Based on Ilizarov's law of tension-stress principle, distraction histogenesis technique has been widely applied in orthopaedic surgery for decades. Derived from this technique, cranial bone transport technique was mainly used for treating cranial deformities and calvarial defects. Recent studies reported that there are dense short vascular connections between skull marrow and meninges for immune cells trafficking, highlighting complex and tight association between skull and brain. Alzheimer's disease (AD) is a progressive neurodegenerative disease and the most common cause of dementia without effective therapy. Meningeal lymphatics have been recognized as an important mediator in neurological diseases. The augmentation of meningeal lymphatic drainage might be a promising therapeutic target for AD. Our proof-of-concept study has indicated that cranial bone transport can promote ischemic stroke recovery via modulating meningeal lymphatic drainage function, providing a rationale for treating AD using cranial bone maneuver (CBM). This study aims to investigate the effects of CBM on AD and to further explore the potential mechanisms.

Transgenic 5xFAD mice model was used in this study. After osteotomy, a bone flap was used to perform CBM without damaging the dura. Open filed test, novel object recognition test and Barn's maze test were used to evaluate neurological functions of 5xFAD mice after CBM treatment. Congo red and immunofluorescence staining were used to evaluate amyloid depositions and Aβ plaques in different brain regions. Lymphangiogenesis and the level of VEGF-C were examined after CBM treatment. OVA-A647 was intra-cisterna-magna injected to evaluate meningeal lymphatic drainage function after CBM treatment.

CBM significantly improved memory functions and reduced amyloid depositions and Aβ plaques in the hippocampus of 5xFAD mice. A significant increase of meningeal lymphatic vessels in superior sagittal sinus and transverse sinus, and the upregulation of VEGF-C in meninges were observed in 5xFAD mice treated with CBM. Moreover, CBM remarkably enhanced meningeal lymphatic drainage function in 5xFAD mice (n=5-16 mice/group for all studies).

CBM may promote meningeal lymphangiogenesis and lymphatic drainage function through VEGF-C-VEGFR3 pathway, and further reduce amyloid depositions and Aβ plaques and alleviate memory deficits in AD.

The Femoral Neck System (FNS) was introduced as an alternative device for the fixation of neck of femur fractures (NOFFs). The purported advantages include superior angular and rotatory stability compared to multiple cancellous screws, via a minimally invasive instrumentation that is simpler than conventional fixed angle devices. There were limited clinical studies regarding the utility of this device. We aimed to study the outcomes of NOFFs fixed with the FNS.

This was a single-institution, retrospective review of all undisplaced elderly (≥60 years old) undisplaced young, and displaced young NOFFs fixed with the FNS. Demographics, surgical parameters, radiographic parameters, and clinical outcomes including complications were reviewed.

Thirty-six subjects with a median age of 75 [44,89] years old, had NOFF fixation using the FNS. Thirty-one (86.1%) had undisplaced fractures. There were 6 (16.7%), 26 (72.2%), and 4 (11.1%) subjects with Pauwels types 1, 2, and 3 respectively. Thirty-two (88.9%) had posterior tilt of <20º. The mean duration of surgery was 71±18 minutes. Excluding 4 patients whom required revision surgery, 2 patients whom demised, and 10 patients whom defaulted reviews, the mean follow-up duration was 55±13 weeks. Four complications were recorded, namely implant cut out at the femoral head at week 8, breaking of the locking screw at the run-off region at week 22, avascular necrosis at week 25, and a refracture following near fall, causing the fracture to fail in varus at week 7 postoperation.

While reasonably fast to instrument, failures still occur and it is likely multifactorial. However, the rate of reoperation is lower than what has been reported for NOFFs fixed with the a fixed-angle device or 3 cancellous screws. In conclusion, the FNS is a reasonably safe instrument to use. Surgeons’ discretion is still needed in patient selection, keeping in mind the need for satisfactory radiological parameters.

Most studies comparing medial pivot to the posterior stabilised (PS) systems sacrifice the PCL. It is unknown whether retaining the PCL in the Medial Congruent (MC) system may provide further benefit compared to the more commonly used PS system.

A retrospective review of a single-surgeon's registry data comparing 44 PS and 25 MC with PCL retained (MC-PCLR) TKAs was performed.

