Alexander C.M. Chong

Structural properties of a novel design of composite analogue humeri models.

Background Mechanical analogue composite bone models have been used as cadaveric bone substitutes in a wide variety of biomechanical tests. The objective of this study was to compare the structural properties of two types (Third- and Fourth-Generation) of commercially available composite analogue humeri. Methods Eighteen of each generation composite analogue humeri were evaluated for flexural rigidity, torsional rigidity, and failure strength. Three tests were performed: medial–lateral four-point bending, anterior–posterior four-point bending, and external rotational torque. Results The Fourth-Generation analogue humeri performed more closely to the biological average with respect to failure strength, flexural rigidity, and torsional stiffness when compared to the Third-Generation humeri. Both the Third- and Fourth-Generation analogues were within the range of published human bone values. There was a statistically significant difference in strength in all modes of testing between the Fourth-Generation humeri and the Third-Generation humeri. Conclusion These composite analogue humeri are ideal for standardization in biomechanical analyses. The advantage of these humeri is that their variability is significantly lower than that of cadaveric specimens for all loading regimens. The widely varying results observed when comparing composite analogue humeri to cadaveric humeri might be derived from the use of different ranges of applied load, varied test methodologies, and diverse methods of computing the stiffness. Mechanical validation of whole Fourth-Generation humeri bone models would be an appropriate follow-up to this study with a direct comparison to cadaveric humeri. Clinical relevance This study validated and advanced our overall understanding of the capacity of composite analogue humeri to model the structural properties of human bone.

Cell-based osteoprotegerin therapy for debris-induced aseptic prosthetic loosening on a murine model

Exogenous osteoprotegerin (OPG) gene modification appears a therapeutic strategy for osteolytic aseptic loosening. The feasibility and efficacy of a cell-based OPG gene delivery approach were investigated using a murine model of knee prosthesis failure. A titanium pin was implanted into mouse proximal tibia to mimic a weight-bearing knee arthroplasty, followed by titanium particles challenge to induce periprosthetic osteolysis. Mouse fibroblast-like synoviocytes were transduced in vitro with either AAV-OPG or AAV-LacZ before transfused into the osteolytic prosthetic joint 3 weeks post surgery. Successful transgene expression at the local site was confirmed 4 weeks later after killing. Biomechanical pullout test indicated a significant restoration of implant stability after the cell-based OPG gene therapy. Histology revealed that inflammatory pseudo-membranes existed ubiquitously at bone–implant interface in control groups, whereas only observed sporadically in OPG gene-modified groups. Tartrate-resistant acid phosphatase+osteoclasts and tumor necrosis factor α, interleukin-1β, CD68+ expressing cells were significantly reduced in periprosthetic tissues of OPG gene-modified mice. No transgene dissemination or tumorigenesis was detected in remote organs and tissues. Data suggest that cell-based ex vivo OPG gene therapy was comparable in efficacy with in vivo local gene transfer technique to deliver functional therapeutic OPG activities, effectively halted the debris-induced osteolysis and regained the implant stability in this model.

Flexion-extension gap in cruciate-retaining versus posterior-stabilized total knee arthroplasty: a cadaveric study.

We re‐examined experimental model results using half‐body specimens with intact extensor mechanisms and navigation to evaluate cruciate‐retaining (CR) and posterior stabilized (PS) total knee arthroplasty (TKA) component gaps through an entire range of motion. Six sequential testing regimens were conducted with the knee intact, with a CR TKA in place, and with a PS TKA in place, with and without 22 N traction in place at each stage. Each of 10 knees was taken through six full ranges of motion from 0° to 120° at every stage using a navigated knee system to record component gapping. No significant difference was found between loaded and unloaded component gaps, and no significant differences were found in component gapping between CR and PS TKAs throughout a full range of motion. Flexion–extension gap measurements were significantly different from previously published data (at 90° flexion). No difference was found in kinematics when comparing CR and PS TKA component designs. Our results suggest that intact extensor mechanisms may be required to perform proper kinematic studies of TKA. Our findings provide evidence that the extensor mechanism may play a major role in the flexion–extension gaps in cadaveric knees.

Specific material effects of wear-particle-induced inflammation and osteolysis at the bone–implant interface: A rat model

Summary Introduction Wear particles produced from prosthetic joints may play critical roles in periprosthetic inflammatory reactions and osteolysis. The objective of this study was to quantify and compare the response to wear debris from different biomaterials at the bone–implant interface in a rat knee model. Methods Sixty rats were divided into titanium alloy (Ti–6Al–4V), cobalt chromium (Co–Cr), ceramic (Al2O3), ultrahigh molecular weight polyethylene (UHMWPE), and control (phosphate buffered saline) groups with 12 animals per group. A nonweight-bearing titanium rod was implanted into the right distal femur of each rat followed by intra-articular injections of the biomaterial particles to the surgical knees for up to 16 weeks. Micro-computed tomography scanning was performed monthly and at the time of sacrifice to determine bone densities around the bone–implant interface. Histological evaluations were executed to quantify local inflammatory reactions and osteoclastogenesis. Results Co–Cr particles resulted in the most severe reductions in bone density. UHMWPE and ceramic particles resulted in a rapid reduction in bone density followed by a recovery. Inflammatory pseudo-membranes were ubiquitously present close to the femoral condyle and pin insertion site. Ceramic particles significantly promoted periprosthetic tissue formation compared with the other groups (p < 0.05). Cathepsin K positive cells were dominantly present at the peri-implant site following challenges of metallic alloy and ceramic particles. Conclusion Different biomaterials in particulate form exert different forms of adverse effects in terms of the amount of osteolysis and inflammatory reactions on bone tissue at the bone–implant interface. It provides information for engineering more appropriate materials for arthroplasty components.

Novel Flexible Suture Fixation for the Distal Tibiofibular Syndesmotic Joint Injury: A Cadaveric Biomechanical Model

Syndesmotic injuries of the ankle commonly occur by an external rotation force applied to the ankle joint. Ten fresh-frozen lower extremities from cadavers were used. A specially designed apparatus was used to stabilize the specimen and rotate the ankle joint from internally rotated 25° to externally rotated 35° at a rate of 6°/s for 10 cycles. Two stages were tested (stage I, specimens intact; and stage II, simulated pronation external rotation type injury with fixation). Group 1 was fixed with a novel suture construct across the syndesmotic joint, and group 2 was fixed with a single metallic screw. The torque, rotational angle, and 3-dimensional syndesmotic diastasis readings were recorded. Three-dimensional tibiofibular diastasis was identified. The fibula of the intact specimens displaced an average of 8.6 ± 1.7, 2.4 ± 1.0, and 1.4 ± 1.0 mm in the anterior, lateral, and superior direction, respectively, when the foot was externally rotated 35°. The sectioning of the syndesmostic ligaments and deltoid ligament resulted in a significant decrease in syndesmotic diastasis and foot torsional force (p < .05). The ligament-sectioned specimen lost 57% (externally rotated) and 17% (internally rotated) torsional strength compared with the intact specimen. Groups 1 and 2 provided similar biomechanical stability in this cadaveric model of a syndesmosis deficiency.

The influence of sequential debridement in total knee arthroplasty on the flexion axis of the knee using computer-aided navigation

The effects of osteophyte debridement, bony cuts, and soft tissue releases on the functional flexion axis of the knee can be assessed by evaluating 3D kinematics following each step of a total knee arthroplasty. Using a navigated knee system with dedicated software, the functional flexion axis (helical axis) can be determined after each step. Five paired fresh‐frozen cadaveric knees were used with a CT scan performed on each specimen identifying implanted fiducial markers. Kinematics data were recorded during each step of sequential osseous cuts and soft tissue releases for both an unloaded and loaded limb by each of three surgeons. The functional helical (flexion/extension) axis was identified for all specimens. The internal/external rotation angle (θ) of the helical axis differed from the transepicondylar axis by −8.3° to +6.7° for the unloaded condition. θ ranged from −7.2° to +7.4° with distraction. Soft tissue releases had no effect on θ; until a bony cut of the articular surface, which increased θ from −0.3° to +9.7°. Implantation of cruciate retaining prosthetic components subsequently reduced the θ range −7.3° to +4.0°. Thus, soft tissue releases had minimal effect on θ of the helical axis except for resection of the proximal tibia. Implantation of the CR prosthesis reduced è close to that of the intact knee. In a minority of knees, the helical axis did not coincide exactly with the transepicondylar axis. Interspecimen and left/right variability of θ were significant, although interinvestigator variability and an applied distraction force were insignificant.

Intrusion Characteristics of Three Bone Cements for Tibial Component of Total Knee Arthroplasty in a Cadaveric Bone Model.

The purpose of this study was to evaluate and compare the intrusion characteristics of Simplex-HV to Simplex-P and Palacos-R in cadaveric proximal tibial bone. Eighteen fresh-frozen cadaver proximal tibiae were examined with standard arthroplasty tibial cuts. Each tibia was randomly assigned to receive one of the three bone cements for use with finger packing technique. Sagittal sections were prepared and analyzed using digital photography and stereoscopic micrographs to evaluate cement intrusion characteristics. The cement penetration depth was measured from the tibial bone cut surface, which did not include the cement thickness under the tibial base plate. Significant differences were detected in the bone cement penetration between the three cements. Penetration was increased using the Simplex-HV (average, 2.7 mm; range, 2.0-3.0 mm) compared with Simplex-P (average, 2.2 mm) and Palacos-R (average, 1.8 mm). These depths approximate to 3.7, 3.2, and 2.8 mm of total cement penetration, respectively. The data suggest that high-viscosity bone cement may provide good fixation of the tibial component of a total knee arthroplasty when using the finger packing technique.

Biomechanical evaluation of CIBOR spine interbody fusion device.

BACKGROUND The CIBOR PEEK spinal interbody fusion device is an anterior lumbar interbody fusion construct with a hollow center designed to accommodate an osteoinductive carbon foam insert to promote bony ingrowth to induce fusion where rigid stabilization is needed. METHODS Three different sizes of the device were investigated. Part-I: implants were tested under axial compression and rotation using polyurethane foam blocks. Part-II: simulated 2-legged stance using cadaveric specimen using the L5-S1 lumbar spine segment. Part-III: a survey feedback form was used to investigate two orthopedic surgeons concern regarding the implant. RESULTS In Part-I, the subsidence hysteresis under axial compression loading was found to be statistical significant difference between these three implant sizes. It was noted that the implants had migration as rotation applied, and the amount of subsidence was a factor of the axial compression loads applied. In Part-II, a minor subsidence and carbon foam debris were observed when compared to each implant size. Poor contact surface of the implant with the end plates of the L5 or S1 vertebrae from the anterior view under maximum loads was observed; however, the implant seemed to be stable. Each surgeon has their own subjective opinion about the CIBOR implant. DISCUSSION Two out of the three different sizes of the device (medium and large sizes) provided appropriate rigid stabilization at the physiological loads. Neither orthopedic surgeon was 100% satisfied with overall performance of the implant, but felt potential improvement could be made. CLINICAL RELEVANCE This study indicates an option for operative treatment of spine interbody fusion, as the CIBOR spine interbody fusion device has a hollow center. This hollow center is designed to accommodate a carbon foam insert to promote bony ingrowth.

Popliteal Artery Thrombosis After Open Reduction and Internal Fixation of the Patella

Case: A 31-year-old man presented with a right patellar fracture after a motor-vehicle accident. He had a history of a myocardial infarction and cerebrovascular accident, for which he reported taking aspirin and clopidogrel daily. One hour after surgery, an acute popliteal artery thrombosis was detected. The patient was ultimately successfully managed with endovascular placement of a catheter and a 14-hour infusion of tissue plasminogen activator. The patient had no further known thromboembolic events after 11 months of follow-up. Conclusion: High suspicion must be maintained for acute thromboembolic events in patients with a history of such events.

Development of a finite element model to study the torsional fracture strength of an analogue tibia with bicortical holes

Fractured bones are often stabilised with orthopaedic fracture plates and screws until healed. If the plates and screws are removed, the vacant screw holes introduce a potential site for re-fracture. This study is aimed at simulating a laboratory torsional fracture test of a composite analogue tibia with vacant screw holes using a finite element (FE) model. This FE model is set up the same as the experimental torsion test, with a section from the distal portion of the tibia. The FE model contains over 35k second-order brick elements and nearly 165k nodes. It utilises an isotropic linear elastic material law with material properties obtained from the analogue tibia manufacturer. Comparisons between the experimental model and the FE model consider the fracture torque, fracture angle, and specific torsional stiffness. Stress contours of the FE model are compared to the fracture path of the experimental model. The FE model predicts the fracture location and a fracture torque within the standard deviation of that determined experimentally.