Recessive multiple epiphyseal dysplasia (rMED) with homozygosity for C653S mutation in the DTDST gene--phenotype, molecular diagnosis and surgical treatment of habitual dislocation of multilayered patella: case report.

BACKGROUND: Multiple epiphyseal dysplasia (MED) is one of the more common generalised skeletal dysplasias. Due to its clinical heterogeneity diagnosis may be difficult. Mutations of at least six separate genes can cause MED. Joint deformities, joint pain and gait disorders are common symptoms. CASE PRESENTATION: We report on a 27-year-old male patient suffering from clinical symptoms of autosomal recessive MED with habitual dislocation of a multilayered patella on both sides, on the surgical treatment and on short-term clinical outcome. Clinical findings were: bilateral hip and knee pain, instability of femorotibial and patellofemoral joints with habitual patella dislocation on both sides, contractures of hip, elbow and second metacarpophalangeal joints. Main radiographic findings were: bilateral dislocated multilayered patella, dysplastic medial tibial plateaus, deformity of both femoral heads and osteoarthritis of the hip joints, and deformity of both radial heads. In the molecular genetic analysis, the DTDST mutation g.1984T > A (p.C653S) was found at the homozygote state. Carrier status was confirmed in the DNA of the patient's parents. The mutation could be considered to be the reason for the patient's disease. Surgical treatment of habitual patella dislocation with medialisation of the tibial tuberosity led to an excellent clinical outcome. CONCLUSIONS: The knowledge of different phenotypes of skeletal dysplasias helps to select genes for genetic analysis. Compared to other DTDST mutations, this is a rather mild phenotype. Molecular diagnosis is important for genetic counselling and for an accurate prognosis. Even in case of a multilayered patella in MED, habitual patella dislocation could be managed successfully by medialisation of the tibial tuberosity.

Infections after bone allograft surgery: a prospective study by a hospital bone bank using frozen femoral heads from living donors.

In the advent of the EU guidelines 2004/23/EG and 2006/17/EG requiring extensive safety and quality steps in bone banking, the prevalence and risk of infection disease transmission from bone allograft needs to be reconsidered. Therefore, we prospectively reviewed the screening process of bone donations and the outcome of surgeries utilizing bone allografts from our internal hospital bone bank with regard to infections according to CDC criteria. One-hundred and eighty-eight allogenic bone transplantation procedures in 160 patients were followed-up for 12-64 months (mean 32 months). Bacterial infection occurred in 11 patients, the overall infection rate therefore was 6.9%. After review of the clinical and intraoperative findings, none of the infections were likely to have been caused by the bone graft. Although no follow-up serologic testing was performed, no HIV of hepatitis infections were observed. Frozen bone allografts derived from live donors and provided by hospitals can generally be considered safe. However, without new and relevant clinical expertise, continuing this technique will be impeded by the new EU guidelines and their national implementations.

Interactive effects of growth factors and three-dimensional scaffolds on multipotent mesenchymal stromal cells.

The creation of tissue-engineered constructs with autologous cells is a central goal in regenerative medicine. With respect to ligament replacement, we have evaluated the influences of matrix and growth factors on hMSCs (human mesenchymal stromal cells). hMSCs were seeded in two different 3D (three-dimensional) systems consisting of either a collagen type I gel or a synthetic PLA [poly-(L-lactic acid)] scaffold. After cultivation for 14 days with rhTGFbeta1 (recombinant human transforming growth factor beta1), rhPDGF-BB (recombinant human platelet-derived growth factor homodimer of B-chain) or rhBMP13 (recombinant human bone morphogenetic protein 13), we assessed the proliferation potential, mRNA expression and protein expression of various matrix-interacting and matrix-degrading molecules by quantitative real-time RT (reverse transcriptase)-PCR, immunohistochemistry and gelatin zymography in comparison with unstimulated cells. Cellular reactions to the type of scaffold or soluble factors could be found in the expression of tenascin-C as well as integrin subunits alpha1, alpha3 and beta1. Collagen type X expression was induced by 3D culture and stimulated by rhTGFbeta1 on PLA. The expression of MMP-1 (matrix metalloproteinase 1) tended to increase, and MMP-13 was induced in the collagen culture system. The activation of MMP-2 was stimulated by the cultivation of MSCs within the collagenous matrix. These results demonstrated that various interactive effects of growth factors and scaffolds influence the cell-biological behaviour of MSCs. It is important to take these complex interactions, which partly differ from differentiated cells, into account in further tissue-engineering approaches.

CYR61/CCN1 and WISP3/CCN6 are chemoattractive ligands for human multipotent mesenchymal stroma cells.

