 8% to 30%. This study describes a novel process method of “stitching-in” ionic silver into the implant surface, in vitro testing and its early clinical usage.

A novel process has been developed to “stitch in” ionic silver into the upper surface of titanium alloy (Ti6Al4V). The process produces a modification by anodisation of the titanium alloy in dilute phosphoric acid, followed by absorption of silver from an aqueous solution. The engineered surface modification is therefore integral with the substrate and loaded with silver by an ion exchange reaction. Using this technique the maximum inventory of silver for typical a mega-prosthesis is 6mg and this is greater than 300 times lower than the No Observable Adverse Affects Level (NOAEL). Scanning electron microscopy revealed that the silver was concentrated in pits and forming reservoirs of ionic silver exposed to the body tissues.

Laboratory-based studies focusing on the safety and efficacy of silver as a bactericidal agent have included investigation into cytotoxicity using fibroblast and osteoblast cell lines, the impact of silver in reducing corrosion and laboratory testing to establish if the modified surface has an effect on the wear and mechanical characteristics. A range of fatigue, static, tensile pull off tests were performed. The silver elution profiles for both silver loaded and HA coated over a silver loaded surface have been examined. Histological studies were also performed to examine the impact of the silver on osseointegration.

The in vitro results confirm that silver is an effective antimicrobial agent. The mechanical characterization studies have identified that the surface treatment has no or minimal impact on the implant surface. Early results of the elution studies are encouraging showing that the HA coating of a silver loaded surface does not “seal” in the silver.

To date (May 10) 147 silver treated mega-prostheses have been implanted since March 2006. The majority of implants were distal femoral (29%), proximal tibial (23%) or hemiplevic (10%). The most common indication was revision of a failed limb salvage reconstruction (58%), with the dominant cause of failure being infection. The next most common indication was bone tumour (31%) and the large majority were used in the high risk skeletal locations of the tibia (44%) and the pelvis (27%). Early clinical results are encouraging indicating a significant reduction in the incidence of infection.

Three implants have been retrieved. An analysis of a proximal humeral replacement that had been in situ for 6 mths identified that there was 10-20% remaining on the implant surface.

This novel process of “stitching-in” silver appears to be a safe and effective surface treatment in helping to control infections of mega-prostheses. This technology has the potential to be transferred to other arthroplasty joints.

Polymethyl methacrylate spacers are commonly used during staged revision knee arthroplasty for infection. In cases with extensive bone loss and ligament instability, such spacers may not preserve limb length, joint stability and motion.

We report a retrospective case series of 19 consecutive patients using a custom-made cobalt chrome hinged spacer with antibiotic-loaded cement. The “SMILES spacer” was used at first-stage revision knee arthroplasty for chronic infection associated with a significant bone loss due to failed revision total knee replacement in 11 patients (58%), tumour endoprosthesis in four patients (21%), primary knee replacement in two patients (11%) and infected metalwork following fracture or osteotomy in a further two patients (11%). Mean follow-up was 38 months (range 24–70). In 12 (63%) patients, infection was eradicated, three patients (16%) had persistent infection and four (21%) developed further infection after initially successful second-stage surgery. Above knee amputation for persistent infection was performed in two patients.

In this particularly difficult to treat population, the SMILES spacer two-stage technique has demonstrated encouraging results and presents an attractive alternative to arthrodesis or amputation.

Medial Displacement Osteotomy (MDO) of the os calcis is used to correct the hind foot valgus in a flat foot deformity. Screw fixation is commonly used although contemporary locking plate systems are now available. This study tested the hypothesis that a 10mm MDO would support a higher load to failure with a locked step plate than with a single cannulated screw.

We performed a retrospective review of 98 patients with malignant tumours of the periacetabular region, treated by resection and endoprosthetic reconstruction between 1971 and 2005 at the Royal National Orthopaedic Hospital, Stanmore and The Royal Orthopaedic Hospital, Birmingham.

The mean age of the patients was 43.6 years (10 to 76). 53 patients (54%) were male. The age distribution demonstrated peaks in the 2nd and 6th decades. The mean follow up was 65 months (2 to 405. The overall 10-year survival rate was 56% (determined by the Kaplan-Meier method).

54 patients (58.1%) had one or more complications. Infection was the most common (30%) with the majority occurring in the first 2 years. Dislocation occurred in 19 (20%) of our patients all in the first year following surgery. All were recurrent with a mean of 2.9 (2 to 6) episodes. Operations performed before 1994 were associated with a dislocation rate of 40.5% and after 1996 the rate was only 3.9% (p < 0.001).

