Aim

The prevention of surgical-site infection (SSI) is of great importance. Airborne particulate correlates with microbial load and SSI. There are many potential sources of airborne particulates in theatre and from an experimental point of view impossible to control. We evaluated the effectiveness of a novel air decontamination-recirculation system (ADRS) in reducing airborne particles in a laboratory environment and controlled the introduction of particulate using diathermy.

Background

Calcium sulfate and phosphate have a long clinical history of use as bone-void fillers (BVF) with established biocompatibility and resorption profiles. It has been widely reported that the addition of ‘impurity’ elements such as Silicon, Strontium and Zinc to calcium phosphate is advantageous, resulting in an improved bone healing response.

Introduction

The possibility of corrosion at the taper junction of hip replacements was initially identified as a concern of generating adverse reactions in the late 1980s. Common clinical findings of failure are pain, clicking, swelling, fluid collections, soft tissue masses, and gluteal muscle necrosis identified intra operatively.

Introduction

Bone marrow stimulation has been a successful treatment option in cartilage repair and microfracture was the procedure of choice since the late 1980s. Despite its success in young and active patients, microfracture has inherent shortcomings such as shallow channels, wall compression, and non-standardized depth and diameter. This in vitro study assessed bone marrow access comparing microfracture, 1 and 2mm K-Wires, 1mm drill, and a recently introduced standardized subchondral bone needling procedure (Nanofracture) that creates 9mm deep and 1mm wide channels.

Summary

Timing for the application and use of fentanyl patches for pre-emptive analgesia and sedation is crucial to obtain good clinical outcomes. Placement and timing is important to maximise clinical effect and apparent levels of analgesia.

Summary Statement

Supercritical fluid (SCF) sterilization produces clean and osteoconductive allograft bone capable of healing a critical-sised bony defect. SCF treated graft induces an increased anabolic response and decreased catabolic reponse compared to gamma irradiated graft.

Introduction

Post-arthroscopic glenohumeral chondrolysis (PAGCL) is a rare, but significant, complication of arthroscopic shoulder surgery that may lead to arthroplasty. Exact causal factors and pathways associated with the development of PAGCL are unknown however a number of patient factors and surgical factors have been implicated. Suture is one of these potential causal factors and currently little is known about the body's immune response to commonly used orthopaedic sutures. The aim of this project is to examine the biological response to 3 commonly used orthopaedic sutures (Ethibond, Fibrewire, and Orthocord) in a murine airpouch model. It was hypothesised that different sutures would elicit a different histological response and that suture wear-debris would induce an increased inflammatory reaction compared to intact suture.

In patients with conventional metal-on-Polyethylene (MoP) hip replacements, osteolysis can occur in response to wear debris. During revision hip surgery, surgeons usually remove the source of osteolysis (polyethylene) but cannot always remove all of the inflammatory granulomatous tissues in the joint. We used a human/rat xenograft model to evaluate the effects of polyethylene granuloma tissues on bone healing. Human osteoarthritic and periprosthetic tissues collected during primary and revision hip arthroplasty surgeries were transplanted into the distal femora of athymic (nude) rats. The tissues were assessed before and after implantation and the bone response to the tissues was evaluated after 1 week and 3 weeks using micro-computed tomography, histology, and immunohistochemistry. After 3 weeks, the majority (70%) of defects filled with osteoarthritic tissues healed, while only 21% of defects with polyethylene granuloma tissues healed. Polyethylene granuloma tissues in trabecular bone defects inhibited bone healing. Surgeons should remove polyethylene granuloma tissues during revision surgery when possible, since these tissues may slow bone healing around a newly implanted prosthesis. This model provides a method for delivering clinically relevant sized particles into an in vivo model for investigation.

Introduction

The need for regeneration and repair of bone presents itself in a variety of clinical situations. The current gold standard of treatment is autograft harvested from the iliac crest or local bone. Inherent disadvantages associated with the use of autogenous bone include limited supply, increased operating time and donor site morbidity. This study utilized a challenging model of posterolateral fusion to evaluate the in vivo response of an engineered collagen carrier combined with nano-structured hydroxyapatite (NanOss Bioactive 3D, Pioneer Surgical) compared to a collagen porous beta-tricalcium phosphate bone void filler (Vitoss BA, Orthovita).

