bluuebunny/crossref_metadata_2025 huggingface dataset:
LONG VERSUS SHORT INTRAMEDULLARY NAILS FOR TROCHANTERIC HIP FRACTURES: A SECONDARY ANALYSIS OF THE INSITE TRIAL
Authors: Schemitsch E. H. , Nowak L. L. , De Beer J. , Brink O. , Poolman R. , Mehta S. , Stengel D. , Bhandari Mohit
Published: July 2023

We aimed to use data from a randomized controlled trial (RCT) comparing the sliding hip screw vs. intramedullary nailing (IMN) for trochanteric fractures to examine complication rates between those managed with a short vs. long IMN.

This is a secondary analysis using one arm of an RCT of patients ≥18 years with trochanteric fractures. We examined differences in fracture-related (femoral shaft fracture, implant failure, surgical site infection (SSI), nonunion, limb shortening, and pain) and medical (organ failure, respiratory distress, stroke, deep vein thrombosis [DVT] gastrointestinal upset, pneumonia, myocardial infarction, sepsis, or urinary tract infection) adverse events (AE), and readmission between short vs. long IMNs.

We included 412 trochanteric fracture patients, 339 (82.2%) of whom received a short (170mm–200mm) nail, while 73 (17.7%) received a long (260mm–460 mm) nail. Patients in the long group were more likely to be admitted from home (vs. an institution), and have comorbidities, or more complex fracture types.

Patients in the long group had higher rates of fracture-related AE (12.3%) vs. the short group (3.5%). Specifically, SSI (5.5% vs. 0.3%) and pain (2.7% vs. 0.0%) were significantly higher in the long group. Patients in the long group were also more likely to develop DVT (2.7% vs. 0.3%), and be readmitted to the hospital (28.8% vs. 20.7%).

Following covariable adjustment, long nails remained associated with a higher odds of fracture-related AE (5.11, 1.96–13.33) compared to short nails. We found no association between the adjusted odds of readmission and nail length (1.00, 0.52–1.94).

Our analyses revealed that trochanteric fracture patients managed with long IMN nails may have a higher odds of fracture-related AE compared to short nails. Future research is required to validate these findings with larger event rates, and further optimize IMN for trochanteric fracture patients.
ACCURACY OF STEM ANTEVERSION IN ROBOTIC TOTAL HIP ARTHROPLASTY: A COMPARISON OF CEMENTED AND CEMENTLESS STEMS
Authors: Sugano N. , Maeda Y. , Fuji H. , Tamura K. , Nakamura N. , Takashima K. , Uemura K. , Hamada H.
Published: July 2023

The purposes of this study were to report the accuracy of stem anteversion for Exeter cemented stems with the Mako hip enhanced mode and to compare it to Accolade cementless stems.

We reviewed the data of 25 hips in 20 patients who underwent THA through the posterior approach with Exeter stems and 25 hips in 19 patients with Accolade stems were matched for age, gender, height, weight, disease, and approaches. There was no difference in the target stem anteversion (20°–30°) between the groups. Two weeks after surgery, CT images were taken to measure stem anteversion.

The difference in stem anteversion between the plan and the postoperative CT measurements was 1.2° ± 3.8° (SD) on average with cemented stems and 4.2° ± 4.2° with cementless stems, respectively (P <0.05). The difference in stem anteversion between the intraoperative measurements and the postoperative CT measurements was 0.75° ± 1.8° with Exeter stems and 2.2° ± 2.3° with Accolade stems, respectively (P <0.05).

This study demonstrated a high precision of anteversion for Exeter cemented stems with the Mako enhanced mode and its clinical accuracy was better with the cemented stems than that with the cementless stems. Although intraoperative stem anteversion measurements with the Mako system were more accurate with the cemented stems than that with the cementless stem, the difference was about 1° and the accuracy of intra-operative anteversion measurements was quite high even with the cementless stems. The smaller difference in stem anteversion between the plan and postoperative measurements with the cemented stems suggested that stem anteversion control was easier with cemented stems under the Mako enhanced mode than that with cementless stems.

Intraoperative stem anteversion measurement with Mako total hip enhanced mode was accurate and it was useful in controlling cemented stem anteversion to the target angle.
HOW MUCH CAN A SURGEON TRUST A ROBOT FOR HIP ARTHROPLASTY?
Authors: Hernigou P.
Published: July 2023

The variables involved in a robotic THA can exceed 52: many parameters as pelvic orientation with CT scan, templating, offset, and leg-length, acetabular reaming, femoral osteotomy, mapping the anatomy; predefining safe zones, robotic execution, femoral head size, thickness of PE etc. with several variables for each parameter, with a total number of variables exceeding 52. This familiar number is the number of cards in a standard deck. The number of possible combinations (factorial 52! = 10^67) to shuffle the cards (and may be to perform a THA) is greater than the number of atoms on earth! Thinking that artificial intelligence and robotics can solve these problems, some surgeons and implant manufacturers have turned to artificial intelligence and robotics.

We asked two questions:1) can robot with artificial intelligence really process 52 variables that represent 10^67 combinations? 2) the safety of the technology was ascertained by interrogating Food and Drug Administration (FDA) database about software-related recalls in computer-assisted and robotic arthroplasty [1], between 2017 and 2022.

1)

The best computers can only calculate around 100 thousand billion combinations (10^14), and with difficulty: it takes more than 100 days to arrive at this number of digits (10^14) after the decimal point for the number π (pi). We can, therefore, expect the robot to be imperfect.

