Efficacy of lysostaphin-coated titanium plates on implant-associated MRSA osteitis in minipigs.

PURPOSE: The growing incidence of implant-associated infections (IAIs) caused by biofilm-forming Staphylococcus aureus in combination with an increasing resistance to antibiotics requires new therapeutic strategies. Lysostaphin has been shown to eliminate this biofilm. Own studies confirm the effectiveness in a murine model. The current study characterizes the effects of lysostaphin-coated plates in an IAI minipig model. METHODS: The femur of 30 minipigs was stabilized with a five-hole plate, a bone defect was created, and in 20 cases methicillin-resistant Staphylococcus aureus was applied. Ten animals served as control group. After 14 days, local debridement, lavage, and plate exchange (seven-hole plate) were performed. Ten of the infected minipigs received an uncoated plate and 10 a lysostaphin-coated plate. On day 84, the minipigs were again lavaged, followed by euthanasia. Bacterial load was quantified by colony-forming units (CFU). Immunological response was determined by neutrophils, as well as interleukins. Fracture healing was assessed radiologically. RESULTS: CFU showed significant difference between infected minipigs with an uncoated plate and minipigs with a lysostaphin-coated plate (p = 0.0411). The infection-related excessive callus formation and calcification was significantly greater in the infected animals with an uncoated plate than in animals with a lysostaphin-coated plate (p = 0.0164/p = 0.0033). The analysis of polymorphonuclear neutrophils and interleukins did not reveal any pioneering findings. CONCLUSION: This study confirms the minipig model for examining IAI. Furthermore, coating of plates using lysostaphin could be a promising tool in the therapeutic strategies of IAI. Future studies should focus on coating technology of implants and on translation into a clinical model.

Is restoration of vertebral body height after vertebral body fractures and minimally-invasive dorsal stabilization with polyaxial pedicle screws just an illusion?

INTRODUCTION: Thoracolumbar spine fractures often require surgical treatment as they are associated with spinal instability. Optimal operative techniques and treatment are discussed controversially. Aim of our prospective cohort study was to investigate the sagittal alignment after reduction, the secondary loss of reduction and the subjective outcome as well as the causal correlation of these parameters after minimally invasive stabilization of thoracic and lumbar fractures with polyaxial pedicle screws. MATERIALS AND METHODS: In a single-center study, a total of 78 patients with an average age of 61 ± 17 years who suffered a fracture of the thoracic or lumbar spine were included and subjected to a clinical and radiological follow-up examination after 8.5 ± 8 months. The kyphotic deformity was measured by determining the vertebral body angle, the mono- and bi-segmental wedge angle at three time points. The patients' subjective outcome was evaluated by the VAS spine score. RESULTS: After surgical therapy, a significant reduction of the traumatic kyphotic deformity was shown with an improvement of all angles (vertebral body angle: 3.2° ± 4.4°, mono- and bi-segmental wedge angle: 3.1° ± 5.6°, 2.0° ± 6.3°). After follow-up, a significant loss of sagittal alignment was observed for all measured parameters with a loss of correction. However, no correlation between the loss of reduction and the subjective outcome regarding the VAS spine scale could be detected. CONCLUSION: The minimally invasive dorsal stabilization of thoracic and lumbar spine fractures with polyaxial pedicle screws achieved a satisfactory reduction of the fracture-induced kyphotic deformity immediately postoperatively with a floss of reduction in the further course. However, maybe the main goal of this surgical procedure should be the prevention of a complete collapse of the vertebral body instead of a long-lasting restoration of anatomic sagittal alignment. LEVEL OF EVIDENCE: II.

The influence of fracture severity on postoperative outcome and quality of life after locking plate fixation of proximal humeral fractures.

