Deep-learning based 3D reconstruction of lower limb bones from biplanar radiographs for preoperative osteotomy planning.

PURPOSE: Three-dimensional (3D) preoperative planning has become the gold standard for orthopedic surgeries, primarily relying on CT-reconstructed 3D models. However, in contrast to standing radiographs, a CT scan is not part of the standard protocol but is usually acquired for preoperative planning purposes only. Additionally, it is costly, exposes the patients to high doses of radiation and is acquired in a non-weight-bearing position. METHODS: In this study, we develop a deep-learning based pipeline to facilitate 3D preoperative planning for high tibial osteotomies, based on 3D models reconstructed from low-dose biplanar standing EOS radiographs. Using digitally reconstructed radiographs, we train networks to localize the clinically required landmarks, separate the two legs in the sagittal radiograph and finally reconstruct the 3D bone model. Finally, we evaluate the accuracy of the reconstructed 3D models for the particular application case of preoperative planning, with the aim of eliminating the need for a CT scan in specific cases, such as high tibial osteotomies. RESULTS: The mean Dice coefficients for the tibial reconstructions were 0.92 and 0.89 for the right and left tibia, respectively. The reconstructed models were successfully used for clinical-grade preoperative planning in a real patient series of 52 cases. The mean differences to ground truth values for mechanical axis and tibial slope were 0.52° and 4.33°, respectively. CONCLUSIONS: We contribute a novel framework for the 2D-3D reconstruction of bone models from biplanar standing EOS radiographs and successfully use them in automated clinical-grade preoperative planning of high tibial osteotomies. However, achieving precise reconstruction and automated measurement of tibial slope remains a significant challenge.

Poly(ADP-Ribose) Polymerases-Inhibitor Talazoparib Inhibits Muscle Atrophy and Fatty Infiltration in a Tendon Release Infraspinatus Sheep Model: A Pilot Study.

Structural muscle changes, including muscle atrophy and fatty infiltration, follow rotator cuff tendon tear and are associated with a high repair failure rate. Despite extensive research efforts, no pharmacological therapy is available to successfully prevent both muscle atrophy and fatty infiltration after tenotomy of tendomuscular unit without surgical repair. Poly(ADP-ribose) polymerases (PARPs) are identified as a key transcription factors involved in the maintenance of cellular homeostasis. PARP inhibitors have been shown to influence muscle degeneration, including mitochondrial hemostasis, oxidative stress, inflammation and metabolic activity, and reduced degenerative changes in a knockout mouse model. Tenotomized infraspinatus were assessed for muscle degeneration for 16 weeks using a Swiss Alpine sheep model (n = 6). All sheep received daily oral administration of 0.5 mg Talazoparib. Due to animal ethics, the treatment group was compared with three different controls from prior studies of our institution. To mitigate potential batch heterogeneity, PARP-I was evaluated in comparison with three distinct control groups (n = 6 per control group) using the same protocol without treatment. The control sheep were treated with an identical study protocol without Talazoparib treatment. Muscle atrophy and fatty infiltration were evaluated at 0, 6 and 16 weeks post-tenotomy using DIXON-MRI. The controls and PARP-I showed a significant (control p < 0.001, PARP-I p = 0.01) decrease in muscle volume after 6 weeks. However, significantly less (p = 0.01) atrophy was observed in PARP-I after 6 weeks (control 1: 76.6 ± 8.7%; control 2: 80.3 ± 9.3%, control 3: 73.8 ± 6.7% vs. PARP-I: 90.8 ± 5.1% of the original volume) and 16 weeks (control 1: 75.7 ± 9.9; control 2: 74.2 ± 5.6%; control 3: 75.3 ± 7.4% vs. PARP-I 93.3 ± 10.6% of the original volume). All experimental groups exhibited a statistically significant (p < 0.001) augmentation in fatty infiltration following a 16-week period when compared to the initial timepoint. However, the PARP-I showed significantly less fatty infiltration (p < 0.003) compared to all controls (control 1: 55.6 ± 6.7%, control 2: 53.4 ± 9.4%, control 3: 52.0 ± 12.8% vs. PARP-I: 33.5 ± 8.4%). Finally, a significantly (p < 0.04) higher proportion and size of fast myosin heavy chain-II fiber type was observed in the treatment group. This study shows that PARP-inhibition with Talazoparib inhibits the progression of both muscle atrophy and fatty infiltration over 16 weeks in retracted sheep musculotendinous units.

