Autologous chondrocyte implantation (ACI) is a widely accepted procedure for the treatment of large, fullthickness chondral defects involving various joints, but its use in developing countries is limited because of high cost and failure rates due to limited resources and support systems. Five patients (age
A variety of reconstructive options exist for revision of both femoral and acetabular components in total hip replacement surgery. The use of impaction bone grafting with morsellised allograft has shown promising results in revision total hip arthroplasty. It works as a biologic reconstitution of bone stock defects and provides a solid construct with stable fixation. We present a case of bilateral revision total hip arthroplasty with poor bone stock where reconstructive surgery was done by using impaction bone grafting, mesh and C-stem implants.
A revision of a metal-on-ultra high molecular weight (UHMWPE) bearing couple for total hip replacement was performed due to aseptic loosening after 23 years in-vivo. It is a major long-term failure identified from wear generation. This study includes performing failure analysis of retrieved polyethylene acetabular cup from Zimmer Trilogy® Acetabular system. The UHMWPE acetabular cup was retrieved from a 61 years old male patient with ability to walk but limited leg movement when he presented to hospital in early 2016 with complaint left thigh pain. It was 23 years after his primary total hip replacement procedure. Surface roughness and morphology condition were measured using 3D laser microscope and Scanning Electron Microscope (SEM) to evaluate and characterize the wear features on polyethylene acetabular cup surface. ATR-Fourier Transform Infra-Red (ATR-FTIR), differential scanning calorimetry (DSC) and gel permeation chromatography (GPC) were used to characterize the chemical composition of carbon-oxygen bonding, crystallinity percentage and molecular weight of the polymer liner that might changes the mechanical properties of polyethylene. Nano indentation is to measure hardness and elasticity modulus where the ratio of hardness to elastic modulus value can be reflected as the degradation of mechanical properties. A prominent difference of thickness between two regions resulted from acentric loading concentration was observed and wear rate were measured. The linear wear rate for thin side and thick side were 0.33 mm/year and 0.05 mm/year respectively. Molecular weight reduction of 57.5% and relatively low ratio of hardness to elastic modulus (3.59 × 10-3) were the indicator of major mechanical properties degradation happened on UHMWPE acetabular cup. This major degradation was contributed by oxidation and polishing wear feature accompanied with delamination, craters, ripple and cracks were the indication of extensive usage of UHMWPE from the suggested life span of acetabular cup application.
In a computerized image analysis environment, the irregularity of a lesion border has been used to differentiate between malignant melanoma and other pigmented skin lesions. The accuracy of the automated lesion border detection is a significant step towards accurate classification at a later stage. In this paper, we propose the use of a combined Spline and B-spline in order to enhance the quality of dermoscopic images before segmentation. In this paper, morphological operations and median filter were used first to remove noise from the original image during pre-processing. Then we proceeded to adjust image RGB values to the optimal color channel (green channel). The combined Spline and B-spline method was subsequently adopted to enhance the image before segmentation. The lesion segmentation was completed based on threshold value empirically obtained using the optimal color channel. Finally, morphological operations were utilized to merge the smaller regions with the main lesion region. Improvement on the average segmentation accuracy was observed in the experimental results conducted on 70 dermoscopic images. The average accuracy of segmentation achieved in this paper was 97.21 % (where, the average sensitivity and specificity were 94 % and 98.05 % respectively).
The causes of groin pain after total hip arthroplasty are numerous, and the condition itself is disabling. Therefore, it is imperative that the cause of the pain is identified and managed appropriately. We report a case where the patient had groin pain after total hip arthroplasty as a result of an oversized cementless acetabular component, which caused a breach in the anterior wall of the acetabulum. The anterior wall of the acetabulum was reconstructed with femoral head allograft, and the patient has been symptom free since.
Total knee arthroplasty is the most preferred option for treatment of severe osteoarthritis of the knee. We report the short-term outcome of 48 total knee replacements in 31 patients utilizing the Apollo Total Knee System after an average follow-up of 48 months (range 15 to 70 months). Records of all patients who underwent TKA using Apollo Total Knee System were retrospectively reviewed. Functional outcome was evaluated using visual analogue scale for pain rating and the Oxford 12-item questionnaire. Postoperative radiographs of the replaced knees were assessed by using the Knee Society Total Knee Arthroplasty Roentgenographic Evaluation and Scoring System. Degenerative osteoarthritis was the commonest indication for TKA. The average patient's age was 63.7 years (range, 30-77 years). The mean visual analogue scale for pre- and post-operative pain was eight and zero respectively. The mean Oxford 12-item questionnaire score pre- and post-operatively was 44.8 and 16.5 respectively. Patient satisfaction was notable in 98% of the cases with an average improvement in arc of flexion of 111 degrees. There were four failures; deep infection (one) and aseptic loosening (three) giving rise to a 94% implant survivor. The short-term results of this series is comparable with or better than a number of outcome studies of the Apollo Knee System or other implants of similar design.
