An anteromedial stabilization procedure has the most protective effect on the anterior cruciate ligament in tibial external rotation. A human knee model study.

INTRODUCTION: Anterior cruciate ligament (ACL) reconstruction remains associated with the risk of re-rupture and persisting rotational instability. Additional extraarticular anterolateral stabilization procedures stabilize the tibial internal rotation and lead to lower ACL failure rate and improved knee stability. However, data for additional stabilization of tibial external rotation is lacking and the importance of an anteromedial stabilization procedure is less well evaluated. Aim of this study is to investigate the influence of an extraarticular anteromedial stabilization procedure for the stabilization of the tibial external rotation and protection of the ACL from these rotational forces. METHODS: Internal and external rotations of the tibia were applied to a finite element (FE) model with anatomical ACL, posterior cruciate ligament (PCL), lateral collateral ligament (LCL), medial collateral ligament (MCL) and intact medial and lateral meniscus. Five additional anatomic structures (Anteromedial stabilization/anteromedial ligament, AML, augmented superficial medial collateral ligament, sMCL, posterior oblique ligament, POL, anterolateral ligament, ALL, and popliteal tendon, PLT) were added to the FE model separately and then combined. The force histories within all structures were measured and determined for each case. RESULTS: The anteromedial stabilization or imaginary AML was the main secondary stabilizer of tibial external rotation (90% of overall ACL force reduction). The AML reduced the load on the ACL by 9% in tibial external rotation which could not be achieved by an augmented sMCL (-1%). The AML had no influence in tibial internal rotation (-1%). In the combined measurements with all additional structures (AML, ALL, PLT, POL) the load on the ACL was reduced by 10% in tibial external rotation. CONCLUSION: This study showed that an additional anteromedial stabilization procedure secures the tibial external rotation and has the most protective effect on the ACL during these external rotational forces.

Long-term results of arthroscopic capsulolabral revision repair for failed anterior shoulder instability repair using suture anchors at a minimum of 10 years follow-up.

INTRODUCTION: Arthroscopic revision anterior shoulder instability repair has been proposed, and early clinical results have been promising. However, long-term results after this procedure and the probable risk factors for failure have not been sufficiently discussed in the literature. MATERIALS AND METHODS: Thirty-eight patients who were diagnosed with recurrent anteroinferior shoulder instability after failed Bankart repair, treated with ACRR between September 1998 and November 2003 and able to be contacted were included. Of these patients, 2 were excluded from the study due to the use of SureTak anchors for fixation, and 5 other patients refused to participate in the study due to lack of interest (3 patients) or lack of time (2 patients). The remaining shoulders were clinically examined at a minimum of ten years after surgery via the ASES, Constant, AAOS, Rowe, Dawson and VAS scores for pain and stability. Degenerative arthropathy was assessed with the modified Samilson-Prieto score. RESULTS: All 31 remaining shoulders were evaluated at a mean time of 11.86 years (142.4 months) after surgery. Six patients (19.35%) reported redisolcation after the revision procedure, 4 of whom were affected by a new significant shoulder trauma. The ROWE and Constant scores improved significantly. Moderate to severe dislocation arthropathy was observed in 19.4% of patients. Five patients (16.2%) were not satisfied with the procedure. CONCLUSION: Long-term follow-up after ACRR shows predictable results, with a high degree of patient satisfaction, good to excellent patient-reported outcome scores and minimal radiological degenerative changes. However, with an average recurrence rate of 19.3% after 11.86 years, the redislocation rate appears high. With careful patient selection, recurrence rates can be significantly reduced.

The lack of retropatellar resurfacing at index surgery is significantly associated with failure in patients following patellofemoral inlay arthroplasty: a multi-center study of more than 260 patients.

