Aims

Adenosine, lidocaine, and Mg²⁺ (ALM) therapy exerts differential immuno-inflammatory responses in males and females early after anterior cruciate ligament (ACL) reconstruction (ACLR). Our aim was to investigate sex-specific effects of ALM therapy on joint tissue repair and recovery 28 days after surgery.

Introduction:

Lateralization of reversed shoulder arthroplasty provides improvement in range of motion and decreases inferior scapular notching. The purpose of this study was to verify if the autologous cancelous bone graft harvested from the humeral head does heal constantly in a large cohort of patients followed for a long time

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. Methods. A total of 12 sheep underwent unilateral single-bundle ACL reconstruction using pSFT. Two femoral fixation devices were investigated: Group 1 (n = 6) used cortical suspensory fixation (Endobutton CL) and Group 2 (n = 6) used cross-pin fixation (Stratis ST). A soft screw was used for tibial fixation. Functional recovery was quantified using force plate analysis at weeks 5, 8, and 11. The sheep were euthanized after 12 weeks and comprehensive histological analysis characterized graft healing at the graft-bone interface and the intra-articular graft (ligamentization). Results. The pSFT remodelled into a ligament-like structure and no adverse inflammatory reaction was seen. The ground reaction force in the operated leg of the Endobutton group was higher at 11 weeks (p < 0.05). An indirect insertion was seen at the graft-bone interface characterized by Sharpey-like fibres. Qualitative differences in tendon remodelling were seen between the two groups, with greater crimp-like organization and more aligned collagen fibres seen with Endobutton fixation. One graft rupture occurred in the cross-pin group, which histologically showed low collagen organization. Conclusion. Decellularized pSFT xenograft remodels into a ligament-like structure after 12 weeks and regenerates an indirect-type insertion with Sharpey-like fibres. No adverse inflammatory reaction was observed. Cortical suspensory femoral fixation was associated with more enhanced graft remodelling and earlier functional recovery when compared with the stiffer cross-pin fixation

Accidents, osteoporosis or cancer can cause severe bone damage requiring grafts to heal. All current grafting methods have disadvantages including scarcity and infection/rejection risks. An alternative is therefore needed. Hydroxyapatite/calcium carbonate (HA/CC) scaffolds mimic the mineral bone composition but lack growth factors present in auto- and allografts, limiting their osteoinductive capacity. We hypothesize that this will increase the osteogenicity and osteoinductivity of scaffolds through the presence of growth factors. The objectives of this study are to develop and mass-produce grafts with enhanced osteoinductive capacity. HA/CC scaffolds were cultured together with umbilical cord mesenchymal stem cells in bioreactors so that they adhere to the surface and deposit growth factors. Cells growing on the scaffolds are confirmed by Alamar blue assays, SEM, and confocal microscopy. ELISA and IHC are used to assess the growth factor content of the finished product. It has been confirmed that cells attach to the scaffolds and proliferate over time when grown in bioreactors. Dynamic seeding of cells is clearly advantageous for cell deposits, equalizing the amount of cells on each scaffold granule. Hydroxyapatite/calcium carbonate scaffolds support cell-growth. This should be confirmed by further research, including Quantification of BMPs and other indicators of osteogenic differentiation such as Runx2, osteocalcin and ALP is pending, and amounts are expected to be increased in enhanced scaffolds and in-vivo implantation

