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BACKGROUND Today, biological fixation of uncemented press-fit acetabular components plays an important role in total hip arthroplasty. Long-term stable fixation of these implants depends on the osseointegration of the acetabular cup bone tissue into the acetabular cup implant, and their ability to withstand functional loads. AIM To compare the strength of bone-implant osseointegration of four types of porous metal implants in normal and osteoporotic bone in rabbits. METHODS The study was performed in 50 female California rabbits divided into non-ovariectomized (non-OVX) and ovariectomized groups (OVX) at 6 mo of age. Rabbits were sacrificed 8 wk after the implantation of four biomaterials [TTM, CONCELOC, Zimmer Biomet's Trabecular Metal (TANTALUM), and ATLANT] in a 5-mm diameter defect created in the left femur. A biomechanical evaluation of the femur was carried out by testing implant breakout force. The force was gradually increased until complete detachment of the implant from the bone occurred. RESULTS The breakout force needed for implant detachment was significantly higher in the non-OVX group, compared with the OVX group for all implants (TANTALUM, 194.7 ± 6.1 N vs 181.3 ± 2.8 N; P = 0.005; CONCELOC, 190.8 ± 3.6 N vs 180.9 ± 6.6 N; P = 0.019; TTM, 186.3 ± 1.8 N vs 172.0 N ± 11.0 N; P = 0.043; and ATLANT, 104.9 ± 7.0 N vs 78.9 N ± 4.5 N; P = 0.001). In the OVX group, The breakout forces in TANTALUM, TTM, and CONCELOC did not differ significantly (P = 0.066). The breakout force for ATLANT in the OVX group was lower by a factor of 2.3 compared with TANTALUM and CONCELOC, and by 2.2 compared with TTM (P = 0.001). In the non-OVX group, the breakout force for ATLANT was significantly different from all other implants, with a reduction in fixation strength by a factor of 1.9 (P = 0.001). CONCLUSION TANTALUM, TTM, and CONCELOC had equal bone-implant osseointegration in healthy and in osteoporotic bone. ATLANT had significantly decreased osseointegration (P = 0.001) in healthy and in osteoporotic bone.

BACKGROUND The incidence of primary osteoarthritis knee is gradually increasing among young individuals. The increasing prevalence of obesity, sedentary lifestyle, sporting activity, and vitamin D deficiency (VDD) has been hypothesized for this shifting disease trend. This study was designed to look for the association of serum vitamin D among these young arthritic patients. AIM To look for the association of serum vitamin D in younger knee osteoarthritis (KOA) patients. METHODS In a 2-year observational study, 146 non-obese KOA patients of 35-60 years were evaluated clinically (Knee injury and Osteoarthritis Outcome Score, KOOS) and radiologically (Kellegren-Lawrence stage, KL). The serum 25(OH)D level of these patients and 146 normal healthy individuals of same age group were estimated. RESULTS Both the groups were comparable in terms of age and sex. The average serum 25(OH)D level in healthy individuals and KOA patients was 45.83 ng/mL and 34.58 ng/mL, respectively (P < 0.001). Inadequate serum 25(OH)D level (< 30 ng/mL) was found in 46.57% of KOA patients and 24% of normal healthy participants indicating a significant positive association (odds ratio 2.77, 95%CI: 1.67-4.54, P < 0.001). The 25(OH)D level in KL grade I, II, III and IV was 43.40, 30.59, 31.56 and 33.93 ng/mL respectively (no difference, P = 0.47). Similarly, the KOOS score in sufficient, insufficient and deficient groups were 65.31, 60.36 and 65.31, respectively (no difference, P = 0.051). CONCLUSION The serum 25(OH)D level is significantly low in younger KOA patients. However, the clinical and radiological severities have no association with serum vitamin D level.

BACKGROUND In rotator cuff repair surgery, the double-row technique is widely performed. Studies have shown that with increased contact area and pressure between tendon and bone interface, better healing is promoted. AIM To assess the different suture configurations with the double-row technique and how this influences the contact area of the rotator cuff tendon to bone. METHODS This was a controlled laboratory study where identical tears were created in 24 fresh porcine shoulders over a 1.5 cm × 2.5 cm infraspinatus insertion footprint. Double-row repair techniques, with 3 to 4-suture anchors in different configurations (2 medial, 2 lateral vs 2 medial, 1 lateral vs 1 medial, 2 lateral), were employed for three control groups. Each group consisted of eight shoulders with identical repair configurations. Footprint contact areas of the repaired tendon against the tuberosity were determined using pressure sensitive Fujifilm placed between the tendon and tuberosity. RESULTS The mean contact area between tendon and insertion footprint from the imprinted Fujifilm was obtained using computer software. The contact area measured from a standard 4-suture anchor double row repair was 75.1 ± 9.3 mm2, whereas areas obtained for the 2 lateral - 1 medial and 2 medial - 1 lateral anchor configurations were 72.9 ± 5.2 mm2 and 75.0 ± 4.9 mm2 respectively. No statistical significance was noted between the three groups. CONCLUSION In the technique of double-row repair, using a 3-suture anchor configuration may offer a non-inferior alternative to the standard 4-anchor construct in terms of efficacy. This may also result in overall cost reduction and shorter surgical time.

Background Septic arthritis is an orthopedic emergency requiring immediate surgical intervention. Current diagnostic standard of care is an invasive joint aspiration. Aspirations provide information about the inflammatory cells in the sample within a few hours, but there is often ambiguity about whether the source is infectious (e.g. bacterial) or non-infectious (e.g. gout). Cultures can take days to result, so decisions about surgery are often made with incomplete data. Novel diagnostics are thus needed. The "Sepsis MetaScore" (SMS) is an 11-mRNA host immune blood signature that can distinguish between infectious and non-infectious acute inflammation. It has been validated in multiple cohorts across heterogeneous clinical settings. Aim To study whether the SMS holds diagnostic validity in determining the etiology of acute arthritis. Methods We conducted a blinded, prospective, non-interventional clinical study of the SMS. All patients undergoing work-up for a septic primary joint were enrolled. Patients proceeded through the normal standard-of-care pathway, including joint aspiration and inflammatory labs [white blood cell (WBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)]. Venous blood was also drawn into PAX gene RNA-stabilizing tubes and mRNAs were measured using Nano String nCounter™. SMS was calculated blinded to clinical results. Results A total of 20 samples were included, of which 11 were infected based on aspiration or intra-operative cultures. The SMS had an area under the ROC curve (AUROC) of 0.87 for separating infectious from non-infectious conditions. For comparison, the AUROCs for ESR = 0.58, CRP = 0.6, and WBC = 0.59. At 100% sensitivity for infection, the specificity of the SMS was 40%, meaning nearly half of non-septic patients could have been ruled out for further intervention. Conclusion In this pilot study, SMS showed a high level of diagnostic accuracy in predicting septic joints compared to other diagnostic biomarkers. This quick blood test could be an important tool for early, accurate identification of acute septic joints and need for emergent surgery, improving clinical care and healthcare spending.

Background Clopidogrel is a widely prescribed drug for prevention of myocardial infarction and stroke in patients at risk. It inhibits thrombus formation via inhibition of the P2Y12 purinergic receptor on platelets, which is important in their activation by ADP. However, the P2Y12 receptor has also been found to be expressed in both osteoblasts and osteoclasts. Accumulated evidence suggests that purinergic receptors regulate important functions of bone turnover. Previous studies on the effect of clopidogrel on bone metabolism indicated potential harmful effects, but their results remain conflicting. Thus, clopidogrel treatment may affect bone healing, but it has not yet been studied. Aim To evaluate if continuous perioperative clopidogrel treatment has any negative effect on bone healing in the rabbit calvarial defect model. Methods Sixteen male white New Zealand rabbits were randomly assigned in two groups: One group received daily 3 mg/kg of clopidogrel per os and the other group received the vehicle alone for a week prior to the surgical procedures; the treatments were continued for another 6 wk postoperatively. The surgical procedures included generation of two circular calvarial defects 11 mm in diameter in every animal. After the 6-wk period of healing, postmortem radiographic and histomorphometric evaluation of the defects was performed. Results Both the surgical procedures and the postoperative period were uneventful and well tolerated by all the animals, without any surgical wound dehiscence, signs of infection or other complication. New bone was formed either inwards from the defect margins or in the central portion of the defect as separated bony islets. While defect healing was still incomplete in both groups, the clopidogrel group had significantly improved radiographic healing scores. Moreover, the histomorphometric analysis showed that bone regeneration (%) was 28.07 ± 7.7 for the clopidogrel group and 19.47 ± 4.9 for the control group, showing a statistically significant difference between them (P = 0.018). Statistically significant difference was also found in the defect bridging (%), i.e. 72.17 ± 21.2 for the clopidogrel group and 41.17 ± 8.5 for the control group, respectively (P = 0.004), whereas there was no statistical difference in bone tissue density between the groups. Conclusion Our results indicate that maintenance of perioperative clopidogrel treatment does not negatively affect bone healing but rather promotes it. Further research is needed in order to find useful applications of this finding.

BACKGROUND Arthroscopic procedures are commonly performed for rotator cuff pathology. Repair of rotator cuff tears is a commonly performed procedure. The intraoperative evaluation of the tear size and pattern contributes to the choice and completion of the technique and the prognosis of the repair. AIM To compare the arthroscopic and open measurements with the real dimensions of three different patterns of simulated rotator cuff tears of known size using a plastic shoulder model. METHODS We created three sizes and patterns of simulated supraspinatus tears on a plastic shoulder model (small and large U-shaped, oval-shaped). Six orthopaedic surgeons with three levels of experience measured the dimensions of the tears arthroscopically, using a 5 mm probe, repeating the procedure three times, and then using a ruler (open technique). Arthroscopic, open and computerized measurements were compared. RESULTS A constant underestimation of specific dimensions of the tears was found when measured with an arthroscope, compared to both the open and computerized measurements (mean differences up to -7.5 ± 5.8 mm, P < 0.001). No differences were observed between the open and computerized measurements (mean difference -0.4 ± 1.6 mm). The accuracy of arthroscopic and open measurements was 90.5% and 98.5%, respectively. When comparing between levels of experience, senior residents reported smaller tear dimensions when compared both to staff surgeons and fellows. CONCLUSION This study suggests that arthroscopic measurements of full-thickness rotator cuff tears constantly underestimate the dimensions of the tears. Development of more precise arthroscopic techniques or tools for the evaluation of the size and type of rotator cuff tears are necessary.

BACKGROUND Locking plate fixation in osteoporotic ankle fractures may fail due to cut-out or metalwork failure. Fibula pro-tibia fixation was a technique prior to the advent of locking plates that was used to enhance stability in ankle fractures by achieving tri or tetra-cortical fixation. With locking plates, the strength of this fixation construct can be further enhanced. There is lack of evidence currently on the merits of tibia-pro-fibula augmented locking plate fixation of unstable ankle fractures. AIM To assess if there is increased strength to failure, in an ankle fracture saw bone model, with a fibula pro-tibia construct when compared with standard locking plate fixation. METHODS Ten osteoporotic saw bones with simulated supination external rotation injuries were used. Five saw bones were fixed with standard locking plates whilst the other 5 saw bones were fixed with locking plates in a fibula pro-tibia construct. The fibula pro-tibia construct involved fixation with 3 consecutive locking screws applied across 3 cortices proximally from the level of the syndesmosis. All fixations were tested in axial external rotation to failure on an electromagnetic test frame (MTS 858 Mini-Bionix test machine, MTS Corp, Eden Praire, MN, United States). Torque at 30 degrees external rotation, failure torque, and external rotation angle at failure were compared between both groups and statistically analyzed. RESULTS The fibula pro-tibia construct demonstrated a statistically higher torque at 30 degrees external rotation (4.421 ± 0.796 N/m vs 1.451 ± 0.467 N/m; t-test P = 0.000), as well as maximum torque at failure (5.079 ± 0.694N/m vs 2.299 ± 0.931 N/m; t-test P = 0.001) compared to the standard locking plate construct. The fibula pro-tibia construct also had a lower external rotation angle at failure (54.7 ± 14.5 vs 67.7 ± 22.9). CONCLUSION The fibula pro-tibia locking plate construct demonstrates biomechanical superiority to standard locking plates in fixation of unstable ankle fractures in this saw bone model. There is merit in the use of this construct in patients with unstable osteoporotic ankle fractures as it may aid improved clinical outcomes.

AIM : To compare the measurements of knee rotation laxity by non-invasive skin pointer with a knee rotation jig in cadaveric knees against a skeletally mounted marker. METHODS : Six pairs of cadaveric legs were mounted on a knee rotation jig. One Kirscher wire was driven into the tibial tubercle as a bone marker and a skin pointer was attached. Rotational forces of 3, 6 and 9 nm applied at 0°, 30°, 45°, 60° and 90° of knee flexion were analysed using the Pearson correlation coefficient and paired t-test. RESULTS : Total rotation recorded with the skin pointer significantly correlated with the bone marker at 3 nm at 0° (skin pointer 23.9 ± 26.0° vs bone marker 16.3 ± 17.3°, r = 0.92; P = 0.0), 30° (41.7 ± 15.5° vs 33.1 ± 14.7°, r = 0.63; P = 0.037), 45° (49.0 ± 17.0° vs 40.3 ± 11.2°, r = 0.81; P = 0.002), 60° (45.7 ± 17.5° vs 34.7 ± 9.5°, r = 0.86; P = 0.001) and 90° (29.2 ± 10.9° vs 21.2 ± 6.8°, r = 0.69; P = 0.019) of knee flexion and 6 nm at 0° (51.1 ± 37.7° vs 38.6 ± 30.1°, r = 0.90; P = 0.0), 30° (64.6 ± 21.6° vs 54.3 ± 15.1°, r = 0.73; P = 0.011), 45° (67.7 ± 20.6° vs 55.5 ± 9.5°, r = 0.65; P = 0.029), 60° (62.9 ± 22.4° vs 45.8 ± 13.1°, r = 0.65; P = 0.031) and 90° (43.6 ± 17.6° vs 31.0 ± 6.3°, r = 0.62; P = 0.043) of knee flexion and at 9 nm at 0° (69.7 ± 40.0° vs 55.6 ± 30.6°, r = 0.86; P = 0.001) and 60° (74.5 ± 27.6° vs 57.1 ± 11.5°, r = 0.77; P = 0.006). No statistically significant correlation with 9 nm at 30° (79.2 ± 25.1° vs 66.9 ± 15.4°, r = 0.59; P = 0.055), 45° (80.7 ± 24.7° vs 65.5 ± 11.2°, r = 0.51; P = 0.11) and 90° (54.7 ± 21.1° vs 39.4 ± 8.2°, r = 0.55; P = 0.079). We recognize that 9 nm of torque may be not tolerated in vivo due to pain. Knee rotation was at its maximum at 45° of knee flexion and increased with increasing torque. CONCLUSION : The skin pointer and knee rotation jig can be a reliable and simple means of quantifying knee rotational laxity with future clinical application. Published version

Aim To develop practical guidelines for diagnosis and treatment of the painful snapping elbow syndrome (SE). Methods Clinical studies were searched in the databases PubMed and Scopus for the phrases "SE", "snapping triceps", "snapping ulnar nerve" and "snapping annular ligament". A total of 36 relevant studies were identified. From these we extracted information about number of patients, diagnostic methods, patho-anatomical findings, treatments and outcomes. Practical guidelines for diagnosis and treatment of SE were developed based on analysis of the data. We present two illustrative patient cases-one with intra-articular pathology and one with extra-articular pathology. Results Snapping is audible, palpable and often visible. It has a lateral (intra-articular) or medial (extra-articular) pathology. Snapping over the medial humeral epicondyle is caused by dislocation of the ulnar nerve or a part of the triceps tendon, and is demonstrated by dynamic ultrasonography. Treatment is by open surgery. Lateral snapping over the radial head has an intra-articular pathology: A synovial plica, a torn annular ligament or a meniscus-like remnant from the foetal elbow. Pathology can be visualized by conventional arthrography, magnetic resonance (MR) arthrography, high resolution magnetic resonance imaging (MRI) and arthroscopy, while conventional MRI and radiographs often turn out normal. Treatment is by arthroscopic or eventual open resection. Early surgical intervention is recommended as the snapping can damage the ulnar nerve (medial) or the intra-articular cartilage (lateral). If medial snapping only occurs during repeated or loaded extension/flexion of the elbow (in sports or work) it may be treated by reduction of these activities. Differential diagnoses are loose bodies (which can be visualized by radiographs) and postero-lateral instability (demonstrates by clinical examination). An algorithm for diagnosis and treatment is suggested. Conclusion The primary step is establishment of laterality. From this follows relevant diagnostic measures and treatment as defined in this guideline.

AIM To analyze how various implants placement variables affect sacroiliac (SI) joint range of motion. METHODS An experimentally validated finite element model of the lumbar spine and pelvis was used to simulate a fusion of the SI joint using various placement configurations of triangular implants (iFuse Implant System®). Placement configurations were varied by changing implant orientation, superior implant length, and number of implants. The range of motion of the SI joint was calculated using a constant moment of 10 N-m with a follower load of 400 N. The changes in motion were compared between the treatment groups to assess how the different variables affected the overall motion of the SI joint. RESULTS Transarticular placement of 3 implants with superior implants that end in the middle of the sacrum resulted in the greatest reduction in range of motion (flexion/extension = 73%, lateral bending = 42%, axial rotation = 72%). The range of motions of the SI joints were reduced with use of transarticular orientation (9%-18%) when compared with an inline orientation. The use of a superior implant that ended mid-sacrum resulted in median reductions of (8%-14%) when compared with a superior implant that ended in the middle of the ala. Reducing the number of implants, resulted in increased SI joint range of motions for the 1 and 2 implant models of 29%-133% and 2%-39%, respectively, when compared with the 3 implant model. CONCLUSION Using a validated finite element model we demonstrated that placement of 3 implants across the SI joint using a transarticular orientation with superior implant reaching the sacral midline resulted in the most stable construct. Additional clinical studies may be required to confirm these results.

AIM To demonstrate the feasibility of the wearable smart glasses, PicoLinker, in guide wire insertion under fluoroscopic guidance. METHODS Under a fluoroscope, a surgeon inserted 3 mm guide wires into plastic femurs from the lateral cortex to the femoral head center while the surgeon did or did not wear PicoLinker, which are wearable smart glasses where the fluoroscopic video was displayed (10 guide wires each). RESULTS The tip apex distance, radiation exposure time and total insertion time were significantly shorter while wearing the PicoLinker smart glasses. CONCLUSION This study indicated that the PicoLinker smart glasses can improve accuracy, reduce radiation exposure time, and reduce total insertion time. This is due to the fact that the PicoLinker smart glasses enable surgeons to keep their eyes on the operation field.

AIM To evaluate the behaviour of two fast-setting polymethylmethacrylate (PMMA) cements CMW® 2G and Palacos® fast R + G, as reference: Standard-setting Palacos® R + G. METHODS The fast-setting cements CMW® 2G and Palacos® fast R + G were studied, using standard-setting high viscosity Palacos® R + G as a reference. Eleven units (of two batch numbers) of each cement were tested. All cements were mixed as specified by the manufacturer and analysed on the following parameters: Handling properties (mixing, waiting, working and hardening phase) according to Kuehn, Mechanical properties according to ISO 5833 and DIN 53435, Fatigue strength according to ISO 16402, Benzoyl Peroxide (BPO) - Content by titration, powder/liquid-ratio by weighing, antibiotic elution profile by High Performance Liquid Chromatography. All tests were done in an acclimatised laboratory with temperatures set at 23.5 °C ± 0.5 °C and a humidity of > 40%. RESULTS Palacos® fast R + G showed slightly shorter handling properties (doughing, hardening phase, n = 12) than CMW® 2G, allowing to reduce operative time and to optimise cemented cup implantation. Data of the quasistatic properties of ISO 5833 and DIN 53435 of both cements tested was comparable. The ISO compressive strength (MPa) of Palacos® fast R + G was significantly higher than CMW® 2G, resulting in ANOVA (P < 0.01) and two sample t-test (P < 0.01) at 0.05 level of significance (n = 20). Palacos® fast R + G showed a higher fatigue strength of about 18% mean (ISO 16402) of 15.3 MPa instead of 13.0 MPa for CMW® 2G (n = 5 × 106 cycles). Palacos® fast R + G and CMW® 2G differed only by 0.11% (n = 6) with the former having the higher content. The BPO-content of both cements were therefore comparable. CMW® 2G had a powder/liquid ratio of 2:1, Palacos® fast R + G of 2.550:1 due to a higher powder content. Despite its higher gentamicin content, CMW® 2G showed a significantly lower antibiotic elution over time than Palacos® fast R + G (n = 3). CONCLUSION Both cements are compliant with international standards and are highly suitable for their specified surgical indications, affording a time-saving measure without detriment to the mechanical properties.

AIM To reduce post treatments of kyphoplasty, as a common treatment for osteoporotic vertebrae. METHODS This study suggests a new method for treating vertebrae by setting the hexagonal porous structure instead of the rigid bone cement mass in the kyphoplasty (KP). The KP procedure was performed on the fresh ovine vertebra of the level L1. Micro finite element modeling was performed based on micro computed tomography of ovine trabecular cube. The hexagonal porous structure was set on one cube instead of the bone cement mass. For the implant designing, two geometrical parameters were considered: Spacing diameter and thickness. RESULTS The results of micro finite element analyses indicated the improvement in the mechanical behavior of the vertebra treated by the hexagonal porous structures, as compared to those treated by vertebroplasty (VP) and KP under static loading. The improvement in the mechanical behavior of the vertebra, was observed as 54% decrease in the amount of maximum Von Misses stress (improvement of stress distribution), in trabecular cube with embedded hexagonal structure, as compared to VP and KP. This is comparable to the results of the experimental study already performed; it was shown that the improvement of mechanical behavior of the vertebra was observed as: 83% increase in the range of displacements before getting to the ultimate strength (increasing the toughness) after setting hexagonal pearls inside vertebrae. Both the material and geometry of implant influenced the amount of Von Mises stress in the structure. CONCLUSION The new proposed method can be offered as a substitute for the KP. The implant geometry had a more obvious effect on the amount of Von Mises stress, as compared to the implant material.

AIM To determine the effects of a cell sheet created from sheep bone marrow and tricalcium phosphate (TCP) on osteogenesis. METHODS Bone marrow cells were harvested from a sheep and cultured in a minimal essential medium (MEM) containing ascorbic acid phosphate (AscP) and dexamethasone (Dex). After 2 wk, the formed osteogenic matrix cell sheet was lifted from the culture dish using a scraper. Additionally, harvested bone marrow cells were cultured in MEM only as a negative control group, and in MEM with AscP, Dex, and β-glycerophosphate as a positive control group. For in vitro evaluation, we measured the alkaline phosphatase (ALP) activity and osteocalcin (OC) content in the media of the cultured cells from each group. For in vivo analysis, a porous TCP ceramic was used as a scaffold. We prepared an experimental group comprising TCP scaffolds wrapped with the osteogenic matrix cell sheets and a control group consisting of the TCP scaffold only. The constructs were implanted subcutaneously into athymic rats and the cell donor sheep, and bone formation was confirmed by histology after 4 wk. RESULTS In the in vitro part, the mean ALP activity was 0.39 ± 0.03 mg/well in the negative control group, 0.67 ± 0.04 mg/well in the sheet group, and 0.65 ± 0.07 mg/well in the positive control group. The mean OC levels were 1.46 ± 0.33 ng/well in the negative control group, 3.92 ± 0.16 ng/well in the sheet group, and 4.4 ± 0.47 ng/well in the positive control group, respectively. The ALP activity and OC levels were significantly higher in the cell sheet and positive control groups than in the negative control group (P < 0.05). There was no significant difference in ALP activity or OC levels between the cell sheet group and the positive control group (P > 0.05). TCP constructs wrapped with cell sheets prior to implantation showed bone formation, in contrast to TCP scaffolds alone, which exhibited poor bone formation when implanted, in the subcutaneous layer both in athymic rats and in the sheep. CONCLUSION This technique for preparing highly osteoinductive TCP may promote regeneration in large bone defects.

AIM To study the effect of balance intervention program using the “FIFA 11+” program on static and dynamic balance and kicking accuracy of young soccer players. METHODS Twenty young soccer players were allocated to experimental (n = 10) or control (n = 10) groups. The experimental group performed the “FIFA 11+” program three times a week for six weeks. The control group performed their normal warm-up routine. The primary outcomes were measured pre and post intervention, and assessed kicking accuracy, static balance and dynamic balance. RESULTS No differences were found in kicking accuracy following intervention, for both groups, however, static balance improved significantly among the experimental group with significant interaction with the control group, and with high effect size. In addition, the dynamic balance of the left leg of the experimental group, with medium effect size for interaction between groups. CONCLUSION The large effect size of balance improvement that was observed following six weeks of intervention sessions, implies that soccer trainers and coaches should consider the inclusion of “FIFA 11+” as components of programs aimed at improving balance ability/control in young soccer players, as improvement in balance abilities may prevent injuries.

AIM To determine whether three-dimensional (3D) reconstruction from conventional magnetic resonance imaging (MRI) is able to accurately detect a meniscal tear, and define the configuration. METHODS Thirty-three patients’ 3T MRI scan data were collected and sagittal uni-planar 3D reconstructions performed from the preoperative MRI. There were 24 meniscal tears in 24 patients, and nine controls. All patients had arthroscopic corroboration of MRI findings. Two independent observers prospectively reported on all 33 reconstructions. Meniscal tear presence or absence was noted, and tear configuration subsequently categorised as either radial, bucket-handle, parrot beak, horizontal or complex. RESULTS Identification of control menisci or meniscal tear presence was excellent (Accuracy: observer 1 = 90.9%; observer 2 = 81.8%). Of the tear configurations, bucket handle tears were accurately identified (Accuracy observer 1 and 2 = 80%). The remaining tear configurations were not accurately discernable. CONCLUSION Uni-planar 3D reconstruction from 3T MRI knee scan sequences are useful in identifying normal menisci and menisci with bucket-handle tears. Advances in MRI sequencing and reconstruction software are awaited for accurate identification of the remaining meniscal tear configurations.

AIM To determine peculiarities of tissue responses to manual and automated Ilizarov bone distraction in nerves and articular cartilage. METHODS Twenty-nine dogs were divided in two experimental groups: Group M - leg lengthening with manual distraction (1 mm/d in 4 steps), Group A - automated distraction (1 mm/d in 60 steps) and intact group. Animals were euthanized at the end of distraction, at 30th day of fixation in apparatus and 30 d after the fixator removal. M-responses in gastrocnemius and tibialis anterior muscles were recorded, numerical histology of peroneal and tibialis nerves and knee cartilage semi-thin sections, scanning electron microscopy and X-ray electron probe microanalysis were performed. RESULTS Better restoration of M-response amplitudes in leg muscles was noted in A-group. Fibrosis of epineurium with adipocytes loss in peroneal nerve, subperineurial edema and fibrosis of endoneurium in some fascicles of both nerves were noted only in M-group, shares of nerve fibers with atrophic and degenerative changes were bigger in M-group than in A-group. At the end of experiment morphometric parameters of nerve fibers in peroneal nerve were comparable with intact nerve only in A-group. Quantitative parameters of articular cartilage (thickness, volumetric densities of chondrocytes, percentages of isogenic clusters and empty cellular lacunas, contents of sulfur and calcium) were badly changed in M-group and less changed in A-group. CONCLUSION Automated Ilizarov distraction is more safe method of orthopedic leg lengthening than manual distraction in points of nervous fibers survival and articular cartilage arthrotic changes.

International audience; AIM To describe, using gait analysis, the development of spinal motion in the growing child. METHODS Thirty-six healthy children aged from 3 to 16 years old were included in this study for a gait analysis (9 m-walk). Various kinematic parameters were recorded and analyzed such as thoracic angle (TA), lumbar angle (LA) and sagittal vertical axis (SVA). The kinetic parameters were the net reaction moments (N.m/kg) at the thoracolumbar and lumbosacral junctions. RESULTS TA and LA curves were not statistically correlated to the age (respectively, p = 0.32 and p = 0.41). SVA increased significantly with age (p < 0.001). Moments in sagittal plane at the lumbosacral junction were statistically correlated to the age (p = 0.003), underlining the fact that sagittal mechanical constraints at the lumbosacral junction increase with age. Moments in transversal plane at the thoracolumbar and lumbosacral junctions were statistically correlated to the age (p = 0.0002 and p = 0.0006), revealing that transversal mechanical constraints decrease with age. CONCLUSION The kinetic analysis showed that during growth, a decrease of torsional constraint occurs while an increase of sagittal constraint is observed. These changes in spine biomechanics are related to the crucial role of the trunk for bipedalism acquisition, allowing stabilization despite lower limbs immaturity. With the acquisition of mature gait, the spine will mainly undergo constraints in the sagittal plane.

AIM To investigate the efficacy of a chitosan/polyethylene glycol blended paste as a local antibiotic delivery device, particularly in musculoskeletal wounds. METHODS Acidic (A) chitosan sponges and neutralized (N) chitosan/polyethylene glycol (PEG) blended sponges were combined in ratios of 3A:2N, 1A:1N, and 2A:3N; then hydrated with phosphate buffered saline to form a chitosan/PEG paste (CPP). Both in vitro and in vivo studies were conducted to determine the potential CPP has as a local antibiotic delivery device. In vitro biocompatibility was assessed by the cytotoxic response of fibroblast cells exposed to the experimental groups. Degradation rate was measured as the change in dry mass due to lysozyme based degradation over a 10-d period. The antibiotic elution profiles and eluate activity of CPP were evaluated over a 72-h period. To assess the in vivo antimicrobial efficacy of the CPP, antibiotic-loaded paste samples were exposed to subcutaneously implanted murine catheters inoculated with Staphylococcus aureus. Material properties of the experimental paste groups were evaluated by testing the ejection force from a syringe, as well as the adhesion to representative musculoskeletal tissue samples. RESULTS The highly acidic CPP group, 3A:2N, displayed significantly lower cell viability than the control sponge group. The equally distributed group, 1A:1N, and the highly neutral group, 2A:3N, displayed similar cell viability to the control sponge group and are deemed biocompatible. The degradation studies revealed CPP is more readily degradable than the chitosan sponge control group. The antibiotic activity studies indicated the CPP groups released antibiotics at a constant rate and remained above the minimum inhibitory concentrations of the respective test bacteria for a longer time period than the control chitosan sponges, as well as displaying a minimized burst release. The in vivo functional model resulted in complete bacterial infection prevention in all catheters treated with the antibiotic loaded CPP samples. All experimental paste groups exhibited injectability and adhesive qualities that could be advantageous material properties for drug delivery to musculoskeletal injuries. CONCLUSION CPP is an injectable, bioadhesive, biodegradable, and biocompatible material with potential to allow variable antibiotic loading and active, local antibiotic release to prevent bacterial contamination.

AIM To provide a “patient-normalized” parameter in the proximal forearm. METHODS Sixty-three cadaveric upper extremities from thirty-five cadavers were studied. A muscle splitting approach was utilized to locate the posterior interosseous nerve (PIN) at the point where it emerges from beneath the supinator. The supinator was carefully incised to expose the midpoint length of the nerve as it passes into the forearm while preserving the associated fascial connections, thereby preserving the relationship of the nerve with the muscle. We measured the transepicondylar distance (TED), PIN distance in the forearm’s neutral rotation position, pronation position, supination position, and the nerve width. Two individuals performed measurements using a digital caliper with inter-observer and intra-observer blinding. The results were analyzed with the Wilcoxon-Mann-Whitney test for paired samples. RESULTS In pronation, the PIN was within two confidence intervals of 1.0 TED in 95% of cases (range 0.7-1.3 TED); in neutral, within two confidence intervals of 0.84 TED in 95% of cases (range 0.5-1.1 TED); in supination, within two confidence intervals of 0.72 TED in 95% of cases (range 0.5-0.9 TED). The mean PIN distance from the lateral epicondyle was 100% of TED in a pronated forearm, 84% in neutral, and 72% in supination. Predictive accuracy was highest in supination; in all cases the majority of specimens (90.47%-95.23%) are within 2 cm of the forearm position-specific percentage of TED. When comparing right to left sides for TEDs with the signed Wilcoxon-Mann-Whitney test for paired samples as well as a significance test (with normal distribution), the P-value was 0.0357 (significance - 0.05) indicating a significant difference between the two sides. CONCLUSION This “patient normalized” parameter localizes the PIN crossing a line drawn between the lateral epicondyle and the radial styloid. Accurate PIN localization will aid in diagnosis, injections, and surgical approaches.

AIM: To evaluate the effect of different elbow and forearm positions on radiocapitellar alignment. METHODS: Fifty-one healthy volunteers were recruited and bilateral elbow radiographs were taken to form a radiologic database. Lateral elbow radiographs were taken with the elbow in five different positions: Maximal extension and forearm in neutral, maximal flexion and forearm in neutral, elbow at 90° and forearm in neutral, elbow at 90° and forearm in supination and elbow at 90° and forearm in pronation. A goniometer was used to verify the accuracy of the elbow’s position for the radiographs at a 90° angle. The radiocapitellar ratio (RCR) measurements were then taken on the collected radiographs using the SliceOmatic software. An orthopedic resident performed the radiographic measurements on the 102 elbows, for a total of 510 lateral elbow radiographic measures. ANOVA paired t-tests and Pearson coefficients were used to assess the differences and correlations between the RCR in each position. RESULTS: Mean RCR values were -2% ± 7% (maximal extension), -5% ± 9% (maximal flexion), and for elbow at 90° and forearm in neutral -2% ± 5%, supination 1% ± 6% and pronation 1% ± 5%. ANOVA analyses demonstrated significant differences between the RCR in different elbow and forearm positions. Paired t-tests confirmed significant differences between the RCR at maximal flexion and flexion at 90°, and maximal extension and flexion. The Pearson coefficient showed significant correlations between the RCR with the elbow at 90° - maximal flexion; the forearm in neutral-supination; the forearm in neutral-pronation. CONCLUSION: Overall, 95% of the RCR values are included in the normal range (obtained at 90° of flexion) and a value outside this range, in any position, should raise suspicion for instability.

AIM: To determine whether use of a precontoured olecranon plate provides adequate fixation to withstand supraphysiologic force in a comminuted olecranon fracture model. METHODS: Five samples of fourth generation composite bones and five samples of fresh frozen human cadaveric left ulnae were utilized for this study. The cadaveric specimens underwent dual-energy X-ray absorptiometry (DEXA) scanning to quantify the bone quality. The composite and cadaveric bones were prepared by creating a comminuted olecranon fracture and fixed with a pre-contoured olecranon plate with locking screws. Construct stiffness and failure load were measured by subjecting specimens to cantilever bending moments until failure. Fracture site motion was measured with differential variable resistance transducer spanning the fracture. Statistical analysis was performed with two-tailed Mann-Whitney-U test with Monte Carlo Exact test. RESULTS: There was a significant difference in fixation stiffness and strength between the composite bones and human cadaver bones. Failure modes differed in cadaveric and composite specimens. The load to failure for the composite bones (n = 5) and human cadaver bones (n = 5) specimens were 10.67 nm (range 9.40-11.91 nm) and 13.05 nm (range 12.59-15.38 nm) respectively. This difference was statistically significant (P ˂ 0.007, 97% power). Median stiffness for composite bones and human cadaver bones specimens were 5.69 nm/mm (range 4.69-6.80 nm/mm) and 7.55 nm/mm (range 6.31-7.72 nm/mm). There was a significant difference for stiffness (P ˂ 0.033, 79% power) between composite bones and cadaveric bones. No correlation was found between the DEXA results and stiffness. All cadaveric specimens withstood the physiologic load anticipated postoperatively. Catastrophic failure occurred in all composite specimens. All failures resulted from composite bone failure at the distal screw site and not hardware failure. There were no catastrophic fracture failures in the cadaveric specimens. Failure of 4/5 cadaveric specimens was defined when a fracture gap of 2 mm was observed, but 1/5 cadaveric specimens failed due to a failure of the triceps mechanism. All failures occurred at forces greater than that expected in postoperative period prior to healing. CONCLUSION: The pre-contoured olecranon plate provides adequate fixation to withstand physiologic force in a composite bone and cadaveric comminuted olecranon fracture model.

AIM To examine the normal morphology of the epiligament tissue of the knee medial collateral ligament (MCL) in humans. METHODS Several samples of the mid-substance of the MCL of the knee joint from 7 fresh human cadavers (3 females and 4 males) were taken. Examination of the epiligament tissue was conducted by light microscopy and photomicrography on semi-thin sections of formalin fixed paraffin-embedded blocks that were routinely stained with haematoxylin and eosin, Mallory stain and Van Gieson’s stain. Electron microscopy of the epiligament tissue was performed on ultra-thin sections incubated in 1% osmium tetroxide and contrasted with 2.5% uranyl acetate, lead nitrate, and sodium citrate. RESULTS The current light microscopic study demonstrated that the epiligament of the MCL consisted of fibroblasts, fibrocytes, adipocytes, neuro-vascular bundles and numerous multidirectional collagen fibers. In contrast, the ligament body was poorly vascularised, composed of hypo-cellular fascicles which were formed of longitudinal groups of collagen fibers. Moreover, most of the vessels of the epiligament-ligament complex were situated in the epiligament tissue. The electron microscopic study revealed fibroblasts with various shapes in the epiligament substance. All of them had the ultrastructural characteristics of active cells with large nuclei, well developed rough endoplasmic reticulum, multiple ribosomes, poorly developed Golgi apparatus, elliptical mitochondria and oval lysosomes. The electron microscopy also confirmed the presence of adipocytes, mast cells, myelinated and unmyelinated nerve fibers and chaotically oriented collagen fibers. CONCLUSION Significant differences exist between the normal structure of the ligament and the epiligament whose morphology and function is to be studied further.

AIM To investigate if there are typical degenerative changes in the ageing sternoclavicular joint (SCJ), potentially accessible for arthroscopic intervention. METHODS Both SCJs were obtained from 39 human cadavers (mean age: 79 years, range: 59-96, 13 F/26 M). Each frozen specimen was divided frontally with a band saw, so that both SCJs were opened in the same section through the center of the discs. After thawing of the specimens, the condition of the discs was evaluated by probing and visual inspection. The articular cartilages were graded according to Outerbridge, and disc attachments were probed. Cranio-caudal heights of the joint cartilages were measured. Superior motion of the clavicle with inferior movement of the lateral clavicle was measured. RESULTS Degenerative changes of the discs were common. Only 22 discs (28%) were fully attached and the discs were thickest superiorly. We found a typical pattern: Detachment of the disc inferiorly in connection with thinning, fraying and fragmentation of the inferior part of the disc, and detachment from the anterior and/or posterior capsule. Severe joint cartilage degeneration ≥ grade 3 was more common on the clavicular side (73%) than on the sternal side (54%) of the joint. In cadavers < 70 years 75% had ≤ grade 2 changes while this was the case for only 19% aged 90 years or more. There was no difference in cartilage changes when right and left sides were compared, and no difference between sexes. Only one cadaver - a woman aged 60 years - had normal cartilages. CONCLUSION Changes in the disc and cartilages can be treated by resection of disc, cartilage, intraarticular osteophytes or medial clavicle end. Reattachment of a degenerated disc is not possible.

Aim To develop methods of articular cartilage preparation for X-ray-electron probe microanalysis and to study its elements content in experimental osteoarthrosis. Methods Twenty dogs aged 2-8 years were divided in research (aged 2 years, induction of osteoarthrosis - IOA) and intact group. Intact group included three subgroups (aged 2, 5 and 8 years). Samples of cartilage after araldite saturation and pouring were partially cut into semithin sections stained with methylene blue and with methylene blue-basic fuchsin. Their smooth surfaces were investigated by X-ray-electron probe microanalysis. Spatial distribution of sulfur, calcium and phosphorus and their concentrations (weight %) were investigated. Results X-ray electron probe microanalysis revealed non-uniform sulfur distribution in cartilage of intact animals: Its content increases from superficial zone to deep one, this regularity was preserved in animals with IOA. Differences of IOA with spontaneous chondropathy were revealed. Spontaneous aging was characterized by calcium and phosphorus storage in deep and calcified zones and compensatory increase of sulfated glycosaminoglycans in intermediate and deep cartilage zones as evidenced by the metachromatic reaction and microanalysis data. Unlike spontaneous chondropathy connected with aging in experimentally stimulated osteoarthrosis more intensive storage of calcium but minor phosphorus in intermediate zone were marked. In IOA the calcified cartilage thinning and osteoclastic resorption are apparent with few changes of elements composition; the only difference from control is minority phosphorus content. Conclusion The obtained results demonstrate specific tricks of X-ray electron probe microanalysis and its possibility in the research of mechanisms of articular cartilage alterations in osteoarthrosis.

AIM: To analyse bone remodeling in regard to the age of scaphoid non-unions (SNU) with immunohistochemistry. METHODS: Thirty-six patients with symptomatic SNU underwent surgery with resection of the pseudarthrosis. The resected material was evaluated histologically after staining with hematoxylin-eosin (HE), tartrate resistant acid phosphatase (TRAP), CD 68, osteocalcin (OC) and osteopontin (OP). Histological examination was performed in a blinded fashion. RESULTS: The number of multinuclear osteoclasts in the TRAP-staining correlated with the age of the SNU and was significantly higher in younger SNU (P = 0.034; r = 0.75). A higher number of OP-immunoreactive osteoblasts significantly correlated with a higher number of OC-immunoreactive osteoblasts (P = 0.001; r = 0.55). Furthermore, a greater number of OP-immunoreactive osteoblasts correlated significantly with a higher number of OP-immunoreactive multinuclear osteoclasts (P = 0.008; r = 0.43). SNU older than 6 mo showed a significant decrease of the number of fibroblasts (P = 0.04). Smoking and the age of the patients had no influence on bone remodeling in SNU. CONCLUSION: Multinuclear osteoclasts showed a significant decrease in relation to the age of SNU. However, most of the immunhistochemical findings of bone remodeling do not correlate with the age of the SNU. This indicates a permanent imbalance of bone formation and resorption as indicated by a concurrent increase in both osteoblast and osteoclast numbers. A clear histological differentiation into phases of bone remodeling in SNU is not possible.

To test antibiotic-loaded coating for efficacy in reducing bacterial biofilm and development of osteomyelitis in an orthopaedic model of implant infection.Phosphatidylcholine coatings loaded with 25% vancomycin were applied to washed and sterilized titanium wires 20 mm in length. A 10 mm segment was removed from rabbit radius (total = 9; 5 coated, 4 uncoated), and the segment was injected with 1 × 10(6) colony forming units (CFUs) of Staphylococcus aureus (UAMS-1 strain). Titanium wires were inserted through the intramedullary canal of the removed segment and into the proximal radial segment and the segment was placed back into the defect. After 7 d, limbs were removed, X-rayed, swabbed for tissue contamination. Wires were removed and processed to determine attached CFUs. Tissue was swabbed and streaked on agar plates to determine bacteriological score.Antibiotic-loaded coatings resulted in significantly reduced biofilm formation (4.7 fold reduction in CFUs; P0.001) on titanium wires and reduced bacteriological score in surrounding tissue (4.0 ± 0 for uncoated, 1.25 ± 0.5 for coated; P = 0.01). Swelling and pus formation was evident in uncoated controls at the 7 d time point both visually and radiographically, but not in antibiotic-loaded coatings.Active antibiotic was released from coated implants and significantly reduced signs of osteomyelitic symptoms. Implant coatings were well tolerated in bone. Further studies with additional control groups and longer time periods are warranted. Antibiotic-loaded phosphatidylcholine coatings applied at the point of care could prevent implant-associated infection in orthopaedic defects.

AIM To investigate the impact of extrinsic visual feedback and additional cognitive/physical demands on single-limb balance in individuals with ankle instability. METHODS Sixteen subjects with ankle instability participated in the study. Ankle instability was identified using the Cumberland Ankle Instability Tool (CAIT). The subject’s unstable ankle was examined using the Athletic Single Leg Stability Test of the Biodex Balance System with 4 different protocols: (1) default setting with extrinsic visual feedback from the monitor; (2) no extrinsic visual feedback; (3) no extrinsic visual feedback with cognitive demands; and (4) no extrinsic visual feedback with physical demands. For the protocol with added cognitive demands, subjects were asked to continue subtracting 7 from a given number while performing the same test without extrinsic visual feedback. For the protocol with added physical demands, subjects were asked to pass and catch a basketball to and from the examiner while performing the same modified test. RESULTS The subject’s single-limb postural control varied significantly among different testing protocols (F = 103; P = 0.000). Subjects’ postural control was the worst with added physical demands and the best with the default condition with extrinsic visual feedback. Pairwise comparison shows subjects performed significantly worse in all modified protocols (P < 0.01 in all comparisons) compared to the default protocol. Results from all 4 protocols are significantly different from each other (P < 0.01) except for the comparison between the “no extrinsic visual feedback” and “no extrinsic visual feedback with cognitive demands” protocols. Comparing conditions without extrinsic visual feedback, adding a cognitive demand did not significantly compromise single-limb balance control but adding a physical demand did. Scores from the default protocol are significantly correlated with the results from all 3 modified protocols: No extrinsic visual feedback (r = 0.782; P = 0.000); no extrinsic visual feedback with cognitive demands (r = 0.569; P = 0.022); no extrinsic visual feedback with physical demands (r = 0.683; P = 0.004). However, the CAIT score is not significantly correlated with the single-limb balance control from any of the 4 protocols: Default with extrinsic visual feedback (r = -0.210; P = 0.434); no extrinsic visual feedback (r = -0.450; P = 0.081); no extrinsic visual feedback with cognitive demands (r = -0.406; P = 0.118); no extrinsic visual feedback with physical demands (r = -0.351; P = 0.182). CONCLUSION Single-limb balance control is worse without extrinsic visual feedback and/or with cognitive/physical demands. The balance test may not be a valid tool to examine ankle instability.

Aim To enhance non-technical skills and to analyse participant's experience of a course tailored for orthopaedic surgeons. Methods A Delphi technique was used to develop a course in human factors specific to orthopaedic residents. Twenty-six residents (six per course) participated in total with seven course facilitators all trained in Crisis Resource Management providing structured feedback. Six scenarios recreated challenging real-life situations using high-fidelity mannequins and simulated patients. Environments included a simulated operating suite, clinic room and ward setting. All were undertaken in a purpose built simulation suite utilising actors, mock operating rooms, mock clinical rooms and a high fidelity adult patient simulator organised through a simulation control room. Participants completed a 5-point Likert scale questionnaire (strongly disagree to strongly agree) before and after the course. This assessed their understanding of non-technical skills, scenario validity, relevance to orthopaedic training and predicted impact of the course on future practice. A course evaluation questionnaire was also completed to assess participants' feedback on the value and quality of the course itself. Results Twenty-six orthopaedic residents participated (24 male, 2 female; post-graduation 5-10 years), mean year of residency program 2.6 out of 6 years required in the United Kingdom. Pre-course questionnaires showed that while the majority of candidates recognised the importance of non-technical (NT) skills in orthopaedic training they demonstrated poor understanding of non-technical skills and their role. This improved significantly after the course (Likert score 3.0-4.2) and the perceived importance of these skills was reported as good or very good in 100%. The course was reported as enjoyable and provided an unthreatening learning environment with the candidates placing particular value on the learning opportunity provided by reflecting on their performance. All agreed that the course achieved its intended aims with realistic simulation scenarios. Participants believed patient care, patient safety and team working would all improve with further human factors training (4.4-4.6). and felt that NT skills learnt through simulation-based training should become an integral component of their training program. Conclusion Participants demonstrated improved understanding of non-technical performance, recognised its relevance to patient safety and expressed a desire for its integration in training.

To explore the effect of platelet-rich plasma on protein expression patterns of transforming growth factor-beta1 (TGF-β1) in cartilage following autologous osteochondral transplantation (AOT) in a rabbit knee cartilage defect model.Twelve New Zealand white rabbits received bilateral AOT. In each rabbit, one knee was randomized to receive an autologous platelet rich plasma (PRP) injection and the contralateral knee received saline injection. Rabbits were euthanized at 3, 6 and 12 wk post-operatively. Articular cartilage sections were stained with TGF-β1 antibody. Histological regions of interest (ROI) (left, right and center of the autologous grafts interfaces) were evaluated using MetaMorph. Percentage of chondrocytes positive for TGF-β1 was then assessed.Percentage of chondrocytes positive for TGF-β1 was higher in PRP treated knees for selected ROIs (left; P = 0.03, center; P = 0.05) compared to control and was also higher in the PRP group at each post-operative time point (P = 6.6 × 10(-4), 3.1 × 10(-4) and 7.3 × 10(-3) for 3, 6 and 12 wk, respectively). TGF-β1 expression was higher in chondrocytes of PRP-treated knees (36% ± 29% vs 15% ± 18%) (P = 1.8 × 10(-6)) overall for each post-operative time point and ROI.Articular cartilage of rabbits treated with AOT and PRP exhibit increased TGF-β1 expression compared to those treated with AOT and saline. Our findings suggest that adjunctive PRP may increase TGF-β1 expression, which may play a role in the chondrogenic effect of PRP in vivo.