PURPOSE: To evaluate the clinical outcomes of patients with a minimum 2-year follow-up following contemporary patellofemoral inlay arthroplasty (PFIA) and to identify potential risk factors for failure in a multi-center study. METHODS: All patients who underwent implantation of PFIA between 09/2009 and 11/2016 at 11 specialized orthopedic referral centers were enrolled in the study and were evaluated retrospectively at a minimum 2-year follow-up. Clinical outcomes included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Tegner Scale, the visual analogue scale (VAS) for pain, and subjective patient satisfaction. Pre- and perioperative risk factors were compared among failures and non-failures to determine potential risk factors. RESULTS: A total of 263 patients (85% follow-up rate) could be enrolled. The mean age at the time of index surgery was 49 ± 12 years with a mean postoperative follow-up of 45 ± 18 months. The overall failure rate was 11% (28 patients), of which 18% (5 patients) were patients with patella resurfacing at index surgery and 82% (23 patients) were patients without initial patella resurfacing. At final follow-up, 93% of the patients who did not fail were satisfied with the procedure with a mean transformed WOMAC Score of 84.5 ± 14.5 points, a mean KOOS Score of 73.3 ± 17.1 points, a mean Tegner Score of 3.4 ± 1.4 points and a mean VAS pain of 2.4 ± 2.0 points. An increased BMI was significantly correlated with a worse postoperative outcome. Concomitant procedures addressing patellofemoral instability or malalignment, the lack of patellofemoral resurfacing at the index surgery and a high BMI were significantly correlated with failure in our patient cohort. CONCLUSION: Patellofemoral inlay arthroplasty shows high patient satisfaction with good functional outcomes at short-term follow-up and thus can be considered a viable treatment option in young patients suffering from isolated patellofemoral arthritis. Patellar resurfacing at index surgery is recommended to decrease the risk of failure. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

All-Arthroscopic Hydrogel-Based Autologous Chondrocyte Transplantation in the Knee Joint: Good Clinical and Magnetic Resonance Imaging Outcome After 24 Months.

PURPOSE: To evaluate subjective and objective clinical and magnetic resonance imaging-based radiologic outcomes after short-term follow-up in patients with focal full-size cartilage lesions of the knee joint treated with all-arthroscopic hydrogel-based autologous chondrocyte transplantation. METHODS: A retrospective study on patients with isolated focal cartilage defects of the knee joint who were treated with arthroscopically conducted matrix-induced autologous chondrocyte transplantation was performed. Clinical scores were assessed at baseline and final follow-up using the Tegner Score, visual analog scale, the International Knee Documentation Committee, and the 5 subscales of the Knee Injury and Osteoarthritis Outcome Score. Magnetic resonance imaging scans of the treated knee joints were evaluated with the updated MOCART (Magnetic Resonance Observation of Cartilage Repair Tissue) 2.0 scoring system at follow-up. RESULTS: Twenty-nine consecutive patients were included in the study. Mean time to follow-up was 24.9 ± 1.1 months. Average visual analog scale decreased significantly from 6.5 ± 3.1 preoperatively to 2.3 ± 1.6 at follow-up (P < .0001). Tegner score increased from 3.1 ± 1.3 to 4.3 ± 1.2 (P < .0001) and the International Knee Documentation Committee from 43.8 ± 21.9 to 64.9 ± 18.9 (P < .0001). Also, all Knee Injury and Osteoarthritis Outcome Score subscales displayed significant improvements. Patients showed similar improvements of nearly all clinical scores independent of the defect size. Average MOCART2.0 score was 70.0 ± 13.6 and 20 patients scored ≥70 points. All 8 patients with large defects (>5 cm2) scored ≥75 points. CONCLUSIONS: In this small study, injectable matrix-induced autologous chondrocyte transplantation therapy in the knee joint led to favourable clinical and radiologic short-term results with significant improvements in all clinical scores and MOCART2.0 scores, confirming morphologic integrity of the transplanted chondrocytes. Therefore, this minimally invasive procedure represents a promising operative technique for cartilage regeneration, even for large-diameter lesions. LEVEL OF EVIDENCE: IV, therapeutic case series.

Predictors for an unsuccessful conservative treatment of patients with medial patellar plica syndrome.

INTRODUCTION: In several cases persistent medial knee pain remains after conservative treatment in patients with medial patellar plica syndrome. In recent literature accepted criteria for surgical indication are lacking. In this retrospective study patients after conservative treatment were evaluated to identify predictors for an unsuccessful outcome. MATERIALS AND METHODS: 117 Patients with medial patellar plica syndrome between 2016 and 2019 were retrospectively evaluated. All patients received conservative treatment for three months. Surgery was indicated due to failed conservative treatment (n = 76) with persistent medial knee pain and restriction of activity after 3 months. Preoperative MRI analysis, Lysholm score, pain by the visual analog scale (VAS), postoperative sports participation (RTS) and Tegner activity score were collected at least 12 months after definite treatment. Statistical analysis was performed to evaluate differences between patients with successful and unsuccessful conservative treatment. RESULTS: There were significant differences in the clinical and radiological findings between patients with successful and unsuccessful conservative treatment. Patients with failed conservative treatment showed a significant larger diameter of the medial patellar plica (0.8 ± 0.3 mm vs. 1.6 ± 0.4 mm; p < 0.05) and a significant higher rate of contact of the plica to the adjacent cartilage. Furthermore, these patients reported a significant higher rate of medial knee pain from flexion to extension and snapping symptoms. At final follow-up the patient-reported outcome by means of Lysholm score (96.25 vs. 95.93), RTS (96.2% vs. 97%) and Tegner activity score (6.0 vs. 6.01) was excellent after conservative and surgical treatment. There were no statistical differences in the preoperative and postoperative outcomes between both. CONCLUSIONS: The diameter of a medial patellar plica and contact of the plica to the retropatellar cartilage as well as clinical signs like persistent medial knee pain from flexion to extension with snapping symptoms might be predictors for an unsuccessful conservative treatment and the need for surgical intervention in patients with painful medial patellar plica syndrome.