2)

For the FDA software-related recalls, 4634 units were involved. The FDA determined root causes were: software design (66.6%), design change (22.2%), manufacturing deployment (5.6%), design manufacturing process (5.6%). Among the manufacturers’ reasons for recalls, a specific error was declared in 88.9%. a coding error in 43.8%. 94.4% software-related recalls were classified as class 2. Return of the device was the main action taken by firms (44.4%), followed by software update (38.9%).

3)

In the same period, no robot complained about its surgeon!

Hip surgeon is as intelligent as a robot and almost twice as safe.
THIRTY-YEAR FOLLOW-UP STUDY OF ROTATIONAL ACETABULAR OSTEOTOMY
Authors: Yasunaga Y. , Ohshima S. , Shoji T. , Adachi N.
Published: July 2023

Satisfactory intermediate and long-term results of rotational acetabular osteotomy (RAO) for the treatment of early osteoarthritis secondary to developmental dysplasia of the hip have been reported. The purpose of this study is to examine the 30-year results of RAO.

Between 1987 and 1994, we treated 49 patients (55 hips) with RAO for diagnosis of pre- OA or early-stage OA. Of those patients, 35 patients (43 hips) were available at a minimum of 28 years. The follow-up rate was 78.2% and the mean follow-up was 30.5 years. The mean age at the time of surgery was 34 years. Clinical evaluation was performed with the Merle d'Aubigne and Postel rating scale, and radiographic analyses included measurements of the center-edge angle, acetabular roof angle, and head lateralization index on preoperative, postoperative AP radiographs of the pelvis. Postoperative joint congruency was classified into four grades. The radiographic evidence of progression of OA was defined as the minimum joint space less than 2.5mm.

The mean preoperative clinical score was 14.0, which improved to a mean of 15.3 at the time of the latest follow-up. The mean center-edge angle improved from 0.6° preoperatively to 34° postoperatively, the mean acetabular roof angle improved from 28.4°preoperatively to 1.0°postoperatively, the mean head lateralization index improved from 0.642 preoperatively to 0.59 postoperatively. Postoperative joint congruency was excellent in 11 hips, good in 29 hips, and fair in 3 hips. Nineteen patients (20 hips) had radiographic OA progression, and 10 patients (11 hips) were converted to THA. Kaplan-Meier survivorship analysis, with radiographic OA progression as the end point, predicted survival of 75.6% at 20 years and 48.8% at 30 years, and with THA conversion as the end point, 90.2% at 20 years and 71.2% at 30 years.

The RAO is an effective surgical procedure for symptomatic dysplastic hips of pre- and early-stage OA and could change the natural history of the dysplastic hip.
RADIOLOGICAL PREDICTORS FOR CLINICAL IMPROVEMENT OF PERIACETABULAR OSTEOTOMY PERSPECTIVE STUDY
Authors: Czubak J. , Kołodziejczyk K. , Czwojdziński A. , Czubak-Wrzosek M.
Published: July 2023

The aim of the study was to evaluate radiological and clinical outcomes of surgical treatment of developmental dysplasia of the hip (DDH) with Periacetabular Osteotomy (PAO) and to determine the values of radiological parameters allowing us to obtain an optimal clinical result.

Radiological evaluation included a standardized AP digital radiograph of the hip joints. Centre edge angle (CEA), medialization, distalization, femoral head coverage (FHC) and ilioischial angle were measured. Clinical evaluation based on HHS, WOMAC, Merle d'Aubigne-Postel scales and Hip Lag Sign. Radiological and clinical evaluation was performed preoperatively and approximately 12 months after the surgery.

Statistically significant (p<0.05) differences in radiological measurements and all clinical scales have been observed pre- and postoperatively for all of the parameters. The results of PAO presented decreased medialization by 3.4mm (range: 3 to 3.7), distalization by 3.5mm (range: 3.2 to 3.8) and the ilioischial angle by 2.7° (range: 2.2 to 3.7). There was also an improvement in the femoral head bone coverage: CEA increased by 16.3° (range: 12.1˚ to 20.5˚) and FHC by 15.2% (range: 10.8 to 19.8). Clinically we observed an increase in HHS by 22 points (range: 15.8 to 28.2) and M. Postel d'Aubigne by 3.5 points (range: 2.0 to 4.4) and a decrease in WOMAC by 24% (range: 22.6 to 25.8). HLS improvement of gluteal muscles’ efficiency has been observed in 67% of patients postoperatively.

This study revealed that the qualification of patients with DDH for an elective PAO is more justified due to the predicted optimal clinical outcomes based on three parameters: CEA <25 degrees, FHC <75%, and ilioischial angle >85.9 degrees. Accordingly, to achieve better clinical results for all scales, it is necessary to increase the average CEA value by 11˚, the average FHC by 11%, and reduce the average ilioischial angle by 3˚.
LONG-TERM POLYETHYLENE WEAR RATES AND CLINICAL OUTCOMES OF OXIDIZED ZIRCONIUM FEMORAL HEADS ON HIGHLY CROSS-LINKED POLYETHYLENE IN TOTAL HIP ARTHROPLASTY
Authors: Buckner B. C. , Urban N. D. , Cahoy K. M. , Garvin K. L.
Published: July 2023

Oxidized zirconium (Oxinium) and highly cross-linked polyethylene (HXLPE) were developed with the purpose of minimizing wear, and subsequent osteolysis, in Total Hip Arthroplasty (THA). However, few articles have been published on long-term results of Oxinium on highly cross-linked polyethylene. The purpose of this investigation is to report minimum 10-year HXLPE wear rates and the clinical outcome of patients in this group and compare this population to a control group of cobalt chrome and ceramic.

