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Journal of Orthopaedics 2021Despite the availability of modern implants and techniques, Revision Total Knee Arthroplasty (R-TKA) still poses a challenge to surgeons, particularly the management of...
Despite the availability of modern implants and techniques, Revision Total Knee Arthroplasty (R-TKA) still poses a challenge to surgeons, particularly the management of bone loss/defects and the secure fixation of implants. Polymethylmethacrylate (PMMA) bone cement plays an important role for fixation as fully uncemented fixation in RTKA is rarely used. Cement can be employed as part of a full cementing construct or as a hybrid construct. While in fully cemented implants, the diaphyseal stem as well as any couplers or connectors in the metaphysis are cemented, in hybrid cementing, only the component parts at the joint surface and metaphysis are cemented, while the diaphyseal stem is fixed in a press-fit manner. In this article the literature on the in vitro as well on the in vivo results of both fixation options is reviewed. Although the fixation mechanism of both constructs are different, radiographic and clinical survivorship appear similar for both techniques. Although there appears to be a trend towards a hybrid fixation method, the choice of which technique to employ in revision total knee arthroplasty will depend on the surgeons' familiarity with each technique as well as the factors peculiar to each patients anatomy.
PubMed: 33442224
DOI: 10.1016/j.jor.2020.12.016 -
JMIR Research Protocols Dec 2022The management of infected metaphyseal nonunion of the tibia is devastating, especially when associated with significant bone loss, poor soft tissues, draining sinuses,...
BACKGROUND
The management of infected metaphyseal nonunion of the tibia is devastating, especially when associated with significant bone loss, poor soft tissues, draining sinuses, axial deformity, knee or ankle joint stiffness, limb discrepancy, and multiresisted pathogens. A systematic review, performed recently by the primary investigators but not yet published, yielded the lack of studies in the field and the huge heterogeneity of the presented results. We found several bias and controversies such as no clear definition of the exact part of the tibia where the nonunion was located, the pathogen causing the fracture-related infection, the number of previous interventions and time to presentation, and the exact type of treatment methods including the use of muscle flaps or bone grafting. Time to final union as a functional score is another important but missing data.
OBJECTIVE
The proposed study is designed to evaluate a sufficient number of patients with infected metaphyseal tibial nonunions using various general health, functional, and bone scores.
METHODS
This prospective clinical trial study, with a minimum follow-up period of 36 months, focuses on the effectiveness of the Ilizarov method after radical nonunion debridement and targeted antibiotic therapy in patients with infected metaphyseal tibial nonunions. The primary outcomes would be the definite healing of nonunion and infection-free results. Secondary outcomes would be limb alignment and discrepancy, alteration in the patient's quality of life, and functional results. A power analysis calculated a minimum of 11 patients to obtain statistical power, but we aim to include at least 25 patients. Limb discrepancy, clinical validation of infection eradication and fracture healing, radiographic validation, and patient-reported outcome measures will be highlighted and correlated. Statistical analysis of the results will offer data missing from the literature so far. Measurements are scheduled at specific times for each patient: preoperatively, 3 and 6 months postoperatively, 1 month after Ilizarov frame removal, and once per semester afterward until the end of the follow-up period (minimum 36 months). Laboratory evaluation will be assessed once per month. Any complication will be reported and treated when it occurs.
RESULTS
The trial has already started. It was funded in June 2020. As of May 2022, 19 participants have been recruited and no major complications have been noticed yet. Data analysis will be performed after data collection ends, and results will be published afterward.
CONCLUSIONS
An infected metaphyseal tibial nonunion is a rare condition with limited treatment options and many controversies. There is no consensus in the literature about the best treatment strategy, and this lack of evidence should be fulfilled.
TRIAL REGISTRATION
International Standard Randomized Controlled Trial Number (ISRCTN) 30905788; https://www.isrctn.com/ISRCTN30905788.
INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)
DERR1-10.2196/39319.
PubMed: 36580353
DOI: 10.2196/39319 -
JBMR Plus Sep 2022Nacre has emerged as a beneficial natural product for bone cells and tissues, but its effect was only studied by gavage in the ovariectomized mouse model. We sought to...