[Cartilage repair procedures for early osteoarthritis]. / Stellenwert der chirurgischen Knorpeltherapie bei Früharthrose.

BACKGROUND: Commonly used cartilage repair procedures have been established for focal cartilage lesions; however, degenerative lesions with accompanying changes of other intraarticular structures are much more common in clinical practice. This stage, in which classic radiological signs of osteoarthritis are absent, is called early osteoarthritis and is characterized by impaired joint homeostasis with biomechanical and biochemical changes that can have a negative effect on regenerative cartilage therapy procedures. INDICATION: Cartilage repair procedures are indicated for symptomatic focal early osteoarthritis, defined as cartilage degeneration ICRS grades I or II around a focal cartilage defect ICRS grades III or IV. In more advanced osteoarthritis with significant narrowing of the joint space, cartilage repair procedures are generally contraindicated. THERAPY: The most studied cartilage repair procedure for early osteoarthritis is autologous chondrocyte implantation, which has shown acceptable results in case series, although higher failure rates are to be expected compared to focal, traumatic cartilage lesions. The use of bone marrow-stimulating techniques seems to be limited in early osteoarthritis and should only be used in cases of lesion < 2 cm2 and very little surrounding cartilage degeneration. Concomitant surgical procedures, especially unloading osteotomies, are very important.

Effects of focal metallic implants on opposing cartilage - an in-vitro study with an abrasion test machine.

BACKGROUND: For focal cartilage defects, biological repair might be ineffective in patients over 45 years. A focal metallic implant (FMI) (Hemi-CAP Arthrosurface Inc., Franklin, MA, USA) was designed to reduce symptoms. The aim of this study was to evaluate the effects of a FMI on the opposing tibial cartilage in a biomechanical set-up. It is hypothesized that a FMI would not damage the opposing cartilage under physiological loading conditions. METHODS: An abrasion machine was used to test the effects of cyclic loading on osteochondral plugs. The machine applied a compressive load of 33 N and sheared the samples 10 mm in the anteroposterior direction by 1 Hz. Tibial osteochondral plugs from porcine knees were placed in opposition to a FMI and cycled for 1 or 6 h. After testing each plug was fixed, stained and evaluated for cartilage damage. RESULTS: After 1 h of loading (n = 6), none of the osteochondral plugs showed histologic signs of degradation. After 6 h of loading (n = 6) three samples had histologic signs of injury in the tangential zone (grade 1) and one had signs of injury in the transitional and deep zones (grade 2). Exploration for 6 h resulted in significant more cartilage damage compared to the shorter exploration time (p = 0.06). However, no significant difference between saline and hyaluronic acid was evident (p = 0.55). CONCLUSION: Under physiologic loading conditions, contact with a FMI leads to cartilage damage in the opposing articular cartilage in six hours. In clinical practice, a thorough analysis of pre-existing defects on the opposing cartilage is recommended when FMI is considered.

Influence of Sutures on Cartilage Integrity: Do Meniscus Sutures Harm Cartilage? An Experimental Animal Study.