Function was assessed according the Toronto Extremity Salvage Sore (TESS). The overall TESS was 59.4. In patients that had a major complication the TESS was 37.1 but in the group that did not the TESS was 70.3 (p < 0.001).

Men experienced higher rates of death, infection and revision than women (p < 0.05). The local recurrence rate was 31% with high grade tumours associated with higher recurrence rates (p < 0.05). Tumour resection in the ilium is associated with higher rates of infection than tumours located in the periacetabular region alone (p < 0.05).

This method of reconstruction is still associated with high complication rates. Function is good if a major complication can be avoided. The lower dislocation rate more recently is probably the result of improved surgical technique and the use of larger femoral heads.

Chondrosarcoma is a malignant tumour and accounts for approximately 20% of bone sarcomas. The pelvis is one of the commonest sites. Chondrosarcoma of the pelvis lends itself to surgical excision and is relatively resistant to irradiation and chemotherapy. A long term survival analysis of this challenging condition is rarely reported in literature. We review and evaluate the oncological and functional results of all the patients operated at our centre and we analyse the survival analysis of these patients with special focus on the prognostic factors.

Fifty-four consecutive patients with chondrosarcoma of the pelvis who were treated at the Royal National Orthopaedic Hospital, Stanmore, UK between 1987 and 2001 were included in the study. Demographic data, case notes, histopathological results and follow-up data were obtained and statistically analysed.

There were 38 males and 16 females with a mean age of 48.4 years [18-77]. The chondrosarcomas were primary [n=38], secondary [n-7] or recurrences [n=9]. The anatomical sites in the pelvis were in the epicentre I [n=24], II [n=20] and III [n=10]. The surgical procedures performed were local resection [n=28], local resection and hip arthroplasty [n=6], hemipelvectomy (+endoprothesis) [n=16], hemipelvectomy [+fibular strut graf] [n=2] and hinquarter amputation [n=2]. The histological grade was Gr [n=27], Gr 2[n=20] and Gr 3 [n=7]. The complication rate was 24%:wound revision [9%], dislocation [8%] and infection [7%]. There was a 5, 10 and 15 year cumulative survival rate of 74%, 65% and 40%. The overall recurrence rate was 24%.

The factors associated with a worse prognosis were high histologic tumour grade, increasing patient age, anatomical location in site I and III, primary surgery outside of tumour centre, inadequate surgical margins, and those treated by local extension. Aggressive surgical approach significantly improves the prognosis of the patients with chondrosarcoma of the pelvis.

When performing limb salvage operations for malignant bone tumours in skeletally immature patients, it is desirable to reconstruct the limb with a prosthesis that can be lengthened without surgery at appropriate intervals to keep pace with growth of the contra-lateral side. We have developed a prosthesis that can be lengthened non-invasively. The lengthening is achieved on the principle of electromagnetic induction.

The purpose of this study was to look at our early experience with the use of the Non Invasive Distal Femoral Expandable Endoprosthesis. A prospective study of 17 skeletally immature patients with osteosarcoma of the distal femur, implanted with the prosthesis, was performed at the Royal National Orthopaedic Hospital, Stanmore. The patients were aged between 9 and 15 years (mean 12.1 years) at the time of surgery. Patients were lengthened at appropriate intervals in outpatient clinics. Patients were functionally evaluated using the Musculoskeletal Tumour Society (MSTS) Scoring System and the Toronto Extremity Severity Score (TESS). Average time from the implantation to the last follow-up was 18.2 months (range 14-30 months). The patients have been lengthened by an average of 25mm (4.25-55mm). The mean amount of knee flexion is 125 degrees. The mean MSTS score is 77% (23/30; range 11-29) and the mean TESS score is 72%. There have been two complications: one patient developed a flexion deformity of 25 degrees at the knee joint and one patient died of disseminated metastatic malignancy.

The early results from patients treated using this device have been encouraging. Using this implant avoids multiple surgical procedures and general anaesthesia. This results in low morbidity, cost savings and reduced psychological trauma. We do need additional data regarding the long-term structural integrity of the prosthesis.

Background

Endoprosthetic reconstruction is an established method of treatment for primary bone tumours in children. Traditionally these were implanted with cemented intramedullary fixation. Hydroxyapatite collars at the shoulder of the implant are now standard on all extremity endoprostheses, but older cases were implanted without collars. Uncemented intramedullary fixation with hydroxyapatite collars has also been used in an attempt to reduce the incidence of problems such as aseptic loosening. Currently there are various indications that dictate which method is used.

Non-invasive expandable prostheses for limb salvage tumour surgery were first used in 2002. These implants allow ongoing lengthening of the operated limb to maintain limb-length equality and function while avoiding unnecessary repeat surgeries and the phenomenon of anniversary operations.

