Effectiveness of virtual reality compared to video training on acetabular cup and femoral stem implantation accuracy in total hip arthroplasty among medical students: a randomised controlled trial.

PURPOSE: Virtual reality (VR) training effectiveness in improving hip arthroplasty surgical skills requires further evaluation. We hypothesised VR training could improve accuracy and the time taken by medical students compared to a control group with only video teaching. METHODS: This single-centre randomized controlled clinical trial collected data from March to June 2023. Surgically naïve volunteer undergraduate medical students performed three sessions on a VR training platform, either cup (VR-Cup=Control-Stem) or stem (VR-Stem=Control-Cup) implantation. The primary outcome was the mean difference between predefined cup inclination (60°) and stem anteversion (20°) compared to the actual implanted values in sawbones between VR and control groups. Secondary outcomes were task completion time and mistake number between the groups. RESULTS: A total of 101 students participated (VR-Cup 47, VR-Stem 54). Groups did not significantly differ concerning age (p = 0.879), gender (p = 0.408), study year (p = 0.938), previous VR use (p = 0.269) and baseline medical and procedural knowledge. The VR-Cup implanted the cup closer to the intended target (p < 0.001) and faster than the Control-Cup group (p = 0.113). The VR-Stem implanted the stem closer to the intended target (p = 0.008) but not faster than the Control-Cup group (p = 0.661). Stem retroversion was commoner in the Control-Stem than in the VR-Stem group (p = 0.016). CONCLUSIONS: VR training resulted in higher rates of accurate procedure completion, reduced time and fewer errors compared to video teaching. VR training is an effective method for improving skill acquisition in THA. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05807828.

The ROSA knee robotic system demonstrates superior precision in restoring joint line height and posterior condylar offset compared to conventional manual TKA: a retrospective case-control study.

PURPOSE: Variations in total knee arthroplasty (TKA) joint line height may lead to complications such as pain and altered joint mechanics, while posterior condylar offset (PCO) can influence knee stability. METHODS: Single-centre, single-surgeon retrospective analysis from December 2019 to May 2023 investigated primary unilateral TKA (Nexgen Legacy, Zimmer Biomet) in patients with knee osteoarthritis, using ROSA robotic system (raTKA) or conventional manual technique (mTKA). Joint line height and PCO were measured and compared in 182 raTKA and 144 mTKA patients. RESULTS: The groups were matched in age (p = 0.847) and sex distribution (p = 0.2). Excellent interobserver agreement (ICC ≥ 0.9). RaTKA mean joint line height difference was - 0.0001 mm (± 3.48, 95% CI - 0.509, 0.509) (p = 0.523), - 0.951 mm for mTKA (± 4.33, 95% CI - 1.664, - 0.237) (p = 0.009). RaTKA mean PCO difference was 0.52 mm (± 2.45, 95% CI 0.160, 0.880) (p = 0.005), 1.15 mm for mTKA (± 4.01, 95% CI - 1.496, 1.818) (p < 0.001). Mean difference in joint line height of 0.95 mm between groups was significant (p = 0.027), and for PCO, it was 0.63 mm, demonstrating tendency towards significance (p = 0.08). Mean absolute value in joint line height difference between groups was not significant (p = 0.235) but highly significant for PCO (p < 0.001). CONCLUSION: The ROSA knee robotic system can more accurately restore joint line height and PCO compared to conventional manual TKA. The improved degree of precision raTKA offers may be a vehicle for better Patient-Reported Outcome Measures, but further correlational studies are required.

Primary Staged Bilateral Total Hip Arthroplasty in a Patient With Short Stature and Hartofilakidis Type I Developmental Dysplasia of the Hip.

Syndromes associated with osteochondrodysplasia, short stature, and DDH are rarely reported in the literature. Total hip arthroplasty (THA) in such cases is a complex procedure with a high rate of complications and difficulties. In this case report, we describe the staged bilateral complex primary THA of a patient with the rare occurrence of a syndrome involving osteochondrodysplasia and DDH, highlighting the surgical challenges and importance of the right prosthesis selection.

