Total Knee Arthroplasty (TKA) improves the quality of life of osteoarthritic and rheumatoid arthritis patients, however, is associated with moderate to severe postoperative pain. There are multiple methods of managing postoperative pain that include epidural anesthesia but it prevents early mobilization and results in postoperative hypotension and spinal infection. Controlling local pain pathways through intra-articular administration of analgesics is a novel method and is inexpensive and simple. Hence, we assess the effects of postoperative epidural bupivacaine injection along with intra-articular injection in total knee replacement patients. The methodology included 100 patients undergoing TKA randomly divided into two groups, one administered with only epidural bupivacaine injection and the other with intra-articular cocktail injection. The results were measured based on a 10-point pain assessment scale, knee's range of motion (ROM), and Lysholm knee score. The VAS score was lower in the intra-articular cocktail group compared to the bupivacaine injection group until the end of 1-week post-administration (p<0.01). Among inter-group comparisons, we observed that the range of motion was significantly more in cocktail injection as compared to the bupivacaine group till the end of one week (p<0.05). Lysholm's score was significantly more in cocktail injection as compared to the bupivacaine group till the end of one week (p<0.05). Our study showed that both epidural bupivacaine injection and intra-articular injection were effective in reducing pain after TKA and have a comparable functional outcome at the end of 4 weeks follow up. However, the pain relief was faster in cases with intra-articular injection, providing the opportunity for early rehabilitation. Thus, we recommend the use of intra-articular cocktail injection for postoperative management of pain after total knee arthroplasty, which enables early rehabilitation and faster functional recovery of these patients

A promising application of Mesenchymal stem cells (MSCs) is the treatment of non-unions. Substituting bone grafts, MSCs are directly injected into the fracture gap. High cell viability seems to be a prerequisite for therapeutic success. Administration of the MSCs via injection creates shear stresses possibly damaging or destroying the cells. Aim of this study was to investigate the effect of the injection process on cell viability. MSCs were isolated and cultivated from femoral tissue of five subjects undergoing arthroplasty. Prior to injection, the cells were identified as MSCs. After dissolving to a concentration of 1 Million cells/ml, 1 ml of the suspension was injected through a cannula of 200 mm length and 2 mm diameter (14 G) with flow rates of 38 and 100 ml/min. The viability of the MSCs at different flow rates was evaluated by staining to detect the healthy cell fraction. It was analyzed statistically against a control group via the Kruskal-Wallis-test and for equivalence via the TOST procedure. Significance level was set to 5 %, equivalence margin to 20 %. The healthy cell fraction of the control group was 85.88 ± 2.98 %, 86.04 ± 2.53 % at 38 ml/min and 85.48 ± 1.64 % at 100 ml/min. There was no significant difference between the fraction of healthy cells (p = 0.99) for different volume flows, but a significant equivalence between the control group and the two volume flows (38 ml/min: p = 0.002, 100 ml/min: p = 0.001). When injecting MSC solutions, e.g. into a non-union, the viability of the injected cells does not deterioriate significant. The injecting technique is therefore feasible

Introduction and Objective. Total shoulder replacement is a common elective procedure offered to patients with end stage arthritis. While most patients experience significant pain relief and improved function within months of surgery, some remain unsatisfied because of residual pain or dissatisfaction with their functional status. Among these patients, when laboratory workup eliminates infection as a possibility, corticosteroid injection (CSI) into the joint space, or on the periprosthetic anatomic structures, is a common procedure used for symptom management. However, the efficacy and safety of this procedure has not been previously reported in shoulder literature. Materials and Methods. A retrospective chart review identified primary TSA patients who subsequently received a CSI into a replaced shoulder from 2011 – 2018 by multiple surgeons. Patients receiving an injection underwent clinical exam, laboratory analysis to rule out infection, and radiographic evaluation prior to CSI. Demographic variables were recorded, and a patient satisfaction survey assessed the efficacy of the injection. Results. Of the 43 responders, 48.8% remembered the injection. The average time from index arthroplasty to injection was median 16.8 months. Overall, 61.9% reported decreased pain, 28.6% reported increased motion, and 28.6% reported long term decreased swelling. Improvement lasted greater than one month for 42.9% of patients, and overall 52.4% reported improvement (slight to great) in the shoulder following CSI. No patient developed a periprosthetic joint infection (PJI) within 2 years of injection. Conclusions. This study suggests that certain patients following TSA may benefit from a CSI. However, this should only be performed once clinical, radiographic, and laboratory examination has ruled out conditions unlikely to improve long term from a CSI. Given these findings, further study in a large, prospective trial is warranted to fully evaluate the benefits of CSI following TSA