A large series of skeletally immature patients have been treated with these implants at the two leading orthopaedic oncology centres in England (Royal National Orthopaedic Hospital, Stanmore, and Royal Orthopaedic Hospital, Birmingham).

An up to date review of these patients has been made, documenting the relevant diagnoses, sites of tumour and types of implant used. 74 patients were assessed, with an age range of 7 – 16 years and follow up range of 4 – 88 months.

We identified five problems with lengthening. One was due to soft tissue restriction which resolved following excision of the hindering tissue. Another was due to autoclaving of the prosthesis prior to insertion and this patient, along with two others, all had successful further surgery to replace the gearbox. Another six patients required mechanism revision when the prosthesis had reached its maximal length. Complications included one fracture of the prosthesis that was revised successfully and six cases of metalwork infection (two of which were present prior to insertion of the implant and three of which were treated successfully with silver-coated implants). There were no cases of aseptic loosening.

Overall satisfaction was high with the patients avoiding operative lengthening and tolerating the non-invasive lengthenings well. Combined with satisfactory survivorship and functional outcome, we commend its use in the immature population of long bone tumour cases.

Introduction: Hydrogenated (acetylene:C2H2) and silanized (tetra methyl silane:TMS) diamond-like-carbon coatings (DLC) are applied to titanium alloy to reduce surface energy, cell adhesion and hydrophilicity. The incorporation of silicon into DLC reduces its surface energy. It was hypothesized that surfaces that have high surface energy and high hydrophilicity favoured the adhesion and maturation of fibroblasts when compared with C2H2 and TMS coated substrates in vitro. This would help in achieving a seal at the prosthesis – soft tissue interface, thereby helping in reducing infection.

Methods: and Materials: Fibroblasts were cultured on 10 mm diameter titanium alloy, C2H2 and TMS coated titanium alloy discs for 4 hours and 24 hours (2500 cells per disc). Cell area, adhesion plaque numbers, number of plaques per unit area (plaque density) and the total area of adhesion plaques per cell were analysed. The results were compared between experimental groups and controls at 4 and 24 hours. In order to measure the strength of adhesion of cells fibroblasts were cultured on discs (30 mm diameter)[machine finished and polished(Ra = 0.031)](density-300,000 cells per disc) for 4 and 24 hours with similar coatings and exposed to radial shear by flow (100 mls/min) of culture media over their surface. These discs were then stained and analysed using Photoshop (ver.5.5) and SPSS (ver.16). Mann-Whitney tests were used to calculate significance (p< 0.05).

Results: At 4 and 24 hours, the number of adhesion plaques was significantly greater on control and C2H2 compared with TMS. At 4 hours, cell area on control discs was significantly greater than C2H2 and TMS. At 24 hours, cell area on control and C2H2 was significantly greater than TMS. Between 4 and 24 hours, the number of adhesion plaques increased significantly on all the surfaces. Cell area increased significantly on C2H2 and TMS between 4 and 24 hours. At 4 hours, shear stress needed to dislodge the cells was highest for polished C2H2 and least for titanium unpolished surface. Cells on polished surfaces in corresponding groups required higher shear stress to remove the cells than cells on unpolished surfaces. At 24 hours, cells on polished C2H2 required significantly higher shear stresses to detach them than cells on unpolished C2H2 and TMS (polished and unpolished). Cells on unpolished Ti required higher stress to dislodge than cells on unpolished TMS. From 4 to 24 hours, a significant increase in shear stress to remove the cells was required on all unpolished surfaces and polished C2H2. A significant correlation was seen between adhesion plaque density at 4 hours and shear stress.

Discussion: This work supports the hypothesis that surfaces with high surface energy and high hydrophilicity lead to increased cell attachment and cell area. It also shows the correlation between adhesion plaque density and the shear stress needed to dislodge fibroblasts from bioactive surfaces.

Between 1997 and 2007, 68 consecutive patients underwent replacement of the proximal humerus for tumour using a fixed-fulcrum massive endoprosthesis. Their mean age was 46 years (7 to 87). Ten patients were lost to follow-up and 16 patients died. The 42 surviving patients were assessed using the Musculoskeletal Tumor Society (MSTS) Score and the Toronto Extremity Salvage Score (TESS) at a mean follow-up of five years and 11 months (one year to ten years and nine months). The mean MSTS score was 72.3% (53.3% to 100%) and the mean TESS was 77.2% (58.6% to 100%).

Four of 42 patients received a new constrained humeral liner to reduce the risk of dislocation. This subgroup had a mean MSTS score of 77.7% and a mean TESS of 80.0%. The dislocation rate for the original prosthesis was 25.9; none of the patients with the new liner had a dislocation at a mean of 14.5 months (12 to 18).