Objective: For proximal humeral fractures open reduction und internal fixation (ORIF) with a fixed-angle plate is considered the gold standard for surgical management. However, it can lead to poor functional outcomes and is associated with postoperative complications. Therefore, the purpose of this study was to investigate the influence of fracture severity by applying a new classification (simple versus complex) on clinical outcome and quality of life after ORIF of proximal humerus fractures. Methods: We conducted a prospective clinical study with an average follow-up period of 12 (SD 1) months after ORIF of proximal humeral fractures with a fixed-angle plate. The postoperative function and quality of life was measured using the Oxford Shoulder Score (OSS) and the Constant Score. Data was tested for statistical significance with the Mann-Whitney test and Fisher's exact test. Based on the findings of this study a simplified fracture classification system has been developed. Results: Seventy-two patients with a mean age of 65 years (SD 12) with 69% being males were included. According to the Neer classification, 35% (n=25) non-displaced ("one-part fractures"), 19% (n=14) two-part fractures, 15% (n=11) three-part fractures and 31% (n=22) four-part fractures were detected. Regarding the AO/OTA classification, 18% (n=13) were type A fractures, 43% (n=31) type B and 39% (n=28) type C fractures. From these criteria we derived our own fracture classification, including 50% (n=36) simple and 50% (n=36) severe fractures. Patients with simple fracture types achieved significantly higher total values in the Constant Score as well as the OSS (p=0.008; p=0.013). The cumulative incidence of complications in the entire patient collective was 14% (n=10) with humeral head necrosis (n=5) occurring only in the severe fracture group. Conclusions: The postoperative clinical outcome as well as the incidence of humeral head necrosis after ORIF of proximal humeral fractures with a fixed-angle plate correlates with the fracture type and severity. The newly derived fracture classification into simple and severe fractures is suitable with regard to clinical results and complication rate. However, prospective studies comparing ORIF vs. conservative treatment of proximal humeral fractures of the same severity are required. Level of Evidence: III.

Plate-associated localized osteitis in mini-pig by biofilm-forming Methicillin-resistant Staphylococcus aureus (MRSA): establishment of a novel experimental model.

PURPOSE: The increasing number of implant-associated infections during trauma and orthopedic surgery caused by biofilm-forming Staphylococcus aureus in combination with an increasing resistance of conventional antibiotics requires new therapeutic strategies. One possibility could be testing for different therapeutic strategies with differently coated plates. Therefore, a clinically realistic model is required. The pig offers the best comparability to the human situation, thus it was chosen for this model. The present study characterizes a novel model of a standardized low-grade acute osteitis with bone defect in the femur in mini-pigs, which is stabilized by a titanium locking plate to enable further studies with various coatings. METHODS: A bone defect was performed on the femur of 7 Aachen mini-pigs and infected with Methicillin-resistant S. aureus (MRSA ATCC 33592). The defect zone was stabilized with a titanium plate. After 14 days, a plate change, wound debridement and lavage were performed. Finally, after 42 days, the animals were lavaged and debrided again, followed by euthanasia. The fracture healing was evaluated radiologically and histologically. RESULTS: A local osteitis with radiologically visible lysis of the bone could be established. The unchanged high Colony-forming Units (CFU) in lavage, the significant differences in Interleukin (IL)-6 in blood compared to lavage and the lack of increase in Alkaline Phosphates (ALP) in serum over the entire observation period show the constant local infection. CONCLUSION: The study shows the successful induction of local osteitis with lysis of the bone and the lack of enzymatic activity to mineralize the bone. Therefore, this standardized mini-pig model can be used in further clinical studies, to investigate various coated implants, bone healing, biofilm formation and immune response in implant-associated osteitis.

Osteogenic differentiation of human mesenchymal stromal cells and fibroblasts differs depending on tissue origin and replicative senescence.

The need for an autologous cell source for bone tissue engineering and medical applications has led researchers to explore multipotent mesenchymal stromal cells (MSC), which show stem cell plasticity, in various human tissues. However, MSC with different tissue origins vary in their biological properties and their capability for osteogenic differentiation. Furthermore, MSC-based therapies require large-scale ex vivo expansion, accompanied by cell type-specific replicative senescence, which affects osteogenic differentiation. To elucidate cell type-specific differences in the osteogenic differentiation potential and replicative senescence, we analysed the impact of BMP and TGF-ß signaling in adipose-derived stromal cells (ASC), fibroblasts (FB), and dental pulp stromal cells (DSC). We used inhibitors of BMP and TGF-ß signaling, such as SB431542, dorsomorphin and/or a supplemental addition of BMP-2. The expression of high-affinity binding receptors for BMP-2 and calcium deposition with alizarin red S were evaluated to assess osteogenic differentiation potential. Our study demonstrated that TGF-ß signaling inhibits osteogenic differentiation of ASC, DSC and FB in the early cell culture passages. Moreover, DSC had the best osteogenic differentiation potential and an activation of BMP signaling with BMP-2 could further enhance this capacity. This phenomenon is likely due to an increased expression of activin receptor-like kinase-3 and -6. However, in DSC with replicative senescence (in cell culture passage 10), osteogenic differentiation sharply decreased, and the simultaneous use of BMP-2 and SB431542 did not result in further improvement of this process. In comparison, ASC retain a similar osteogenic differentiation potential regardless of whether they were in the early (cell culture passage 3) or later (cell culture passage 10) stages. Our study elucidated that ASC, DSC, and FB vary functionally in their osteogenic differentiation, depending on their tissue origin and replicative senescence. Therefore, our study provides important insights for cell-based therapies to optimize prospective bone tissue engineering strategies.