Collared versus collarless hydroxyapatite-coated stems for primary cementless total hip arthroplasty; a systematic review of comparative studies. Is there any difference in survival, functional, and radiographic outcomes?

INTRODUCTION: This systematic review aims to critically assess the literature comparative studies investigating collared and collarless Corail stem in primary total hip arthroplasty (THA) to find differences in revision rates, radiographic and clinical outcomes, and postoperative complications between these two types of the same stem. METHODS: Eligible studies were found by searching PubMed, Science Direct/Scopus, and the Cochrane Database of Systematic Reviews from conception till May 2023. The PRISMA guidelines were followed. The investigation encompassed randomized controlled trials, case series, comparative, cohort, and observational studies that assessed at least one comparative outcome or complication between collared and collarless Corail stems. RESULTS: Twelve comparative studies with 90,626 patients undergoing primary THA were included. There were 40,441 collared and 58,543 collarless stems. The follow-up ranged from 12 to 360 months. Our study demonstrated no significant difference in stem revision relative risk (RR = 0.68; 95% confidence interval (CI), 0.23, 2.02; p = 0.49), number of radiolucent lines (RR = 0.3; 95% CI, 0.06, 2.28; p = 0.29) and overall complication risk (RR = 0.62; 95% CI, 0.22, 1.76; p = 0.37) between collared and collarless stems. The collared stems demonstrated significantly lesser subsidence (mean difference: 1.01 mm; 95% CI, -1.77, -0.25; p = 0.009) and risk of periprosthetic fractures (RR = 0.52; 95% CI, 0.29, 0.92; p = 0.03). CONCLUSION: The comparative studies between collared and collarless stem groups showed similar survival and overall complication rates and functional outcomes. The similar revision rates between groups make the impact of higher subsidence for collarless stems uncertain. The lower risk of periprosthetic fractures in the collared stems group must be clarified further but could be related to increased rotational stability.

Acetabular Reconstruction in a Rare Case of Ligamentum Teres Tenosynovial Giant Cell Tumour (TGCT) Causing Extensive Destruction.

Tenosynovial giant cell tumour (TGCT), previously called pigmented villonodular tenosynovitis (PVNS), is a rare benign, locally aggressive condition that primarily affects the synovial lining of large joints, such as the knee, the hip, and the ankle. TGCT of the hip joint is a relatively scarce entity, and its diagnosis is often challenging. This article reports a case of TGCT affecting the left acetabulum, the left femoral head, and the ligamentum teres of the hip joint in a 39-year-old woman who presented to our clinic three months after the onset of symptoms. The patient underwent a biopsy, computer tomography (CT), and magnetic resonance imaging (MRI). All tests were inconclusive. Total hip arthroplasty (THA) was subsequently performed, leading to healing of the lesion previously present. Following surgery, a second biopsy classified this lesion as TGCT. By sharing our experience with this rare manifestation, we aim to contribute to the growing body of knowledge on the diagnosis and management of TGCT, specifically when it occurs in the hip joint.

Molecular sequencing technologies in the diagnosis and management of prosthetic joint infections.

INTRODUCTION: Prosthetic joint infections (PJIs) can be challenging to eradicate and have high morbidity and mortality. Current microbiology culture methods can be associated with a high false-negative rate of up to 50%. Early and accurate diagnosis is crucial for effective treatment, and negative results have been linked to a greater rate of reoperation. AREAS COVERED: There has been increasing investigation of the use of next-generation sequencing (NGS) technology such as metagenomic shotgun sequencing to help identify causative organisms and decrease the uncertainty around culture-negative infections. The clinical importance of the organisms detected and their management, however, requires further study. The polymerase chain reaction (PCR) has shown promise, but in recent years multiple studies have reported similar or lower sensitivity for bacteria detection in PJIs when compared to traditional culture. Furthermore, issues such as high cost and complexity of sample preparation and data analysis are to be addressed before it can move further toward routine clinical practice. EXPERT OPINION: Metagenomic NGS has shown results that inspire cautious optimism - both in culture-positive and culture-negative cases of joint infection. Refinement of technique could revolutionize the way PJIs are diagnosed, managed, and drastically improve outcomes from this currently devastating complication.

The impact of stem fixation method on Vancouver Type B1 periprosthetic femoral fracture management.

INTRODUCTION: Our understanding of the impact of the stem fixation method in total hip arthroplasty (THA) on the subsequent management of periprosthetic femoral fractures (PFF) is still limited. This study aimed to investigate and quantify the effect of the stem fixation method, i.e., cemented vs. uncemented THA, on the management of Vancouver Type B1 periprosthetic femoral fractures with the same plate. METHODS: Eight laboratory models of synthetic femora were divided into two groups and implanted with either a cemented or uncemented hip prosthesis. The overall stiffness and strain distribution were measured under an anatomical one-legged stance. All eight specimens underwent an osteotomy to simulate Vancouver type B1 PFF's. Fractures were then fixed using the same extramedullary plate and screws. The same measurements and fracture movement were taken under the same loading conditions. RESULTS: Highlighted that the uncemented THA and PFF fixation constructs had a lower overall stiffness. Subsequently, the mechanical strain on the fracture plate for the uncemented construct was higher compared to the cemented constructs. CONCLUSION: PFF fixation of a Vancouver type B1 fracture using a plate may have a higher risk of failure in uncemented THAs.

Surgical Advances in Osteosarcoma.

Osteosarcoma (OS) is the most common primary bone cancer in children and, unfortunately, is associated with poor survival rates. OS most commonly arises around the knee joint, and was traditionally treated with amputation until surgeons began to favour limb-preserving surgery in the 1990s. Whilst improving functional outcomes, this was not without problems, such as implant failure and limb length discrepancies. OS can also arise in areas such as the pelvis, spine, head, and neck, which creates additional technical difficulty given the anatomical complexity of the areas. We reviewed the literature and summarised the recent advances in OS surgery. Improvements have been made in many areas; developments in pre-operative imaging technology have allowed improved planning, whilst the ongoing development of intraoperative imaging techniques, such as fluorescent dyes, offer the possibility of improved surgical margins. Technological developments, such as computer navigation, patient specific instruments, and improved implant design similarly provide the opportunity to improve patient outcomes. Going forward, there are a number of promising avenues currently being pursued, such as targeted fluorescent dyes, robotics, and augmented reality, which bring the prospect of improving these outcomes further.

Co-localisation of intra-nuclear membrane type-1 matrix metalloproteinase and hypoxia inducible factor-2α in osteosarcoma and prostate carcinoma cells.

Increased membrane type-1 matrix metalloproteinase (MT1-MMP) expression in osteosarcoma is predictive of poor prognosis and directs bone metastasis in prostate carcinoma. MT1-MMP subcellular localisation varies with oxygen tension, and, therefore, the aim of the present study was to assess protein interactions between MT1-MMP and the hypoxia inducible factors (HIF-1α and HIF-2α). MT1-MMP protein expression was investigated across a panel of cancer cell lines, including a positive and negative control. The hypoxia-induced alteration in subcellular location of MT1-MMP, HIF-1α and HIF-2α in the U2OS osteosarcoma cell line was assessed using subcellular fractionation. A proximity ligation assay was utilised to assess protein to protein interactions in the osteosarcoma U2OS and prostate carcinoma PC3 cell lines. U2OS and PC3 cells exhibited a significantly increased intra-nuclear interaction between MT1-MMP and HIF-2α in response to hypoxia. The role of this warrants further investigation as it may unveil novel opportunities to target MT1-MMP, which is of particular significance for osteosarcoma since current treatment options are limited.

Nailed cementoplasty: a salvage technique for rorabeck type II periprosthetic fractures in octogenarians.

Periprosthetic femoral fractures around a total knee arthroplasty present a surgical challenge in octogenarians with advanced osteoporosis. We describe a salvage technique combining retrograde intramedullary nailing augmented with polymethylmethacrylate cement in 5 patients followed up for a median time of 12 months. The nail/cement construct bridges the femoral canal tightly and simulates a stemmed cemented revision component. All patients had an uncomplicated recovery and returned to their preinjury functional status within 4 months. This procedure does not disrupt the soft tissue envelope around the fracture site, is easy to perform and permits immediate full range of movement. When standard retrograde nailing or plating alone is inadequate in maintaining severely osteoporotic fracture reduction, nailed cementoplasty is proposed as a salvage procedure in octogenarians unfit for lengthy interventions.

Modelling the effect of minor orthopaedic day surgery on patient mood at the early post-operative period: a prospective population-based cohort study.

OBJECTIVE: The effect of minor orthopaedic day surgery (MiODS) on patient's mood. METHODS: A prospective population-based cohort study of 148 consecutive patients with age above 18 and less than 65, an American Society of Anaesthesiology (ASA) score of 1, and the requirement of general anaesthesia (GA) were included. The Medical Outcomes Study - Short Form 36 (SF-36), Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI) were used pre- and post-operatively. RESULTS: The mean physical component score of SF-36 before surgery was 45.3 (SD=+/-10.1) and 8 weeks following surgery was 44.9 (SD=+/-11.04) [n=148, p=0.51, 95% CI=(-1.03 to 1.52)]. For the measurement of the changes in mood using BDI, BAI and SF-36, latent construct modelling was employed to increase validity. The covariance between mood pre- and post-operatively (cov=69.44) corresponded to a correlation coefficient, r=0.88 indicating that patients suffering a greater number of mood symptoms before surgery continue to have a greater number of symptoms following surgery. When the latent mood constructs were permitted to have different means the model fitted well with chi(2) (df=1)=0.86 for which p=0.77, thus the null hypothesis that MiODS has no effect on patient mood was rejected. CONCLUSIONS: MiODS affects patient mood which deteriorates at 8 weeks post-operatively regardless of the pre-operative patient mood state. More importantly patients suffering a greater number of mood symptoms before MiODS continue to have a greater number of symptoms following surgery.

The "safe zone" in medial percutaneous calcaneal pin placement.

Percutaneous pin insertion into the medial calcaneus places a number of structures at risk. Evidence suggests that the greatest risk is to the medial calcaneal nerve (MCN). The medial calcaneal region of 24 cadavers was dissected to determine the major structures at risk. By using four palpable anatomical landmarks, the inferior tip of the medial malleolus (point A), the posterior superior portion of the calcaneal tuberosity (point B), the navicular tuberosity (point C), and the medial process of the calcaneal tuberosity (point D), we attempted to define the safe zone taking into account all possible variables in our dissections including ankle position, side, gender, and possible anatomical variations of the MCN. The commonest arrangement of the MCN was two MCNs that arose independently, one arising before the bifurcation of the tibial nerve and the other arising from the medial plantar nerve. A zone could be defined posterior to 75% of the distance along the lines AB, CD, AD, and CB which would avoid most structures. The posterior branches of the MCN, however, would still be at risk and placing the pin too far posteriorly risks an avulsion fracture. This is the first study to employ four palpable anatomical landmarks to identify a zone to minimize damage to neurovascular structures. It may not be possible, however, to avoid injury of the MCN and consequent sensory loss to the sole of the foot.

Mesenchymal stromal cells for bone sarcoma treatment: Roadmap to clinical practice.

Over the past few decades, there has been growing interest in understanding the molecular mechanisms of cancer pathogenesis and progression, as it is still associated with high morbidity and mortality. Current management of large bone sarcomas typically includes the complex therapeutic approach of limb salvage or sacrifice combined with pre- and postoperative multidrug chemotherapy and/or radiotherapy, and is still associated with high recurrence rates. The development of cellular strategies against specific characteristics of tumour cells appears to be promising, as they can target cancer cells selectively. Recently, Mesenchymal Stromal Cells (MSCs) have been the subject of significant research in orthopaedic clinical practice through their use in regenerative medicine. Further research has been directed at the use of MSCs for more personalized bone sarcoma treatments, taking advantage of their wide range of potential biological functions, which can be augmented by using tissue engineering approaches to promote healing of large defects. In this review, we explore the use of MSCs in bone sarcoma treatment, by analyzing MSCs and tumour cell interactions, transduction of MSCs to target sarcoma, and their clinical applications on humans concerning bone regeneration after bone sarcoma extraction.

