Unstable distal tibia fractures are challenging injuries requiring surgical treatment. Intramedullary nails are frequently used; however, distal fragment fixation problems may arise, leading to delayed healing, malunion or nonunion. Recently, a novel angle-stable locking nail design has been developed that maintains the principle of relative construct stability, but introduces improvements expected to reduce nail toggling, screw migration and secondary loss of reduction, without the requirement for additional intraoperative procedures. The aim of this study was to investigate the biomechanical competence of a novel angle-stable intramedullary nail concept for treatment of unstable distal tibia fractures, compared to a conventional nail in a human cadaveric model under dynamic loading. Ten pairs of fresh-frozen human cadaveric tibiae with a simulated AO/OTA 42-A3.1 fracture were assigned to 2 groups for reamed intramedullary nailing using either a conventional (non-angle-stable) Expert Tibia Nail with 3 distal screws (Group 1) or the novel Tibia Nail Advanced system with 2 distal angle-stable locking low-profile screws (Group 2). The specimens were biomechanically tested under conditions including quasi-static and progressively increasing combined cyclic axial and torsional loading in internal rotation until failure of the bone-implant construct, with monitoring by means of motion tracking. Initial axial construct stiffness, although being higher in Group 2, did not significantly differ between the 2 nail systems, p=0.29. In contrast, initial torsional construct stiffness was significantly higher in Group 2 compared to Group 1, p=0.04. Initial nail toggling of the distal tibia fragment in varus and flexion was lower in Group 2 compared to Group 1, being significant in flexion, p=0.91 and p=0.03, respectively. After 5000 cycles, interfragmentary movements in terms of varus, flexion, internal rotation, axial displacement and shear displacement at the fracture site were all lower in Group 2 compared to Group 1, with flexion and shear displacement being significant, p=0.14, p=0.04, p=0.25, p=0.11 and p=0.04, respectively. Cycles to failure until both interfragmentary 5° varus and 5° flexion were significantly higher in Group 2 compared to Group 1, p=0.04. From a biomechanical perspective, the novel angle-stable intramedullary nail concept has the potential of achieving a higher initial axial and torsional relative stability and maintaining it with a better resistance towards loss of reduction under dynamic loading, while reducing the number of distal locking screws, compared to conventional locking in intramedullary nailed unstable distal tibia fractures

The clinical success of osteochondral autografts is heavily reliant on their mechanical stability, as grafts which protrude above or subside below the native cartilage can have a negative effect on the tribological properties of the joint [1]. Furthermore, high insertion forces have previously been shown to reduce chondrocyte viability [2]. Commercial grafting kits may include a dilation tool to increase the diameter of the recipient site prior to insertion. The aim of this study was to evaluate the influence of dilation on the primary stability of autografts. Six human cadaveric femurs were studied. For each femur, four 8.5 × 8mm autografts were harvested from the trochlear groove and implanted into the femoral condyles using a Smith & Nephew Osteochondral grafting kit. Two grafts were implanted into dilated recipient sites (n=12) and two were implanted with no dilation (n=12). Insertion force was measured by partially inserting the graft and applying a load at a rate of 1 mm/min, until the graft was flush with the surrounding cartilage. Push-in force was measured by applying the same load, until the graft had subsided 4mm below congruency. Significance was taken as (p<0.05). Average maximum insertion force of dilated grafts was significantly lower (p<0.001) than their non-dilated equivalent [28.2N & 176.7N respectively]. There was no significant difference between average maximum push-in force between the dilated and non-dilated groups [1062.8N & 1204.2N respectively]. This study demonstrated that significantly less force is required to insert dilated autografts, potentially minimising loss of chondrocyte viability. However, once inserted, the force required to displace the grafts below congruency remained similar, indicating a similar degree of graft stability between both groups

Arthritis is a common and debilitating disease and is associated with an increased fall risk. The purpose of this study was to examine the effect of impacted joint and limb on fall risk as measured by the margin of stability (MOS). There were 110 participants, including healthy controls (HC; n=30), ankle arthritis (AA; n=30), knee arthritis (KA; n=20) and hip arthritis (HA; n=30) patients. All protocols were Institutional Review Board approved and all participants signed informed consent. Participants walked approximately 6 meters at a self-selected pace. MOS was calculated in the foot coordinate system in the anterior/posterior (AP) and medial/lateral (ML) directions at heel strike. A one-way ANOVA was used to examine group effects (HC, AA, KA, HA) on gait speed. A two-way repeated measures ANOVA was used to examine the effects of limb (Non-Surgical, Surgical) and group on AP and ML MOS. HC had the fastest gait speed (1.40±0.24 m/s; p<0.001) when compared to AA (0.85±0.24 m/s), KA (0.94±0.22 m/s) and HA (1.05±0.22 m/s). HA participants had a greater gait speed compared to AA (p=0.004). AP MOS was greater in the surgical limb compared to the non-surgical limb for AA (p<0.001) and HA (p<0.001). AP MOS was smaller in HC compared to AA, KA, and HA, regardless of limb (p<0.030). AP MOS was similar between AA, KA, and HA for the non-surgical limb (p>0.194) and the surgical limb (p>0.096). ML MOS was greater in the surgical compared to non-surgical limb (p=0.003). ML MOS was smaller in KA participants compared to all other groups (p<0.001). Our results demonstrate stability during gait varies between limbs in arthritis patients, with a more conservative pattern for the surgical limb and suggest KA may be at an increased risk of falls with a smaller ML MOS