Endoprosthetic replacement for tumours of the proximal humerus using this prosthesis is a reliable operation yielding good results without the documented problems of unconstrained prostheses. The performance of this prosthesis is expected to improve further with a new constrained humeral liner, which reduces the risk of dislocation.

Bone marrow cells are well known for improving healing. Recent studies report that stromal cell-derived factor-1 (SDF-1) and its receptor CXC chemokine receptor 4 (CXCR4) play roles in stem cell homing and are related to short-term and long-term engraftment. SDF-1 secreted from an injured organ can pass the endothelium barrier in a CXCR4-dependent manner into the bone marrow and recruit hematopoietic progenitors to the circulation. There is evidence to show that SDF-1 also has chemoat-tractive effects and is able to recruit mesenchymal stem cells and osteoprogenitors. Our previous study also showed that SDF-1 has an enhanced effect on osteoblas-tic differentiation of human mesenchymal stem cells. The purpose of this study is to investigate the effects of genetically modified bone marrow cells that overexpress SDF-1 on bone fracture healing in rat model. The hypothesis is that genetically modified rat bone marrow cells (rBMCs) that over expresses SDF-1 will enhance the fracture healing process compared to non-treated groups or to groups treated with only rBMCs. rBMCs were harvested from femora of young male Wistar rats. rBMCs were expanded ex vivo, and cells of passage 3 were used in the experiment. SDF-1 over-expressing rBMCs (rBMC-SDF-1) were engineered by infection of adenovirus carrying human SDF-1 gene at the multiplicity of infection (MOI) 500. Eighteen adult female Wistar rats were divided into three groups with 6 rats in each group:

rBMC-SDF-1,

A 3mm gap in the middle of femur was created during surgery and stabilized by an external fixator. In two groups three hundred thousand rBMCs or rBMCs-SDF-1 were seeded into a collagen sponge and transplanted into the gap. For the control group, sponges without cells were used. Rats were sacrificed 3 weeks after operation and the femora were harvested. Bone mineral content within the gap was measured immediately after operation and compared with the bone mineral content within the same gap at the third week by dual energy X-ray absorptiometry (DEXA) scanning. The area of new bone formation was measured using histomorphometery on H& E stained sections and quantified by imaging analysis system. In the present study, the rBMC-SDF-1 group showed the most dominant influence in both new bone formation and bone mineral increase. rBMC-SDF-1 not only increases new bone formation but also has higher bone mineral content after 3 weeks compare with the rBMC only. This bone healing progress may due to the enhanced local SDF-1/CXCR4 interaction that recruited more host’s stem cells into the fracture site. The control group showed an increased new bone formation in the histological analysis but a reduced bone mineral content after 3 weeks whereas in comparison the rBMC group showed a similar new bone area to the control group but a significantly higher bone mineral content. This may indicate a faster bone repairing ability with the BMCs. Both rBMC and rBMC-SDF-1 groups have a higher bone mineral content and a more compact new bone structure that may indicate an accelerate effect of rBMC in the bone mineralization. In this study, we show that SDF-1 induces improved bone formation in early fracture healing.

We investigated the hypothesis that autologous bone marrow stromal cells (BMSC) sprayed on the surface of acetabular cups would improve bone formation and bone implant contact.

Total hip replacements were implanted in 11 sheep, randomly assigned to receive either acetabular implants sprayed with autologous BMSCs suspended in fibrin (study group) or fibrin only (control group). Sheep were sacrificed after six months and the acetabulum with the implant was retrieved and prepared for undcalcified histology. Implant bone contact in both groups was compared, by microscopically noting the presence or absence of new bone or fibrous tissue along the implant at 35 consecutive points (every 1000 μm). The observers undertaking the histological analysis were blinded.

Significantly increased bone implant contact was noted in the BMSC treated group 30.71% ± 2.95 compared to the control group 5.14% ± 1.67 (p = 0.014). The mean thickness of fibrous tissue in contact with the implant was greater at the periphery 887.21mm ± 158.89 and the dome 902.45mm ± 80.67 of the implant in the control group compared to the BMSC treated group (327.49mm ± 20.38 at the periphery and 739.1 mm ±173.72 at the centre). Conversely direct bone contact with the implant surface was significantly greater around the cups with stem cells.

BMSC sprayed on surface of implants improves bone implant contact. Spraying acetabular cups using stem cells could be used in humans where acetabular bone contact is compromised such as in revision procedures.

