VEGF-D-mediated signaling in tendon cells is involved in degenerative processes.

Vascular endothelial growth factor (VEGF) signaling is crucial for a large variety of cellular processes, not only related to angiogenesis but also in nonvascular cell types. We have previously shown that controlling angiogenesis by reducing VEGF-A signaling positively affects tendon healing. We now hypothesize that VEGF signaling in non-endothelial cells may contribute to tendon pathologies. By immunohistochemistry we show that VEGFR1, VEGFR2, and VEGFR3 are expressed in murine and human tendon cells in vivo. In a rat Achilles tendon defect model we show that VEGFR1, VEGFR3, and VEGF-D expression are increased after injury. On cultured rat tendon cells we show that VEGF-D stimulates cell proliferation in a dose-dependent manner; the specific VEGFR3 inhibitor SAR131675 reduces cell proliferation and cell migration. Furthermore, activation of VEGFR2 and -3 in tendon-derived cells affects the expression of mRNAs encoding extracellular matrix and matrix remodeling proteins. Using explant model systems, we provide evidence, that VEGFR3 inhibition prevents biomechanical deterioration in rat tail tendon fascicles cultured without load and attenuates matrix damage if exposed to dynamic overload in a bioreactor system. Together, these results suggest a strong role of tendon cell VEGF signaling in mediation of degenerative processes. These findings give novel insight into tendon cell biology and may pave the way for novel treatment options for degenerative tendon diseases.

Intracranial Penetration During Temporal Soft Tissue Filler Injection-Is It Possible?

BACKGROUND: Treating temporal volume loss for aesthetic and reconstructive purposes can be achieved by superficial or deep injections of soft tissue fillers into the temples. The latter is performed with bone contact that can lead to intracranial penetration when the bone is accidentally penetrated. OBJECTIVE: Based on a clinical case, the potential risk of accidental intracranial penetration was investigated. MATERIALS AND METHODS: Twenty fresh-frozen hemi-faces (all Caucasian ethnicity, 10 women, 10 men, mean age 72.8 ± 11.2 years) were investigated. Shape of pterion and bone-stability parameters of the temporal fossa were investigated. Bone stability was tested using uniaxial mechanical indentation (18-G, 1.25-mm diameter, 15-mm length blunt-tip device) until intracranial perforation occurred. RESULTS: Variations in the shape of the pterion, bone thickness, and density correlates were detected, however, without statistical significant differences in side symmetry. Minimum force necessary to penetrate intracranially was 40.4 N. Maximum force generated by an 18-g, 70-mm length blunt-tip cannula was 32.1 ± 4.2 N in 70 mm length and 75.3 ± 10.2 N in 15 mm length. CONCLUSION: Based on the results of this investigation, it can be concluded that there is a risk for intracranial penetration performing the deep temple injection technique with direct pressure on the bone.

The Humerusblock NG: a new concept for stabilization of proximal humeral fractures and its biomechanical evaluation.

BACKGROUND: The Humerusblock NG represents a new semi-rigid angular stable fixation device for minimally invasive stabilization of proximal humeral fractures. This study evaluates the function and stability of the Humerusblock NG and its biomechanical properties on the basis of two different fracture models under cyclic loading. METHODS: Six fresh frozen human humeri were tested in a dynamic shoulder joint abduction motion test bench, simulating abduction between 15° and 45°. A stable wedge fracture with intact medial hinge and an unstable fracture with 5-mm gap were loaded for 500 cycles. Radiological measurement of implant migration was performed. RESULTS: The stable fracture model showed a slow constant fracture settling. The unstable fracture model showed initial fracture settling with closure of the medial fracture gap during the first 20 cycles. Thereafter, a slow constant settling of the fracture was measured comparable to the stable fracture model. Maximum varus tilt was 3.17° for the stable and 3.68° for the unstable fracture pattern. Radiological analysis showed no change in the tip apex distance and a significant settling of the implants fixation pins in the unstable fracture model. None of the specimen failed during the testing. CONCLUSION: The Humerusblock NG allows for angular stable dynamic fixation of two-part proximal humeral fractures. It enables closure of the fracture gap and maintains fracture compression during loading, a concept already established in the stabilization of femoral neck fractures (dynamic hip screw). Clinical trials will be necessary to evaluate the value of this device in daily practice. LEVEL OF EVIDENCE: Basic science study.

Femoral antetorsion after calcar-guided short-stem total hip arthroplasty: A cadaver study.