Engineering Tendon Assembloids to Probe Cellular Crosstalk in Disease and Repair.

Tendons enable locomotion by transferring muscle forces to bones. They rely on a tough tendon core comprising collagen fibers and stromal cell populations. This load-bearing core is encompassed, nourished, and repaired by a synovial-like tissue layer comprising the extrinsic tendon compartment. Despite this sophisticated design, tendon injuries are common, and clinical treatment still relies on physiotherapy and surgery. The limitations of available experimental model systems have slowed the development of novel disease-modifying treatments and relapse-preventing clinical regimes. In vivo human studies are limited to comparing healthy tendons to end-stage diseased or ruptured tissues sampled during repair surgery and do not allow the longitudinal study of the underlying tendon disease. In vivo animal models also present important limits regarding opaque physiological complexity, the ethical burden on the animals, and large economic costs associated with their use. Further, in vivo animal models are poorly suited to systematic probing of drugs and multicellular, multi-tissue interaction pathways. Simpler in vitro model systems have also fallen short. One major reason is a failure to adequately replicate the three-dimensional mechanical loading necessary to meaningfully study tendon cells and their function. The new 3D model system presented here alleviates some of these issues by exploiting murine tail tendon core explants. Importantly, these explants are easily accessible in large numbers from a single mouse, retain 3D in situ loading patterns at the cellular level, and feature an in vivo-like extracellular matrix. In this protocol, step-by-step instructions are given on how to augment tendon core explants with collagen hydrogels laden with muscle-derived endothelial cells, tendon-derived fibroblasts, and bone marrow-derived macrophages to substitute disease- and injury-activated cell populations within the extrinsic tendon compartment. It is demonstrated how the resulting tendon assembloids can be challenged mechanically or through defined microenvironmental stimuli to investigate emerging multicellular crosstalk during disease and injury.

Reducing residual forces in spinal fusion using a custom-built rod bending machine.

BACKGROUND AND OBJECTIVE: As part of spinal fusion surgery, shaping the rod implant to align with the anatomy is a tedious, error-prone, and time-consuming manual process. Inadequately contoured rod implants introduce stress on the screw-bone interface of the pedicle screws, potentially leading to screw loosening or even pull-out. METHODS: We propose the first fully automated solution to the rod bending problem by leveraging the advantages of augmented reality and robotics. Augmented reality not only enables the surgeons to intraoperatively digitize the screw positions but also provides a human-computer interface to the wirelessly integrated custom-built rod bending machine. Furthermore, we introduce custom-built test rigs to quantify per screw absolute tensile/compressive residual forces on the screw-bone interface. Besides residual forces, we have evaluated the required bending times and reducer engagements, and compared our method to the freehand gold standard. RESULTS: We achieved a significant reduction of the average absolute residual forces from for the freehand gold standard to (p=0.0015) using the bending machine. Moreover, our bending machine reduced the average time to instrumentation per screw from to . Reducer engagements per rod were significantly decreased from an average of 1.00±1.14 to 0.11±0.32 (p=0.0037). CONCLUSION: The combination of augmented reality and robotics has the potential to improve surgical outcomes while minimizing the dependency on individual surgeon skill and dexterity.

In Vitro Assessment of Bacterial Adhesion and Biofilm Formation on Novel Bioactive, Biodegradable Electrospun Fiber Meshes Intended to Support Tendon Rupture Repair.