Background: Osseointegrated amputation prostheses avoid soft tissue complications associated with traditional socket prostheses. Forces are transmitted directly to the skeleton resulting in improved function. However, approximately 50% of transcutaneous implants become infected due to the lack of a successful skin-implant seal. Intraosseous Transcutaneous Amputation Prostheses (ITAP) are designed to integrate with the skin preventing epithelial downgrowth and infection.

Fibronectin adsorption enhances fibroblast adhesion in vitro; however, in vivo, fibronectin becomes desorbed from the implant surface. Covalent attachment of fibronectin by silanisation has been shown to be durable in vitro. The silanisation process for fibronectin includes a stage of passivation with sulphuric acid which alters surface characteristics.

Aims: The aim of this study was to determine if in vitro fibroblast adhesion to silanised fibronectin (SiFn) titanium alloy could be improved by omitting or reducing the length of time of passivation. The study also assessed the effects of SiFn on dermal attachment in vivo comparing the results with adsorbed fibronectin substrates and with uncoated controls.

Methods: Scanning electron microscopy, Ra profilometry and contact angle measurement (n=6) were used for topographical characterization of surfaces. Anti-vinculin antibodies were used to immunolocalize fibroblast adhesion sites after 24 hours. The morphology of fibroblasts on each surface was evaluated using scanning electron microscopy. Subcutaneous plates were implanted onto the tibiae of an ovine model (n=3) in order to evaluate the performance of the modified SiFn surface in vivo. Hydroxyapatite (HA) and adsorption of fibronectin to HA (HAFn) were also tested because HA coatings are currently applied to the dermal section of ITAP in clinical trials. After four weeks, a histological assessment of the percentage of soft-tissue attachment and cell alignment relative to the implant was performed.

Results: Passivation produced rougher, more hydrophobic surfaces with numerous microcracks and was associated with poorer fibroblast adhesion and spreading than un-passivated controls in vitro.

SiFn with passivation resulted in poorer cell adhesion than SiFn without passivation. Reducing the time period for passivation did not reduce the detrimental effects of passivation In vivo, HAFn and SiFn resulted in higher median values for soft-tissue attachment than simple adsorption of fibronectin; however, the differences were not statistically significant. Cell alignment was significantly different for HAFn and SiFn compared with controls (p< 0.05), with cells on the fibro-nectin treated surfaces orientated more perpendicular to the implant surface.

Conclusion: Omission of passivation improves fibro-blast adhesion to SiFn surfaces in vitro. Coating with fibronectin either by silanisation onto titanium alloy or by adsorption onto HA surfaces affected the orientation of cells in vivo, implying that tissue attachment was enhanced. A time course may be of value to determine if fibronectin coatings are lost over time in vivo.

Introduction: Due to uneven distribution of stress between the stump and the socket in amputees pain, infection and necrosis of soft tissue can be problematic (Dudek, Marks, & Marshall 2006)Implants have been developed that allow the external prostheses to attach directly to the skeleton by a percutaneous section by osseointegration that reduces the stresses on the soft tissue alleviating the problems associated with a socket (Lai et al. 1998). It has been postulated that surface coatings can enhance soft tissue attachment and increase the in growth of fibroblastic dermal tissues enhancing the seal at the skin implant interface and reducing infection (Pendegrass et al. 2006). Hydrogenated (acetylene: C2H2) and silanized (tetra methyl silane: TMS) diamond-like-carbon coating (DLC) can be applied to titanium(Ti) alloy to reduce surface energy and hydrophilicity. It was hypothesized that biomaterial surfaces having high surface energy and high hydrophilicity eg, Ti alloy enhance the adhesion and maturation of human dermal fibroblasts when compared with C2H2 and TMS coated substrates in vitro.

Methods: Fibroblasts were cultured on 10 mm diameter Ti alloy, C2H2 and TMS coated Ti alloy discs for 4 hours and 24 hours (2500 cells per disc). Cell area and attachment were analysed using Image Analysis and quantification of immunolocalised vinculin containing adhesion plaques respectively. The number of plaques per cell and cell area were compared between experimental groups and controls at 4 and 24 hours. The change in cell area and number of adhesion plaques between 4 and 24 hours were compared for each substrate type. SPSS version 10 was used for the statistical analysis.

Results: At 4 and 24 hours, the number of adhesion plaques was significantly greater on control and C2H2 compared with TMS (p< 0.001). No significant difference was observed between control and C2H2 discs (p> 0.05). At 4 hours, cell area was significantly greater in control compared to both C2H2 and TMS (p< 0.001). At 4 hours, the cell area in TMS was significantly greater than C2H2 (p< .001). At 24 hours, the cell area on control and C2H2 was significantly greater than TMS(p< 0.001). However, there was no significant difference between cell area on control and C2H2 (p> 0.05). From 4 to 24 hours, the number of adhesion plaques increased significantly on all the surfaces (p< 0.001). Cell area increased significantly on C2H2 and TMS between 4 and 24 hours. No significant increase in the cell area was observed on control substrates

Discussion: This supports the hypothesis that surfaces with high surface energy and high hydrophilicity lead to increased cell attachment and cell area. Thus, it can be concluded that the hydrophilic surfaces with higher surface energies favour the adhesion of dermal fibroblasts.