BACKGROUND: Knee laxity measurements have been shown to be associated with some medical conditions such as chronic joint pain and collagen tissue diseases. The aim of this study was to determine the effects of demographic factors and anthropometric measures on knee laxity.
MATERIALS AND METHODS: Data were collected from 521 visitors, staffs and students from the University Malaya Medical Centre and University of Malaya between December 2009 and May 2010. Knee laxity was measured using a KT-1000 arthrometer. Multiple regression analysis was used to find the association of knee laxity with age and anthropometric measures.
RESULTS: Using ANOVA, knee laxity did not show significant differences among ethnic groups for both genders. The average knee laxity in men was 3.47 mm (right) and 3.49 mm (left); while in women were 3.90 mm (right) and 3.67 mm (left). Knee laxity in women was significantly higher (right knee p<0.01 and left knee p<0.05) than men. Right knee laxity of men was negatively associated with height (p<0.05) and BMI (p<0.05); also a negative association was observed between left knee laxity and BMI (p<0.05). Overweight and obese men had less knee laxity than normal weight and underweight individuals. Elderly men and women (age 55 and above) had lower knee laxity (p<0.01) than young adults (ages 21-39).
CONCLUSION: These results suggest that age and body size are important factors in predicting knee laxity.
KEYWORDS: Age; Anthropometric measures; Joint mobility; KT 1000; Knee laxity
Avascular necrosis and non-union are two most dreaded complications of femoral neck fracture fixations. Hip replacement seems to be a simple solution for this complex problem. However, the long-term efficacy of prosthetic replacement in the young population with higher functional demand is still questionable. Femoral head preserving valgus subtrochanteric osteotomies in properly selected cases have strong support from literature. The conventional technique of valgus subtrochanteric osteotomy involves lateral based wedge resection. Alternatively, a simpler sliding oblique subtrochanteric osteotomy without any wedge removal can also be performed. We hereby describe a successful case of sliding subtrochanteric osteotomy with 135° dynamic hip screw (DHS) plate fixation in treating non-union neck of femur fracture in a young gentleman.
The use of mesenchymal stem cells (MSCs) for cartilage repair has generated much interest owing to their multipotentiality. However, their significant presence in peripheral blood (PB) has been a matter of much debate. The objectives of this study are to isolate and characterize MSCs derived from PB and, compare their chondrogenic potential to MSC derived from bone marrow (BM). PB and BM derived MSCs from 20 patients were isolated and characterized. From 2 ml of PB and BM, 5.4 ± 0.6 million and 10.5 ± 0.8 million adherent cells, respectively, were obtained by cell cultures at passage 2. Both PB and BM derived MSCs were able to undergo tri-lineage differentiation and showed negative expression of CD34 and CD45, but positively expressed CD105, CD166, and CD29. Qualitative and quantitative examinations on the chondrogenic potential of PB and BM derived MSCs expressed similar cartilage specific gene (COMP) and proteoglycan levels, respectively. Furthermore, the s-GAG levels expressed by chondrogenic MSCs in cultures were similar to that of native chondrocytes. In conclusion, this study demonstrates that MSCs from PB maintain similar characteristics and have similar chondrogenic differentiation potential to those derived from BM, while producing comparable s-GAG expressions to chondrocytes.
Most studies highlight mesenchymal stem cells (MSCs) extracted primarily from bone marrow (BM), very few report the use of peripheral blood (PB), often due to the associated low seeding density and difficulties with extraction techniques. As ageing populations are becoming more predominant globally, together with escalating demands for MSC transplantation and tissue regeneration, obtaining quality MSCs suitable for induced differentiation and biological therapies becomes increasingly important. In this study, BM and PB were obtained from elderly patients and extracted MSCs grown in vitro to determine their successful isolation and expansion. Patients' socio-demographic background and other medical information were obtained from medical records. Successful and failed cultures were correlated with key demographic and medical parameters. A total of 112 samples (BM or PB) were used for this study. Of these, 50 samples (44.6%) were successfully cultured according to standardised criteria with no signs of contamination. Our comparative analyses demonstrated no statistical correlation between successful MSC cultures and any of the six demographic or medical parameters examined, including sample quantity, age, sex, race, habits and underlying comorbidities of sample donors. In conclusion, the present study demonstrates that typical demographics and comorbidities do not influence successful MSC isolation and expansion in culture.
