An analytical strategy for challenging members of the microplastic family: Particles from anti-corrosion coatings

Potentially hazardous particles from paints and functional coatings are an overlooked fraction of microplastic (MP) pollution since their accurate identification and quantification in environmental samples remains difficult. We have applied the most relevant techniques from the field of microplastic analysis for their suitability to chemically characterize anti-corrosion coatings containing a variety of polymer binders (LDIR, Raman and FTIR spectroscopy, Py-GC/MS) and inorganic additives (ICP-MS/MS). We present the basis of a possible toolbox to study the release and fate of coating particles in the (marine) environment. Our results indicate that, due to material properties, spectroscopic methods alone appear to be unsuitable for quantification of coating/paint particles and underestimate their environmental abundance. ICP-MS/MS and an optimized Py-GC/MS approach in combination with multivariate statistics enables a straightforward comparison of the multi-elemental and organic additive fingerprints of paint particles. The approach can improve the identification of unknown particles in environmental samples by an assignment to different typically used coating types. In future, this approach may facilitate allocation of emission sources of different environmental paint/coating particles. Indeed, future work will be required to tackle various remaining analytical challenges, such as optimized particle extraction/separation of environmental coating particles.

Operative versus conservative treatment in pelvic ring fractures with sacral involvement

BACKGROUND

To evaluate the performance in activities of daily living (ADL), level of pain, mortality and rate of complications in patients with a pelvic ring fracture with sacral involvement who were treated conservatively compared to a surgically treated patient collective using percutaneous iliosacral screw fixation.

HYPOTHESIS

Conservative treatment does not result in inferior clinical outcome compared to operative treatment.

PATIENTS AND METHODS

A retrospective study of 112 conservatively (n=46) or operatively (n=66) treated patients with an isolated posterior or a combined posterior and anterior pelvic ring fracture was performed. The analysis included: age, sex, mechanism of injury, fracture type according to AO/OTA classification, energy of trauma sustained (no-, low-, high-energy trauma), type of treatment (operative or conservative), complications as well as duration of in-hospital stay. To assess clinical and activity outcome, the visual analog scale for pain (VAS), Barthel Scale, American Society of Anaesthesiologists (ASA) scores as well as mortality were assessed. The mean follow-up was 29.3±14.6 months. Furthermore, a geriatric subgroup (n=68, age≥60, low-energy trauma only) was analyzed.

RESULTS

The majority of the patients were female (79%) and suffered from low-energy trauma (n=64, 58%). There were no significant differences in the operative and the conservative groups and subgroups concerning VAS, Barthel scores and ASA scores. The survival analyses showed a significantly lower survival rate in the conservative group (41.8±3.6 months) compared to the operative group (55.9±2 months, p=0.002). Similar findings were encountered in the geriatric subgroup analysis.

CONCLUSION

This study demonstrates equivalent clinical outcome in conservatively and surgically treated patients using a percutaneous iliosacral screw fixation at a mid-term follow-up. However, operatively treated patients showed decreased mortality. This needs to be carefully considered in clinical decision-making but must be further explored using a prospective randomized study approach.

LEVEL OF EVIDENCE

III.

Outcomes in very elderly ICU patients surgically treated for proximal femur fractures

Proximal femur fractures (PFF) are a common injury in elderly patients that significantly impact mobility and daily living activities. Mortality rates in this population are also high, making effective treatment essential. Recent advances in intensive and geriatric care have enabled complex surgical interventions that were previously not feasible. However, there is a lack of studies focusing on outcome parameters in very elderly patients (≥ 90 years) who receive intensive care treatment following PFFs. In this retrospective study, we analyzed multi-layered data of 148 patients who were 90 years or older and received intensive care after trauma and orthopedic surgical treatment for PFFs or periprosthetic fractures between 2009 and 2019. All patients received a 365-day follow-up. To identify potential predictors of mortality, all deceased and surviving patients were subjected to multiple logistic regression analyses. We found that 22% of patients deceased during in-hospital care, and one-year survival was 44%. Independent predictors of one-year all-cause mortality included higher CCI and SOFA scores at ICU admission. Overall, 53% of patients who resided in private dwellings prior to admission were able to return home. Our study highlights the utility of using CCI and SOFA scores at ICU admission as prognostic indicators in critically ill very elderly patients who undergo surgical treatment for PFFs. These scores can provide valuable insight into the severity of illness and potential outcomes, which can inform resource allocation, prioritize endangered patients, and aid in end-of-life discussions and planning with patients and their families. Our findings can help improve the management of PFFs in very elderly patients and contribute to optimized patient care.

Tibial plateau fracture: does fracture classification influence the choice of surgical approach? A retrospective multicenter analysis

PURPOSE

The role of classification systems for the choice of surgical approach and the management of tibial plateau fractures remains unclear. The purpose of this study was to investigate the potential of classification systems to choose the appropriate operative approach. Current surgical management strategies were investigated in a large multicenter assessment.

METHODS

In this study, we retrospectively analyzed all patients with tibial plateau fractures that have received surgical treatment in one of the five Level I trauma facilities between 2012 and 2015. Fractures were classified in each center by a senior orthopedic surgeon using the AO/OTA and the Luo classification. Demographics, trauma mechanism, as well as the surgical approach were recorded.

RESULTS

538 patients (46.1% male, 53.9% female) were included. The anterolateral approach was used most frequently with 54.8% of all single approaches; 76.2% of all combined approaches used anterolateral as part of the approach. Combined approaches were used in 22.5% of the cases; a combination of the anterolateral and medial (10%), anterolateral, and posteromedial approach (5.8%) were used most frequently. The lowest number was found for the posterolateral (1.3%) and the combined approaches dorsal/anterolateral and medial/dorsal (1.7%, 1.1%). The AO/OTA classification showed a peak for 41.B2 (21.9%) and B3 (35.5%) fractures. Regarding the Luo classification, the dorsal column was involved in 45.7%. In contrast, only 14.7% of the surgical approaches used were able to address the dorsal tibial plateau potentially.

CONCLUSION

The use of dorsal approach seems to be of minor importance than expected in daily clinical practice in this multicenter study. It was not possible to specify whether the AO/OTA or the Luo classification can reliably predict the choice of surgical approach. The operative treatment strategy of tibial plateau fractures seems to rather rely on the surgeons' experience, education, and preferences.

Conventional rotator cuff versus all-suture anchors-A biomechanical study focusing on the insertion angle in an unlimited cyclic model

PURPOSE

The purpose of this study was to compare the biomechanical properties of an all-suture anchor to a conventional anchor used commonly in rotator cuff repairs. Furthermore, the biomechanical influence of various implantation angles was evaluated in both anchor types in a human cadaveric model.

METHODS

30 humeri were allocated into three groups with a similar bone density. The two different anchor types were inserted at a predefined angle of 45°, 90° or 110°. Biomechanical testing included an initial preload of 20N followed by a cyclic protocol with a stepwise increasing force of 0,05N for each cycle at a rate of 1Hz until system failure. Number of cycles, maximum load to failure, stiffness, displacement and failure mode were determined.

RESULTS

27 anchors failed by pullout. There was no significant difference between the conventional and the all-suture anchor regarding mean pullout strength. No considerable discrepancy in stiffness or displacement could be perceived. Comparing the three implantation angles no significant difference could be observed for the all-suture or the conventional anchor.

CONCLUSION

All-suture anchors show similar biomechanical properties to conventional screw shaped anchors in an unlimited cyclic model. The exact insertion angle is not a significant predictor of failure.

Determination of bone density in patients with sacral fractures via CT scan

BACKGROUND

Gold standard to diagnose osteoporosis is standard dual-energy X-ray absorptiometry (DXA). CT is a standard diagnostic tool to detect injuries to the pelvic ring. The aim of the study was to collect information on bone density without DXA by determination of Hounsfield units (HU) in CT scans of patients with sacral fractures, to draw conclusions on the prevalence of osteoporosis in patients admitted to the investigating institution.

HYPOTHESIS

Is the determination of HU in CT scans a useful method to gain more information about bone density in patients with sacral fractures?

PATIENTS AND METHODS

We performed a retrospective analysis of all patients treated from 2004-2014 with sacral fractures confirmed with a CT scan. A total of 531 patients (398 female, 133 male) were included in the study. Bone density was measured with CT scans in Hounsfield units in vertebral body L5. The assessment was performed by placing a single oval over the trabecular bone in the axial view. In the sagittal plane, the correct position in the middle of the vertebral body was checked. As in previously published studies, we defined bone of less than 100 HU as osteoporotic, 100-150 HU as osteopenic and above 150 HU as normal.

RESULTS

In 71.6% of the patients, bone density was reduced. Seventy-five percent of patients aged 65 or more exhibited manifest osteoporosis. With each additional year of age, bone density decreased by 2.7 Hounsfield units (p˂0.001). Female patients were predominant in the patient group with osteoporotic bone (p˂0.001).

CONCLUSIONS

There is significant prevalence of reduced bone density in the investigated patient group. The methodology used in this study is an uncomplicated procedure to further assess bone quality in patients with fractures of the pelvic ring. Fractures of the posterior pelvic ring in women over 65 years with low-energy trauma are most probably osteoporotic.

LEVEL OF EVIDENCE

III.

High incidence of osteochondral lesions after open reduction and internal fixation of displaced ankle fractures: Medium-term follow-up of 100 cases

BACKGROUND

The incidence of osteochondral lesions (OCLs) in association with displaced ankle fractures has only been examined in two previous studies. In both studies magnetic resonance imaging (MRI) was performed prior to open reduction and internal fixation (ORIF). Because MRI may overdiagnose or overestimate the extent of OCLs in an acute trauma setting the aim of this study was to determine the incidence of OCLs after ORIF of displaced ankle fractures using MRI at medium-term follow-up, and to analyse if the severity of fracture or the clinical outcome correlates with the incidence of OCLs.

PATIENTS AND METHODS

Following institutional review board approval a total of 100 patients (mean age, 41.3 years; range, 17.9-64.3 years) with a displaced ankle fracture who had undergone ORIF according to the AO principles were included in this study. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was used to quantify the clinical outcome and MR images were evaluated for OCLs of the talus and distal tibia after a mean of 34.5 months (range, 17.5-54.1 months).

RESULTS

OCLs were found in 40.4% of the patients. Logistic regression revealed a significant correlation between the severity of fracture and the incidence of OCLs. Patients with a trimalleolar fracture (p=0.04) or an ankle fracture dislocation (p=0.003) had a significantly higher risk for developing an OCL compared to those with a type B fracture. Logistic regression also demonstrated a significant correlation between the clinical outcome (AOFAS score) and the incidence of OCLs (p=0.01). The risk for developing an OCL increases up to 5.6% when the AOFAS score decreases by one point.

CONCLUSION

OCLs were frequently found in association with acute ankle fractures at medium-term follow-up, and the severity of fracture was associated with an increased number of OCLs. Considering the disadvantages of MRI including the high cost and limited availability, the results of this study may help to explain why anatomic surgical realignment of displaced ankle fractures may still be associated with poor clinical outcomes.

Pronator quadratus repair after volar plating of distal radius fractures or not? Results of a prospective randomized trial

BACKGROUND

The purpose of the present study was to investigate the influence of the pronator quadratus (PQ) muscle repair following volar plate fixation of distal radius fractures with special regards to the forearm pronation strength. During the early recovery period of 3 months, an improvement of pronation strength and functional scorings was hypothesized for the PQ repair when compared to no repair.

METHODS

The inclusion criteria were (1) men or women between 18 and 80 years, (2) isolated, closed fractures of the distal radius, (3) A2 to B2 types of fracture according to the AO fracture classification system, (4) primary volar locking plate osteosynthesis. Patients were randomized to group A = PQ repair and group B = no repair. Follow-up examinations after 6 and 12 weeks included bilateral isometric pronation strength measurement, range of motion, the QuickDASH and the Mayo-Wrist-Score, and a visual analog scale (VAS).

RESULTS

60 patients (n = 31 in group A and n = 29 in group B) with an average age of 54 years (range 22-77 years) returned for both follow-up visits. The pronation strength measurements showed no significant differences between groups (PQ repair vs. no repair) neither at 6 weeks nor at 12 weeks. Additionally, no statistical significant differences were noted for ROM, QuickDASH-Score or Mayo-Wrist-Score. The VAS scoring revealed a significant decreased pain level after PQ repair at 6 weeks postoperatively (p = 0.017).

CONCLUSION

An improved pronation strength after PQ repair in the early rehabilitation period could not be confirmed. However, the PQ repair might reduce pain in the early postoperative period.

TRIAL REGISTRATION NUMBER

NCT02595229 (ClinicalTrials.gov, registered 02 November 2015).

Chondrogenic predifferentiation of human mesenchymal stem cells in collagen type I hydrogels

Hyaline cartilage displays a limited regenerative potential. Consequently, therapeutic approaches have been developed to treat focal cartilage lesions. Larger-sized lesions are commonly treated by osteochondral grafting/mosaicplasty, autologous chondrocyte implantation (ACI) or matrix-induced chondrocyte implantation (MACI). As an alternative cell source to chondrocytes, multipotent mesenchymal stem cells (MSCs) are regarded a promising option. We therefore investigated the feasibility of pre-differentiating human MSCs incorporated in hydrogels clinically applied for MACI (CaReS®). MSC-laden hydrogels were cast and cultured over 10 days in a defined chondrogenic differentiation medium supplemented with TGF-β1. This was followed by an 11-day culture in TGF-β1 free media. After 21 days, considerable contraction of the hydrogels was observed. Histochemistry showed cells of a chondrocyte-like morphology embedded in a proteoglycan-rich extracellular matrix. Real-time polymerase chain reaction (RT-PCR) analysis showed the expression of chondrogenic marker genes, such as collagen type II and aggrecan. In summary, we demonstrate that chondrogenic differentiation of human mesenchymal stem cells embedded in collagen type I hydrogels can be induced under the influence of TGF-β1 over a period of 10 days.

Fungal periprosthetic joint infection in total knee arthroplasty: a systematic review

Fungal periprosthetic joint infection (PJI) is a rare but devastating complication following total knee arthroplasty (TKA). A standardized procedure regarding an accurate treatment of this serious complication of knee arthroplasty is lacking. In this systematic review, we collected data from 36 studies with a total of 45 reported cases of a TKA complicated by a fungal PJI. Subsequently, an analysis focusing on diagnostic, medicaments and surgical procedures in the pre-, intra- and postoperative period was performed. Candida spp. accounts for about 80% (36 out of 45 cases) of fungal PJIs and is therefore the most frequently reported pathogen. A systemic antifungal therapy was administered in all but one patient whereas a local antifungal therapy, e.g. the use of an impregnated spacer, is of inferior relevance. Resection arthroplasty with delayed re-implantation (two-stage revision) was the surgical treatment of choice. However, in 50% of all reported cases the surgical therapy was heterogeneous. The outcome under a combined therapy was moderate with recurrent fungal PJI in 11 patients and subsequent bacterial PJI as a main complication in 5 patients. In summary, this systematic review integrates data from up to date 45 reported cases of a fungal PJI of a TKA. On the basis of the current literature strategies for the treatment of this devastating complication after TKA are discussed.

What is the frequency of nerve injuries associated with acetabular fractures?

BACKGROUND

Acetabular fractures and surgical interventions used to treat them can result in nerve injuries. To date, only small case studies have tried to explore the frequency of nerve injuries and their association with patient and treatment characteristics. High-quality data on the risk of traumatic and iatrogenic nerve lesions and their epidemiology in relation to different fracture types and surgical approaches are lacking.

QUESTIONS/PURPOSES

The purpose of this study was to determine (1) the proportion of patients who develop nerve injuries after acetabular fracture; (2) which fracture type(s) are associated with increased nerve injury risk; and (3) which surgical approach was associated with the highest proportion of patients developing nerve injuries using data from the German Pelvic Trauma Registry. Two secondary aims were (4) to assess hospital volume-nerve-injury relationship; and (5) internal data validity.

METHODS

Between March 2001 and June 2012, 2236 patients with acetabular fractures were entered into a prospectively maintained registry from 29 hospitals; of those, 2073 (92.7%) had complete records on the endpoints of interest in this retrospective study and were analyzed. The neurological status in these patients was captured at their admission and at the discharge. A total of 1395 of 2073 (67%) patients underwent surgery, and the proportions of intervention-related and other hospital-acquired nerve injuries were obtained. Overall proportions of patients developing nerve injuries, risk based on fracture type, and risk of surgical approach type were analyzed.

RESULTS

The proportion of patients being diagnosed with nerve injuries at hospital admission was 4% (76 of 2073) and at discharge 7% (134 or 2073). Patients with fractures of the "posterior wall" (relative risk [RR], 2.0; 95% confidence interval [CI], 1.4-2.8; p=0.001), "posterior column and posterior wall" (RR, 2.9; CI, 1.6-5.0; p=0.002), and "transverse+posterior wall" fracture (RR, 2.1; CI, 1.3-3.5; p=0.010) were more likely to have nerve injuries at hospital discharge. The proportion of patients with intervention-related nerve injuries and that of patients with other hospital-acquired nerve injuries was 2% (24 of 1395 and 46 of 2073, respectively). They both were associated with the Kocher-Langenbeck approach (RR, 3.0; CI, 1.4-6.2; p=0.006; and RR, 2.4; CI, 1.4-4.3; p=0.004, respectively).

CONCLUSIONS

Acetabular fractures with the involvement of posterior wall were most commonly accompanied with nerve injuries. The data suggest also that Kocher-Langenbeck approach to the pelvic ring is associated with a higher risk of perioperative nerve injuries. Trauma surgeons should be aware of common nerve injuries, particularly in posterior wall fractures. The results of the study should help provide patients with more exact information on the risk of perioperative nerve injuries in acetabular fractures.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The role of inter-prosthetic distance, cortical thickness and bone mineral density in the development of inter-prosthetic fractures of the femur

It is becoming increasingly common for a patient to have ipsilateral hip and knee replacements. The inter-prosthetic (IP) distance, the distance between the tips of hip and knee prostheses, has been thought to be associated with an increased risk of IP fracture. Small gap distances are generally assumed to act as stress risers, although there is no real biomechanical evidence to support this.

The purpose of this study was to evaluate the influence of IP distance, cortical thickness and bone mineral density on the likelihood of an IP femoral fracture.

A total of 18 human femur specimens were randomised into three groups by bone density and cortical thickness. For each group, a defined IP distance of 35 mm, 80 mm or 160 mm was created by choosing the appropriate lengths of component. The maximum fracture strength was determined using a four-point bending test.

The fracture force of all three groups was similar (p = 0.498). There was a highly significant correlation between the cortical area and the fracture strength (r = 0.804, p <  0.001), whereas bone density showed no influence.

This study suggests that the IP distance has little influence on fracture strength in IP femoral fractures: the thickness of the cortex seems to be the decisive factor.

Cite this article: Bone Joint J 2014;96-B:1378–84.

[CT-based classification aid for acetabular fractures: evaluation and clinical testing]

BACKGROUND

The basis for the classification of acetabular fractures depends on accurate radiological diagnostics. The use of conventional X-rays alone implicates a low intrapersonal reproducibility and interpersonal reliability. By applying computed tomography (CT) at an early stage in the emergency room, the typical diagonal X-rays of ala and obturator, on which the classification is based, are no longer recommended. The aim of this study was to develop a new reliable classification system based on standardized CT slices according to the system of Judet and Letournel without using diagonal X-rays.

MATERIALS AND METHODS

In this study 12 select cases with acetabular fractures were peer reviewed. In each case eight characteristic CT slices (five axial, two coronal and one sagittal) were selected as well as the conventional anteroposterior X-ray of the pelvis. All cases were peer reviewed by 14 members of the "AG Becken" (working group pelvis). The classification of the acetabular fractures was based on Judet and Letournel and the results were compared with the reference classification. The results were scaled according to differences to the original classification and the relevance to the approach as well as the medical qualification of the member.

RESULTS

A total of 167 out of 168 possible classifications were conducted, 90 cases (54 %) were in accordance with the reference classification. In 69 cases (41 %) the outcome was different, which would have had no influence on the choice of the surgical approach. A wrong classification was present eight times (5 %). According to the medical qualification status the senior physicians were right in 54%, the residents in 53 %. Within the group of senior physicians 7.5 % of the classifications were completely wrong and 93 % of the participating members would have preferred to have more CT slices.

CONCLUSION

The CT-based classification developed represents an adaption to the current standard of diagnostics of acetabular fractures and represents a step towards simplification of the classification. It is suitable to estimate the correct surgical approach and the behavior of the fracture. For an accurate classification and the association to one of the fracture types in the system of Judet and Letournel more slices and 3D reconstructions (MPR) are necessary.

Biomechanical advantage of C1 pedicle screws over C1 lateral mass screws: a cadaveric study

PURPOSE

The established technique for posterior C1 screw placement is via the lateral mass. Use of C1 monocortical pedicle screws is an emerging technique which utilizes the bone of the posterior arch while avoiding the paravertebral venous plexus and the C2 nerve root. This study compared the relative biomechanical fixation strengths of C1 pedicle screws with C1 lateral mass screws.

METHODS

Nine human C1 vertebrae were instrumented with one lateral mass screw and one pedicle screw. The specimens were subjected to sinusoidal, cyclic (0.5 Hz) fatigue loading. Peak compressive and tensile forces started from ±25 N and constantly increased by 0.05 N every cycle. Testing was stopped at 5 mm displacement. Cycles to failure, displacement, and initial and end stiffness were measured. Finally, CT scans were taken and the removal torque measured.

RESULTS

The pedicle screw technique consistently and significantly outperformed the lateral mass technique in cycles to failure (1,083 ± 166 vs. 689 ± 240 cycles), initial stiffness (24.6 ± 3.9 vs. 19.9 ± 3.2 N/mm), end stiffness (16.6 ± 2.7 vs. 11.6 ± 3.6 N/mm) and removal torque (0.70 ± 0.78 vs. 0.13 ± 0.09 N m). Only 33 % of pedicle screws were loose after testing compared to 100 % of lateral mass screws.

CONCLUSIONS

C1 pedicle screws were able to withstand higher toggle forces than lateral mass screws while maintaining a higher stiffness throughout and after testing. From a biomechanical point of view, the clinical use of pedicle screws in C1 is a promising alternative to lateral mass screws.

Cement augmentation of the proximal femoral nail antirotation for the treatment of osteoporotic pertrochanteric fractures--a biomechanical cadaver study

INTRODUCTION

Proximal femoral fractures will gain increasing importance in the future due to the epidemiological development. Osteoporosis is often a limiting factor in the achievement of implant stability. New nailing systems offer the possibility of augmentation of the femoral neck component with cement. The aim of this study was to perform a biomechanical comparison of implant stability in osteoporotic pertrochanteric fractures using the proximal femoral nail antirotation (PFNA, Synthes GmbH, Umkirch, Germany) with cement augmented and non-augmented blades.

MATERIALS AND METHODS

Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry (DEXA) in six pairs of fresh-frozen human femurs. Standardised pertrochanteric fractures (AO31-A2.3) were treated with a PFNA. Cement augmentation was performed in six constructs. Axial loading was applied according to a single-leg-stance model using a hydraulic testing machine increasing to 1400N over 10,000 cycles. Biomechanical comparisons between the two groups that were comparable concerning BMD, tip-apex-distance and native stiffness were made with regard to postoperative stiffness, survived cycles, load to failure, failure mechanism and axial displacement.

RESULTS

The stiffness of all stabilised femurs was significantly lower than for native specimens (native 702.5±159.6N/mm vs. postoperative 275.4±53.8N/mm, p<0.001). Stiffness after instrumentation was significantly greater for the cement augmented group than for the non-augmented group (300.6±46.7N/mm vs. 250.3±51.6N/mm, respectively, p=0.001). Five of the twelve constructs survived cyclic testing. Statistically significant differences of the BMD were detected between survived and failed constructs (0.79±0.17g/cm(2) vs. 0.45±0.12g/cm(2), respectively, p=0.028). The failure loads for specimens surviving 10,000 cycles were 4611.9±2078.9N in the cement augmented group (n=3) and 4516.3N and 3253.5N in the non-augmented group (n=2). Postoperative stiffness was found to be a positive predictor of maximum force to failure (R(2)=0.83, p=0.02).

CONCLUSIONS

The results of this biomechanical study show that cement augmentation of the PFNA increases the implant stability in osteoporotic pertrochanteric fractures. Further studies are necessary to evaluate this procedure in providing long term clinical results.

What is the risk of stress risers for interprosthetic fractures of the femur? A biomechanical analysis

PURPOSE

Due to increasing life expectancy we see a rising number of joint replacements. Along with the proximal prosthesis in the femur, more and more people have a second implant on the distal ipsilateral side. This might be a retrograde nail or a locking plate to treat distal femur fractures or a constrained knee prosthesis in the case of severe arthrosis. All these constructs can lead to fractures between the implants. The goal of this study was to evaluate the risk of stress risers for interprosthetic fractures of the femur.

METHODS

Thirty human cadaveric femurs were divided into five groups: (1) femurs with a prosthesis on the proximal side only, (2) hip prosthesis on the proximal end and a distal femur nail, (3) femurs with both a hip prosthesis and a constrained knee prosthesis, (4) femurs with a hip prosthesis on the proximal side and a 4.5-mm distal femur locking plate; the locking plate was 230 mm in length, with ten holes in the shaft, and (5) femurs with a proximal hip prosthesis and a 4.5-mm distal femur locking plate; the locking plate was 342 mm in length, with 16 holes in the shaft.

RESULTS

Femurs with a hip prosthesis and knee prosthesis showed significantly higher required fracture force compared to femurs with a hip prosthesis and a distal retrograde nail. Femurs with a distal locking plate of either length showed a higher required fracture force than those with the retrograde nail.

CONCLUSIONS

The highest risk for a fracture in the femur with an existing hip prosthesis comes with a retrograde nail. A distal locking plate for the treatment of supracondylar fractures leads to a higher required fracture force. The implantation of a constrained knee prosthesis that is not loosened on the ipsilateral side does not increase the risk for a fracture.

A prospective multicenter study on the outcome of type I collagen hydrogel-based autologous chondrocyte implantation (CaReS) for the repair of articular cartilage defects in the knee

BACKGROUND

The Cartilage Regeneration System (CaReS) is a novel matrix-associated autologous chondrocyte implantation (ACI) technique for the treatment of chondral and osteochondral lesions (Outerbridge grades III and IV). For this technology, no expansion of the chondrocytes in a monolayer culture is needed, and a homogeneous cell distribution within the gel is guaranteed.

PURPOSE

To report a prospective multicenter study of matrix-associated ACI of the knee using a new type I collagen hydrogel (CaReS).

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

From 2003 to 2008, 116 patients (49 women and 67 men; mean age, 32.5 ± 8.9 years) had CaReS implantation of the knee in 9 different centers. On the basis of the International Cartilage Repair Society (ICRS) Cartilage Injury Evaluation Package 2000, the International Knee Documentation Committee (IKDC) score, pain score (visual analog scale [VAS]), SF-36 score, overall treatment satisfaction and the IKDC functional status were evaluated. Patient follow-up was performed at 3, 6, and 12 months after surgery and annually thereafter. Mean follow-up was 30.2 ± 17.4 months (range, 12-60 months). There were 67 defects of the medial condyle, 14 of the lateral, 22 of the patella/trochlea, and 3 of the tibial plateau, and 10 patients had 2 lesions. The mean defect size was 5.4 ± 2.4 cm(2). Thirty percent of the defects were <4 cm(2) and 70% were >4 cm(2).

RESULTS

The IKDC score improved significantly from 42.4 ± 13.8 preoperatively to 70.5 ± 18.7 (P < .001) at latest follow-up. Global pain level significantly decreased (P < .001) from 6.7 ± 2.2 preoperatively to 3.2 ± 3.1 at latest follow-up. There also was a significant increase of both components of the SF-36 score. The overall treatment satisfaction was judged as very good or good in 88% by the surgeon and 80% by the patient. The IKDC functional knee status was grade I in 23.4%, II in 56.3%, III in 17.2%, and IV in 3.1% of the patients.

CONCLUSION

Matrix-associated ACI employing the CaReS technology for the treatment of chondral or osteochondral defects of the knee is a safe and clinically effective treatment that yields significant functional improvement and improvement in pain level. However, further investigation is necessary to determine the long-term viability and clinical outcome of this procedure.