The surgical repair of a ruptured tendon faces two major problems: specifically increased fibrous adhesion to the surrounding tissue and inferior mechanical properties of the scar tissue compared to the native tissue. Bacterial attachment to implant materials is an additional problem as it might lead to severe infections and impaired recovery. To counteract adhesion formation, two novel implant materials were fabricated by electrospinning, namely, a random fiber mesh containing hyaluronic acid (HA) and poly(ethylene oxide) (PEO) in a ratio of 1:1 (HA/PEO 1:1) and 1:4 (HA/PEO 1:4), respectively. Electrospun DegraPol (DP) treated with silver nanoparticles (DP-Ag) was developed to counteract the bacterial attachment. The three novel materials were compared to the previously described DP and DP with incorporated insulin-like growth factor-1 (DP-IGF-1), two implant materials that were also designed to improve tendon repair. To test whether the materials are prone to bacterial adhesion and biofilm formation, we assessed 10 strains of Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, and Enterococcus faecalis, known for causing nosocomial infections. Fiber diameter, pore size, and water contact angle, reflecting different degrees of hydrophobicity, were used to characterize all materials. Generally, we observed higher biofilm formation on the more hydrophobic DP as compared to the more hydrophilic DP-IGF-1 and a trend toward reduced biofilm formation for DP treated with silver nanoparticles. For the two HA/PEO implants, a similar biofilm formation was observed. All tested materials were highly prone to bacterial adherence and biofilm formation, pointing toward the need of further material development, including the optimized incorporation of antibacterial agents such as silver nanoparticles or antibiotics.

Automatic registration with continuous pose updates for marker-less surgical navigation in spine surgery.

Established surgical navigation systems for pedicle screw placement have been proven to be accurate, but still reveal limitations in registration or surgical guidance. Registration of preoperative data to the intraoperative anatomy remains a time-consuming, error-prone task that includes exposure to harmful radiation. Surgical guidance through conventional displays has well-known drawbacks, as information cannot be presented in-situ and from the surgeon's perspective. Consequently, radiation-free and more automatic registration methods with subsequent surgeon-centric navigation feedback are desirable. In this work, we present a marker-less approach that automatically solves the registration problem for lumbar spinal fusion surgery in a radiation-free manner. A deep neural network was trained to segment the lumbar spine and simultaneously predict its orientation, yielding an initial pose for preoperative models, which then is refined for each vertebra individually and updated in real-time with GPU acceleration while handling surgeon occlusions. An intuitive surgical guidance is provided thanks to the integration into an augmented reality based navigation system. The registration method was verified on a public dataset with a median of 100% successful registrations, a median target registration error of 2.7 mm, a median screw trajectory error of 1.6°and a median screw entry point error of 2.3 mm. Additionally, the whole pipeline was validated in an ex-vivo surgery, yielding a 100% screw accuracy and a median target registration error of 1.0 mm. Our results meet clinical demands and emphasize the potential of RGB-D data for fully automatic registration approaches in combination with augmented reality guidance.

Rotator Cuff Repair and Overlay Augmentation by Direct Interlocking of a Nonwoven Polyethylene Terephthalate Patch Into the Tendon: Evaluation in an Ovine Model.

BACKGROUND: Arthroscopic repair of large rotator cuff tendon tears is associated with high rates of retear. Construct failure often occurs at the suture-tendon interface. Patch augmentation can improve mechanical strength and healing at this interface. PURPOSE: To introduce a novel technique for suture-free attachment of an overlaid patch and evaluate its biomechanical strength and biological performance. STUDY DESIGN: Descriptive and controlled laboratory studies. METHODS: An established ovine model of partial infraspinatus tendon resection and immediate repair was used. After a nonwoven polyethylene terephthalate patch was overlaid to the resected tendon, a barbed microblade was used to draw fibers of the patch directly into the underlying tissue. In vivo histological assessment of healing was performed at 6 and 13 weeks after implantation. Ex vivo models were used to characterize primary repair strength of the suture-free patch fixation to tendon. Additional ex vivo testing assessed the potential of the technique for patch overlay augmentation of suture-based repair. RESULTS: The in vivo study revealed no macroscopic evidence of adverse tissue reactions to the interlocked patch fibers. Histological testing indicated a normal host healing response with minimal fibrosis. Uniform and aligned tissue ingrowth to the core of the patch was observed from both the tendon and the bone interfaces to the patch. There was no evident retraction of the infraspinatus muscle, lengthening of the tendon, or tendon gap formation over 13 weeks. Ex vivo testing revealed that direct patch interlocking yielded tendon purchase equivalent to a Mason-Allen suture (150 ± 58 vs 154 ± 49 N, respectively; P = .25). In an overlay configuration, fiber interlocked patch augmentation increased Mason-Allen suture retention strength by 88% (from 221 ± 43 N to 417 ± 86 N; P < .01) with no detectable difference in repair stiffness. CONCLUSION: Testing in an ovine model of rotator cuff tendon repair suggested that surgical interlocking of a nonwoven medical textile can provide effective biomechanical performance, support functional tissue ingrowth, and help avoid musculotendinous retraction after surgical tendon repair. CLINICAL RELEVANCE: The novel technique may facilitate patch augmentation of rotator cuff repairs.

