A cavovarus foot deformity was simulated in cadaver specimens by inserting metallic wedges of 15° and 30° dorsally into the first tarsometatarsal joint. Sensors in the ankle joint recorded static tibiotalar pressure distribution at physiological load.

The peak pressure increased significantly from neutral alignment to the 30° cavus deformity, and the centre of force migrated medially. The anterior migration of the centre of force was significant for both the 15° (repeated measures analysis of variance (ANOVA), p = 0.021) and the 30° (repeated measures ANOVA, p = 0.007) cavus deformity. Differences in ligament laxity did not influence the peak pressure.

These findings support the hypothesis that the cavovarus foot deformity causes an increase in anteromedial ankle joint pressure leading to anteromedial arthrosis in the long term, even in the absence of lateral hindfoot instability.

A pin-on-disc tribometer test with a rotating disc and a sector-wise loaded pin was used to determine friction coefficients for different material pairings. The four pin materials porcine cartilage, subchondral bone of the porcine cartilage, UHMWPE, vitamin E enhanced, crosslinked UHMWPE (VEPE) in combination with the three-disc materials zirconia toughened alumina ceramic (ZTA), CoCr, carbon-fibre-reinforced carbon (CrC) were tested. Stepwise loading was employed with the forces 10 N, 5 N, 2 N and 1 N. Test duration was 1 h. Diluted calf serum according ISO 14242-1 was used to determine the friction coefficients. The surface topography of all pins was examined using optical profilometry before and after the rotation tribometer tests. - No wear related modifications of the surface roughness parameters could be found. The coefficients of friction (COF) were lowest for the cartilage pins against all three-disc materials, with steady-state values between 0.01 and 0.02 for the highest applied load (10 N). Friction of subchondral bone yielded COF in the range 0.2 … 0.6, depending on the counterpart material. The two polyethylene materials behaved similar in this friction test with COF of about 0.1. The Ra roughness values of the different pins reflect the COF results: Ra of subchondral bone was one order of magnitude higher than Ra of the cartilage. This is in-line with the COF-values of bone being one order of magnitude higher than those of cartilage. These results will be discussed in view of the use of the disc materials as orthopaedic hemi-prostheses.

Background. Medial open wedge high tibial osteotomy (MOWHTO) has been accepted as a highly effective option for the treatment of medial unicompartmental osteoarthritis of the knee. Although pain in the medial joint line is significantly relieved after MOWHTO, some patients complain of pain over pes anserinus after the osteotomy, necessitating implant removal for pain relief. Purpose. The purpose of this study is to define the implant removal rate after MOWHTO due to patient complaints. Methods. 103 knees of 72 patients who underwent MOWHTO for medial unicompartmental osteoarthritis between 2010 and 2018 with a follow-up of at least 24 months were enrolled in the study. Patients were evaluated with the Knee Injury and Osteoarthritis Outcome Score (KOOS), Oxford Knee Score (OKS) and Visual Analogue Score (VAS) for pain in the medial knee joint (VAS-MJ). All tests were performed before the surgery, at 12 months after surgery. VAS value for pain over pes anserinus (VAS-PA) was recorded at 12 months after MOWHTO and at 3 months after implant removal. Results. Mean follow-up was 31±5.4 months. TomoFix® medial high tibia plate (DePuy Synthes, Raynham, MA, USA) was used for the fixation of osteotomy in all cases. Significant improvement in KOOS, OKS and VAS-MJ were observed 12 months after MOWHTO. Average values of VAS-MJ and VAS-PA were 21.7±7.1 and 34±8.4, respectively. Implant removal was needed for 65 (63.1%) knees. There were no significant differences in regard of postoperative KOOS (p=0.134), OKS (p=0.287) and VAS-MJ (p=0.416) scores between patients for which implant removal was needed or not. VAS-PA value decreased significantly at 3 months after implant removal (p<0.001). Conclusion. A large portion of patients needed implant removal after MOWHTO to relieve pain over pes anserinus even if knee function was significantly improved. Lower profile plates may be preferred to avoid secondary implant removal surgery after MOWHTO