Surgical debridement for medial epicondylitis (ME) is indicated for patients with refractory ME. The clinical efficacy of simple debridement has not been studied sufficiently. Moreover, authors experienced surgical outcome of ME was not as good as lateral epicondylitis. In this regard, authors have combined the atelocollagen injection in the debridement surgery of ME. The purpose of study was to compare clinical outcomes between simple debridement and debridement combined with atelocollagen injection in the ME. Twenty-five patients with refractory ME and underwent surgical debridement were included in the study. Group A (n=13) was treated with isolated debridement surgery, and group B (n=12) was treated with debridement combined with 1.0 mL of type I atelocollagen. Pain and functional improvements were assessed using visual analogue scale, Mayo Elbow Performance Score (MEPS) and quick Disabilities of the Arm, Shoulder and Hand (DASH) scale respectively before surgery, at 3, 6 months after surgery and at the final follow-up. Demographic data did not show significant difference between two groups before surgical procedures. Both groups showed improvement in pain and functional score postoperatively. However, at the 3 months after surgery, group B showed significantly better improvement as compared to group A(VAS 3.1 / 2.0, MEPS 71/82 qDASH 29/23). At the 6 months after surgery and final follow-up, both groups did not show any difference. Surgical debridement combined with atelocollagen is effective treatment option in refractory ME and showed better short-term outcomes compared to isolated surgery

Intra-articular punctures and injections are performed routinely on patients with injuries to and chronic diseases of joints, to release an effusion or haemarthrosis, or to inject drugs. The purpose of this study was to investigate the accuracy of placement of the needle during this procedure. A total of 76 cadaver acromioclavicular joints were injected with a solution containing methyl blue and subsequently dissected to distinguish intra- from peri-articular injection. In order to assess the importance of experience in achieving accurate placement, half of the injections were performed by an inexperienced resident and half by a skilled specialist. The specialist injected a further 20 cadaver acromioclavicular joints with the aid of an image intensifier. The overall frequency of peri-articular injection was much higher than expected at 43% (33 of 76) overall, with 42% (16 of 38) by the specialist and 45% (17 of 38) by the resident. The specialist entered the joint in all 20 cases when using the image intensifier. Correct positioning of the needle in the joint should be facilitated by fluoroscopy, thereby guaranteeing an intra-articular injection

Introduction and Objective. Osteoarthritis (OA) is the most common inflammatory and degenerative joint disease. Mesenchymal Stromal Cells (MSCs), with their chondro-protective and immune-regulatory properties, have been considered as a new approach to treat OA. Considering the risk of cell leakage outside the articular space and the poor survival rate after intra-articular (IA) injection, we hypothesized that cell encapsulation in cytoprotective hydrogels could overcome these limitations and provide cells with a suitable 3D microenvironment supporting their biological activity. We previously generated micromolded alginate particles (diameter 150 μm) and demonstrated the long-term viability of microencapsulated MSCs isolated from human adipose tissue (hASCs). Encapsulated cells maintained their in vitro ability to sense and respond to a pro-inflammatory environment (IFN-γ/TNF-α or synovial fluids from OA patients) by secreting PGE. 2. , IDO, HGF and TGF-β. In this study, we evaluated the anti-OA efficacy of these microencapsulated hASCs in a post-traumatic OA model in rabbits. Materials and Methods. OA was surgically induced by anterior cruciate ligament transection (ACLT)-mediated destabilization of the right knee in rabbits (n=24). Eight weeks after surgery, destabilized joints were injected (IA, 26G needle) with 200 μL of either PBS, blank microparticles, non-encapsulated or microencapsulated cells (5×10. 5. cells). Six weeks after injection, rabbits were euthanized and all destabilized (right) and sham-operated (left contralateral) joints were dissected and analyzed for OA severity. Tibial subchondral bone histomorphometric parameters were measured by quantitative micro-computed tomography (micro-CT). Histological sections of samples were analyzed after Safranin-O staining and quantitatively assessed according to a modified Osteoarthritis Research Society International (OARSI) scoring system. Immunohistochemical detection of NITEGE was performed to assess the extracellular matrix degradation. Results. Micro-CT analysis of destabilized joints confirmed that the rabbit ACLT significantly affected the tibial subchondral bone architecture as early as eight weeks, as revealed by significant changes of the subchondral bone parameters of operated joints compared to the sham operated joints. In particular, destabilized joints exhibited a Bone Volume/Tissue Volume ratio (BV/TV) ranging from 53.4% to 56.6%, compared to a mean BV/TV of 65.4% for sham operated joints. All destabilized joints also exhibited a significantly increased modified OARSI score, ranging from 7.4±0.4 for those injected with encapsulated cells to 8.9±0.2 for those injected with PBS, as compared to 4.8±0.4 for sham-operated joints. Of interest, we identified a slight, while not significant, reduction of the severity of OA lesions after injection of microencapsulated cells using the modified OARSI scoring. Finally, semi-quantitative analysis of NITEGE immunostaining revealed a significant increase in all destabilized joints that were injected with PBS or blank microparticles, in comparison with sham ones. On the contrary, NITEGE immunostaining in destabilized joints that were injected with non-encapsulated or encapsulated hASC revealed a significant reduced NITEGE immunostaining, indicating a decreased matrix degradation. Conclusions. Our data suggest that the microencapsulated hASCs exerted their anti-OA properties after IA injection in rabbit knees, as evidenced by the tendency toward a reduced modified OARSI score, and most importantly a significant reduction in NITEGE immunostaining associated matrix degradation. Further studies are now warranted to investigate the anti-OA efficacy of microencapsulated hASCs in the long-term