Nacre has emerged as a beneficial natural product for bone cells and tissues, but its effect was only studied by gavage in the ovariectomized mouse model. We sought to assess the antiosteoporotic effect of nacre through a nutritional supplementation in the ovariectomized rat model. Sixteen-week-old female Wistar rats were either Sham-operated or bilateral ovariectomized (OVX) and then fed with standard diet (Sham and OVX groups) or standard diet supplemented with either 0.25% CaCO or nacre (OVX CaCO and OVX Nacre group, respectively) for 28 days ( = 10/group). The bone microarchitecture was assessed at appendicular and axial bones by micro-computed tomography (μCT). Histomorphometric analysis was performed to determine cellular and dynamic bone parameters. Bone metabolism was also evaluated by biochemical markers and gene expression levels. Nacre-based diet prevented the OVX-induced bone loss better than that of the CaCO supplement, given the significant changes in trabecular bone volume fraction (BV/TV) both at the femoral distal metaphysis (difference, 35%; = 0.004) and at the second lumbar spine (difference, 11%; = 0.01). Trabecular osteoclast surfaces (Oc.S/BS) were also 1.5-fold lower at the tibial proximal metaphysis in OVX Nacre group compared with OVX CaCO group ( = 0.02) By principal component analysis (PCA), OVX Nacre group formed a cluster away from OVX group and with a trend closest to Sham group. These data were consistent with biological measurements demonstrating a positive profile related to nacre supplementation, which blunted an increase in serum CTX level and enhanced serum P1NP secretion 14 days post-OVX compared with CaCO supplementation. mRNA expression in OVX Nacre group was +1.76-fold ( = 0.004) and +1.30-fold ( = 0.20) compared with OVX and OVX CaCO groups, respectively. We conclude that supplementation with nacre could effectively limit bone loss induced by estrogen deficiency just after OVX in rats by modulating the negative imbalance of bone turnover. © 2022 The Authors. published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
PubMed: 36111203
DOI: 10.1002/jbm4.10655 -
Clinical Orthopaedics and Related... Sep 2020Accurate quantification of bone loss facilitates preoperative planning and standardization for research purposes in patients who undergo revision TKA. The most commonly... (Observational Study)
Observational Study
BACKGROUND
Accurate quantification of bone loss facilitates preoperative planning and standardization for research purposes in patients who undergo revision TKA. The most commonly used classification to rate bone defects in this setting, the Anderson Orthopaedic Research Institute classification, does not quantify diaphyseal bone loss and reliability has not been well studied.
QUESTIONS/PURPOSES
We developed a new classification scheme to rate bone defects in patients undergoing revision TKA and tested (1) the intraobserver and interobserver reliability of this classification for revision TKA based on preoperative radiographs, and (2) whether additional CT images might improve interobserver reliability.
METHODS
This was a preregistered observational study. Interobserver reliability was analyzed using preoperative radiographs of 61 patients who underwent (repeat) revision TKA, and their bone defects were rated by five experienced orthopaedic surgeons. For intraobserver reliability, ratings were repeated at least 2 weeks after the first rating (Timepoints 1 and 2). Directly after the radiographic assessments of Timepoint 2, the observers were provided with CT images of each patient and asked to rate the bone defects for a third time (Timepoint 3), to assess the additional value of CT. Intraobserver and interobserver reliability were tested using Gwet's agreement coefficient 2, which is a measure of agreement between observers in categorical data. Substantial agreement was defined as coefficients between 0.61 to 0.8 and almost perfect agreement as > 0.8.
RESULTS
The intraobserver reliability varied between 0.55 (95% CI 0.40 to 0.71) and 0.87 (95% CI 0.78 to 0.96) in the epiphysis, between 0.69 (95% CI 0.58 to 0.80) and 0.98 (95% CI 0.95 to 1) in the metaphysis, and between 0.95 (95% CI 0.90 to 0.99) and 0.99 (95% CI 0.98 to 1) in the diaphysis. The interobserver reliability varied between 0.48 (95% CI 0.39 to 0.57) and 0.49 (95% CI 0.42 to 0.56) in the epiphysis and between 0.81 (95% CI 0.75 to 0.87) and 0.88 (95% CI 0.83 to 0.93) in the metaphysis, and was 0.96 (95% CI 0.93 to 0.99) in the diaphysis at Timepoint 1. The interobserver reliability at Timepoint 2 was similar to that of Timepoint 1. The addition of CT images did not improve reliability (Timepoint 3).
