Peripheral Blood Lymphocyte Subpopulations in Patients Following Small Diameter Metal-On-Metal Total Hip Replacement at Long-Term Follow-Up.

(1) Background: The objective of the present study was to investigate peripheral blood lymphocyte subpopulations in patients with small diameter metal-on-metal total hip arthroplasty (MoM THA) and elevated blood metal ion concentrations at long-term follow-up. The hypothesis was that increased blood metal ion levels or the presence of adverse local tissue reactions (ALTR) would be associated with changes in the peripheral expression of lymphocyte subpopulations, which could potentially serve as early diagnostic markers for metal wear related complications. (2) Methods: Peripheral blood samples were analyzed for leucocyte subgroups (CD3+, CD4+, CD8+, CD14+, CD16+/CD56+, CD25+/CD127-, CD19+, IFN-γ+, IL-4+ and IL-17A+ cells) in 34 patients with elevated blood metal ion levels (combined cobalt and chromium levels >2 µg/L) following small head MoM THA at a mean follow-up of 15.6 years. Fifteen patients with small head MoM THA and blood metal ion levels within the normal range and 15 patients with conventional ceramic-on-polyethylene THA served as control groups. In addition, blood metal ion levels and leucocyte subpopulations were compared between patients with and without adverse local tissue reactions (ALTR), which was investigated by MRI in 27 patients of the study cohort. (3) Results: There was a significant decrease in the levels of IFN-γ+ Type-1 T helper cells (Th1) in patients with MoM THA compared to the ceramic-on-polyethylene control group (p < 0.001). No statistically significant differences in the cell counts of other lymphocyte subpopulations were found between the three groups. Cobalt ion levels were significantly higher in patients with ALTR (p < 0.001) compared to the non-ALTR group, but no differences in the levels of lymphocyte subsets were found between the two groups. (4) Conclusions: No adverse systemic effects with respect to peripheral blood leucocyte subpopulations could be detected in the present study in patients following THA with a small diameter MoM articulation at long-term follow-up. We found a significant decrease of IFN-γ+ Th1 cells in patients with MoM THA compared to the control group, but no differences in the peripheral expression of leucocyte subpopulations were seen between patients with and without ALTR. Future studies with larger patient cohorts and additional histopathological investigations could help to better understand the role of Th1 cells and other cell lines of the adaptive immune system in the development of metal wear related complications after total joint replacement.

T Helper Cell Infiltration in Osteoarthritis-Related Knee Pain and Disability.

Despite the growing body of literature demonstrating a crucial role of T helper cell (Th) responses in the pathogenesis of osteoarthritis (OA), only few clinical studies have assessed interactions between Th cells and OA-related symptoms. Yet, the inclusion of clinical data in the interpretation of cellular analyses of Th cell infiltration is essential to reveal the mechanisms underlying the complex pathophysiology of OA pain and disability. Thus, the aim of the study was to analyze the infiltration pattern of Th cells in systemic (peripheral blood) and joint-derived (synovial membrane and fluid) samples from patients with knee OA in relation to OA-induced pain and disability. Therefore, radiographic OA severity, knee pain and function of 47 OA patients undergoing knee arthroplasty were evaluated prior to surgery. In parallel, samples of peripheral blood (PB), synovial membrane (SM) and synovial fluid (SF) were harvested and analyzed for different Th subsets using flow cytometry. According to surface marker expression Th cells (CD3+ CD4+ CD8-) were assigned to the Th subsets Th1 (CXCR3+, CCR5+), Th2 (CCR3+, CCR4+) and Th17 (CD161+, CCR6+). Interestingly, infiltration of the SM with all Th subtypes (Th1, Th2, Th17) significantly correlated with OA-induced disability. Most importantly, synovial CCR5+ and CCR3+ Th cell infiltration was associated with OA-related knee pain and disability. Furthermore, higher percentage rates of CXCR3+ Th cells in all tissue samples (PB, SM, SF) showed significant associations with OA severity. In contrast, increasing percentage rates of CD161+ Th cells in SM samples corresponded to a better functional outcome. In conclusion, the current study provides an extensive profile of the Th cell infiltration pattern in PB, SF and SM from patients with clinically relevant knee OA. Th cell infiltration of the SM might play a crucial role not only in the pathogenesis of OA but also in the development of OA-related knee pain and disability.

