Tibial Tunnel Positioning Technique Using Bony/Anatomical Landmarks in Anatomical Anterior Cruciate Ligament Reconstruction.

Because various biomechanical studies and clinical results have shown the effectiveness of an anatomical approach for anterior cruciate ligament (ACL) reconstruction, this approach has become gradually commonplace to improve postoperative performance. Standard tunnel positioning methods with accuracy, reproducibility, and adaptability to varied concepts are essential for the success of anatomical ACL reconstruction. However, there were no standard tibial tunnel positioning methods to satisfy these conditions. This technical note reports our tibial tunnel positioning technique using bony and/or anatomical landmarks for anatomical ACL reconstruction.

A three-dimensional block structure consisting exclusively of carbon nanotubes serving as bone regeneration scaffold and as bone defect filler.

Many recent studies have been conducted to assess the ability of composite materials containing carbon nanotubes (CNTs) with high bone affinity to serve as scaffolds in bone regenerative medicine. These studies have demonstrated that CNTs can effectively induce bone formation. However, no studies have investigated the usefulness of scaffolds consisting exclusively of CNTs in bone regenerative medicine. We built a three-dimensional block entity with maximized mechanical strength from multi-walled CNTs (MWCNT blocks) and evaluated their efficacy as scaffold material for bone repair. When MWCNT blocks containing recombinant human bone morphogenetic protein-2 (rhBMP-2) were implanted in mouse muscle, ectopic bone was formed in direct contact with the blocks. Their bone marrow densities were comparable to those of PET-reinforced collagen sheets with rhBMP-2. On day 1 and day 3, MC3T3-E1 preosteoblasts were attached to the scaffold surface of MWCNT blocks than that of PET-reinforced collagen sheets. They also showed a maximum compression strength comparable to that of cortical bone. Our MWCNT blocks are expected to serve as bone defect filler and scaffold material for bone regeneration.

Remnant-Preserving Tibial Tunnel Positioning Using Anatomic Landmarks in Double-Bundle Anterior Cruciate Ligament Reconstruction.

PURPOSE: To assess (1) if 6 anatomic landmarks (ALs) could be arthroscopically confirmed with remnant preservation and (2) if creating tibial tunnels using these landmarks reduces individual variation and improves reproducibility in double-bundle anterior cruciate ligament (ACL) reconstruction. METHODS: We retrospectively reviewed data of patients who chronologically underwent double-bundle ACL reconstruction by either referencing the footprint after remnant dissection (non-AL group) or subsequently with the ALs (AL group). Using operative videos, 3 independent observers judged whether they could confirm 6 ALs (medial intercondylar ridge, medial and lateral intercondylar tubercles, anterior horn of lateral meniscus, Parsons' knob, and L-shaped ridge) in 20 patients randomly selected from the AL group. We then compared tunnel positions between the 2 groups, measured from the anterior and medial borders of the proximal tibia and expressed as percentage of the total depth and width of the proximal tibia using 3-dimensional computed tomography. RESULTS: One hundred four patients (non-AL group, n = 54; AL group, n = 50) were included. All 6 ALs were arthroscopically confirmed in most cases (89.7% to 100%). The mean percentages of the anteroposterior (AP) depth for anteromedial (AM) tunnel, mediolateral (ML) width for AM tunnel, AP depth for posterolateral (PL) tunnel, and ML width for PL tunnel, respectively, were 27.8% ± 6.6%, 46.7% ± 2.8%, 41.4% ± 7.3%, and 46.1% ± 2.6% for the non-AL group and 30.7% ± 4.5%, 45.7% ± 2.2%, 45.2% ± 4.5%, and 46.9% ± 2.1% for the AL group, revealing significantly less variation in the AL group compared with the non-AL group, excluding the ML width of the PL tunnel (P = .007, .046, .002, .209, respectively). CONCLUSIONS: Six landmarks could be reliably confirmed in cases with remnant preservation, and creating tibial tunnels using these landmarks were reproducible and resulted in less individual variation. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

What Components Comprise the Measurement of the Tibial Tuberosity-Trochlear Groove Distance in a Patellar Dislocation Population?