Calcar-guided short stems in total hip arthroplasty (THA) permit surgeons to successfully reconstruct postoperative femoroacetabular offset, accurately restore leg length, and adequately re-establish a wide range of caput-collum-diaphyseal angles. However, their effect on femoral antetorsion is less known. Indeed, controlling antetorsion of the femoral stem can be challenging because of the differences in individual femoral geometry and curvature. Therefore, we investigated if calcar-guided short-stem THA alters femoral antetorsion and compared it with conventional-stem THA. Using 12 Thiel-fixed, full-body cadaver specimens from donors without known hip disorders, we compared an uncemented calcar-guided femoral short-stem prosthesis with an uncemented conventional straight-stem prosthesis. In a paired study setup, each specimen received a calcar-guided short stem on one side and a conventional stem on the other. On the acetabular side, all specimens received a press-fit, monobloc acetabular cup. Femoral antetorsion angles were measured using the Waidelich method, and pre- and post-operative angles of both sides were recorded. The mean preoperative femoral antetorsion angles were similar in both groups (24.8° ± 7.5° vs. 23.8° ± 6.1°, p = 0.313). Mean postoperative femoral antetorsion angles were 23.0° ± 5.5° in short-stem and 13.5° ± 7.1° in conventional-stem hips. Short-stem hips had a small but nonsignificant difference in femoral antetorsion angles pre- and post-operatively (1.8° ± 3.2°, p = 0.109), while the difference for conventional-stem hips was much larger and highly significant (10.3° ± 5.8°, p < 0.001). Calcar-guided short-stem THA effectively restores femoral antetorsion. However, how this affects long-term clinical outcomes and complications warrants further exploration.

Aortic Root Pressurizing Device: Aortic Valve Evaluation During Cardioplegic Arrest.

PURPOSE: The aortic root pressurizing device was developed for aortic valve repair surgery. It allows echocardiographic evaluation of the aortic valve during cardioplegic arrest by mimicking diastolic afterload. DESCRIPTION: This polyoxymethylene or polyether ether ketone-based device consists of a sealing cap nut, a sealing ring, a plug screw, and both a filling and a ventilation line. It can be easily connected to any size of aortic Dacron grafts. EVALUATION: The device was tested in 15 porcine hearts using a beating heart biosimulator including hemodynamic and echocardiographic monitoring. Valve competence was analyzed on both the beating and resting heart at 60 and 45 mm Hg root pressure. Aortic insufficiency was surgically induced by leaflet manipulation. Native aortic valves showed either none or trivial aortic insufficiency. After leaflet manipulation echocardiographic proof of valve insufficiency was possible in all specimen. Jet direction was identic in all cases at 60 mm Hg and 93% at 45 mm Hg root pressure. CONCLUSIONS: The aortic root pressurizing device shows highly comparable results of echocardiographic aortic valve evaluation between static and dynamic settings under experimental conditions.

Mechanical characteristics of articular cartilage bonds.

BACKGROUND: Sutures for adaptation of articular cartilage are used in arthritis therapy techniques. However, little is known about the mechanical functionality of these sutures. The objective of the present work was to compare the mechanical properties of articular cartilage bonds either generated by suture, or, alternatively, by chemical cross-linking of the opposing surfaces or in vitro integrative repair of cartilage blocks. METHODS: Bonding was achieved by suture in varying numbers, positions and orientations, by surface cross-linking using carbodiimide in combination with pepsin or guanidine (immediate bonding), or by cultivation for 14 days, either with or without testosterone. The mechanical properties of the cartilage bonds were measured under tensile loading. FINDINGS: Suture led to the highest maximal load at failure and by far to the highest strain and lowest stiffness of the bonded samples. Immediate bonding by chemical cross-linking in combination with pepsin led to a low force at failure, but the highest stiffness, as compared to all other groups. Cultivation in the presence of testosterone led to a higher force at failure and a higher strain than chemical cross-linking. INTERPRETATION: Suture technique for bonding of cartilage surfaces leads to a very elastic adaptation which allows synovial fluid flow in between the interface of cartilage wounds. Long-term bonding of cartilage wounds would be counteracted by a fluid flow through the interface during motion of the joint. Immediate bonding of cartilage wounds by chemical cross-linking reagents might be a useful alternative tool. Even more promising, with regard to the mechanical properties, appears to be integrative repair of cartilage blocks stimulated by testosterone.

Influence of defect size and localization on the engagement of reverse Hill-Sachs lesions.