Introduction and Objective. Pectus carinatum is a common congenital anterior chest wall deformity, characterized by outward protrusion of sternum and ribcage resulted from rib cartilage overgrowth. The protrusion may be symmetrical or asymmetrical. Pectus carinatum association with mitral valve diseases, Marfan's syndrome, and scoliosis enforces that poor connective tissue development as possible etiological factor. Despite the coexistence of pectus carinatum and scoliosis has attracted the attention of some researchers, the association between pectus carinatum and the other spinal deformities has not been studied comprehensively. The frequency of spinal deformity in patients with pectus carinatum and the mutual relationships of their subtypes are needed to be studied to determine the epidemiological character of the combined deformity and to plan patient evaluation and management. Our study aimed to investigate the association, define the incidence and evaluate the characteristics between different types of spinal deformities and Pectus carinatum. Materials and Methods. Radiological and physical examinations were performed for 117 pectus carinatum patients in Marmara university hospital/Turkey in the years between 2006 and 2013. The incidence of spinal deformity was calculated. Spinal deformities were classified as scoliosis, kyphosis, kyphoscoliosis, and spinal asymmetry, whereas pectus carinatum were subdivided into symmetric and asymmetric subgroups. The relationship between spinal deformities and the symmetrical-asymmetric subtype of pectus excavatum was statistically analyzed, Pearson chi-square test was used to compare the association of qualitative data. The significance level was accepted as p <0.05. Lastly, the angular values of the deformities of scoliosis and kyphosis patients were measured using the Cobb method. In this way, the magnitude of the deformity was given as a numerical value. Results. Spinal deformity was detected in 23 (17 symmetrical PE and 6 asymmetrical PE) of 117 pectus excavatum patients. Scoliosis and kyphosis were seen equally in symmetrical pectus carinatum, whereas scoliosis was seen in 33.3% and kyphosis in 50% in asymmetric pectus carinatum patients, respectively. However, there were no statistically significant differences in the distribution of scoliosis and kyphosis in patients with symmetrical and asymmetrical PE. Idiopathic scoliosis constituted the most common scoliosis group. Congenital kyphosis was not found in any kyphosis patient. The average Cobb angle of scoliosis patients was 32°, and the mean T2-T12 kyphosis angle of these patients was 55.5°, while the average kyphosis angle of those with kyphosis deformity was 71°. Conclusions. Patients with Pectus carinatum have a higher incidence of spinal deformities than the normal population. Such high concomitant incidence should be taken under consideration in evaluating and treating patients presenting with either deformity

Osteoarthritis (OA) is a common cause of chronic pain. Subchondral bone is highly innervated, and bone structural changes directly correlate with pain in OA. Mechanisms underlying skeletal–neural interactions are under-investigated. Bone derived axon guidance molecules are known to regulate bone remodelling. Such signals in the nervous system regulate neural plasticity, branching and neural inflammation. Perturbation of these signals during OA disease progression may disrupt sensory afferents activity, affecting tissue integrity, nociception, and proprioception. Osteocyte mechanical loading and IL-6 stimulation alters axon guidance signalling influencing innervation, proprioception, and nociception. Human Y201 MSC cells, embedded in 3D type I collagen gels (0.05 × 106 cell/gel) in 48 well plastic or silicone (load) plates, were differentiated to osteocytes for 7 days before stimulation with IL-6 (5ng/ml) with soluble IL-6 receptor (sIL-6r (40ng/ml) or unstimulated (n=5/group), or mechanically loaded (5000 μstrain, 10Hz, 3000 cycles) or not loaded (n=5/group). RNA extracted 1hr and 24hrs post load was quantified by RNAseq whole transcriptome analysis (NovaSeq S1 flow cell 2 × 100bp PE reads and differentially expressed neurotransmitters identified (>2-fold change in DEseq2 analysis on normalised count data with FDR p<0.05). After 24 hours, extracted IL-6 stimulated RNA was quantified by RT-qPCR for neurotrophic factors using 2–∆∆Ct method (efficiency=94-106%) normalised to reference gene GAPDH (stability = 1.12 REfinder). Normally distributed data with homogenous variances was analysed by two-tailed t test. All detected axonal guidance genes were regulated by mechanical load. Axonal guidance genes were both down-regulated (Netrin1 0.16-fold, p=0.001; Sema3A 0.4-fold, p<0.001; SEMA3C (0.4-fold, p<0.001), and up-regulated (SLIT2 2.3-fold, p<0.001; CXCL12 5-fold, p<0.001; SEMA3B 13-fold, p<0.001; SEMA4F 2-fold, p<0.001) by mechanical load. IL6 and IL6sR stimulation upregulated SEMA3A (7-fold, p=0.01), its receptor Plexin1 (3-fold, p=0.03). Neutrophins analysed in IL6 stimulated RNA did not show regulation. Here we show osteocytes regulate multiple factors which may influence innervation, nociception, and proprioception upon inflammatory or mechanical insult. Future studies will establish how these factors may combine and affect nerve activity during OA disease progression