Introduction

The reduction of intraoperative blood loss during total knee arthroplasty (TKA) and total hip arthroplasty (THA) and even organ resection is an important factor for surgeons as well as the patient. In order to cauterize blood vessels to stop bleeding diathermy is commonly used and involves the use of high frequency and induces localized tissue damage and burning. Saline-coupled bipolar sealing RFE technology however has been shown to reduce tissue carbonization, however the dosage effects of RFE are not well known for both bone and soft tissue. This study examined sealing progression of blood vessels using a range of energy levels of saline-coupled bipolar RFE on bone and various soft tissues in a non-survival animal study.

Fibrocartilaginous entheses are formed through endochondral ossification and characterized by four zones morphologically separated into tendon, uncalcified fibrocartilage, calcified fibrocartilage and bone [1]. These zones are not successfully regenerated following surgical repair. Demineralized Bone (DBM) presented at the tendon bone interface may improve healing between tendon and bone.

Fifty six female nude rats were randomly allocated into either a control reconstruction or treatment group (DBM at the tendon-bone healing site). A modified rodent model of anterior cruciate ligament reconstruction was adopted [2]. Animals were sacrificed at 2, 4 and 6 weeks following surgery. Four rats per group were prepared for histology at each time point while eight rats were culled for biomechanical testing at 4 and 6 week time points. ANOVA and post hoc tests were used to examine differences which were considered significant at p < 0.05.

The surgical procedure was well tolerated. Macroscopic dissection did not reveal any infection and all joint surfaces appeared normal. An intra-articular graft between the femur and tibia was present in all specimens. Mechanical differences were noted between groups. Peak loads were significantly higher in treatment group at 4 and 6 weeks (6.0 ± 3.6N and 9.1 ± 2.6 N, respectively) compared to controls (2.9 ± 1.9 N and 5.8 ± 2.7 N). No statistical differences were found in graft stiffness between the groups at 4 or 6 week time points. Histology showed an initial influx of inflammatory cells coupled with formation of a loose disorganized fibrovascular interface layer between tendon and bone in both groups. By the 6 weeks the interface layer in the DBM group fused into the newly formed bone to create a continuum between the tendon and bone, in an interdigitated fashion, containing Sharpy's like fibres. In the control group the continuum was less apparent with evidence of large areas of discontinuity between the two zones. A thicker region of newly formed woven bone with increased osteoblast activity along the bone tunnel was evident in the DBM group.

DBM has the potential to increase the quality of repair following surgical procedures involving reattachment of tendon to bone.

The biological properties of morselised bone allograft treated with either a supercritical fluid process or low-dose (15 kGy) gamma irradiation were compared using radiological, histological and immunohistological techniques. The aims were to investigate any differences in the biological properties of supercritical fluid treated allograft and low-dose gamma irradiated allograft in-vivo.

Rabbit allograft were cleaned of all soft tissue, cartilage and processed into ‘corticancellous crunch’ using a Noviomagus Bone Mill. Pooled samples were either gamma irradiated (15 kGy) or treated by NovaSterilis using super critical carbon dioxide. A well-reported tibial defect model in ten rabbits was used to examine the in vivo response of the different treatments at two and four weeks following surgery (n=5 per time point). Radiographic (x-ray, CT and micro CT), histology and immunohistochemistry was used to assess the in vivo response.

Radiographic results revealed an initial response to the gamma-irradiated samples compared to SCF. Histology confirmed this reaction to be inflammatory in nature at two weeks that continued at four weeks for the gamma irradiated samples. In contrast, the SCF treated sample demonstrated new bone formation while the inflammatory reaction was muted compared to the gamma irradiated samples. Four week x-rays and histology confirmed new bone formation in both groups while the lack of significant inflammatory response in the SCF group was noted.