BACKGROUND: Reverse Hill-Sachs (RHS) lesions can cause recurrent posterior shoulder instability because of engagement with the posterior glenoid rim; however, the effect of defect size and localization have yet to be determined. HYPOTHESIS: Both size and localization are critical for the engagement of an RHS defect with the posterior glenoid rim. STUDY DESIGN: Controlled laboratory study. METHODS: Ten RHS defects with predefined extent and localization were created through an anterolateral rotator cuff sparing approach in 10 fresh-frozen cadaveric shoulder specimens using a custom-made saw guide. Computed tomography scans of all specimens were completed, and standardized measurements were performed to determine the size (alpha angle) and localization (beta angle) of the defect as well as a combination of both parameters (gamma angle). Internal rotation motions were imposed on the shoulder joint in different arm positions and with varying amount of posterior translation by means of a robot-assisted shoulder simulator. The association between engagement of the defects and the defined parameters (alpha, beta, and gamma angles) was analyzed. RESULTS: In 0° of abduction, a cutoff value between engaging and nonengaging defects of 37.5° for the alpha angle (100% sensitivity; 75% specificity; area under the curve [AUC], 0.875; P = .055) and 36.5° for the beta angle (100% sensitivity; 25% specificity; AUC, 0.708; P = .286) was determined. The gamma angle showed the highest discriminatory power (AUC, 0.938; P = .025) with a cutoff value of 85.5° rendering 100% sensitivity and 75% specificity in the prediction of engagement. An increase in the applied posterior translation force decreased the degrees of internal rotation necessary before engagement occurred. No engagement occurred during internal rotation with the arm in 60° of abduction or 60° of flexion. CONCLUSION: The size and localization of RHS defects are both critical factors for engagement. The combination of both parameters in terms of the gamma angle measurement might be a helpful tool to identify defects prone to engagement. CLINICAL RELEVANCE: Not only the size but also the localization is decisive for engagement of RHS defects. The standardized measurement of the gamma angle combines both factors and might be a helpful tool to identify defects prone to engagement warranting surgical treatment.

Impact of constrained dual-screw anchorage on holding strength and the resistance to cyclic loading in anterior spinal deformity surgery: a comparative biomechanical study.

STUDY DESIGN: Biomechanical in vitro laboratory study. OBJECTIVE: To compare the biomechanical performance of 3 fixation concepts used for anterior instrumented scoliosis correction and fusion (AISF). SUMMARY OF BACKGROUND DATA: AISF is an ideal estimate for selective fusion in adolescent idiopathic scoliosis. Correction is mediated using rods and screws anchored in the vertebral bodies. Application of large correction forces can promote early weakening of the implant-vertebra interfaces, with potential postoperative loss of correction, implant dislodgment, and nonunion. Therefore, improvement of screw-rod anchorage characteristics with AISF is valuable. METHODS: A total of 111 thoracolumbar vertebrae harvested from 7 human spines completed a testing protocol. Age of specimens was 62.9 ± 8.2 years. Vertebrae were potted in polymethylmethacrylate and instrumented using 3 different devices with identical screw length and unicortical fixation: single constrained screw fixation (SC fixation), nonconstrained dual-screw fixation (DNS fixation), and constrained dual-screw fixation (DC fixation) resembling a novel implant type. Mechanical testing of each implant-vertebra unit using cyclic loading and pullout tests were performed after stress tests were applied mimicking surgical maneuvers during AISF. Test order was as follows: (1) preload test 1 simulating screw-rod locking and cantilever forces; (2) preload test 2 simulating compression/distraction maneuver; (3) cyclic loading tests with implant-vertebra unit subjected to stepwise increased cyclic loading (maximum: 200 N) protocol with 1000 cycles at 2 Hz, tests were aborted if displacement greater than 2 mm occurred before reaching 1000 cycles; and (4) coaxial pullout tests at a pullout rate of 5 mm/min. With each test, the mode of failure, that is, shear versus fracture, was noted as well as the ultimate load to failure (N), number of implant-vertebra units surpassing 1000 cycles, and number of cycles and related loads applied. RESULTS: Thirty-three percent of vertebrae surpassed 1000 cycles, 38% in the SC group, 19% in the DNS group, and 43% in the DC group. The difference between the DC group and the DNS group yielded significance (P = 0.04). For vertebrae not surpassing 1000 cycles, the number of cycles at implant displacement greater than 2 mm in the SC group was 648.7 ± 280.2 cycles, in the DNS group was 478.8 ± 219.0 cycles, and in the DC group was 699.5 ± 150.6 cycles. Differences between the SC group and the DNS group were significant (P = 0.008) as between the DC group and the DNS group (P = 0.0009). Load to failure in the SC group was 444.3 ± 302 N, in the DNS group was 527.7 ± 273 N, and in the DC group was 664.4 ± 371.5 N. The DC group outperformed the other constructs. The difference between the SC group and the DNS group failed significance (P = 0.25), whereas there was a significant difference between the SC group and the DC group (P = 0.003). The DC group showed a strong trend toward increased load to failure compared with the DNS group but without significance (P = 0.067). Surpassing 1000 cycles had a significant impact on the maximum load to failure in the SC group (P = 0.0001) and in the DNS group (P = 0.01) but not in the DC group (P = 0.2), which had the highest number of vertebrae surpassing 1000 cycles. CONCLUSION: Constrained dual-screw fixation characteristics in modern AISF implants can improve resistance to cyclic loading and pullout forces. DC constructs bear the potential to reduce the mechanical shortcomings of AISF.