Disarticulation of the hip in patients with high-grade tumours in the upper thigh results in significant morbidity. In patients with no disease of the proximal soft tissue a femoral stump may be preserved, leaving a fulcrum for movement and weight-bearing. We reviewed nine patients in whom the oncological decision would normally be to disarticulate, but who were treated by implantation of an endoprosthesis in order to create a functioning femoral stump. The surgery was undertaken for chondrosarcoma in four patients, pleomorphic sarcoma in three, osteosarcoma in one and fibrous dysplasia in one. At follow-up at a mean of 80 months (34 to 132), seven patients were alive and free from disease, one had died from lung metastases and another from a myocardial infarction. The mean functional outcome assessment was 50 (musculoskeletal tumor society), 50 and 60 (physical and mental Short-form 36 scores).

Implantation of an endoprosthesis into the stump in carefully selected patients allows fitting of an above-knee prosthesis and improves wellbeing and the functional outcome.

The use of massive endoprostheses following bone tumour resection is well recognised. Where possible, joint salvage rather than joint replacement is usually attempted. However cases arise where there is insufficient bone following tumour resection to allow adequate fixation of a joint sparing prosthesis. We reporta series of 4 patients (aged 4–12), treated between 1994 and 2008, in which irradiated autologous bone has been combined with a diaphyseal or distal femoral replacement in order to preserve the native hip joint.

There were 3 cases of osteosarcoma and 1 case of Ewing‘s sarcoma. After a mean follow-up of 53.5 months (range 9–168), all four patients are alive without evidence of local recurrence or metastases. One implant was revised after 14 years following fracture of the extending component of the growing endoprosthesis. There have been no cases of loosening or periprosthetic fracture.

This is the first report of irradiated autologous bone with joint sparing endoprostheses in skeletally immature patients.

This case highlights the close association between osteo-fibrous dysplasia (OFD) and adamantinoma, drawing attention to the role for more radical treatment options when treating OFD. We discuss the advancements in joint-sparing endoprostheses using bicortical fixation. Finally we describe a unique biomedical design allowing for manufacture of an end cap to allow amputation through a custom made joint-sparing proximal tibial replacement as opposed to an above knee amputation.

A 37 year old presented 7 years ago having sustained a pathological fracture of her tibia. Subsequent biopsy revealed OFD, curettage with bone graft was performed. She later developed recurrence, two percutaneous biopsies confirmed OFD. 6 years following her initial diagnosis she was referred to RNOH with further recurrence, a biopsy at this stage revealed a de-differentiated adamantinoma. A joint-sparing proximal tibial replacement was performed and adjuvant chemotherapy administered, she remained well for one year. Recurrence was noted at the distal bone-prosthesis interface, histology revealed a high grade dedifferentiated osteosarcoma, limb preservation was not deemed possible and an amputation was performed through the prosthesis. The proximal tibial device was uncoupled leaving a residual 7 cms insitu, a small custom made end cap was attached to the remaining prosthesis and a myocutaneous flap fashioned over it, this ultimately enabled the patient to mobilise well with a below–knee orthotic device.

This case highlights the need for more radical surgery when treating cases of OFD and the relationship between OFD and adamantinoma. It also introduces a joint-sparing proximal tibial device for use in proximal tibial tumours that do not invade the proximal tibial metaphysis. The biomechanical design solution has given us the unique option of preserving the knee joint allowing the patient a below knee amputation whereas previously an above knee amputation would have been performed thereby significantly reducing her functional outcome.

Following resection of tumours in the distal femur, reconstruction with joint-sparing prostheses have shown good short-term functional outcomes. There is however limited literature on the affect of knee-sparing prostheses on function of the distal femoral physis in children of bone growing age.

We discuss two patients, a male (11yrs) and female (10yrs) who had joint-sparing distal femoral prostheses inserted for treatment of Ewing’s sarcoma. The knee joint, along with the distal growth plate, was preserved and fixed to the distal end of the prosthesis using uni-cortical screws positioned distal to the physis. In the female, these screws were removed 6 months postop due to prominence of the screws under the skin. In both patients, we assessed radiographs from immediately post[surgery and the most recent follow-up (20 and 28 months respectively). In each set, for the operated limb, we measured the height and width of the distal femoral epiphysis, the total length of the femur and the length of the proximal femoral bone segment from the femoral head to the proximal bone-prosthesis interface. In addition, postoperative assessments of leg lengths, bilaterally, were documented.