CONCLUSIONS
The bone defect classification was less reliable in the epiphyseal area compared with the metaphysis and diaphysis. This finding may be explained by prosthetic components obscuring this region or the more severe bone defects in this region. The addition of CT scans did not improve reliability. Further testing of reliability with observers from other institutions is necessary, as well as validity testing, by testing the classification in relation to intraoperative findings.
LEVEL OF EVIDENCE
Level III, diagnostic study.
Topics: Arthroplasty, Replacement, Knee; Bone Diseases; Diaphyses; Epiphyses; Female; Femur; Humans; Male; Middle Aged; Observer Variation; Preoperative Period; Reoperation; Reproducibility of Results; Tibia; Tomography, X-Ray Computed
PubMed: 32023232
DOI: 10.1097/CORR.0000000000001084 -
JSES Reviews, Reports, and Techniques Aug 2023Methods to determine whether a stemless humeral component is appropriate for anatomic total shoulder arthroplasty are varied and often subjective. Objective preoperative...
BACKGROUND
Methods to determine whether a stemless humeral component is appropriate for anatomic total shoulder arthroplasty are varied and often subjective. Objective preoperative data regarding metaphyseal bone quality may help guide surgical decision-making. This study sought to evaluate preoperative proximal humeral bone quality and determine whether it is predictive of intraoperative conversion to a stemmed humeral component.
METHODS
Consecutive patients who underwent primary anatomic total shoulder arthroplasty from a single-surgeon practice were enrolled. All patients received a preoperative computed tomography (CT) scan for surgical templating purposes. The exclusion criteria were lack of a preoperative CT scan, preoperative plan for a stemmed component, and intraoperative conversion to a stem for a reason other than bone quality (ie, fracture). Preoperative CT scans were analyzed with an automated templating software. Cortical index and thickness were calculated, and bone density of the proximal diaphysis, cancellous metaphysis, and cortical metaphysis was obtained by averaging Hounsfield units (HU) across anatomically defined regions using a previously validated technique. The decision to convert to a stemmed humeral component was made intraoperatively based on a lack of stability of the trial stemless component. Bone quality measurements were compared between stemless and stemmed groups. An exact logistic regression was used incorporating gender and age.
RESULTS
A total of 79 patients who underwent primary anatomic total shoulder arthroplasty were included in this study. Of these patients, 6 underwent intraoperative conversion to a stemmed humeral component (7.6%). There was no significant difference between cohorts in terms of cortical index and bone density within the proximal diaphysis and cortical metaphysis. On univariate analysis, cortical thickness, metaphyseal cancellous bone density, and gender were significantly different between groups. Patients receiving a stem had significantly lower metaphyseal cancellous bone density than those receiving stemless components (5.5 ± 11.2 HU vs. 47.6 ± 29.4 HU, <.001). All patients converted to stems were female individuals ( = .01) and had metaphyseal cancellous bone density less than 20 HU (<.001).
CONCLUSIONS
Metaphyseal cancellous bone density can be calculated on preoperative CT scans and is associated with intraoperative conversion to a stemmed humeral component in anatomic shoulder arthroplasty. A threshold of 20 HU can be used to predict which patients are more likely to require stemmed components.
PubMed: 37588492
DOI: 10.1016/j.xrrt.2023.01.009 -
Scientific Reports Apr 2023This retrospective cross-sectional study investigated the association between bone marrow lesions (BMLs) and bone mineral density (BMD) in the proximal tibia of...
This retrospective cross-sectional study investigated the association between bone marrow lesions (BMLs) and bone mineral density (BMD) in the proximal tibia of end-stage osteoarthritic knees from a large patient sample. Overall, 1308 end-stage osteoarthritic knees were enrolled before total knee arthroplasty. The preoperative range of motion was recorded. Bone mineral density in the medial tibial plateau (MTP), lateral tibial plateau (LTP), and metaphysis were measured using dual-energy X-ray absorptiometry. The MTP/LTP, MTP/metaphysis, and LTP/metaphysis ratios were calculated. BMLs were scored using a whole-organ magnetic resonance imaging scoring system. The relationship between BMD and BML scores was investigated using linear regression analysis. The highest BMD was 0.787 ± 0.176 g/cm at the MTP, followed by 0.676 ± 0.180 g/cm and 0.572 ± 0.145 g/cm at the metaphysis and LTP, respectively. The prevalence of BMLs was 90.4% and 24.2% in the MTP and LTP, respectively. In women, higher BML scores at the MTP were positively correlated with the BMD of the MTP (p < 0.001, r = 0.278), MTP/LTP (p < 0.001, r = 0.267), and MTP/metaphysis ratios (p < 0.001, r = 0.243). Regression analysis showed that higher BML scores in the MTP were correlated with higher BMD in the MTP (p < 0.001) and lower BMD in the LTP (p < 0.001). High BML scores in the MTP were positively associated with high BMD in the MTP, which also induced the medial to lateral imbalance of BMD in the proximal tibia.