Prospective Long-term Follow-up of Autologous Chondrocyte Implantation With Periosteum Versus Matrix-Associated Autologous Chondrocyte Implantation: A Randomized Clinical Trial.

BACKGROUND: Matrix-associated autologous chondrocyte implantation (MACI) is a further development of the original autologous chondrocyte implantation periosteal flap technique (ACI-P) for the treatment of articular cartilage defects. PURPOSE: We aimed to establish whether MACI or ACI-P provides superior long-term outcomes in terms of patient satisfaction, clinical assessment, and magnetic resonance imaging (MRI) evaluation. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: A total of 21 patients with cartilage defects at the femoral condyle were randomized to MACI (n = 11) or ACI-P (n = 10) between the years 2004 and 2006. Patients were assessed for subjective International Knee Documentation Committee (IKDC) score, Lysholm and Gillquist score, Tegner Activity Score, and 36-Item Short Form Health Survey (SF-36) preoperatively (T0), at 1 and 2 years postoperatively (T1, T2), and at the final follow-up 8 to 11 years after surgery (T3). Onset of osteoarthritis was determined using the Kellgren-Lawrence score and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score, and delayed gadolinium-enhanced MRI of cartilage was used to evaluate the cartilage. Adverse events were recorded to assess safety. RESULTS: There were 16 patients (MACI, n = 9; ACI-P, n = 7) who were reassessed on average 9.6 years after surgery (76% follow-up rate). The Lysholm and Gillquist score improved in both groups after surgery and remained elevated but reached statistical significance only in ACI-P at T1 and T2. IKDC scores increased significantly at all postoperative evaluation time points in ACI-P. In MACI, IKDC scores showed a significant increase at T1 and T3 when compared with T0. In the majority of the patients (10/16; MACI, 5/9; ACI-P, 5/7) a complete defect filling was present at the final follow-up as shown by the MOCART score, and 1 patient in the ACI-P group displayed hypertrophy of the repair tissue, which represents 6% of the whole study group and 14.3% of the ACI-P group. Besides higher SF-36 vitality scores in ACI-P at T3, no significant differences were seen in clinical scores and MRI scores between the 2 methods at any time point. Revision rate was 33.3% in MACI and 28.6% in ACI-P at the last follow-up. CONCLUSION: Our long-term results suggest that first- and third-generation ACI methods are equally effective treatments for isolated full-thickness cartilage defects of the knee. With the number of participants available, no significant difference was noted between MACI and ACI-P at any time point. Interpretation of our data has to be performed with caution due to the small sample size, which was further limited by a loss to follow-up of 24%.

Blood Metal Ion Release After Primary Total Knee Arthroplasty: A Prospective Study.