Introduction. Ostochondral lesion of the knee is a common cause of chronic knee pain. Arthroscopic treatment with subcondral microfracture is a widespread technique leading to noticeable improvement of knee function and pain. To improve the effectiveness of this treatment options, we thought to add intra (PRF) or post-operative (PRP) growth factors. Platelet rich plasma (PRP) is obtained by centrifugation of the blood to produce a plasma with high concentration of platelets and growth factors. This latter represents a promising method to manage degenerative cartilage lesion and can be used postoperatively to improve clinical results of patients treated arthroscopically. Platelet Rich Fibrin (PRF) has been presented as a second-generation platelet concentrate, and it is used intraoperatively to cover the microfracuteres’ holes. No literature was found about using of PRF intraoperative in association with arthroscopic microfracture technique. The aim of this study is to compare clinical outcomes of the treatment of knee osteochondral lesion using arthroscopic microfracture technique alone or in association with PRF Intraoperative application using “Vivostat” system or with PRP “ReGen Lab” postoperative injection. Patients & Methods. 90 patients with clinical and radiographic evidence of osteochondral lesion of the medial or lateral compartment of the knee were enrolled. All patients received arthroscopic debridement and Microfractures and were randomised into 3 groups: 30 patients received microfractures and intraoperative PRF “Vivostat” injection(Group A), 30 patients received microfracture and 3 intra-articular injections of 5.5 mL PRP “Regen”(Group B), 30 patients received microfracture only. IKDC, KOOS and VAS score were administered to all patients before starting the treatment, at 1, 6 and 12 months from the end of the management. Results. Patients who received microfracture and PRF intraoperative application provided the best outcomes, showing a significant higher clinical scores (P<0.001) compared to the other two groups. Patients underwent PRP postoperative administration reported significant higher score than those undergoing arthroscopic microfracture alone (P<0.005), but lesser than Intraoperative PRF group at 6 months and 1 year follow up. Discussion/Conclusion. Treatment of osteochondral lesions of the knee using microfracture technique significantly improved functional and pain scores from the pre- to postoperatively time in the overall cohort. Intraoperative application of PRF shows significantly better outcome than postoperative PRP injections. However, additional treatment with intra-articular PRP injection as an adjunct to microfracture technique may offer better clinical outcomes over microfracture technique alone

Objectives. Recent studies have shown that systemic injection of rapamycin can prevent the development of osteoarthritis (OA)-like changes in human chondrocytes and reduce the severity of experimental OA. However, the systemic injection of rapamycin leads to many side effects. The purpose of this study was to determine the effects of intra-articular injection of Torin 1, which as a specific inhibitor of mTOR which can cause induction of autophagy, is similar to rapamycin, on articular cartilage degeneration in a rabbit osteoarthritis model and to investigate the mechanism of Torin 1’s effects on experimental OA. Methods. Collagenase (type II) was injected twice into both knees of three-month-old rabbits to induce OA, combined with two intra–articular injections of Torin 1 (400 nM). Degeneration of articular cartilage was evaluated by histology using the Mankin scoring system at eight weeks after injection. Chondrocyte degeneration and autophagosomes were observed by transmission electron microscopy. Matrix metallopeptidase-13 (MMP-13) and vascular endothelial growth factor (VEGF) expression were analysed by quantitative RT-PCR (qPCR).Beclin-1 and light chain 3 (LC3) expression were examined by Western blotting. Results. Intra-articular injection of Torin 1 significantly reduced degeneration of the articular cartilage after induction of OA. Autophagosomes andBeclin-1 and LC3 expression were increased in the chondrocytes from Torin 1-treated rabbits. Torin 1 treatment also reduced MMP-13 and VEGF expression at eight weeks after collagenase injection. Conclusion. Our results demonstrate that intra-articular injection of Torin 1 reduces degeneration of articular cartilage in collagenase-induced OA, at least partially by autophagy activation, suggesting a novel therapeutic approach for preventing cartilage degeneration and treating OA. Cite this article: N-T. Cheng, A. Guo, Y-P. Cui. Intra-articular injection of Torin 1 reduces degeneration of articular cartilage in a rabbit osteoarthritis model. Bone Joint Res 2016;5:218–224. DOI: 10.1302/2046-3758.56.BJR-2015-0001

