Core decompression with autologous bone marrow aspirate injection in humeral head osteonecrosis in adults with sickle cell disease.

PURPOSE: Sickle cell disease is often associated with osteonecrosis of the humeral head with a risk of progression to humeral head collapse. The aim of this study was to evaluate the clinical outcome and the effect on the necrosis evolution of humeral head core decompression with autologous bone marrow aspirate injection in these patients. METHODS: Forty shoulders in 23 patients were treated with core decompression with autologous concentrated iliac crest bone marrow aspirate injection. Patients were followed for a minimum of two  years (limits from 2 to 10 years). Functional outcomes metrics included the simple shoulder test (STT) and subjective shoulder value (SSV) as well as assessment of radiographic progression of disease. RESULTS: Shoulder function improved significantly at final follow-up. The STT improved by 2.9 points (p = 0.001) and the SVV improved by 15 % (p = 0.001). However, based on radiologic features, the intervention did not halt the radiographic progression of disease nor did it result in healing of the lesion. The benefits were mainly clinical with diminished pain and functional improvement. CONCLUSION: Improvement in shoulder function was observed following core decompression and bone marrow aspirate injection in patients with sickle cell disease and early humeral head necrosis stages. The procedure should not be considered for grade 3 or greater disease and for asymptomatic cases whatever the grade. Given the lack of radiographic improvement observed in this study, further study in the context of prospective controlled trials should be undertaken before this intervention can be widely recommended.

Preoperative planning of tibial tubercle medialisation according to the trochlear groove angle.

The tibial tubercle-trochlear groove distance (TT-TG) was first described four decades ago. Since then, a considerable body of research has become available on the pathophysiology of chronic patellar instability, whose diagnosis and treatment remain challenging. Tibial tubercle medialisation can correct an abnormal TT-TG. Preoperative planning based on the TT-TG and trochlear angle may avoid both under-correction inducing persistent instability and overcorrection responsible for pain. Preoperative planning should be patient-specific. With appropriate preoperative planning, compensation for moderate trochlear dysplasia can be achieved without any additional procedure.

Reverse total shoulder arthroplasty using helical blade to optimize glenoid fixation and bone preservation: preliminary results in thirty five patients with minimum two year follow-up.

PURPOSE: Glenoid loosening is a common cause of reverse total shoulder arthroplasty (RTSA) failure, and grafting of the glenoid is often required for revision due to bone loss due to the central peg in most glenoid baseplates. Helical blades have been used in the hip to optimize bone fixation in proximal femoral fracture. This study presents the initial results of specifically designed helical blade in the shoulder to optimize glenoid bone fixation and preservation as part of RTSA. METHODS: Thirty-five patients underwent RTSA with glenoid helical blade fixation. An uncemented glenoid baseplate was used with a central helical blade partially coated with hydroxyapatite and two or three screws. Outcome analysis was performed pre-operatively and at two years. RESULTS: All patients were satisfied with the results and significant improvement was observed in functional outcome scores between baseline and final follow-up. There was a single intra-operative undisplaced glenoid fracture which did not compromise the baseplate fixation. There was no radiographic evidence of loosening or radiolucencies around the helical blade. CONCLUSIONS: The helical blade provides a satisfactory primary fixation. Because of its length (21 mm), care should be taken in cases of pre-existing bone loss or sclerotic bone to avoid glenoid fracture or anterior cortical perforation. Helical blade has the potential to facilitate glenoid implant revision by preserving the glenoid bone stock.

Shoulder Arthroplasty: Historical Considerations.

BACKGROUND: The first articular metal prosthesis was implanted in the shoulder more than 120 years ago. The aim of this paper is to report shoulder arthroplasty evolution during this time thru the literature of the twentieth century. METHODS: A literature review was performed selecting the founding papers about shoulder arthroplasty. RESULTS: After being almost forgotten during the first part of the 20th century, various implants were introduced in the 1950s with Charles Neer as a leader. The reverse concept appeared in the 1970s and knew many failures before Grammont's design. CONCLUSION: After many unfortunate trials, the shoulder prosthesis is now widely disseminated with products of many companies.