BACKGROUND: CCN-proteins are known to be involved in development, homeostasis and repair of mesenchymal tissues. Since these processes implicate recruitment of cells with the potential to be committed to various phenotypes, we studied the effect of CYR61/CCN1 and WISP3/CCN6 on migration of human bone marrow derived mesenchymal stroma cells (MSCs) in comparison to in vitro osteogenic differentiated MSCs using a modified Boyden chamber assay. RESULTS: CYR61 and WISP3 were purified as fusion proteins with a C-terminal Fc-tag from baculovirus infected SF21 cells using protein G sepharose columns. CYR61 and WISP3 stimulated cell migration of undifferentiated MSCs in a dose-dependent manner. CYR61 and WISP3 had similar effects on committed osteogenic precursor cells. Checkerboard analysis revealed that CYR61 and WISP3 stimulated true directed cell migration (chemotaxis) of MSCs and committed osteogenic precursors. In MSCs the chemotactic activity of WISP3 but not CYR61 was mediated through integrin alphanuss5. CONCLUSION: Our results indicate that CYR61 and WISP3 can function as soluble ligands transmitting chemotactic signals to human MSCs but differ in the involvement of integrin alphanuss5. This may be relevant for their possible role in connective tissue repair.

Human mesenchymal progenitor cell responses to a novel textured poly(L-lactide) scaffold for ligament tissue engineering.

Biocompatibility and cell seeding capability of a new cell scaffold made of textured polylactic acid (PLA) fibers was investigated as a new material for tissue engineering of anterior cruciate ligaments (ACL). Adhesion and proliferation of human mesenchymal progenitor cells (MPC) was investigated after 15 days by scanning electron microscopy and standard histology. Expression of collagen type I and III, fibronectin, tenascin C, decorin, smooth muscle actin, and the matrix metalloproteinases MMP-1 and MMP-2, as well as their tissue inhibitors TIMP-1 and TIMP-2 was analyzed using real-time PCR. Protein expression of collagen I and III, tenascin C, and proliferating nuclear antigen (PCNA) was determined by immunohistology. Apoptosis was analyzed by detection of p53 expression and TUNEL staining. MPC seeded the scaffold homogeneously and showed good cell growth and no increased rate of apoptosis. After 15 days, the matrix forming genes collagen type I, tenascin C, and decorin were upregulated, indicating the formation of a ligament-like matrix. MMP-1 and TIMP-1 were also significantly increased, suggesting initial matrix remodeling. It was concluded that the new porous PLA scaffold allowed homogeneous cell seeding, a fibroblastic phenotype and the production of a ligament-like matrix and, therefore, might be a suitable cell carrier for ACL tissue engineering.

Adjacent segment mobility after rigid and semirigid instrumentation of the lumbar spine.

STUDY DESIGN: Retrospective radiographic analysis of lumbar spine range of motion (ROM) after monosegmental fusion and posterior dynamic stabilization at the level L4-L5. OBJECTIVE: Comparison of segmental ROM at the index level and the cranial and caudal adjacent levels and of global lumbar spine ROM after monosegmental fusion and posterior dynamic stabilization. SUMMARY OF BACKGROUND DATA: The postulated advantage of nonfusion technology compared with fusion is based on the assumption that preservation of motion at the treated segment reduces the incidence of adjacent segment effects. Therefore, it is imperative to provide evidence that dynamic stabilization devices avoid hypermobility at the adjacent segments because this might substantiate a protective effect on the adjacent segments. METHODS: Twenty-six patients with low back pain and claudication due to degenerative instability at the level L4-L5 with concomitant spinal stenosis were treated either with decompression and Dynesys (n = 11) or with decompression and fusion (n = 15). All patients underwent flexion/extension radiographs before surgery and at latest follow-up. ROM was assessed at the index level (L4-L5), the cranial/caudal adjacent levels (L3-L4/L5-S1), and at the lumbar spine from L2 to S1. RESULTS: There was a significant reduction of the global ROM of the lumbar spine (L2-S1) and the segmental ROM at the index level (L4-L5) in the fusion group, whereas adjacent level ROM did not change significantly. In the Dynesys group, no significant changes of global lumbar spine ROM (L2-S1) and segmental ROM (index level and cranial/caudal adjacent levels) were seen. CONCLUSION: This study shows that neither monosegmental instrumented fusion nor monosegmental posterior dynamic stabilization with Dynesys alter the ROM of the cranial and caudal adjacent levels. Consequently, monosegmental posterior dynamic stabilization with Dynesys has no effect with regard to adjacent segment mobility compared with monosegmental fusion.

Index level mobility after total lumbar disc replacement: is it beneficial or detrimental?