Periprosthetic joint infection (PJI) is one of the most common complications after total hip arthroplasty (THA). Two-stage revision surgery is one of the treatment options for PJI, however, it has been associated with poor patient tolerance, reduced patient mobility, and periarticular tissue contracture leading to difficulty during second-stage reconstruction. The custom-made articulating spacer (CUMARS) was developed to provide an alternative that is better tolerated and to reduce the complexity of second-stage reconstruction. This study details the treatment of a patient with PJI post-THA with significant periosteal reaction using a CUMARS construct, which enabled immediate post-operative weight bearing, eventual eradication of infection, restoration of femoral bone stock, and avoidance of second-stage reconstruction.
Platelet rich concentrate (PRC) is a natural adjuvant that aids in human mesenchymal stromal cell (hMSC) proliferation in vitro; however, its role requires further exploration. This study was conducted to determine the optimal concentration of PRC required for achieving the maximal proliferation, and the need for activating the platelets to achieve this effect, and if PRC could independently induce early differentiation of hMSC. The gene expression of markers for osteocytes (ALP, RUNX2), chondrocytes (SOX9, COL2A1), and adipocytes (PPAR-γ) was determined at each time point in hMSC treated with 15% activated and nonactivated PRC since maximal proliferative effect was achieved at this concentration. The isolated PRC had approximately fourfold higher platelet count than whole blood. There was no significant difference in hMSC proliferation between the activated and nonactivated PRC. Only RUNX2 and SOX9 genes were upregulated throughout the 8 days. However, protein expression study showed formation of oil globules from day 4, significant increase in ALP at days 6 and 8 (P ≤ 0.05), and increased glycosaminoglycan levels at all time points (P < 0.05), suggesting the early differentiation of hMSC into osteogenic and adipogenic lineages. This study demonstrates that the use of PRC increased hMSC proliferation and induced early differentiation of hMSC into multiple mesenchymal lineages, without preactivation or addition of differentiation medium.
The use of growth differentiation factor 5 (GDF-5) in damaged tendons has been shown to improve tendon repair. It has been hypothesized that further improvements may be achieved when GDF-5 is used to promote cell proliferation and induce tenogenic differentiation in human bone marrow-derived mesenchymal stem cells (hMSCs). However, the optimal conditions required to produce these effects on hMSCs have not been demonstrated in previous studies. A study to determine cell proliferation and tenogenic differentiation in hMSCs exposed to different concentrations of GDF-5 (0, 5, 25, 50, 100 and 500 ng/ml) was thus conducted. No significant changes were observed in the cell proliferation rate in hMSCs treated at different concentrations of GDF-5. GDF-5 appeared to induce tenogenic differentiation at 100 ng/ml, as reflected by (1) a significant increase in total collagen expression, similar to that of the primary native human tenocyte culture; (2) a significant upregulation in candidate tenogenic marker gene expression, i.e. scleraxis, tenascin-C and type-I collagen; (3) the ratio of type-I collagen to type-III collagen expression was elevated to levels similar to that of human tenocyte cultures, and (4) a significant downregulation of the non-tenogenic marker genes runt-related transcription factor 2 and sex determining region Y (SRY)-box 9 at day 7 of GDF-5 induction, further excluding hMSC differentiation into other lineages. In conclusion, GDF-5 does not alter the proliferation rates of hMSCs, but, instead, induces an optimal tenogenic differentiation response at 100 ng/ml.
We carried out a prospective study of 47 Exeter (Stryker Inc, Warsaw, Ind) small stem total hip arthroplasty in 42 patients with an average age of 58 years and a mean follow-up of 8.5 years. The Oxford hip score improved from a preoperative mean of 47 to 17 at last follow-up. More than 87% patients had excellent or good Harris hip scores, and 90% were able to walk with little or no pain. Stem subsidence within the cement mantle was observed in 26% of cases, and none showed evidence of aseptic loosening or implant failure. Two stems were removed due to infection. The survival rate of this implant was 95.7% at 10 years. This first series of Exeter small stem showed excellent medium-term results, comparable to its larger counterparts.
