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Vertebroplasty is a minimally invasive surgical procedure used to treat vertebral fractures, which conventionally involves injecting poly(methyl methacrylate) (PMMA) bone cement into the fractured vertebra. A common risk associated with vertebroplasty is cement leaking out of the vertebra during the injection, which may occur due to a lack of understanding of the complex flow behavior. Therefore, experiments to quantify the cement's flow properties are necessary for understanding and proper handling of the bone cement. In this study, we aimed to characterize the behavior of PMMA bone cement in its curing stages to obtain parameters that govern the flow behavior during injection. We used rotational and oscillatory rheometry for our measurements, as well as a custom-made injector setup that replicated a typical vertebroplasty setting. Our results showed that the complex viscoelastic behavior of bone cement is significantly affected by deformations and temperature. We found that the results from rotational tests, often used for characterizing the bone cement, are susceptible to measurement artifacts caused by wall slip and "ridge"-like formations in the test sample. We also found the Cox-Merz rule to be conditionally valid, which affects the use of oscillatory tests to obtain the shear-thinning characteristics of bone cement. Our findings identify important differences in the measured flow behavior of PMMA bone cement when assessed by different rheological methods, an understanding that is crucial for its risk-free usage in downstream medical applications.

Background: Patient-specific aiming devices (PSAD) may improve precision and accuracy of glenoid component positioning in total shoulder arthroplasty, especially in degenerative glenoids. The aim of this study was to compare precision and accuracy of guide wire positioning into different glenoid models using a PSAD versus a standard guide., Methods: Three experienced shoulder surgeons inserted 2.5 mm K-wires into polyurethane cast glenoid models of type Walch A, B and C (in total 180 models). Every surgeon placed guide wires into 10 glenoids of each type with a standard guide by DePuy Synthes in group (I) and with a PSAD in group (II). Deviation from planned version, inclination and entry point was measured, as well as investigation of a possible learning curve., Results: Maximal deviation in version in B- and C-glenoids in (I) was 20.3° versus 4.8° in (II) (p < 0.001) and in inclination was 20.0° in (I) versus 3.7° in (II) (p < 0.001). For B-glenoid, more than 50% of the guide wires in (I) had a version deviation between 11.9° and 20.3° compared to ≤ 2.2° in (II) (p < 0.001). 50% of B- and C-glenoids in (I) showed a median inclination deviation of 4.6° (0.0°-20.0°; p < 0.001) versus 1.8° (0.0°-4.0°; p < 0.001) in (II). Deviation from the entry point was always less than 5.0 mm when using PSAD compared to a maximum of 7.7 mm with the standard guide and was most pronounced in type C (p < 0.001)., Conclusion: PSAD enhance precision and accuracy of guide wire placement particularly for deformed B and C type glenoids compared to a standard guide in vitro. There was no learning curve for PSAD. However, findings of this study cannot be directly translated to the clinical reality and require further corroboration., (© 2024. The Author(s).)

The internal architecture of tissue-like constructs is fundamental to their structural and biological functions. Here, we introduce a simple and robust method to fabricate cryogels based on derivatized extracellular matrix (ECM) macromolecules with porosity arranged according to the typical Benninghoff zonal architecture of articular cartilage. To obtain this arcade-like structure, the technique used the growth of ice crystals from copper pins at cryogenic temperatures. The directional cryogel formation enabled the organized growth of ice crystals over a large distance (>4 mm). The compositional properties were achieved by forming double networks (DNs) of hyaluronic acid and collagen derivatives (MeHA and CollGTA, respectively), which also served to improve the mechanical properties of the otherwise weak collagen scaffolds. Compositionally biomimetic and more resilient MeHA-CollGTA DNs (Young's modulus ≈ 200 kilopascals) were therefore produced. The technique presented expands the fabrication methods available for providing ECM macromolecules with architectural elements mimicking cartilage complexity.

Background: Posttraumatic shoulder stiffness remains a problem after proximal humerus fracture (PHF) despite good healing rates. The aim of this pilot study was to determine whether the implant material and overlying soft tissue have an effect on shoulder range of motion (ROM) before and after implant removal (IR)., Methods: 16 patients (mean age 55.2 ± 15.3 (SD) years; 62.5% female) were included who underwent operative treatment with locking plates of either carbon fiber reinforced Polyetheretherketone (PEEK) (PEEKPower® humeral fracture plate, Arthrex, Naples, Florida, USA, n = 8) or titanium alloy (Ti) (Philos®, DePuy Synthes, Johnson & Johnson Medical, Raynham, Massachusetts, USA, n = 8) for PHF. All patients presented with a limited ROM and persistent pain in everyday life after the fracture had healed, whereupon IR was indicated. ROM before and after IR were compared as well as the Constant Score (CS) and the CS compared to the contralateral shoulder (%CS) 1 year after IR., Results: In group PEEK, elevation was 116.3° ± 19.2° pre- and 129.4° ± 23.7° post-IR (p = 0.027). External rotation was 35.0° ± 7.6° pre- and 50.6° ± 21.8° post-IR (p = 0.041). External rotation with the humerus abducted 90° was 38.8° ± 18.1° pre- and 52.5° ± 25.5° post-IR (p = 0.024). In group Ti, elevation was 110.0° ± 34.6° pre- and 133.8° ± 31.1° post-IR (p = 0.011). External rotation with the humerus at rest was 33.8° ± 23.1° pre- and 48.8° ± 18.7° post-IR (p = 0.048). External rotation with the humerus abducted 90° was 40.0° ± 31.6° pre- and 52.5° ± 22.5° post-IR (p = 0.011). Comparison of the two implant materials showed no significant difference. The overall CS was 90.3 ± 8.8, the %CS was 91.8% ± 14.7%., Conclusion: There was no significant difference in ROM, CS and %CS with respect to plate materials, although lower cell adhesion is reported for the hydrophobic PEEK. However, all patients showed improved functional outcomes after IR in this pilot study. In patients with shoulder stiffness following locked plating for PHF, implants should be removed and open arthrolysis should be performed, independently from the hardware material., Level of Evidence: II., (© 2022. The Author(s).)

Cortical bone and its microstructure are crucial for bone strength, especially at the long bone diaphysis. However, it is still not well-defined how imaging procedures can be used as predictive tools for mechanical bone properties. This study evaluated the capability of several high-resolution imaging techniques to capture cortical bone morphology and assessed the correlation with the bone's mechanical properties. The microstructural properties (cortical thickness [Ct.Th], porosity [Ct.Po], area [Ct.Ar]) of 11 female tibial diaphysis (40-90 years) were evaluated by dual-energy X-ray absorptiometry (DXA), high-resolution peripheral-quantitative-computed-tomography (HR-pQCT), micro-CT (μCT) and histomorphometry. Stiffness and maximal torque to failure were determined by mechanical testing. T-Scores determined by DXA ranged from 0.6 to -5.6 and a lower T-Score was associated with a decrease in Ct.Th (p ≤ 0.001) while the Ct.Po (p ≤ 0.007) increased, and this relationship was independent of the imaging method. With decreasing T-Score, histology showed an increase in Ct.Po from the endosteal to the periosteal side (p = 0.001) and an exponential increase in the ratio of osteons at rest to those after remodelling. However, compared to histomorphometry, HR-pQCT and μCT underestimated Ct.Po and Ct.Th. A lower T-Score was also associated with significantly reduced stiffness (p = 0.031) and maximal torque (p = 0.006). Improving the accuracy of Ct.Po and Ct.Th did not improve prediction of the mechanical properties, which was most closely related to geometry (Ct.Ar). The ex-vivo evaluation of mechanical properties correlated with all imaging modalities, with Ct.Th and Ct.Po highly correlated with the T-Score of the tibial diaphysis. Cortical microstructural changes were underestimated with the lower resolution of HR-pQCT and μCT compared to the histological 'gold standard'. The increased accuracy did not result in an improved prediction for local bone strength in this study, which however might be related to the limited number of specimens and thus needs to be evaluated in a larger collective., (© 2020 The Authors. Journal of Anatomy published by John Wiley & Sons Ltd on behalf of Anatomical Society.)

