Evaluation of Cytocompatibility of PEEK-Based Composites as a Function of Manufacturing Processes.

The biocompatible polymer polyetheretherketone (PEEK) is a suitable candidate to be part of potential all-polymer total joint replacements, provided its use is associated with better osseointegration, mechanical performance, and wear resistance. Seeking to meet the aforementioned requirements, respectively, we have manufactured a PEEK composite with different fillers: carbon fibers (CF), hydroxyapatite particles (HA) and graphene platelets (GNP). The mechanical outcomes of the composites with combinations of 0, 1.5, 3.0 wt% GNP, 5 and 15 wt% HA and 30% of wt% CF concentrations pointed out that one of the best filler combinations to achieve the previous objectives was 30 wt% CF, 8 wt% HA and 2 wt% of GNP. The study compares the bioactivity of human osteoblasts on this composite prepared by injection molding with that on the material manufactured by the Fused Filament Fabrication 3D additive technique. The results indicate that the surface adhesion and proliferation of human osteoblasts over time are better with the composite obtained by injection molding than that obtained by 3D printing. This result is more closely correlated with morphological parameters of the composite surface than its wettability behavior.

Fractura aislada del hueso grande asociada a quiste traumático sinovial: presentación de un caso en un niño / Isolated capitate fracture associated with a traumatic synovial cyst: A pediatric case Report

Introducción: Las fracturas aisladas del hueso grande son muy infrecuentes en los niños y se producen por traumatismos de alta energía. Pueden pasar desapercibidas en la valoración inicial y las radiografías solo permiten identificar las lesiones en huesos osificados, por lo que son necesarias pruebas complementarias, como la resonancia magnética, para descartar posibles lesiones del carpo asociadas, sobre todo en menores de 10 años. Se presenta el caso de una fractura aislada del hueso grande con aparición de quiste sinovial por causa traumática en un paciente pediátrico, tratado mediante inmovilización con yeso antebraquial durante cuatro semanas, con buena evolución. Conclusión: El manejo de estos casos depende de la gravedad de la lesión y, aunque por lo común evolucionan bien con un tratamiento conservador, su diagnóstico precoz permite elegir la mejor opción y evitar posibles complicaciones, como la falta de consolidación o la necrosis avascular. Nivel de Evidencia: IV

Introduction: Isolated capitate fractures, caused by high-energy trauma, are rare in children. They can be missed at the initial assessment of the patient and radiographs only allow the identification of lesions in ossified bones, so complementary tests such as magnetic resonance imaging are necessary to rule out possible associated carpal lesions, especially in children under 10 years old. We present the case of an isolated capitate bone fracture with the appearance of a synovial cyst due to trauma in a pediatric patient, treated by immobilization with a short arm cast for four weeks, with good evolution. Conclusion: The management of these cases depends on the severity of the injury. In most cases conservative treatment is enough but early diagnosis allows us to choose the best option and avoid possible complications as nonunion or avascular necrosis. Level of Evidence: IV

Spontaneous regression of solitary osteochondromas in children: An option to consider in clinical practice.

Osteochondromas are neoplasm that belong to the family of cartilaginous histogenesis tumors and represent 90% of all forms of exostoses. As most osteochondromas are asymptomatic, underdiagnosis is frequent. Symptomatic forms usually manifest before the age of 20 years, and the most common symptoms are pain and the detection of a bony mass. Herein, we report four cases of spontaneous regression of solitary osteochondromas in the light of literature. We consider that orthopedic surgeons should take into account the possibility of spontaneous regression of these tumors, before recommending surgery. Symptoms are usually mild and we recommend following these patients with X-ray and physical examination annually.

Osteosynthesis in Vancouver type B1 periprosthetic fractures.

