The direct anterior approach provokes varus stem alignment when using a collarless straight tapered stem.

INTRODUCTION: Inaccurate stem implantation can cause unsatisfactory offset reconstruction and may result in insufficient gluteal muscle function or aseptic loosening. In this study, stem alignment of a collarless straight tapered HA-coated stem was retrospectively analyzed during the learning phase of the direct anterior approach (DAA) for primary total hip arthroplasty (THA). MATERIAL AND METHODS: From Jan 2013 to Jun 2015, a total of 93 cementless THA were implanted in patients with unilateral coxarthrosis via the DAA in a two surgeon setting using the Corail® or Trendhip® stem (DePuy Synthes or Aesculap). Varus(+)/Valgus(-) stem alignment was analyzed in postoperative anteroposterior pelvic radiographs. Effects on femoral offset reconstruction and correlation to patient's individual clinical and radiological parameters were evaluated. RESULTS: 55 stems were implanted in varus (59%), 32 in neutral (34%) and 6 in valgus alignment (7%). Mean stem alignment in varus position was + 2.2° (SD ± 1.4°). Varus alignment was associated with male gender and preoperative coxa vara deformity: low CCD, high femoral offset and long thigh neck (p ≤ 0.001). Alignment was not correlated to femoral offset restoration, BMI or leg length difference. Mean cup inclination was 44° (SD ± 4.7°) and 90% matched the coronal Lewinnek safe zone. CONCLUSION: In the learning curve, the DAA can be associated with a high incidence of varus stem alignment when using a straight tapered stem, especially in men with coxa vara deformity: low CCD, high femoral offset and long thigh neck. An insufficient capsule release makes femur exposure more difficult and might be an additional factor for this finding. We recommend intraoperative X-ray in the learning phase of the DAA to verify correct implant positioning and to adjust offset options.

Biomechanical Stability and Osteogenesis in a Tibial Bone Defect Treated by Autologous Ovine Cord Blood Cells-A Pilot Study.

The aim of this study was to elucidate the impact of autologous umbilical cord blood cells (USSC) on bone regeneration and biomechanical stability in an ovine tibial bone defect. Ovine USSC were harvested and characterized. After 12 months, full-size 2.0 cm mid-diaphyseal bone defects were created and stabilized by an external fixateur containing a rigidity measuring device. Defects were filled with (i) autologous USSC on hydroxyapatite (HA) scaffold (test group), (ii) HA scaffold without cells (HA group), or (iii) left empty (control group). Biomechanical measures, standardized X-rays, and systemic response controls were performed regularly. After six months, bone regeneration was evaluated histomorphometrically and labeled USSC were tracked. In all groups, the torsion distance decreased over time, and radiographies showed comparable bone regeneration. The area of newly formed bone was 82.5 ± 5.5% in the control compared to 59.2 ± 13.0% in the test and 48.6 ± 2.9% in the HA group. Labeled cells could be detected in lymph nodes, liver and pancreas without any signs of tumor formation. Although biomechanical stability was reached earliest in the test group with autologous USSC on HA scaffold, the density of newly formed bone was superior in the control group without any bovine HA.

Prostacyclin suppresses twist expression in the presence of indomethacin in bone marrow-derived mesenchymal stromal cells.

BACKGROUND: Iloprost, a stable prostacyclin I2 analogue, seems to have an osteoblast-protective potential, whereas indomethacin suppresses new bone formation. The aim of this study was to investigate human bone marrow stromal cell (BMSC) proliferation and differentiation towards the osteoblastic lineage by administration of indomethacin and/or iloprost. MATERIAL/METHODS: Human bone marrow cells were obtained from 3 different donors (A=26 yrs/m; B=25 yrs/f, C=35 yrs/m) via vacuum aspiration of the iliac crest followed by density gradient centrifugation and flow cytometry with defined antigens (CD105+/73+/45-/14-). The cells were seeded and incubated as follows: without additives (Group 0; donor A/B/C), with 10(-7) M iloprost only (Group 0+ilo; A/B), with indomethacin only in concentrations of 10(-6) M (Group 1, A), 10(-5) M (Group 2, B), 10(-4) M (Group 3, A/B), and together with 10(-7) M iloprost (Groups 4-6, A/B/C). On Day 10 and 28, UV/Vis spectrometric and immunocytochemical assays (4 samples per group and donor) were performed to investigate cell proliferation (cell count measurement) and differentiation towards the osteoblastic lineage (CD34-, CD45-, CD105+, type 1 collagen (Col1), osteocalcin (OC), alkaline phosphatase (ALP), Runx2, Twist, specific ALP-activity). RESULTS: Indomethacin alone suppressed BMSC differentiation towards the osteoblastic lineage by downregulation of Runx2, Col1, and ALP. In combination with indomethacin, iloprost increased cell proliferation and differentiation and it completely suppressed Twist expression at Day 10 and 28. Iloprost alone did not promote cell proliferation, but moderately enhanced Runx2 and Twist expression. However, the proliferative effects and the specific ALP-activity varied donor-dependently. CONCLUSIONS: Iloprost partially antagonized the suppressing effects of indomethacin on BMSC differentiation towards the osteoblast lineage. It enhanced the expression of Runx2 and, only in the presence of indomethacin, it completely suppressed Twist. Thus, in the treatment of avascular osteonecrosis or painful bone marrow edema, the undesirable effects of indomethacin might be counterbalanced by iloprost.

PGE2 and BMP-2 in bone and cartilage metabolism: 2 intertwining pathways.

Osteoarthritis and lesions to cartilage tissue are diseases that frequently result in impaired joint function and patient disability. The treatment of osteoarthritis, along with local bone defects and systemic skeletal diseases, remains a significant clinical challenge for orthopaedic surgeons. Several bone morphogenetic proteins (BMPs) are known to have osteoinductive effects, whereof BMP-2 and BMP-7 are already approved for clinical applications. There is growing evidence that the metabolism of bone as well as the cartilage damage associated with the above disease processes are strongly inter-related with the interactions of the inflammation-related pathways (in particular prostaglandin E2 (PGE2)) and osteogenesis (in particular bone morphogenetic protein-2 (BMP-2)). There is strong evidence that the pathways of prostaglandins and bone morphogenetic proteins are intertwined, and they have recently come into focus in several experimental and clinical studies. This paper focuses on PGE2 and BMP-2 intertwining pathways in bone and cartilage metabolism, and summarizes the recent experimental and clinical data.

Does Needle Design Affect the Regenerative Potential of Bone Marrow Aspirate? An In Vitro Study.

While autologous bone is still the gold standard for treatment of bone defects, its availability is limited. Sufficient numbers of mesenchymal stroma cells (MSC) may be an alternative. Small volumes of bone marrow aspirate (BMA) were harvested with two different needle systems comparing the yield and regenerative potency of the MSCs. BMA (10 mL) was aspirated from the posterior iliac crest of 12 patients with degenerative spinal disc disease using both needle systems in each patient: the Jamshidi needle (JAM) and on the contralateral side the Marrow Cellution® Needle (AMC). Number of mononuclear cells (MNCs) and regeneration capacity (colony-forming unit/CFU) were determined. MSCs were characterized for surface markers and their differentiation into trilineages. There was no significant difference between the two harvesting needles regarding the quantity of MNCs in BMA: 5.2 ± 1.8 × 109 MNC/mL for AMC vs. 4.8 ± 2.5 × 109 MNC/mL for JAM, p = 0.182. The quantity of CFUs per ml BMA was similar for both groups: 3717 ± 5556 for AMC and 4305 ± 5507 for JAM (p = 0.695). The potency of MSCs expressed as colony-forming potential per 106 MNC resulted in 0.98 ± 1.51 for AMC and 1.00 ± 0.96 for JAM (p = 0.666). Regardless of the needle design, 10 mL bone marrow aspirate contains a sufficient number of about 40,000 MSCs that can be used to enhance bone healing.

Results of advanced core decompression in patients with osteonecrosis of the femoral head depending on age and sex-a prospective cohort study.

BACKGROUND: Core decompression is a common surgical technique to treat osteonecrosis of the femoral head. The aim of this study is to evaluate the effect of the parameters "age" and "sex" on the outcome of this type of treatment. METHODS: A prospective cohort study was performed. Eighty-six osteonecrotic hips with a mean follow-up of 32.5 months (± 24.8) after advanced core decompression were analysed regarding age- and sex-dependent treatment failure. Additionally, the modified Harris Hip Score and Numeric Rating Scale were compared regarding the parameters age and sex. RESULTS: The mean hip survival of the male participants was 51.3 months (39.4% treatment failure), whereas females presented a longer, thus not significant, mean survival of 61.4 months (30% therapy failure; p = 0.48). The further evaluation revealed significantly better survival in the patients aged < 40 years (mean survival 66.09 months, 16% treatment failure) in comparison to those aged ≥ 40 years (mean survival 50.14 months, 46% therapy failure; p = 0.03). The modified Harris Hip Score and Numeric Rating Scale results of patients whose treatment did not fail during the study period were similar, irrespective of the patient's sex or age. CONCLUSIONS: The study shows that the number of therapy failures is significantly higher in older patients, with 40 years of age marking the borderline. Patients' sex does not seem to affect the outcome of treatment, and postoperative clinical scores appear to be identical with individuals not affected by therapy failure. Since age and sex are unalterable parameters, the study helps to provide valuable predictions regarding the chances of long-term hip survival after treatment of osteonecrosis.

The 'critical trochanter angle': a predictor for stem alignment in total hip arthroplasty.

INTRODUCTION: Stem malalignment can affect offset reconstruction and may result in gluteal muscle insufficiency. In this retrospective study, a novel geometric angle named 'critical trochanter angle' (CTA) is described and investigated towards the risk of malposition of a collarless straight tapered hydroxyapatite-coated stem in primary total hip arthroplasty (THA). MATERIAL AND METHODS: A total of 100 cementless THA were implanted in patients with unilateral coxarthrosis via the direct anterior (n = 50) or direct lateral Hardinge approach (n = 50) in a two surgeon setting using the Corail® or Trendhip® stem (DePuy Synthes or Aesculap). Stem alignment was analysed in postoperative AP pelvic radiographs and correlated to the CTA: the angle crest was defined by the intersection of the femoral shaft and neck axis and the angle was measured between the shaft axis and a leg intersecting the vertex between the lateral and superoposterior facet of the trochanter. RESULTS: Forty-seven stems were implanted in varus (≥ + 1°), 42 in neutral (< + 1°/> - 1°) and 11 in valgus position (≤ - 1°). The mean critical trochanter angle was 25.0° (SD ± 7.5°), and there was a negative and statistically significant correlation to stem alignment (r = - 0.52; p ≤ 0.001) independent from the surgical approach. For stem malposition of 2° and above (n = 23), mean CTA was 17.2° for varus (n = 20) and 31.6° for valgus (n = 3). A CTA lesser or equal to 22.75° had a sensitivity of 90% and specificity of 80% for varus stem position of 2° or greater. Specificity raised to 100% with a cutoff CTA of 12.5° or lesser. CONCLUSION: Varus stem alignment in THA is associated with coxa vara deformity and a radiological low CTA. In preoperative planning, the critical trochanter angle can help to evaluate the risk for intraoperative stem malpositioning. If navigation or robotic assistance is not available when using this stem design, we recommend an intraoperative x-ray to verify correct implant positioning in patients with a CTA under 20° or above 30°.

Transforaminal lumbar interbody fusion with expandable cages: Radiological and clinical results of banana-shaped and straight implants.

PURPOSE: Expandable titanium transforaminal lumbar interbody fusion (TLIF) devices are a relatively new group of implants allowing restoration of lumbar lordosis (LL) and thus improvement of sagittal alignment. The purpose of our study is to compare clinical and radiological results of two different expandable TLIF devices. MATERIALS AND METHODS: In a retrospective study, patients who underwent TLIF surgery with a banana-shaped or straight TLIF cage in our spine center were analyzed. Primary outcome was change of disc height (DH), segmental lordosis angle (SLA), and lumbar lordotic angle (LLA). Moreover, basic patients parameters and cage subsidence were evaluated. RESULTS: Sixty-one patients were studied (33 banana-shaped and 28 straight cages). DH changed in the banana group from 4.8 mm (standard deviation SD 2.5) to 10.4 (SD 2.4) and in the straight cage group from 6.2 mm (SD 2.5) to 9.6 mm (SD 1.7). The difference was statistically significant (P = 0.03). In addition, SLA correction was higher in the banana group with 5.8° (SD 5.0)-3.7° (SD 3.6), but not significant. LLA improved in the straight group with 5.2 (SD 6.4) compared to 3.7° (SD 5.8) in the banana group. We found subsidence in four patients (6.6%) in the banana-shaped group and nine cases (14.8%) in the other group. CONCLUSIONS: Expandable titanium implants show similar improvements in restoring segmental and global lordosis. Banana-shaped expandable cages offer higher potency restoring the intervertebral DH and show less rates of subsidence compared to straight expandable cages.

Who benefits more in osteoporotic fractures: Pedicle screw instrumentation or kyphoplasty for American Society of Anesthesiologists II/III patients?

PURPOSE: Osteoporotc fractures with posterior wall injury are commonly treated with a pedicle srcrew instrumentation (PSI) or a ballonkyphoplasty (BKP). A predictor for complications for these patients is the American Society of Anesthesiologists (ASA) class. Clinical results in ASA II/III patients who underwent BKP and PSI due to OF were evaluated to find the optimal treatment regimen. MATERIALS AND METHODS: In a retrospective study design, ASA Class II and III patients with OF type OF 2 and OF 3 according to the German Society of Orthopedics and Trauma Surgery classification who underwent surgery between 2011 and 2016 were enrolled. Perioperative data such as time of surgery, cement leakage, adjacent level fractures, screw loosening, wound infections, and segmental kyphosis correction were measured and a statistical analysis was conducted. RESULTS: Ninety-nine patients met the inclusion criteria, 17 were classified as ASA II and 82 patients were classified as ASA III. Twenty-eight individuals were treated by PSI, whereas 71 underwent BKP. Not only a longer average operation (120 min) and hospital stay (21 days) were documented in the PSI group but also a better kyphosis correction (7.5°). In comparison, the BKP group required an average operation time of 35.5 min with a mean kyphosis correction of 2.1°. A statistical analysis revealed the surgical procedure and not the ASA class to be a relevant factor for complication and revision surgery. CONCLUSIONS: BKP is a safe and effective therapy including also fractures with posterior wall defects while PSI showed advantages in restoring the sagittal realignment but higher complication and revision risk.

The Double-Transforaminal Lumbar Interbody Fusion: An Innovative One-Stage Surgical Technique for Posterior Kyphosis Correction.

Posttraumatic deformities after vertebral fractures are challenging for orthopedic surgeons in the non-operative and operative field. Especially osteoporotic fractures may cause a hyperkyphosis resulting in segmental or global sagittal imbalance and chronic back pain. Different vertebral osteotomies are potent to restore sagittal profile but show a very high perioperative risk including neurological and soft tissue complications. In addition, some of these extensive operations require a two-step procedure including posterior and anterior approaches. Therefore, these established techniques may be contraindicated in elderly or multimorbide patients suffering from concomitant diseases. The authors describe the double transforaminal lumbar interbody fusion (TLIF) osteotomy (DTO) as an innovative one-stage and low-invasive surgical technique to correct a fixed posttraumatic kyphosis in the thoracolumbar junction. The procedure includes posterior release (laminectomy, facettectomy, nucleotomy) combined with two expandable TLIF implants (sandwich technique) and posterior instrumentation and is illustrated by a case of a multimorbide 78-year old female.

Osteogenic differentiation and proliferation of bone marrow-derived mesenchymal stromal cells on PDLLA + BMP-2-coated titanium alloy surfaces.

RhBMP-2 is clinically applied to enhance bone healing and used in combination with titanium fixation implants. The purpose of this in vitro study was to compare the osteogenic differentiation and proliferation of hMSC on native polished versus sandblasted titanium surfaces (TS) and to test their behavior on pure poly-D,L-lactide (PDLLA) coated as well as PDLLA + rhBMP-2 coated TS. Furthermore, the release kinetics of PDLLA + rhBMP-2-coated TS was investigated. Human bone marrow cells were obtained from three different donors (A: male, 16 yrs; B: male, 27 yrs, C: male, 49 yrs) followed by density gradient centrifugation and flow cytometry with defined antigens. The cells were seeded on native polished and sandblasted TS, PDLLA-coated TS and PDLLA + rhBMP-2-coated TS. Osteogenic differentiation (ALP specific activity via ALP and BCA assay) and proliferation (LDH cytotoxicity assay) was examined on day 7 and 14 and release kinetics of rhBMP-2 was investigated on day 3, 7, 10, and 14. We found significant higher ALP specific activity and LDH activity on native polished compared to native sandblasted surfaces. PDLLA led to decreased ALP specific and LDH activity on both surface finishes. Additional rhBMP-2 slightly diminished this effect. RhBMP-2-release from coated TS decreased nearly exponentially with highest concentrations at the beginning of the cultivation period. The results of this in vitro study suggest that native TS stimulate hMSC significantly stronger toward osteogenic differentiation and proliferation than rhBMP-2 + PDLLA-layered TS in the first 14 days of cultivation. The PDLLA-layer seems to inhibit local hMSC differentiation and proliferation.