Topics: Humans; Female; Bone Density; Tibia; Bone Marrow; Osteoarthritis, Knee; Retrospective Studies; Cross-Sectional Studies; Knee Joint; Bone Diseases
PubMed: 37085519
DOI: 10.1038/s41598-023-33251-7 -
Journal of Pineal Research Oct 2008Several reports indicate that melatonin is involved in the regulation of bone metabolism. To examine the direct effect of melatonin on osteoclasts and osteoblasts, we... (Review)
Review
Several reports indicate that melatonin is involved in the regulation of bone metabolism. To examine the direct effect of melatonin on osteoclasts and osteoblasts, we developed an in vitro assay using fish scales that contain osteoclasts, osteoblasts, and bone matrix, all of which are similar to those found in mammalian membrane bone. Using the assay, we demonstrated that melatonin suppressed osteoclastic and osteoblastic activities. These findings are in agreement with the reports from in vivo studies in mice and rats. In an attempt to develop molecules that increase bone mass, novel bromomelatonin derivatives were synthesized, and the effects of these chemicals on osteoclasts and osteoblasts using the scale assay were examined. As a result, novel bromomelatonin derivatives with the ability to possibly increase bone formation were identified. In scale osteoclasts, particularly, 1-benzyl-2,4,6-tribromomelatonin had a more potent activity than melatonin. In reference to osteoblasts, this agent (10(-9)-10(-6)M) significantly activated osteoblasts. The effect of 1-benzyl-2,4,6-tribromomelatonin on bone formation was confirmed in ovariectomized rats. Thus, the oral administration of 1-benzyl-2,4,6-tribromomelatonin augmented the total bone mineral density of the femoral metaphysis of ovariectomized rats. The stress-strain index of the diaphysis in 1-benzyl-2,4,6-tribromomelatonin-treated rats significantly increased in comparison with that in ovariectomized rats. In rats fed a low-calcium diet, the total bone mineral density of the femoral metaphysis significantly increased following the oral administration of 1-benzyl-2,4,6-tribromomelatonin. These studies identified a melatonin derivative that may have potential use in the treatment of bone diseases, such as osteoporosis.
Topics: Animals; Bone Density; Bone Diseases; Bone Matrix; Calcium, Dietary; Diaphyses; Goldfish; Melatonin; Osteoblasts; Osteoclasts; Osteogenesis; Osteoporosis; Ovariectomy; Rats
PubMed: 18691356
DOI: 10.1111/j.1600-079X.2008.00623.x -
Bone & Joint Research Nov 2022This study examined whether systemic administration of melatonin would have different effects on osseointegration in ovariectomized (OVX) rats, depending on whether this...
AIMS
This study examined whether systemic administration of melatonin would have different effects on osseointegration in ovariectomized (OVX) rats, depending on whether this was administered during the day or night.
METHODS
In this study, a titanium rod was implanted in the medullary cavity of one femoral metaphysis in OVX rats, and then the rats were randomly divided into four groups: Sham group (Sham, n = 10), OVX rat group (OVX, n = 10), melatonin day treatment group (OVX + MD, n = 10), and melatonin night treatment group (OVX + MN, n = 10). The OVX + MD and OVX + MN rats were treated with 30 mg/kg/day melatonin at 9 am and 9 pm, respectively, for 12 weeks. At the end of the research, the rats were killed to obtain bilateral femora and blood samples for evaluation.
RESULTS
Micro-CT and histological evaluation showed that the bone microscopic parameters of femoral metaphysis trabecular bone and bone tissue around the titanium rod in the OVX + MD group demonstrated higher bone mineral density, bone volume fraction, trabecular number, connective density, trabecular thickness, and lower trabecular speculation (p = 0.004) than the OVX + MN group. Moreover, the biomechanical parameters of the OVX + MD group showed higher pull-out test and three-point bending test values, including fixation strength, interface stiffness, energy to failure, energy at break, ultimate load, and elastic modulus (p = 0.012) than the OVX + MN group. In addition, the bone metabolism index and oxidative stress indicators of the OVX + MD group show lower values of Type I collagen cross-linked C-telopeptide, procollagen type 1 N propeptide, and malondialdehyde (p = 0.013), and higher values of TAC and SOD (p = 0.002) compared with the OVX + MN group.
CONCLUSION
The results of our study suggest that systemic administration with melatonin at 9 am may improve the initial osseointegration of titanium rods under osteoporotic conditions more effectively than administration at 9 pm.Cite this article: 2022;11(11):751-762.
PubMed: 36317318
DOI: 10.1302/2046-3758.1111.BJR-2022-0017.R2 -
Osteoarthritis and Cartilage Jun 2023To determine the effects of acute (≤7 days) femoral head ischemia on the proximal femoral growth plate and metaphysis in a piglet model of Legg-Calvé-Perthes disease...
OBJECTIVE
To determine the effects of acute (≤7 days) femoral head ischemia on the proximal femoral growth plate and metaphysis in a piglet model of Legg-Calvé-Perthes disease (LCPD). We hypothesized that qualitative and quantitative histological assessment would identify effects of ischemia on endochondral ossification.
DESIGN
Unilateral femoral head ischemia was surgically induced in piglets, and femurs were collected for histological assessment at 2 (n = 7) or 7 (n = 5) days post-ischemia. Samples were assessed qualitatively, and histomorphometry of the growth plate zones and primary spongiosa was performed. In a subset of samples at 7 days, hypertrophic chondrocytes were quantitatively assessed and immunohistochemistry for TGFβ1 and Indian hedgehog was performed.
RESULTS
By 2 days post-ischemia, there was significant thinning of the proliferative and hypertrophic zones, by 63 μm (95% CI -103, -22) and -19 μm (95% CI -33, -5), respectively. This thinning persisted at 7 days post-ischemia. Likewise, at 7 days post-ischemia, the primary spongiosa was thinned to absent by an average of 311 μm (95% CI -542, -82) in all ischemic samples. TGFβ1 expression was increased in the hypertrophic zone at 7 days post-ischemia.
CONCLUSIONS
Alterations to the growth plate zones and metaphysis occurred by 2 days post-ischemia and persisted at 7 days post-ischemia. Our findings suggest that endochondral ossification may be disrupted at an earlier time point than previously reported and that growth disruption may occur in the piglet model as occurs in some children with LCPD.
Topics: Animals; Swine; Legg-Calve-Perthes Disease; Femur Head; Growth Plate; Hedgehog Proteins; Ischemia
PubMed: 36696941
DOI: 10.1016/j.joca.2023.01.011 -
Journal of Orthopaedic Research :... May 2022Numerous animal and human studies have demonstrated the benefit of controlled interfragmentary motion on fracture healing. In this study, we quantified interfragmentary...
Numerous animal and human studies have demonstrated the benefit of controlled interfragmentary motion on fracture healing. In this study, we quantified interfragmentary motion and load transfer in tibial fractures fixed using a novel intramedullary nail (IMN) that allows controlled axial motion. Fifty composite tibias with various fracture patterns were utilized. For all test conditions, two interlocking screws were used to fix the nail in the proximal metaphysis, and two interlocking screws through the distal metaphysis. The nail allowed either no motion (static mode) or 1 mm (dynamic mode) of cyclic axial motion between the two fracture fragments for every fracture pattern tested. As expected, strain shielding was more prominent under static nail conditions. In contrast, specimens tested under dynamic nail conditions transferred axial load between the fracture fragments such that strains near the fracture site were generally similar to those measured on an intact tibia. Maximum shear strains proximal to the fracture were significantly lower in specimens with oblique or butterfly fracture patterns (p < 0.01) compared to intact specimens. This decrease in shear strain indicates that strain shielding effects were likely present due to the implant. However, strain shielding appeared to be reduced in tensile and compressive principal strains. In summary, the novel IMN allowed controlled axial motion between the fragments in a variety of common diaphyseal tibial fracture patterns. Clinical Significance: The present in vitro biomechanical study investigated a novel intramedullary nail capable of controlled axial interfragmentary motion which may potentially enhance fracture healing.
Topics: Biomechanical Phenomena; Bone Nails; Fracture Fixation, Intramedullary; Humans; Tibia; Tibial Fractures
PubMed: 34251706
DOI: 10.1002/jor.25134