Cortical thickness determined at the humerus can serve as an easy and reliable screening tool to predict the local bone status when quantitative bone mineral density (BMD) measurements are not available. It can therefore serve as a rapid screening tool in fragility fractures to identify patients requiring further diagnostic or osteoporosis treatment., Introduction: Quantitative bone mineral density (BMD) of the humerus is difficult to determine but relevant for osteoporosis and fracture treatment. Dual-energy X-ray absorptiometry (DXA) of the femur and lumbar spine overestimates the humeral BMD and is not ubiquitously available. Therefore, this study evaluated whether the cortical bone thickness (CBT) of the humerus or DXA of the forearm is able to predict humeral BMD., Methods: Humeral BMD of 54 upper cadaver extremities (22 pairs, 10 single) (19-90 years) was determined by high-resolution peripheral-quantitative-computed-tomography (HR-pQCT) (volumetric BMD (vBMD)) and DXA (areal BMD (aBMD)) of the proximal humerus and distal forearm. Average and gauge cortical bone thickness (CBTavg/ CBTg) of the humeral diaphysis was determined from standard radiographs (XR) and computed-tomography (CT) and compared to the humeral BMD. Pearson (r) and intraclass-correlation-coefficients (ICC) were used to compare results and rater-reliability., Results: CBTavg from XR strongly correlated with the humeral BMD (r = 0.78 aBMD (DXA) and r = 0.64 vBMD (HR-pQCT) (p < 0.0001)). The CBTg revealed a weaker correlation (r = 0.57 aBMD and r = 0.43 vBMD). CBT derived from XR strongly correlated to those from the CT (r = 0.82-0.90) and showed an excellent intra- and inter-rater correlation (ICC 0.79-0.92). Distal forearm aBMD correlated well with the humeral aBMD (DXA) (r = 0.77) and paired specimens highly correlated to the contralateral side (humerus r = 0.89, radius r = 0.97)., Conclusions: The CBTavg can reliably be determined from standard radiographs and allows a good prediction of quantitative humeral bone mineral density (aBMD or vBMD) if measurements are not available. Furthermore, the distal forearm or the contralateral humerus can serve as a side to estimate the BMD if the ipsilateral side is impaired.

Hydroxyapatite (HA) coatings have become very popular in uncemented total hip arthroplasty (THA). Analysis of retrievals and tissue samples from an HA-coated femoral stem, which failed within 14 months after THA, provides exceptional insights into the failure mechanism, as well as the process of osteointegration of such an implant., Methods: Retrievals were photo-documented. Samples were examined by micro-computed tomography, X-ray diffraction (XRD) and embedded in polymethylmethacrylate for histology., Results: The coating had partially delaminated. The sandblasted surface of the stem was partially polished by the delaminated HA coating, indicating failure before revision. In the tissue samples, the HA coating was well integrated by newly formed bone trabeculae. No adverse biological reaction was observed. XRD analysis showed that residues of the HA coating were still present and could clearly be differentiated from the surrounding bone. Preferential orientation of the HA crystallites could be identified within the newly formed bone, representing a potential mechanical weakness induced either by physiologic strain or by the coating., Conclusion: current HA coatings, relatively thick and made of high crystallinity HA, may be prone to delamination, as also seen in our study. Recent efforts have aimed towards thinner (<1 μm) coatings with nanocrystalline HA structures that possibly relate to lower delamination risks. However, the question arises if HA coatings are beneficial since sandblasted non-coated stems offer similar results without the risk of delamination. XRD not only permits differentiation between the HA from the coating and the HA of the ongrown bone, it also provides new insights into the microstructure of this newly formed bone.

Objective: Titanium (Ti)- and Zirconia (ZrO 2 )-implants in mini pig maxillae were compared with respect to Ti/zirconium (Zr) release into the surrounding bone tissues, the resulting short term tissue responses and the potential toxicity., Methods: Ti/Zr release from Ti- and ZrO 2 -implants in mini pig maxillae was determined with inductively coupled plasma optical emission spectrometry (ICP-OES) and inductively coupled plasma mass spectrometry (ICP-MS). The spatial distribution of Ti and Zr in maxilla tissues near the implant surface was assessed with laser ablation-inductively coupled plasma-mass spectrometry (LA-ICP-MS). A histological analysis was performed to investigate the tissue responses after 12 weeks of implantation. The cytotoxicity and DNA damage of Ti particles and ZrO 2 particles were studied with XTT and Comet assay., Results: The mean Ti content in the bone adjacent to Ti-implants was 1.67 mg/kg-bone weight. The highest Ti content detected was 2.17 mg/kg-bone weight. The mean Zr content in the bone adjected to ZrO 2 -implants was 0.59 mg/kg-bone weight. The highest Zr content was 0.75 mg/kg-bone weight. The spatial distribution of the Ti and Zr in bone showed mainly a higher intensity of Ti and Zr close to the screw thread outer tip rather. Histological analysis indicated that near both implant-types signs of bone marrow fibrosis were present. EC 50 of commercially available ZrO 2 -nanoparticles (NPs, <100 nm) and ZrO 2 -microparticles (MPs, <5 μm) was 13.96 mg/ml and 80.99 mg/ml, respectively. ZrO 2 -NPs and ZrO 2 -MPs can induce DNA damage at 70 μg/ml and 810 μg/ml, respectively., Significance: After 12-weeks of implantation, increased concentrations of Ti and Zr can be detected in bone/tissues near Ti- and ZrO 2 -implants in mini pig maxillae. Ti content released from Ti-implants is two times higher than the Zr content released from ZrO 2 -implants. ZrO 2 -NPs showed lower cytotoxicity and DNA damage compared to results reported for Ti-NPs in human cells., (Copyright © 2020 The Academy of Dental Materials. Published by Elsevier Inc. All rights reserved.)

Orthopedic device-related infection (ODRI) is a potentially devastating complication arising from the colonization of the device with bacteria, such as Staphylococcus aureus. The aim of this study was to determine if intraoperative loading of a clinically approved calcium phosphate (CaP) coating with gentamicin can protect from ODRI in vivo. First, CaP-coated titanium aluminium niobium (TAN) discs were used to investigate the adsorption and release kinetics of gentamicin in vitro. Gentamicin loading and subsequent release from the coating were both rapid, with maximum loading occurring following one second of immersion, and >95% gentamicin released within 15 min in aqueous solution, respectively. Second, efficacy of the gentamicin-loaded CaP coating for preventing ODRI in vivo was investigated using a CaP-coated unicortical TAN screw implanted into the proximal tibia of skeletally mature female Wistar rats, following inoculation of the implant site with S. aureus. Gentamicin-loading prevented ODRI in 7/8 animals, whereas 9/9 of the non-gentamicin treated animals were infected after 7 days. In conclusion, gentamicin can be rapidly and simply loaded onto, and released from, CaP-based implant coatings, and this is an effective strategy for preventing peri-operative S. aureus-induced ODRI in vivo., Competing Interests: The authors have declared that no competing interests exist.