PURPOSE: To evaluate whether different suture materials in meniscal repair may harm cartilage. METHODS: A preloaded linear friction testing setup including porcine knees with porcine cartilage, porcine meniscus, and different suture materials (braided nonabsorbable, absorbable monofilament) was used. Five groups with different tribological pairs were tested: cartilage on meniscus (control), cartilage on cartilage (control No. 2), and cartilage on different meniscus sutures (3 groups). Cartilage integrity was analyzed macroscopically by the India ink method and histologically using Giemsa-eosin-stained undecalcified methyl methacrylate sections. Cartilage lesions were classified by using a quantitative scoring system. RESULTS: The control groups did not show cartilage damage, either macroscopically or histologically. Loading cartilage with sutured menisci led to significant damage of the superficial radial and transitional zones with braided nonabsorbable (P = .03) and absorbable monofilament (P = .02) sutures at final examination. Menisci sutured with braided nonabsorbable material resulted in deeper damage to the cartilage. However, there were no significant differences between the suture materials. Sutures oriented perpendicular to surface motion led to a larger defect than parallel-oriented sutures. CONCLUSIONS: Braided nonabsorbable and absorbable monofilament suture materials cause significant damage to cartilage during long-term cyclic loading in vitro. The extent of damage depends on suture orientation. CLINICAL RELEVANCE: This study provides data on the extent to which different suture materials in meniscus repair may harm cartilage.

Guanine nucleotide-binding proteins of the G12 family shape immune functions by controlling CD4+ T cell adhesiveness and motility.

Integrin-mediated adhesion plays a central role in T cell trafficking and activation. Genetic inactivation of the guanine nucleotide-binding (G) protein alpha-subunits Galpha(12) and Galpha(13) resulted in an increased activity of integrin leukocyte-function-antigen-1 in murine CD4(+) T cells. The interaction with allogeneic dendritic cells was enhanced, leading to an abnormal proliferative response in vitro. In vivo, T cell-specific inactivation of Galpha(12) and Galpha(13) caused lymphadenopathy due to increased lymph node entry and enhanced T cell proliferation, and the susceptibility toward T cell-mediated diseases was enhanced. Mechanistically, we show that in the absence of Galpha(12) and Galpha(13) the activity of the small GTPases Rac1 and Rap1 was increased, whereas signaling of the small GTPase RhoA was strongly reduced. Our data indicate that locally produced mediators signal through Galpha(12)- and Galpha(13)-coupled receptors to negatively regulate cell polarization and adhesiveness, thereby fine-tuning T cell trafficking, proliferation, and susceptibility toward T cell-mediated diseases.

Langmuir Analysis of the Binding Affinity and Kinetics for Surface Tethered Duplex DNA and a Ligand-Apoprotein Complex.

In this work, the hybridization and dehybridization of ssDNA with 20 bases at gold coated sensor surfaces modified with complementary 20 bases capture probe ssDNA was investigated at 18 °C by quartz crystal microbalance measurements with dissipation monitoring (QCM-D). A sequence of 20 base pairs with a melting temperature of about 64 °C was chosen, since in many biosensor studies the target molecules are DNA or RNA oligomers of similar length. It turned out that at the applied experimental conditions the DNA hybridization was irreversible, and therefore the hybridization and dehybridization process could not be described by the Langmuir model of adsorption. Nevertheless, quantitative dehybridization could be achieved by rinsing the sensor surface thoroughly with pure water. When in contrast the hybridization of a target with only 10 bases complementary to the outermost 10 bases of the 20 bases capture probe was studied, binding and unbinding were reversible, and the hybridization/dehybridization process could be satisfactorily described by the Langmuir model. For the 10 base pair sequence, the melting temperature was about 36 °C. Apparently, for Langmuir behavior, it is important that the experiments are applied at a temperature sufficiently close to the melting temperature of the sequence under investigation to ensure that at least traces of the target molecules are unhybridized (i.e., there needs to be an equilibrium between hybridized and dehybridized target molecules). To validate the reliability of our experimental approach we also studied the reconstitution and disassembly of the flavoprotein dodecin at flavin-terminated DNA monolayers, as according to previous studies it is assumed that the apododecin-flavin system can be well described by the Langmuir model. As a result, this assumption could be verified. Using three different approaches, KD values were obtained that differ not more than by a factor of 4.

Rapid determination of binding parameters of chitin binding domains using chitin-coated quartz crystal microbalance sensor chips.