Structural Musculotendinous Parameters That Predict Failed Tendon Healing After Rotator Cuff Repair.

Background: Healing of the rotator cuff after repair constitutes a major clinical challenge with reported high failure rates. Identifying structural musculotendinous predictors for failed rotator cuff repair could enable improved diagnosis and management of patients with rotator cuff disease. Purpose: To investigate structural predictors of the musculotendinous unit for failed tendon healing after rotator cuff repair. Study Design: Cohort study; Level of evidence, 2. Methods: Included were 116 shoulders of 115 consecutive patients with supraspinatus (SSP) tear documented on magnetic resonance imaging (MRI) who were treated with an arthroscopic rotator cuff repair. Preoperative assessment included standardized clinical and imaging (MRI) examinations. Intraoperatively, biopsies of the joint capsule, the SSP tendon, and muscle were harvested for histological assessment. At 3 and 12 months postoperatively, patients were re-examined clinically and with MRI. Structural and clinical predictors of healing were evaluated using logistic and linear regression models. Results: Structural failure of tendon repair, which was significantly associated with poorer clinical outcome, was associated with older age (ß = 1.12; 95% CI, 1.03 to 1.26; P = .03), shorter SSP tendon length (ß = 0.89; 95% CI, 0.8 to 0.98; P = .02), and increased proportion of slow myosin heavy chain (MHC)-I/fast MHC-II hybrid muscle fibers (ß = 1.23; 95% CI, 1.07 to 1.42; P = .004). Primary clinical outcome (12-month postoperative Constant score) was significantly less favorable for shoulders with fatty infiltration of the infraspinatus muscle (ß = -4.71; 95% CI, -9.30 to -0.12; P = .044). Conversely, a high content of fast MHC-II muscle fibers (ß = 0.24; 95% CI, 0.026 to 0.44; P = .028) was associated with better clinical outcome. Conclusion: Both decreased tendon length and increased hybrid muscle fiber type were independent predictors for retear. Clinical outcome was compromised by tendon retearing and increased fatty infiltration of the infraspinatus muscle. A high content of fast MHC-II SSP muscle fibers was associated with a better clinical outcome. Registration: NCT02123784 (ClinicalTrials.govidentifier).

Automatic 3D Postoperative Evaluation of Complex Orthopaedic Interventions.

In clinical practice, image-based postoperative evaluation is still performed without state-of-the-art computer methods, as these are not sufficiently automated. In this study we propose a fully automatic 3D postoperative outcome quantification method for the relevant steps of orthopaedic interventions on the example of Periacetabular Osteotomy of Ganz (PAO). A typical orthopaedic intervention involves cutting bone, anatomy manipulation and repositioning as well as implant placement. Our method includes a segmentation based deep learning approach for detection and quantification of the cuts. Furthermore, anatomy repositioning was quantified through a multi-step registration method, which entailed a coarse alignment of the pre- and postoperative CT images followed by a fine fragment alignment of the repositioned anatomy. Implant (i.e., screw) position was identified by 3D Hough transform for line detection combined with fast voxel traversal based on ray tracing. The feasibility of our approach was investigated on 27 interventions and compared against manually performed 3D outcome evaluations. The results show that our method can accurately assess the quality and accuracy of the surgery. Our evaluation of the fragment repositioning showed a cumulative error for the coarse and fine alignment of 2.1 mm. Our evaluation of screw placement accuracy resulted in a distance error of 1.32 mm for screw head location and an angular deviation of 1.1° for screw axis. As a next step we will explore generalisation capabilities by applying the method to different interventions.