BACKGROUND: The tibial tuberosity-trochlear groove distance is used as an indicator for medial tibial tubercle transfer; however, to our knowledge, no studies have verified whether this distance is strongly affected by tubercle lateralization at the proximal part of the tibia. We hypothesized that the tibial tuberosity-trochlear groove distance is mainly affected by tibial tubercle lateralization at the proximal part of the tibia. METHODS: Forty-four patients with a history of patellar dislocation and forty-four age and sex-matched controls were analyzed with use of computed tomography. The tibial tuberosity-trochlear groove distance, tibial tubercle lateralization, trochlear groove medialization, and knee rotation were measured and were compared between the patellar dislocation group and the control group. The association between the tibial tuberosity-trochlear groove distance and three other parameters was calculated with use of the Pearson correlation coefficient and partial correlation analysis. RESULTS: There were significant differences in the tibial tuberosity-trochlear groove distance (p < 0.001) and knee rotation (p < 0.001), but there was no difference in the tibial tubercle lateralization (p = 0.13) and trochlear groove medialization (p = 0.08) between the patellar dislocation group and the control group. The tibial tuberosity-trochlear groove distance had no linear correlation with tubercle lateralization (r = 0.21) or groove medialization (r = -0.15); however, knee rotation had a good positive correlation in the patellar dislocation group (r = 0.62). After adjusting for the remaining parameters, knee rotation strongly correlated with the tibial tuberosity-trochlear groove distance (r = 0.69, p < 0.001), whereas tubercle lateralization showed moderate significant correlations in the patellar dislocation group (r = 0.42; p = 0.005). CONCLUSIONS: Because the tibial tuberosity-trochlear groove distance is affected more by knee rotation than by tubercle malposition, its use as an indicator for tibial tubercle transfer may not be appropriate. CLINICAL RELEVANCE: Surgical decisions of tibial tubercle transfer should be made after the careful analysis of several underlying factors of patellar dislocation.

Specific biological responses of the synovial membrane to carbon nanotubes.

Biological evaluation of carbon nanotubes (CNTs) is typically performed in the lung or abdominal cavity; however, biological reactions to CNTs are predicted to be markedly different in other tissues. In applications of CNTs as reinforcement for artificial joints and drug delivery systems, including their use in bone regeneration, the intra-articular synovial membrane makes contact with the CNTs. Herein, we analyzed the reaction of the synovial membrane with multiwalled CNTs (MWCNTs). Injection of MWCNTs into rat knee joints revealed their dose-dependent incorporation into deep synovial membranes and the formation of granulation tissue, without long-term inflammation. MWCNTs were incorporated into human fibroblast-like synoviocytes (HFLSs), with less cytotoxicity than that observed in macrophages (RAW264 cells). Moreover, MWCNTs inhibited the release of cytokines and chemokines from HFLSs. The reaction of the synovial membrane with MWCNTs differed from that observed in other tissues; thus, detailed biological evaluation at each target site is necessary for clinical applications.

Endocytosis of Multiwalled Carbon Nanotubes in Bronchial Epithelial and Mesothelial Cells.

Bronchial epithelial cells and mesothelial cells are crucial targets for the safety assessment of inhalation of carbon nanotubes (CNTs), which resemble asbestos particles in shape. Intrinsic properties of multiwalled CNTs (MWCNTs) are known to cause potentially hazardous effects on intracellular and extracellular pathways. These interactions alter cellular signaling and affect major cell functions, resulting in cell death, lysosome injury, reactive oxygen species production, apoptosis, and cytokine release. Furthermore, CNTs are emerging as a novel class of autophagy inducers. Thus, in this study, we focused on the mechanisms of MWCNT uptake into the human bronchial epithelial cells (HBECs) and human mesothelial cells (HMCs). We verified that MWCNTs are actively internalized into HBECs and HMCs and were accumulated in the lysosomes of the cells after 24-hour treatment. Next, we determined which endocytosis pathways (clathrin-mediated, caveolae-mediated, and macropinocytosis) were associated with MWCNT internalization by using corresponding endocytosis inhibitors, in two nonphagocytic cell lines derived from bronchial epithelial cells and mesothelioma cells. Clathrin-mediated endocytosis inhibitors significantly suppressed MWCNT uptake, whereas caveolae-mediated endocytosis and macropinocytosis were also found to be involved in MWCNT uptake. Thus, MWCNTs were positively taken up by nonphagocytic cells, and their cytotoxicity was closely related to these three endocytosis pathways.