A poly(vinyl alcohol) (PVA) hydrogel composite scaffold containing N,O-carboxymethylated chitosan (NOCC) was tested to assess its potential as a scaffold for cartilage tissue engineering in a weight-bearing environment. The mechanical properties under unconfined compression for different hydration periods were investigated. The effect of supplementing PVA with NOCC (20wt.% PVA:5vol.% NOCC) produced a porosity of 43.3% and this was compared against a non-porous PVA hydrogel (20g PVA: 100ml of water, control). Under non-hydrated conditions, the porous PVA-NOCC hydrogel behaved in a similar way to the control non-porous PVA hydrogel, with similar non-linear stress-strain response under unconfined compression (0-30% strain). After 7days' hydration, the porous hydrogel demonstrated a reduced stiffness (0.002kPa, at 25% strain), resulting in a more linear stiffness relationship over a range of 0-30% strain. Poisson's ratio for the hydrated non-porous and porous hydrogels ranged between 0.73 and 1.18, and 0.76 and 1.33, respectively, suggesting a greater fluid flow when loaded. The stress relaxation function for the porous hydrogel was affected by the hydration period (from 0 to 600s); however the percentage stress relaxation regained by about 95%, after 1200s for all hydration periods assessed. No significant differences were found between the different hydration periods between the porous hydrogels and control. The calculated aggregate modulus, H(A), for the porous hydrogel reduced drastically from 10.99kPa in its non-hydrated state to about 0.001kPa after 7days' hydration, with the calculated shear modulus reducing from 30.92 to 0.14kPa, respectively. The porous PVA-NOCC hydrogel conformed to a biphasic, viscoelastic model, which has the desired properties required for any scaffold in cartilage tissue engineering.
We report our early experience of 20 cases of metal on metal articulation total hip arthroplasty in 19 young patients. Avascular necrosis of the femoral head (63%) was the commonest diagnosis for patients undergoing this procedure, followed by osteoarthritis (21%). In general, most of the patients were young and physically active with an average age of 43.1 years (range, 25 to 58 years). The average follow-up period was 18 months (range, 7 to 46 months). The mean total Harris Hip Score preoperatively and at final follow-up was 31 points and 89 points respectively. The mean total Pain Score improved from an average of 11.5 to 41.1 points at final follow-up. Sixteen (84%) of the patients had a good to excellent hip score. There was one dislocation, which stabilized after reduction and conservative management. One case of early infection underwent a two-staged revision.
Presence of sulfated polysaccharides like heparan sulphate has often been implicated in the regulation of chondrogenesis. However, recently there has been a plethora of interest in the use of non-animal extracted analogs of heparan sulphate. Here we remodeled alginate (1.5%) by incorporating fucoidan (0.5%), a natural sulphated polysaccharide extracted from seaweeds to form a composite hydrogel (Al-Fu), capable of enhancing chondrogenesis of human mesenchymal stromal cells (hMSCs). We confirmed the efficiency of fucoidan incorporation by FTIR and EDX analysis. Further, its ability to support hMSC attachment and chondrogenic differentiation was confirmed by SEM, biochemical glycosaminoglycan quantification, real-time quantitative PCR and immunocytochemical analyses of chondrogenic markers Sox-9, Collagen II, Aggrecan and COMP. Effect of Al-Fu hydrogel on hMSC hypertrophy was also confirmed by the downregulation of hypertrophic genes Collagen X and Runx2. This composite scaffold can hence be used as a cartilage biomimetic biomaterial to drive hMSC chondrogenesis and for other cartilage repair based therapies.
To compare the effect of bovine bone derived porous hydroxyapatite (BDHA) scaffold on proliferation and osteogenic differentiation of human bone marrow-derived mesenchymal stromal cells (hMSCs) compared with commercial hydroxyapatite (CHA) scaffold.
The role for mechanical stimulation in the control of cell fate has been previously proposed, suggesting that there may be a role of mechanical conditioning in directing mesenchymal stromal cells (MSCs) towards specific lineage for tissue engineering applications. Although previous studies have reported that calcium signalling is involved in regulating many cellular processes in many cell types, its role in managing cellular responses to tensile loading (mechanotransduction) of MSCs has not been fully elucidated. In order to establish this, we disrupted calcium signalling by blocking stretch-activated calcium channel (SACC) in human MSCs (hMSCs) in vitro. Passaged-2 hMSCs were exposed to cyclic tensile loading (1 Hz + 8% for 6, 24, 48, and 72 hours) in the presence of the SACC blocker, gadolinium. Analyses include image observations of immunochemistry and immunofluorescence staining from extracellular matrix (ECM) production, and measuring related tenogenic and apoptosis gene marker expression. Uniaxial tensile loading increased the expression of tenogenic markers and ECM production. However, exposure to strain in the presence of 20 μM gadolinium reduced the induction of almost all tenogenic markers and ECM staining, suggesting that SACC acts as a mechanosensor in strain-induced hMSC tenogenic differentiation process. Although cell death was observed in prolonged stretching, it did not appear to be apoptosis mediated. In conclusion, the knowledge gained in this study by elucidating the role of calcium in MSC mechanotransduction processes, and that in prolonged stretching results in non-apoptosis mediated cell death may be potential useful for regenerative medicine applications.