In atrophic non-union models, a minimally invasive technique is used to deliver stem cells into the fracture site via percutaneous injection. This technique is significantly affected by a backflow leakage and the net number of cells might be reduced. The Z-track method is a technique used in clinical practice for intramuscular injections to prevent backflow leakage. We evaluated the potential of the Z-track injection technique for preventing cell loss in non-union models by determining the behaviour of observable marker fluids. Firstly, toluene blue stain was used as an injection material to allow visual detection of its distribution. Rat's cadaver legs were used and tibias were kept unbroken to ensure intact skin and overlying soft tissue. Technique includes pulling the skin over the shin of tibia towards the ankle and injection of the dye around the mid-shaft. The needle was then partially pulled back, the skin was returned to its normal position and a complete extraction of the needle was followed. Secondly, a mixture of contrast material and toluene blue was used to allow direct visual and radiological detection of the injected material into the fracture site. Ante-grade nailing of tibia via tibial tuberosity was carried out followed by a 3 point closed fracture. Injection was performed into the fracture gap similarly to the steps above. X-rays were taken to visualise the location and distribution of the injected material. Observation revealed no blue stain could be detected over the skin, X -rays revealed that the radiopaque dye remained around the tibia with no escape of the material into the superficial layers or onto the skin surface. Therefore, the number of cells delivered and maintained at a target site could be increased by the Z-track method and therefore, the therapeutic benefit of stem cell injections could be optimised with this simple technique

Aging has been associated with decreases in muscle strength and bone quality. In elderly patients, paravertebral muscle atrophy is accompanied by vertebral osteoporosis. The purpose of this study was to use paravertebral injection of botulinum toxin-A (BTX) to investigate the effects of paravertebral muscle atrophy on lumbar vertebral bone quality. Forty 16-week-old female SD rats were randomly divided into four groups: (1) a control group (CNT); (2) a resection of erector spinae muscles group (RESM); (3) a botulinum toxin-A group (BTX) that was treated with local injection of 5U BTX into the paravertebral muscles bilaterally; and (4) a positive control group (OVX) that underwent bilateral ovariectomy. At 3 months post-surgery the lumbar vertebrae (L3 – L6) were collected. The BMDs of the RESM and BTX groups were significantly lower than that of the CNT group (P < 0.01). Micro-CT scans showed that rats in the three experimental groups had fewer trabeculae and trabecular connections than rats in the CNT group. The bone loss trend of the trabecular networks was most obvious in the OVX rats. Vertebral compression testing revealed that the three experimental groups had significantly lower maximum load, energy absorption, maximum stress, and elastic modulus values than the CNT group (P < 0.01), and these parameters were lowest in the OVX group (P < 0.05). Our results demonstrate that the new paravertebral muscle atrophy model using local BTX injection causes sufficient muscle atrophy and dysfunction to result in local lumbar vertebral bone loss and quality deterioration

Introduction. Subacromial corticosteroid injection is widely used in the treatment of Subacromial Impingement Syndrome (SIS). There is increasing interest in using ultrasound (US) to improve the accurate placement of injections. This study investigated whether the accuracy of placement of US-guided subacromial corticosteroid injections influences patients' outcome of pain and function. Method. Secondary analysis of data from a 2−2 factorial randomised controlled trial investigating exercise and corticosteroid injection for pain and function in SIS. US-guided injections were delivered according to a pre-defined protocol. Video images were reviewed to categorise accuracy of injection into the subacromial bursa into 3 accuracy groups using pre-defined criteria: 1) not in the subacromial bursa; 2) probably in the subacromial bursa; and 3) definitely in the subacromial bursa. The primary outcome measure was the self-reported Shoulder Pain and Disability Index (SPADI) total score, compared at 6 weeks and 6 months. Secondary outcomes included SPADI pain and function subscales and participant global rating of overall change from baseline. A mixed effects model was used to compare accuracy groups' outcomes at 6 weeks and 6 months, adjusted for baseline covariates. Results. US-guided injection accuracy data were available for 114 participants; with 22 participants in group 1, 21 in group 2 and 71 in group 3. There were no significant differences in mean SPADI scores among the three injection accuracy groups at 6 weeks (group 2 vs. 1: 8.22 (95% CI −4.01, 20.50); group 3 vs. 1: −0.57 (−10.27, 9.13)) and 6 months (group 2 vs. 1: 12.38 (−5.34, 30.10); group 3 vs. 1: 3.10 (−11.04, 17.23)). Similarly, no differences between accuracy groups were seen in SPADI pain, SPADI function or participant global rating of change. Conclusion. The accuracy of US-guided subacromial corticosteroid injection in SIS does not influence clinical response to the injection, questioning the need for guided injections. Larger, adequately powered studies are required to explore this further