Biologic augmentation of rotator cuff repair with mesenchymal stem cells during arthroscopy improves healing and prevents further tears: a case-controlled study.

PURPOSE: The purpose of this study was to evaluate the efficiency of biologic augmentation of rotator cuff repair with iliac crest bone marrow-derived mesenchymal stem cells (MSCs). The prevalence of healing and prevention of re-tears were correlated with the number of MSCs received at the tendon-to-bone interface. METHODS: Forty-five patients in the study group received concentrated bone marrow-derived MSCs as an adjunct to single-row rotator cuff repair at the time of arthroscopy. The average number of MSCs returned to the patient was 51,000 ± 25,000. Outcomes of patients receiving MSCs during their repair were compared to those of a matched control group of 45 patients who did not receive MSCs. All patients underwent imaging studies of the shoulder with iterative ultrasound performed every month from the first postoperative month to the 24th month. The rotator cuff healing or re-tear was confirmed with MRI postoperatively at three and six months, one and two years and at the most recent follow up MRI (minimum ten-year follow-up). RESULTS: Bone marrow-derived MSC injection as an adjunctive therapy during rotator cuff repair enhanced the healing rate and improved the quality of the repaired surface as determined by ultrasound and MRI. Forty-five (100 %) of the 45 repairs with MSC augmentation had healed by six months, versus 30 (67 %) of the 45 repairs without MSC treatment by six months. Bone marrow concentrate (BMC) injection also prevented further ruptures during the next ten years. At the most recent follow-up of ten years, intact rotator cuffs were found in 39 (87 %) of the 45 patients in the MSC-treated group, but just 20 (44 %) of the 45 patients in the control group. The number of transplanted MSCs was determined to be the most relevant to the outcome in the study group, since patients with a loss of tendon integrity at any time up to the ten-year follow-up milestone received fewer MSCs as compared with those who had maintained a successful repair during the same interval. CONCLUSION: This study showed that significant improvement in healing outcomes could be achieved by the use of BMC containing MSC as an adjunct therapy in standard of care rotator cuff repair. Furthermore, our study showed a substantial improvement in the level of tendon integrity present at the ten-year milestone between the MSC-treated group and the control patients. These results support the use of bone marrow-derived MSC augmentation in rotator cuff repair, especially due to the enhanced rate of healing and the reduced number of re-tears observed over time in the MSC-treated patients.

Coracoid process x-ray investigation before Latarjet procedure: a radioanatomic study.

BACKGROUND: The purpose of this study was to determine whether a preoperative radiologic assessment of the coracoid process is predictive of the amount of bone available for coracoid transfer by the Latarjet procedure. MATERIAL: Thirty-five patients with anterior instability undergoing a Latarjet procedure were included. A preoperative radiologic assessment was performed with the Bernageau and true anteroposterior (true AP) views. METHODS: The length of the coracoid process was measured on both radiographic views and the values were compared with the length of the bone block during surgery. Statistical analysis was carried out by ANOVA and Wilcoxon tests (P < .05). RESULTS: On radiologic examination, the mean coracoid process length was 29 ± 4 and 33 ± 4 mm on the Bernageau and true AP views, respectively. The mean bone block length during surgery was 21.6 ± 2.7 mm. A significant correlation was found (P = .032) between the coracoid process length on the true AP view and the intraoperative bone block length. DISCUSSION: Preoperative planning for the Latarjet procedure, including graft orientation and screw placement, requires knowledge of the length of coracoid bone available for transfer. This can be facilitated with the use of preoperative standard radiographs, thus avoiding computed tomography. This planning allows the detection of coracoid process anatomic variations or the analysis of the remaining part of the coracoid process after failure of a first Latarjet procedure to avoid an iliac bone graft. CONCLUSION: Radiologic preoperative coracoid process measurement is an easy, reliable method to aid preoperative planning of the Latarjet procedure in primary surgery and reoperations.

Osteoblastic differentiation of human mesenchymal stem cells with platelet lysate.