INTRODUCTION: The incidence of hip periprosthetic fractures (PPF) has been increasing in recent years. In Vancouver type B1 there are several osteosynthesis options. The aim of this paper is to assess both the treatment and results of Vancouver type B1 PPF in patients operated at our centre. MATERIAL AND METHOD: An observational retrospective study of patients operated at Hospital Universitario Miguel Servet for type B1 PPF via osteosynthesis with plate between January 2014 and March 2017. Such details were documented and analysed as type of implant used for fixation, patient demographics, complications, time to union and function score using the Harris Hip Score. The minimum follow up was 2 years. RESULTS: Overall, 37 patients (21 women)  were available for review with a mean age of 80.7 years (range 54-99). 8 of these patients died, with an average age of 85.6 (83-95). Out of these 8 dead patients, 4 died in the first year, with an average age of 87 (83-95). 19 fractures had cemented stems whereas 18 were uncemented. According to prosthesis type, 8 had a cemented partial arthroplasty, 11 a cemented total hip arthroplasty (THA), 18 a non-cemented THA; with an average period until PPF of 2.5 years (0.2-5.6), 7 years (0.09-18.1) and 8.1 years (2.6-12.7) respectively. Devises used for stabilisation of the fracture included 27 Cable-Ready® plates (Zimmer-Biomet), 5 Dall-Miles® plates (Stryker) and 5 femur NCB® plates (Zimmer-Biomet). Complications included 5 acute superficial infections of surgical wound, 1 chronic infection, 5 pressure ulcers (4 sacral, 1 heel), 7 patients required intra-operational blood transfusion. The mean time to union was 10.35 weeks (range 6-13). The mean Harris Hip Score postoperatively was 65 (44-95). DISCUSSION: Treatment via open reduction and internal fixation with locked lateral plate covering most of the femur in elderly patients or those with poor bone quality, or a plate with proximal cerclages and distal screws in patients with better bone quality are appropriate treatment methods. To achieve good results using these techniques, we consider minimisation of soft tissue dissection highly important likewise using a meticulous osteosynthesis technique with special attention to biology and biomechanics.

Surgical treatment of congenital pseudoarthrosis of the clavicle: Our 22-year, single-center experience.

OBJECTIVES: This study reports the surgical outcomes in a patient cohort with congenital pseudarthrosis of the clavicle (CPC). PATIENTS AND METHODS: A total of nine pediatric patients (5 males, 4 females; mean age: 4.43 years; range, 2 to 12 years) who were diagnosed with CPC and treated surgically with a minimum one-year follow-up between January 1996 and December 2018 were retrospectively analyzed. The patients were divided into two groups according to the fixation method as the Kirschner wire (K-wire; Group A, n=2) or stabilization with a plate (Group B, n=7). The physical function and symptoms were evaluated using the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scale. RESULTS: The mean age at the time of diagnosis was 2.95 (range, 0 to 12) years. Six cases were atrophic pseudarthrosis and three cases were hypertrophic. Radiographic consolidation occurred in all cases with a mean duration of 103.8±39.1 days, indicating no significant difference between the groups (p>0.05). Complications registered were a K-wire breakage in a patient in Group A and an internal fixation plate loosening in a patient in Group B. The mean postoperative follow-up was 2.98±1.82 years. The QuickDASH score was 0 points in all patients. CONCLUSION: The early surgical indication based on refreshment of the pseudarthrosis focus, with bone autograft interposition when a failure exists to restore adequate clavicular length, and fixation are reliable alternatives with favorable clinical and radiological results in the mid- and long-term with fewer complications.

Surgical clavicle reconstruction after aneurysmal bone cyst resection in a child: A simple method.

The clavicle is an infrequent location for primary tumors in general, and aneurysmal bone cyst (ABC) of the clavicle is particularly rare. The challenge of the functional and esthetic result in the treatment of these lesions in the pediatric population is high when considering the reconstruction of critical bone defects. In this article, we present the case of a seven-year-old boy with an ABC in the middle third of the clavicle, treated by resection and reconstruction with free autograft of the fibula stabilized by using an intramedullary titanium nail. We offer a description of the used technique, considerations about treatment options in children, and a follow-up of more than two-and-a-half years.

[Patellar osteomyelitis. A diagnostic challenge.] / Osteomielitis de rótula. Un reto diagnóstico.

Osteomyelitis is a rare infection that is considered to be a children's disease. Diagnosis is frequently delayed because it is an uncommon pathology and is presented in various ways. After its diagnosis and treatment, the result is favourable in children. We present a clinical case that shows difficulties in its diagnosis. A high index of suspicion should be addressed for early recognition.