One hundred forty THAs were performed for 123 patients using an Oxinium head with an HXLPE liner. Ninety-seven had 10 years of clinical follow-up (avg. 14.5). Harris Hip Scores (HHS) were collected preoperatively and at the most recent follow-up. Radiographs of 85 hips were available for a minimum 10-year follow-up (avg. 14.5) and used to calculate wear using PolyWare software. Control groups of cobalt chrome and ceramic articulation on HXLPE with a minimum 10-year follow-up were studied.

Clinical follow-up of the Oxinium group showed a statistical improvement compared to preoperative and was similar to the control group of patients. Radiographic evaluation found the linear and volumetric wear rates for the Oxinium group of 0.03 mm/year (range 0.00–0.08) and 3.46 mm3/year (range 1.0 to 15.0) respectively. There was no statistically significant difference in linear or volumetric wear rate between the groups (P-value 0.92 and 0.55 respectively). None of these patients underwent revision of their hip for any reason.

Oxinium on highly cross-linked polyethylene has performed exceptionally with wear rates comparable to those of cobalt chrome or ceramic on HXLPE.
NATIONWIDE RISK OF READMISSION AND PATIENT ATTITUDE TOWARDS DAY-CASE TOTAL HIP ARTHROPLASTY
Authors: Halken C. Holmgrün , Jensen C. Bredgaard , Henkel C. , Gromov K. , Troelsen A.
Published: July 2023

The interest in day-case hip arthroplasty is increasing; however, there are conflicting results regarding readmission risk, and little is known about patients’ attitude towards day-case surgery. We aimed to investigate differences in 30-day readmission rates between day-case patients and single-overnight-stay patients following total hip arthroplasty (THA) and explore patients’ attitude towards day-case surgery.

From the Danish National Patient Register we identified 29,486 THAs (1353 day-case THAs and 28,133 single-overnight-stay THAs) performed between 2010 and 2020. Day-case surgery was defined as discharge on the day-of-surgery. Overnight admissions within 30 days of surgery were considered readmissions. Differences in readmission rates between day-case and single-overnight-stay patients were investigated using logistic regression adjusted for patient characteristics and year of surgery. In a single-center descriptive study, 2395 hip arthroplasty patients from 2016 to start-2023 answered a questionnaire on patient characteristics, attitude towards day-case surgery and patient-reported outcome measures (PROM).

The overall 30-day readmission rate was 4.4% (CI: 4.2–4.6%) with no difference between day-case (4.4%) and single-overnight-stay THAs (4.4%) (odds-ratio: 1.2 [CI: 0.91–1.6]). In the descriptive study answers to the question whether patients were interested in being discharged on the day of surgery, were: “Yes” = 41%, “Do not know” = 20%, “No” = 39%. Patients responding “No” had lower preoperative PROM-scores, were older (“No” = 70.2 y vs. “Yes” = 65.3 y), and more often female (“No” = 72% vs. “Yes” = 52% female).

Based on nationwide data from 2010–2020, day-case THA patients were not more likely to be readmitted compared to single-overnight-stay patients. However, most patients were not positive towards day-case surgery. While surgeons may consider day-case surgery to be safe, patients are not intuitively positive, indicating an attitude mismatch. To achieve high success rate and patient satisfaction in day-case surgery, shared-decision making initiatives within day-case surgery are needed.
LOW FORCE DIRECT ANTERIOR HIP ARTHROPLASTY
Authors: Cobb J.
Published: July 2023

The trend towards more minimal access has led to a series of instruments being developed to enable adequate access for Direct Anterior Approach (DAA) for hip arthroplasty. These include longer levers, hooks attached to the operating table and a series of special attachments to the operating table to position the leg and apply traction where necessary. The forces applied in this way may be transmitted locally, damaging muscle used as a fulcrum, or the knee and ankle joints when torque has to be applied to the femur through a boot. The arthroplasty surgeon's aim is to minimise the forces applied to both bone and soft tissue during surgery.

We surmised that the forces needed for adequate access were related to the extent of the capsular and soft tissue releases, and that they could be measured and optimised. with the aim of minimising the forces applied to the tissues around the hip.

Eight fresh frozen specimens from pelvis to mid tibia from four cadavers were approached using the DAA. A 6-axis force/torque sensor and 6-axis motion tracking sensor were attached to a threaded rod securely fastened to the tibial and femoral diaphysis. The torque needed to provide first extension, then external rotation, adequate for hip arthroplasty were measured as the capsular structures were divided sequentially.

The Zona Orbicularis (ZO) and Ischiofemoral Ligament(IFL) contributed most of the resistance to both extension (4.0 and 3.1Nm) and external rotation torque (5.8 and 3.9Nm). The contributions of the conjoint tendon (1.5 and 2.4Nm) and piriformis (1.2 and 2.3Nm) were substantially smaller.

By releasing the Zona Orbicularis and Ischiofemoral Ligament, the torque needed to deliver the femur for hip arthroplasty could be reduced to less than the torque needed to open a jar (2.9–5.5Nm).
RETURN TO SPORTS FOLLOWING LOWER LIMB MUSCULOSKELETAL TUMOUR SURGERY: A SYSTEMATIC REVIEW
Authors: Buldu M. , Sacchetti F. , Yasen A. , Furtado S. , Parisi V. , Gerrand C.
Published: July 2023

Primary malignant bone and soft tissue tumours often occur in the lower extremities of active individuals including children, teenagers and young adults. Survivors routinely face long-term physical disability. Participation in sports is particularly important for active young people but the impact of sarcoma treatment is not widely recognised and clinicians may be unable to provide objective advice about returning to sports. We aimed to identify and summarise the current evidence for involvement in sports following treatment of lower limb primary malignant bone and soft tissue tumours.