To evaluate the efficacy of using a novel button-suture construct in place of traditional screws to provide bone block fixation for the Latarjet procedure. Four paired cadaveric shoulders (n=8) were denuded, with the exception of the conjoint tendon on the coracoid, and were potted. A 15% anterior glenoid bone defect was simulated. Right and left specimens were randomised into two groups: double-screw versus quadruple-button Latarjet reconstruction techniques. A uniaxial mechanical actuator loaded the Latarjet reconstructed glenoid articular surface via a 47mm diameter metallic hemisphere. Cyclic loading between 50–200N was applied to the glenoid at a rate of 1Hz for 1000 cycles. Testing was repeated three times for conjoint tendon loads of 0N, 10N and 20N. The relative positions of three points on the inferior, central and superior edges of the coracoid bone fragment were optically tracked with respect to a glenoid coordinate system throughout testing. Screw and button constructs were compared on the basis of maximum relative displacement at these points (RINF, RCENT, RSUP). Statistical significance was assessed using a paired-samples t-test in SPSS. When conjoint tendon loading was not present the double screw and quadruple button constructs were not significantly (P>0.779) different (0N: RINF: 0.11 (0.05)mm vs. 0.12 (0.03)mm, RCENT: 0.12 (0.04)mm vs. 0.12 (0.03)mm, RSUP: 0.13 (0.04)mm vs. 0.12 (0.03)mm). Additionally, the double screw construct was not found to differ (P>0.062) from the quadruple button in terms of resultant coracoid displacement for all central and superior points, regardless of conjoint loading (10N: RCENT: 0.11 (0.03)mm vs. 0.19 (0.05)mm, RSUP: 0.11 (0.01)mm vs. 0.18 (0.04)mm; 20N: RCENT: 0.13 (0.01)mm vs. 0.30 (0.13)mm, RSUP: 0.13 (0.03)mm vs. 0.26 (0.14)mm). It was only for the inferior point with conjoint loading of 10N and 20N that the double screw construct began to produce significantly lower displacements than the quadruple button (10N: RINF: 0.11 (0.03)mm vs. 0.23 (0.05)mm, P=0.047; 20N: RINF: 0.12 (0.02)mm vs. 0.39 (0.15)mm, P=0.026). The results of the screw and button constructs when conjoint tendon loading was absent suggest that the button may be a suitable substitute to the screw when the coracoid is used as a bone block. Due to the small resultant displacements (max: screw = 0.19mm, button = 0.52mm), it is suggested that buttons may also act as a substitute to screws for Latarjet procedures, provided conjoint tendon overloading is minimised during the post-operative graft healing period. These in-vitro results support the in-vivo results of Boileau et al (2015) that demonstrated the suture-button technique to be an excellent alternative to screw fixation Latarjet, with graft healing in 91% of their subjects

Limb salvage is the gold standard to treat sarcoma patients, but bone stock should be retained for the future, as many of these patients are young and active. For this observational clinical study, 107 patients that presented with 108 malignant or locally aggressive benign bone tumours were treated by wide en-bloc resection of the affected bone, extracorporeal irradiation with 300 Gy to eradicate the tumour, and reimplantation of the bone as an orthotopic autograft. The irradiated bone was rigidly fixed to the remaining bone with classical intramedullary or extramedullary osteosynthesis material. We made a subdivision between intercalary, composite and osteoarticular grafts. The pelvis was considered a third separate entity, as it was considered both an intercalary and an osteoarticular graft when the acetabulum was involved. The incidence of local recurrence with the use of an orthotopic autograft comprised the primary endpoint of this study. Secondary endpoints: preservation of bone stock with graft healing and evaluation of factors that determine preservation. No local recurrences could be detected in the irradiated grafts. One local recurrence was detected in the surrounding soft tissue. At 5 years follow-up, graft healing occurred in 64% of cases, providing stable and lasting reconstruction. Eleven percent of the grafts had to be removed due to several incidents, but none could be proven significant. All patient subgroups displayed comparable results. Early infection appeared to be a significant determinant for the development of pseudarthrosis. Pelvic reconstructions showed a worse outcome. According to the results, guidelines for indications and surgical guidelines, such as rigid fixation and bridging of the graft, are proposed for using this technique. In general sarcoma resection, extracorporeal irradiation, and reimplantation provides a stable and lasting reconstruction with preservation of bone stock

Aims

The effects of remnant preservation on the anterior cruciate ligament (ACL) and its relationship with the tendon graft remain unclear. We hypothesized that the co-culture of remnant cells and bone marrow stromal cells (BMSCs) decreases apoptosis and enhances the activity of the hamstring tendons and tenocytes, thus aiding ACL reconstruction.