Intrameniscal Gouty Tophi in the Knee: A Case Report.

CASE: We report a case of recurrent acute arthritis and restricted range of motion in the knee joint, with magnetic resonance imaging subsequently detecting a nodular lesion within the lateral meniscus. Knee arthroscopy and histology revealed that the lesion was intrameniscal gouty tophi. After arthroscopic synovectomy and excision of the tophi, the symptoms resolved and the patient remained symptom-free at two years of follow-up. CONCLUSION: Surgeons should be aware of the presence of such pathology and consider arthroscopic surgery if the mechanical symptoms persist.

Biological responses according to the shape and size of carbon nanotubes in BEAS-2B and MESO-1 cells.

This study aimed to investigate the influence of the shape and size of multi-walled carbon nanotubes (MWCNTs) and cup-stacked carbon nanotubes (CSCNTs) on biological responses in vitro. Three types of MWCNTs - VGCF(®)-X, VGCF(®)-S, and VGCF(®) (vapor grown carbon fibers; with diameters of 15, 80, and 150 nm, respectively) - and three CSCNTs of different lengths (CS-L, 20-80 µm; CS-S, 0.5-20 µm; and CS-M, of intermediate length) were tested. Human bronchial epithelial (BEAS-2B) and malignant pleural mesothelioma cells were exposed to the CNTs (1-50 µg/mL), and cell viability, permeability, uptake, total reactive oxygen species/superoxide production, and intracellular acidity were measured. CSCNTs were less toxic than MWCNTs in both cell types over a 24-hour exposure period. The cytotoxicity of endocytosed MWCNTs varied according to cell type/size, while that of CSCNTs depended on tube length irrespective of cell type. CNT diameter and length influenced cell aggregation and injury extent. Intracellular acidity increased independently of lysosomal activity along with the number of vacuoles in BEAS-2B cells exposed for 24 hours to either CNT (concentration, 10 µg/mL). However, total reactive oxygen species/superoxide generation did not contribute to cytotoxicity. The results demonstrate that CSCNTs could be suitable for biological applications and that CNT shape and size can have differential effects depending on cell type, which can be exploited in the development of highly specialized, biocompatible CNTs.

Early Postoperative Intratunnel Migration of an EndoButton After Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction: A Case Report.

CASE: We report a rare case of early postoperative migration of an EndoButton following anatomic double-bundle anterior cruciate ligament reconstruction with use of the EndoButton for femoral fixation. Although secure fixation of the EndoButton was confirmed during the operation, one-week postoperative radiographs revealed an intratunnel displacement of the posterolateral EndoButton. We performed a reoperation and refixed the EndoButton to the surface of the femoral cortex; we also hooked and tied both ends of the sutures to make a knot in order to prevent remigration. CONCLUSION: Orthopaedic surgeons should be aware that EndoButton displacement and migration could arise at an early postoperative stage.

Culture medium type affects endocytosis of multi-walled carbon nanotubes in BEAS-2B cells and subsequent biological response.

We examined the cytotoxicity of multi-walled carbon nanotubes (MWCNTs) and the resulting cytokine secretion in BEAS-2B cells or normal human bronchial epithelial cells (HBEpCs) in two types of culture media (Ham's F12 containing 10% FBS [Ham's F12] and serum-free growth medium [SFGM]). Cellular uptake of MWCNT was observed by fluorescent microscopy and analyzed using flow cytometry. Moreover, we evaluated whether MWCNT uptake was suppressed by 2 types of endocytosis inhibitors. We found that BEAS-2B cells cultured in Ham's F12 and HBEpCs cultured in SFGM showed similar biological responses, but BEAS-2B cells cultured in SFGM did not internalize MWCNTs, and the 50% inhibitory concentration value, i.e., the cytotoxicity, was increased by more than 10-fold. MWCNT uptake was suppressed by a clathrin-mediated endocytosis inhibitor and a caveolae-mediated endocytosis inhibitor in BEAS-2B cells cultured in Ham's F12 and HBEpCs cultured in SFGM. In conclusion, we suggest that BEAS-2B cells cultured in a medium containing serum should be used for the safety evaluation of nanomaterials as a model of normal human bronchial epithelial cells. However, the culture medium composition may affect the proteins that are expressed on the cytoplasmic membrane, which may influence the biological response to MWCNTs.

