Richard R. Pelker

Biomechanical properties of bone allografts

The biomechanical properties of allograft bone can be altered by the methods chosen for its preservation and storage. These effects are minimal with deep-freezing or low-level radiation. Freeze-drying, however, markedly diminishes the torsional and bending strength of bone allografts but does not deleteriously affect the compressive or tensile strength. Irradiation of bone with more than 3.0 megarad or irradiation combined with freeze-drying appears to cause a significant reduction in breaking strength. These factors should be considered when choosing freeze-dried or irradiated allogeneic bone that will be subjected to significant loads following implantation.

NLRP3 inflammasome plays a critical role in the pathogenesis of hydroxyapatite-associated arthropathy.

The proinflammatory and catabolic cytokine IL-1β has been implicated in the pathogenesis of osteoarthritis (OA) by mediating synovial inflammation and cartilage degeneration. Although synovial macrophages are suggested to be the source of IL-1β, the mechanism remains unclear. Ectopic deposition of hydroxyapatite (HA) crystals in joints is closely associated with OA and other arthropathies, but the precise role of HA in arthritis pathogenesis has not been clearly demonstrated. Here we show that HA crystals of a particular size and shape can stimulate robust secretion of proinflammatory cytokines IL-1β and IL-18 from murine macrophages in a NLRP3 inflammasome-dependent manner. HA-induced inflammasome activation is dependent on potassium efflux, generation of reactive oxygen species (ROS), and lysosomal damage, but independent of cell death. Mice lacking the inflammasome components are protected against HA-induced neutrophilic inflammation in the air-pouch model of synovitis, and they show decreased joint pathology accompanying spontaneous HA deposition in the ank-deficient mouse model of arthritis. Moreover, calcium crystal positive synovial fluids from some OA patients exhibited inflammasome-stimulatory activity in vitro. These results demonstrate that the NLRP3 inflammasome mediates the pathological effect of HA crystals in vitro and in vivo and suggest a critical role for the inflammasome in the pathogenesis of OA.

Current practices of AAHKS members in the treatment of adult osteonecrosis of the femoral head.

BACKGROUND There is currently no standardized protocol for evaluating and treating osteonecrosis of the femoral head in adults in the United States. We sought to understand current treatment practices of a group of surgeons who commonly treat this disease to determine if there was agreement on some aspects of care. METHODS We designed a two-staged mixed-mode (mailed and faxed) sixteen-question self-administered descriptive survey questionnaire to be sent to all 753 active members of the American Association of Hip and Knee Surgeons (AAHKS). The survey design was based on Dillmans survey research methodology, and the questionnaire included hypothetical clinical scenarios based on the Steinberg classification system. The responses elucidated the opinions and treatment preferences of high-volume arthroplasty surgeons who treat adult patients with osteonecrosis of the femoral head. RESULTS Of the 753 active members of the AAHKS, 403 (54%) responded to the questionnaire. Total hip replacement was reported to be the most frequent intervention for treatment of postcollapse (Steinberg stage-IIIB, IVB, V, and VI) osteonecrosis; core decompression was reported to be the most commonly offered intervention for symptomatic, precollapse (Steinberg stage-IB and IIB) osteonecrosis. Less frequently offered treatments included nonoperative management, osteotomy, vascularized and non-vascularized bone-grafting, hemiarthroplasty, and arthrodesis. CONCLUSIONS The care of adults with osteonecrosis of the femoral head varies among American orthopaedic surgeons specializing in hip and knee surgery. A consensus may evolve with a continued concerted effort on the part of interested surgeons, but it will require randomized, controlled, prospective studies of treatment of each stage of the disease and collaborative multicenter studies. LEVEL OF EVIDENCE Therapeutic Level V.

Rollback in posterior cruciate ligament—retaining total knee arthroplasty: A radiographic analysis

A clinical and radiographic study of 49 posterior cruciate ligament-retaining total knee arthroplasties in 38 patients (11 bilateral, 27 unilateral), using prostheses of the same design, was undertaken to quantify the amount of in vivo rollback (ie, the anteroposterior translation of the tibia with respect to the femur during flexion). The mean difference in the distances between the contact points of the knees in full extension and in 90 degrees flexion (ie, the rollback distance) was a posterior translation of the contact point of -0.2 mm (-12.7 to +7l6 mm; SD, 4.7 mm) relative to the prosthetic tibial tray, corresponding to an average translation of 0% of the prosthetic tibial tray depth, and -0.2 mm (-12.5 to +9.1 mm; SD, 4.8 mm) relative to the tibia itself, corresponding to an average translation of 0% of the true tibial surface depth. The differences between the rollback values obtained from the 90 degrees and full-extension radiographs relative to the prosthetic tibial tray (P = .63) and the true tibia (P = .89) were not statistically significant. Intraobserver (P = .27-.50) and interobserver (P = .13-.72) reliability tests showed that the differences between radiographic measurements taken by the same observer at two different points in time and by two different observers were not statistically significant. No correlations were found between the degree of translation of the tibiofemoral contact point relative to the prosthetic tibial tray and the posterior tilt of the tibial tray (R2 = .12), the preoperative tibiofemoral angle (R2 = .34), and the postoperative tibiofemoral angle (R2 = .027). No correlations were found between the degree of translation of the tibiofemoral contact point relative to the true tibia and the posterior tilt of the tibial tray (R2 = .16), the preoperative tibiofemoral angle (R2 = .14), and the postoperative tibiofemoral angle (R2 = .034). In conclusion, this study indicated no demonstrable rollback occurring in the posterior cruciate ligament-retaining total knee arthroplasty used in this study.