To assess the outcome of periprosthetic femoral fractures (Vancouver B3 type) around loose stems treated by impaction grafting revision, 106 B3 fractures were reviewed. To assess the association between those who healed and those who did not for the factors of interest such as stem length, impaction grafting and the combination of the above, odd ratios along with their 95% CI and their p-values were reported. Logistic regression in STATA version 7.0 employed. 75 out of 89 fractures treated with long stem revision and 10 out of 17 with sort stem healed. 74 out of 89 fractures treated with impaction grafting and 11 out of 17 treated without impaction grafting healed. 66 out of 75 fractures treated with long stem and impaction grafting and 9 out of 14 treated with with long stem but no impaction grafting healed. 8 out of 14 fractures treated with short stem and impaction healed. Average healing 8.5 months. Those treated with long stem are almost four times more likely to heal than those treated with short stem (odds ratio = 3.75 95%CI: 1.21–11.6 p=0.022) and those with impaction grafting are also more likely, but not statistically significant, to heal than those without impaction grafting (odds ratio = 2.69, 95%CI: 0.86– 8.45 p=0.090). Furthermore, those with long stem and impaction are significantly more likely to heal than those without impaction grafting and those with short stem and impaction grafting (odds ratios = 4.07, 95%CI: 1.10 – 15.0 p=0.035 and 5.5, 95%CI: 1.54 – 19.6 p=0.009 respectively). Impaction grafting is an increasingly popular technique for the restoration of femoral bone stock. It can successfully be applied to periprosthetic femoral fractures but a long stem should be used to bypass the distal fracture line

Structural bone allografts are a viable option in reconstructing massive bone defects in patients following musculoskeletal (MSK) tumour resection and revision hip/knee replacements. To decrease infection risk, bone allografts are often sterilised with gamma-irradiation, which consequently degrades the bone collagen connectivity and makes the bone brittle. Clinically, irradiated bone allografts fracture at rates twice that of fresh non-irradiated allografts. Our lab has developed a method that protects the bone collagen connectivity through ribose pre-treatment while still undergoing gamma-irradiation. Biomechanical testing of bone pretreated with our method provided 60–70% protection of toughness and 100% protection of strength otherwise lost with conventional irradiation. This study aimed to determine if the ribose-treated bone allografts are biocompatible with host bone. The New Zealand White rabbit (NZWr) radius segmental defect model was used, in which 15-mm critically-sized defects were created. Bone allografts were first harvested from the radial diaphysis of donor female NZWr, and treated to create 3 graft types: C=untreated controls, I=conventionally-irradiated (33 kGy), R=our ribose pretreated + irradiation method. Recipient female NZWr (n=24) were then evenly randomised into the 3 graft groups. Allografts were surgically fixed with a 0.8-mm Kirschner wire. Post-operative X-rays were taken at 2, 6, and 12 weeks, with bony healing assessed by a blinded MSK radiologist using an established radiographic scoring system. The reconstructed radii were retrieved at 12 weeks and analysed using bone histomorphometry and microCT. Kruskal-Wallis and Mann-Whitney tests were utilised to compare groups, with statistical significance when p<0.05. Radiographic analysis revealed no differences in periosteal reaction and degree of osteotomy site union between the groups at any time point. Less cortical remodeling was observed in R and I grafts compared to untreated controls at 6 weeks (p=0.004), but was no longer evident by 12 weeks. Radiographic union was achieved in all groups by 12 weeks. Histologic and microCT analysis further confirmed union at the graft-host bone interface, with the presence of mineralising callus and osteoid. Histomorphometry also showed the bridging external callus originated from host bone periosteum and a distinct cement line between allograft and host bone was present at the union site. Previous studies have shown that the presence of non-enzymatic glycation end products in bone can impair fracture healing. However, these studies investigated bony healing in the setting of diabetic states. Our findings showed that under normal conditions, ribose pretreated grafts healed at rates similar to controls via mechanisms also seen in retrieved human allografts clinically in use. These findings that grafts pretreated with our method are biocompatible with host bone in the rabbit help to further advance this technology for clinical trials