Implications of the center of rotation concept for the reconstruction of anterior column lordosis and axial preloads in spinal deformity surgery.

OBJECT: In thoracolumbar deformity surgery, anterior-only approaches are used for reconstruction of anterior column failures. It is generally advised that vertebral body replacements (VBRs) should be preloaded by compression. However, little is known regarding the impact of different techniques for generation of preloads and which surgical principle is best for restoration of lordosis. Therefore, the authors analyzed the effect of different surgical techniques to restore spinal alignment and lordosis as well as the ability to generate axial preloads on VBRs in anterior column reconstructions. METHODS: The authors performed a laboratory study using 7 fresh-frozen specimens (from T-3 to S-1) to assess the ability for lordosis reconstruction of 5 techniques and their potential for increasing preloads on a modified distractable VBR in a 1-level thoracolumbar corpectomy. The testing protocol was as follows: 1) Radiographs of specimens were obtained. 2) A 1-level corpectomy was performed. 3) In alternating order, lordosis was applied using 1 of the 5 techniques. Then, preloads during insertion and after relaxation using the modified distractable VBR were assessed using a miniature load-cell incorporated in the modified distractable VBR. The modified distractable VBR was inserted into the corpectomy defect after lordosis was applied using 1) a lamina spreader; 2) the modified distractable VBR only; 3) the ArcoFix System (an angular stable plate system enabling in situ reduction); 4) a lordosizer (a customized instrument enabling reduction while replicating the intervertebral center of rotation [COR] according to the COR method); and 5) a lordosizer and top-loading screws ([LZ+TLS], distraction with the lordosizer applied on a 5.5-mm rod linked to 2 top-loading pedicle screws inserted laterally into the vertebra). Changes in the regional kyphosis angle were assessed radiographically using the Cobb method. RESULTS: The bone mineral density of specimens was 0.72 ± 22.6 g/cm(2). The maximum regional kyphosis angle reconstructed among the 5 techniques averaged 9.7°-16.1°, and maximum axial preloads averaged 123.7-179.7 N. Concerning correction, in decreasing order the LZ+TLS, lordosizer, and ArcoFix System outperformed the lamina spreader and modified distractable VBR. The order of median values for insertion peak load, from highest to lowest, were lordosizer, LZ+TLS, and ArcoFix, which outperformed the lamina spreader and modified distractable VBR. In decreasing order, the axial preload was highest with the lordosizer and LZ+TLS, which both outperformed the lamina spreader and the modified distractable VBR. The technique enabling the greatest lordosis achieved the highest preloads. With the ArcoFix System and LZ+TLS, compression loads could be applied and were 247.8 and 190.6 N, respectively, which is significantly higher than the insertion peak load and axial preload (p < 0.05). CONCLUSIONS: Including the ability for replication of the COR in instruments designed for anterior column reconstructions, the ability for lordosis restoration of the anterior column and axial preloads can increase, which in turn might foster fusion.

Characterization of esterified hyaluronan-gelatin polymer composites suitable for chondrogenic differentiation of mesenchymal stem cells.

Composite scaffolds of homogeneously mixed esterified hyaluronan (HY) and gelatin (G) were manufactured with variable component compositions (HY100%; HY95%/G5%; HY70%/G30%). The goals of this study were to analyze the produced composite scaffolds using physical and chemical methods, for example, scanning electron microscopy, IR-spectroscopy, water contact angle, protein assay, and tensile testing as well as to assess the effects of adding gelatin to the composite scaffolds on attachment, proliferation, and chondrogenic differentiation of human mesenchymal stem cells. Numbers of attached cells were significantly higher on the composite material compared to pure hyaluronan at different time points of two-dimensional or three-dimensional cell culture (p< 0.02). In composite scaffolds, a significantly greater amount of cartilage-specific extracellular matrix components was deposited after 28 days in culture (glycosaminoglycan: p < 0.001; collagen: p < 0.001) as compared with 100% hyaluronan scaffolds. Additionally, gelatin-containing composite scaffolds displayed stronger promotion of collagen type II expression than pure hyaluronan scaffolds. The mechanism, based on which gelatin influences cell adhesion, was examined. The effect was inhibited by collagenase treatment of the composites or by addition of alpha5beta1-integrin blocking antibodies to the cell suspension. In summary, the results describe the establishment of a class of composite polymer scaffolds, consisting of esterified hyaluronan and gelatin, which are potentially useful for cell-based tissue engineering approaches using mesenchymal stem cells for chondrogenic differentiation.