A comprehensive search strategy was used to identify relevant studies combining the main concepts of interest: (1) Bone/Soft Tissue Tumour, (2) Lower Limb, (3) Surgical Interventions and (4) Sports. Studies were selected according to eligibility criteria with the consensus of three authors. Customised data extraction and quality assessment tools were used.

22 studies were selected, published between 1985 – 2020, and comprising 1005 patients. Fifteen studies with data on return to sports including 705 participants of which 412 (58.4%) returned to some form of sport at a mean follow-up period of 7.6 years. Four studies directly compared limb sparing and amputation; none of these were able to identify a difference in sports participation or ability.

Return to sports is important for patients treated for musculoskeletal tumours, however, there is insufficient published research to provide good information and support for patients. Future prospective studies are needed to collect better pre and post-treatment data at multiple time intervals and validated clinical and patient sports participation outcomes such as type of sports participation, level and frequency and a validated sports specific outcome score, such as UCLA assessment. In particular, more comparison between limb sparing and amputation would be welcome.
HISTOLOGICAL EVALUATION OF SUBCHONDRAL BONE DRILLING FOR PREIMPLANTATION PREPARATION OF OSTEOCHONDRAL ALLOGRAFTS
Authors: Luk J.
Published: July 2023

Despite the growing success of OCA transplantation in treating large articular cartilage lesions in multiple joints, revisions and failures still occur. While preimplantation subchondral drilling is intended to directly decrease allograft bioburden and has been associated with significant improvements in outcomes after OCA transplantation, the effects of size, number, and spacing of subchondral bone drill sites have not been fully evaluated. This study aimed to investigate the effects of drill size with or without pulse-lavage of OCA subchondral bone by quantifying remnant marrow elements using histomorphometry.

With IRB and ACUC approvals, human and canine OCAs were acquired for research purposes. Portions of human tibial plateau OCAs acquired from AATB-certified tissue banks that would otherwise be discarded were recovered and sectioned into lateral and medial hemiplateaus (n=2 each) with a thickness of 7 mm. Canine femoral condyles and tibial plateaus were split into lateral and medial components with a thickness of 7 mm (n=8). Using our clinical preimplantation preparation protocol, holes were drilled into the subchondral bone of each condyle and hemiplateau OCA using either 1.6 mm OD or 3.2 mm OD drill bits from the cut surface to the cortical subchondral bone plate. One femoral condyle and one hemiplateau per drill bit size were pulse-lavaged while the corresponding OCAs were not. The mean total %-fill remaining marrow elements for each treatment group was calculated.

Little to no quantifiable bone marrow element retention was noted to remain within the subchondral bone of human or canine OCA specimens after subchondral drilling of allograft bone with either drill bit size evaluated and with or without pulse-lavage. The %-fill was consistent across zones, ranging from 1-5%.

This project was designed to provide a preliminary histologic evaluation of the effects of drill size on OCA preimplantation preparation efficacy based on amount of remaining bone marrow elements in human and canine femoral condyle and tibial plateau specimens. Based on these initial findings, choice of drill bit size for OCA subchondral drilling may need to be based on the associated biomechanical effects rather than effects on donor bone marrow element removal.
SYNOVIAL FLUID NEUTROPHILS PLAY A ROLE IN THE PATHOPHYSIOLOGY OF KNEE OSTEOARTHRITIS: A PHENOTYPIC AND FUNCTIONAL STUDY
Authors: Manukyan G. , Gallo J. , Mikulkova Z. , Trajerova M. , Savara J. , Slobodova Z. , Kriegova E.
Published: July 2023

An increased number of neutrophils (NEUs) has long been associated with infections in the knee joints; their contribution to knee osteoarthritis (KOA) pathophysiology remains largely unexplored. This study aimed to compare the phenotypic and functional characteristics of synovial fluid (SF)-derived NEUs in KOA and knee infection (INF).

Flow cytometric analysis, protein level measurements (ELISA), NEU oxidative burst assays, detection of NEU phagocytosis (pHrodoTM Green Zymosan BiparticlesTM Conjugate for Phagocytosis), morphological analysis of the SF-derived/synovial tissue NEUs, and cultivation of human umbilical vein endothelial cells (HUVECs) using SF supernatant were used to characterise NEUs functionally/morphologically.

Results: Compared with INF NEUs, KOA NEUs were characterised by a lower expression of CD11b, CD54 and CD64, a higher expression of CD62L, TLR2 and TLR4, and lower production of inflammatory mediators and proteases, except CCL2.

Functionally, KOA NEUs displayed an increased production of radical oxygen species and phagocytic activity compared with INF NEUs. Morphologically, KOA and INF cells displayed different cell sizes and morphology, histological characteristics of the surrounding synovial tissues and influence on endothelial cells. KOA NEUs were further subdivided into two groups: SF containing <10% and SF with 10%–60% of NEUs. Analyses of two KOA NEU subgroups revealed that NEUs with SF <10% were characterised by 1) higher CD54, CD64, TLR2 and TLR4 expression on their surface; 2) higher concentrations of TNF-α, sTREM-1, VILIP-1, IL-1RA and MMP-9 in SFs.

Our findings reveal a key role for NEUs in the pathophysiology of KOA, indicating that these cells are morphologically and functionally different from INF NEUs. Further studies should explore the mechanisms that contribute to the increased number of NEUs and their crosstalk with other immune cells in KOA.

