Objective

Human bone marrow stromal cells (HBMSCs) are multipotent and can form bone, cartilage or other tissues under different inductive conditions. The aim of this study was to investigate the effects of enamel matrix derivative (EMD) on the growth and osteogenic differentiation of HBMSCs.

Introduction: Anterior cruciate ligament (ACL) rupture impairs knee stability. Reconstruction of the ACL is therefore performed to restore knee stability and avert risk of subsequent ligament and meniscal injury. Bone-patellar tendon-bone autograft is the most commonly employed technique for ACL reconstruction and considered the “gold standard”. Although 10% postoperative patellar tendon shortening has been reported with this technique, there are no systematic studies assessing the effect of this shortening on patellofemoral joint (PFJ) biomechanics under loading conditions simulating normal physiologic activity. The purpose of this study was to determine if 10% shortening of the patellar tendon affected PFJ biomechanics.

Methods: Patellofemoral contact characteristics were evaluated in cadaveric knees before and after patellar tendon shortening. Tendon shortening was performed using a specifically designed device that shortened the tendon without interfering with its anatomic and physiologic integrity. Conditions simulating light physical activity such as level walking were recreated by applying physiological quadriceps loads and corresponding angles of tibial rotation to the PFJ at 15°, 30° and 60° of knee flexion. PFJ contact areas were measured at each position of knee flexion before and after patellar tendon shortening using the silicone oil-carbon black powder suspension squeeze technique (3S technique, Yao & Seedhom, Proc Instn Mech Engrs1991;205:69–72). Differences were compared using the Wilcoxon signed rank t-test, with p< 0.05 required for statistical significance.

Results: Twelve unembalmed cadaveric knees (median age 81.8 years, 8 female: 4 male) were available for study. Five knees had evidence of osteoarthritic changes, and were rejected. The remaining 7 knees were macroscopically intact and were considered adequate for the experimental procedure. The mean patellofemoral contact areas and stresses determined preoperatively were comparable to those reported in normal knees in previous studies. Following patellar tendon shortening, PFJ contact areas were displaced superiorly on the patellar articular surface and distally on the femoral articular surface. Although the PFJ contact area increased by 17% at 15° of knee flexion (p=0.04), no significant change occurred at 30° or 60° of knee flexion (p> 0.05). Patellofemoral contact stress did not differ before and after patellar tendon shortening (p> 0.05) at any angle of knee flexion.

Conclusions: Our results suggest that with light activity such as level walking, a 10% postoperative shortening of the patellar tendon does not alter patellar tracking (in particular contact stresses) and therefore may not impact biomechanics of the patellofemoral joint. Extrapolating these results to the clinical scenario, deleterious consequences on the patellofemoral joint are unlikely after bone-patellar tendon-bone autograft reconstruction of the ACL despite the possibility of postoperative patellar tendon shortening.

Aim: To develop a 3-D pre-surgical planner that facilitates selection and placement of correct prosthetic components in the joint, and the design of patient specific templates to use intra-operatively to reproduce the pre-planned implantation procedure, in total knee replacement (TKR) surgery.

Design/Methods: The process begun with loading of pre-operative CT scan data of cadaver knee, onto medical software, followed by reconstructions of 3D models of the joint. Then measurements of anterior-posterior diameter of the femoral condyles of the 3D models of the joint were used to select and import a correct CAD drawing of prostheses from a database of electronic files available in a range of sizes. The selected prosthetic components were positioned and aligned on the 3-d model of the joint, making sure that the anterior flange of the femoral prosthesis component did not violate superior cortical bone of trochlea. Whilst the tibial stem was placed central within the medullar space of the bone, and the plane of the tibial cut was perpendicular to the long axis of the tibia. The planned data were next exported to a CAD environment where template to prepare the bone to receive the prostheses, was designed. A template was designed to press fit on a bone (e.g. femur), via minimum number of cylindrical protrusions with their ends made to conform to the geometry of that bone at the regions of contact. The integrated surgical tools were secured to the bones with pins through each of the protrusions, and were equipped with saw guide slits for cutting the bone, and with drill guides for drilling the fixation holes. Thereafter the files describing templates and prosthetic components selected for cadaveric joint concerned were sent to rapid prototyping machine for manufacturing.

Results: Fourteen procedures were performed on cadaveric knees to date. Visual examination of the joint has revealed the 3-D planning system enabled correct selection of appropriate prosthetic components and alignment, as evidenced by absence of protrusions or overhanging beyond the edges of the bones. The resected bone surfaces were visually smooth and flat. Gaps between the bones and the internal surfaces of the prosthetic components were measured using steel shim gauges, and largest recorded was 0.9mm. Laxity between the femur and tibia was absent and the joint attained full range of flexion. Dimensional deviations of post-operative scans of the prepared bones from the pre-planned ones were between 0.5 and 0.9mm. The templates after their use were shown capable to withstand the rigors of theatre environment.