OBJECTIVES: To investigate the course of in vivo blood metal ion levels in patients undergoing primary total knee arthroplasty (TKA) and to investigate potential risk factors associated with metal ion release in these patients. METHODS: Twenty-five patients with indication for TKA were included in this prospective study. Whole blood metal ion analysis was performed pre-operatively and at 1 week, 6 weeks, 3 months, 6 months, and 12 months postoperatively. Clinical scores were obtained using the American Knee Society Score (AKSS) and the Oxford Knee Score (OKS) at each follow-up and patients' activity levels were assessed by measuring the mean annual walking cycles at 12 months follow-up. Anteroposterior and lateral radiographs of the operated knee were evaluated postoperatively and at 12-month follow-up with regard to implant position and radiological signs of implant loosening. Correlation analysis using multivariate linear regression was performed to investigate the influence of different variables (age, gender, functional scores, number of walking cycles, and body mass index [BMI]) on blood cobalt ion concentrations. RESULTS: Mean metal ion levels of cobalt, chromium, molybdenum, and titanium were 0.28 µg/L (SD, 0.14), 0.43 µg/L (SD, 0.49), 0.62 µg/L (SD, 0.45), and 1.96 µg/L (SD, 0.98), respectively at 12-month follow-up. Mean cobalt ion levels significantly increased 1-year after surgery compared to preoperative measurements. There was no statistically significant increase of mean metal ion levels of chromium, titanium, and molybdenum at 1-year follow-up. Overall, metal ion levels were low and no patient demonstrated cobalt ion levels above 1 µg/L. Postoperative radiographs demonstrated well-aligned TKAs in all patients and no signs of osteolysis or implant loosening were detected at 1-year follow-up. Both the AKSS and OKS significantly improved during the course of the study up to the final follow-up. Multivariate regression analysis did not show a statistically significant correlation between the tested variables and blood cobalt ion concentrations. CONCLUSION: A statistically significant increase of mean cobalt ion concentration at 1-year follow-up was found in this cohort of patients with well-functioning TKA, although overall blood metal ion levels were relatively low. Despite low systemic metal ion concentrations seen in this cohort, the local effects of increased metal ion concentrations in the periprosthetic environment on the long-term outcome of TKA should be further investigated.

Synovial Cytokines Significantly Correlate with Osteoarthritis-Related Knee Pain and Disability: Inflammatory Mediators of Potential Clinical Relevance.

The aim of this study was to identify inflammatory mediators of potential clinical relevance in synovial fluid (SF) samples of patients with knee osteoarthritis (OA). Therefore, radiographic OA severity, knee pain and function of 34 OA patients undergoing unicompartmental (UC) and bicompartmental (BC) knee arthroplasty were assessed prior to surgery and SF samples were analyzed for a broad variety of inflammatory mediators, including interleukins (ILs), interferons (IFNs), C-X-C motif ligand chemokines (CXCLs), and growth factors (nerve growth factor; NGF, vascular endothelial growth factor; VEGF, and stem cell growth factor ß; SCGF-ß) using multiplex assay. Significant differences were observed between the SF levels of different inflammatory markers. When compared to UC OA, significantly higher concentrations of IL-7, IL-8, IL-10, IL-12, IL-13, IFN-γ, VEGF and CXCL1 were detected in BC OA. Correlation analyses revealed significant associations between OA severity and IL-6, IL-8, IFN-γ, SCGF-ß, VEGF, CXCL1. Interestingly, increases in both anti- (IL-10, IL-13) and pro-inflammatory (IL-7, IL-12, IFN-γ) cytokines, as well as growth factors (SCGF-ß, VEGF), correlated significantly with the level of knee pain. Poorer knee function was associated with higher IL-6, IL-10, IL-12, IL-13, IL-18, ßNGF, SCGF-ß, VEGF and CXCL9 levels. In conclusion, this study provides an extensive profile of synovial inflammatory mediators in knee OA and identifies cytokines of potential clinical relevance. In fact, five of the mediators examined (IL-10, IL-12, IL-13, SCGF-ß, VEGF) significantly correlate with both knee pain and function.

Posterior-only surgery with preoperative skeletal traction for management of severe scoliosis.