This study was supported by the Ministry of Health of the Czech Republic (NU20-06-00269; NU21-06-00370).
A POLY(SBMA) ZWITTERIONIC HYDROGEL COATING OF POLYIMIDE SURFACES TO REDUCE THE FOREIGN BODY REACTION TO INVASIVE NEURAL INTERFACES
Authors: Gori M. , Giannitelli S.M. , Vadalà G. , Papalia R. , Zollo L. , Rainer A. , Denaro V.
Published: July 2023

Intraneural electrodes can be harnessed to control neural prosthetic devices in human amputees. However, in chronic implants we witness a gradual loss of device functionality and electrode isolation due to a nonspecific inflammatory response to the implanted material, called foreign body reaction (FBR). FBR may eventually lead to a fibrous encapsulation of the electrode surface. Poly(ethylene glycol) (PEG) is one of the most common low-fouling materials used to coat and protect electrode surfaces. Yet, PEG can easily undergo encapsulation and oxidative damage in long-term in vivo applications. Poly(sulfobetaine methacrylate) - poly(SBMA) - zwitterionic hydrogels may represent more promising alternatives to minimize the FBR due to their ultra-low fouling features. Here, we tested and compared the poly(SBMA) zwitterionic hydrogel coating with the PEG coating in reducing adhesion and activation of pro-inflammatory and pro-fibrotic cells to polyimide surfaces, which are early hallmarks of FBR. We aimed to coat polyimide surfaces with a hydrogel thin film and analysed the release of a model drug from the hydrogel.

We performed hydrogel synthesis, mechanical characterization and biocompatibility analysis. Cell adhesion, viability and morphology of human myofibroblasts cultured on PEG- and hydrogel-coated surfaces were evaluated through confocal microscopy-based high-content analysis (HCA). Reduced activation of pro-inflammatory human macrophages cultured on hydrogels was assessed as well as the hydrogel drug release profile.

Because of its high hydration, biocompatibility, low stiffness and ultra-low fouling characteristics the hydrogel enabled lower adhesion and activation of pro-inflammatory and pro-fibrotic cells vs. polystyrene controls, and showed a long-term release of the anti-fibrotic drug Everolimus. Furthermore, a polyimide surface was successfully coated with a hydrogel thin film.

Our soft zwitterionic hydrogel could outperform PEG as more suitable coating material of neural electrodes for mitigating the FBR. Such poly(SBMA)-based biomaterial could also be envisioned as long-term delivery system for a sustained release of anti-inflammatory and anti-fibrotic drugs in vivo.
FRACTIONAL LASER TREATMENT COMBINED WITH DYNAMIC SELF-REGENERATING CARTILAGE FORMS A NEW PARADIGM FOR ARTICULAR CARTILAGE REJUVENATION
Authors: Randolph M. , Guastaldi F. , Fan Y. , Yu R. , Wang Y. , Farinelli W. , Redmond R.
Published: July 2023

Lesions in the joint surface are commonly treated with osteoarticular autograft transfer system (OATS), autologous cell implantation (ACI/MACI), or microfracture. Tissue formed buy the latter commonly results in mechanically inferior fibrocartilage that fails to integrate with the surrounding native cartilage, rather than durable hyaline cartilage. Fractional laser treatment to make sub-millimeter (<500 µm) channels has been employed for tissue regeneration in the skin to facilitate rejuvenation without typical scarring. Additionally, we have pioneered a means to generate articular cartilage matrix from chondrocytes—dynamic Self-Regenerating Cartilage (dSRC). Combining these two approaches by performing fractional laser treatment of the joint cartilage and treating with dSRC is a new paradigm for joint surface restoration. This approach was refined in a series of in vitro experiments and tested in swine knee defects during a 6-month study in 12 swine.

dSRC are generated by placing 107 swine knee chondrocytes into sealed 15-mL polypropylene tubes and cultured on a rocker at 40 cycles per minute for 14 days at 37°C. The chondrocytes aggregate and generate new extracellular matrix to form a pellet of dSRC. Channels of approximately 300-500 µm diameter were created by infrared laser ablation in swine cartilage (in vitro) and swine knees (in vivo). The diameter and depth of the ablated channel in the cartilage was controlled by the light delivery parameters (power, spot size, pulse duration) from a fractional 2.94 µm Erbium laser. The specimens were evaluated with histology (H&E, safranin O, toluidine blue) and polarized-sensitive optical coherence tomography for collagen orientation.

We can consistently create laser-ablated channels in the swine knee and successfully implant new cartilage from dSRC to generate typical hyaline cartilage in terms of morphology and biochemical properties. The neocartilage integrates with host cartilage in vivo.

These findings demonstrate our novel combinatorial approach for articular cartilage rejuvenation.
DOES YOUR APPROACH MATTER?
Authors: Lebleu J. , Kordas G. , Van Overschelde P.
Published: July 2023

There is controversy regarding the effect of different approaches on recovery after THR. Collecting detailed relevant data with satisfactory compliance is difficult. Our retrospective observational multi-center study aimed to find out if the data collected via a remote coaching app can be used to monitor the speed of recovery after THR using the anterolateral (ALA), posterior (PA) and the direct anterior approach (DAA).

771 patients undergoing THR from 13 centers using the moveUP platform were identified. 239 had ALA, 345 DAA and 42 PA. There was no significant difference between the groups in the sex of patients or in preoperative HOOS Scores. There was however a significantly lower age in the DAA (64,1y) compared to ALA (66,9y), and a significantly lower Oxford Hip Score in the DAA (23,9) compared to PA(27,7). Step count measured by an activity tracker, pain killer and NSAID use was monitored via the app. We recorded when patients started driving following surgery, stopped using crutches, and their HOOS and Oxford hip scores at 6 weeks.