CCD angle & hip fractures - Predictor of fracture symmetry?

BACKGROUND: Hip fracture caused by fall is a common injury of the elderly. The risk of sustaining a contralateral hip fracture has been reported to be 5-10%. Aging society heightens the need of efficient prevention tools. To be able to cope with this demand, understanding of biomechanics of hip fractures are mandatory. Previous studies suggest that geometry of the proximal femur could play an important role for fracture probability and fracture type. Thus, analysis of hip geometry could play an important role in the prediction and prevention of bilateral hip fractures. Aim of this study was to elucidate the influence of caput collum diaphyseal angle on the fracture type of proximal femur. MATERIAL AND METHODS: In a retrospective analysis, data of patients with an acute hip fracture who underwent surgical treatment within five years were included. Data was separated into two groups: (I) intra capsular femur fracture (femoral neck fractures) and (II) extra capsular femur fracture (inter- and subtrochanteric femur fractures). Occurrence of a bilateral fracture, age, gender, weight, height and caput collum diaphyseal angle (standardized measurement of the opposite joint on preoperative digital x-rays) of each group were further analyzed. RESULTS: Data of 448 patients were included ((I): 250 vs. (II): 198 patients). Group (I) showed a significant higher mean caput collum diaphyseal angle of 133.9 ± 7.0° (mean ± standard deviation) compared to group (II) with 127.6 ± 6.1° (F (1, 451) = 106.5, p = 0.00). In group (I) 0 patients had a caput collum diaphyseal angle <120° (varus), 214 patients (86%) 120°-140° and 35 patients (14%) angle>140° (valgus). In contrast, in group (II) 21 patients (10%) had a caput collum diaphyseal angle <120° (varus), 175 patients (86%) 120°-140° and 7 patients (4%) >140° (valgus). 52 patients had a bilateral hip fracture. 36 patients (69%) sustained a bilateral hip fracture of the same fracture type. CONCLUSION: Patients with an intra capsular proximal femur fracture showed a significantly higher caput collum diaphyseal angle compared to patients with an extra capsular proximal femur fracture. Moreover, intra capsular femur fractures are correlated with an indifferent (120-140°) or valgus (>140°) femoral neck configuration. Extra capsular femur fractures correlate with an indifferent (120-140°) or varian femoral neck configuration (<120°). The results support the assumption that the caput collum diaphyseal angle has an influence on fracture type of the proximal femur. This could possibly be a predictor for the fracture type of the contralateral hip (second fracture). Based on this, present data may benefit prosthetists in developing new and more efficient hip protectors. LEVEL OF EVIDENCE: Level III. Retrospective comparative study.

The acromiohumeral distance in the MRI should not be used as a decision criterion to assess subacromial space width in shoulders with an intact rotator cuff.

PURPOSE: The acromiohumeral distance is in practice often evaluated on MRI by radiologists and a reduction diagnosed as subacromial impingement. However, the acromiohumeral distance as indicator for a decentered glenohumeral joint is defined on a true AP radiograph with the patient standing or sitting. The present study therefore evaluated the influence of the patient position by comparing the acromiohumeral distance in both modalities in shoulders with an intact rotator cuff. METHODS: On MRI images and true AP radiographs of patients > 20 and < 80 years with an intact rotator cuff the acromiohumeral distance was measured. The maximum cranio-caudal size of the glenoid was measured as a reference to allow a direct comparison of both modalities. RESULTS: Two-hundred and thirty-four shoulders (mean patients age 45.8 ± 14.3 years) were included. The mean acromiohumeral distance/glenoid size ratio of all shoulders was significantly larger (P < 0.0001) on the MRI with 4.6 ± 1.0 in comparison to 4.1 ± 0.9 in the radiographs indicating a smaller acromiohumeral distance on the MRI. In absolute values, a mean acromiohumeral distance of 9.2 mm ± 1.8 on MRI in comparison to 10.4 mm ± 2.4 on the radiographs was calculated. Herewith, the acromiohumeral distance in the MRI was in the average 1.2 mm ± 2.1 (13%) smaller than the in corresponding radiographs (P < 0.0001). CONCLUSION: The acromiohumeral distance is significantly smaller in the MRI in comparison to AP radiographs in shoulders with an intact rotator cuff and should not be used as a decision criterion on MRI to assess glenohumeral centering or subacromial space width. LEVEL OF EVIDENCE: IV.