PURPOSE: The surgical treatment of severe adolescent spinal deformities is challenging and carries substantial risks of mortality and morbidity. To mitigate this risk, surgeons have employed various methods as this study designed to evaluate the safety and effectiveness of preoperative halo-femoral or halo gravity traction (HGT) followed by posterior-only surgery in the management of severe scoliosis. METHOD: A total number of 23 patients with severe scoliosis treated by preoperative skeletal traction (halo gravity or halo femoral) followed by posterior fusion and instrumentation in one stage. All patients were followed for a minimum of 2 years after surgery. RESULTS: The average age of the patients was 12.7 years at the time of surgery. Mean of the Cobb angle improved from 99.9° ± 8.2° preoperatively to 75.3° ± 8° post-traction and 49.5° ± 7.7° postoperatively. Kyphosis angle corrected from 56.4° ± 9.5° to 38.6° ± 5.8°. The preop-FVC% was 41 ± 6.1% and after 1 year follow-up FVC% was 45.7 ± 7.7%. No patients required an anterior release due to amount of their deformity. DISCUSSION: Despite the benefits of modern instrumentation procedures, the treatment of severe scoliosis can be very competing. We think that by applying preoperative halo femoral traction and halo-gravity traction, managing severe scoliosis will be in safe and easy manner and can lead to better deformity correction and less neurological complications and facilitate to avoid anterior operation for severe scoliosis and its related complications.

Management of Retinal Vein Occlusion, Who Is Responsible?

Retinal vein occlusion (RVO) is a common retinal vascular occlusive disorder and is associated with a variety of systemic risk factors. The aim of this study was to investigate whether the underlying diseases were evaluated and managed appropriately by ophthalmologists. We performed a study of 1344 patients with retinal vein occlusion (RVO). Patients were evaluated with a questionnaire including ten closed questions to determine whether ophthalmologists evaluated and informed their patients about the underlying systemic diseases. None of the patients' homocysteine levels were measured. Only a small percentage of the patients were asked about the history of thrombotic diseases or family history of thrombotic diseases. We believe that most ophthalmologists are still not entirely convinced of their responsibility of managing the underlying predisposing factors of RVO. Ophthalmologists should either manage or engage other healthcare providers in the management of RVO to guarantee the patient the best care.

Treatment of nonunion of the forearm bones with posterior interosseous bone flap.

BACKGROUND: Reconstructions of forearm fracture nonunions are frequently complex. A few studies that help guide the treatment of forearm nonunion have been reported. We offer a novel surgical technique to treat nonunion of the forearm using a regional vascularized bone graft. METHODS: Four females and 5 males ranging from 27 to 74 years of age with 7 ulna and 2 radius nonunions were surgically treated by pedicle grafting with a posterior interosseous bone flap (PIBF) and internal fixation with a plate. There were no cases with extensive soft tissue damage or infection. Pre- and postoperatively (mean 21 months), all patients were assessed by radiographs and for function by the Disabilities of the Arm, Shoulder and Hand (DASH) score. RESULTS: Function of the upper extremity was improved in all patients. DASH scores improved from 61.2 points pre-operatively to 12 points at final follow-up. All nonunions were united uneventfully. CONCLUSIONS: Following debridement of the necrotic tissue, the bone defect can be filled with a vascularized graft from posterior interosseous pedicles. Pedicled PIBF is a safe and useful novel technique in cases of atrophic or hypertrophic nonunion of the middle third of the radius or proximal two-thirds of the ulna.

A supplemental video teaching tool enhances splinting skills.

BACKGROUND: The ability to apply casts and splints is a technical skill that requires practice and understanding of basic principles of musculoskeletal medicine. A video in which a given procedure is simulated on a dummy can represent reality under controlled conditions. A decrease in physician competency in musculoskeletal medicine is the result of educational deficiencies at the medical school level. QUESTIONS/PURPOSES: We asked whether (1) a supplemental video educational program enhances performance of medical students' musculoskeletal clinical skills and (2) factors such as the proportion of orthopaedic professors to students, sex, age, and previous scores of medical students affected the clinical skills of medical students. METHODS: We allocated 474 medical students into one of two groups: all participants received 90 minutes of lecture instruction on how to splint and cast but one group viewed the supplemental instructional video and the other did not. There were no differences in terms of sex, age, basic science exam scores, or grade point average of the groups. Thirteen specific skills in splinting an injured limb were evaluated. We recorded grade point averages. We developed a 10-point scoring system and graded each student on their splinting skills 6 months after the lectures. RESULTS: The medical students who watched the video had an average score of 7.6, whereas the control group's average score was 2.0. We observed a positive association between watching the educational video and clinical exam score. A higher professor-to-student ratio was associated with lower student Objective Structured Clinical Examination score. CONCLUSIONS: Our observations suggest a supplemental video instructional program improved the performance of musculoskeletal clinical skills in comparison to only a traditional lecture series.

Effectiveness of educational intervention on undermanagement of osteoporosis in fragility fractures.

PURPOSE: Fragility fractures are characterized by a low energy trauma and should be considered as potentially osteoporosis-related fractures. This study aimed to determine whether the orthopedic surgeons' awareness could increase the osteoporosis management rate in patients with fragility fractures. METHOD: This study was undertaken in three phases: evaluation of existing practice patterns, educational intervention and evaluation of the effect of the training. During the study period, orthopedic surgeons who worked at academic hospitals attended five educational sessions and were provided with posters and brochures. Patients were interviewed at sixth and twelfth months after discharge using an evaluation questionnaire regarding their perceptions of the barriers to osteoporosis treatment. RESULTS: Seventy-two orthopedic surgeons volunteered to participate in the study between June 2008 and December 2011. The patients were followed for a minimum of 1 year. Rate of calcium and vitamin D prescriptions increased from 10 to 91 %. The rate of bisphosphonate administration reached to 73 %. The number of follow-up evaluations did not differ significantly. CONCLUSION: The detection and medication rates for osteoporosis in patients with fragility fractures increased more than tenfold after the intervention program.

Biological plate osteosynthesis of comminuted subtrochanteric fractures: a clinical study.

BACKGROUND: Comminuted subtrochantric fractures represent a challenge for trauma surgeons. Achieving appropriate reduction and stable fixation can be difficult, some techniques being associated with technical difficulties and complications. The aim of this study is the assessment of biologic fixation in comminuted subtrochantric fractures. METHOD: Twenty six men with comminuted subtrochanteric femoral fractures treated by bridging dynamic hip screw were prospectively studied. Patients were assessed clinically for pain, hip and knee range of motion, angular and rotational deformities and leg-length discrepancy. Union was assessed radiographically. RESULTS: Seinheimer classification: 8 fractures were type III, 11 patients type IV and seven patients type V. Fixation was performed with dynamic hip screw (DHS). Union occurred in all cases. None of the patients had clinical pain or dysfunction. DISCUSSION: We highly recommend submuscular plating in the treatment of comminuted subtrochantric fractures especially in the third world.

Are hospitalized patients with fragile fractures managed properly in relation to underlying osteoporosis?

BACKGROUND: Osteoporotic fractures are an important reason of morbidity and mortality in the elderly population and impose huge economic burden on health services. There have been major advances in the treatment of osteoporosis, and many steps can be taken to prevent or even reduce the risk of fractures. Orthopedic surgeons manage most of these fractures and are often the only clinician seen by the patient. METHODS: We performed a survey of 515 patients with osteoporotic fractures who were admitted to 3 level I trauma hospitals in Tehran, Iran. Patients were evaluated with a questionnaire to determine whether orthopedic surgeons informed their patients about aspects of osteoporosis other than their fracture, and if appropriate, evaluation and treatment for osteoporosis were initiated. The questionnaires were completed in 2 years (mean) from their admissions. RESULTS: Only 10.5% patients reported that they had been told by an orthopedic surgeon that they had osteoporosis. Only 3.3% had bone mineral density appointments. Few had received treatment for osteoporosis-only 8.2% of patients had been treated with calcium and vitamin D, and 3.5% with a bisphosphonate. DISCUSSION: We believe that the majority of the orthopedic surgeons lacked sufficient training in osteoporosis; therefore, engaging other providers in their healthcare system can create a pathway for the assessment and treatment of osteoporosis, to guarantee the patient the best care.