While high-performance ceramics like alumina and zirconia exhibit excellent wear resistance, they provide poor osseointegration capacity. As osseointegration is crucial for non-cemented joint prostheses, new techniques have been successfully developed for biofunctionalizing high-performance ceramic surfaces. Stable cell adhesion can be achieved by covalently bound specific peptides. In this study we investigate the effect of sterilization processes on organo-chemically functionalized surfaces. To enhance the performance of alumina-toughened zirconia ceramics (ATZ), a 3-aminopropyldiisopropylethoxysilane (APDS) monolayer was applied and coupled with cyclo-RGD peptides (cRGD) by using bifunctional crosslinker bis(sulfosuccinimidyl)suberat (BS³). The samples were sterilized using e-beam or gamma-sterilization at 25 kGy, either before or after biofunctionalization with cRGD. Functionalization stability was investigated by contact angle measurements. The functionality of cRGD after sterilization was demonstrated using proliferation tests and cytotoxicity assays. Immunofluorescence staining (pFAK, Actin, DAPI) was conducted to evaluate the adhesion potential between the samples and human mesenchymal stem cells (hMSCs). Functionalized samples before and after sterilization showed no significant difference regarding their contact angles. A proliferation test demonstrated that the cells on functionalized samples proliferate significantly more than on untreated samples before and after sterilization. hMSCs showed a significant higher proliferation on gamma sterilized samples compared to all other groups after 14 days. It was confirmed that the samples did not exhibit cytotoxic behavior before or after sterilization. Fluorescence microscopy demonstrated that both, cells on sterilized and on non-sterilized samples, expressed high levels of pFAK-Y397. The investigated functionalization enables improved adhesion and proliferation of hMSCs and is stable against the investigated sterilization processes. This is of importance as the option of having a sterile product enables the start of the translation of this biofunctional coating towards preclinical and subsequently first-in-man applications. Acknowledgments: We acknowledge the financial support of the Federal Ministry of Education and Research, BMBF (13GW0452A-C)

Abstract. Objectives. Osteochondral grafting (OCG) is one treatment strategy for osteoarthritis with good clinical results. Decellularised tissues provide a promising alternative to standard autografts or allografts. This study aimed to compare the stability of traditional OCG and decellularised scaffolds upon initial implantation. Methods. Host cubes (N=16) were extracted from porcine femoral condyles around an artificial defect hole. Grafts (N=11) were harvested from the trochlear groove; porcine decellularized osteochondral scaffold (N=5) were prepared. Each host was secured in fixtures and submerged in PBS at 37 ºC. Each graft or scaffold was press fit into one of the hosts, then pushed in for 5 mm, using an indenter (Instron3365) and pushed out in the opposite direction for 10 mm. Parameters analysed were the force required to initiate movement (Dislodging Force) and the maximum force (Max Force). Results. The Dislodging Force of grafts (mean ± std. dev) was 133±15 N for the push in test and 109±11 N for the push out test. This was significantly higher than values for scaffolds: IN 24±1 N and OUT 26±5 N. The Max Force were also larger in the grafts than the scaffolds: IN 152±16 N vs. 41±4 N and OUT 118±14 N vs. 33±3 N. Conclusions. The force required to dislodge a graft or scaffold from a host environment was similar for the push in test and the push out test, suggesting it is a good measure of initial stability. Upon initial implantation, the decellularised scaffolds were easier to dislodge than the OCG. Previously, the decellularisation process was found to soften bone, relative stiffness may thus be an important consideration in graft fixation. A greater press fit may be necessary for decellularised scaffolds in order to achieve the same level of graft stability as natural OCG when used in vivo. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Abstract. Objectives. The aim of this study was to develop an open-source finite element model of the ankle for identification of the best clinical treatment to restore stability to the ankle after injury. Methods. The ankle geometry was defined from the Visible Human Project Female CT dataset available from the National Library of Medicine, and segmented using Dragonfly software (Object Research Systems, 2020). The finite element model was created with FEBio (University of Utah, 2021) using the dynamic nonlinear implicit solver. Linear isotropic material properties were assigned to the bones (E=7300MPa, ν=0.3, ρ=1730kg/m. 3. ) and cartilage (E=10MPa, ν=0.4, ρ=1100kg/m. 3. ). Spring elements were used to represent the ligaments and material properties were taken from Mondal et al. [1]. Lagrangian contact was defined between the cartilaginous surfaces with μ=0.003. A standing load case was modelled, assuming even distribution of load between the feet. A reaction force of 344.3N was applied to the base of the foot, a muscle force of 252.2N, and the proximal ends of the tibia and fibula were fully constrained. Results. The von Mises stresses closely matched those reported by Mondal et al. for the fibula (Present study: 1.00MPa, Mondal: 1.30MPa) and the talus (Present study: 2.20MPa, Mondal: 2.39MPa). However stresses within the tibia were underpredicted (Present study: 1.08MPa, Mondal: 5.86MPa). This was because the present study modelled a shorter tibial length because of a limitation in the CT slices available, which reduced the bending force. Conclusions. This first step in producing an open source ankle model for the orthopaedics community has shown the potential of the model to generate results comparable with those found in the literature. Future work is underway to examine the robustness of the model under different loading and explore alternative open-source CT datasets. [1] Mondal, S., & Ghosh, R. (2017). J Orthopaedics, 14(3), 329–335. . https://doi.org/10.1016/j.jor.2017.05.003