STUDY DESIGN: Analysis of segmental and total lumbar range of motion (ROM) before and after total lumbar disc replacement. OBJECTIVE: To examine the relationship between absolute segmental and total lumbar ROM and evolution of ROM on clinical outcome. SUMMARY OF BACKGROUND DATA: At the moment, data are scarce with regard to the evolution of total lumbar ROM (t-ROM) and segmental ROM (s-ROM) after total lumbar disc replacement. Moreover, the influence of ROM on clinical outcome still is unclear and remains a matter of controversial debate. METHODS.: Forty patients operated on for mono- or bisegmental symptomatic degenerative disc disease with a total of 45 artificial discs (ProDisc-L, Synthes) were analyzed. Pre- and postoperative s-ROM and t-ROM were measured on flexion/extension radiographs. The Oswestry Low Back Pain Disability Questionnaire and the Short Form 36 Health Survey were obtained pre- and postoperatively with a minimum follow-up of 3 years (37-64 months). RESULTS: Neither the s-ROM (pre-/postoperatively: 6.9 degrees/7.3 degrees) nor the t-ROM (pre-/postoperatively: 34.9 degrees/35.8 degrees) did change significantly after implantation of an artificial disc. Postoperatively, there was an increase of s-ROM (t-ROM) in 40% (40%), a decrease in 35% (30%), and no change in 25% (30%) of the patients. A significant inferior clinical outcome only was observed in patients with decreased t-ROM. The resulting postoperatively s-ROM had no significant impact on outcome. CONCLUSION: Neither the absolute s-ROM nor the evolution of s-ROM (increase, decrease, unchanged) was positively correlated with better clinical outcome. Although a positive correlation was observed with regard to t-ROM.

Mesenchymal progenitor cells communicate via alpha and beta integrins with a three-dimensional collagen type I matrix.

BACKGROUND/AIMS: The aim of our study was to investigate interactions of mesenchymal progenitor cells (MPCs) with collagen matrices. METHODS: Human bone-marrow-derived MPCs were cultivated in collagen type I gels with and without inhibition of beta(1)-integrin by a specific antibody. Collagen gel contraction, cell morphology, expression of integrin subunits and several genes related to matrix synthesis and turnover as well as MPC differentiation were analyzed over 14 days. RESULTS: Human MPCs markedly contracted free-floating collagen gels. Contraction was nearly completely inhibited by blocking beta(1)-integrin. Cellular morphology was elongated in the absence and mostly round in the presence of the antibody. Expression of integrin alpha(1), alpha(2) and beta(1) subunits showed several changes partly dependent on beta(1)-integrin blocking. Expression of matrix metalloproteinase-1 was elevated irrespective of beta(1)-integrin blocking and tenascin-C was subsequently induced during gel contraction. Spontaneous induction of chondrogenic, osteogenic or adipogenic differentiation was observed neither in the presence nor in the absence of the beta(1)-integrin antibody. CONCLUSION: Our results indicate that the interaction of human MPCs with fibrillar collagen type I involves beta(1)- and alpha-integrin subunits and induces changes in gene expression related to extracellular matrix synthesis and turnover but not differentiation to the chondrogenic, osteogenic or adipogenic phenotype.

Computer-assisted posterior instrumentation of the cervical and cervico-thoracic spine.

Posterior instrumentation of the cervical spine has become increasingly popular in recent years. Dissatisfaction with lateral mass fixation, especially at the cervico-thoracic junction, has led spine surgeons to use pedicle screws. The improved biomechanical stability of pedicle screws and transarticular C1/2 screws allows for shorter instrumentations and improves the repositioning possibilities. Nevertheless, there are potential risks of iatrogenic damage to the spinal cord, nerve roots or the vertebral artery with both techniques. Therefore, the aim of this study was to evaluate whether C1/2 transarticular screws and transpedicular screws can be applied safely and with high accuracy in the cervical spine and the cervico-thoracic junction using a computer-assisted surgery system (CAS system). Posterior instrumentation was performed using the Brainlab VectorVision System (BrainLAB, Heimstetten, Germany) in 19 patients. Surface matching was used for registration. We placed 22 transarticular screws C1/2, 31 cervical pedicle screws, 10 high thoracic pedicle screws and one lateral mass screw C1. The screw position was evaluated postoperatively using CT with multiplanar reconstruction in the screw axis of each screw. None of the transarticular screws or pedicle screws was significantly (>2 mm) misplaced and no screw-related injury to vascular, neurogenic or bony structures was observed. No screw revision was necessary. The mean operation time was 144 min (90-240 min) and the mean blood loss was 234 ml (50-800 ml). C1/2 transarticular screws, as well as transpedicular screws in the cervical spine and the cervico-thoracic junction, can be applied safely and with high accuracy using a CAS system. Computer-assisted instrumentation is recommended especially for pedicle screws at C3-C6.