Allograft sterilisation techniques do not result in the same initial response when evaluated in vivo. Removal of lipids and cellular debris following SCF treatment may influence the in vivo response. While both techniques can provide a sterile product, the in vivo response requires further investigation.

Posterolateral spinal fusion using autograft in adult rabbits has been reported by many groups using the Boden model. Age in general has an adverse effect on skeletal healing; although, its role in posterolateral fusion is not well understood. This study examined the influence of animal age on spinal fusion using a standard model and experimental endpoints. We hypothesised that fusion quality and quantity would be less with increasing age.

A single level posterolateral fusion between the fifth and sixth lumbar segments were performed in six-month and two-year-old New Zealand white rabbits (n=6 per group) using morcelized iliac crest autograft. All animals were sacrificed at 12 weeks following surgery. Posteroanterior Faxitron radiographs and CT scans were taken and DICOM data was analysed (MIMICS Version 12, Materialise, Belgium). Axial, sagittal, coronal and three-dimensional models were created to visualise the fusion masses. Bone mineral density (BMD) of the fusion mass was measured using a Lunar DPXL Dexa machine. An MTS Bionix testing machine was then used to assess peak load and stiffness. Sagittal and coronal plane histology was evaluated in a blinded fashion using H&E, Tetrachrome and Pentachrome stains. Assessment included overall bony response on and between the transverse processes. Radiographs and CT confirmed a more robust healing response in younger animals. Radiographic union rates decreased from 83% to 50% in the aged animals. A neo- cortex surrounding the fusion mass was observed in the younger group but absent in the aged animals. Fusion mass BMD and that of the vertebral body was decreased in the older animals (P<0.05). Tensile mechanical data revealed a 30% reduction in peak load (P=0.024) and 34% reduction in stiffness (P=0.073) in the two-year-old animals compared with the six-month-old animals. Histological evaluation demonstrated a reduction in overall biological activity in the two-year-old animals. This reduction in activity was observed in the more challenging intertransverse space as well as adjacent to the transverse processes and vertebral bodies at the decortication sites. Numerous sites of new bone formation was present in the middle of the fusion mass in the six-month-old animals while the bone graft in the two-year- old animals were less viable.

Skeletal healing is complex and mediated by both local and systemic factors. This study demonstrated that ageing leads to an impaired and delayed skeletal repair.

Where autograft is utilised, diminished graft osteoinductivity and reduced levels of growth factors and nutritional supply in the surrounding milieu explains our observations. The aged rabbit posterolateral spinal fusion model has not been previously described but would be a useful to evaluate new treatment modalities in a more challenging host environment.

Single level posterolateral spinal fusion in rabbits is the accepted preclinical model for evaluating bone graft substitutes or treatments to enhance/augment healing. This study aimed to improve preclinical testing by developing a multi-level unilateral fusion model that could be used as a screening tool prior to larger scale preclinical experiments.

A four level unilateral posterolateral fusion was performed in nine animals. The materials were randomly allocated and placed between the decorticated surfaces of the transverse processes and vertebral bodies. Animals were euthanised at three, six and 12 weeks. The materials were (1) 25 kGy y-irradiated rabbit allograft chips (RAC), (2) SCF RAC, (3) 60% tri-calcium phosphate, 40% hydroxyapatite formagraft (BiOstetic) (4) Autograft (1.5 cc morsellised to 1-2.5 mm granules). The autograft was harvested from the iliac crest using the L5-L6 incision. Endpoints included x-ray, CT, micro CT and histology.

The animals tolerated the surgery well. Radiographic data provided a useful method to differentiate between groups. Micro CT however was extremely valuable demonstrating new bone formation as early as three weeks across the groups. Gamma irradiated samples demonstrated an initial inflammatory reaction while the autograft, SCF allograft and synthetic TCP did not show this response. As expected, time was an important factor demonstrating the maturity in the fusions. These materials responded in a similar fashion in this model as observed in a single level fusion.

A unilateral multi-level fusion can be performed in rabbits to provide a useful screening for different materials. Gamma irradiated allograft has an initial inflammatory reaction that may be related to the presence of residual cellular material whereas SCF and synthetic materials do not.