In both patients, distal femoral epiphyseal height and width in the operated leg showed no significant change following endoprosthetic replacement. In the female, growth did not resume even after removal of the epiphyseal screws. In both patients, lengths of the femur and the proximal bone segment increased significantly following surgery. The patients demonstrated no clinical leg length discrepancy at the most recent follow-up.

This study suggests that the function of the distal femoral growth plate ceases following insertion of joint-sparing distal femoral endoprostheses, probably due to trans-physeal fixation. This does not appear to resume following early removal of distal screws. The proximal growth plate, however, continues to function adequately enough to maintain symmetry in overall leg length.

Purpose: To determine if Cobalt-Chrome (CoCr) femoral components of knee replacement components roughen significantly, and when significant roughening may start.

Methods:

Retrieval study:

14 knee replacement components were retrieved after revision procedures. The average surface roughness (Ra) of the articulating regions of each condyle was measured by surface profilometry and compared to Ra of non-articulating regions, which acted as controls on each implant.

In vitro testing:

Pin-on-plate testing of 6 paired CoCr pins and vacuum γ-irradiated UHMWPE discs was carried out under a force of 2.3kN at 1Hz to investigate how the articular Ra of CoCr pins varied with increasing number of cycles. Ra was measured at 0, 10, 100 and 1000 cycles using surface profilometry.

Results:

Retrieval analysis:

Average medial femoral condyle Ra was significantly greater than control Ra (p=0.040). Average lateral femoral condyle Ra was not significantly greater than control Ra (p=0.158). Significantly higher average Ra was seen on the medial condyles when compared with the lateral condyles (p < 0.05). 8/14 retrieved femoral components had ≥1 significantly roughened condyle (p< 0.05).

In vitro testing:

At 100 and 1000 cycles the Ra of the CoCr pins was significantly greater than Ra at 0 cycles (p< 0.05).

Conclusion: A large proportion of femoral components of knee replacement implants roughen significantly in vivo, a finding supported by our in vitro testing which indicates that roughening may begin very early on. This may have important implications for aseptic loosening of knee replacement components. However, the average Ra of those CoCr surfaces significantly (p< 0.05) roughened was within acceptable limits for orthopaedic implants (0.050μm).

Despite advances in total hip arthroplasty, failure of acetabular cup remains a concern. The role of bone marrow stromal cells (BMSCs) to aid osseointegration of orthopaedic implants have been recently studied. We investigated the hypothesis that autologous BMSCs sprayed on the surface of acetabular cups would improve bone formation and bone implant contact.

Total hip replacements were implanted in 11 sheep, randomly assigned to receive either acetabular implants sprayed with autologous BMSCs suspended in fibrin (study group) or fibrin only (control group). Sheep were sacrificed after six months and the acetabulum with the implant was retrieved and prepared for undecalcified histology. Implant bone contact in both groups was compared microscopically, by noting the presence or absence of new bone or fibrous tissue along the implant at 35 consecutive points (every 1000 μm). The observers undertaking the histological analysis were blinded.

Significantly increased bone implant contact was noted in the BMSC treated group 30.71% ± 2.95 compared to the control group 5.14% ± 1.67 (p = 0.014). The mean thickness of fibrous tissue in contact with the implant was greater at the periphery 887.21mm ± 158.89 and the dome 902.45mm ± 80.67 of the implant in the control group compared to the BMSC treated group (327.49mm ± 20.38 at the periphery and 739.1 mm ± 173.72 at the centre). Conversely, direct bone contact with the implant surface was significantly greater around the cups with BMSCs.

Our data demonstrate that BMSC sprayed on surface of acetabular implants improves bone implant contact. Spraying acetabular cups using stem cells could be used in humans where acetabular bone contact is compromised such as in revision procedures.

Introduction: The non-invasive growing prosthesis continues to be used successfully for the treatment of limb salvage operations in tumour patients. We report our continued experience in 17 skeletally immature patients with osteosarcoma of the distal femur.

Methods: Patients had a mean age of 10.2 years (range 6 to 15) at the time of surgery. The endoprosthesis was lengthened at appropriate intervals in outpatient clinics without anaesthesia using the principle of electromagnetic induction.

Results: The mean follow-up was 28 months (range 2 to 55). The prostheses were lengthened by a mean of 47.4 mm (range 0.5 to 208) and maintained a mean knee flexion of 110 degrees (range 90 to 120 degrees).