Infection associated with an implant is a complication feared in surgery, as it leads to loosening and dysfunction. This report documents an unexpected good bony integration of a porous tantalum shoulder prosthesis despite infection. A shoulder prosthesis with a porous tantalum glenoidal base plate was retrieved after 3 years of ongoing infection with Staphylococcus spp. Methyl-methacrylate embedded sections of the retrieved glenoidal component were analyzed by optical and scanning electron beam microscopy (SEM). Bone ongrowth and ingrowth were quantified. Bone had formed at the implant surface and within the open cell structure of the porous tantalum. The bone implant contact index was 32%. The bone ingrowth or relative bone area within the open structure was 8.2%, respectively 11.9% in the outer 50% of the thickness. Due to the section thickness, bone ongrowth could best be documented in SEM. Despite long-lasting and ongoing infection, the glenoidal base plate of the prosthesis showed good bony integration upon removal. The bone ingrowth into the porous tantalum was comparable to the values previously reported for the undersurface of retrieved proximal humerus resurfacing implants. Good integration of the implant however did not solve the problem of infection, and related morbidity. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 2924-2931, 2018., (© 2018 Wiley Periodicals, Inc.)

OBJECTIVE To evaluate and compare surface and cross-sectional structure as well as localized electrochemical corrosion and ion release for cast stainless steel (SS) tibia plateau leveling osteotomy (TPLO) plates retrieved from dogs with and without osteosarcoma (OSA) and to compare these findings with similar variables for forged SS TPLO plates retrieved from dogs. SAMPLE 47 TPLO plates explanted from 45 client-owned dogs (22 cast plates from dogs with OSA, 22 cast plates from dogs without OSA, and 3 forged plates from dogs without OSA). PROCEDURES Histologic evaluations of tissue samples collected from implant sites at the time of plate retrieval were performed to confirm implant site tumor status of each dog. Surfaces and metallographic cross sections of retrieved plates were examined, and the microcell technique was used to obtain local electrochemical corrosion and ion release measurements. RESULTS Findings indicated that all cast SS plates demonstrated high spatial variability of their electrochemical surface properties and inhomogeneous superficial and cross-sectional composition, compared with forged plates. Greater metal ion release was observed in cast plates than in forged plates and in cast plates from dogs with OSA than in cast or forged from dogs without OSA. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that accumulation of metal ions from implants could be a trigger for neoplastic transformation in neighboring cells. Metal ion release caused by corrosion of implants that do not comply with recommended standards of the American Society for Testing and Materials International or the International Organization for Standardization could potentially place patients at increased risk of tumor development.

The ability to engineer scaffolds that resemble the transition between tissues would be beneficial to improve repair of complex organs, but has yet to be achieved. In order to mimic tissue organization, such constructs should present continuous gradients of geometry, stiffness and biochemical composition. Although the introduction of rapid prototyping or additive manufacturing techniques allows deposition of heterogeneous layers and shape control, the creation of surface chemical gradients has not been explored on three-dimensional (3D) scaffolds obtained through fused deposition modelling technique. Thus, the goal of this study was to introduce a gradient functionalization method in which a poly(ε-caprolactone) surface was first aminolysed and subsequently covered with collagen via carbodiimide reaction. The 2D constructs were characterized for their amine and collagen contents, wettability, surface topography and biofunctionality. Finally, chemical gradients were created in 3D printed scaffolds with controlled geometry and porosity. The combination of additive manufacturing and surface modification is a viable tool for the fabrication of 3D constructs with controlled structural and chemical gradients. These constructs can be employed for mimicking continuous tissue gradients for interface tissue engineering., (Copyright © 2017 John Wiley & Sons, Ltd.)

After implantation of an internal fracture fixation device, blood contacts the surface, followed by protein adsorption, resulting in either soft-tissue adhesion or matrix adhesion and mineralization. Without protein adsorption and cell adhesion under the presence of micro-motion, fibrous capsule formation can occur, often surrounding a liquid filled void at the implant-tissue interface. Clinically, fibrous capsule formation is more prevalent with electropolished stainless steel (EPSS) plates than with current commercially pure titanium (cpTi) plates. We hypothesize that this is due to lack of micro-discontinuities on the standard EPSS plates. To test our hypothesis, four EPSS experimental surfaces with varying microtopographies were produced and characterized for morphology using the scanning electron microscope, quantitative roughness analysis using laser profilometry and chemical analysis using X-ray photoelectron spectroscopy. Clinically used EPSS (smooth) and cpTi (microrough) were included as controls. Six plates of each type were randomly implanted, one on both the left and right intact tibia of 18 white New Zealand rabbits for 12 weeks, to allow for a surface interface study. The results demonstrate that the micro-discontinuities on the upper surface of internal steel fixation plates reduced the presence of liquid filled voids within soft-tissue capsules. The micro-discontinuities on the plate under-surface increased bony integration without the presence of fibrous tissue interface. These results support the hypothesis that the fibrous capsule and the liquid filled void formation occurs mainly due to lack of micro-discontinuities on the polished smooth steel plates and that bony integration is increased to surfaces with higher amounts of micro-discontinuities. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 705-715, 2018., (© 2017 Wiley Periodicals, Inc.)

Fractures of the proximal humerus are highly related to age and osteoporotic bone remodeling. Previous studies have highlighted the cortex as a major side of the bone loss, but the microstructural changes of the humerus have not been evaluated entirely. Sixty-four (n = 64) humeri of a representative collective (18-100 years) were scanned with high-resolution peripheral quantitative computed tomography (82 µm). Bone mineral density (BMD), trabecular bone volume fraction (Tb.BV/TV), cortical thickness (Ct.Th), and cortical porosity (Ct.Po) were determined with respect to four age groups. The BMD (r = -0.42), Ct.Th (r = 0.57), and Tb.BV/TV (r = 0.68) showed an age group-related decrease, while the Ct.Po increased (r = -0.55). The oldest group (80-100 years) revealed an extensively higher Ct.Po of +87% compared to the youngest group (18-44 years), while the Ct.Th and Tb.BV/TV were significantly lower by -35 and -49% (p < 0.05). The main cortical bone loss occurred after 65 years with the Ct.Th (-34%) and Tb.BV/TV (-40%) being clearly lower and the Ct.Po (+93%) clearly higher compared to the youngest group. In summary, osteoporosis leads to an age-related higher Ct.Po and reduced Ct.Th at the humeral cortex of the surgical neck. The bone loss of the cortex predominantly occurs around the age of 65 years and is very likely to reduce the mechanical strength and highly increases the fracture risk.

Fabrication of composite scaffolds using stereolithography (SLA) for bone tissue engineering has shown great promises. However, in order to trigger effective bone formation and implant integration, exogenous growth factors are commonly combined to scaffold materials. In this study, we fabricated biodegradable composite scaffolds using SLA and endowed them with osteopromotive properties in the absence of biologics. First we prepared photo-crosslinkable poly(trimethylene carbonate) (PTMC) resins containing 20 and 40wt% of hydroxyapatite (HA) nanoparticles and fabricated scaffolds with controlled macro-architecture. Then, we conducted experiments to investigate how the incorporation of HA in photo-crosslinked PTMC matrices improved human bone marrow stem cells osteogenic differentiation in vitro and kinetic of bone healing in vivo. We observed that bone regeneration was significantly improved using composite scaffolds containing as low as 20wt% of HA, along with difference in terms of osteogenesis and degree of implant osseointegration. Further investigations revealed that SLA process was responsible for the formation of a rich microscale layer of HA corralling scaffolds. To summarize, this work is of substantial importance as it shows how the fabrication of hierarchical biomaterials via surface-enrichment of functional HA nanoparticles in composite polymer stereolithographic structures could impact in vitro and in vivo osteogenesis., Statement of Significance: This study reports for the first time the enhance osteopromotion of composite biomaterials, with controlled macro-architecture and microscale distribution of hydroxyapatite particles, manufactured by stereolithography. In this process, the hydroxyapatite particles are not only embedded into an erodible polymer matrix, as reported so far in the literature, but concentrated at the surface of the structures. This leads to robust in vivo bone formation at low concentration of hydroxyapatite. The reported 3D self-corralling composite architecture provides significant opportunities to develop functional biomaterials for bone repair and tissue engineering., (Copyright © 2017. Published by Elsevier Ltd.)