Culture of expanded mesenchymal stem cells (MSCs) seeded on biomaterials may represent a clinical alternative to autologous bone graft in bone regeneration. Foetal bovine serum (FBS) is currently used for MSC expansion, despite risks of infectious disease transmission and immunological reaction due to its xenogenic origin. This study aimed to compare the osteogenic capacities of clinical-grade human MSCs cultured with FBS or allogenic human platelet lysate (PL). In vitro, MSCs cultured in PL both accelerate the expansion rate over serial passages and spontaneously induce osteoblastic gene expression such as alkaline phosphatase (ALP), bone sialoprotein (BSP), osteopontin (Op) and bone morphogenetic protein-2 (BMP-2). In vivo, ectopic bone formation is only observed on ceramics seeded with MSCs grown in PL medium implanted under the skin of immunodeficient mice for 7 weeks. In conclusion, allogenic human PL accelerates MSC proliferation and enhances MSC osteogenic differentiation.

Cell therapy of hip osteonecrosis with autologous bone marrow grafting.

BACKGROUND: One of the reasons for bone remodeling leading to an insufficient creeping substitution after osteonecrosis in the femoral head may be the small number of progenitor cells in the proximal femur and the trochanteric region. Because of this lack of progenitor cells, treatment modalities should stimulate and guide bone remodeling to sufficient creeping substitution to preserve the integrity of the femoral head. Core decompression with bone graft is used frequently in the treatment of osteonecrosis of the femoral head. In the current series, grafting was done with autologous bone marrow obtained from the iliac crest of patients operated on for early stages of osteonecrosis of the hip before collapse with the hypothesis that before stage of subchondral collapse, increasing the number of progenitor cells in the proximal femur will stimulate bone remodeling and creeping substitution and thereby improve functional outcome. MATERIALS AND METHODS: Between 1990 and 2000, 342 patients (534 hips) with avascular osteonecrosis at early stages (Stages I and II) were treated with core decompression and autologous bone marrow grafting obtained from the iliac crest of patients operated on for osteonecrosis of the hip. The percentage of hips affected by osteonecrosis in this series of 534 hips was 19% in patients taking corticosteroids, 28% in patients with excessive alcohol intake, and 31% in patients with sickle cell disease. The mean age of the patients at the time of decompression and autologous bone marrow grafting was 39 years (range: 16-61 years). The aspirated marrow was reduced in volume by concentration and injected into the femoral head after core decompression with a small trocar. To measure the number of progenitor cells transplanted, the fibroblast colony forming unit was used as an indicator of the stroma cell activity. RESULTS: Patients were followed up from 8 to 18 years. The outcome was determined by the changes in the Harris hip score, progression in radiographic stages, change in volume determined by digitizing area of the necrosis on the different cuts obtained on MRI, and by the need for hip replacement. Total hip replacement was necessary in 94 hips (evolution to collapse) among the 534 hips operated before collapse (Stages I and II). Sixty-nine hips with stage I osteonecrosis of the femoral head at the time of surgery demonstrated total resolution of osteonecrosis based on preoperative and postoperative MRI studies; these hips did not show any changes on plain radiographs. Before treatment, these 69 osteonecrosis had only a marginal band like pattern as abnormal signal and a volume less than 20 cubic centimeters. The intralesional area had kept a normal signal as regards the signal of the femoral head outside the osteonecrosis area. For the 371 other hips without collapse at the most recent follow up (average 12 years), the mean preoperative volume of the osteonecrosis was 26 cm(3) (minimum 12, maximum 30 cm(3)). The mean volume of the abnormal signal measured on MRI at the most recent follow up (mean 12 years) was 12 cm(3). The abnormal signal persisting as a sequelae was seen on T1 images as an intralesional area of low intensity signal with a disappearance of the marginal band like pattern. CONCLUSION: According to our experience, best indication for the procedure is symptomatic hips with osteonecrosis without collapse. In some patients who had Steinberg stage III osteonecrosis (subchondral lucency, no collapse) successful outcomes (no further surgery) has been obtained between 5 to 10 years. Therefore in selected patients, even more advanced disease can be considered for core decompression. Patients who had the greater number of progenitor cells transplanted in their hips had better outcomes.

Ceramic-ceramic bearing decreases osteolysis: a 20-year study versus ceramic-polyethylene on the contralateral hip.