Is CT-based cinematic rendering superior to volume rendering technique in the preoperative evaluation of multifragmentary intraarticular lower extremity fractures?

PURPOSE: Cinematic rendering (CR), a recently launched, FDA-approved rendering technique converts CT image datasets into nearly photorealistic 3D reconstructions by using a unique lighting model. The purpose of this study was to compare CR to volume rendering technique (VRT) images in the preoperative visualization of multifragmentary intraarticular lower extremity fractures. METHOD: In this retrospective study, CT datasets of 41 consecutive patients (female: n = 13; male: n = 28; mean age: 52.3 ± 17.9y) with multifragmentary intraarticular lower extremity fractures (calcaneus: n = 16; tibial pilon: n = 19; acetabulum: n = 6) were included. All datasets were acquired using a 128-row dual-source CT. A dedicated workstation was used to reconstruct CR and VRT images which were reviewed independently by two experienced board-certified traumatologists trained in special trauma surgery. Image quality, anatomical accuracy and fracture visualization were assessed on a 6-point-Likert-scale (1 = non-diagnostic; 6=excellent). The regular CT image reconstructions served as reverence standard. For each score, median values between both readers were calculated. Scores of both reconstruction methods were compared using a Wilcoxon-Ranksum test with p < 0.05 indicating statistical significance. Inter-reader agreement was calculated using Spearman's rank correlation coefficient. RESULTS: Compared to VRT, CR demonstrated a higher image quality (VRT:2.5; CR:6.0; p < 0.001), a higher anatomical accuracy (VRT:3.5; CR:5.5; p < 0.001) and provided a more detailed visualization of the fracture (VRT:2.5; CR:6.0; p < 0.001). An additional benefit of CR reconstructions compared to VRT reconstructions was reported by both readers in 65.9 % (27/41) of all patients. CONCLUSIONS: CR reconstructions are superior to VRT due to higher image quality and higher anatomical accuracy. Traumatologists find CR reconstructions to improve visualization of lower extremity fractures which should thus be used for fracture demonstration during interdisciplinary conferences.

Doctor, when can I drive? - Range of functional ankle motion during driving.

BACKGROUND: Driving a motor vehicle needs a specific joint mobility and yet only limited knowledge exists regarding the necessary ankle range of motion. The goal of this study is to characterize the sequence and range of ankle motion. METHODS: The arc of plantarflexion/dorsiflexion and supination/pronation was recorded in the right and left ankle using electrogoniometers while thirty laps were driven by fifteen healthy participants around a course in a manual transmission car with a left sided steering wheel. The driver was required to perform the following maneuvers during each lap: (I) Vehicle acceleration and gear change, (II) Sudden evasion, (III) Routine turning, (IV) Rapid turning, (V) Vehicle acceleration followed by emergency braking. RESULTS: Driving required the right ankle to plantarflex 13±9 and dorsiflex 22±7 while supinating 15±7 degrees and pronating minimally. The left ankle plantarflexed 19±10and dorsiflexed 17±10 while supinating 15±7 degrees and pronating minimally. The right ankle dorsiflexed significantly more (p=0.00), and yet the left ankle had a significantly higher maximum plantarflexion and range of plantarflexion/dorsiflexion (p=0.00). Emergency braking resulted in a significantly higher maximum plantarflexion as well as plantarflexion/dorsiflexion range when compared to other maneuvers. CONCLUSION: This study describes the range of ankle motion identified to drive a car with a manual transmission and a left-sided steering wheel. The right and left ankle exhibit different arcs of motion during driving. This knowledge may assist when evaluating a patient's driving capability. Further studies are needed to investigate whether movement restrictions impair driving. LEVEL OF EVIDENCE: Basic science study.

Human iPSC-derived iMSCs improve bone regeneration in mini-pigs.