Carcinogenicity evaluation for the application of carbon nanotubes as biomaterials in rasH2 mice.

The application of carbon nanotubes (CNTs) as biomaterials is of wide interest, and studies examining their application in medicine have had considerable significance. Biological safety is the most important factor when considering the clinical application of CNTs as biomaterials, and various toxicity evaluations are required. Among these evaluations, carcinogenicity should be examined with the highest priority; however, no report using transgenic mice to evaluate the carcinogenicity of CNTs has been published to date. Here, we performed a carcinogenicity test by implanting multi-walled CNTs (MWCNTs) into the subcutaneous tissue of rasH2 mice, using the carbon black present in black tattoo ink as a reference material for safety. The rasH2 mice did not develop neoplasms after being injected with MWCNTs; instead, MWCNTs showed lower carcinogenicity than carbon black. Such evaluations should facilitate the clinical application and development of CNTs for use in important medical fields.

Biocompatibility and bone tissue compatibility of alumina ceramics reinforced with carbon nanotubes.

AIMS: The addition of carbon nanotubes (CNTs) remarkably improves the mechanical characteristics of base materials. CNT/alumina ceramic composites are expected to be highly functional biomaterials useful in a variety of medical fields. Biocompatibility and bone tissue compatibility were studied for the application of CNT/alumina composites as biomaterials. METHODS & RESULTS: Inflammation reactions in response to the composite were as mild as those of alumina ceramic alone in a subcutaneous implantation study. In bone implantation testing, the composite showed good bone tissue compatibility and connected directly to new bone. An in vitro cell attachment test was performed for osteoblasts, chondrocytes, fibroblasts and smooth muscle cells, and CNT/alumina composite showed cell attachment similar to that of alumina ceramic. DISCUSSION & CONCLUSION: Owing to proven good biocompatibility and bone tissue compatibility, the application of CNT/alumina composites as biomaterials that contact bone, such as prostheses in arthroplasty and devices for bone repair, are expected.

Comparison between continuous and discontinuous multiple vertebral compression fractures.

BACKGROUND: The majority of multiple vertebral fractures (MVFs) occur under high-energy conditions; however, some cases occurring under minor-energy conditions exist. Fractures in successive vertebrae (continuous type) and in skipped vertebrae (discontinuous type) can exist. PURPOSE: The objective of this study was to compare and evaluate the cause, level of injury, and relationship to osteoporosis between continuous and discontinuous MVFs. METHODS: We studied 77 subjects (173 vertebrae) who had presented with acute back pain between September 2007 and April 2010 and who received diagnoses of fresh MVFs through magnetic resonance imaging. Subjects with continuous and discontinuous fractures were evaluated based on age, sex, bone mineral density (BMD), level of affected vertebrae, and cause of injury. RESULTS: Subjects with discontinuous MVFs were significantly older and comprised more female patients. Mean BMD, measured by dual-emission X-ray absorptiometry, was 0.70 and 0.58 g/cm(3) for the continuous and discontinuous MVFs, respectively, demonstrating a significant difference. Of 34 patients with discontinuous MVFs, 32 (94%) exhibited vertebral fractures in the thoracolumbar junction. In subjects with continuous MVFs, the MVFs of 19 (44%) subjects were caused by high-energy trauma, whereas mild trauma and unknown cause were identified in 14 (41%) and 13 (38%) subjects with discontinuous MVFs, respectively. CONCLUSIONS: Discontinuous MVFs generally caused by mild outer force, and often occurred at the thoracolumbar junction. Continuous MVFs, frequently, were caused by high-energy trauma.

DJ-1 as a potential biomarker for the development of biocompatible multiwalled carbon nanotubes.