Chitin present in fungal cell walls has been considered as a diagnostic polymer for the detection of fungal infections. Chitin staining can be achieved with different dyes such as Calcofluor white or Congo red, but these methods have not entered into clinical routine diagnosis due to problems with sensitivity and specificity. More accurate detection can be achieved using chitin binding domains (CBDs) from a large variety of naturally occurring proteins that specifically interact with chitin. The chitin binding properties of most of these proteins have not yet been determined, because chitin is an insoluble fibrillar material rendering accurate determination of chitin binding kinetics challenging. Here we report a quartz crystal microbalance with dissipation monitoring (QCM-D) based method to determine binding constants of CBDs on chitin-coated gold surfaces. For this purpose, chitin was trimethylsilylated and coated onto the sensor chips. After desilylation, regular fibril-like structures with a typical center-to-center spacing of 85 nm were observed by atomic force microscopy. Using different experimental conditions and data evaluation methods for QCM-D measurements, we determined kon and koff and calculated the KD values for binding of a recombinant CBD from Bacillus circulans chitinase A1. Depending on the evaluation method, the KD values ranged between 0.6 and 2.5 µM. The obtained KD values were in good agreement with those measured for other bacterial CBDs usually ranging between 1 to 10 µM. Hence, we propose that the experimental approach developed in this study can be applied to determine yet unknown binding affinities of various CBDs from different origin.

Critical View on Electrochemical Impedance Spectroscopy Using the Ferri/Ferrocyanide Redox Couple at Gold Electrodes.

Electrochemical or faradaic impedance spectroscopy (EIS) using the ferri/ferrocyanide couple as a redox probe at gold working electrodes was evaluated with respect to its ability to monitor consecutive surface modification steps. As a model reaction, the reversible hybridization and dehybridization of DNA was studied. Thiol-modified single stranded DNA (ssDNA, 20 bases, capture probe) was chemisorbed to a gold electrode and treated with a solution of short thiols to release nonspecifically adsorbed DNA before hybridization with complementary ssDNA (20 bases, target) was carried out. Reversible dehybridization was achieved by intense rinsing with pure water. The experimental procedures were optimized by kinetic surface plasmon resonance (SPR) and quartz crystal microbalance with dissipation (QCM-D) measurements to maximize the increase in reflectivity or decrease in frequency upon hybridization before hybridization/dehybridization was also monitored by EIS. In contrast to SPR and QCM-D, repeatable EIS measurements were not possible at first. Combined SPR/EIS and QCM-D/EIS measurements revealed that during EIS the gold surface is seriously damaged due to the presence of CN(-) ions, which are released from the ferri/ferrocyanide redox probe. Even at optimized experimental conditions, etching the gold electrodes could not be completely suppressed and the repeatability of the EIS measurements was limited. In three out of four experimental runs, only two hybridization/dehybridization steps could be monitored reversibly by EIS. Thereafter etching the gold electrode significantly contributed to the EIS spectra whereas the QCM-D response was still repeatable. Hence great care has to be taken when this technique is used to monitor surface modification at gold electrodes.

Thickness Dependence of Bovine Serum Albumin Adsorption on Thin Thermoresponsive Poly(diethylene glycol) Methyl Ether Methacrylate Brushes by Surface Plasmon Resonance Measurements.

This study reports on the dependence of the temperature-induced changes in the properties of thin thermoresponsive poly(diethylene glycol) methyl ether methacrylate (PDEGMA) layers of end-tethered chains on polymer thickness and grafting density. PDEGMA layers with a dry ellipsometric thickness of 5-40 nm were synthesized by surface-initiated atom transfer radical polymerization on gold. To assess the temperature-induced changes, the adsorption of bovine serum albumin (BSA) was investigated systematically as a function of film thickness, temperature, and grafting density by surface plasmon resonance (SPR), complemented by wettability and quartz crystal microbalance with dissipation monitoring (QCM-D) measurements. BSA adsorption on PDEGMA brushes is shown to differ significantly above and below an apparent transition temperature. This surface transition temperature was found to depend linearly on the PDEGMA thickness and changed from 35 °C at 5 nm thickness to 48 °C at 23 nm. Similarly, a change of the grafting density enables the adjustment of this transition temperature presumably via a transition from the mushroom to the brush regime. Finally, BSA that adsorbed irreversibly on polymer brushes at temperatures above the transition temperature can be desorbed by reducing the temperature to 25 °C, underlining the reversibly switchable properties of PDEGMA brushes in response to temperature changes.

A biomechanical, micro-computertomographic and histological analysis of the influence of diclofenac and prednisolone on fracture healing in vivo.