Injection or aspiration of the ankle may be performed through either an anteromedial or an anterolateral approach for diagnostic or therapeutic reasons. We evaluated the success of an intra-articular puncture in relation to its site in 76 ankles from 38 cadavers. Two orthopaedic surgical trainees each injected methylene blue dye into 18 of 38 ankles through an anterolateral approach and into 20 of 38 through an anteromedial. An arthrotomy was then performed to confirm the placement of the dye within the joint. Of the anteromedial injections 31 of 40 (77.5%, 95% confidence interval (CI) 64.6 to 90.4) were successful as were 31 of 36 (86.1%, 95% CI 74.8 to 97.4) anterolateral injections. In total 62 of 76 (81.6%, 95% CI 72.9 to 90.3) of the injections were intra-articular with a trend towards greater accuracy with the anterolateral approach, but this difference was not statistically significant (p = 0.25). In the case of trainee A, 16 of 20 anteromedial injections and 14 of 18 anterolateral punctures were intra-articular. Trainee B made successful intra-articular punctures in 15 of 20 anteromedial and 17 of 18 anterolateral approaches. There was no significant difference between them (p = 0.5 and p = 0.16 for the anteromedial and anterolateral approaches, respectively). These results were similar to those of other reported studies. Unintended peri-articular injection can cause complications and an unsuccessful aspiration can delay diagnosis. Placement of the needle may be aided by the use of ultrasonographic scanning or fluoroscopy which may be required in certain instances

Objectives. This study aimed to examine the effects of SRT1720, a potent SIRT1 activator, on osteoarthritis (OA) progression using an experimental OA model. Methods. Osteoarthritis was surgically induced by destabilization of the medial meniscus in eight-week-old C57BL/6 male mice. SRT1720 was administered intraperitoneally twice a week after surgery. Osteoarthritis progression was evaluated histologically using the Osteoarthritis Research Society International (OARSI) score at four, eight, 12 and 16 weeks. The expression of SIRT1, matrix metalloproteinase 13 (MMP-13), a disintegrin and metalloproteinase with thrombospondin motifs-5 (ADAMTS-5), cleaved caspase-3, PARP p85, and acetylated nuclear factor (NF)-κB p65 in cartilage was examined by immunohistochemistry. Synovitis was also evaluated histologically. Primary mouse epiphyseal chondrocytes were treated with SRT1720 in the presence or absence of interleukin 1 beta (IL-1β), and gene expression changes were examined by real-time polymerase chain reaction (PCR). Results. The OARSI score was significantly lower in mice treated with SRT1720 than in control mice at eight and 12 weeks associated with the decreased size of osteophytes at four and eight weeks. The delayed OA progression in the mice treated with SRT1720 was also associated with increased SIRT1-positive chondrocytes and decreased MMP-13-, ADAMTS-5-, cleaved caspase-3-, PARP p85-, and acetylated NF-κB p65-positive chondrocytes and decreased synovitis at four and eight weeks. SRT1720 treatment partially rescued the decreases in collagen type II alpha 1 (COL2A1) and aggrecan caused by IL-1β, while also reducing the induction of MMP-13 by IL-1β in vitro. Conclusion. The intraperitoneal injection of SRT1720 attenuated experimental OA progression in mice, indicating that SRT1720 could be a new therapeutic approach for OA. Cite this article: K. Nishida, T. Matsushita, K. Takayama, T. Tanaka, N. Miyaji, K. Ibaraki, D. Araki, N. Kanzaki, T. Matsumoto, R. Kuroda. Intraperitoneal injection of the SIRT1 activator SRT1720 attenuates the progression of experimental osteoarthritis in mice. Bone Joint Res 2018;7:252–262. DOI: 10.1302/2046-3758.73.BJR-2017-0227.R1