Both groups had similar baseline demographics in terms of age, gender, body mass index, and American Society for Anaesthesiology score. There was no significant difference in their preoperative range of motion (ROM) (104º±20º vs. 102º±20º,p=0.80), Oxford Knee Score (OKS) (27±6 vs. 26±7,p=0.72), and Knee Society Scoring System (KS) Function Score (KS-FS) (52±24 vs. 56±24,p=0.62). The preoperative KS Knee Score (KS-KS) was significantly lower in the PS group (44±14 vs. 54 ± 18,p<0.05). At 3-months postoperation, the PS group had significantly better OKS (38±6 vs. 36±6,p=0.02) but similar ROM (111º±14º vs. 108º±12º,p=0.25), KS-FS (73±20 vs. 68±23, p=0.32) and KS-KS (87±10 vs. 86±9,p=0.26). At 12-months postoperation, both groups had similar ROM (115º±13º vs. 115º±11º,p=0.99), OKS (41±5 vs. 40±5,p=0.45), KS-FS (74±22vs.78±17,p=0.80), and KS-KS (89±10vs.89±11,p=0.75). There was statistically significant improvement in all parameters at 1-year postoperation (p<0.05). The PS group had significant improvement in all parameters from preoperation to 3-month postoperation (p<0.05), but not from 3-month to 1-year postoperation (p≥0.05). The MC-PCLR group continued to have significant improvement from 3-month to 1-year postoperation (p<0.05).

The MC provides stability in the medial compartment while allowing a degree of freedom in the lateral compartment. Preserving the PCL when using MC may paradoxically cause an undesired additional restrain that slows the recovery process of the patients after TKA.

In conclusion, compared to MC-PCLR, a PS TKA may expect significantly faster improvement at 3 months post operation, although they will achieve similar outcomes at 1-year post operation.

Aims

This study aimed to identify the effect of anatomical tibial component (ATC) design on load distribution in the periprosthetic tibial bone of Koreans using finite element analysis (FEA).

Introduction

Reinforcement ring with allograft bone is commonly used for acetabular reconstruction of bone defects because it can achieve stable initial fixation of the prosthesis. It is not clear whether the allograft bone can function as a viable host bone and provide long-standing structural support. The purpose of this study was to assess to long-term survival of the reinforcement rings and allograft bone incorporation after acetabular revisions.

Introduction

Total knee arthroplasty (TKA) is an excellent treatment for end-stage osteoarthritis of the knee. In Asian countries, the number of TKA performed has rapidly increased, and is expected to continue so with its 4.4 billion population and increasing life expectancy. Asians' knees are known to be kinematically different to Caucasians after TKA. Controversy exists as to whether multi-radius (MR) or the newer single-radius (SR) TKA has superior outcome. Studies regarding this have been largely based on Caucasian data with few small sample Asian data.

Purpose

The fourth generation ceramic, in which zirconia is incorporated into the alumina matrix, was developed to reduce the risk of ceramic fractures. The purpose of this study was to evaluate the survivorship, clinical and radiographic results, and bearing-related failures associated with total hip arthroplasty using zirconia-toughened alumina ceramic-on-ceramic bearings over a minimum follow-up of 5 years.

Introduction

The use of tranexamic acid (TXA) in primary total hip arthroplasty (THA) is supported by many studies that confirm its efficacy for decreasing blood loss, but the comparison between topical intra-articular (IA) and intra-venous (IV) is unclear, especially combined with chemical prophylaxis. The purpose of this study is to verify non-inferior efficacy of topical IA TXA compared with IV TXA in primary THA.

The purpose of this study was to compare the results of proximal and distal chevron osteotomy in patients with moderate hallux valgus.

We retrospectively reviewed 34 proximal chevron osteotomies without lateral release (PCO group) and 33 distal chevron osteotomies (DCO group) performed sequentially by a single surgeon. There were no differences between the groups with regard to age, length of follow-up, demographic or radiological parameters. The clinical results were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system and the radiological results were compared between the groups.