Introduction: Monobutyrin (MB) has been shown to be a potent angiogenic factor for adipose tissue. It is one of the many compounds secreted from adipocytes adding to the knowledge that adipose tissue is not merely a storage unit but has an endocrine function. Adipocytes and osteoblasts share a common precursor. In osteoporosis the proportion of fat in bone increases. As both are present at a fracture site the addition of MB may enhance fracture healing by stimulating angiogenesis.

Method: 138 Sprague Dawley rodents were ovarect-omised at 12 weeks of age. After a further 24 weeks each animal underwent a right closed femoral fracture stabilized with a retrograde k-wire using a standard model (Walsh et al. 1997). Animals were randomised into control (empty or substrate only) or MB of varying concentrations (2.5μg, 7.5μg, 25μg, 75μg). A percutaneous injection of 0.2mls of each of the above was then injected into the fracture site. Animals were culled at 1, 3 and 6 week time points post surgery. The right and left femurs were dissected out and analyzed using radiographic, mechanical testing, micro computed tomography and histology endpoints. Statistical analysis was perfomed with SPSS for windows.

Results: All animals recovered well from the procedure and no adverse reactions were noted following the addition of MB. A progression to union was seen with time in all groups. Mechanical testing did not result in a statistical difference between groups, however the trend showed improved healing in the 7.5μg Monobutyrin group. Radiographic grading again showed no statistical difference however, interestingly micro CT data showed an increasing trend in both trabecular number and bone surface area to volume with increasing concentrations of MB.

The histology results implied a potential acceleration in the early stage of fracture healing in the high dose (75 μg) MB group. However progression to union following this initial early phase acceleration was delayed as callus volume increased rather than union according to micro CT and histological data.

Discussion: The ability to augment fracture healing has significant clinical implications considering the “greying of society”. This study investigated the possibility of improving fracture healing by incorporating the angiogenic factor, Monobutyrin in an estrogen deficient animal model. Although the results do not conclusively demonstrate an improvement in fracture healing, they do imply that MB does affect the early phase of fracture healing in the estrogen deficient model. This study is limited in that the effects of MB on fracture healing in a non-estrogen deficient model was not considered. The ideal release kinetics for Monobutyrin as well as other factors remains unknown.

Distraction osteogenesis (DO) is useful for bone lengthening and deformity correction. Unfortunately, this often requires prolonged use of an external fixator with concomitant morbidities. This study investigates whether low-magnitude, high-intensity vibrations (Dynamic Motion Therapy, DMT) can accelerate maturation of regenerate bone in DO, thus reducing the duration of external fixation. 28 NZ White Rabbits underwent a right mid-tibial osteotomy with application of an Orthofix M-103 fixator (Orthofix, Busselengo, Italy). Distraction commenced on day 3 at 0.5 mm every 12 hours for 12 days. All animals were sacrificed on day 45. Animals were randomly assigned into 4 groups:

control group;

DMT was applied with the Juvent platform (Juvent, Somerset, NJ) for 10 minutes/day. X-ray and CT scans were taken prior to mechanical testing. All specimens were processed for histology. X-rays and CT scans showed evidence of cortical remodelling and re-establishment of the medullary canal in animals treated with DMT (groups 2, 3 and 4). This was most pronounced in animals treated during the distraction and consolidation phases (group 4). Regenerate bone in the control group (group 1) was more disorganised, with a delayed union evident in 1 animal. Group 1 achieved peak torque and stiffness values of 70% and 50% of the contralateral (unoperated) tibia respectively. No significant difference was seen in peak torque and stiffness between groups 2, 3, and 4, however each was significantly higher than group 1 (P< 0.05). H& E staining revealed less porosity in the newly formed cortical bone and a more defined medullary canal in animals treated with DMT than in the control group. Low-magnitude, high-intensity vibrations appear to accelerate cortical remodelling and reestablishment of a medullary canal. Regenerate bone in animals treated with DMT was also mechanically superior. The timing of DMT therapy did not appear to be important. Further studies are required to determine the optimal timing and duration of DMT therapy.