Background. Carpometacarpal osteoarthritis is a degenerative disease of the hand that causes pain, stiffness and weakness. Currently, no drugs are available to prevent progression or cure this disease. Ultimately, the last treatment option is the surgical removal of the trapezium bone. In order to this limited treatment options, the utilization of autologous fat injections or adipose-derived stem progenitor cells (ADSPCs) provides a novel treatment option to inhibit the progression of this disease and potentially regenerate the damaged tissue. Objective. By utilizing next-generation-sequencing (NGS), we aim to uncover novel factors, released by ADSPCs or whole-fat aspirates, that might be involved into the metabolism of osteoarthritic cartilage. Materials and Methods. Human fat tissue was collected from five patients undergoing abdominal liposuction. Fat- and ADSPCs-conditioned medium was prepared by incubating fat and ADSPCs for 48 h in culture medium with and without TNFα to stimulate the secretion of immunomodulatory factors. The transcriptome of stimulated and non-stimulated fat and ADSPCs was analyzed by NGS. Chondrocytes from osteoarthritic cartilage from seven patients undergoing trapeziectomy were isolated, expanded and pooled. Chondrocytes were treated with six different conditions for 72 h. While standard culture medium with and without TNFα served as control groups. Fat-conditioned medium with and without TNFα, as well as ADSPCs-conditioned medium with and without TNFα served as experimental groups. Before and after cultivation of osteoarthritic chondrocytes with conditioned medium, chondrocytes were analyzed by NGS to evaluate the effect of fat- and ADSPCs-conditioned medium onto transcriptional changes in osteoarthritic chondrocytes. Results. To determine which factors might be involved in the anti-inflammatory effect of fat- and ADSPCs- conditioned medium, stimulated and non-stimulated fat and ADSPCs were analyzed by NGS. The most promising genes are cytokines, tissue inhibitors of matrix metalloproteinases and growth factors. In order to see the effect of conditioned medium from fat and ADSPCs on chondrocytes before and after cultivation with conditioned medium, NGS was performed. The gene expression of matrix metalloproteinases, cytokines, suppressors of cytokine signaling and cartilage specific proteins is of special interest. Conclusion. We aimed to investigate in our study if the clinically approved fat injection into osteoarthritic joints has the same therapeutical effect as the not yet clinically approved injection of isolated ADSPCS. Since the use of autologous fat injections is not only clinically approved but also much more convenient for a clinical approach, it is of utmost interest to know if both injection methods have a sufficient treatment effect on osteoarthritis

Osteoarthritis (OA) is a degenerative and inflammatory joint disease that affects the whole joint. Mesenchymal stem cells ability to secrete anti-inflammatory and immuno-modulatory factors represents an attractive tool in the treatment of OA. Considering the risk of cell leakage and the massive cell death upon intra-articular injection, we developed a micromolding protocol of encapsulation that allows to obtain particles that (i) could be injected with a 26G needle into a mouse joint and (ii) could provide a 3D microenvironment supporting cell biological activity. Polydimethylsiloxane (PDMS) chips containing circular micromolds were manufactured and a solution of alginate (2% w/v) containing human adipose stem cells (3 millions/mL) was deposited on the chips. Cell loading into the micromolds was performed either by sedimentation or by centrifugation. Following Ca2+ crosslinking, alginate particles (diameter 150±0.7μm) were obtained. The number of cells per particle was 5 times higher when the micromolds were loaded by centrifugation. Cell number and metabolic activity remained stable for 7 days after encapsulation and injection through a 26G needle had no impact on cell viability. When cells were stimulated with TNF-alpha and INF-gamma, prostaglandin E2 (PGE2) concentration in the supernatant was multiplied by 13 and 7 and indoleamine2,3-dioxygenase (IDO) activity was 2 and 4 times higher when cell loading was performed by sedimentation or centrifugation, respectively. We have demonstrated that encapsulated cells were able to sense and respond to an inflammatory stimulus and their therapeutic potential will be evaluated in a murine model of osteoarthritis