Overall compliance with data request was 80%. Patients achieved their preoperative activity level after 25.8, 17,7 and 23.3 days, started driving a car after 33.6, 30.3 and 31.7 days, stopped painkillers after 27.5, 20.2 and 22.5 days, NSAID after 30.3, 25.7, and 24.7 days for ALA, DAA and PA respectively. Painkillers were stopped and preoperative activity levels were achieved significantly earlier favoring DAA over ALA. Similarly, crutches were abandoned significantly earlier (39.9, 29.7 and 24.4 days for ALA, DAA and PA respectively) favoring DAA and PA over ALA. HOOS scores and Oxford Hip scores improved significantly in all 3 groups at 6 weeks, without any statistically significant difference between groups in either Oxford Hip or HOOS subscores.

No final conclusion can be drawn as to the superiority of either approach in this study but the remote coaching platform allowed the collection of detailed data which can be used to advise patients individually, manage expectations, improve outcomes and identify areas for further research.
FIT QUANTIFICATION OF VARYING NAIL PLACEMENTS IN STRAIGHT ANTEGRADE HUMERAL NAILING USING 3D COMPUTER MODELLING
Authors: Pareatumbee P. , Yew A. , Koh J. , Zainul-Abidin S. , Howe T.S. , Tan M.H.
Published: July 2023

To quantify bone-nail fit in response to varying nail placements by entry point translation in straight antegrade humeral nailing using three-dimensional (3D) computational analysis

CT scans of ten cadaveric humeri were processed in 3D Slicer to obtain 3D models of the cortical and cancellous bone. The bone was divided into individual slices each consisting of 2% humeral length (L) with the centroid of each slice determined. To represent straight antegrade humeral nail, a rod consisting of two cylinders with diameters of 9.5mm and 8.5mm and length of 0.22L mm and 0.44L mm respectively joined at one end was modelled. The humeral head apex (surgical entry point) was translated by 1mm in both anterior-posterior and medio-lateral directions to generate eight entry points. Total nail protrusion surface area, maximum nail protrusion distance into cortical shell and top, middle, bottom deviation between nail and intramedullary cavity centre were investigated. Statistical analysis between the apex and translated entry points was conducted using paired t-test.

A posterior-lateral translation was considered as the optimal entry point with minimum protrusion in comparison to the anterior-medial translation experiencing twice the level of protrusion. Statistically significant differences in cortical protrusion were found in anterior-medial and posterior-lateral directions producing increased and decreased level of protrusion respectively compared to the apex. The bottom anterior-posterior deviation distance appeared to be a key predictor of cortical breach with the distal nail being more susceptible. Furthermore, nails with anterior translation generated higher anterior-posterior deviation (>4mm) compared to posterior translation (<3mm).

Aside from slight posterolateral translation of the entry point from the apex, inclusion of a distal posterior-lateral bend into current straight nail design could improve nail fitting within the curved humeral bone, potentially improving distal working length within the flat and narrow medullary canal of the distal humeral shaft.
BIOMECHANICAL STUDY COMPARING THE DOUBLE-LASSO LOOP TECHNIQUE TO INTERFERENCE SCREW FIXATION FOR BICEPS TENODESIS IN AN OVINE MODEL
Authors: Teo B. , Yew A. , Tan M.W.P. , Chou S.M. , Lie D.T.T.
Published: July 2023

This study aims to compare the biomechanical properties of the “Double Lasso-Loop” suture anchor (DLSA) technique with the commonly performed interference screw (IS) technique in an ex vivo ovine model.

Fourteen fresh sheep shoulder specimens were used in this study. Dissection was performed leaving only the biceps muscle attached to the humerus and proximal radius before sharply incised to simulate long head of biceps tendon (LHBT) tear. Repair of the LHBT tear was performed on all specimens using either DSLA or IS technique. Cyclical loading of 500 cycles followed by load to failure was performed on all specimens. Tendon displacement due to the cyclical loading at every 100 cycles as well as the maximum load at failure were recorded and analysed. Stiffness was also calculated from the load displacement graph during load to failure testing.

No statistically significant difference in tendon displacement was observed from 200 to 500 cycles. Statistically significant higher stiffness was observed in IS when compared with DSLA (P = .005). Similarly, IS demonstrated significantly higher ultimate failure load as compared with DSLA (P = .001). Modes of failure observed for DSLA was mostly due to suture failure (7/8) and anchor pull-out (1/8) while IS resulted in mostly LHBT (4/6) or biceps (2/6) tears. DSLA failure load were compared with previous studies and similar results were noted.

After cyclical loading, tendon displacement in DLSA technique was not significantly different from IS technique. Despite the higher failure loads associated with IS techniques in the present study, absolute peak load characteristics of DLSA were similar to previous studies. Hence, DLSA technique can be considered as a suitable alternative to IS fixation for biceps tenodesis.
HELICAL VERSUS STRAIGHT PLATING OF PROXIMAL THIRD HUMERAL SHAFT FRACTURES - A BIOMECHANICAL STUDY
Authors: Pastor T. , Zderic I. , van Knegsel K.P. , Link B-C , Beeres F.J.P. , Migliorini F. , Babst R. , Nebelung S. , Ganse B. , Schöneberg C. , Gueorguiev B. , Knobe M.
Published: July 2023

Proximal humeral shaft fractures are commonly treated with long straight locking plates endangering the radial nerve distally. The aim of this study was to investigate the biomechanical competence in a human cadaveric bone model of 90°-helical PHILOS plates versus conventional straight PHILOS plates in proximal third comminuted humeral shaft fractures.