Conclusion: With the planning software, it has been shown that it is possible to design a simple to use implantation guidance system according to the final position of the restorative prosthesis and the bone pathological condition. Pre-operative planner system relieves the clinician from multiple intra-operative decisions. The system is ideal for critical anatomical situations and eliminates possible manual placement errors such as those from extra and intra-medullary alignment tool. Less inventory required of both implants and instrumentation means reduced complexity of procedure, surgical time and cost.

Aim: The aim of this study is to visualize the structural changes of both the matrix collagen meshwork and the chondrocyte cytoskeleton of articular cartilage when it is subjected to tensile strain.

Materials and Methods: Dumbbell-shape specimens were harvested from the articular surface of the femur. Specimens were placed with the articular surface uppermost each in individual mini tension device and subjected to a graded series of tensile strains, whilst being observed with phase contrast light microscopy. Thereafter each specimen was fixed in its particular position of strain, and stained with fluorochrome conjugated primary antibodies specific for actin and vimentin and with DAPI for nuclear staining for observation by confocal laser scanning microscopy (CLSM).

Results: Phase contrast microscopy visualized the reorganization of the matrix which became aligned parallel to the direction of strain, resulting in the deformation of the chondrocyte and their nuclei into an elliptical shape. CLSM demonstrated the reorganization of the matrix and chondrocyte cytoskeleton; at no strain, the vimentin meshwork spanned the cytoplasm from plasma membrane to nuclear membrane. At 20% strain, the vimentin meshwork became aligned parallel to the direction of strain and the nucleus was deformed into elliptical shape.

Discussions: There are two possibilities to explain the structural changes in the chondrocyte under tensile strain. 1.The collagen meshwork becomes aligned parallel to the direction of tensile strain, squeezing the chondrocyte into the observed elliptical shape subsequently with the cytoskeleton reorganizing in response to it. 2.The collagen meshwork transfers the tensile strain through the plasma membrane to the vimentin meshwork which reorganizes and subsequently results in the changes in chondrocyte morphology. Further explanation is required to test the above two hypotheses.

Introduction: Cartilage is an anisotropic material whose structure and tensile properties vary with the depth from the articular surface. Further, ultrastructural changes of articular cartilage under strain are poorly understood. The aim of this study therefore was to visualize the zonal variations in ultrastructural changes of cartilage when subjected to a range of tensile strains to failure.

Materials and Methods: 3 osteochondral plugs were harvested from the femur of a 3 years old bovine with a cylindrical reamer. Cartilage was cut parallel to the articular surface into the superficial, middle and deep layers, 300μm thick each and then each was cut normal to the surface into dumbbell shaped specimen 10 mm long. Each specimen (9 in total) was clamped in an individual mini tension device and subjected to a specific strain, then fixed and processed whilst still under strain within its tension device for observation with SEM.

Results: When specimens were observed in en face view under no strain, a fibrillar meshwork was seen to run parallel to the articular surface in the superficial layer, randomly in the middle layer and perpendicular to the articular surface in the deep layer. Under strain the fibrillar meshwork began to reorient parallel to strain (tangential to the surface) in each layer. At 20% strain the whole fibrillar meshwork was reoriented and formed bundles in the superficial layer. In the middle layer almost whole of the fibrillar meshwork was reoriented at 40% strain. In the deep layer the fibrillar mesh-work was reoriented parallel to the strain in some areas, while in the other areas it was still seen perpendicular to the surface even at 70% strain.

Conclusions: The collagen meshwork of cartilage was reorganised under strain and this appears to play an important role in cartilage extension. Thus the more rapid reorientation in the superficial layer may result in its reduced extensibility compared to that of the deeper layers.

Introduction: Isolated PCL ruptures are most frequently treated non-operatively, although PCL deficiency may ultimately lead to degenerative changes within the patellofemoral compartment. This study investigated, for the first time under physiological loading conditions, the change in patellar tracking as a result of PCL deficiency, hoping to further understand the clinical consequences in situations where such an injury is treated conservatively.

Method: Using eight fresh cadaveric knees, physiological axial tibiofemoral loads and rotatory torques occurring during level walking, were applied to determine tibial rotation angles. These were then used under dynamic Quadriceps femoris loading to determine contact areas and stresses within the patellofemoral joint at 15°, 30°, 60° and 90° of knee flexion. The PCL was then severed, and the procedure repeated under the same loading conditions.

Results: Significant increases in patellofemoral contact stress in the PCL deficient knees were observed at 15° and 30° knee flexion, both in internal and external rotation of the tibia (TABLE I). For these respective rotation positions the increases were 23% and 20% at 15°, and 19% and 28% at 30°, (in all cases p≤0.05). These significantly increased stresses coincided with unchanged contact patterns on the inferior third of the patella, spanning both its medial and lateral facets.