Although ceramic implants have been in use for many years and they are intended to minimize wear debris it is unknown whether alumina-on-alumina or alumina-on-polyethylene produce less wear and osteolysis. We therefore investigated wear and osteolysis on 28 bilateral arthroplasties (one ceramic-ceramic and the contralateral ceramic-polyethylene) of patients who had survived 20 years without revision and without loosening of either hip. Osteolysis was identified on anteroposterior pelvic radiographs and 3-D volume from CT scans. The number of osteolytic lesions detected with CT scan was higher than with radiographs. The number of lesions was higher on the side with the alumina-PE couple. With a similar length of followup on each side, the surface and the volume of osteolysis were consistently higher on the side with the alumina-PE couple. We found no correlation between the volume of osteolysis and the volume of estimated wear in each couple of friction. Hips with osteolysis had a lower Harris score.

Long-term functional and structural outcome in patients with intact repairs 1 year after open transosseous rotator cuff repair.

HYPOTHESIS: Tendon-to-bone suture and a fatty degeneration index (FDI)

Total shoulder arthroplasty using the superior approach: influence on glenoid loosening and superior migration in the long-term follow-up after Neer II prosthesis installation.

Glenoid component loosening and superior humeral translation are common after Neer II total shoulder arthroplasty using the anterior approach. To determine whether the superior approach reduced these complications, we retrospectively reviewed 20 shoulders in 16 patients. Both components were cemented. Patient satisfaction, unweighted Constant score, and imaging studies were evaluated at a mean of 3.5 years and at a mean of 11.1 years. Fourteen patients were satisfied or very satisfied. The mean unweighted Constant score improved from 25/100 preoperatively to 57/100 after 3.5 years and to 51/100 after 11.1 years. Pain relief contrasted with low strength. Radiolucent lines appeared around 95% of glenoid components and 20% of humeral stems. Computed tomography showed severe glenoid osteolysis in 3 of 13 shoulders. Humeral superior translation did not occur. This study confirms the glenoid component fixation issue. The superior approach may reduce the risk of humeral superior translation and radiologic glenoid component loosening.

Total THA in adult osteonecrosis related to sickle cell disease.

UNLABELLED: Most previous studies of THA in sickle cell disease report high risks of medical and orthopaedic complications, including infections and a higher incidence of failure than observed after THA for osteonecrosis related to other conditions. Based on our experience (1245 orthopaedic procedures during the last 25 years), we questioned these conclusions and retrospectively reviewed 312 arthroplasties performed in 244 patients with sickle cell disease. The mean age of the 126 women and 118 men at the time of surgery was 32 years. The minimum followup was 5 years (mean, 13 years; range, 5-25 years). We revised 10 hips (3%) for infection at a mean 11 years (range, 7-15 years) after the primary procedure and revised 21 cups (8%) and 17 stems (5%) for aseptic loosening at a mean of 14 years. We observed medical complications after 85 operations (27%) and orthopaedic complications in 42 cases (13%). Although THA carries a high risk of complication in patients with sickle cell disease, the benefits for the patient are substantial, and the risk of revision for loosening or infection appeared less than described in previous literature. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Mouse femoral intramedullary injection model: technique and microCT scan validation.

The murine femoral intramedullary injection model is frequently used to examine the in vivo effects of biomaterials or cancer cells. The surgical technique includes a knee arthrotomy with patellar dislocation for intramedullary access. This study examined a less invasive surgical approach of direct injection of particles via the transpatellar tendon without patellar dislocation. By using polymethylmethacrylate injection and microCT scan, we found that, compared with the traditional technique, this new approach was more reproducible, less time consuming, and achieved identical volumes of intramedullary injections. Animal morbidity and the biomechanics of the joints were also improved as a result of the simplified procedure. Furthermore, our study suggested that an intramedullary volume in excess of 10 microL can lead to major vascular filling and so should be avoided.

Modulation of allograft incorporation by continuous infusion of growth factors over a prolonged duration in vivo.