Summary Statement. There are no standardised methods for assessing the cement flow behaviour in vertebroplasty. We propose a novel methodology to help understand the interaction of cement properties on the underlying displacement of bone marrow by bone cement in porous media. Introduction. Concerns related to cement extravasation in vertebroplasty provide the motivation for the development of methodologies for assessing cements (novel and commercially available) and delivery systems. Reproducible and pathologically representative three-dimensional bone surrogates are used to understand the complex rheology underlying the two-phase flow in porous media. Patients & Methods. The bone surrogates were achieved by first developing CAD models then manufacturing the physical models through a suitable rapid prototyping technique. MicroCT 100 (Scanco Medical, Switzerland) was used to assess the variability in the model morphology (n=8). Contact angle measurements were performed on the material to compare the surface wettability to that of bone. The surrogates were filled with bone marrow substitute (Carboxymethyl cellulose 2.5 % in water, 0.4 Pa.s) then 5 ml of silicone oil (Dow Corning Corp. 200® Fluid, 60 Pa.s) was injected at a constant flow rate (3mL/min) using a syringe pump. The injection was radiographically monitored and the video sequences were captured. Experiments were repeated three times. The displacement of the syringe plunger and the force applied on the plunger were recorded. Image processing was performed on the video sequences to quantitatively describe the resulting flow patterns and calculate parameters including the time of leakage and the mean spreading distance. Results. The variability in the model morphology was very low with a strut thickness of 0.253 ± 0.010 mm and a pore spacing of 0.83 + 0.01 mm. The surface wettability was very similar between all materials with a contact angle around 65°. The measured displacement of the syringe plunger confirmed the flow rate to be constant at 3 ml/min. The peak injection pressure was 0.443 ± 0.013 MPa which is well below the reported clinical measurement of injection pressure during vertebroplasty. 1. Anterior oil leakage occurred at 34.6 ± 4.71 seconds. The oil never reached the posterior wall and the mean spreading distance at the end of the injection was 23.39 ± 1.11 mm. Discussion/Conclusion. These complex three-dimensional bone surrogates provide a clinically relevant representation of the in vivo situation in terms of geometry, porosity and permeability. They overcome limitations of previous models by being constant in terms of both porosity and geometry which is crucial to reduce the variability, render the experiments reproducible and shift the focus onto understanding the cement flow behaviour. The proposed methodology will help study cement-fluid interaction to get better representation of in vivo cement flow patterns and provide a tool for validating computational simulations. Funding was provided by the EU under the FP7 Marie Curie Action (PITN-GA-2009-238690-SPINEFX)

Poly-ether-ether-ketone (PEEK) is a biomaterial commonly used for spinal implants and screws. It is often desirable for orthopaedic implants to osseointegrate, but as PEEK is biologically inert this will not occur. The aim of this project was to determine if injection mould nanopatterning can be used to create a make PEEK bioactive and stimulate osteogenesis in vitro. PEEK substrates were fabricated by injection mould nanopatterning to produce near-square (NSQ) nanopatterned PEEK and planar (FLAT) PEEK samples. Atomic force microscopy (AFM) and scanning electron microscopy were used to characterize the surface topography. Human bone marrow stromal cells (hBMSCs) were isolated from patients undergoing primary hip replacement operations and seeded onto the PEEK substrates. After 6 weeks the cells were stained using alizarin red S (ARS) stain (to detect calcium) and the von Kossa technique (to detect phosphate) and analyzed using CellProfiler image analysis software to determine: surface coverage; cell number; and expression of either calcium (ARS stain) or phosphate (von Kossa technique). ARS stain showed calcium expression (quantified relative to the number of cells) was increased on NSQ PEEK compared to FLAT PEEK (not statistically significant) and the surface coverage was similar. Von Kossa staining revealed more surface coverage on FLAT PEEK (69.1% cf. 31.9%), cell number was increased on FLAT PEEK (9803 ± 4066 cf. 4068 ± 1884) and phosphate expression relative to cell number was also increased (seven-fold) on NSQ PEEK (P < 0.05) compared to FLAT PEEK. Although hBMSCs may adhere to NSQ PEEK in smaller numbers, the cells expressed a relatively larger amount of calcium and phosphate. This indicates that the cells adopted a more osteoblastic phenotype and that nanopatterning PEEK induces hBMSC differentiation and stimulates osteogenesis. Injection mould nanopatterning therefore has the potential to improve osseointegration of PEEK implants in vivo

The nature of the Aneurysmal Bone Cyst (ABC) is still controversial among benign tumor, often identifiable in the “aggressive” form (Enneking stage 3) or pseudotumoral lesion. It is well known instead the very high risk of intraoperative bleeding, indicating a strongly unfavorable relationship between the surgical morbidity and the nature of the disease. Recently, excellent results have been obtained in the treatment of ABC by repeated arterial embolizations (SAE), without any surgery, while initial experiences with administration of denosumab and doxycycline are still under study. This study presents the results of our initial experience in the treatment of vertebral ABC through the use of concentrated autologous mesenchymal stem cells (MSCs). Two teenagers aged 15 years, male, and 14 years, female, came to our attention both with diagnosis of ABC in C2 vertebra which was histologically confirmed. They were both neurologically intact, the girl complained of neck pain. The arteriography showed in both cases close relationships between the pathological ABC vascularization and the vertebral and cervical ascending arteries, making treatment by selective arterial embolization unsuitable. After discussion with the parents of patients, we jointly decided to undertake the treatment by direct injection of MSCs preceded, in the same operative session, by harvesting from the iliac crest of 60 cc of bone marrow (by needle aspiration) and its separation with the use of concentration system Res-Q ™ 60 BMC. In the second case the treatment was repeated two times at distance of 4 months. The clinical and radiological follow-up is to of 30 months from the first treatment in both cases. In the first case the presence of newly formed bone within the ABC appeared as a clear sign of recovery just a month after the first treatment and increased gradually, until the cyst appeared completely ossified one year after the treatment, with associated disappearance of the pain. In the second case an initial sclerotic peripheral margin appeared after the second treatment and later ossification progressed, concurrently with the disappearance of the pain. Treatment with selective serial arterial embolization is considered effective in the treatment of ABC even if not without risks, mainly related to the frequent and repeated exposure to ionizing radiation. Furthermore, in a certain percentage of cases the procedure is not technically executable, especially for the presence of arteries afferent to the medullar vascularization. Inconsistent results were obtained with other procedures: the injection of calcitonin, steroid, alcoholic solutions, or the use of sclerosing substances. Radiation therapy, though very effective, it is not considered the first choice. Recently, promising results have been achieved by the injection of mononuclear cells derived from bone marrow in the treatment of Aneurysmal Bone Cyst. Based on the early results obtained in the two cases described, the injection of MSCs can be considered a valid alternative in the treatment of vertebral ABCs untreatable by embolization