Giant cell tumour of the patella with local recurrence: successful management with excision, curettage and artificial bone grafting.

Primary patellar neoplasms are rare, comprising 0.12% of primary bone tumours; thus, no standardised treatment related to staging exists. 70%-90% of primary patellar neoplasms are benign or intermediate with giant cell tumour (GCT) being the most common. GCTs are locally aggressive, have a high recurrence rate and metastasise in 1%-2%. We report the case of a 23-year-old man with histologically confirmed recurrent GCT of the patella to demonstrate that aggressive surgical management options described in the literature, such as patellectomy with or without complex reconstruction, may be excessive and cause patients undue morbidity. Initially, the patient underwent intralesional curettage with excellent recovery, but presented again with a local recurrence within a year. A further definitive operation was performed which included excision of the inferior pole followed by curettage of the patellar body and artificial bone grafting. The patient made a good recovery and at 5-year follow-up has maintained good function.

TNF-related apoptosis-inducing ligand (TRAIL) for bone sarcoma treatment: Pre-clinical and clinical data.

Bone sarcomas are rare, highly malignant mesenchymal tumours that affect teenagers and young adults, as well as older patients. Despite intensive, multimodal therapy, patients with bone sarcomas have poor 5-year survival, close to 50%, with lack of improvement over recent decades. TNF-related apoptosis-inducing ligand (TRAIL), a member of the tumour necrosis factor (TNF) ligand superfamily (TNFLSF), has been found to induce apoptosis in cancer cells while sparing nontransformed cells, and may therefore offer a promising new approach to treatment. We cover the existing preclinical and clinical evidence about the use of TRAIL and other death receptor agonists in bone sarcoma treatment. In vitro studies indicate that TRAIL and other death receptor agonists are generally potent against bone sarcoma cell lines. Ewing's sarcoma cell lines present the highest sensitivity, whereas osteosarcoma and chondrosarcoma cell lines are considered less sensitive. In vivo studies also demonstrate satisfactory results, especially in Ewing's sarcoma xenograft models. However, the few clinical trials in the literature show only low or moderate efficacy of TRAIL in treating bone sarcoma. Potential strategies to overcome the in vivo resistance reported include co-administration with other drugs and the potential to deliver TRAIL on the surface of primed mesenchymal or immune cells and the use of targeted single chain antibodies such as scFv-scTRAIL.

Current clinical evidence for the use of mesenchymal stem cells in articular cartilage repair.

INTRODUCTION: Articular cartilage is renowned for its poor intrinsic capacity for repair. Current treatments for osteoarthritis are limited in their ability to reliably restore the native articular cartilage structure and function. Mesenchymal stem cells (MSCs) present an attractive treatment option for articular cartilage repair, with a recent expansion of clinical trials investigating their use in patients. AREAS COVERED: This paper provides a current overview of the clinical evidence on the use of MSCs in articular cartilage repair. EXPERT OPINION: The article demonstrates robust clinical evidence that MSCs have significant potential for the regeneration of hyaline articular cartilage in patients. The majority of clinical trials to date have yielded significantly positive results with minimal adverse effects. However the clinical research is still in its infancy. The optimum MSC source, cell concentrations, implantation technique, scaffold, growth factors and rehabilitation protocol for clinical use are yet to be identified. A larger number of randomised control trials are required to objectively compare the clinical efficacy and long-term safety of the various techniques. As the clinical research continues to evolve and address these challenges, it is likely that MSCs may become integrated into routine clinical practice in the near future.

Treatment of multiple myeloma bone disease: experimental and clinical data.