Autologous bone marrow concentrate (BMC) and mesenchymal stem cells (MSCs) have beneficial effects on the healing of bone defects. To address the shortcomings associated with the use of primary MSCs, induced pluripotent stem cell (iPSC)-derived MSCs (iMSCs) have been proposed as an alternative. The aim of this study was to investigate the bone regeneration potential of human iMSCs combined with calcium phosphate granules (CPG) in critical-size defects in the proximal tibias of mini-pigs in the early phase of bone healing compared to that of a previously reported autograft treatment and treatment with a composite made of either a combination of autologous BMC and CPG or CPG alone. iMSCs were derived from iPSCs originating from human fetal foreskin fibroblasts (HFFs). They were able to differentiate into osteoblasts in vitro, express a plethora of bone morphogenic proteins (BMPs) and secrete paracrine signaling-associated cytokines such as PDGF-AA and osteopontin. Radiologically and histomorphometrically, HFF-iMSC + CPG transplantation resulted in significantly better osseous consolidation than the transplantation of CPG alone and produced no significantly different outcomes compared to the transplantation of autologous BMC + CPG after 6 weeks. The results of this translational study imply that iMSCs represent a valuable future treatment option for load-bearing bone defects in humans.

Normal CRP and WBC values in total hip arthroplasty (THA) with signs of loosening. Do we need a joint aspiration?

PURPOSE: Overall Total hip arthroplasty (THA) is a very successful procedure. However, in case of complication dedicated management is required. Two major complications of THA failures are aseptic loosening (AL) and periprosthetic joint infection (PJI). The primary hypothesis of this study was that joint aspirations in patients with signs of loosening after THA are capable to detect PJI in suspected AL with negative serologic testing. METHODS: In this study a total of 108 symptomatic patients with radiographic signs of prosthetic loosening and hip pain in THA were included. Based on a standardized algorithm all patients underwent serological testing followed by joint aspiration preoperatively. Intraoperatively harvested samples were subjected to microbiological testing and served as the gold standard in differential diagnosis. Demographics, as well as the results of serologic and microbiological testing were collected from the medical records. RESULTS: Of the included patients 85 were finally diagnosed with an AL and 23 with PJI. Within the patients with PJI 13 (56%) patients demonstrated elevated CRP and WBC counts, as well as positive synovial cultures after joint aspiration. In ten patients (44%) diagnosed with PJI neither CRP nor WBC were abnormal. CONCLUSION: The diagnosis of PJI can be difficult in THA with radiographic signs of loosening. Clinical features including pain, fever, and local sings of infection are uncommon especially a long period after index operation. First-line screening testing relies on serological evaluation of CRP and WBC. However, normal CRP and WBC values cannot rule out a PJI. These cases can be detected by joint aspiration and synovial cultures reliably.

Aseptic Loosening after THA and TKA - Do gender, tobacco use and BMI have an impact on implant survival time?

PURPOSE: Aseptic loosening (AL) has been reported to be one of the most frequent complications in Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA). The aim of this study was to identify the effects of gender, current tobacco use and BMI on the incidence of AL and implant survival time in THA and TKA. METHODS: Between July 2012 and December 2016 all patients that were diagnosed with an AL of a primary THA or primary TKA and underwent revision surgery at a single institution were retrospectively reviewed for this study. For each patient gender, current tobacco use, BMI, and implant survival time were obtained from the medical records. RESULTS: 202 patients with 85 THA and 117 TKA were included in this study. There was no impact of the gender on implant survival times (p > 0.05) in THA and TKA. In the TKA group current tobacco use was associated with a significant shorter implant survival time (p < 0.05). For THA and TKA with cemented stem fixation a significant increase of AL was seen in overweight compared to normal weight patients (p < 0.05) and in obese compared to normal weight patients (p < 0.05). CONCLUSION: The results demonstrate that current tobacco use and elevated BMI are associated with increased rates of AL in TKA. Also, in THA with cemented stem fixation an elevated BMI is associated with an increased incidence of AL.

Assessment of glycosaminoglycan content in intervertebral discs of patients with leg length discrepancy: A pilot study.