Conclusions: The increased stresses were due to increased patellofemoral joint reaction force, caused by a decreased angle between the quadriceps and patellar tendons due directly to posterior tibial translation in the PCL deficient knees. Significantly increased patellofemoral contact stresses at 15° and 30° of knee flexion, may be implicated in the degeneration of articular cartilage, on both the medial and lateral facets of the inferior third of the patella. These results point out the need for further biomechanical studies to investigate the effects of more strenuous loading conditions. There is also need for clinical studies to investigate focal lesions associated with long-term PCL deficiency.

It was aimed to investigate the isolated effect of hydrostatic pressure on chondrocyte metabolism. Chondrocytes obtained from bovine metatarso-phalangeal joints were cultured in cylindrical 2% agarose gels. A special apparatus which was designed and constructed, allowed the application of hydrostatic pressure of either 2 MPa or 5 MPa on the chondrocytes for 4 hours either in a pulsatile (1Hz) or a static manner. Changes in the syntheses of glycosaminoglycan (GAG) and DNA during and after the application of the hydrostatic pressure were analysed with ³⁵S-sulphate and ³H-thymidine incorporation, respectively. Radiolabelling was carried out for the following conditions: (a) 4 hours during the application of hydrostatic pressure; (b) 4 hours and (c) 20 hours immediately after the application of load. In addition, the experiments were carried out at 2 days, 7 days and 14 days after embedding the chondrocytes in agarose gels. Static hydrostatic pressure of 5 MPa caused a significant increase by 13% on average in the GAG synthesis during the load application on Day 2 7 and 14 (p < 0.05). On the contrary, pulsatile pressure of 2 MPa caused a significant decrease by 17% in the GAG synthesis measured at 20 hours after the loading on Day 14 (p < 0.01). In addition, there was a significant decrease by 29% in the DNA synthesis measured at 4 hours after the pulsatile loading of 5 MPa on Day 7 (p < 0.01). The results suggest that hydrostatic pressure alone, which causes no cell deformation, can affect the GAG synthesis and proliferation of chondrocytes. In addition, the effect of hydrostatic pressure on the chondrocyte metabolism varies according to the regimes of loading and with the period of cell culture.

There are various methods of measuring proprioception at the knee. Beard et al (1993) have described a delay in reflex hamstring contraction in anterior cruciate deficient knees. We have repeated their experiment and were unable to detect any significant difference in reflex hamstring contraction between the injured and uninjured legs. We discuss possible neurophysiological and biomechanical causes for the conflicting results and conclude that this method may not be a valid measure of proprioception.

We describe a new method for the reconstruction of ruptures of the patellar ligament or the quadriceps tendon, using the flexible open-weave polyester Leeds-Keio prosthetic ligament. Of 25 operations performed since 1985, we were able to review 18 patients (19 knees) with a mean follow-up of 3.5 years (3 to 6.5). No patient had required immobilisation of the knee after operation and the average period to return to normal activities without a walking aid was 10.5 weeks. The average range of motion was 146 degrees, and four patients could squat fully in the Japanese style. There was an extension lag (< 10 degrees) in only four patients; eight patients had some patellar crepitus which was mildly painful in three. There were no cases of infection, persistent joint effusion or rerupture of the extensor apparatus.

The healing of anterior cruciate ligaments reconstructed with the Leeds-Keio artificial ligament was observed by arthroscopy in 42 knees and biopsy in 19 knees at intervals from 3 to 24 months after implantation. By three months the implant was covered with immature new tissue, and a dense vascular network crossed its surface. At 12 months a new ligament had developed and matured, looking like the natural one in most cases. Histology at this stage showed abundant collagenous fibres running parallel and longitudinally, while the synovial membrane showed no more than very slight inflammatory changes. By 18 to 24 months, the new ligament often had the arthroscopic appearance of a normal anterior cruciate ligament. These results suggest that this scaffold type of artificial ligament is effective for cruciate reconstruction, giving satisfactory healing without significant complications.

The effects of advancement of the tibial tuberosity by inserting bony wedges was studied on cadaveric specimens of the knee. The geometry, the contact areas and the forces acting on the patellofemoral joint were investigated, and the forces acting on the tibiofemoral compartment were calculated. A 1 cm advancement was found to be optimal in reducing the high patellofemoral joint forces occurring at 90 degrees and 110 degrees of flexion, whilst causing least reduction of the contact areas; the stresses on the joint were reduced significantly. Advancement by 2 cm and by 3 cm drastically reduced the congruity and the size of the contact area. It was also shown that 2 cm and 3 cm advancement caused an increase in forces at the patellofemoral joint and also in the tibiofemoral joint in a direction tangential to the articular surfaces.