Total Hip Arthroplasty (THA) is a well-established, cost-effective treatment for improving function and alleviating pain in patients who have disabling hip disease with excellent long-term results. Based on the excellent results, there is an ongoing trend for THA to be performed in younger and more active patients, having higher physical demands on their new total joints. Polyethylene (PE) wear and its biological consequences are one of the main causes of implant failure in THA. Macrophages phagocytise PE wear particles and this will result in osteolysis and loss of periprosthetic bone. The risk of these complications can be estimated in relation to the amount of volumetric wear based on two assumptions: that the number of PE particles dispersed in the peri-prosthetic tissues is controlled by the amount of PE wear; and that the development of osteolysis and the resulting aseptic loosening is triggered by these PE particles. Based on these assumptions, a model was developed to estimate the osteolysis-free life of a THA, depending on the Linear Wear Rate (LWR) and femoral head size of the PE bearing. A review of the literature was conducted to provide an estimate of the radiologic osteolysis threshold based on the volumetric wear of the PE bearing. This review demonstrates that this radiologic osteolysis threshold is approximated 670 mm3 for conventional PE. The osteolysis-free life of the THA was estimated by simply dividing this threshold volume by the annual Volumetric Wear Rate (VWR) of the bearing. The annual VWR is basically controlled by two parameters: (1) annual LWR and (2) head size, and was calculated by using published formulae. For 28 mm heads, following osteolysis-free life was determined in function of the annual LWR. LWR: 10 µm/y => 116.6 years / LWR: 25 µm/y => 46.6 years / LWR: 50 µm/y => 23.3 years / LWR: 100 µm/y => 11.6 years. For 40 mm heads, following osteolysis-free life was determined in function of the annual LWR. LWR: 10 µm/y => 57.1 years / LWR: 25 µm/y => 22.9 years / LWR: 50 µm/y => 11.4 years / LWR: 100 µm/y => 5.7 years. The osteolysis-free life determined by this model is in good agreement with the clinical results of PE bearings having a 28 mm head size and demonstrates that extreme low LWRs are mandatory to assure a descent osteolysis-free life for THA (PE bearings) using large heads, such as 40 mm. For such head sizes, small variations of the LWR may have large impacts on the osteolysis-free life of the THA

Summary Statement. Pulmonary embolism (PE) after total knee arthroplasty can have a significant impact on patient outcomes and healthcare costs. Efforts to prevent or minimise PE over the last 10 years have not had a significant impact on its occurrence at the national level. Introduction. Pulmonary embolism (PE) is a rare but known potentially devastating complication of total knee arthroplasty (TKA). Significant healthcare resources and pharmaceutical research has been recently focused on preventing this complication but limited data exists regarding the early results of this great effort. The purpose of this study was to assess recent national trends in PE occurrence after TKA and evaluate patient outcomes related to this adverse event. Methods. International Classification of Disease - 9th Revision (ICD-9) procedure codes were used to search the National Hospital Discharge Survey (NHDS) for all patients admitted to US hospitals after primary TKA for each year between 2001 and 2010. ICD-9 diagnosis codes were then used to identify patients from this population who developed an acute PE during the same admission. Data regarding patient demographics, hospitalization length, discharge disposition, deep vein thrombosis, mortality, and hospital size/location were gathered from the NHDS. Trends were evaluated by linear regression with Pearson's correlation coefficient (r) and statistical comparisons were made using Student's t-test, z-test for proportions, and chi-square analysis with a significance level of 0.05. Results. 35,220 patients admitted for a primary TKA were identified. 159 (0.045%) of these patients developed an acute PE during the same admission. After adjusting for fluctuations in annual TKA performed, the development of PE after TKA demonstrated a weak negative correlation with time (r=0.17), insignificantly decreasing from an average rate of 0.049% between 2001–2005 to 0.041% between 2006–2010 (p=0.26). The size of the hospital was found to significantly impact the incidence of PE and primary TKA, with the lowest rate seen in hospitals under 100 beds (0.23%) and the highest rate seen in those with over 500 beds (0.65%, p=0.01). No significant differences in PE incidence were noted based on US region (p=0.38). The mean age of patients with PE was 67.7 years. This group included 54 men and 105 women. The non-PE group had a mean patient age that was insignificantly lower at 66.6 years (p=0.21) and included 12,450 men and 22,611 women. Gender was also not significantly different (p=0.68) between those with PE and those without PE. The number of medical co-morbidities was significantly higher in those with PE (mean 6.42 diagnoses) than those without PE (mean 4.89 diagnoses, p<0.01). Average hospitalization length also varied based on PE status, with significantly longer stays for those with PE (8.2 days, range 2–53) compared to those without PE (3.7 days, range 1–95, p<0.01). The rate of deep vein thrombosis was higher in the PE group (12.7%) versus the non-PE group (0.48%, p<0.01). Mortality was also significantly higher for the PE group (3.9%) compared to the non-PE group (0.09%, p<0.01). Discharge disposition did not significantly vary based on PE status, with 61.5% of PE and 64.0% of non-PE patients able to go directly home (p=0.59) after their inpatient stay. Discussion/Conclusion. This study demonstrates that PE can have a significant impact on patient outcomes and healthcare costs, with an associated 43-fold increase in mortality and a doubling of the inpatient admission duration. Additionally, although the risk of PE after primary TKA remains rare, it still persists. Efforts to prevent or minimise this complication over the last 10 years have not had a significant impact on its occurrence at the national level. This risk of PE appears to be greatest in patients with multiple medical co-morbidities and established DVTs. Interestingly, the PE rate also demonstrated variability based on hospital size. The reasons for this are not clear, but we suspect larger hospitals are more likely to be tertiary-care centers and thus care for more medically-complex patients