Cervical spine stabilization. A three-dimensional, biomechanical evaluation of rotational stability, strength, and failure mechanisms.

The three-dimensional rotational biomechanical properties of several different types of posterior stabilizing procedures are reported. A severe ligamentous and bony Injury was simulated with three vertebral body human cervical some segments. Good stabilization was noted for all of the repairs Inflexion loading. Without polymeth-yimethacrytate supplementation, none of the repairs was stable in extension. All of the repairs provided reasonable stabilization for lateral bending except for the posterior wiring without methacrytete, and all but the posterior wiring and facet fusion provided reasonable stabilization against axial rotation loading. The supplementation of all of these repairs with porymethylniethacrylate added considerably to the stability of all the constraints. These findings may be useful in clinical decision-making for determining the kind of repairs and postoperative brace protection to use.

Stress wave propagation in bone.

The traveling wave characteristics for a single compressive pulse were studied in fresh and embalmed human long bones. The stress wave was generated by the longitudinal impact of a steel ball on one end of a bone and was monitored by bonded strain gages. The dynamic properties, namely velocity, attenuation coefficient and dispersion were correlated with the mineral density, porosity, and cross-sectional area of the specimens. Statistically significant relationships were found between several of these parameters. These stress wave propagation characteristics are important for our understanding of the dynamic loading of bone and they may also provide a basis for the development of noninvasive techniques for studies of diseased or fractured bone.

The Nicolas Andry Award-1995. Fracture healing. Radiation induced alterations.

This study investigated the effects of radiation on fractures in a rat femur model. Two different radiation dosage fractionation schemes (1100 rads given in one dose and 2500 rads given in 10 divided doses over 12 days) and three different times of initiation of radiation (1 day before fracture, 3 or 10 days after fracture) were studied. Fractures exposed to these levels of radiation all appeared to heal during the course of this experiment, although with varying degrees of delay, with the exception of those exposed to a single dose of 1100 rads 3 days after fracture. These animals remained at a more immature level of repair histologically compared with the control group, throughout the entire time evaluated. The strength of the final repair remained less than the control for all the groups receiving treatment. These results may offer some explanation for the clinical observations of an increased incidence of delayed union and nonunion of fractures, an increased incidence of fracture and refracture in irradiated bone, and an increased incidence of fracture and nonunion in constructs using radiation in conjunction with allogeneic bone. Furthermore, the observed effects were generally no different in the animals treated with the two clinically relevant dose fractionation schemes chosen for this study.

Proximal femoral epiphysiolysis in the neonate.

Seven neonates with eight proximal femoral epiphysiolyses were reviewed. Pain elicited by leg motion was the common diagnostic finding in all. Radiography showed lateralization of the shaft similar to congenital hip dysplasia. However, the acetabular index was normal in all but one child. Arthrography confirmed the diagnosis, showing a located proximal femoral epiphysis and a laterally displaced, externally rotated proximal metaphysis. Treatment usually consisted of traction followed by abduction splinting. The long-term results were excellent in six fractures. Growth complications included angular deformation (bowing) in one patient and coxa vara due to localized premature epiphysiodesis in one patient. Duplication of the lesion in stillborn cadavers showed that the fracture was usually a type 1 physeal injury traversing the entire physis beneath both the capital femur and the greater trochanter. The periosteal sleeve was intact posteriorly and still attached to the proximal physis. However, in two instances there was comminution (rather than crushing) of the epiphysis, physis, and metaphysis medially, which might explain the residual varus deformation and premature growth arrest seen infrequently as complications of this particular proximal femoral injury. An experimental animal model also duplicated these morphologic observations.

Wave propagation across a bony discontinuity simulating a healing fracture.

Stress wave propagation in a long bone with a progressively increasing defect in the bony cortex, simulating a healing fracture, was studied by recording the outputs of bonded semiconductor strain gages, proximal and distal to the defect. Statistically significant relations were found between the relative size of the discontinuity and the transmission coefficient, dispersion and transit time across the fracture. We also showed that the stress wave in a bone could be monitored from the vibration response of a traction pin, placed in a magnetic field. The results may be helpful for the development of new methods to measure the rate of fracture healing, as well as aiding our understanding of the dynamic loading of bone.

The injured canine cervical spine after six months of healing : an in vitro three-dimensional study

The cervical spine is a common site of spinal injuries. The stability of an injured cervical spine is not only dependent on injury severity, but also on the degree of healing time. Using a canine model, three injuries of varying degrees of severity were surgically produced at the C4-C5 level and allowed to heal for 6 months. No internal or external support was provided. The harvested cervical spines (C2-C7) were subjected to three-dimensional biomechanical testing by applying individually six pure moments. The resulting three-dimensional displacements were recorded using stereophotogrammetry, and the intervertebral motions were calculated. The results are compared with the in vivo behavior of the same specimens and with an in vitro control group. At 1 N-m, the average flexion-extension range of motion (ROM) for the intact C4-C5 level was 24.5° (standard deviation [SD], 6.6°). A facetectomy at this level significantly increased the in vitro ROM to 51.1° (SD, 4.4°). The in vitro ROM decreased to 19.8° (SD, 7.3°) in the facetectomized group of this study, which were allowed to heal for 6 months before death. Similar results were obtained in axial rotation and lateral bending. The findings show that after 6 months of healing, the injured canine spine, although acutely hypermobile, exhibited biomechanical characteristics that were not different from those of the normal intact specimens.