Abstract. Approximately 20% of primary and revision Total Knee Arthroplasty (TKA) patients require multiple revisions, which are associated with poor survivorship, with worsening outcomes for subsequent revisions. For revision surgery, either endoprosthetic replacements or metaphyseal sleeves can be used for the repair, however, in cases of severe defects that are deemed “too severe” for reconstruction, endoprosthetic replacement of the affected area is recommended. However, endoprosthetic replacements have been associated with high complication rates (high incidence rates of prosthetic joint infection), while metaphyseal sleeves have a more acceptable complication profile and are therefore preferred. Despite this, no guidance exists as to the maximal limit of bone loss, which is acceptable for the use of metaphyseal sleeves to ensure sufficient axial and rotational stability. Therefore, this study assessed the effect of increasing bone loss on the primary stability of the metaphyseal sleeve in the proximal tibia to determine the maximal bone loss that retains axial and rotational stability comparable to a no defect control. Methods. to determine the pattern of bone loss and the average defect size that corresponds to the clinically defined defect sizes of small, medium and large defects, a series of pre-operative x-rays of patients with who underwent revision TKA were retrospectively analysed. Ten tibiae sawbones were used for the experiment. To prepare the bones, the joint surface was resected the typical resection depth required during a primary TKA (10mm). Each tibia was secured distally in a metal pot with perpendicular screws to ensure rotational and axial fixation to the testing machine. Based on X-ray findings, a fine guide wire was placed 5mm below the cut joint surface in the most medial region of the plateau. Core drills (15mm, 25mm and 35mm) corresponding to small, medium and large defects were passed over the guide wire allowing to act at the centre point, before the bone defect was created. The test was carried out on a control specimen with no defect, and subsequently on a Sawbone with a small, medium or large defect. Sleeves were inserted using the published operative technique, by trained individual using standard instruments supplied by the manufacturers. Standard axial pull-out (0 – 10mm) force and torque (0 – 30°) tests were carried out, recording the force (N) vs. displacement (mm) curves. Results. A circular defect pattern was identified across all defects, with the centre of the defect located 5mm below the medial tibial base plate, and as medial as possible. Unlike with large defects, small and medium sized defects reduced the pull-out force and torque at the bone-implant interface, however, these reductions were not statistically significant when compared to no bony defect. Conclusions. This experimental study demonstrated that up to 35mm radial defects may be an acceptable “critical limit” for bone loss below which metaphyseal sleeve use may still be appropriate. Further clinical assessment may help to confirm the findings of this experimental study. This study is the first in the literature to aim to quantify “critical bone loss” limit in the tibia for revision knee arthroplasty. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

The quest for optimal treatment of acute distal tibiofibular syndesmotic disruptions is still in progress. Using suture-button repair devices is one of the dynamic stabilization options, however, they may not be always appropriate for stabilization of length-unstable syndesmotic injuries. Recently, a novel screw-suture repair system was developed to address such issues. The aim of this study was to investigate the performance of the novel screw-suture repair system in comparison to a suture-button stabilization of unstable syndesmotic injuries. Eight pairs of human cadaveric lower legs were CT scanned under 700 N single-leg axial loading in five foot positions – neutral, 15° external/internal rotation and 20° dorsi-/plantarflexion – in 3 different states: (1) pre-injured (intact); (2) injured, characterized by complete syndesmosis and deltoid ligaments cuts simulating pronation-eversion injury types III and IV as well as supination-eversion injury type IV according to Lauge-Hansen; (3) reconstructed, using a screw-suture (FIBULINK, Group 1) or a suture-button (TightRope, Group 2) implants for syndesmotic stabilization, placed 20 mm proximal to the tibia plafond. Following, all specimens were: (1) biomechanically tested over 5000 cycles under combined 1400 N axial and ±15° torsional loading; (2) rescanned. Clear space (diastasis), anterior tibiofibular distance, talar dome angle and fibular shortening were measured radiologically from CT scans. Anteroposterior (AP), axial, mediolateral and torsional movements at the distal tibiofibular joint level were evaluated biomechanically via motion tracking. In each group clear space increased significantly after injury (p ≤ 0.004) and became significantly smaller in reconstructed compared with both pre-injured and injured states (p ≤ 0.041). In addition, after reconstruction it was significantly smaller in Group 1 compared to Group 2 (p < 0.001). AP and axial movements were significantly smaller in Group 1 compared with Group 2 (p < 0.001). No further significant differences were identified/detected between the groups (p ≥ 0.113). Although both implant systems demonstrate ability for stabilization of unstable syndesmotic injuries, the screw-suture reconstruction provides better anteroposterior translation and axial stability of the tibiofibular joint and maintains it over time under dynamic loading. Therefore, it could be considered as a valid option for treatment of syndesmotic disruptions

The quest for optimal treatment of acute distal tibiofibular syndesmotic disruptions is still in full progress. Using suture-button repair devices is one of the dynamic stabilization options, however, they may not be always appropriate for stabilization of length-unstable syndesmotic injuries. Recently, a novel screw-suture repair system was developed to address such issues. The aim of this study was to investigate the performance of the novel screw-suture repair system in comparison to a suture-button stabilization of unstable syndesmotic injuries. Eight pairs of human cadaveric lower legs were CT scanned under 700 N single-leg axial loading in five foot positions – neutral, 15° external/internal rotation and 20° dorsi-/plantarflexion – in 3 different states: (1) pre-injured (intact); (2) injured, characterized by complete syndesmosis and deltoid ligaments cuts simulating pronation-eversion injury types III and IV, and supination-eversion injury type IV according to Lauge-Hansen; (3) reconstructed, using a screw-suture (FIBULINK, Group 1) or a suture-button (TightRope, Group 2) implants for syndesmotic stabilization, placed 20 mm proximal to the tibia plafond/joint surface. Following, all specimens were: (1) biomechanically tested over 5000 cycles under combined 1400 N axial and ±15° torsional loading; (2) rescanned. Clear space (diastasis), anterior tibiofibular distance, talar dome angle and fibular shortening were measured radiologically from CT scans. Anteroposterior, axial, mediolateral and torsional movements at the distal tibiofibular joint level were evaluated biomechanically via motion tracking. In each group clear space increased significantly after injury (p ≤ 0.004) and became significantly smaller in reconstructed compared with both pre-injured and injured states (p ≤ 0.041). In addition, after reconstruction it was significantly smaller in Group 1 compared to Group 2 (p < 0.001). Anteroposterior and axial movements were significantly smaller in Group 1 compared with Group 2 (p < 0.001). No further significant differences were detected between the groups (p ≥ 0.113). Conclusions. Although both implant systems demonstrate ability for stabilization of unstable syndesmotic injuries, the screw-suture reconstruction provides better anteroposterior translation and axial stability of the tibiofibular joint and maintains it over time under dynamic loading. Therefore, it could be considered as a valid option for treatment of syndesmotic disruptions

Surgical treatment of fragility sacrum fractures with percutaneous sacroiliac (SI) screw fixation is associated with high failure rates in terms of screw loosening, cut-through and turn-out. The latter is a common cause for complications, being detected in up to 20% of the patients. The aim of this study was to develop a new screw-in-screw concept and prototype implant for fragility sacrum fracture fixation and test it biomechanically versus transsacral and SI screw fixations. Twenty-seven artificial pelves with discontinued symphysis and a vertical osteotomy in zone 1 after Denis were assigned to three groups (n = 9) for implantation of their right sites with either an SI screw, the new screw-in-screw implant, or a transsacral screw. All specimens were biomechanically tested to failure in upright position with the right ilium constrained. Validated setup and test protocol were used for complex axial and torsional loading, applied through the S1 vertebral body. Interfragmentary movements were captured via optical motion tracking. Screw motions in the bone were evaluated by means of triggered anteroposterior X-rays. Interfragmentary movements and implant motions in terms of pull-out, cut-through, tilt, and turn-out were significantly higher for SI screw fixation compared to both transsacral screw and screw-in-screw fixations. In addition, transsacral screw and screw-in-screw fixations revealed similar construct stability. Moreover, screw-in-screw fixation successfully prevented turn-out of the implant, that remained at 0° rotation around the nominal screw axis unexceptionally during testing. From biomechanical perspective, fragility sacrum fracture fixation with the new screw-in-screw implant prototype provides higher stability than with the use of one SI screw, being able to successfully prevent turn-out. Moreover, it combines the higher stability of transsacral screw fixation with the less risky operational procedure of SI screw fixation and can be considered as their alternative treatment option

MicroRNA´s are regulatory sequences which influence the posttranscriptional synthesis of about 70% of protein encoding genes. In different studies, MicroRNA-146a (miR-146a) was associated with inflammatory and autoimmunological processes. In vitro it was shown, that miR-146a influences the bone metabolism by regulating differentiation of mesenchymal stem cells. The miR-146a deficient mouse starts to develop lymphoproliferative and myeloproliferative disease by 6–8 months of age. In this study, we investigate the influence of miR-146a deficiency on bone structure and stability dependent on age and gender. Material and Methods. Male and female mice of wild type (WT) and miR-146a deficient (KO) animals at the age of 2–3 and 5–7 month were analyzed Femur, Tibia and lumbar vertebra (LWK4) were dissected and used für structural analyses by microcomputer tomography (µCT). Parameters like bone volume/tissue volume, trabecular bone volume, trabecular thickness, number and separation as well as cortical thickness were determined. Biomechanical stability as load to failure testing was determined using torsional testing for the long bones and axial compression testing for the vertebra body. Statistical analysis was performed using Graph Pad Prism (Mann-Whitney-U-Test, significance: p<0.05). Results. Structural analyses of the bone structure in the long bones (femur, tibia) revealed a significant higher bone volume/tissue volume (BV/TV) and trabecular bone mass in the elder (5–7 month) miR-146a deficient female mice compared to the male group or wild type animals of either age. In the diaphysis of the femur a BV/TV of 21% was determined for the elder miR-146a deficient females compared to 9% BV/TV in the age matching WT group. These changes were due to an increase in trabecular thickness and trabecular number in this area. In contrast to that, the cortical thickness of all bones analyzed was lowered in the miR-146a deficient animals (male and female) compared to wild type. Biomechanical stability of long bones as well as the vertebra body of the older, female KO group was significantly lower compared to wild type bones. Femurs showed a maximal torque of 20Nmm compared to 34Nmm in the wild type group. The vertebra of the KO mice showed a maximal force at failure of 22N compared to 40N in the wild type group. Male groups and younger females revealed values comparable to wild type animals. Conclusion. The deficiency of miR-146a leads to an increase of trabecular bone in the long bones of female 5–7 month old mice, but to lowered biomechanical bone stability. If this is due to alterations in differentiation or proliferation of mesenchymal stem cells remains unclear and will be analyzed further. Additionally, gender relation of our observations points to the influence of female specific regulatory mechanisms like the involvement of estrogen receptor related mechanisms

Introduction and Objective. Intramedullary nails are frequently used for treatment of unstable distal tibia fractures. However, insufficient fixation of the distal fragment could result in delayed healing, malunion or nonunion. The quality of fixation may be adversely affected by the design of both the nail and locking screws, as well as by the fracture pattern and bone density. Recently, a novel concept for angular stable nailing has been developed that maintains the principle of relative stability and introduces improvements expected to reduce nail toggling, screw migration and secondary loss of reduction. It incorporates polyether ether ketone (PEEK) inlays integrated in the distal and proximal canal portions of the nail for angular stable screw locking. The nail can be used with new standard locking screws and low-profile retaining locking screws, both designed to enhance cortical fixation. The low-profile screws are with threaded head, anchoring in the bone and increasing the surface contact area due to the head's increased diameter. The objective of this study was to investigate the biomechanical competence of the novel angular stable intramedullary nail concept for treatment of unstable distal tibia fractures, compared with four other nail designs in an artificial bone model under dynamic loading. Materials and Methods. The distal 70 mm of thirty artificial tibiae (Synbone) were assigned to 5 groups for distal locking using either four different commercially available nails – group 1: Expert Tibia Nail (DePuy Synthes); group 2: TRIGEN META-NAIL with Internal Hex Captured Screws (Smith & Nephew); group 3: T2 Alpha with Locking Screws (Stryker); group 4: Natural Nail System featuring StabiliZe Technology (Zimmer) – or the novel angular stable TN-Advanced nail with low-profile screws (group 5, DePuy Synthes). The distal locking in all groups was performed using 2 mediolateral screws. All specimens were biomechanically tested under quasi-static and progressively increasing combined cyclic axial and torsional loading in internal rotation until failure, with monitoring by means of motion tracking. Results. Initial nail toggling of the distal tibia fragment in group 5 was significantly lower as compared with group 3 in varus (p=0.04) or with groups 2 and 4 in flexion (p≤0.02). In addition, the toggling in varus was significantly lower in group 1 versus group 4 (p<0.01). Moreover, during dynamic loading, within the course of the first 10,000 cycles the movements of the distal fragment in terms of varus, flexion, internal rotation, as well as axial and shear displacements at the fracture site, were all significantly lower in group 5 compared with group 4 (p<0.01). Additionally, group 5 demonstrated significantly lower values for flexion versus groups 2 and 3 (p≤0.04), for internal rotation versus group 1 (p=0.03), and for axial displacement versus group 3 (p=0.03). A trend to significantly lower values was detected in group 5 versus group 1 for varus, flexion and shear displacement – with p ranging between 0.05 and 0.07 – and versus group 3 for shear displacement (p=0.07). Cycles to failure were highest in group 5 with a significant difference to group 4 (p<0.01). Conclusions. From a biomechanical perspective, the novel angular stable intramedullary nail concept with integrated PEEK inlays and low-profile screws provides ameliorated resistance against nail toggling and loss of reduction under static and dynamic loading compared with other commercially available intramedullary nails used for fixation of unstable distal tibia fractures

Osteosynthesis of high-energy metaphyseal proximal tibia fractures is still challenging, especially in patients with severe soft tissue injuries and/or short stature. Although the use of external fixators is the traditional treatment of choice for open comminuted fractures, patients' acceptance is low due to the high profile and therefore the physical burden of the devices. Recently, clinical case reports have shown that supercutaneous locked plating used as definite external fixation could be an efficient alternative. Therefore, the aim of this study was to evaluate the effect of implant configuration on stability and interfragmentary motions of unstable proximal tibia fractures fixed by means of externalized locked plating. Based on a right tibia CT scan of a 48 years-old male donor, a finite element model of an unstable proximal tibia fracture was developed to compare the stability of one internal and two different externalized plate fixations. A 2-cm osteotomy gap, located 5 cm distally to the articular surface and replicating an AO/OTA 41-C2.2 fracture, was virtually fixed with a medial stainless steel LISS-DF plate. Three implant configurations (IC) with different plate elevations were modelled and virtually tested biomechanically: IC-1 with 2-mm elevation (internal locked plate fixation), IC-2 with 22-mm elevation (externalized locked plate fixation with thin soft tissue simulation) and IC-3 with 32-mm elevation (externalized locked plate fixation with thick soft tissue simulation). Axial loads of 25 kg (partial weightbearing) and 80 kg (full weightbearing) were applied to the proximal tibia end and distributed at a ratio of 80%/20% on the medial/lateral condyles. A hinge joint was simulated at the distal end of the tibia. Parameters of interest were construct stiffness, as well as interfragmentary motion and longitudinal strain at the most lateral aspect of the fracture. Construct stiffness was 655 N/mm (IC-1), 197 N/mm (IC-2) and 128 N/mm (IC-3). Interfragmentary motions under partial weightbearing were 0.31 mm (IC-1), 1.09 mm (IC-2) and 1.74 mm (IC-3), whereas under full weightbearing they were 0.97 mm (IC-1), 3.50 mm (IC-2) and 5.56 mm (IC-3). The corresponding longitudinal strains at the fracture site under partial weightbearing were 1.55% (IC-1), 5.45% (IC-2) and 8.70% (IC-3). From virtual biomechanics point of view, externalized locked plating of unstable proximal tibia fractures with simulated thin and thick soft tissue environment seems to ensure favorable conditions for callus formation with longitudinal strains at the fracture site not exceeding 10%, thus providing appropriate relative stability for secondary bone healing under partial weightbearing during the early postoperative phase

Abstract. Objectives. Oil-based fluids can be used to enhance the properties of polyethylene materials. For example, vitamin E infused polyethylene has a superior oxidation resistance and Lipiodol infused polyethylene has an enhanced X-ray attenuation. The aim of this study was to evaluate the long-term influence of oily fluid on the chemical, physical and tensile properties of polyethylene. Methods. An accelerated ageing procedure (an elevated temperature (80. °. C) for four weeks in air. 1. ) was used to investigate the oxidative stability (ASTM F2012-17). 2. , tensile (ISO 527). 3. and thermal properties. 4. of oil treated polyethylene (n=5, GUR 1050, Celanese, Germany)and compared with clinically used polyethylene controls (oil-free standard and thermally treated polyethylene). All the experiments were performed on aged and unaged specimens in accordance to international standards and compared to currently available literature. A Kruskal-Wallis test was performed using a custom MATLAB code (R2017a, USA); with p < 0.05 considered statistically significant. Results. Samples treated with an oil (Vitamin E or Lipiodol) had a higher oxidation stability than currently used medical grade polyethylene, indicated by a smaller increase in oxidation index after ageing (Vitamin E 36%, Lipiodol 40%, untreated 136 %, thermally treated 164%). The mechanical degradation of oil treated polyethylene was also less significant than the untreated controls, as all the tensile properties of oil treated polyethylene after ageing were significantly higher than the standard controls (p>0.05). There was also no alteration in the percentage crystallinity of oil treated samples after ageing. Conclusion. The result of this study indicate that the presence of an oily fluid in polyethylene does not reduce its oxidative stability or tensile properties, providing improved material properties for long term implant applications. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Normal function of the patellofemoral joint is maintained by a complex interaction between soft tissues and articular surfaces. No quantitative data have been found on the relative contributions of these structures to patellar stability. Eight knees were studied using a materials testing machine to displace the patella 10 mm laterally and medially and measure the force required. Patellar stability was tested from 0° to 90° knee flexion with the quadriceps tensed to 175 N. Four conditions were examined: intact, vastus medialis obliquus relaxed, flat lateral condyle, and ruptured medial retinaculae. Abnormal trochlear geometry reduced the lateral stability by 70% at 30° flexion, while relaxation of vastus medialis obliquus caused a 30% reduction. Ruptured medial retinaculae had the largest effect at 0° flexion with 49% reduction. There was no effect on medial stability. There is a complex interaction between these structures, with their contributions to loss of lateral patellar stability varying with knee flexion

Thermostability is a key property in determining the suitability of local delivery of antibiotics in the treatment of orthopaedic infections. Herein, we aimed to assess the thermal stability and antibacterial activity of ciprofloxacin, ceftriaxone, gentamycine and vancomycine in high temperature conditions. Using a standardized E-test method, minimally inhibited concentration of each antibiotic substance against Staphylococcus aureus cultures were determined. The solutions of antimicrobial drugs ciprofloxacin 2 mg/ml, ceftriaxone 200 mg/ml, gentamycine 40 mg/ml and vancomycine 200 mg/ml were diluted twofold in deionised water. Acquired solutions were divided into three aliquots. The first aliquot was held at 40°C for 30 min in a waterbath, the second and the third aliquots were exposed to 80 and 100°C for 30 min in hot-air sterilizer, respectively. The treated solutions were tested for residual activity against S. aureus using a standardized disk diffusion method. Mediums with untreated antibiotic solutions and S. aureus were used as control. Plates were incubated at 37°C, at which time zones of inhibition (ZoI) were measured to the nearest whole millimeter for 14 days. The investigation indicated that the temperature elevation impacted considerably on antimicrobial activity and antibiotic stability overall. The in vitro temperature-response curves showed that ZoI diameter decreases logarithmically with elevated temperatures. Gentamicin was the only drug that was found to be affected to some extent. Results from the study provides a valuable dataset for orthopaedic surgeons considering local application of antibiotics and methods of antibiotic impregnation

Introduction. Despite decades of clinical research in artificial joints and underlying failure mechanisms, systematical and reproducible identification of reasons for complications in total knee replacements (TKR) remains difficult. Due to the complex dynamic interaction of implant system and biological situs, malfunction eventually leading to failure is multifactorial and remains not fully understood. The aim of present study was to evaluate different TKR designs and positions with regard to joint kinematics and stability under dynamic conditions by using a robot-based hardware-in-the-loop (HiL) setup. Material & methods. An industrial 6-axis robot with 6-axis force-torque sensor mounted into its end-effector moved and loaded real, commercially available TKR (bicondylar, cruciate-retaining) that were in virtual interaction with a subject-specific computational multibody model representing the anatomical situs of the knee joint while performing passive seated deep knee flexion. The subject-specific musculoskeletal multibody model (MMB) included rigid bones of the lower right extremity. Bone and cartilage geometries were reconstructed from MRT/ CT data sets preserving anatomical landmarks and allowing for the calculation of inertial properties. M. quadriceps femoris was modeled as single passive tensile force elements. Knee ligaments were modelled as elastic spring elements with a nonlinear force-displacement characteristic. Providing the flexion angle, the robot moved and loaded the mounted femoral implant component with respect to the tibial component while being in continuous interaction with the MMB. Several influencing parameters like implant position (internal/external rotation, varus/valgus alignment) and design (fixed vs. mobile bearing, tibia-insert height) as well as ligament insufficiency and joint loading on joint kinematics and stability was systematically analysed. Results. Improper implant positioning caused joint instability, which was demonstrated in higher magnitudes of the relative kinematics. Negative effects by incorrect implant positioning could be partially compensated by a mobile bearing design. However, this was accompanied with an increase in tibiofemoral contact forces. High correlation of tibia-insert height on ligament and contact force was found. After releasing ligament structures, lower tibiofemoral contact forces and joint opening during deep knee flexion were observed. Conclusion. By means of HiL simulation different clinical and technical parameters of TKR were evaluated in a systematical and reproducible fashion under physiological-like boundary conditions with regard to joint kinematics and stability. The proposed HiL test setup combining robot-based testing with MMBs can contribute to deeper understanding of knee joint function and improvement of total knee implant systems. Acknowledgement. The authors would like to thank the Deutsche Forschungsgemeinschaft (grant numbers: WO WO 452/8-1, BA 3347/3-1 and KL 2327/4-1) for supporting the project

Objectives. Thermal stability is a key property in determining the suitability of an antibiotic agent for local application in the treatment of orthopaedic infections. Despite the fact that long-term therapy is a stated goal of novel local delivery carriers, data describing thermal stability over a long period are scarce, and studies that avoid interference from specific carrier materials are absent from the orthopaedic literature. Methods. In this study, a total of 38 frequently used antibiotic agents were maintained at 37°C in saline solution, and degradation and antibacterial activity assessed over six weeks. The impact of an initial supplementary heat exposure mimicking exothermically curing bone cement was also tested as this material is commonly used as a local delivery vehicle. Antibiotic degradation was assessed by liquid chromatography coupled to mass spectrometry, or by immunoassays, as appropriate. Antibacterial activity over time was determined by the Kirby-Bauer disk diffusion assay. Results. The heat exposure mimicking curing bone cement had minimal effect on stability for most antibiotics, except for gentamicin which experienced approximately 25% degradation as measured by immunoassay. Beta-lactam antibiotics were found to degrade quite rapidly at 37°C regardless of whether there was an initial heat exposure. Excellent long-term stability was observed for aminoglycosides, glycopeptides, tetracyclines and quinolones under both conditions. Conclusions. This study provides a valuable dataset for orthopaedic surgeons considering local application of antibiotics, and for material scientists looking to develop next-generation controlled or extended-release antibiotic carriers. Cite this article: E. Samara, T. F. Moriarty, L. A. Decosterd, R. G. Richards, E. Gautier, P. Wahl. Antibiotic stability over six weeks in aqueous solution at body temperature with and without heat treatment that mimics the curing of bone cement. Bone Joint J 2017;6:296–306. DOI: 10.1302/2046-3758.65.BJR-2017-0276.R1

Insufficiency of the lateral collateral ligamentous complex causes posterolateral rotatory instability (PLRI). During reconstruction surgery the joint capsule is repaired, but its biomechanical influence on elbow stability has not been described. We hypothesized that capsular repair reduces ROM and varus angle after reconstruction of the lateral collateral complex. Six fresh frozen cadaveric elbow specimens were used. Varus laxity in supination, pronation and neutral forearm rotation with 1 Nm load and forearm rotaitonal range of motion (ROM) with 0.3 Nm torque were measured using a Microscribe 3DLX digitizing system (Revware Inc, Raleigh, NC). Each specimen was tested under four different conditions: Intact, Complete Tear with LUCL, RCL and capsule tear, LUCL/RCL reconstruction + capsule repair and LUCL/RCL reconstruction only. Reconstruction was performed according to the docking technique (Jones, JSES, 2013) and the capsule was repaired with mattress sutures. Each condition was tested in 30°, 60° and 90° elbow flexion. A two-way ANOVA with Tukey's post-hoc test was used to detect statistical differences between the conditions. Total ROM of the forearm significantly increased in all flexion angles from intact to Complete tear (p<0.001). ROM was restored to normal in 30° and 60° elbow flexion in both reconstruction conditions (p>0.05). LUCL/RCL Reconstruction + capsule repair in 90° elbow flexion was associated with a significantly lower ROM compared to intact (p=0.0003) and reconstruction without capsule repair (p=0.015). Varus angle increased significantly from intact to complete tear (p<0.0001) and restored to normal in both reconstruction conditions (p>0.05) in 30° and 60° elbow flexion. In contrast varus angle was significantly lower in 90° elbow flexion in both reconstruction conditions compared to intact (both p<0.0001). Reconstruction of the lateral collateral complex restores elbow stability, ROM and varus laxity independent of capsular repair. Over tightening of the elbow joint occurred in 90° elbow flexion, which was aggravated by capsular repair. Over all capsular repair can be performed without negatively affecting elbow joint mobility

Summary Statement. Proximal femoral bony deficits present a surgical and biomechanical challenge to implant longevity in revision hip arthroplasty. This work finds comparable primary stability when a distally fixing tapered fluted stem was compared with a conical design in cadaveric tests. Introduction. Proximal bony deficits complicate revision hip surgery and compromise implant survival. Longer distally fixing stems which bypass such defects are therefore required to achieve stability compatible with bony ingrowth and implant longevity. Aims. It is hypothesised that a tapered stem will provide superior rotational stability to a conical design. This work therefore aims to compare the primary stability and biomechanical properties of a new design of tapered fluted modular femoral stem (Redapt®, Smith & Nephew) with that of a conical fluted stem (Restoration®, Stryker). Materials & Methods. 7 Pairs of cadaveric femora were obtained according to strict inclusion/exclusion criteria. Each underwent dual energy x-ray absorptiometry and calibration plain-film radiographs were taken. Digital templating was performed using TraumaCad (Voyant Health, Brainlab) to determine implant sizing. Both stems are fluted, modular and manufactured from titanium. The control stem (Restoration) featured a straight conical design and the investigation stem (Redapt) a straight tapered design. Implantation was performed by a revision arthroplasty surgeon familiar with both systems. Proximal bone deficiency was reproduced using an extended trochanteric osteotomy with removal of metaphyseal bone before reattaching the osteotomy. Primary stability in the axial, sagittal and coronal planes was assessed using micromotion transducers (HBM, Darmstadt, Germany) and also by Radiostereometric Analysis (RSA). RSA employs simultaneous biplanar radiographs to measure relative movement. Two 1mm tantalum beads were mounted on the prosthesis with the centre of the femoral head taken as the third reference point. Beads were placed proximally in the surrounding bone as rigid body markers. Each bone was potted according to the ISO standard for fatigue testing and cyclically loaded at 1Hz for at least 3 increments (750–350N, 1000–350N, 1500–350N) for 1000 cycles. RSA radiographs were taken at baseline and on completion of each cycle. A strain analysis was concurrently performed using a PhotoStress® (Vishay Precision Group, Raleigh, USA) photoelastic coating on the medial femoral cortex. Each bone was loaded intact and then with the prosthesis in-situ at 500N increments until strain fringes were identified. Once testing was completed, the stems were sectioned at the femoral isthmus and data is presented on the cross-sectional fit and fill observed. Results. Both stem designs showed comparable primary stability with all stems achieving clinically acceptable micromotion (<150 μm) when loaded at body weight. A larger proportion of the control stems remained stable as loading increased to x2-3 body weight. Transducer-recorded migration appeared greatest in the axial plane (y axis) with negligible distal movement in the coronal or sagittal planes. Point motion analysis (RSA) indicated most movement to be in the coronal plane (x-axis) whereas segment motion analysis showed rotation about the long axis of the prosthesis to be largest. Photoelastic strain patterns were transferred more distally in both designs, however substantial stress shielding was also observed. Discussion/Conclusion. Both designs achieved adequate distal fixation and primary stability under representative clinical loading conditions. This work supports the continued use of this novel stem design for revision surgery in the presence of extensive proximal bone loss