In the last decade, skeletal muscle has been recognized as an endocrine organ able to release molecules that may act as paracrine or endocrine factors, namely myokines. Among these, irisin is secreted upon muscle contraction after physical exercise (PE) and has been demonstrated to yield anabolic effects on different cell types. Recently, irisin has been shown to improve cortical bone mass, geometry and strength, hence resembling the effect of PE. It has also been reported that irisin levels in the serum and synovial fluid of patients with knee osteoarthritis (OA) were negatively correlated with OA severity. Therefore, we hypothesized that irisin may improve cartilage metabolism and blunt the osteoarthritic process. Human osteoarthritic chondrocytes (hOAC) were isolated from osteochondral specimens of patients undergoing total knee joint replacement. After in vitro expansion, hOAC were put in a three-dimensional culture system (alginate beads) and treated with either phosphate-buffered saline (control) or irisin (25 ng/mL). After 1 week, the amount of glycosaminoglycans (GAG) was evaluated using dimethylmethylene blue (DMMB) and PicoGreen assays. Quantitative real-time polymerase chain reaction (qRT-PCR) was performed to detect interleukin (IL)-1 and -6, matrix metalloproteinase (MMP)-1 and -13, inducible nitric oxide synthase (iNOS) and tissue inhibitor of matrix metalloproteinases (TIMP)-1 and -3 gene expression levels. hOAC treated with irisin showed a significant higher GAG content compared to the control group (p < 0.01). Moreover, irisin was able to reduce the expression of catabolic (MMP-1, -13, iNOS) and pro-inflammatory (IL-1, IL-6) markers, while incrementing the expression of TIMP-1 and -3 (p < 0.001). Our results showed that irisin was able to stimulate GAG synthesis and diminish extracellular matrix catabolism in hOAC, demonstrating the existence of a cross-talk between cartilage and muscle possibly supporting the beneficial role of PE on cartilage homeostasis

INTRODUCTION. Highly cross linked polyethylenes (HXPE) have to be treated thermally after irradiation to eliminate residual free radicals. By adding vitamin E in the polyethylene powder a post-irradiation thermal treatment is not necessary. In this review the correlation between the intrinsic properties and the long-term stability of Vitelene® as a high performance material for artificial hip articulation will be displayed. MATERIALS & METHODS. Three different types of polyethylene (UHMWPE; GUR1020) were analyzed to compare mechanical properties as well as oxidative stability: PE. STD. (γ, 30 kGy, N. 2. ), HXPE. REM. (γ, 75 kGy, remelted, EO), Vitelene® (β, 80 kGy, 0.1% Vitamin E, EO). Artificial aging (ASTM F2003 − 70 °C, O. 2. at 5 bar) was used to simulate environmental damage. To evaluate the oxidation stability the Oxidation-Induction-Time (OIT) was measured by Differential Scanning Calorimetry (DSC - ASTM D3895) and the Oxidation Index (OI) was determined by Fourier-Transformation-Infrared-Spectroscopy (FTIR - ASTM F2102). The mechanical properties were analyzed by tensile- and impact investigations (ASTM D638 and ISO 11542-2) as well as by Small Punch Testing (SPT - ASTM F2183). The amount of wear was measured gravimetrically (ISO 14242-2). RESULTS. OIT [minutes], after 0, 14, 28, 42, 56 and 70 days aging, respectively 0.47, 0.41, 0.45, 0.42, 0.42 and not determined (nd) for PE. STD,. 0.46, 0.46, 0.47, 0.41, 0.41 and nd for HXPE. REM,. 12.09±0.50, 11.67±0.54, 10.78±0.25, 10.42±0.36, nd and 9.25±0.19 for Vitelene®. Cristallinity [%], after 0, 14, 28 and 42 days aging, respectively 55±2, 63±2, 79±4, 88±3 for PE. STD. , 47±2, 48±0, 50±1, 57±1 for HXPE. REM. , 52±1, 51±1, 53±14, 53±2 for Vitelene®. OI, after 0, 14, 28, 35 and 42 days aging, respectively 0.11±0.03, 0.67±0.15, 4.48±1.17 for PE. STD. , 0.07±0.05, 0.06±0.02, 0.09±0.02, 0.24±0.05, 0.69±0.36 for HXPE. REM. , 0.06±0.01, 0.08±0.01, 0.08±0.01, 0.09±0.01, 0.09±0.01 for Vitelene®. Tensile Strength [MPa], after 0 and 42 days aging, respectively 47.9±10, 0.7±0 for PE. STD. , 56.0±4.0, 25.0±2.0 for HXPE. REM. , 53.1±1.0, 52.0±4.3 for Vitelene®. Elongation [%], after 0 and 42 days aging, respectively 469±69 and 0 for PE. STD. , 343±14, 7±3 for HXPE. REM. , 372±11, 380±15 for Vitelene®. Impact Strength [kJ/m²], after 0 and 42 days aging, respectively 149±6, 4±1 for PE. STD. , 95±1, 5±1 for HXPE. REM. , 86±10, 91±7 for Vitelene®. SPT - Average Ultimate Load [N], after 0, 14 and 28 days aging, respectively 61.5±4.0, 56.3±5.3, 8.2±0.2 for PE. STD. , 71.4±2.2, 68.0±9.9, 64.4±8.2 for Vitelene®. Wear [mg/Mio cycles] (Ø36 mm Biolox® delta), after 0, 14 and 42 days aging, respectively 19.0±0.6, 30.3±3.1 and 365.8±37,2 for PE. STD. , 2.0±0.3, nd and 52.0±16.4 for HXPE. REM. , 2.5±0.5, nd and 2.3±0.7 for Vitelene®. CONCLUSION. The mechanical properties of Vitelene® are unchanged even after 42 days of artificial aging which is correlated to low wear in total hip arthroplasty. Vitamin E stabilization is effective in preventing oxidation and aging of the polyethylene after irradiation cross linking