Osteoconductive Scaffold Placed at the Femoral Tunnel Aperture in Hamstring Tendon ACL Reconstruction: A Randomized Controlled Trial.

Background: Bone tunnel enlargement after single-bundle anterior cruciate ligament reconstruction remains an unsolved problem that complicates revision surgery. Hypothesis: Positioning of an osteoconductive scaffold at the femoral tunnel aperture improves graft-to-bone incorporation and thereby decreases bone tunnel widening. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: In a 1:1 ratio, 56 patients undergoing primary anterior cruciate ligament reconstruction were randomized to receive femoral fixation with cortical suspension fixation and secondary press-fit fixation at the tunnel aperture of the tendon graft only (control) or with augmentation by an osteoconductive scaffold (intervention). Adverse events, patient-reported outcomes, and passive knee stability were recorded over 2 years after the index surgery. Three-dimensional bone tunnel widening was assessed using computed tomography at the time of surgery and 4.5 months and 1 year postoperatively. Results: The intervention group exhibited a similar number of adverse events as the control group (8 vs 10; P = .775) including 2 partial reruptures in both groups. The approach was feasible, although 1 case was encountered where the osteoconductive scaffold was malpositioned without adversely affecting the patient's recovery. There was no difference between the intervention and control groups in femoral bone tunnel enlargement, as expressed by the relative change in tunnel volume from surgery to 4.5 months (mean ± SD, 36% ± 25% vs 40% ± 25%; P = .644) and 1 year (19% ± 20% vs 17% ± 25%; P =.698). Conclusion: Press-fit graft fixation with an osteoconductive scaffold positioned at the femoral tunnel aperture is safe but does not decrease femoral bone tunnel enlargement at postoperative 1 year. Registration: NCT03462823 (ClinicalTrials.gov identifier).

Guidelines for ex vivo mechanical testing of tendon.

Tendons are critical for the biomechanical function of joints. Tendons connect muscles to bones and allow for the transmission of muscle forces to facilitate joint motion. Therefore, characterizing the tensile mechanical properties of tendons is important for the assessment of functional tendon health and efficacy of treatments for acute and chronic injuries. In this guidelines paper, we review methodological considerations, testing protocols, and key outcome measures for mechanical testing of tendons. The goal of the paper is to present a simple set of guidelines to the nonexpert seeking to perform tendon mechanical tests. The suggested approaches provide rigorous and consistent methodologies for standardized biomechanical characterization of tendon and reporting requirements across laboratories.

Posterior stability of the shoulder depends on acromial anatomy: a biomechanical study of 3D surface models.

PURPOSE: Primary glenohumeral osteoarthritis is commonly associated with static posterior subluxation of the humeral head. Scapulae with static/dynamic posterior instability feature a superiorly and horizontally oriented acromion. We investigated whether the acromion acts as a restraint to posterior humeral translation. METHODS: Five three-dimensional (3D) printed scapula models were biomechanically tested. A statistical shape mean model (SSMM) of the normal scapula of 40 asymptomatic shoulders was fabricated. Next, a SSMM of scapular anatomy associated with posterior subluxation was generated using data of 20 scapulae ("B1"). This model was then used to generate three models of surgical correction: glenoid version, acromial orientation, and acromial and glenoid orientation. With the joint axially loaded (100N) and the humerus stabilized, an anterior translation force was applied to the scapula in 35°, 60° and 75° of glenohumeral flexion. Translation (mm) was measured. RESULTS: In the normal scapula, the humerus translates significantly less to contact with the acromion compared to all other configurations (p < .000 for all comparisons; i.e. 35°: "normal" 8,1 mm (± 0,0) versus "B1" 11,9 mm (± 0,0) versus "B1 Acromion Correction" 12,2 mm (± 0,2) versus "B1 Glenoid Correction" 13,3 mm (± 0,1)). Restoration of normal translation was only achieved with correction of glenoid and acromial anatomy (i.e. 75°: "normal" 11 mm (± 0,8) versus "B1 Acromion Correction" 17,5 mm (± 0,1) versus "B1 Glenoid Correction" 19,7 mm (± 1,3) versus "B1 Glenoid + Acromion Correction" 11,5 mm (± 1,1)). CONCLUSIONS: Persistence or recurrence of static/dynamic posterior instability after correction of glenoid version alone may be related to incomplete restoration of the intrinsic stability that is conferred by a normal acromial anatomy. LEVEL OF EVIDENCE V: biomechanical study.