Acute osteomyelitis of the radius or ulna in children is rare and may be associated with complications including pathological fracture, growth disturbance and cosmetic problems. Purpose:. To highlight the outcome of acute pyogenic osteomyelitis of the forearm bones in children. Methods:. Eleven children were treated for osteomyelitis of the radius (6) and ulna (5) over 15 years. Staphylococcus aureus was cultured following initial incision and drainage. Two had signs of compartment syndrome. Late complications included gap defects of 2–6 cm (radius 1 and ulna 2). Larger defects with physeal involvement were seen in the distal ulna (4) proximal radius (1) and whole radius (1). The late clinical features included pseudarthrosis (9), distal radioulnar instability (3), radial head dislocation (3) and “radial clubhand” type deformity (1). Treatment:. Gap defects <2 cm were filled with autogenous grafts (3). Segmented iliac crest grafts threaded over a K wire were used in 1 patient with an 8 cm gap defect. Radio-ulnar synostosis was performed in 4 cases. The carpus was centralized onto the ulna in 1 child. Results:. Reconstructive grafts healed by 6–12 weeks. Residual elbow contracture <30° occurred in 3 children. Ten children had improved grip strength and stability of the wrist and elbow and forearm length was decreased by 2–5 cm. The child with a radial clubhand deformity had severe shortening and stiffness of the hand. Conclusion:. Osteomyelitis of the forearm bones can be missed and present late. Complications include disproportionate growth, proximal or distal radio-ulnar instability and radial clubhand type deformity. Treatment is challenging requiring reconstruction of gap defects. Radio-ulnar synostosis is a useful salvage procedure to improve function and cosmesis

Patient presenting with clinically significant cervical spinal cord compression have a variety of surgical strategies that may be appropriate. The common denominator for successful intervention is satisfactory decompression of the neural elements, while avoiding early or late complications. In general, one may think of situations with one or two motion segment involvement versus three or more foci of compression. As most applicable cervical pathology causes anterior cord compression, the logic of direct anterior decompression is very compelling. Thus anterior decompression and fusion procedures have been the mainstay of treatment in many quarters. On the other hand, complications with graft healing or displacement, speech and swallowing disturbance, etc. remain an issue. This is especially true for multi-level disease. Under these circumstances, indirect decompression with posterior surgery plays an important role. Laminoplasty, and to a lesser degree laminectomy and fusion, may prove every bit capable of spinal cord decompression and often with fewer complications. Each case must be evaluated on its own merits and the procedure chosen to optimize the likelihood of success

Purpose: We hypothesized that lateralization of the RSA, with a glenoid bone graft taken from the osteotomised humeral head, would prevent those problems without increasing torque on the glenoid component by keeping the center of rotation within the glenoid. The objectives of this study were to describe the results of the first 12 patients that underwent a bony increased-offset RSA (BIO RSA). Method: Thirty-six shoulders in 34 consecutive patients with cuff tear arthritis (mean age 72 years, range 52–86 years) received a BIO RSA, consisted of a RSA incorporating an autogenous humeral head bone graft placed beneath the glenoid baseplate. A baseplate with a lengthened central peg (+25 mm) was inserted in the glenoid vault, securing the bone graft beneath the baseplate and screws. All patients underwent clinical and radiographic (computed tomography) review at a minimum 1-year follow-up. Results: All patients were satisfied or very satisfied and all had no or slight pain. Mean active elevation increased from 72° to 142° (p< 0.05), external rotation from 10° to 18° (p< 0.05) and internal rotation from L4 to L3 (p> 0.05). Constant Score improved from 27 to 63 points (p< 0.05). The Subjective Shoulder Value (SSV) increased from 27% to 73% (p< 0.05). Radiographically, the graft healed to the native glenoid in all cases and no graft resorption under the baseplate was observed. Complications included one patient with scapular notching (stage 1) and one patient with previous radiotherapy had a deep infection. No postoperative instability, and no glenoid loosening were observed. Conclusion: The use of an autologous bone graft harvested from the humeral head can lateralize the center of rotation of a RSA while keeping the center of rotation at the glenoid bone-prosthesis interface. The clinical advantages of a BIO RSA are a decrease in scapular notching, enhanced stability and mobility, and improved shoulder contour while keeping the center of rotation at the glenoid bone-prosthesis interface. This bony lateralization allows maintenance of the principles of Grammont and seems to be more appropriate than prosthetic lateralization. These promising early results of this novel procedure warrant further investigation