Bonding of articular cartilage using a combination of biochemical degradation and surface cross-linking.

After trauma, articular cartilage often does not heal due to incomplete bonding of the fractured surfaces. In this study we investigated the ability of chemical cross-linkers to facilitate bonding of articular cartilage, either alone or in combination with a pre-treatment with surface-degrading agents. Articular cartilage blocks were harvested from the femoropatellar groove of bovine calves. Two cartilage blocks, either after pre-treatment or without, were assembled in a custom-designed chamber in partial apposition and subjected to cross-linking treatment. Subsequently, bonding of cartilage was measured as adhesive strength, that is, the maximum force at rupture of bonded cartilage blocks divided by the overlap area. In a first approach, bonding was investigated after treatment with cross-linking reagents only, employing glutaraldehyde, 1-ethyl-3-diaminopropyl-carbodiimide (EDC)/N-hydroxysuccinimide (NHS), genipin, or transglutaminase. Experiments were conducted with or without compression of the opposing surfaces. Compression during cross-linking strongly enhanced bonding, especially when applying EDC/NHS and glutaraldehyde. Therefore, all further experiments were performed under compressive conditions. Combinations of each of the four cross-linking agents with the degrading pre-treatments, pepsin, trypsin, and guanidine, led to distinct improvements in bonding compared to the use of cross-linkers alone. The highest values of adhesive strength were achieved employing combinations of pepsin or guanidine with EDC/NHS, and guanidine with glutaraldehyde. The release of extracellular matrix components, that is, glycosaminoglycans and total collagen, from cartilage blocks after pre-treatment was measured, but could not be directly correlated to the determined adhesive strength. Cytotoxicity was determined for all substances employed, that is, surface degrading agents and cross-linkers, using the resazurin assay. Taking the favourable cell vitality after treatment with pepsin and EDC/NHS and the cytotoxic effects of guanidine and glutaraldehyde into account, the combination of pepsin and EDC/NHS appeared to be the most advantageous treatment in this study. In conclusion, bonding of articular cartilage blocks was achieved by chemical fixation of their surface components using cross-linking reagents. Application of compressive forces and prior modulation of surface structures enhanced cartilage bonding significantly. Enzymatic treatment in combination with cross-linkers may represent a promising addition to current techniques for articular cartilage repair.

Steroid hormones strongly support bovine articular cartilage integration in the absence of interleukin-1beta.

OBJECTIVE: Posttraumatic integration of articular cartilage at fracture sites is essential for mechanical stability of cartilage, and ruptured cartilage is a prerequisite for early osteoarthritis. This study was undertaken to investigate effects on articular cartilage integration mediated by steroid hormones, interleukin-1beta (IL-1beta), and combinations thereof. METHODS: Articular cartilage blocks were cultured in partial apposition for 2 weeks with ascorbic acid, testosterone, 17beta-estradiol, and dehydroepiandrosterone (DHEA), with or without IL-1beta. Mechanical integration was measured as adhesive strength, i.e., the maximum force at rupture of integrated cartilage blocks divided by the overlap area. Glycosaminoglycan content was used to study synthesized extracellular matrix. RESULTS: Culture in medium without supplements did not lead to integration (adhesive strength 0 kPa). With administration of ascorbic acid (100 microg/ml), the median adhesive strength was 49 kPa. In comparison with ascorbic acid alone, all steroid hormones induced a strong, concentration-dependent stimulation of integration (with maximum values observed with DHEA at 3 x 10(-5)M, testosterone at 10(-8)M, and 17beta-estradiol at 10(-11)M). For testosterone and 17beta-estradiol, this was also reflected by an increase of glycosaminoglycan content. Adhesive strength was increased with IL-1beta at 10 pg/ml, but not at 1 pg/ml or 100 pg/ml. In the presence of both IL-1beta and sex hormones, integration of articular cartilage was reduced. CONCLUSION: This is the first study to demonstrate that steroid hormones such as 17beta-estradiol, DHEA, and testosterone stimulate articular cartilage integration. This effect is abrogated by low concentrations of IL-1beta. In the absence of IL-1beta or after neutralization of IL-1beta, steroid hormones might be favorable adjuvant compounds to optimize cartilage integration.