BACKGROUND: In the present study, we investigated whether DJ-1 could serve as a biomarker for assessing the biocompatibility of multiwalled carbon nanotubes (MWCNTs), using the highly purified carbon nanotube, HTT2800. METHODS: Using Western blot analysis, we determined DJ-1 protein levels in two different types of cells (one capable and the other incapable of HTT2800 endocytosis). Using quantitative real-time polymerase chain reaction, we also investigated the ability of purified nanotubes to alter DJ-1 mRNA levels. RESULTS: We demonstrated that the DJ-1 protein concentration was reduced, regardless of the cytotoxic activity of intracellular HTT2800. Furthermore, HTT2800 decreased the DJ-1 mRNA levels in a dose-dependent manner. This decrease in DJ-1 mRNA levels was not observed in the case of Sumi black or cup-stacked carbon nanotubes. CONCLUSION: These data indicate that modification of DJ-1 expression is caused by the cell response to MWCNTs. We conclude that DJ-1 is a promising candidate biomarker for the development of biocompatible MWCNTs.

Toxicoproteomic evaluation of carbon nanomaterials in vitro.

Carbon nanotubes (CNTs) have already been successfully implemented in various fields, and they are anticipated to have innovative applications in medical science. However, CNTs have asbestos-like properties, such as their nanoscale size and high aspect ratio (>100). Moreover, CNTs may persist in the body for a long time. These properties are thought to cause malignant mesothelioma and lung cancer. However, based on conventional toxicity assessment systems, the carcinogenicity of asbestos and CNTs is unclear. The reason for late countermeasures against asbestos is that reliable, long-term safety assessments have not yet been developed by toxicologists. Therefore, a new type of long-term safety assessment, different from the existing methods, is needed for carbon nanomaterials. Recently, we applied a proteomic approach to the safety assessment of carbon nanomaterials. In this review, we discuss the basic concept of our approach, the results, the problems, and the possibility of a long-term safety assessment for carbon nanomaterials using the toxicoproteomic approach.

Elucidation mechanism of different biological responses to multi-walled carbon nanotubes using four cell lines.

We examined differences in cellular responses to multi-walled carbon nanotubes (MWCNTs) using malignant pleural mesothelioma cells (MESO-1), bronchial epithelial cells (BEAS-2B), neuroblastoma cells (IMR-32), and monoblastic cells (THP-1), before and after differentiation. MESO-1, BEAS-2B and differentiated THP-1 cells actively endocytosed MWCNTs, resulting in cytotoxicity with lysosomal injury. However, cytotoxicity did not occur in IMR-32 or undifferentiated THP-1 cells. Both differentiated and undifferentiated THP-1 cells exhibited an inflammatory response. Carbon blacks were endocytosed by the same cell types without lysosomal damage and caused cytokine secretion, but they did not cause cytotoxicity. These results indicate that the cytotoxicity of MWCNTs requires not only cellular uptake but also lysosomal injury. Furthermore, it seems that membrane permeability or cytokine secretion without cytotoxicity results from several active mechanisms. Clarification of the cellular recognition mechanism for MWCNTs is important for developing safer MWCNTs.

Effect of dispersants of multi-walled carbon nanotubes on cellular uptake and biological responses.

Although there have been many reports about the cytotoxicity of multi-walled carbon nanotubes (MWCNTs), the results are still controversial. To investigate one possible reason, the authors investigated the influence of MWCNT dispersants on cellular uptake and cytotoxicity. Cytotoxicity was examined (measured by alamarBlue(®) assay), as well as intracellular MWCNT concentration and cytokine secretion (measured by flow cytometry) in human bronchial epithelial cells (BEAS-2B) exposed to a type of highly purified MWCNT vapor grown carbon fiber (VGCF(®), Showa Denko Kabushiki-gaisha, Tokyo, Japan) in three different dispersants (gelatin, carboxylmethyl cellulose, and 1,2-dipalmitoyl-sn-glycero-3-phosphocholine). The authors also researched the relationship between the intracellular concentration of MWCNTs and cytotoxicity by using two cell lines, BEAS-2B and MESO-1 human malignant pleural mesothelioma cells. The intracellular concentration of VGCF was different for each of the three dispersants, and the levels of cytotoxicity and inflammatory response were correlated with the intracellular concentration of VGCF. A relationship between the intracellular concentration of VGCF and cytotoxic effects was observed in both cell lines. The results indicate that dispersants affect VGCF uptake into cells and that cytotoxicity depends on the intracellular concentration of VGCF, not on the exposed dosage. Thus, toxicity appears to depend on exposure time, even at low VGCF concentrations, because VGCF is biopersistent.