Aims: The purpose of this study is to to assess the surgical results, complications, and long-term results of vascularized fibula in the treatment of congenital pseudarthrosis of the tibia. Methods: Seven patients who had congenital pseudarthrosis of the tibia were treated consecutively at our clinic between 1992 and 2000 with free vascularized fibular graft. There were four females and three males. The mean age at the time of operation averaged 6.5 years (range 1–12 years). Four left tibias and 3 right tibias were involved. Stability was maintained with internal fixation in four patients, external fixation in two patients and intramedullary pin in one patient. Results: The average follow-up was 2.6 years (range 6 months to 8 years). In five patients, both ends of the graft healed primarily within 2.7 months (range 1.5 to 3 months), and hypertrophy of the fibular graft occurred rapidly with a well-formed medullary canal. In one patient the distal junction did not unite and although required three subsequent operations still not healed. Stress fracture occurred in one patient underwent four additional operations before union achieved. Conclusions: Despiting the continuing problems and the relatively high complication rate, the ultimate results with free vascularized fibula transplant are generally good specially as compared with published series in whom conventional grafting techniques had failed. However, even achieving union of pseudarthrosis is not enough for the resolution of this disease and is only half of the problem; the other half is to maintaining

Background: The major objectives in total hip replacement for coxarthrosis secondary to DDH are: – Anatomical restoration of the hip rotation center – The restoration of the acetabular contention function – The reconstruction of the acetabular bone stock. Patients and Method: Between 1999 – 2003 there were operated 83 cases of coxarthrosis secondary to hip dysplasia, by total hip arthroplasty both cemented and uncemented. 27 cases were operated with uncemented cups and acetabular reconstruction 20 cases received a HA coated Stryker Secure Fit 40–42 mm cup 7 cases received Zweimuller screwed cup The mean age of the patients was 39 years (21–57 years) The mean weight was 69.5 kg (58–82 kg) Body mass index 28 (25–31) The dysplasia grade was Crowe II 11 cases, Crowe III 16 cases. Results: The mean dimension of the graft (S2), measured on the AP Rx was 43 % of the cup weight bearing surface The S2/S1 fraction exceeded 1 in one case that necessitated revision at 4,5 years due to the resorbtion of the graft All the grafts healed to the host bone in a 6 month interval. Discussions and Conclusions For defects smaller than 20% of the weight bearing surface of the cup, there was an intrinsic stability of the cup and the acetabuloplasty was optional For defects between 20–50% of the cup weight bearing surface it was necessary to perform acetabuloplasty with auto graft from the femoral head fixed with screws in compression For defects larger than 50 % of the weight bearing surface of the cup the fraction S2/S1 is greater than 1 with risk of the resorbtion and collapse of the graft. In such cases we recommend slight ascending of the cup in a position with better bone stock or a protrusion technique method