La osteomielitis es una infección infrecuente considerada como una enfermedad infantil. El diagnóstico suele demorarse, ya que es una patología rara y con forma de presentación variable. Tras su diagnóstico y tratamiento, la evolución en los niños suele ser favorable. Presentamos un caso que muestra las dificultades en su diagnóstico. Debe dirigirse un alto índice de sospecha para su precoz reconocimiento.

Disseminated Tuberculosis Resulting From Reinfection in a Pediatric Patient Sequentially Treated With Etanercept and Adalimumab.

Treatment with tumor necrosis factor α inhibitors is a risk factor for tuberculosis (TB). Despite previous treatment with isoniazid for latent TB, a 9-year-old girl with juvenile idiopathic arthritis developed disseminated TB after changing therapy with etanercept to adalimumab and after new contact with a smear-positive relative. Genotyping strain matches and susceptibility to isoniazid make reinfection more likely than reactivation in our patient.

Comparative Analysis of the Biomechanical Behaviour of Two Cementless Short Stems for Hip Replacement: Linea Anatomic and Minihip.

A comparative study between two stems (Linea Anatomic and Minihip) has been performed in order to analyse the differences in their biomechanical behaviour, concerning stem micromotions and load transmission between stem and bone. From the corresponding finite element models, a parametric study was carried out to quantify ranges of micromotions taking into account: friction coefficient in the stem-bone interface, press-fit and two types of gait cycle. Micromotions were evaluated for each stem at six different levels along repeated gait cycles. An initial and marked stem subsidence at the beginning of the simulation was observed, followed by an asymptotic decrease due to friction forces. Once migration occurs, a repeated reversible cyclic micromotion is developed and stabilized as gait cycle times are simulated. The general motion pattern exhibited higher amplitude of micromotion for Minihip compared to Linea stem. The load transmission mechanism was analyzed, identifying the main internal forces. The results show higher local forces for Minihip stem up to 80% greater than for Linea stem. The differences of design between Minihip and Linea conditioned different distributions of load, influencing the posterior stress-shielding. Consequently, short stems require high bone stock and quality should, being indicated for young patients with high bone quality.

Cementless hydroxyapatite coated hip prostheses.

More than twenty years ago, hydroxyapatite (HA), calcium phosphate ceramics, was introduced as a coating for cementless hip prostheses. The choice of this ceramic is due to its composition being similar to organic apatite bone crystals. This ceramic is biocompatible, bioactive, and osteoconductive. These qualities facilitate the primary stability and osseointegration of implants. Our surgical experience includes the implantation of more than 4,000 cementless hydroxyapatite coated hip prostheses since 1990. The models implanted are coated with HA in the acetabulum and in the metaphyseal area of the stem. The results corresponding to survival and stability of implants were very satisfactory in the long-term. From our experience, HA-coated hip implants are a reliable alternative which can achieve long term survival, provided that certain requirements are met: good design selection, sound choice of bearing surfaces based on patient life expectancy, meticulous surgical technique, and indications based on adequate bone quality.

Prevalence of osteoporotic vertebral fracture in Spanish women over age 45.

The aim of this work is to study the prevalence of osteoporotic vertebral fractures in Spanish women over 45 years of age, based on the selection of a nationwide sample. An observational, cross-sectional, multicenter study was conducted during 2006, in all of Spain's regions. The sample analyzed was of 5000 individuals, representative of the female population over age 45 in Spain. A questionnaire was used to determine which factors are most often associated with vertebral fractures. We also assessed whether the Prevalent Vertebral Fracture Index, proposed by Vogt, is useful in indicating a possible osteoporotic vertebral fracture. Five hundred orthopedic surgeons, from various Spanish regions, were trained in different aspects of the study: inclusion and exclusion criteria, management of the risk factor questionnaire, and implementation of the Vogt questionnaire. The number of fracture cases was 1549 (31.79%). 528 Women (34.08%) had a single vertebral fracture, and 1021 (65.92%) had multiple vertebral fractures. The following factors were statistically significantly associated with vertebral fracture: age, late menarche, early menopause, diabetes mellitus, hyperparathyroidism, rheumatoid arthritis, height loss, daily physical activity, corticosteroid therapy, personal history of osteoporotic fracture and previous diagnosis of osteoporosis. The differences in Vogt score according to age and fracture status were statistically significant. The conclusion of the study is that vertebral osteoporotic fracture in the female Spanish population is frequent. The high prevalence in the Spanish population older than 60 years is probably related to malnutrition in the period from 1936 to 1952.