INTRODUCTION: Bone disease is present in the majority of patients with multiple myeloma and can seriously affect quality of life and survival rate. In addition to suppression of osteoclastogenesis, there have been developments made in terms of the therapeutic agents available, such as novel immunomodulating agents, proteasome and receptor activator of nuclear factor κB ligand inhibitors. AREAS COVERED: AREAS COVERED include in vitro, in vivo and clinical evidence was collected using MEDLINE (1950 - May 2014), EMBASE (1980 - May 2014) and Google Scholar (1980 - May 2014) databases. EXPERT OPINION: Bisphosphonates are the mainstay of myeloma bone disease treatment. Oral clodronate and intravenous pamidronate and zoledronic acid are currently used drugs and seem to have comparable results in preventing skeletal-related events of the disease. Zoledronate can also have survival benefits and based on the available evidence is the superior bisphosphonate; however, its side effects have to be monitored. Denosumab had comparable results with zoledronate on myeloma bone disease treatment; its use has not been completely proven yet. There is an expanding set of drugs, proteasome inhibitors, under investigation with great potential to reduce the negative effects of myeloma cells on bone. Future clinical studies should compare both the catabolic and anabolic effects of these agents on bone.

Skeletal tissue engineering using mesenchymal or embryonic stem cells: clinical and experimental data.

INTRODUCTION: Mesenchymal stem cells (MSCs) can be obtained from a wide variety of tissues for bone tissue engineering such as bone marrow, adipose, birth-associated, peripheral blood, periosteum, dental and muscle. MSCs from human fetal bone marrow and embryonic stem cells (ESCs) are also promising cell sources. AREAS COVERED: In vitro, in vivo and clinical evidence was collected using MEDLINE® (1950 to January 2014), EMBASE (1980 to January 2014) and Google Scholar (1980 to January 2014) databases. EXPERT OPINION: Enhanced results have been found when combining bone marrow-derived mesenchymal stem cells (BMMSCs) with recently developed scaffolds such as glass ceramics and starch-based polymeric scaffolds. Preclinical studies investigating adipose tissue-derived stem cells and umbilical cord tissue-derived stem cells suggest that they are likely to become promising alternatives. Stem cells derived from periosteum and dental tissues such as the periodontal ligament have an osteogenic potential similar to BMMSCs. Stem cells from human fetal bone marrow have demonstrated superior proliferation and osteogenic differentiation than perinatal and postnatal tissues. Despite ethical concerns and potential for teratoma formation, developments have also been made for the use of ESCs in terms of culture and ideal scaffold.

Sclerostin monoclonal antibodies on bone metabolism and fracture healing.

INTRODUCTION: The biological enhancement of fracture healing may prevent complications such as non-union and revision surgery. Sclerostin is produced by osteocytes and binds to the LRP5/6 receptor. This inhibits the Wnt signalling pathway and thereby reduces bone formation. AREAS COVERED: Targeted deletion of the sclerostin gene has been found to enhance bone formation and fracture healing in rodent models. A number of in vivo studies have investigated the effect of sclerostin antibody on bone density with promising results. It also has an ability to promote fracture healing, screw fixation and metaphyseal bone healing in vivo. Early clinical studies have also demonstrated that it can increase bone mineral density, whilst being safe and well tolerated by patients. EXPERT OPINION: The data support the further investigation of this agent for the promotion of fracture healing. We aim to review the current literature and present an update on the use of this agent to promote bone formation and healing.

Preclinical and clinical data for the use of mesenchymal stem cells in articular cartilage tissue engineering.

INTRODUCTION: With an ageing population, the prevalence of osteoarthritis (OA) has increased. Mesenchymal Stem Cells (MSCs) have been proposed to be an attractive alternative candidate in the tissue engineering of articular cartilage primarily due to its abundant source, reduced cartilage donor site morbidity, and strong capacity for proliferation and potential to differentiate toward a chondrogenic phenotype. AREAS COVERED: A current overview of human, in vivo, and in vitro evidence on the use of MSCs in cartilage tissue engineering. EXPERT OPINION: We demonstrate robust evidence that MSCs have the potential to regenerate articular cartilage. We also identify the complexity of designing a suitable preclinical model and the challenges in considering its clinical application such as type of MSC, scaffold, culture construct and the method by which growth factors are delivered. Of great interest is further characterization of the factors that may prevent MSC-derived chondrocytes to undergo premature hypertrophy and to understand what enables the terminal developmental pathway for permanent hyaline cartilage regeneration. Despite this, there is an abundance of evidence suggesting that MSCs are a desirable cell source and will have significant impact in tissue engineering of cartilage in the future.