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs) have long been suspected of negatively affecting fracture healing, although numerous disputes still exist and little data are available regarding diclofenac. Glucocorticoids interfere in this process over a similar and even broader mechanism of action. As many previously conducted studies evaluated either morphological changes or biomechanical properties of treated bones, the conjunction of both structural measures is completely missing. Therefore, it was our aim to evaluate the effects of diclofenac and prednisolone on the fracture callus biomechanically, morphologically and by 3-dimensional (3D) microstructural analysis. METHODS: Femura of diclofenac-, prednisolone- or placebo-treated rats were pinned and a closed transverse fracture was generated. After 21 days, biomechanics, micro-CT (µCT) and histology were examined. RESULTS: The diclofenac group showed significantly impaired fracture healing compared with the control group by biomechanics and µCT (e.g. stiffness: 57.31 ± 31.11 N/mm vs. 122.44 ± 81.16 N/mm, p = 0.030; callus volume: 47.05 ± 15.67 mm3 vs. 67.19 ± 14.90 mm3, p = 0.037, trabecular thickness: 0.0937 mm ± 0.003 vs. 0.0983 mm ± 0.003, p = 0.023), as confirmed by histology. Biomechanics of the prednisolone group showed obviously lower absolute values than the control group. These alterations were confirmed in conjunction with µCT and histology. CONCLUSIONS: The inhibiting effects of both substances were not only mediated by absolute parameters (e.g. breaking load, BV), but we have shown, for the first time, that additional changes occurred in the microstructural bony network. Especially in patients at risk for delayed bone healing (arteriosclerosis, diabetes mellitus, smoking), the administration of these drugs should be weighed carefully.

Growth factor release by vesicular phospholipid gels: in-vitro results and application for rotator cuff repair in a rat model.

BACKGROUND: Biological augmentation of rotator cuff repair is of growing interest to improve biomechanical properties and prevent re-tearing. But intraoperative single shot growth factor application appears not sufficient to provide healing support in the physiologic growth factor expression peaks. The purpose of this study was to establish a sustained release of granulocyte-colony stimulating factor (G-CSF) from injectable vesicular phospholipid gels (VPGs) in vitro and to examine biocompatibility and influence on histology and biomechanical behavior of G-CSF loaded VPGs in a chronic supraspinatus tear rat model. METHODS: G-CSF loaded VPGs were produced by dual asymmetric centrifugation. In vitro the integrity, stability and release rate were analyzed. In vivo supraspinatus tendons of 60 rats were detached and after 3 weeks a transosseous refixation with G-CSF loaded VPGs augmentation (n = 15; control, placebo, 1 and 10 µg G-CSF/d) was performed. 6 weeks postoperatively the healing site was analyzed histologically (n = 9; H&E by modified MOVIN score/Collagen I/III) and biomechanically (n = 6). RESULTS: In vitro testing revealed stable proteins after centrifugation and a continuous G-CSF release of up to 4 weeks. Placebo VPGs showed histologically no negative side effects on the healing process. Histologically in vivo testing demonstrated significant advantages for G-CSF 1 µg/d but not for G-CSF 10 µg/d in Collagen III content (p = 0.035) and a higher Collagen I/III ratio compared to the other groups. Biomechanically G-CSF 1 µg/d revealed a significant higher load to failure ratio (p = 0.020) compared to control but no significant differences in stiffness. CONCLUSIONS: By use of VPGs a continuous growth factor release could be obtained in vitro. The in vivo results demonstrate an improvement of immunohistology and biomechanical properties with a low dose G-CSF application via VPG. The VPG itself was well tolerated and had no negative influence on the healing behavior. Due to the favorable properties (highly adhesive, injectable, biocompatible) VPGs are a very interesting option for biologic augmentation. The study may serve as basis for further research in growth factor application models.

Arthroscopic Suture Anchor Fixation of Bony Bankart Lesions: Clinical Outcome, Magnetic Resonance Imaging Results, and Return to Sports.