Donor site reconstruction in iliac crest tricortical bone graft: surgical technique.

BACKGROUND AND PURPOSE: Autogenous bone grafts from the iliac crest are frequently harvested for autologous bone transplantation, because this is still the gold standard in the treatment of many bone defects. However, significant donor site morbidity must be considered. We have developed a simple method to treat the bone defect in the donor site in order to reduce some of the morbidity. In this method, the bone defect size and shape determines its application. METHOD: After the conventional method of tricortical bone harvesting from the iliac crest, bone defect is repaired by means of a transversal fence of appropriate thin tricortical chips obtained from the posterior lateral wall of the bone defect itself. The mechanical stability of this fence results from impactation of the ends of the tricortical chips into both lateral cancellous bone walls of the repaired bone defect. Thus, no hardware is required, and both the bone defect and ilium contour are restored. RESULTS: This simple method allows ilium bone defect healing and bone contour recovery after graft harvest, by using the same gold standard graft. Although not much time is necessary to reconstruct the donor site, the bone defect size and shape determine its application. INTERPRETATION: This method may be a recommendable option for bone defect reconstruction after iliac crest tricortical bone graft harvest as the primary procedure. The advantages of this technique are bone defect healing and bone contour restoration with prevention of a visible deformity over the groin, with no foreign material insertion, thus avoiding additional cost.

Hematogenous osteomyelitis of the patella.

Osteomyelitis is an uncommon infection that is considered to be a childhood disease. Diagnosis is frequently delayed, as it is a very rare condition and also because of its variable presentation. After an accurate diagnosis and treatment, the outcome is favorable in children. We present one case without recent previous infection, antecedent trauma, or penetrating injury, illustrating the difficulties in diagnosis. Nontraumatic osteomyelitis of the patella should be regarded as a rare hematogenous infection. A high index of suspicion should be addressed for early recognition. Study design is level of evidence: level IV.

The treatment of proximal humerus nonunions in older patients with reverse shoulder arthroplasty.

INTRODUCTION: Experience with treating proximal humeral nonunions with reverse total shoulder arthroplasty is limited. We report our results. PATIENTS: Eighteen patients with proximal humeral atrophic nonunion were treated with reverse total shoulder prosthesis. There were 12 women and 6 men, with a mean age of 78.8 years (range, 75-84 years). The mean follow up after reverse arthroplasty was 28 months (range, 24-32 months). Extensive proximal humeral bone loss that was found in six cases was treated adding a proximal humeral allograft. A long humeral stem was always used. RESULTS: The mean Constant score increased from 26% preoperatively to 55% postoperatively (p <0.0001). The average anterior elevation increased from 35° to 90° (p<0.0001), abduction from 35° to 85° (p<0.0001), external rotation from 15° to 30° (p <0.0001) and internal rotation from 25° to 55° (p <0.0001). The average subjective shoulder score increased from 10% preoperatively to 50% postoperatively (p <0.0001). All but 4 patients would undergo the same procedure again if faced with the same problem. Eight patients were very satisfied, 6 satisfied and 4 unhappy with the operation. We had one case of transitory axillary nerve palsy and two cases of infection. Two prosthetic dislocations occurred; they were successfully treated by revision with a larger polyethylene glenosphere of 44 mm. CONCLUSIONS: Reverse total shoulder arthroplasty improves function and motion in patients with proximal humeral fracture sequelae. However, the rate of dislocation is high.

Benign calcifying fibrous-myofibroblastic tumor mimicking myositis ossificans in a 22-month-old girl.

Myositis ossificans circumscripta (MOC), with nonneoplastic heterotopic bone formation in soft tissue and skeletal muscle, is rare in children. Extraskeletal osteosarcoma is a very rare malignant mesenchymal neoplasm of soft tissues in children. At onset, it may be difficult to distinguish MOC from a musculoskeletal infection or neoplasm, particularly in the absence of trauma, and a biopsy is frequently required. However, differentiating MOC from malignant neoplasm is imperative. We describe the case of a 22-month-old girl who presented with a benign fibrous-myofibroblastic tumor mimicking MOC. However, extraskeletal osteosarcoma was also considered in the differential diagnosis due to the absence of attachment of the lesion to the skeleton. Pathologic findings after a previous needle biopsy and posterior marginal resection exclude both differential diagnoses. Close follow-up during 3 years postoperatively showed no signs of recurrence.

Fibular rotational osteotomy for the treatment of distal tibial osteochondroma: a technical modification for deformity correction and improved outcomes.

The technique of choice for excision of osteochondromas located in the lateral aspect of the tibia is a transfibular approach to expose the lesion for resection. A drawback of this approach is that removal of the lesion leaves a void that may cause a visible deformity and adversely affect long-term function. Fibular rotational osteotomy followed by fibular graft may minimize the resultant deformity, producing a more satisfactory functional and cosmetic result. The authors report a retrospective case series consisting of 5 cases in which a fibular graft rotation was performed after rotational osteotomy via a transfibular approach. Retrograde intramedullary fixation by means of a Kirschner wire, in combination with the design of the fibular osteotomy, provided rotational graft and fibular stability until healing occurred.

The in vivo behaviour of a sol-gel glass and a glass-ceramic during critical diaphyseal bone defects healing.

The in vivo evaluation, in New Zealand rabbits, of a sol-gel glass 70% CaO-30% SiO2 (in mol%) and a glass-ceramic obtained from thermal treatment of the glass, both bioactive in Kokubo's simulated body fluid (SBF), is presented. Femoral bone diaphyseal critical defects were filled with: (i) sol-gel glass cylinders, (ii) glass-ceramic cylinders, or (iii) no material (control group). Osteosynthesis was done by means of anterior screwed plates with an associate intramedullar Kirschner wire. Each group included 10 mature rabbits, 9 months old. Follow-up was 6 months. After sacrifice, macroscopic study showed healing of bone defects, with bone coating over the cylinders, but without evidence of satisfactory repair in control group. Radiographic study showed good implant stability and periosteal growth and bone remodelling around and over the filled bone defect. The morphometric study showed minimum evidences of degradation or resorption in glass-ceramic cylinders, maintaining its original shape, but sol-gel glass cylinders showed abundant fragmentation and surface resorption. An intimate union of the new-formed bone to both materials was observed. Mechanical study showed the higher results in the glass-ceramic group, whereas sol-gel glass and control group showed no differences. The minimum degradation of glass-ceramic cylinders suggests their application in critical bone defects locations of transmission forces or load bearing. The performance of sol-gel glass cylinders suggests their usefulness in locations where a quick resorption should be preferable, considering the possibility of serving as drug or cells vehicle for both of them.

The in vivo performance of a sol-gel glass and a glass-ceramic in the treatment of limited bone defects.

The in vivo evaluation, in New Zealand rabbits, of a SiO(2)-P(2)O(5)-CaO sol-gel glass and a SiO(2)-P(2)O(5)-CaO-MgO glass-ceramic, both bioactive in Kokubo's simulated body fluid (SBF), is presented. Bone defects, performed in the lateral aspect of distal right femoral epiphysis, 5mm in diameter and 4mm in depth, were filled with (i) sol-gel glass disks, (ii) glass-ceramic disks, or (iii) no material (control group). Each group included 8 mature and 8 immature rabbits. A 4-month radiographic study showed good implant stability without axial deviation of extremities in immature animals and periosteal growth and remodelling around and over the bone defect. After sacrifice, the macroscopic study showed healing of bone defects, with bone coating over the implants. The morphometric study showed a more generous bone formation in animals receiving sol-gel glass or glass-ceramic disks than in control group. Histomorphometric study showed an intimate union of the new-formed bone to the implants. This study allows considering both materials as eligible for bone substitution or repair. Their indications could include cavities filling and the coating of implant surfaces. The minimum degradation of glass-ceramic disks suggests its application in locations of load or transmission forces. As specific indication in growth plate surgery, both materials could be used as material of interposition after bony bridges resection.