OBJECTIVE: Leg length discrepancy (LLD) could be a predisposing factor for early degeneration of lumbar intervertebral discs (IVD). The purpose of this study was to elucidate the molecular effect of LLD on IVDs. METHODS: IVDs of Eleven patients (25.6 ±â€¯4.3years) with LLD (>10 mm) and 14 control subjects (23.9 ±â€¯3.5years) were compared using a 3T-MR scanner. Morphological T2-weighted and glycosaminoglycan-chemical-exchange-saturation-transfer (gagCEST) sequences were performed. RESULTS: No differences in morphological Pfirrmann grading were found (p > 0.05). In contrast, nucleus-pulposus-gagCEST-values of L5/S1 were significantly lower (p = 0.0008). CONCLUSION: Our results suggest that LLD is a predisposing factor for molecular IVD alterations, which are detectable even before morphological pathologies could be found.

Characterisation of Victims Of Violence in the A & E Department and Analysis of the Acceptance of a Medico-Legal Expertise Centre After its Implementation vs. Multi-Year Consolidation. / Charakterisierung unfallchirurgischer Gewaltopfer und Erfassung der Inanspruchnahme nach Implementierung und mehrjähriger Etablierung einer rechtsmedizinischen Gewaltopferambulanz.

BACKGROUND: People who have become victims of domestic or public violence often suffer long-term physical, psychological and social impairment. Due to physical injury, the first contact with the health care system is frequently an A & E Department. Thus, physicians and especially surgeons play a key role in detecting victims of domestic or public violence. The specific needs of victims are adequate medical treatment of injuries, forensic documentation, as well as interdisciplinary medical support to prevent further morbidity and violence. To take this into account, so-called expertise centres for victims of violence have been established at several locations in Germany in recent years. In this study: I. We tried to define the characteristics of victims of domestic and public violence to ensure better identification by physicians/surgeons. II. We elucidate the acceptance and effectiveness of such an expertise centre one year after its implementation and for a period of three years (2007 - 2009) and for a follow-up period of three years (2014 - 2016) after establishment. MATERIAL AND METHODS: Patients were prospectively classified as victims of violence by the attending physician at the A & E Department and further treatment was initiated by the expertise centre for victims of violence. Medical reports from the A & E Department were analysed anonymously and compared with the number of patients of the expertise centre for victims of violence who had been referred from A & E Department. RESULTS: Orthopaedic and trauma surgery is the main referring discipline for the expertise centre for victims of violence. 0.9% of patients (2007 - 2009) and in the follow-up period (2014 - 2016) even 1.6% of patients were identified as victims of violence. However, the acceptance of such a centre fell from 22.2% (2007 - 2009) to 17.2% (2014 - 2016). CONCLUSION: Physicians and especially trauma surgeons are responsible for identifying victims of domestic or public violence and ensuring further treatment. Accordingly, it is crucial that the expertise centre should characterise the victims of violence and be aware of their different needs, if the expertise centre is to be accepted. The results of this study indicate that interdisciplinary training and close cooperation between traumatology and legal medicine are the main prerequisites for continuous improvement in the treatment of victims of violence.

Is computerised 3D templating more accurate than 2D templating to predict size of components in primary total hip arthroplasty?

INTRODUCTION: The aim of this study was to compare the accuracy of preoperative templating in total hip arthroplasty (THA) using conventional 2-dimensional (2D) and computed tomography (CT)-based 3-dimensional (3D) measures. METHODS: One hundred and sixteen consecutive primary THAs were analysed. The preoperative diagnosis was primary osteoarthritis in all cases. The 2D templating and the 3D templating were performed by two different residents. All templating results were available for the orthopaedic surgeon performing the procedure. Accuracies with regard to the predicted and actual implant sizes were determined for each procedure. Implantation of the size as planned was defined as "exact", whereas the use of components within one size larger or smaller (±1) as planned were defined as "accurate." RESULTS: The 3D templating was significantly more accurate in predicting implant sizing compared to 2D templating for primary total hip arthroplasty (THA). The difference was statistically significant for the cup templating (''exact'' p = 0.02; ''accurate'' p = 0.01) and for the stem templating (''exact'' p = 0.04; ''accurate'' p = 0.01). CONCLUSION: Our results support the superiority of 3D templating over 2D templating in predicting implant size.

Fractures in German elite male soccer players.