Bioactive and Elastic Emulsion Electrospun DegraPol Tubes Delivering IGF-1 for Tendon Rupture Repair.

Tendon injuries can result in two major drawbacks. Adhesions to the surrounding tissue may limit the range of motion, while fibrovascular scar formation can lead to poor biomechanical outcomes. Prosthetic devices may help to mitigate those problems. Emulsion electrospinning was used to develop a novel three-layer tube based on the polymer DegraPol (DP), with incorporated insulin-like growth factor-1 (IGF-1) in the middle layer. Scanning electron microscopy was utilized to assess the fiber diameter in IGF-1 containing pure DP meshes. Further characterization was performed with Fourier Transformed Infrared Spectroscopy, Differential Scanning Calorimetry, and water contact angle, as well as through the assessment of mechanical properties and release kinetics from ELISA, and the bioactivity of IGF-1 by qPCR of collagen I, ki67, and tenomodulin in rabbit Achilles tenocytes. The IGF-1-containing tubes exhibited a sustained release of the growth factor up to 4 days and showed bioactivity by significantly upregulated ki67 and tenomodulin gene expression. Moreover, they proved to be mechanically superior to pure DP tubes (significantly higher fracture strain, failure stress, and elastic modulus). The novel three-layer tubes intended to be applied over conventionally sutured tendons after a rupture may help accelerate the healing process. The release of IGF-1 stimulates proliferation and matrix synthesis of cells at the repair site. In addition, adhesion formation to surrounding tissue can be reduced due to the physical barrier.

An automated optimization pipeline for clinical-grade computer-assisted planning of high tibial osteotomies under consideration of weight-bearing.

3D preoperative planning for high tibial osteotomies (HTO) has increasingly replaced 2D planning but is complex, time-consuming and therefore expensive. Several interdependent clinical objectives and constraints have to be considered, which often requires multiple rounds of revisions between surgeons and biomedical engineers. We therefore developed an automated preoperative planning pipeline, which takes imaging data as an input to generate a ready-to-use, patient-specific planning solution. Deep-learning based segmentation and landmark localization was used to enable the fully automated 3D lower limb deformity assessment. A 2D-3D registration algorithm allowed the transformation of the 3D bone models into the weight-bearing state. Finally, an optimization framework was implemented to generate ready-to use preoperative plannings in a fully automated fashion, using a genetic algorithm to solve the multi-objective optimization (MOO) problem based on several clinical requirements and constraints. The entire pipeline was evaluated on a large clinical dataset of 53 patient cases who previously underwent a medial opening-wedge HTO. The pipeline was used to automatically generate preoperative solutions for these patients. Five experts blindly compared the automatically generated solutions to the previously generated manual plannings. The overall mean rating for the algorithm-generated solutions was better than for the manual solutions. In 90% of all comparisons, they were considered to be equally good or better than the manual solution. The combined use of deep learning approaches, registration methods and MOO can reliably produce ready-to-use preoperative solutions that significantly reduce human workload and related health costs.

PIEZO1 gain-of-function gene variant is associated with elevated tendon stiffness in humans.