Eight pairs of humeral cadaveric humeri were instrumented using either a long 90°-helical plate (group1) or a straight long PHILOS plate (group2). An unstable proximal humeral shaft fracture was simulated by means of an osteotomy maintaining a gap of 5cm. All specimens were tested under quasi-static loading in axial compression, internal and external rotation as well as bending in 4 directions. Subsequently, progressively increasing internal rotational loading until failure was applied and interfragmentary movements were monitored by means of optical motion tracking.

Flexion/extension deformation (°) in group1 was (2.00±1.77) and (0.88±1.12) in group2, p=0.003. Varus/valgus deformation (°) was (6.14±1.58) in group1 and (6.16±0.73) in group2, p=0.976. Shear (mm) and displacement (°) under torsional load were (1.40±0.63 and 8.96±0.46) in group1 and (1.12±0.61 and 9.02±0.48) in group2, p≥0.390. However, during cyclic testing shear and torsional displacements and torsion were both significantly higher in group 1, p≤0.038. Cycles to catastrophic failure were (9960±1967) in group1 and (9234±1566) in group2, p=0.24.

Although 90°-helical plating was associated with improved resistance against varus/valgus deformation, it demonstrated lower resistance to flexion/extension and internal rotation as well as higher flexion/extension, torsional and shear movements compared to straight plates. From a biomechanical perspective, 90°-helical plates performed inferior compared to straight plates and alternative helical plate designs with lower twist should be investigated in future paired cadaveric studies.
BIOMECHANICAL EVALUATION OF AN ALLOGRAFT FIXATION SYSTEM FOR ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN COMPARISON WITH THE INTERFERENCE SCREW
Authors: Benca E. , van Knegsel K. , Zderic I. , Caspar J. , Strassl A. , Hirtler L. , Fuchssteiner C. , Gueorguiev B. , Windhager R. , Widhalm H. , Varga P.
Published: July 2023

Screw fixation is an established method for anterior cruciate ligament (ACL) reconstruction, although with a high rate of implant-related complications. An allograft system for implant fixation in ACL reconstruction, the Shark Screw ACL (surgebright GmbH) could overcome some of the shortcomings of bioabsorbable screws, such as foreign body reaction, need for implant removal and imaging artefacts. However, it needs to provide sufficient mechanical stability. Therefore, the aim of this study was to investigate the biomechanical stability, especially graft slippage, of the novel allograft system versus a conventional bioabsorbable interference screw (BioComposite Interference Screw; Arthrex Inc.) for tibial implant fixation in ACL reconstruction.

Twenty-four paired human proximal tibiae (3 female, 9 male, 72.7 ± 5.6 years) underwent ACL reconstruction. The quadrupled semitendinosus and gracilis tendon graft were fixed in one specimen of each pair using the allograft fixation system Shak Screw ACL and the contralateral one using an interference screw. All specimens were cyclically loaded at 1 Hz with peak load levels monotonically increased from 50 N at a rate of 0.1 N/cycle until catastrophic failure. Relative movements of the graft versus the tibia were captured with a stereographic optical motion tracking system (Aramis SRX; GOM GmbH).

The two fixation methods did not demonstrate any statistical difference in ultimate load at graft slippage (p = 0.24) or estimated survival at slippage (p = 0.06). Both, the ultimate load and estimated survival until failure were higher in the interference screw (p = 0.04, and p = 0.018, respectively). Graft displacement at ultimate load reached values of up to 7.2 mm (interference screw) and 11.3 mm (Shark Screw ACL).

The allograft screw for implant fixation in ACL reconstruction showed similar behavior in terms of graft slippage compared to the conventional metal interference screw but underperformed in terms of ultimate load. However, the ultimate load may not be considered a direct indicator of clinical failure.
RADIOLOGIC FEATURES AS A PROGNOSTIC INDICATOR OF FOREARM FRACTURES
Authors: Knopp B. , Harris M.
Published: July 2023

This study was conducted to investigate the characteristics, complications, radiologic features and clinical course of patients undergoing reduction of forearm fractures in order to better inform patient prognosis and postoperative management.

We conducted a retrospective cohort study of 1079 pediatric patients treated for forearm fractures between January 2014 and September 2021 in a 327 bed regional medical center. A preoperative radiological assessment and chart review was performed. Percent fracture displacement, location, orientation, comonution, fracture line visibility and angle of angulation were determined by AP and lateral radiographs. Percent fracture displacement was derived by: (Displacement of Bone Shafts / Diameter) x 100% = %Fracture Displacement. Angle of angulation and percent fracture displacement were calculated by averaging AP and lateral radiograph measurements.

80 cases, averaging 13.5±8.3 years, were identified as having a complete fracture of the radius and/or ulna with 69 receiving closed reduction and 11 receiving fixation via an intramedullary device or percutaneous pinning. Eight patients (10%) experienced complications with four resulting in a refracture and four resulting in significant loss of reduction (LOR) without refracture. Fractures in the proximal ⅔s of the radius were associated with a significant increase in complications compared to fractures in the distal ⅓ of the radius (31.6% vs 3.4%) (P=.000428). Likewise, a higher percent fracture displacement was associated with a decreased risk of complications (28.7% vs 5.9% displacement)(P=0.0403). No elevated risk of complications was found based on fracture orientation, angulation, fracture line visibility, forearm bone(s) fractured, sex, age or arm affected.

Our result highlights radius fracture location and percent fracture displacement as markers with prognostic value following forearm fracture. These measurements are simply calculated via pre-reduction radiographs, providing an efficient method of informing risk of complications following forearm fracture.
PATIENT SATISFACTION WITH IN-OFFICE HAND PROCEDURES
Authors: Knopp B. , Kushner J. , Esmaeili E.
Published: July 2023

In the field of hand surgery, physicians are working to improve patient satisfaction by offering several minor procedures in the physician's office via the WALANT method. We seek to investigate the degree of patient satisfaction, out of pocket cost, convenience and comfort experienced with in-office hand procedures.