Abstract

Abstract. Objectives. The purpose of this trial is to investigate the safety and efficacy of immediate weight-bearing (IWB) and range of motion exercise regimes following ORIF of unstable ankle fractures with a particular focus on functional outcomes and complication rates. Methods. A pragmatic randomised controlled multicentre trial, comparing IWB in a walking boot and ROM within 24 hours versus NWB and immobilisation in a cast for six weeks, following ORIF of all types of unstable adult ankle fractures. The exclusion criteria are skeletal immaturity and tibial plafond fractures. The primary outcome measure is the functional Olerud-Molander Ankle Score (OMAS). Secondary outcomes include wound infection, displacement of osteosynthesis, the full arc of ankle motion, RAND-36 Item Short Form Survey (SF-36) scoring, time to return to work and postoperative hospital length of stay. Results. We recruited 160 patients with an unstable ankle fracture. Participants’ ages ranged from 15 to 94 years (M = 45.5, SD = 17.2), with 54% identified as female. The mean time from injury to surgical fixation was 1.3 days (0 to 17 days). Patients in the IWB group had a 9.5-point higher mean OMAS at six weeks postoperatively (95% CI 1.48, 17.52) P = 0.021 with a similar result at three months. The complications rate was similar in both groups. The rate of surgical site infection was 4.3%. One patient had DVT, and another patient had a PE, both were randomised to NWB. Length of hospital stay was 1 ± 1.5 (0, 12) for the IWB group vs 1.5 ± 2.5 (0, 19) for the NWB group. Conclusion. In this large multicentre RCT, we investigated WB following ORIF of all ankle fracture patterns in the usual care condition using standard fixation methods. Our result suggests that IWB following ankle fracture fixation is safe and resulted in a better functional outcome

Abstract. Objectives. Osteocytes function as critical regulators of bone homeostasis by sensing mechanical signals. Stimulation of the mechanosensitive ion channel, Piezo1 promotes bone anabolism and deletion of Piezo1 in osteoblasts and osteocytes decreases bone mass and bone strength in mice. This study determined whether loading of osteocytes in vitro results in upregulation of the Piezo1 pathway. Methods. Human MSC cells (Y201), embedded in type I collagen gels and differentiated to osteocytes in osteogenic media for 7-days, were subjected to pathophysiological load (5000 µstrain, 10Hz, 5 mins; n=6) with unloaded cells as controls (n=4). RNA was extracted 1-hr post load and Piezo1 activation assessed by RNAseq analysis (NovaSeq S1 flow cell 2 × 100bp PE reads). To mimic mechanical load and activate Piezo1, Y201s were differentiated to osteocytes in 3D gels for 13 days and treated, with Yoda1 (5µM, 2 hours, n=4); vehicle treated cells served as controls (n=4). Extracted RNA was subjected to RT-qPCR and data analysed by Minitab. Results. Low mRNA expression of PIEZO1 in unloaded cells was upregulated 5-fold following 1-hr of mechanical load (p=0.003). In addition, the transcription factor NFATc1, a known regulator of Piezo1 mechanotransduction, was also upregulated by load (2.4-fold; p=0.03). Y201 cells differentiated in gels expressed the osteocyte marker, SOST. Yoda1 upregulated PIEZO1 (1.7-fold; p=0.057), the early mechanical response gene, cFOS (4-fold; p=0.006), COL1A1 (3.9-fold; p=0.052), and IL-6 expression (7.7-fold; p=0.001). Discussion. This study reveals PIEZO1 as an important mechanosenser in osteocytes. Piezo 1 mediated increases in the bone matrix protein, type I collagen, and IL-6, a cytokine that drives inflammation and bone resorption. This provides a direct link between mechanical activation of Piezo 1, bone remodelling and inflammation, which may contribute to mechanically-induced joint degeneration in osteoarthritis. Mechanistically, we hypothesise this may occur through promoting Ca2+ influx and activation of the NFAT1 signalling pathway