Morselized cancellous allograft bone is frequently used in the reconstruction of bone defects in cases of revision total joint replacement, trauma, spine fusion and treated infection. However, the initial lack of viable bone cells in morselized allograft bone significantly slows the process of graft incorporation compared to autograft bone. This study examined the effects of prolonged local infusion of the growth factors bone morphogenic protein-7 (BMP-7 or OP-1) and fibroblast growth factor-2 (FGF-2 or basic FGF) in the process of allograft incorporation using a rabbit tibial chamber model. New bone formation was evaluated by two indices, the activity of alkaline phosphatase and the level of birefringence. The markers of osteoclast-like cells were also measured. Without the infusion of the growth factors, lower levels of new bone formation were observed in the allograft group, compared to the autograft group. Infusion of growth factors FGF-2 and OP-1, singly or in combination, for 4 weeks, diminished this difference. The numbers of osteoclast-like cells were much higher in the allograft group before the growth factors were delivered. The infusion of FGF, singly, diminished this difference. However, the infusion of OP-1 or the combination of FGF and OP-1 did not decrease the number of osteoclast-like cells to a level comparable to autograft only. Local infusion of growth factors appears to be a useful adjunct to promote the incorporation of allograft bone in vivo.

Infraspinatus delamination does not affect supraspinatus tear repair.

Supraspinatus full-thickness tears with associated infraspinatus delamination are a frequent lesion, although the results of repair have not been reported. We retrospectively identified 35 patients treated for this cuff lesion among 378 open repaired full-thickness cuff tears. The aim of the study was to assess the subjective, objective, and anatomic outcomes of a subset of patients with supraspinatus tears involving delamination of the whole infraspinatus tendon. Thirty of the 35 patients were reviewed with magnetic resonance imaging at a minimum followup of 2 years (mean, 3.5 years; range, 2-6.5 years). The mean nonweighted Constant-Murley score at followup was 80/100 points, with an average gain of 17 points. Magnetic resonance imaging revealed all supraspinatus tendons but two were continuous. We observed no tear of the infraspinatus tendon, although a persistent delamination was present in 11 cases. One half of the patients had minor weakness in external rotation. One third of the infraspinatus muscles had minor fatty infiltration. Conservation of the infraspinatus tendon after closing the delamination did not seem to compromise the outcome of the supraspinatus repair. Avoiding resection of the infraspinatus delamination and treatment with simple curettage and closure yields satisfactory midterm functional and anatomic results.

Anatomical variations of the extensor tendons to the fingers over the dorsum of the hand: a study of 50 hands and a review of the literature.

The extensor tendons to the fingers were studied in dissections of 50 fresh cadaveric hands, and the divisions of the tendons, as well as the communications (juncturae), were analyzed. The pattern of distribution most frequently observed was as follows. The extensor digitorum communis provided one tendon to the index finger, one to the middle finger, two to the ring finger, and none to the little finger. The extensor indicis exhibited one tendon, whereas the extensor digiti minimi exhibited two tendons. The extensor indicis tendon was always observed to lack a junctura tendinum. The extensor indicis was absent in both hands of one cadaver. A tendon slip from the extensor digiti minimi to the ring finger was observed in one hand. All surgeons must bear in mind the existence of these variations when performing common tendon transfers.

Shoulder surgery: from cuff repair to joint replacement. An update.

REPAIRING FULL THICKNESS CUFF TEARS.--Despite the sound rationale for repairing full-thickness rotator cuff tears, the procedure may fail to restore cuff integrity, which is indispensable to optimal cuff function. The functional role of each cuff muscle and the factors associated with anatomic failure (particularly those related to the muscles and tendons) provide a basis for rational patient selection and for determination of the best surgical strategy on a case-by-case basis. SHOULDER ARTHROPLASTY IN PATIENTS WITH GLENOHUMERAL JOINT DISEASE.--Total shoulder arthroplasty in patients with glenohumeral joint disease provides better outcomes than humeral hemiarthroplasty. The choice between a semi-constrained total prosthesis and a reverse constrained total prosthesis should be based on the nature of the joint disease (either centered humeral head or normal cuff function or migrated humeral head and abnormal cuff function). At present, only the semi-constrained total prosthesis has been proved effective in the long-term when used in a patient with a centered humeral head and active cuff. This provides additional support for repairing cuff tears whenever possible in patients who are still young.