Purpose: Intra-osseous leiomyosarcoma (IOLM) is a rare tumour. Imaging aspects are not specific. Pathology is required to establish diagnosis. The appropriate treatment remains controversial because no method has demonstrated certain efficacy. We report two cases and review the literature on this malignant tumour. Material and methods: The first patient was a 43-year-old woman who suffered right knee pain for six months. Plain x-rays of the tibia revealed an metaphyseo-epiphyseal zone of osteolysis with soft tissue involvement as did 18-FDG uptake on the scintigram and computed tomography. Pathology diagnosis was high-grade IOLM. Search for extension was negative. Tumour resection was performed with implantation of a massive prosthesis followed by chemotherapy and radiotherapy. The second patient was a 50-year-old man who was referred ten days after spontaneous fracture of the lower femur. Plain x-rays, computed tomography and magnetic resonance imagine as well as the PET-scan were difficult to interpret. Pathology examination of a biopsy specimen was in favour of a benign lesion. The final diagnosis was IOLM. Search for extension was negative and radiotherapy was given. Results: At mean 18-month follow-up, both patients were living. The first patient was able to walk without crutches and the second patient achieved bipodal stance with crutches. Radiologically, the prosthesis was stable and the graft healed. Positive diagnosis was established on the basis of immunohistochemistry and study of the ultrastructure. Unfortunately, treatment of this malignant tumour remains difficult. Chemotherapy and radiotherapy are ineffective. Surgical treatment, even when oncological resection can be achieved, has not demonstrated superior efficacy compared with more conservative treatment in terms of survival or secondary spread. Associating medical and surgical treatment does not guarantee a better result. Conclusion: IOLM is a rare tumour which requires immunohistochemistry and study of the ultrastructure for positive diagnosis. The appropriate therapeutic option cannot be established, but it would appear that tentatively curative surgery associated with radiotherapy may provide better outcome despite the poor short-term prognosis

Easier patient positioning and less extensive soft tissue dissection have spurred a trend for anterior instrumentation and fusion for C-spine fracture/ dislocations. We present group of forty-six patients treated over an eighteen month period with an anterior approach. There were no permanent approach related complications, infections, hardware failures or graft displacements. One patient had worsened post-operative neurological findings. One patient required additional posterior stabilization for a missed injury. Two patients were not reducible from the front and required posterior reduction and stabilization followed by anterior instrumentation and fusion. All grafts healed within four months of the operation. The purpose of this study was to assess the efficacy of anterior instrumentation and fusion for Cervical Spine fracture/ dislocations. Over an eighteen month period, forty-six out of fifty-two patients with C-spine injuries requiring surgical treatment were followed prospectively. All patients underwent anterior approaches to stabilize and fuse the unstable segments using tricortical bone grafting and application of an anterior plate (CSLP, Synthes). Thirty-eight patients had single level injuries treated with discectomy and fusion. Two patients had two level discecomies. Six patients underwent corpectomy and fusions for fractures of the vertebral bodies. There were no approach related complications such as recurrent laryngeal nerve injuries, oesophageal perforations, vascular injuries or strokes. One patient deteriorated neurologically. All other patients either improved neurologically or remained with their original findings. Two patients required oral antibiotics for superficial infections at the donor site. There were no spine infections, hardware loosening or graft extrusions. All bone grafts healed within four months both clinically and radiologically. Forty-one patients complained of minor or no pain after four months. Five patients continued to have moderate discomfort. One of these patients had a missed injury above his two-level fusion with gradual progression into kyphosis requiring posterior stabilization. Halo vest immobilization and posterior stabilization for C-spine fracture /dislocations have been the treatment of choice for many surgeons. The low complication and failure rate has spurred on a gradual change towards anterior instrumentation and fusion. Our study very strongly supports this trend. We see little indication for the more invasive posterior approach given our present results

Aims

Proliferation, migration, and differentiation of anterior cruciate ligament (ACL) remnant and surrounding cells are fundamental processes for ACL reconstruction; however, the interaction between ACL remnant and surrounding cells is unclear. We hypothesized that ACL remnant cells preserve the capability to regulate the surrounding cells’ activity, collagen gene expression, and tenogenic differentiation. Moreover, extracorporeal shock wave (ESW) would not only promote activity of ACL remnant cells, but also enhance their paracrine regulation of surrounding cells.