Prolonged periods of increased physical demands can elicit anabolic tendon adaptations that increase stiffness and mechanical resilience or conversely can lead to pathological processes that deteriorate tendon structural quality with ensuing pain and potential rupture. Although the mechanisms by which tendon mechanical loads regulate tissue adaptation are largely unknown, the ion channel PIEZO1 has been implicated in tendon mechanotransduction, with human carriers of the PIEZO1 gain-of-function variant E756del displaying improved dynamic vertical jump performance compared with noncarriers. Here, we sought to examine whether increased tendon stiffness in humans could explain this increased performance. We assessed tendon morphological and mechanical properties with ultrasound-based techniques in 77 participants of Middle- and West-African descent, and we measured their vertical jumping performance to assess potential functional consequences in the context of high tendon strain-rate loading. Carrying the E756del gene variant (n = 30) was associated with 46.3 ± 68.3% (P = 0.002) and 45.6 ± 69.2% (P < 0.001) higher patellar tendon stiffness and Young's modulus compared with noncarrying controls, respectively. Although these tissue level measures strongly corroborate the initial postulate that PIEZO1 plays an integral part in regulating tendon material properties and stiffness in humans, we found no detectable correlation between tendon stiffness and jumping performance in the tested population that comprised individuals of highly diverse physical fitness level, dexterity, and jumping ability.NEW & NOTEWORTHY The E756del gene variant causes overactivity of the mechanosensitive membrane channel PIEZO1 and is suspected to upregulate tendon collagen cross linking. In human carriers of E756del, we found increased patellar tendon stiffness but similar tendon lengths and cross-sectional areas, directly supporting the premise that PIEZO1 regulates human tendon stiffness at the level of tissue material properties.

Finite element analysis of medial closing and lateral opening wedge osteotomies of the distal femur in relation to hinge fractures.

PURPOSE: Intraoperative hinge fractures in distal femur osteotomies represent a risk factor for loss of alignment and non-union. Using finite element analysis, the goal of this study was to investigate the influence of different hinge widths and osteotomy corrections on hinge fractures in medial closed-wedge and lateral open-wedge distal femur osteotomies. METHODS: The hinge was located at the proximal margin of adductor tubercle for biplanar lateral open-wedge and at the upper border of the lateral femoral condyle for biplanar medial closed-wedge distal femur osteotomies, corresponding to optimal hinge positions described in literature. Different hinge widths (5, 7.5, 10 mm) were created and the osteotomy correction was opened/closed by 5, 7.5 and 10 mm. Tensile and compressive strain of the hinge was determined in a finite element analysis and compared to the ultimate strain of cortical bone to assess the hinge fracture risk. RESULTS: Doubling the correction from 5 to 10 mm increased mean tensile and compressive strain by 50% for lateral open-wedge and 48% for medial closed-wedge osteotomies. A hinge width of 10 mm versus 5 mm showed increased strain in the hinge region of 61% for lateral open-wedge and 32% for medial closed-wedge osteotomies. Medial closed-wedge recorded a higher fracture risk compared to lateral open-wedge osteotomies due to a larger hinge cross-section area (60-67%) for all tested configurations. In case of a 5 mm hinge, medial closed-wedge recorded 71% higher strain in the hinge region compared to lateral open-wedge osteotomies. CONCLUSION: Due to morphological features of the medial femoral condyle, finite element analysis suggests that lateral-open wedge osteotomies are the preferable option if larger corrections are intended, as a thicker hinge can remain without an increased hinge fracture risk.

Improved suture pullout through genipin-coated sutures in human biceps tendons with spatially confined changes in cell viability.

BACKGROUND: The suture-tendon interface often constitutes the point of failure in tendon suture repair. In the present study, we investigated the mechanical benefit of coating the suture with a cross-linking agent to strengthen the nearby tissue after suture placement in human tendons and we assessed the biological implications regarding tendon cell survival in-vitro. METHODS: Freshly harvested human biceps long head tendons were randomly allocated to control (n = 17) or intervention (n = 19) group. According to the assigned group, either an untreated or a genipin-coated suture was inserted into the tendon. 24 h after suturing, mechanical testing composed of cyclic and ramp-to-failure loading was performed. Additionally, 11 freshly harvested tendons were used for short-term in vitro cell viability assessment in response to genipin-loaded suture placement. These specimens were analyzed in a paired-sample setting as stained histological sections using combined fluorescent/light microscopy. FINDINGS: Tendons stitched with a genipin-coated suture sustained higher forces to failure. Cyclic and ultimate displacement of the tendon-suture construct remained unaltered by the local tissue crosslinking. Tissue crosslinking resulted in significant cytotoxicity in the direct vicinity of the suture (<3 mm). At larger distances from the suture, however, no difference in cell viability between the test and the control group was discernable. INTERPRETATION: The repair strength of a tendon-suture construct can be augmented by loading the suture with genipin. At this mechanically relevant dosage, crosslinking-induced cell death is confined to a radius of <3 mm from the suture in the short-term in-vitro setting. These promising results warrant further examination in-vivo.