Roughness is one of the key parameters for successful osseointegration of dental implants. The understanding of how roughness affects cell response is thus crucial to improve implant performance. Surface gradients, which allow rapid and systematic investigations of cell-surface interactions, have the potential to facilitate this task. In this study, a novel method aiming to produce roughness gradients at the surface of zirconia using hydrofluoric acid etching was implemented. The topography was exhaustively characterized at the microscale and nanoscale by white light interferometry and atomic force microscopy, including the analysis of amplitude, spatial, hybrid, functional, and fractal parameters. A rapid screening of the influence of roughness on human mesenchymal stem cell morphology was conducted and potential correlations between roughness parameters and cell morphology were investigated. The roughness gradient induced significant changes in cell area (p < 0.001), aspect ratio (p = 0.01), and solidity (p = 0.026). Nanoroughness parameters were linearly correlated to cell solidity (p < 0.005), while microroughness parameters appeared nonlinearly correlated to cell area, highlighting the importance of multiscale optimization of implant topography to induce the desired cell response. The gradient method proposed here drastically reduces the efforts and resources necessary to study cell-surface interactions and provides results directly transferable to industry. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 104A: 2502-2514, 2016., (© 2016 Wiley Periodicals, Inc.)

Introduction: Primary press fit and secondary osteointegration is a precondition for component anchoring in articular surface replacements, also in the case of proximal interphalangeal (PIP) joint. Nevertheless, many existing prostheses for the PIP joint have failed to show sufficient osteointegration. CapFlex-PIP(©) implant is a modular metal-polyethylene surface replacement for the PIP joint consisting of a proximal and distal component each having a titanium pore backside, which allows secondary osteointegration at the bone-implant interface. To evaluate osseous integration of this implant, we report a histological analysis of an explantation of a CapFlex-PIP(©) finger implant., Case Presentation: We present a case of a removed CapFlex-PIP(©) implant due to a soft tissue complication in an 84-year-old woman. The patient received bisphosphonate medication as treatment for osteoporosis. For the histological analysis, the bone-implant contact (BIC) was measured on all stained sections using a Zeiss Axioplan microscope. The summated BIC was 40.7 % for the proximal component and 46.5 % for the distal component of the implant. Histology showed that the implant was in direct contact with the bone at various locations, with no signs of wear or degradation., Conclusions: This case demonstrates successful osteointegration of the CapFlex-PIP(©) implant. Both components of the investigated implant show osseous integration to an extent which is comparable to that of other load-bearing and articulating implants at different locations in the human body.

Articular cartilage displays very little self-healing capabilities, generating a major clinical need. Here, we introduce a thermoresponsive hyaluronan hydrogel for cartilage repair obtained by covalently grafting poly(N-isopropylacrylamide) to hyaluronan, to give a brush co-polymer HpN. The gel is fluid at room temperature and becomes gel at body temperature. In this pilot study HpN safety and repair response were evaluated in an osteochondral defect model in rabbit. Follow-up was of 1 week and 12 weeks and the empty defect served as a control, for a total of four experimental groups. At 12 weeks the defect sites were evaluated macroscopically and histologically. Local lymph nodes, spleen, liver, and kidneys were analyzed for histopathological evaluation. HpN could be easily injected and remained into the defect throughout the study. The macroscopic score was statistically superior for HpN versus empty. Histological score gave opposite trend but not statistically significant. A slight tissue reaction was observed around HpN, however, vascularization and subchondral bone formation were not impeded. An upper proteoglycans rich fibro-cartilaginous tissue with fairly good continuity and lateral integration into the existing articular cartilage was observed in all cases. No signs of local or systemic acute or subacute toxicity were observed. In conclusion, HpN is easily injectable, remains into an osteochondral defect within a moving synovial joint, is biocompatible and does not interfere with the intrinsic healing response of osteochondral defects in a rabbit model. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 104A: 1469-1478, 2016., (© 2016 Wiley Periodicals, Inc.)

Pericyte recruitment is essential for the stability of newly formed vessels. It was also suggested that pericytes represent common ancestor cells giving rise to mesenchymal stem cells (MSCs) in the adult. Here, we systematically investigated pericytes and MSCs from different human tissues in terms of their angiogenic and multilineage differentiation potential in vitro in order to assess the suitability of the different cell types for the regeneration of vascularised tissues. Magnetic-activated cell sorting (MACS®) was used to enrich CD34-CD146+ pericytes from adipose tissue (AT) and bone marrow (BM). The multilineage potential of pericytes was assessed by testing their capability to differentiate towards osteogenic, adipogenic and chondrogenic lineage in vitro. Pericytes and endothelial cells were co-seeded on Matrigel™ and the formation of tube-like structures was examined to study the angiogenic potential of pericytes. MSCs from AT and BM were used as controls. CD34-CD146+ cells were successfully enriched from AT and BM. Only BM-derived cells exhibited trilineage differentiation potential. AT-derived cells displayed poor chondrogenic differentiation upon stimulation with transforming growth factor-β1. Interestingly, osteogenic differentiation was more efficient in AT-PC and BM-PC compared to the respective full MSC population. Matrigel™ assays revealed that pericytes from all tissues integrated into tube-like structures. We show that MACS®-enriched pericytes from BM and AT have the potential to regenerate tissues of different mesenchymal lineages and support neovascularisation. MACS® represents a simple enrichment strategy of cells, which is of particular interest for clinical application. Finally, our results suggest that the regenerative potential of pericytes depends on their tissue origin, which is an important consideration for future studies.

Background/objective: Advanced synthetic biomaterials that are able to reduce or replace the need for autologous bone transplantation are still a major clinical need in orthopaedics, dentistry, and trauma. Key requirements for improved bone substitutes are optimal handling properties, ability to fill defects of irregular shape, and capacity for delivering osteoinductive stimuli., Materials and Methods: In this study, we targeted these requirements by preparing a new composite of β-tricalcium phosphate (TCP) and a thermoresponsive hyaluronan (HA) hydrogel. Dissolution properties of the composite as a function of the particle size and polymeric phase molecular weight and concentration were analysed to identify the best compositions., Results: Owing to its amphiphilic character, the composite was able to provide controlled release of both recombinant human bone morphogenetic protein-2 and dexamethasone, selected as models for a biologic and a small hydrophobic molecule, respectively., Conclusion: The TCP-thermoresponsive HA hydrogel composite developed in this work can be used for preparing synthetic bone substitutes in the form of injectable or mouldable pastes and can be supplemented with small hydrophobic molecules or biologics for improved osteoinductivity.

Osteoporosis is a systemic disorder predominantly affecting postmenopausal women but also men at an advanced age. Both genders may suffer from low-energy fractures of, for example, the proximal humerus when reduction of the bone stock or/and quality has occurred.The aim of the current study was to compare the amount of bone in typical fracture zones of the proximal humerus in osteoporotic and non-osteoporotic individuals.The amount of bone in the proximal humerus was determined histomorphometrically in frontal plane sections. The donor bones were allocated to normal and osteoporotic groups using the T-score from distal radius DXA measurements of the same extremities. The T-score evaluation was done according to WHO criteria. Regional thickness of the subchondral plate and the metaphyseal cortical bone were measured using interactive image analysis.At all measured locations the amount of cancellous bone was significantly lower in individuals from the osteoporotic group compared to the non-osteoporotic one. The osteoporotic group showed more significant differences between regions of the same bone than the non-osteoporotic group. In both groups the subchondral cancellous bone and the subchondral plate were least affected by bone loss. In contrast, the medial metaphyseal region in the osteoporotic group exhibited higher bone loss in comparison to the lateral side.This observation may explain prevailing fracture patterns, which frequently involve compression fractures and certainly has an influence on the stability of implants placed in this medial region. It should be considered when planning the anchoring of osteosynthesis materials in osteoporotic patients with fractures of the proximal humerus.

Background: Conflicting reports in the literature have raised the question whether radial extracorporeal shock wave therapy (rESWT) devices and vibrating massage devices have similar energy signatures and, hence, cause similar bioeffects in treated tissues., Methods and Findings: We used laser fiber optic probe hydrophone (FOPH) measurements, high-speed imaging and x-ray film analysis to compare fundamental elements of the energy signatures of two rESWT devices (Swiss DolorClast; Electro Medical Systems, Nyon, Switzerland; D-Actor 200; Storz Medical, Tägerwillen, Switzerland) and a vibrating massage device (Vibracare; G5/General Physiotherapy, Inc., Earth City, MO, USA). To assert potential bioeffects of these treatment modalities we investigated the influence of rESWT and vibrating massage devices on locomotion ability of Caenorhabditis elegans (C. elegans) worms., Results: FOPH measurements demonstrated that both rESWT devices generated acoustic waves with comparable pressure and energy flux density. Furthermore, both rESWT devices generated cavitation as evidenced by high-speed imaging and caused mechanical damage on the surface of x-ray film. The vibrating massage device did not show any of these characteristics. Moreover, locomotion ability of C. elegans was statistically significantly impaired after exposure to radial extracorporeal shock waves but was unaffected after exposure of worms to the vibrating massage device., Conclusions: The results of the present study indicate that both energy signature and bioeffects of rESWT devices are fundamentally different from those of vibrating massage devices., Clinical Relevance: Prior ESWT studies have shown that tissues treated with sufficient quantities of acoustic sound waves undergo cavitation build-up, mechanotransduction, and ultimately, a biological alteration that "kick-starts" the healing response. Due to their different treatment indications and contra-indications rESWT devices cannot be equated to vibrating massage devices and should be used with due caution in clinical practice.

Cementless-surface-replacement-arthroplasty (CSRA) of the shoulder aims for functional joint restoration with minimal bone loss. Good clinical results have been reported, but due to the radiopaque metal shell no data is available on the structure, osseous integration, and bone stock under the implant. 14 hemi-CSRAs (4 manufacturers) with two geometries (crown [n = 7]/ stem [n = 7] fixation) were retrieved from patients undergoing revision due to glenoidal erosion. Histological sections cutting through the implant centre and bone were analysed. Quantitative histomorphometry evaluated the bone-implant-contact and compared the bone-area to native humeral retrievals (n = 7). The bone-implant-interface was further assessed by scanning-electron-microscopy (SEM) and energy-dispersive-x-ray (EDX). Qualitative histology revealed a reduced and inhomogeneous bone stock. Obvious signs of stress shielding were observed with bone predominantly visible at the stem and implant rim. Quantitative histomorphometry confirmed the significantly reduced bone-area (9.2 ± 3.9% [crown 9.9 ± 4.3%, stem 8.6 ± 3.6%]) compared to native humeri (21.2 ± 9.1%; p < 0.05). Bone-implant-contact was 20.5 ± 5.8% (crown 21.8 ± 6.2%, stem 19.2 ± 5.6%) which was confirmed by SEM and EDX. Altogether, CRSA shows satisfactory bone ingrowth at the interface suggesting sufficient primary stability to allow osseous integration. However, clear signs of stress shielding with an inhomogeneous and reduced bone stock were observed. The impact on the long-term-results is unclear requiring further investigation., (© 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

Background Context: The human iliolumbar ligament connects the transverse process of L5 to the iliac crest and contributes to lumbosacral stability and has been associated with low back pain. However, different opinions exist regarding the functional relevance of the ligament., Purpose: In the present study, we analyze the regional molecular composition of the ligament extracellular matrix., Study Design: Special attention is given to the attachment sites, to determine whether the ligament is subjected to a certain mechanical environment., Methods: Iliolumbar ligament samples, extending from one enthesis to the other, were removed from 11 cadavers and fixed in methanol. Cryosections were immunolabeled with a panel of antibodies directed against collagens, glycosaminoglycans, proteoglycans, matrix proteins, and neurofilament., Results: The mid-substance of the ligament labeled for all the molecules normally found in dense fibrous connective tissue including types I, III, and VI collagen, versican, dermatan -, chondroitin 4 -, and keratan sulfate. However, both entheses were fibrocartilaginous and labeled for type II collagen, aggrecan, and chondroitin 6- sulfate. A common feature was fat between the fiber bundles near the entheses. Occasionally this fat contained nerve fibers., Conclusions: The existence of fibrocartilaginous entheses suggests that the insertion sites of the ligament are subject to both tensile and compressive loading-probably because of insertional angle changes between ligament and bone during loading. Our findings support the suggestion that the iliolumbar ligament might play an important role in the stabilization of the lumbosacral junction., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Rotator cuff tears are of increasing clinical impact in the physically active elderly patients. Recent research revealed, that a high percentage of these patients present with significant loss of bone mineral density at the insertion site of the rotator cuff, thereby compromising suture anchorage for operative repair. We therefore hypothesized that augmentation of suture anchors improves biomechanical properties in low bone quality., Methods: 28 osteoporotic humeral heads were included in this biomechanical study. Bone quality at the anchor insertion sites (group 1: posterior-medial; group 2: anterior-lateral) within the greater tuberosity was analyzed using HR-pQCT (voxel size: 82μm). Anchor positions of identical quality were then randomized to either conventional screw anchorage or polymethylmethacrylat augmented screw anchorage. All anchors were cyclically ramp-loaded until pullout., Findings: Pullout strength accounted for 226N in group I for conventional anchorage and for 332N in augmented technique. In group 2 (anterior-lateral) the pullout strength was 209N (conventional) and 304N (augmented). Pull-out strength of augmented screw anchors was significantly higher in both groups (p<0.05)., Interpretation: Compared to conventional insertion techniques, the cement augmentation technique increases the pullout strength of suture anchors in low bone quality significantly. Cement augmentation could therefore be a helpful tool for improved suture anchor stability, especially in locations of low bone quality., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Cementless surface replacement arthroplasty (CSRA) of the shoulder was designed to preserve the individual anatomy and humeral bone stock. A matter of concern in resurfacing implants remains the stress shielding and bone remodeling processes. The bone remodeling processes of two different CSRA fixation designs, conical-crown (Epoca RH) and central-stem (Copeland), were studied by three-dimensional (3-D) finite element analysis (FEA) as well as evaluation of contact radiographs from human CSRA retrievals. FEA included one native humerus model with a normal and one with a reduced bone stock quality. Compressive strains were evaluated before and after virtual CSRA implantation and the results were then compared to the bone remodeling and stress-shielding pattern of eight human CSRA retrievals (Epoca RH n=4 and Copeland n=4). FEA revealed for both bone stock models increased compressive strains at the stem and outer implant rim for both CSRA designs indicating an increased bone formation at those locations. Unloading of the bone was seen for both designs under the central implant shell (conical-crown 50-85%, central-stem 31-93%) indicating high bone resorption. Those effects appeared more pronounced for the reduced than for the normal bone stock model. The assumptions of the FEA were confirmed in the CSRA retrieval analysis which showed bone apposition at the outer implant rim and stems with highly reduced bone stock below the central implant shell. Overall, clear signs of stress shielding were observed for both CSRAs designs in the in vitro FEA and human retrieval analysis. Especially in the central part of both implant designs the bone stock was highly resorbed. The impact of these bone remodeling processes on the clinical outcome as well as long-term stability requires further evaluation., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: In the management of proximal humeral fractures intramedullary implants with bent and straight shape of the proximal part of nail are available. Based on data from previous studies on bone distribution in the humeral head, we hypothesized, that higher densities might exist in the bone stock surrounding straight nails in comparison to their angulated counterparts. With a known positive correlation between bone density and mechanical stability, this could indicate potentially higher rigidity of osteosyntheses done with straight implants., Methods: We performed high resolution peripheral quantitative computed tomographies of the potential straight and bent implant bearing regions of 27 cadaveric proximal humeri. The acquired data were analyzed for differences between straight and bent Volumes of Interest as well as intra- and interindividual bone stock distribution., Results: For both straight and bent volumes of interest a considerably declining bone mineral density was found in craniocaudal direction. Mean densities of bent volumes were significantly lower in comparison to their corresponding straight counterparts (p < 0.01) Intra-individual comparison yielded high bivariate correlations of the corresponding Volumes of Interest of the right and the left side (p < 0.01)., Conclusions: Based on the volumetric data a statistically relevant biomechanical superiority of straight shaped implants can be assumed. Since we found a rapid decrease of bone density in cranio-caudal direction, intramedullary implants should be anchored as proximally in the subcortical area as possible to minimize the risk of displacement or cutout. The high correlation between the Volumes of Interest of the corresponding right and left sides could aid in preoperative planning when considering an intra- or extramedullary approach.

Purpose: This study aimed to propose a technique to quantify dynamic hip screw (DHS®) migration on serial anteroposterior (AP) radiographs by accounting for femoral rotation and flexion., Methods: Femoral rotation and flexion were estimated using radiographic projections of the DHS® plate thickness and length, respectively. The method accuracy was evaluated using a synthetic femur fixed with a DHS® and positioned at pre-defined rotation and flexion settings. Standardised measurements of DHS® migration were trigonometrically adjusted for femoral rotation and flexion, and compared with unadjusted estimates in 34 patients., Results: The mean difference between the estimated and true femoral rotation and flexion values was 1.3° (95% CI 0.9-1.7°) and -3.0° (95% CI - 4.2° to -1.9°), respectively. Adjusted measurements of DHS® migration were significantly larger than unadjusted measurements (p = 0.045)., Conclusion: The presented method allows quantification of DHS® migration with adequate bias correction due to femoral rotation and flexion.

Two different imaging techniques used to determine bone tissue response to dental implants were compared. Dental implants were implanted into the maxillae of 18 pigs, which were sacrificed after 4, 8 and 12 weeks. Implants with surrounding bone tissue were retrieved for methyl methacrylate histology and contact radiography. On identical sections peri-implant bone density and bone implant contact (BIC) ratio were assessed with two different imaging methods. Evaluation of Giemsa eosin stained and contact radiographed sections showed direct osseous integration for all implants and both methods showed a strong correlation with correlation coefficient r = 0.930 (P < 0.0001) for peri-implant bone density and r = 0.817 (P < 0.0001) for bone implant contact ratio. While the two imaging methods showed moderate differences for peri-implant bone density there were significant differences between the BIC values determined. In general, contact radiography tends to underestimate BIC for approximately 4.5 % (P = 0.00003).

Purpose: Rotator cuff (RC) repair-especially in the elderly population-is problematic since the patients suffer to a high extent from bone mineral density loss at the reattachment site. Therefore, the study was primarily driven by the question whether it is possible to reach more or qualitatively better cancellous bone and thus a more stable postoperative result if anchors with greater length are used for RC repair and/or the conventional anchors are screwed deeper into the bone. In anatomical terms, the question is raised whether cancellous bone is of better quality close to or far off the RC enthesis., Methods: Axial HRqCT scans (X-tremeCT, Scanco Medical) of 36 human cadaveric humeral heads (75 ± 11 years) were performed to determine the ratio of bone volume to total volume (BV/TV), trabecular thickness (Trab Th), number of trabecles (Trab N), trabecular separation (Trab Sp) as well as non-metric indices such as connectivity density (Conn Dens) and structure model index (SMI). Within the greater tuberosity (GT), 6 volumes of interest (VOI) (A1, B1, C1, A2, B2, C2), in the lesser tuberosity (LT) 2 VOIs (D1, D2) and one control VOI in the subchondral bone were set. The analyzed bone cylinder of each VOI was divided into a superficial and a deep portion., Results: The parameters BV/TV, Trab N, Trab Th and Conn Dens in all volumes of the GT and LT revealed higher values in the superficial portion reaching different levels of significance (p < 0.001/<0.05). The only parameter presenting a higher value in the deep portion was Trab Sp, but this was the case for all GT and LT regions. Interestingly, the difference between the superficial and deep portion reached significance for the non-metric parameter SMI in no volume of the GT/LT, although the higher values were found superficially., Conclusions: Our data show that cancellous bone presents with decreasing bone quality when analyzing increasingly deeper portions of the bone cylinders of the GT and LT starting at the articular surface. This information seems to be crucial for shoulder surgeons, especially when treating elderly patients. Our results clearly prove that screwing in anchors to a deeper extent will not improve stability, since the deeper bone stock is of worse quality.

Background: Age-dependent trabecular changes of the humeral head might weaken the fixation of suture anchors used for rotator cuff (RC) repair. This might lead to suture anchor loosening and thus compromise the integrity of the repair. The aim of this study was to analyze whether the trabecular microstructure within the RC footprint is influenced by age, gender or handedness., Methods: Axial HR-pQCT scans (Scanco Medical) of 64 freshly frozen cadaveric human humeral head specimens (age 72.3 ± 17.4 years) were analyzed to determine the bone volume-to-total volume ratio (BV/TV), trabecular thickness (Trab Th), trabecular number (Trab N) and connectivity density (Conn Dens). Within the RC footprint, 2 volumes of interest (VOI), posteromedial (PM) and anterolateral (AL) and one control VOI in the subarticular bone (SC) were set., Results: The highest BV/TV was found in SC: 0.22 ± 0.06% vs. PM: 0.04 ± 0.05% vs. AL: 0.02 ± 0.04%; p < 0.05. Trab Th accounted for 0.26 ± 0.05 μm in SC, 0.23 ± 0.09 μm in AL and 0.21 ± 0.05 μm in PM. In parallel, Trab N and Conn Dens were found to be the highest in SC. Gender analysis yielded higher values for BV/TV, Trab Th, Trab N and Conn Dens for PM in males compared to females (p < 0.05). There were no significant findings when comparing both sides. We furthermore found a strong inverse correlation between age and BV/TV, which was more pronounced in the female specimens (r = -0.72, p < 0.00001)., Conclusions: The presented microarchitectural data allow for future subtle biomechanical testing comprising knowledge on age- and sex-related changes of the tuberosities of the humeral head. Furthermore, the insights on the trabecular structure of the humeral head of the elderly may lead to the development of new fixation materials in bone with inferior bone quality.

Introduction: Thermoreversible hydrogels have potential in spine research as they provide easy injectability and mild gelling mechanism (by physical cross-link). The purpose of this study was to assess the potential of thermoreversible hyaluronan-based hydrogels (HA-pNIPAM) (pNIPAM Mn = 10, 20, 35 × 10(3) g mol(-1)) as nucleus pulposus cells (NPC) carrier., Materials and Methods: Cytocompatibility (WST-1 assay), viability (trypan blue), morphology (toluidine blue), sulphated glycosaminoglycan synthesis (DMMB assay) and gene expression profile (real-time PCR) of bovine NPC cultured in HA-pNIPAM were followed for 1 week and compared to alginate gel bead cultures. The injectability and cell survival in a whole disc organ culture model were assessed up to day 7., Results: All HA, HA-pNIPAM and their degradation products were cytocompatible to NPC. HA-pNIPAM hydrogels with no volume change upon gelling maintained NPC viability and characteristic rounded morphology. Glycosaminoglycan synthesis was similar in HA-pNIPAM and alginate gels. Following NPC expansion, both gels induced re-differentiation toward the NPC phenotype. Significant differences between the two gels were found for COLI, COLII, HAS1, HAS2 and ADAMTS4 but not for MMPs and TIMPs. Higher expression of hyaluronan synthases (HAS1, HAS2) and lower expression of COLI and COLII mRNA were noted in cells cultured in HA-pNIPAM (pNIPAM = 20 × 10(3)g mol(-1)). NPC suspension in HA-pNIPAM was injectable through a 22-G needle without loss of cell viability. Ex vivo, NPC viability was maintained in HA-pNIPAM for 1 week., Conclusion: A HA-pNIPAM composition suitable for nucleus pulposus repair that provides an injectable carrier for NPC, maintains their phenotype and promotes extracellular matrix generation was identified.

Purpose: The nature and the distribution of fibrocartilage at the human glenoid labrum are unclear, and a better understanding may help to restore its function in open and arthroscopic Bankart repair. Aim of this study was to describe the fibrocartilage extent within the labrum at clinically relevant sites of the glenoid in order to relate the molecular composition of the labrum to its mechanical environment., Methods: Twelve fresh frozen human cadaveric shoulders (mean age 38 years) were obtained, and sections perpendicular to the glenoid rim at the 12, 2, 3, 4, 6 and 9 o' clock position were labelled with antibodies against collagen I and II, aggrecan and link protein., Results: A fibrocartilaginous transition zone with a characteristic collagen fibre orientation was found in 81% of cases, evenly distributed (83-92%) around the glenoid rim. The percentage of labrum cross-sectional area comprised of fibrocartilage averaged 28% and ranged from 26% at 12 o'clock on the glenoid clock face to 30% at 3 o'clock. The highest amount of fibrocartilage (82%) was found in the region neighbouring the hyaline articular cartilage. In the region beyond the bony edge of the glenoid, fibrocartilage cross-sectional area did not exceed 12-17%., Conclusion: Fibrocartilage is present at all examined positions around the glenoid rim and constitutes up to 1/3 of the cross-sectional area of the labrum. In turn, the percentage of fibrocartilage in different regions of its cross-section varies considerably. The findings suggest that the penetration of fibrocartilaginous tissue may be reduced by avoiding the highly fibrocartilage transition zone during restoration of labral detachment.

Objectives: To compare the bone tissue response to surface-modified zirconia (ZrO2 ) and titanium implants., Methods: Cylindrical low-pressure injection moulded zirconia (ZrO2 ) implants were produced with an acid-etched surface. Titanium implants with identical shape, sandblasted and acid-etched surface (SLA) served as controls. Eighteen adult miniature pigs received both implant types in the maxilla 6 months after extraction of the canines and incisors. The animals were euthanized after 4, 8 and 12 weeks and 16 zirconia and 18 titanium implants with the surrounding tissue were retrieved, embedded in methylmethacrylate and stained with Giemsa-Eosin. The stained sections were digitized and histomorphometrically analysed with regard to peri-implant bone density (bone volume/total volume) and bone-implant contact (BIC) ratio. Statistical analysis was performed using Mann-Whitney' U-test., Results: Histomorphometrical analysis showed direct osseous integration for both materials. ZrO2 implants revealed mean peri-implant bone density values of 60.4% (SD ± 9.9) at 4 weeks, 65.4% (SD ± 13.8) at 8 weeks, and 63.3% (SD ± 21.5) at 12 weeks after implantation, whereas Ti-SLA implants demonstrated mean values of 61.1% (SD ± 6.2), 63.6% (SD ± 6.8) and 68.2% (SD ± 5.8) at corresponding time intervals. Concerning the BIC ratio, the mean values for ZrO(2) ranged between 67.1% (SD ± 21.1) and 70% (SD ± 14.5) and for Ti-SLA between 64.7% (SD ± 9.4) and 83.7% (SD ± 10.3). For the two parameters investigated, no significant differences between both types of implants could be detected at any time point., Conclusion: The results indicate that there was no difference in osseointegration between ZrO2 implants and Ti-SLA controls regarding peri-implant bone density and BIC ratio., (© 2011 John Wiley & Sons A/S.)

Study Design: Retrospective clinical study in patients with dorso-ventral thoraco-lumbar spondylodesis., Objective: To investigate whether the ratio between graft cross sectional area and the surface area of the adjacent endplates has any effect on the midterm stability of the spondylodesis. Dorso-ventral spondylodesis in the region of the thoraco-lumbar spine is one of the most frequent operations in orthopaedic surgery. Anterior stabilization with autologous iliac crest graft currently is a standard approach in many hospitals. Although numerous recommendations are given how to perform this technique, no clinical advice is available with regard to minimum graft size., Methods: Sixty-four-slice CT-scans were obtained from 82 patients 4-12 months after posterior spondylodesis with anterior implantation of iliac crest graft and stabilization with an internal fixator. The scans were analyzed using image analysis software. First, the cross sectional area of the graft was calculated and then the surface area of the adjacent endplates. The ratio between graft cross sectional area and endplate surface area was then calculated from these two values. The grafts were then evaluated in sagittal reconstruction for signs of fracture., Results: The probability for graft fracture in autologous tricortical grafts was >0.1% (p < 0.001) if the graft cross sectional area exceeded 23.9% of the surface area of the adjacent endplates. Patients with lower ratio values had a higher fracture risk and below a value of 10% all grafts fractured., Conclusion: The relationship between graft cross sectional area and adjacent endplate area has an important effect on graft midterm stability in ventral spondylodesis of the thoraco-lumbar spine. In our opinion, the risk of graft fractures in dorso-ventral spondylodesis can be reduced by implantation of an appropriately sized graft without any additional procedures or instrumentation.

Background: In cases of distal radius fractures information about the regional distribution of cancellous bone is essential for adequate fixation of osteosynthesis material., Materials and Methods: Using quantitative computed tomography (qCT) measurements 12 distal radii were divided into 2 groups (good and bad bone quality). High-resolution CT scans were obtained at 13 locations (1-40 mm distant from radial styloid processes). The resulting cross-sections were divided into 4 quadrants and the cancellous bone density was assessed in each of them., Results: In both groups regional cancellous bone density was highest immediately beneath the joint surface and decreased towards the metaphyseal region. Comparing the radial with the ulnar quadrants significant differences were found between distances of 4 mm and 12 mm from the joint surface in both groups. The comparison of the palmar and the dorsal quadrants resulted in an almost identical cancellous bone distribution., Conclusion: In osteoporotic distal radii cancellous bone density decrease occurs homogeneously in all regions and is least pronounced beneath the joint surface. Comparing the regional cancellous bone density (radial versus ulnar and palmar versus dorsal) significant differences were mainly found near the joint surface in both groups.

In tissue engineering, a variety of methods are commonly used to evaluate survival of cells inside tissues or three-dimensional (3D) carriers. Among these methods confocal laser scanning microscopy opened accessibility of 3D tissue using live cell imaging into the tissue or 3D scaffolds. However, although this technique is ideally applied to 3D tissue or scaffolds with thickness up to several millimetres, this application is surprisingly rare and scans are often done on slices with thickness <20 μm. Here, we present novel protocols for the staining of 3D tissue (e.g. intervertebral disc tissue) and scaffolds, such as fibrin gels or alginate beads.

Background: Spinal injuries are common and a standard procedure for the stabilisation of spinal injuries is ventral spondylodesis with an autograft from the iliac crest. Because of the high incidence of harvesting complications there is a need to search for alternative materials. The aim of our study was to evaluate graft integration in the lumbar spine of bovine cancellous bone compared to autologous iliac crest material., Material and Methods: Two groups of eight female adult sheep (median age 3 years, range 2.4-3.8 years) received surgical treatment in the form of anterior monosegmental spondylodesis. The spondylodesis was performed in all animals in the motion segment L3/4 through a lateral approach with the animals lying on their right sides. To produce serial sections, the explanted vertebral segments were implanted in methyl methacrylate. On one side the histological preparation was examined qualitatively and in addition we analysed the quantity of the bone structure with special software., Results: The bone structure in both groups did not differ significantly and demonstrated integration of the grafts in the adjacent vertebral bodies. Fractures and lysis occurred in the region of the intervertebral disc and were more frequent in the group with the bovine graft., Conclusion: The bony integration of the grafts of both groups was not significantly different and showed good results. Almost all of the bovine grafts fractured or presented regions of lysis. In our opinion bovine cancellous bone graft is not a good alternative to autologous iliac crest., (© Georg Thieme Verlag KG Stuttgart · New York.)

Study Design: A comparative study on growth of the sheep and human spine., Objective: To validate the immature sheep spine as model for the growing human spine and to yield a database for planning and interpretation of future animal experiments., Summary of Background Data: With the current change of paradigm to nonfusion strategies for pediatric spine deformities, experimental surgery on spines of growing goats, sheep, and pigs has gained importance as preclinical proof-of-concept test. However, despite the proceeding use of animals, there is a lack of knowledge regarding the growth of the sheep spine and the relation to the human spine., Methods: Thoracic and lumbar cadaver spines were harvested from 50 Swiss alpine sheep. Specimens were obtained from newborn, 1, 3, 6, 9 and 12, 15 and 18 months old female sheep. Direct spondylometry yielded vertebral body heights, widths, and depths and spinal canal size, which were compared to pooled data on human spine growth retrieved from the literature., Results: Sheep spine growth ceases at age 15 to 18 months, which corresponds to a time-lapse model of human growth. Main growth occurs within the first 3 to 6 months of life, as opposed to human spines with maximal growth during the first 4 years and puberty. The relation between sheep and human vertebral shape is continuously changing with growth: at birth, sheep vertebrae are twice as tall, but equally wide and deep. At skeletal maturity, height is 15% to 25% bigger in sheep, but width 15% to 30% and depth 30% to 50% are smaller., Conclusion: The immature sheep spine offers fast effects if growth-modulating interventions are performed within the first 3 to 6 months of age. The differences in vertebral shapes and further distinctions between human and sheep spines such as biomechanics, facet anatomy, and rib cage morphology have to be considered when interpreting results after experimental surgery.

Study Design: Sheep anterior spinal fusion model with autogenous and xenogenous bone grafts., Objective: To investigate whether the relationship between cross-sectional area of the bone graft and area of the adjacent vertebral endplates has an effect on graft fracture rate., Summary of Background Data: Anterior spondylodesis with autogenous iliac crest transplant is a frequently performed operation to stabilize spinal motion segments but to date no precise recommendations with respect to minimum graft size are available in the literature., Methods: Anterior spondylodesis using autogenous and xenogenous grafts of constant size in combination with an angular stable plate (Macs TL). Autogenous iliac crest graft was inserted in eight sheep and xenogenic, commercially available bovine graft (Tutobone) in the additional eight animals. The surface areas of the endplates of the fused intervertebral space were calculated using CT scans and contact radiographs of the specimens obtained after 24 weeks. The graft itself was evaluated for fractures and osteolysis., Results: A fracture occurred in tricortical, autogenous grafts if the graft cross-sectional area was less than 21% of the area of the adjacent endplates. All xenogenic grafts fractured and therefore a comparable value could not be determined., Conclusion: The results clearly indicate that the relation between graft cross-sectional area and endplate area defines the survival or fracture of the graft in anterior spinal fusion. Although it is difficult to directly apply the results to the clinical situation it is suggested to choose a sufficiently large graft, in order to reduce the risk of autogenous graft fracture in anterior spondylodesis., (2009 Elsevier Ltd. All rights reserved.)

Background: Tears of the rotator cuff are highly prevalent in patients older than 60 years, thereby presenting a population also suffering from osteopenia or osteoporosis. Suture fixation in the bone depends on the holding strength of the anchoring technique, whether a bone tunnel or suture anchor is selected. Because of osteopenic or osteoporotic bone changes, suture anchors in the older patient might pull out, resulting in failure of repair., Hypothesis: The aim of our study was to analyze the bone quality within the tuberosities of the osteoporotic humeral head using high-resolution quantitative computed tomography (HR-pQCT)., Study Design: Descriptive laboratory study., Methods: Thirty-six human cadaveric shoulders were analyzed using HR-pQCT. The mean bone volume to total volume (BV/TV) as well as trabecular bone mineral densities (trabBMDs) of the greater tuberosity (GT) and the lesser tuberosity (LT) were determined. Within the GT, 6 volumes of interest (VOIs) within the LT, and 2 VOIs and 1 control volume within the subchondral area beyond the articular surface were set., Results: Comparing BV/TV of the medial and the lateral row, significantly higher values were found medially (P < .001). The highest BV/TV, 0.030% + or - 0.027%, was found in the posteromedial portion of the GT (P < .05). Regarding the analysis of the LT, no difference was found comparing the superior (BV/TV: 0.024% + or - 0.022%) and the inferior (BV/TV: 0.019% + or - 0.016%) portion. Analyzing trabBMD, equal proportions were found. An inverse correlation with a correlation coefficient of -0.68 was found regarding BV/TV of the posterior portion of the GT and age (P < .05)., Conclusion: Significant regional differences of trabecular microarchitecture were found in our HR-pQCT study. The volume of highest bone quality resulted for the posteromedial aspect of the GT. Moreover, a significant correlation of bone quality within the GT and age was found, while the bone quality within the LT seems to be independent from it., Clinical Relevance: The shape of the rotator cuff tear largely determines the bony site of tendon reattachment, although the surgeon has distinct options to modify anchor positioning. According to our results, placement of suture anchors in a medialized way at the border to the articular surface might guarantee a better structural bone stock.