Entire posterior process talus fracture: a report of two cases.

The complex anatomy of the posterior process of the talus includes the medial and lateral tubercles extending from the talar body. Review of the current literature indicates that fracture of the entire posterior process of the talus is a rare injury. Two patients presented to our emergency department after motor vehicle accidents, and both were diagnosed with entire posterior process talus fractures. After evaluation of each patient, treatment of each was undertaken by means of open reduction and internal fixation via the posteromedial approach to fracture. Headless screws were used to fixate the reduced posterior tubercle in each case. Based on our experience with the patients described in this report, open reduction and internal fixation appear to be suitable methods of treatment for complete posterior process fractures of the talus.

Knowledge of orthopaedic surgeons in managing patients with fragility fracture.

PURPOSE: Fragility fractures represent a major health problem, as they cause deformity, disability and increased mortality rates. Orthopaedic surgeons should identify patients with fragility fractures and manage their osteoporosis in order to reduce the risk of future fracture; therefore, orthopaedic surgeons' knowledge about managing fragile fracture should be evaluated. METHODS: A questionnaire was administered to 2,910 orthopaedic surgeons to address the respondents' knowledge. The questions covered the topics of diagnosis, treatment and approach to a patient with a fragility fracture. The data-collection period for this survey spanned one year. RESULTS: There were 2,021 orthopaedic surgeons who participated in this study. Less than 10% of the respondents included bone mass densitometry (BMD) when evaluating patients with fragile fractures 32% prescribed proper dosage of calcium and vitamin D; approximately 30% would refer if falling from a height was suspected. CONCLUSIONS: The majority of orthopaedic surgeons questioned lacked knowledge of fragility fracture management. This is reflected by limited knowledge of osteoporosis assessment and treatment in most areas. An appropriate method should be created to manage patients with fragility fractures to guarantee the patient the best possible care.

Pin and plate fixation in complex distal humerus fractures: surgical technique and results.

PURPOSE: Complex distal humerus fractures are difficult to fix by conventional methods, especially in comminuted low distal humerus fractures. We propose a technique using small diameter K-wires and a plate on the humeral shaft. METHODS: Between May 2007 and March 2009, 19 patients with poor bone quality showing comminuted or low distal humerus fractures involving the articular surface were referred to our institution and were primarily treated by this technique that we called "pin and plate fixation". We have reviewed all the cases treated by this method. RESULTS: The average age was 46 years. All of the patients were followed up for a mean of 12 months and had a good range of motion (the average total arc of flexion-extension was 99°); the average Disabilities of the Arm, Shoulder and Hand (DASH) score was 18 points. The Mayo Elbow Performance Index was measured and the mean score was 88 in our patients. CONCLUSIONS: In this study, a technique has been evaluated for the treatment of complex distal humerus fractures. We recommend this technique in comminuted, osteoporotic or low distal humerus fractures in which other fixation methods seem difficult or even impossible.

Treatment of Kienböck disease by lunate core decompression.

PURPOSE: Kienböck disease is characterized by avascular necrosis of the lunate bone, which is usually progressive without treatment. This study examined lunate core decompression for its treatment potential. METHODS: We surgically treated 20 patients with stage 1 to 3b Kienböck disease with lunate core decompression. We evaluated pain, range of motion, functional disability, and radiographic indices in these patients at baseline and 5 years after surgery. RESULTS: The mean age of the patients was 29 years; 16 were men. Ten patients had Lichtman stage 1 disease, 6 had stage 2 disease, 3 had stage 3a, and 1 had stage 3b disease. Range of motion scores showed meaningful improvement. Two patients did not improve with this technique and were revised with radial shortening procedures. CONCLUSIONS: Lunate core decompression is a simple surgical procedure that is effective in the treatment of Kienböck disease. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.