A ten question survey consisting of a ten-point Likert scale of agreement and questions asking for a numerical answer was administered via phone call to 33 patients treated with minor hand operations in the office setting in the United States.

There were 18 male and 15 female respondents with an average age of 65.59±12.64 years. Respondents underwent procedures including trigger finger release (18), needle aponeurotomy (7), and other minor hand operations. Survey responses indicated strong agreement with questions 1-3 and 6–8, with responses averaging 9.60±0.23 in these positive metrics. Questions 4 and 5, which asked whether the surgery and recovery period were painful, respectively, averaged 2.65±0.49, indicating a mild level of disagreement that either was “painful”. Additionally, most patients responded that they did not take time off work (12) or are not currently employed (11). Other respondents (3) reported taking between one to five days off work post-operatively. 27 respondents also reported an out of pocket cost averaging $382±$976, depending on insurance coverage.

Patients reported a small degree of pain in the operative and post-operative period, a high degree of comfort and convenience and a high degree of satisfaction. Likewise, the patient-reported out of pocket cost was far lower than comparable surgical costs in alternate settings. These results support the use of in-office procedures for minor hand surgeries from a patient perspective and indicate a nearly universal intent to repeat any future hand operations in the office setting.
MULTIFUNCTIONAL ORTHOPAEDIC BIOMATERIALS LOADED WITH CISPLATIN FOR LOCAL TREATMENT OF BONE TUMOURS
Authors: Wang Z. , van den Beucken J. , van den Geest I. , Leeuwenburgh S.
Published: July 2023

Residual tumor cells left in the bone defect after malignant bone tumor resection can result in local tumor recurrence and high mortality. Therefore, ideal bone filling materials should not only aid bone reconstruction or regeneration, but also exert local chemotherapeutic efficacy. However, common bone substitutes used in clinics are barely studied in research for local delivery of chemotherapeutic drugs. Here, we aimed to use facile manufacturing methods to render polymethylmethacrylate (PMMA) cement and ceramic granules suitable for local delivery of cisplatin to limit bone tumor recurrence.

Porosity was introduced into PMMA cement by adding 1-4% carboxymethylcellulose (CMC) containing cisplatin, and chemotherapeutic activity was rendered to two types of granules via adsorption. Then, mechanical properties, porosity, morphology, drug release kinetics, ex vivo reconstructive properties of porous PMMA and in vitro anti-cancer efficacy against osteosarcoma cells were assessed. Morphologies, molecular structures, drug release profiles and in vitro cytostatic effects of two different drug-loaded granules on the proliferation of metastatic bone tumor cells were investigated.

The mechanical strengths of PMMA-based cements were sufficient for tibia reconstruction at CMC contents lower than 4% (≤3%). The concentrations of released cisplatin (12.1% and 16.6% from PMMA with 3% and 4% CMC, respectively) were sufficient for killing of osteosarcoma cells, and the fraction of dead cells increased to 91.3% within 7 days. Functionalized xenogeneic granules released 29.5% of cisplatin, but synthetic CaP granules only released 1.4% of cisplatin over 28 days. The immobilized and released cisplatin retained its anti-cancer efficacy and showed dose-dependent cytostatic effects on the viability of metastatic bone tumor cells.

Bone substitutes can be rendered therapeutically active for anticancer efficacy by functionalization with cisplatin. As such, our data suggest that multi-functional PMMA-based cements and cisplatin-loaded granules represent viable treatment options for filling bone defects after bone tumor resection.
FACTORS AFFECTING POSTERIOR TIBIAL SLOPE DURING PROXIMAL TIBIAL OSTEOTOMIES: A SIMPLE CLINICAL TOOL AND ILLUSTRATED GUIDE
Authors: MacLeod A. , Roberts S. , Mandalia V. , Gill H.
Published: July 2023

Conventional proximal tibial osteotomy is a widely successful joint-preserving treatment for osteoarthritis; however, conventional procedures do not adequately control the posterior tibial slope (PTS). Alterations to PTS can affect knee instability, ligament tensioning, knee kinematics, muscle and joint contact forces as well as range of motion.

This study primarily aimed to provide a comprehensive investigation of the variables influencing PTS during high tibial osteotomy using a 3D surgical simulation approach. Secondly, it aimed to provide a simple means of implementing the findings in future 3D pre-operative planning and /or clinically.

The influence of two key variables: the gap opening angle and the hinge axis orientation on PTS was investigated using three independent approaches: (1) 3D computational simulation using CAD software to perform virtual osteotomy surgery and simulate the post-operative outcome. (2) Derivation of a closed-form mathematical solution using a generalised vector rotation approach (3) Clinical assessment of synthetically generated x-rays of osteoarthritis patients (n=28; REC reference: 17/HRA/0033, RD&E NHS, UK) for comparison against the theoretical/computational approaches.

The results from the computational and analytical assessments agreed precisely. For three different opening angles (6°, 9° and 12°) and 7 different hinge axis orientations (from −30° to 30°), the results obtained were identical. A simple analytical solution for the change in PTS, ΔPs, based on the hinge axis angle, α, and the osteotomy opening angle, θ, was derived:

ΔPs=sin-1(sin α sin θ)

The clinical assessment demonstrated that the absolute values of PTS, and changes resulting from various osteotomies, matched the results from the two relative prediction methods.

This study has demonstrated that PTS is impacted by the hinge axis angle and the extent of the osteotomy opening angle and provided computational evidence and analytical formula for general use.