Abstract. INTRODUCTION. The mechanisms underlying abnormal joint mechanics are poorly understood despite it being a major risk factor for developing osteoarthritis. Glutamate signalling has been implicated in osteoarthritic bone changes and AMPA/kainate glutamate receptor (GluR) antagonists alleviate degeneration in rodent models of osteoarthritis. We investigated whether glutamate signalling molecules are mechanically regulated in a human, cell-based 3D model of bone. METHODS. Human Y201 MSC cells embedded in 3D type I collagen gels (0.05 × 106 cell/gel) differentiated to osteocytes were mechanically loaded in silicone plates (5000 µstrain, 10Hz, 3000 cycles) or not loaded (n=5/group). RNA extracted 1-hr post load was quantified by RTqPCR and RNAseq whole transcriptome analysis (NovaSeq S1 flow cell 2 × 100bp PE reads). Differentially expressed GluRs and glutamate transporters (GluTs) were identified using DEseq2 analysis on normalised count data. Genes were considered differentially expressed if >2 fold change and FDR p<0.05. RESULTS. Cells expressed mature osteocyte markers (E11, sclerostin, DMP-1). DEseq2 analysis, revealed 981 mechanically regulated genes. Mechanical loading upregulated kainate GluRs, GRIK2 (1.6 fold, p=0.024) and GRIK5 (4.2 fold, p=0.045); the NMDA GluR GRIN3B (3.25 fold, p=0.047) and the GluT SLC1A1 (3 fold, p=0.037). Conversely, AMPA GRIA3, NMDA GluRs GRIN2A&C, and the GluT SLC1A2 were down regulated by 50–60%, although not significant. Kainate GRIK3&4; AMPA GRIA2, NMDA GRIN1, and GluTs SLC1A6&A7 were not expressed in control or loaded osteocytes, whereas GluRs (GRIK1, GRIA1&4, GRIN2B&2D&3A) and GluT SLC1A3 were expressed but not regulated by mechanical loading. DISCUSSION. Mechanical loading of human osteocytes in 3D revealed that they regulated expression of glutamate receptors and transporters. This is consistent with our observation that mechanical perturbation after joint injury in rodent models of OA regulates glutamatergic signalling in the bone thus linking mechanical stimuli to inflammatory and nociceptive pathways mediated by glutamate receptors. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

Medical grade polyurethanes have been widely promoted for biomedical applications. In particular, the use of polycarbonate-urethanes (PCU) has drawn considerable attention in the orthopaedic device industry as a result of their excellent mechanical properties, biostability and biocompatibility. PCUs have been extensively utilized in vascular grafts, stents and artificial heart valves. Specifically, bionate thermoplastic PCU, commercially produced by DSM PTG (Berkeley, California), has been of great interest in the field of orthopaedics because of its outstanding load-bearing properties and excellent wear resistance. Also, it is characterized by its long-term durability and resistance to hydrolytic degradation making it a good candidate for in-vivo orthopaedic applications. PCUs have been considered for meniscal replacement because of its unique weight-bearing capabilities, ability to withstand intense forces within the knee joint and ease of lubrication due to its hydrophilic nature. In addition, the low frictional properties essential for a meniscal replacement is obtainable with PCUs. Materials used for this study were a commercial polycarbonate-urethanes, Bionate PCU 80A (B8) and 90A (B9) pellets, and polyethylene continuous strands fibres (PE) obtained from DSM Polymer Technology Group, USA. Some quantity of the B8 and B9 pellets were dried separately in a vacuum oven at 100°C for 14 hours. A custom mould was designed for the production of the mechanical test samples. The quantity of the constituent materials was determined using composite theory known as the Rule of Mixtures. E. c. =. E. m. V. m. +. E. f. E. f. where V. m. and V. f. are the volume fraction of the matrix and fibre respectively. Three specimens each of the prepared composites were tested for tensile and compression strength and at a crosshead speed of 12 mm/min using a Zwick/Roell 1484 Material Testing Machine. The PCUs were not as stiff as their fibre-reinforced composites, which indicate that the stiffness of the PCU composite materials is a function of both the stiffness of the PCU matrix and the interspersed fibres. The tensile moduli of composites of B8 and B9 increased appreciably with PE. An increase of 227% was obtained for the B8 with the incorporation of PE fibres while percentage increase in stiffness for B9 was 148% for PE reinforcement fibres. The compressive modulus dropped with the inclusion of the PE fibres in the B9, a reduction of 55% was recorded while an increment of 4% was obtained with PE added to the B8. The results from this study demonstrate that the tensile and compressive properties of PCU can be custom-tailored to that of the meniscal tissue by systematically embedding reinforcement fibres into the PCU matrix such that a composite with desirable mechanical properties is obtained. The results of both tensile and compressive results visibly revealed the reinforcing effect of the fibres used in this study. However, additional studies are required to completely describe the PCU composite as a candidate meniscal substitute capable of gaining its full functionality