Altered regional 3D shear wave velocity patterns in youth competitive alpine skiers suffering from patellar tendon complaints - a prospective case-control study.

Patellar tendon (PT) complaints are frequent throughout the population, with increased occurrence in athletes and, particularly, in youth competitive alpine skiers. Timely detection and treatment might improve prospects of recovery. Diagnostic modalities in clinical use to date rely on pain symptoms, manual palpation, and potentially, magnetic resonance imaging (MRI); however, MRI-based imaging yields limited sensitivity. Quantitatively measuring the morphological and mechanical properties of PTs by means of B-mode ultrasound and shear wave elastography (SWE), instead, may allow improved diagnosis or even early detection. We performed B-mode scans and three-dimensional ultrasound shear wave velocity (SWV) mapping and MRI of the PT in 106 youth skiers. A prospective one-year survey on health problems combined with clinical assessments served to categorize symptomatic and asymptomatic youth skiers. Skiers suffering from distal or proximal tendon complaints showed lower SWV in the respective tendon region than asymptomatic skiers (p = 0.035 and p = 0.019, respectively). Youth skiers with distal tendon complaints additionally exhibited decreased SWV in the proximal region compared to asymptomatic counterparts (p = 0.020). Cross-validated analysis of retrospective prediction indicated sensitivity and specificity in detecting tendon complaints in the range of 0.606-0.621 and 0.536-0.650, respectively. MRI detected distal tendon complaints with a sensitivity of 0.410 (12/29) but failed to detect any proximal cases. This study agrees with the most recent literature in that SWE holds promise as a valuable adjunct modality for the diagnosis of PT complaints or even the detection of subclinical prestages. However, to evaluate its prospective predictive value, long-term studies are warranted.Highlights Patellar tendon complaints are a frequent complaint in athletes, particularly in youth competitive alpine skiers, but timely quantitative detection of related tendon properties remains challenging.Quantitative B-mode US and three-dimensional ultrasound shear wave elastography assessments and magnetic resonance imaging were performed in youth competitive alpine skiers.Three-dimensional shear wave elastography was able to discern symptomatic from asymptomatic patellar tendons both in the distal and proximal tendon regions, whereas magnetic resonance imaging failed to detect any proximal cases.

The Stiffness-Sensitive Transcriptome of Human Tendon Stromal Cells.

Extracellular matrix stiffness is a major regulator of cellular states. Stiffness-sensing investigations are typically performed using cells that have acquired "mechanical memory" through prolonged conditioning in rigid environments, e.g., tissue culture plastic (TCP). This potentially masks the full extent of the matrix stiffness-driven mechanosensing programs. Here, a biomaterial composed of 2D mechanovariant silicone substrates with simplified and scalable surface biofunctionalization chemistry is developed to facilitate large-scale cell culture expansion processes. Using RNA sequencing, stiffness-mediated mechano-responses of human tendon-derived stromal cells are broadly mapped. Matrix elasticity (E.) approximating tendon microscale stiffness range (E. ≈ 35 kPa) distinctly favors transcriptional programs related to chromatin remodeling and Hippo signaling; whereas compliant stiffnesses (E. ≈ 2 kPa) are enriched in processes related to cell stemness, synapse assembly, and angiogenesis. While tendon stromal cells undergo dramatic phenotypic drift on conventional TCP, mechanovariant substrates abrogate this activation with tenogenic stiffnesses inducing a transcriptional program that strongly correlates with established tendon tissue-specific expression signature. Computational inference predicts that AKT1 and ERK1/2 are major stiffness-sensing signaling hubs. Together, these findings highlight how matrix biophysical cues may dictate the transcriptional identity of tendon cells, and how matrix mechano-reciprocity regulates diverse sets of previously underappreciated mechanosensitive processes in tendon fibroblasts.