PURPOSE: The purpose of this study was to evaluate the outcome, return to sporting activity, and postoperative articular cartilage and bony morphology of shoulders that underwent arthroscopic suture anchor repair of bony Bankart lesions. METHODS: The inclusion criteria for this retrospective study were anterior glenoid rim fractures after traumatic shoulder instability that were treated with arthroscopic suture anchor repair. Patients were surveyed by a questionnaire including sport-specific outcome, Rowe score, Western Ontario Shoulder Instability Index, and Oxford Instability Score. Three-tesla magnetic resonance imaging could be performed in 30 patients to assess osseous integration, glenoid reconstruction, and signs of osteoarthritis. RESULTS: From November 1999 to April 2010, 81 patients underwent an anterior bony Bankart repair in our department (50 arthroscopic suture anchor repairs, 5 arthroscopic screw fixations, and 26 open repairs). The 55 arthroscopic repairs comprised a consecutive cohort of patients treated by a single surgeon. Of the 50 patients in the suture anchor group, 45 (90%) were available for evaluation. At 82 ± 31 months postoperatively, the mean Rowe score was 85.9 ± 20.5 points, the mean Western Ontario Shoulder Instability Index score was 89.4% ± 14.7%, and the mean Oxford Instability Score was 13.6 ± 5.4 points. Compared with the contralateral shoulder, all scores showed a significantly reduced outcome (P < .001, P < .001, and P < .001, respectively). A redislocation occurred in 3 patients (6.6%). Regarding satisfaction, 35 patients (78%) were very satisfied, 9 (20%) were satisfied, and 1 was partly satisfied. Overall, 95% of patients returned to any sporting activity after surgery. The number of sports disciplines (P < .001), duration (P = .005), level (P = .02), and risk category (P = .013) showed a significant reduction compared with the pretrauma condition. However, only 19% of patients reported that shoulder complaints were the reason for the reduction in activity. Nonunion occurred in 16.6%, with a higher frequency in patients with chronic lesions (P = .031). Anatomic reduction was achieved in 72%, the medial step-off in patients with nonanatomic reduction averaged 1.8 ± 0.9 mm, and the remaining glenoid defect size averaged 6.8% ± 7.3%. Full-thickness cartilage defects of the anterior glenoid were detected in 70% of patients. CONCLUSIONS: Arthroscopic suture anchor repair may enable an anatomic reduction of bony Bankart lesions with no or only minimal articular steps and provides successful midterm outcomes concerning clinical scores, recurrence, and patient satisfaction. The return to activity is limited for various, mostly non-shoulder-related causes. Chronic lesions may have an inferior healing potential; therefore early surgical stabilization of acute Bankart fragments is suggested to avoid possible nonunion. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Value of additional acromioclavicular cerclage for horizontal stability in complete acromioclavicular separation: a biomechanical study.

PURPOSE: To evaluate whether isolated anatomical coracoclavicular (CC) ligament reconstruction with two suture-button devices provides equal horizontal acromioclavicular joint (ACJ) stability compared to additional ACJ suture tape cerclage. METHODS: A servohydraulic testing machine was used to assess horizontal ACJ translation in 12 fresh-frozen human shoulders during 5,000 cycles of dynamic anteroposterior directed loading (70 N). Horizontal ACJ stability was assessed for native specimen (n = 6) and compared to specimen with dissected AC ligaments but intact CC ligaments (n = 6). After complete AC/CC dissection, an anatomical CC reconstruction was performed with two suture-button devices (n = 6) and compared to the additional ACJ suture tape cerclage (n = 6). RESULTS: Native specimen showed an mean horizontal amplitude of 10.8 mm [standard deviation (SD) 3.29]. After 5,000 cycles of horizontal loading (70 N), mean amplitude increased by 1.5 mm (SD 0.75, p = 0.005). Specimen with dissected AC ligaments started at an mean amplitude of 14.1 mm (SD 4.11), which was increased by 0.9 mm (SD 0.56, n.s.) after loading. Initially, amplitude of specimen with anatomical CC reconstruction was 13.2 mm (SD 2.75), which increased by 2.9 mm (SD 1.45, p = 0.001) after loading. The specimen with additional AC cerclage initially showed an amplitude of 10.6 mm (SD 2.35). After loading, translation was increased by 3.0 mm (SD 0.97, p = 0.001). There was no failure of any surgical reconstruction in the tests. CONCLUSION: The results of this study suggest that only combined AC and CC reconstruction can adequately re-establish physiological horizontal ACJ stability. Therefore, it is likely that a combined surgical procedure with double suture-button devices and AC suture tape cerclage can adequately re-establish horizontal AC joint stability in case of an acute injury (≥type Rockwood IV and may allow superior clinical outcomes for patients, especially if early functional rehabilitation is intended).

A matched-pair comparison of two different locking plates for valgus-producing medial open-wedge high tibial osteotomy: peek-carbon composite plate versus titanium plate.