Introduction. Precision error (PE) in Dual Energy X-Ray Absorptiometry (DXA) is important for accurate monitoring of changes in Bone-Mineral-Density (BMD). It has been demonstrated that BMD PE increases with increasing BMI. In vivo PE for the Trabecular-Bone-Score (TBS) has not been reported. This study aimed to evaluate the short-term PE (STPE)) of BMD and TBS and to investigate the effect of obesity on DXA PE. Method. DXA lumbar spine scans (L1–L4) were performed using GE Lunar Prodigy. STPE was measured in 91 women (Group A) at a single visit by duplicating scans with repositioning in-between. PE was calculated as the percentage coefficient of variation (%CV). Group A was sub-divided into four groups based on BMI (A.1. <25kg/m2, A.2. 25–29.9kg/m2, A.3. 30–35kg/m2 and A.4. >35kg/m2) to assess the effect of obesity on STPE. Abnormally different vertebrae were excluded from the analysis in accordance with The International Society for Clinical Densitometry (ISCD) recommendations. Results. The Group A STPE was 1.26 % for BMD and 2.04% for TBS. Short-term PE for BMD and TBS respectively in the BMI subgroups was: A.1. 1.07% and 1.82%, A.2. 1.34% and 2.26%, A.3. 1.25% and 2.35%, A.4. 1.68% and 1.82%. Conclusion. The results show that STPE is higher for TBS than for BMD. Short-term PE for both BMD and TBS are adversely affected by increasing BMI but this effect is mitigated in the highest BMI category where use of the ‘thick’ scanning mode improves signal to noise ratio

The renewed interest in the clinically proven low wear of the metal-on-metal bearing combined with the capacity of inserting a thin walled cementless acetabular component has fostered the reintroduction of hip resurfacing. As in other forms of conservative hip surgery, i.e. pelvic osteotomies and impingement surgery, patient selection will help minimize complications and the need for early reoperation.

Femoral neck fractures remain the leading cause of early failure after metal-on-metal hip resurfacing. Although its' exact pathomechanism has yet to be fully elucidated, current retrieval analysis has shown that either an osteonecrotic event and/or significant surgical trauma to the femoral head neck junction are the leading causes. It is most likely that no single factor like patient selection and/or femoral component orientation can fully avoid their occurrence. As in osteonecrosis of the native hip joint, a certain cell injury threshold may have to be reached in order for femoral neck fracture to occur. These insults are not limited to the surgical approach, but also include femoral head preparation, neck notching, and cement penetration.

Although some have argued that the posterior approach does not represent an increased risk fracture for ON after hip resurfacing because of the so-called intraosseous blood supply to the femoral head, to date, the current body of literature on femoral head blood flow in the presence of arthritis has confirmed the critical role of the extraosseous blood supply from the ascending branch of the medial circumflex, as well as the lack of any substantial intraosseous blood supply. Conversely, anterior hip dislocation of both the native hip joint as well as the arthritic hip preserves femoral head vascularity. The blood supply can be compromised by either sacrificing the main branch of the ascending medial femoral circumflex artery or damaging the retinacular vessels at the femoral head-neck junction. Thus an approach which preserves head vascularity, while minimizing soft tissue disruption would certainly be favorable for hip resurfacing. This presentation will review the current state of knowledge on vascularity of the femoral head as well as surgical techniques enhancing its preservation.

We have investigated whether the presence of polyethylene (PE) alone is sufficient to cause an aggressive periprosthetic tissue response, or whether certain mechanical interface conditions can allow bone to grow while in the presence of PE. An experimental implant was loaded in the presence and absence of particulate PE under stable and unstable conditions. Bone with a thin, discontinuous fibrous membrane formed in both groups of stable implants, either in the presence or absence of PE. By contrast, a continuous fibrous membrane consistently formed in both groups of unstable implants. The membrane consisted of loose fibrous connective tissue when PE was absent, and dense connective tissue with macrophages and a synovial lining when PE was present. In this model, if the interface was stable, the presence of PE was not sufficient to prevent the formation of bone or to produce a phagocytic tissue response. Only when the interface was unstable did a fibrous membrane form, and only then in the presence of PE