At a mean follow-up of 14.6 months (14 to 32) there were no significant differences in the mean AOFAS scores between the DCO and PCO groups (93.9 (82 to 100) and 91.8 (77 to 100), respectively; p = 0.176). The mean hallux valgus angle, intermetatarsal angle and sesamoid position were the same in both groups. The metatarsal declination angle decreased significantly in the PCO group (p = 0.005) and the mean shortening of the first metatarsal was significantly greater in the DCO group (p < 0.001).

We conclude that the clinical and radiological outcome after a DCO is comparable with that after a PCO; longer follow-up would be needed to assess the risk of avascular necrosis.

Cite this article: Bone Joint J 2013;95-B:649–56.

Purpose

The purpose of this study was to evaluate the complications related to the prosthesis design in patients managed with cemented total knee arthroplasty (TKA) with the anterior-posterior glide (APG) mobile bearing prosthesis.

Background: Arthroscopy of the knee is one of the commonest procedures performed by orthopaedic surgeons in Australia today. Total knee replacement (TKR) is also a common procedure, however, there appears to be no indication as to how many patients whom have undergone arthroscopy subsequently undergo TKR. The role of this study was to develop an understanding of the rates of progression from knee arthroscopy to TKR and to develop an appreciation of the role of knee arthroscopy in delaying arthroplasty.

Methods: We conducted a retrospective case note review for all patient’s whom had undergone a knee arthroscopy, for a single year, conducted be a single orthopaedic surgeon. These patients were followed up over a period of 15 years to establish whom subsequently underwent TKR.

Results: A total of 473 knee arthroscopies were conducted, with a total of 11 (2.75% of patients) undergoing a TKR over the course of the following 15 year period. Patient characteristics for those who underwent TKR were mean age 59.3 years (range 41–70) and mean time between initial arthroscopy and TKR was 71.3 months (range 5 – 178). All patients who underwent TKR, on initial arthroscopy had defects in multiple compartments. Two patients underwent TKR within 5 months of arthroscopy due to significant findings on arthroscopy and ongoing symptoms.

Discussion: Our results suggest a very low rate of progression to TKR following arthroscopy. Following exclusion of patients who were scheduled for TKR immediately post arthroscopy (< 6 months), mean time to TKR was approximately 8 years. These findings are considered to show the importance of arthroscopy in managing knee complaints given that there are no statistics in the literature to suggest the rate of progression from arthroscopy to TKR.

Conclusion: Arthroscopy is a practical and valuable procedure with minimal associated morbidity or complications. Accuracy of diagnosis helps to avoid unnecessary operations (including TKR). These results are important given that life expectancy is increasing, the age at which individuals are undergoing TKR is decreasing and the limited duration of life of TKR.

We carried out a retrospective study to assess the clinical results of lengthening the fourth metatarsal in brachymetatarsia in 153 feet of 106 patients (100 female, six males) using three different surgical techniques. In one group lengthening was performed by one-stage intercalary bone grafting secured by an intramedullary Kirschner-wire (45 feet, 35 patients). In the second group lengthening was obtained gradually using a mini-external fixator after performing an osteotomy with a saw (59 feet, 39 patients) and in the third group lengthening was achieved in a gradual manner using a mini-external fixator after undertaking an osteotomy using osteotome through pre-drilled holes (49 feet, 32 patients). The mean age of the patients was 26.3 years (13 to 48). Pre-operatively, the fourth ray of the bone-graft group was longer than that of other two groups (p < 0.000). The clinical outcome was compared in the three groups. The mean follow-up was 22 months (7 to 55).

At final follow-up, the mean lengthening in the bone-graft group was 13.9 mm (3.5 to 23.0, 27.1%) which was less than that obtained in the saw group with a mean of 17.8 mm (7.0 to 33.0, 29.9%) and in the pre-drilled osteotome group with a mean of 16.8 mm (6.5 to 28.0, 29.4%, p = 0.001). However, the mean time required for retention of the fixation in the bone-graft group was the shortest of the three groups. Patients were dissatisfied with the result for five feet (11.1%) in the bone-graft group, eight (13.6%) in the saw group and none in the pre-drilled osteotomy group (p < 0.000). The saw group included eight feet with failure of bone formation after surgery. Additional operations were performed in 20 feet because of stiffness (n = 7, all groups), failure of bone formation (n = 4, saw group), skin maceration (n = 4, bone-graft group), malunion (n = 4, bone-graft and saw groups) and breakage of the external fixator (n = 1, saw group).

We conclude that the gradual lengthening by distraction osteogenesis after osteotomy using an osteotome produces the most reliable results for the treatment of fourth brachymetatarsia.

Background: Adolescent Idiopathic Scoliosis is a 3-dimensional deformity of the spine affecting peri-pubertal adolescents (10-17-y) mostly. Although generalised osteopenia is well documented in AIS, the patho-physiology of AIS related osteopenia is uncertain.

Aim: We studied the association between pubertal-growth, BMD, bone-turnover, calcium intake (CA) and physical-activity (PA) in AIS and compared to those of healthy girls.

Methods: 894 girls (594 AIS & 300 healthy controls) aged 11–16-y entered the study. Anthropometric parameters, areal-BMD of the proximal-femur and volumetric-BMD of the distal-tibia were determined by Dual-x-ray-Absorptiometry and peripheral QCT respectively. Bone-turnover-markers: bone-alkaline-phosphatase (bALP) and deoxypyridonine (Dpd) were assayed. CA and weight-bearing PA were assessed by FFQ method.

Results: Weight of AIS at < 12-y and 13-y was significantly lower than controls (P< 0.05). From 13-y, corrected right and arm-span of AIS were significantly longer than the controls (P< 0.02). aBMD and vBMD were 6.7% and 8.4% respectively lower than the controls across the ages (P< 0.05). The disparity in BMD compared with controls increased with age. CA was not different between the AIS and controls (361 mg/d, IQR:230–532mg/d vs. 319 mg/d, IQR:220–494mg/d; P=0.063). Weight-bearing PA of AIS was significantly lower than those of controls (P< 0.02).

CA of AIS and controls reached < 40% of the Chinese calcium DRI (1000 mg/d). Both CA and weight-bearing PA were correlated with BMD in AIS (P< 0.04 & P=0.002 respectively). Both CA and PA were independent predictors on the variations of aBMDs (P< 0.03) and vBMDs (P< 0.04) in AIS after controlling for confounders in multivariate analysis. Regarding bone turn-over rate, bALP in AIS was 38.6% higher than the controls from 13-y onwards (P< 0.005) while Dpd of AIS was 30.4% lower than controls at age 15-y (P=0.003). Furthermore, bALP in AIS was negatively correlated with age-adjusted BMD (r=−0.34, P< 0.001) while the correlation was weaker in the controls (P=0.14, P< 0.002).

Conclusion: The correlation of calcium intake and physical activity with BMD occurred predominantly in AIS only and that these two factors were also independent determinants on BMD of AIS implying that calcium intake and physical activity were significant modulators on BMD in AIS. Significantly faster physical-growth, higher bone formation rate were associated with lower BMD. Osteopenia in AIS could be interplayed by abnormally faster pubertal-growth and bone-turnover. In fact, Calcium intake of AIS was too low to meet the calcium demand for bone-mineralization. A controlled calcium supplementation and programmed physical activity intervention trial is merited to confirm the effect of Calcium intake and physical activity on bone acquisition in AIS at peripubertal period.

Background: Low bone mass in patients with adolescent idiopathic-scoliosis has been well reported in cross-sectional studies. No large-scale longitudinal-study has been conducted to track bone-mineral-density (BMD) trajectory in peripubertal AIS with varying scoliosis-severity.

Aim: We evaluated the BMD trajectory and factors determining BMD accretion in AIS during peripubertal period.

Method: One hundred and ninety-six newly diagnosed AIS girls with Cobb-angle > 100 and 122 healthy girls, aged 12–15 years were followed-up for two years. Weight, height, leg length, menarche and Cobb-angle were determined. Areal lumbar-spinal BMD (LSBMD) and femoral-neck BMD (FNBMD), and volumetric distal-tibial BMD (TiBMD) were evaluated by dual-energy-x-ray-absorptiometry and peripheral QCT respectively. BMD growth-models were fitted by multilevel modelling (mixed longitudinal design).

Results: At baseline, 93% participants were pre-menarchial or within three years of menarche. Average Cobb-angles at baseline and subsequent follow-ups were 260, 230 and 260 respectively. TiBMD of AIS (moderate- and severe-severity) was significantly lower than the controls from 13–16 years (ANOVA, P< 0.05). Posthoc-test showed that TiBMD of severe-AIS was lower than moderate-AIS at 15–16 years (P< 0.05). LSBMD accrual was significantly lower among AIS (moderate- and severe-severity) than the controls from age 13–17 years (ANOVA, P< 0.05). FNBMD of AIS (moderate- and severe-severity) was lower than the controls at 15 years (ANOVA, P< 0.05). BMD trajectories of individuals differed inter-personally and intra-personally over time and that BMD growth followed a curvilinear pattern. The rates of BMD accretion reduced with retarded growth across peripubertal-period. Weight and height were significant time-varying predictors on BMD growth. BMD of AIS was persistently lower than the healthy girls throughout the study (P< 0.05).

Conclusions: This large-scale longitudinal study in AIS girls with moderate to severe-curve-severity showed for the first time that both the volumetric and areal BMD were persistently lower when compared to the age-matched healthy girls throughout 12–17 years. AIS with more severe curve-severity were found to have much lower BMD throughout the peripubertal period. Promotion of a higher bone-mass is important for AIS to modify scoliosis-progression and to achieve peak bone mass in order to reduce the risk of osteoporosis later in life.

Aims: There are multiple proximal prosthetic geometries for humeral head replacement for treatment of four-part proximal humerus fractures. We compared four proximal prosthetic geometries in stable and unstable fracture patterns with a standard tuberosity þxation method. Methods: Twelve synthetic shoulders and 4 cadaver shoulders had a simulated four-part fracture created with an oscillating saw. The following proximal prosthetic geometries were used: smooth circular shape (SCS), diamond shape (DS), irregular multiple þn shape (IMFS), and IMFS with deeper þns (IMSDF). A standardized þxation method using vertical sutures, horizontal sutures and medial based cerclage straps was performed. Passive motion from 0–45 degrees was carried out using a robotic articulator at a rate of 10 degrees per second. Interfragmentary displacement was measured from tuberosity to tuberosity as well as tuberosity to the shaft using mercury strain gauges. This was repeated for stable and unstable fracture patterns. Results: When comparing interfragmentary motion between the four different geometries the greatest amount of motion occurred with the SCS in a stable fracture (0.69mm, p< 0.0001) and unstable fracture (0.71 mm, p< 0.0001). The geometry that provided the most stability was the IMFSDF in stable (0.08mm) and unstable (0.09 mm) fracture patterns. Conclusion: The geometry of the prosthetic device does affect the stability of the tuberosity reconstruction. A smooth circular prosthetic design in a stable or unstable fracture pattern does not prevent excessive interfragmentary motion, while an irregular multiple þn shaped prosthesis with deep þns augments the þxation construct even in an unstable fracture pattern.

There are multiple proximal prosthetic geometries available for a surgeon to select when humeral head replacement is indicated for four-part proximal humerus fractures. We compared different proximal prosthetic geometries in stable and unstable fracture patterns, with a standard tuberosity fixation method.

Simulated four-part fractures were created with an oscillating saw in six synthetic shoulder models. Three different proximal prosthetic geometries used polymetylmethacrelate (PMMA) – a smooth circular shape (SCS), a diamond shape (DS) and an irregular multiple fin shape (IMFS) prostheses. A standardised fixation method using vertical, and horizontal straps along with a medial based cerclage strap was performed. Passive motion was then carried out using a robotic articulator. Interfragmentary displacement was measured from tuberosity to tuberosity as well as tuberosity to shaft using mercury strain gauges.

The least amount of interfragmentary motion occurred when an IMFS was used in a stable fracture pattern. This geometry provided more interfragmentary stability even with the unstable fracture pattern than the DS or SCS. The least stable construct was the SCS prosthesis with an unstable fracture pattern.

Prosthetic geometry does affect stability of tuberosity reconstruction in proximal humerus fractures. An irregular shaped prosthesis augments the fixation construct. When using a smooth prosthetic design a stable fracture pattern must be achieved to prevent excessive interfragmentary motion. A smooth prosthetic design for tuberosity reconstruction is not recommended.