BACKGROUND: Aim of this retrospective cohort study was to identify fracture epidemiology and off times after different types of fractures in German male elite soccer players from the first division Bundesliga based on information from the public media. METHODS: Exposure and fracture data over 7.5 consecutive seasons (2009/10 until the first half of 2016/17) were collected from two media-based register (transfermarkt.de® and kicker.de®). RESULTS: Overall, 357 fractures from 290 different players were recorded with an incidence of 0.19/1000 hours of exposure (95% CI: 0.14-0.24). Most fractures in German elite soccer players involved the lower extremities (35.3%), the head/face (30.3%) and the upper extremities (24.9%). The median off time after a fracture in German elite male professional soccer in 7.5 Season was 51.1 days (range 0-144). The number of fractures per 100 players per season decreased between 2009 and 2016. There was no significant difference in overall fracture incidence when comparing players at different position (P=0.11). Goalkeepers have a significantly (P<0.02) higher likelihood of suffering hand and finger fractures and they are significantly (P<0.03) less prone of suffering foot fractures, cranial and maxillofacial fractures (P<0.04). compared to outfield players. CONCLUSIONS: This study can confirm that male professional soccer teams experience 1-2 fractures per season in German elite soccer. The incidence of fractures in elite German soccer players decreased between 2009 and 2016. The most fractures occur in the lower extremities and there is no difference in overall fracture risk for players at different playing positions. The information from our study might be of a great importance to medical practitioners, soccer coaches and soccer manager.

Anterior cruciate ligament ruptures in German elite soccer players: Epidemiology, mechanisms, and return to play.

BACKGROUND: Anterior cruciate ligament ruptures (ACLRs) are severe sports-related injuries with significant consequences for affected players and teams. This study aims to identify the epidemiology and injury-related lay-off after ACLR in professional male soccer players from the first-division German Bundesliga. METHODS: Exposure times and incidence of anterior cruciate ligament ruptures were collected during 7.5 consecutive seasons using two media-based registers. RESULTS: A total of 72 total ACLRs were registered in 66 different players with an incidence of 0.040 per 1000h of exposure (95% CI 0.009-0.12). On average there were 9.6 ACLRs per season and 0.53 per team and season. The mean age of players affected was 24 (standard deviation±3.6) years. The number of ACLRs recorded per season fluctuated during the period observed. Goalkeepers are significantly (P<0.05) less prone to suffer an ACLR compared to outfield players. CONCLUSIONS: Understanding ACLR loading mechanisms, knowing risk factors for the injury and mean off time after ACLR are essential information for the coach, the medical staff, the elite soccer players, the insurance and team managers. Our results are in accordance with reports based on information from medical team staff. Therefore, our analysis of ACLR based on media sources may serve as an alternative for injury reports in elite soccer. The information of this study may be helpful for the medical staff taking care of professional soccer players and for orthopedic surgeons performing ACL reconstructions in this patient population.

Molecular- and microarray-based analysis of diversity among resting and osteogenically induced porcine mesenchymal stromal cells of several tissue origin.

Mesenchymal stromal cells (MSCs) play a pivotal role in modern therapeutic approaches in bone-healing disorders. Although bone marrow-derived MSCs are most frequently used, the knowledge that many other adult tissues represent promising sources for potent MSCs has gained acceptance. In the present study, the osteogenic differentiation potential of porcine skin fibroblasts (FBs), as well as bone marrow- (BMSCs), adipose tissue- (ASCs) and dental pulp-derived stromal cells (DSCs) were evaluated. However, additional application of BMP-2 significantly elevated the delayed osteogenic differentiation capacity of ASC and FB cultures, and in DSC cultures the supplementation of platelet-rich plasma increased osteogenic differentiation potential to a comparable level of the good differentiable BMSCs. Furthermore, microarray gene expression performed in an exemplary manner for ASCs and BMSCs revealed that ASCs and BMSCs use different gene expression patterns for osteogenic differentiation under standard media conditions, as diverse MSCs are imprinted dependent from their tissue niche. However, after increasing the differentiation potential of ASCs to a comparable level as shown in BMSCs, a small subset of identical key molecules was used to differentiate in the osteogenic lineage. Until now, the importance of identified genes seems to be underestimated for osteogenic differentiation. Apparently, the regulation of transmembrane protein 229A, interleukin-33 and the fibroblast growth factor receptor-2 in the early phase of osteogenic differentiation is needed for optimum results. Based on these results, bone regeneration strategies of MSCs have to be adjusted, and in vivo studies on the osteogenic capacities of the different types of MCSs are warranted. Copyright © 2016 The Authors Tissue Engineering and Regenerative Medicine published by John Wiley & Sons, Ltd.