Summary Statement. The chemistry, amount, morphology, and size distribution of wear debris from silicon nitride coatings generated in the bearing surface can potentially reduce the negative biological response and increase the longevity compared to conventional materials in joint replacements. Introduction. Total hip implants have a high success rate at 15 years of implantation, but few survive over 25 years. At present, revisions are mostly due to aseptic loosening, believed to mainly be caused by the biological response to wear debris generated in the joint bearing. For the polymer liners the size of the wear debris determines the biological response, while for metal bearing surfaces a limitation is the metal ion release. When ceramics are used, the wear debris is in general small and mechanical factors may be the main cause for failure. A more recent, experimental alternative is to let the well-known metallic substrate serve as the soft, tough bulk, and additionally apply a hard and smooth ceramic coating. In this way a lower wear rate and reduced metal ion release could be obtained. Furthermore, the chosen composition, silicon nitride (SixNy), contains no detrimental ions, and silicon nitride debris has been shown to slowly dissolve in aqueous medium. Altogether, it can potentially increase the longevity of the implant. However, the debris from SixNy coatings has not yet been characterised. In this study, a wear model test was performed to generate wear debris from SixNy coatings. The debris was characterised using scanning electron microscopy (SEM) and energy-dispersive X-ray spectroscopy (EDS) in combination with computational calculations. Methods. Silicon nitride coatings deposited on flat cobalt chromium alloy (ASTM F75) were worn in a reciprocating ball on disc setup in a 25% serum solution at 37°C against an alumina ball with a load of 1.5 N. Wear debris was separated using serum digestion with hydrochloric acid (ISO 17853:2011) and examined in SEM in combination with EDS. As reference polyethylene (PE) was used to verify that relevant particles sizes were achieved. The SEM images were processed using a modified MATLAB-script originating from Cervera Gontard et al. [1], identifying the particles and calculating their size. Results. Particles generated from SixNy coatings (n=62) a size distribution D50 [D10-D90] of 0.29 µm [0.16–0.69] and were round to oval in shape. The PE particles (n=70) had a size distribution of 0.29 µm [0.13–1.3], shaped similar to the SixNy particles or with a more elongated shape. Discussion and conclusions. PE wear debris has been reported to lie in the size range of nm up to several μm in vivo, with a large proportion within the critical size for macrophage activation (0.2 to 0.8 μm). The model test reports relevant sizes and shape of PE debris, confirming the validity of the method. Particles generated from the SixNy coatings showed a smaller size range than PE, however most particles were within the critical size range for biological activation. In conclusion, this model test could be used to generate what we believe are relevant sizes and shapes of PE and SixNy wear debris and to learn more at an early stage of prediction of wear debris. Further dissolution studies as well as studies on the in vitro and in vivo cell response to these types of particles will be performed. The authors thank the Swedish Foundation for Strategic Research (SSF) through MS2E and FP7 NMP project LifeLongJoints for financial support, as well as Linköping University for the coating facilities and expertise

Introduction. Simultaneous correction of knee varus malalignment with medial open wedge high tibial osteotomy (MOWHTO) combined with anterior cruciate ligament (ACL) surgery aims to address symptomatic unicompartmental osteoarthritis in addition to restore knee stability in order to improve outcomes. The aim of this study is to present at least 5 years results of 32 patients who underwent simultaneous knee realignment osteotomy with ACL surgery. Methods. Patients with symptomatic instability due to chronic ACL deficiency or failed previous ACL surgery together with a varus malalignment of ≥6°, previous medial meniscectomy and symptomatic medial compartment pain who were treated with MOWHTO combined with ACL surgery were enrolled. ACL surgery was performed with the anatomical single bundle all-inside technique using TightRope. ®. RT (Arthrex, Naples, FL, USA) and MOWHTO using TomoFix. ®. medial high tibia plate (DePuy Synthes, Raynham, MA, USA) in all cases. Patients were evaluated preoperatively and at 6 months, 12 months and annually postoperatively using the Knee Injury and Osteoarthritis Outcome Score (KOOS), Oxford Knee Score (OKS) and Euroqol's Visual Analogue Score (VAS) for pain. Results. 32 patients (22 men and 10 women) with a mean age of 41.2 years and mean BMI of 28.6 kg/m. 2. , underwent the combined procedures. Tibiofemoral neutral re-alignment was achieved in all patients with HTO. Complete subjective and objective scores have been obtained in 84.4% of patients with at least 5 years of follow-up (mean 8.7 years). An improvement in total KOOS of 27.1 points (p<0.003), OKS of 15.1 (p<0.003) and VAS for pain of 24.7 points (p<0.001) were detected. No ACL reconstruction failure was noted. Complications consisted of one superficial wound infection and one delayed union. Plate removal was needed in 20 (62.5%) patients due to pes anserinus pain. Conclusions. Simultaneous restoration of coronal knee axis by applying HTO and stability by ACL reconstruction/revision were reported to offer excellent improvement in early outcomes in patients with ACL rupture and symptomatic unicompartmental osteoarthritis. The combined procedure requires careful pre-operative planning and is therefore technically challenging. However, by restoring the neutral axis and providing stability, it represents a good joint preserving alternative to arthroplasty for active middle-aged patients