In vitro femoral studies have demonstrated the addition of hydroxyapatite (HA), to morcellised bone graft (MBG) decreases femoral prosthesis subsidence. However, with an increased risk of femoral fracture during the impaction of a MBG:HA mixture, possibly due to greater force transmission to the femoral cortex via the HA. The aim was to compare the hoop strains and subsidence of a 1:1 mixture of MBG:HA with pure bone allograft during impaction and subsequent endurance testing in a revision hip arthroplasty model. Materials and methods Large Sawbone femurs were prepared to represent a femur with bone loss (Sawbones, Sweden). 12 uniaxial strain gauges were attached to each femur at 0, 90, 180 and 270 degrees, at distal, midshaft, proximal points to measure hoop strain. Impaction grafting was performed using X-Change 2 instruments and an Instron servohydaulic machine for 2 distal impactions and 4 proximal impactions for 60 impactions each. Study groups. The study consisted of four experimental groups: 1)Pure MBG, force of 1.98 kN 2)Pure MBG, force 3.63kN. 3)1:1 mixture of MBG: porous HA (pHA), 4)1:1 mixture MBG: non porous HA (npHA). 6 samples of each group were performed. Endurance testing. The potted femur was loaded in a manner representing the walking cycle (1.98kN) at 1 Hz for 50 000 cycles. The displacement of the femoral head during loading was measured by two displacement transducers (LVDT) were mounted on aluminum brackets to measure vertical displacement and rotation. Statistical analysis. Statistical analysis was performed using a Mann – Whitney U test for total subsidence and prosthesis cyclical movement at 6 hours between the control MBG1.98 and the other experimental groups. Subsequent analysis compared pHA and npHA mixes with and HA to MBG3. 65kN. Level of significance was taken at p<0.05. Results. Distal strain gauges:. All experimental groups had a significantly greater distal hoop strain than MBG1.98 kN (p=0.004). Middle strain gauges:. No significant differences between the HA groups and MBG1.98. MBG3.65 was significantly greater (p=0.02). Top strain gauges:. No significant differences, p=0.9. Endurance testing There was a non significant trend towards decreased subsidence in the HA groups compared to the bone groups. (p=0.7) but significantly less cyclical subsidence between HA groups and MBG 1.98 (p=0.02). No difference between the MBG 3.65 kN and HA groups for the cyclical subsidence. Statistically significant difference in cyclical rotation between both the MBG1.98 and the pHA (p=0.02) and npHA(p=0.02) and the bone 3.65 and pHA and npHA groups(p=0.04). Conclusion. The addition of HA to MBG decreases total and cyclical subsidence. There were significantly greater hoop strains in the distal and midshaft strain gauges with greater impaction force and in the distal gauges with the use of HA. Endurance testing demonstrated a significant decrease in cyclical motion and cyclical rotational stability of the prosthesis with a trend to a decrease in total subsidence during endurance testing with HA groups. The addition of HA might have longer term benefits in terms of prosthesis stability and subsequent graft healing but caution is needed during impaction

Objectives: The replacement tissue used for anterior cruciate ligament reconstruction undergoes extensive biologic remodelling and incorporation after implantation. These changes, in which the tendon loses some of its characteristic features and adopts those typically associated with ligaments, has been referred to as ligamentization. The purpose of this study was to identify the proinflammatory response in the healing graft in the early phase. Methodes: Twenty New Zealand White Rabbits underwent ACL reconstruction with a semitendinosus tendon. Animals were sacrificed at 3 and 6 weeks. The harvested tissue including parts of remaining grafted tendon and genuine anterior cruciate ligament at time of the surgery as well as the tendon graft withdrawn at sacrification were prepared for immunohistochemical, histomorphometry and electromicroscopical analysis; synovia samples were taken at the sacrification as well. The tissues were immunostained for IL-1beta, TGF-beta, TNF-alpha (induction of inflammatory cascade), COX-2 (mediator of inflammatory response), Matrix Metalloproteinases (MMP-1, MMP-3, MMP-13, matrix destructive enzymes), TIMP-2 (Tissue Inhibitor of MMPs); the PGE2 (mediator of inflammatory response) content in the synovia was quantified by ELISA. Results: At 3 weeks after surgery the COX-2+ cells accounted for 70% of all cells present in the graft tissue, and decreased to 28% at 6 weeks. Similar, IL-1beta+ cells within the tendon decreased from week 3 to week 6. Controversly, there was an increase of COX-2, IL-1beta and MMP-1 in the intercellular tissue. The numbers of COX-2+ cells and IL-1beta+ cells at 3 weeks as well as the intercellular area stained positiv for COX-2, IL-1beta and MMP-1 at 6 weeks were significantly larger compared to the genuine ACL (p =< 0.05). At 3 weeks some cells stained positiv for MMP-3 and MMP-13, but not at 6 weeks. There was a slight pericellular staining for TIMP-2 at 3 weeks. TGF-beta+ cells and TNF-alpha+ cells were almost not detectable at every time point. Thus, proinflammatory cytokines and MMPs were synthesized in the early phase after ACL reconstruction by the tendon cells and accumulated at 6 weeks in the intercellular tissue. Conclusions: In the early phase of the graft healing after ACL reconstruction, there was a signifikant increase in proinflammatory cytokines and matrix destructive enzymes in the tendon graft. With the capability of synthesizing cytokines, tendon cells may play a critical role in tendon healing at early time points. Facing the widespread use the bias of cox-2 inhibitors on these immunologic processes has to be checked. Activating matrix destructive enzymes, cytokines appear to be crucial for connective tissue remodelling and graft stability after ACL reconstruction

This study reviews the results of the treatment of non-union of fractures of the scaphoid by the use of micro-surgical, vascular pedicle grafts (VPG). The indications for VPG included long-standing non-union of a fracture of the scaphoid, avascular necrosis of the proximal pole and failed conventional grafting. The contraindications were periscaphoid degenerative changes (scaphoid non-union advanced collapse) and vascular damage from previous surgery. The technique in each involved harvesting a vascularised bone graft from the distal radius based on a vascular pedicle with retrograde flow from one of a number of described vessels that constitute the vascular plexus over the carpus. The scaphoid was prepared to receive an inlay graft and then the graft was positioned and its stability was determined. Some were secured with a single 0.7mm diameter Kirschner wire. The wrist was then immobilised in a plaster cast until either the fracture had healed or it was evident that the procedure had failed to result in union. Fourteen patients have undergone VPG over 30 months. Of these eight have healed (four fractures of the waist and four of the proximal poles), four have failed (one waist and three proximal poles) and two are still in plaster casts. The mean time to healing was 20.6 weeks (range: 12.7–28.7 weeks). Of the eight that healed, seven were aged between 21 and 27 years. The four failures were aged between 34 and 44 years. The mean time since the fracture in the healed group was 2.9 years (range: 1.2 years to five years) and in the failed group it was 6.5 years (range: two years to 20 years). The first failure was related to deep infection and a subsequent Matte-Russe procedure has also failed. In the second failure the graft healed to the distal pole but the very small proximal pole collapsed resulting in a wrist arthrodesis. The graft in the third failure healed to the distal pole but failed to unite with the small proximal pole. No further treatment has been planned. The fourth failure was a non-union of the waist of 20 years standing. The graft became dislodged from the scaphoid but no further surgery has been carried out. One of the successful unions had a poor result because of degeneration in the scaphoid-trapezoid-trapezium (STT) joint secondary to damage done at the time of previous surgery (Herbert screw). A successful STT arthrodesis was done subsequently. VPG is technically challenging. Careful patient selection is vital as is preoperative planning and vessel selection. VPG can be used successfully to salvage obstinate non-unions of fractures of the scaphoid