PURPOSE: The first purpose of this study was to compare the clinical and radiographic outcome of two different locking plates used for valgus-producing medial open-wedge high tibial osteotomy (HTO). The second purpose was to histologically evaluate peek-carbon wear for biocompatibility. METHODS: Twenty-six consecutive patients undergoing open-wedge HTO using the first-generation PEEKPower HTO-Plate® (Group I) were matched with 26 patients after open-wedge HTO with the TomoFix™ plate (Group II). Clinical scores (visual analogue scale for pain, WOMAC, Lysholm score) were obtained preoperatively and at a minimum follow-up of 24 months postoperatively. Fixation stability was evaluated radiographically by comparing the medial proximal tibial angle (MPTA) and tibial slope 2 days after open-wedge HTO and after implant removal. Tissue samples of Group I were collected at the time of implant removal for histologic evaluation. RESULTS: Implant-related complications occurred in 15 % (n = 4) of Group I and 0 % of Group II. Out of them, 3 implant replacements were excluded from statistical analyses. After a final median follow-up of 25 months (range 24-31), the clinical scores in both groups showed significant improvements compared to preoperatively (visual analogue scale, WOMAC, Lysholm score; p < 0.001), without significant group differences (visual analogue scale, n.s.; WOMAC, n.s.; Lysholm score, n.s.). No significant differences between baseline and follow-up measurements for MPTA and tibial slope were observed within each group (MPTA: Gr. I, n.s.; Gr. II, n.s.; tibial slope: Gr. I, n.s.; Gr. II, n.s.) or between the two groups (MPTA, n.s.; tibial slope, n.s.). In histologic samples, CF PEEK abrasion did not induce inflammation or tissue necrosis. CONCLUSION: The first-generation PEEKPower HTO-Plate® provided a higher rate of implant-related complications compared to the TomoFix™ plate at a minimum follow-up of 24 months after valgus-producing open-wedge HTO. Therefore, it is not recommended to use the first-generation PEEKPower HTO-Plate® in the clinical practice. LEVEL OF EVIDENCE: III.

Prospective evaluation of a new plate fixator for valgus-producing medial open-wedge high tibial osteotomy.

PURPOSE: The purpose of this study was to prospectively evaluate the clinical, radiographic, and sports-related outcome at 24 months after valgus-producing medial open-wedge high tibial osteotomy (owHTO) using a 2nd generation peek-carbon composite plate. METHODS: Between 2010 and 2011, the 2nd generation PEEKPower HTO-Plate(®) was used for medial owHTO in 28 consecutive patients (19 men, 9 women; mean age ± SD: 45 ± 11 years; mean varus deviation ± SD: 4° ± 2°). All of the patients had an osteotomy gap height of ≤12 mm without bone grafting. Visual analog scale (VAS) for pain, WOMAC score, and Lysholm score were evaluated preoperatively and at 12 and 24 months postoperatively. Sports-related outcomes included the Tegner scale, and a self-designed questionnaire preoperatively and 24 months postoperatively. Fixation stability of the implant was evaluated radiographically in two planes by comparing the medial proximal tibial angle (MPTA) and tibial slope 2 days after medial owHTO (baseline measurements) and after implant removal (follow-up measurements). Complications were recorded during the whole study period. RESULTS: Compared to preoperative conditions, VAS, WOMAC, and Lysholm scores improved significantly (p < 0.05) at the 12- and 24-month follow-up. No significant differences were found between the 12- and 24-month follow-up. After 24 months, the sports frequency increased significantly (p < 0.05). No significant differences between baseline and follow-up measurements for the MPTA and tibial slope were observed. Total complication rate was 4 %, with one patient developing non-union. CONCLUSION: In the clinical practice, the 2nd generation PEEKPower HTO-Plate(®) is a safe and efficient implant for medial owHTO without bone grafting in patients with an osteotomy gap of ≤12 mm. LEVEL OF EVIDENCE: III.

Determination of the pH dependent redox potential of glucose oxidase by spectroelectrochemistry.

The pH dependent redox potential of the oxidoreductase glucose oxidase (GOx) from Aspergillus niger, which is the most frequently applied enzyme in electrochemical glucose biosensors and biofuel cells, was measured between pH 4.5 and 8.5 using UV/vis spectroelectrochemistry. In the entire pH range under investigation, the flavin adenine dinucleotide cofactor of GOx changed directly from the oxidized quinone to the doubly reduced hydroquinone. No stable semiquinoid species could be detected if electrochemical equilibrium was reached. From the pH dependency of the GOx redox potential, a pK(a) of 7.2 has been determined for the GOx flavohydroquinone. At pH values ≤6.0, a dependency of the reduction mechanism and the GOx redox potential on the presence of halides, especially on Cl(-), was observed. For the development of glucose biosensors and glucose biofuel cell anodes working at physiological or neutral pH, the GOx redox potentials at pH 7.4 and pH 7.0 are of main interest. Here values of E(1/2 pH 7.4) = -97 ± 3 mV and E(1/2 pH 7.0) = -80 ± 4 mV have been determined.