Although effects of mechanical stimulation with high frequency, low magnitude vibrations on bone mass and bone mineral density in animal and clinical studies have been proven effective, its effects on fracture healing is less well described.

20 Sham and 20 ovarectomised (Ovx) Sprague Dawley rats at 22 weeks of age, had intra-medullary k-wire fixation followed by controlled mid-shaft fractures.

The animals were divided into subgroups of 3 week Sham and Ovx treated and non-treated and 6 week Sham and Ovx treated and non-treated groups.

The treated animals were vibrated for 20mins daily on a DMT (dynamic motion therapy) platform which had a frequency of 30hz, 8-micron vertical displacement and 3g force, the non treated animals allowed to move freely. Xrays, DEXA studies, micro computed tomography, Histological analysis and Mechanical studies performed at the end point.

DMT treated animals had more bridging callus on radiographic and micro computed tomographic analysis compared to non-treated groups especially the OVX groups at 3 weeks compared to controls or Shams (using Image J software). DEXA studies showed increased bone mineral density and bone mineral content in the treated animals compared to the controls. Histological analysis showed increased callus and woven bone being laid down in the treated OVX groups.

In the 6-week groups, the treated OVX groups had healed, remodelled fractures compared to the non-treated groups or Sham controls where the fracture gaps were still visible. Although significance was not achieved on mechanical analysis due to small sample size, in the OVX non-operated femora group that were treated with DMT there were indications that they were stronger than the control counterparts.

High frequency low magnitude vibrations with the Juvent DMT device enhances fracture healing in oestrogen deficient models and this model could be used as a platform for clinical studies in future.

Introduction: The use of bioabsorbable devices in sports medicine surgery in the shoulder and knee continues to evolve as new designs, devices and materials become available. Concerns over potential problems associated with metal artifacts and permanent metal devices continue to motivate the development and use of polymeric based devices. Calaxo interference screws (Smith & Nephew Endoscopy, Andover, MA) are composed of a novel bioabsorbable material blend of poly DL- lactide – co – glycolide 85:15 (65%) and calcium carbonate (35%). These screws have been shown to be osteoconductive when placed in the centre of a 4 stranded tendon graft in an ovine ACL reconstruction [1]. The screws are fully resorbed at 26 weeks with new bone formation in the tunnel. In general, osteoconductive materials are often more effective when placed adjacent to a bony bed. This study investigated whether positioning the Calaxo screw adjacent to the bone tunnel was superior to screw placement within the tendon as in our previous study [1].

Materials and Methods: An intra-articular anterior cruciate ligament (ACL) reconstruction model using 2 doubled over tendon autografts whip stitched and inserted into the right hind limb of 8 sheep were used. Animals were culled at 26 or 52 weeks following surgery (n=4 per time point) and data was compared using the same surgical model but with screws placed in the center of the 4 stranded graft (Walsh et al., 2006). The tibias were CT scanned and processed for paraffin histology along the axis of the bone tunnel. Three dimensional models using the DICOM data obtained from the CT where made using MIMICS (Materialise, Belgium).

Result & Discussion: Results showed excellent biocompatibility of the screws with no adverse reactions at 26 and 52 weeks as in our previous study [1]. The screws were fully resorbed by 26 weeks with new bone replacing the PLC material. Similarly, the screws were not detectable at 52 weeks with new bone formation where the screw had previously resided. The intra-articular portion of the graft, articular cartilage and synovium was normal at 26 and 52 weeks as previously reported [1]. Tendon – bone healing proximal to the screw progressed in a normal fashion. No calcification of the intraarticular portion of the graft was noted. Computed tomography, 3D models and histology revealed an osteoconductive response to the PLC material with new bone formation as the material degraded in vivo.

Placement of the screw adjacent to the tendon graft and thus against the bone tunnel appears to provide superior results compared to screw placement in the middle of the graft sleeve device. This effect may be due to direct contact of the osteoconductive material to the adjacent bone bed.

[1] Walsh et al., Arthroscopy 2006, in press.