Complications developed in seven patients: two implants failed requiring revision, one peri-prosthetic fracture occurred, one developed a flexion deformity of 25 degrees at the knee joint, which was subsequently overcome and three died of disseminated disease.

Discussion: The medium term results from patients treated with this device have continued to show a promising outcome. Four patients successfully completed desired lengthening, six patients are continuing with ongoing lengthening. The implant avoids multiple surgical procedures, general anaesthesia and assists in maintaining leg-length equality.

Scarf osteotomy is widely used as a surgical treatment for hallux valgus. It is a versatile osteotomy, allowing shortening, depression or medial displacement of the capital fragment but it remains uncertain how stresses within the bone subsequently vary. The aim of this study was to design a computerised model to explore the effect on bone stress of changing the position of bony cuts for a scarf osteotomy.

A computerised image was constructed using finite element analysis. This utilises a mathematical technique to form element equations which represent the effect of applied force to the object appropriate to each finite element. Maximum bone stresses were then measured using different osteotomy variables. The osteotomy variables studied were the length of the longditudinal cut, apex of the distal cut to articular cartilage, resection level of the longditudinal cut and combinations of these variables. A saw bone model was used to test the findings of the study.

The results of this study show that lowering the longditudinal resection level and shortening via the distal cut beyond 6 mm will decrease bone stress. Additionally, raising the longditudinal resection level and shortening via the proximal cut caused an increase in bone stress. A saw bone model confirmed the findings of the study.

In conclusion, our experience is that finite element analysis is a very useful model in studying the bony stresses for a scarf osteotomy and assists in optimising the direction and angle of bony cuts used.

Introduction: Recent studies have shown that MSCs can be isolated from the peripheral blood of many different species. Hematopoietic stem cell (HSC) mobilization from the bone marrow to the circulating bloodstream can be induced using granulocyte colony stimulating factors (G-CSF). As it has been shown that HSCs and MSCs have positive interactions with each other, it may be possible that G-CSF also promotes the release of circulating peripheral blood MSCs (PBMSCs). The hypothesis of this study was that G-CSF would increase the mobilization of peripheral blood-derived stromal-like cells.

Materials and Methods: Six sheep with normal hematological profiles were given 5& #956;g/kg Neupogen& #63721; (filgrastim, G-CSF) subcutaneously for five days. Pre- and post-G-CSF treatment, blood was taken 4, 12, 24, and 2 weeks post-treatment. PBMSCs were isolated from the blood and cells plated at a cell density of 4.0 x 10e4 nucleated cells/cm2. Fibroblastic colony forming units (CFU-F) were counted 7 and 14 days after initial culture. The cells were tested for their multipotency by treating them with osteogenic, adipogenic, and chondrogenic supplements, and staining with the Von Kossa, Oil Red ‘O,’ and Alcian Blue stains, respectively, to show differentiation down the different lineages.

Results: No CFU-F formation was observed in all blood samples taken before G-CSF therapy (0 CFU-F) after 7 and 14 days in culture. After G-CSF treatment, CFU-Fs were observed in blood samples taken 4, 12, and 336 hours (2 weeks) post-G-CSF. The CFU-F count was highest after 14 days in culture in the blood samples obtained 2 weeks post-G-CSF administration (1.027 ± 30.1353 CFU-F/cm2), compared to the lowest count, which was at 12 hours post-G-CSF treatment (0.064 ± 0.064 CFU-F/cm2). Hematology showed an increase in white blood cell (WBC), neutrophil, and eosinophil counts 24 hours after G-CSF administration. Two weeks post-G-CSF treatment, WBC, neutrophil, lymphocyte, and monocyte counts dropped back to normal range values. The highest number of CFU-F/cm2 were observed at this time. When WBC numbers were correlated with CFU-F counts using Pearson’s correlation co-efficient, the result was 0.523, a significant value (p=0.023) indicating that 27.4% of the WBC counts were related to CFU-F counts and vice versa. When time was accounted for as a third variable using the test for partial correlation coefficients, the co-efficient was found to be −0.0063, and was not significant (p=0.492). Expanded cells were fibroblastic in morphology, and upon differentiation were positive for the Von Kossa, Oil Red ‘O,’ and Alican Blue stains, indicating differentiation down the osteogenic, adipogenic, and chondrogenic lineages, respectively.

Discussion and Conclusions: We have shown that PBMSCs can be isolated after G-CSF administration in sheep, and that the numbers of CFU-F increase after WBC levels have returned to normal. A previous in vitro study proposed that the increased BMSC growth observed when co-cultured with CD45+ HSCs was due to positive interactions between HSCs and MSCs, indicating a possible steady-state balance. PBMSCs may have important future applications in bone tissue regeneration.