Segmental bone transport (SBT) using an external fixator is currently a standard treatment for large-diameter bone defects at the donor site with low morbidity. However, long-term application of the device is needed for bone healing. In addition, patients who received SBT treatment sometimes fail to show bone repair and union at the docking site, and require secondary surgery. The objective of this study was to investigate whether a single injection of recombinant human bone morphogenetic protein 2 (rhBMP-2)-loaded artificial collagen-like peptide gel (rhBMP-2/ACG) accelerates consolidation and bone union at the docking site in a mouse SBT model. Six-month-old C57BL/6J mice were reconstructed by SBT with external fixator that has transport unit, and a 2.0-mm bone defect was created in the right femur. Mice were divided randomly into four treatment groups with eight mice in each group, Group CONT (immobile control), Group 0.2mm/d, Group 1.0mm/d, and Group BMP-2. Mice in Group 0.2mm/d and 1.0mm/d, bone segment was moved 0.2 mm per day for 10 days and 1.0 mm per day for 2 days, respectively. Mice in Group BMP-2 received an injection of 2.0 μg of rhBMP-2 dissolved in ACG into the bone defect site immediately after the defect-creating surgery and the bone segment was moved 1.0 mm/day for 2 days. All animals were sacrificed at eight weeks after surgery. Consolidation at bone defect site and bone union at docking site were evaluated radiologically and histologically. At the bone defect site, seven of eight mice in Group 0.2mm/d and two of eight mice in Group 1.0mm/d showed bone union. In contrast, all mice in Group CONT showed non-union at the bone defect site. At the docking site, four of eight mice in Group 0.2 mm/d and three of eight mice in Group 1.0 mm/d showed non-union. Meanwhile, all mice in Group BMP-2 showed bone union at the bone defect and docking sites. Bone volume and bone mineral content were significantly higher in Group 0.2mm/d and Group BMP-2 than in Group CONT. HE staining of tissue from Group 0.2mm/d and Group BMP-2 showed large amounts of longitudinal trabecular bone and regenerative new bone at eight weeks after surgery at the bone defect site. Meanwhile, in Group CONT and Group 1.0mm/d, maturation of regenerative bone at the bone defect site was poor. Differences between groups were analyzed using one-way ANOVA and a subsequent Bonferroni's post-hoc comparisons test. P < 0.05 was considered significant. rhBMP-2/ACG combined with SBT may be effective for enhancing bone healing in large bone defects without the need for secondary procedures

Background. Epidural steroid injections can provide temporary relief of symptoms in the treatment of lumbar spinal stenosis. Surgery is indicated when conservative measures fail. We hypothesise that patients who gain temporary relief of symptoms from the administration of epidural steroid injections are more likely to result in an improvement in symptoms following surgical intervention compared to patients who do not respond to injection therapy. Method. The records of patients who had received both an epidural injection and surgical intervention for lumbar spinal stenosis between July 2008 and July 2010 were identified and retrospectively reviewed. Relief of symptoms following epidural injection was noted at 6 weeks post procedure and the patients symptoms following surgical intervention was noted and classified according to MacNab's criteria at 3 months post-surgery. Results. 60 patients who received both an epidural injection and surgical intervention for lumbar spinal stenosis were identified. 76% of patients who gained relief of symptoms from epidural injection scored good or excellent according to MacNab's criteria following surgery (n=34). Only 30% of patients who did not respond to injection therapy scored good or excellent according to MacNab's criteria following surgical intervention (n=5). Conclusion. Patients who gained temporary relief of symptoms from epidural injection were more likely to benefit from surgical intervention in the treatment for lumbar spinal stenosis. No conflicts of interest. No funding obtained. We confirm that this abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting