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Papers by Chris Arts

Orthopaedic Proceedings

AimProsthetic joint infections pose a major clinical challenge. Developing novel material surface... more AimProsthetic joint infections pose a major clinical challenge. Developing novel material surface technologies for orthopedic implants that prevent bacterial adhesion and biofilm formation is essential. Antimicrobial coatings applicable to articulating implant surfaces are limited, due to the articulation mechanics inducing wear, coating degradation, and toxic particle release. Noble metals are known for their antimicrobial activity and high mechanical strength and could be a viable coating alternative for orthopaedic implants [1]. In this study, the potential of thin platinum-based metal alloy coatings was developed, characterized, and tested on cytotoxicity and antibacterial properties.MethodThree platinum-based metal alloy coatings were sputter-coated on medical-grade polished titanium discs. The coatings were characterized using optical topography and scanning electron microscopy with energy dispersive spectroscopy (SEM/EDS). Ion release was measured using inductively coupled pl...

Orthopaedic Proceedings, Feb 21, 2018

Journal of Bone and Joint Surgery, American Volume, Sep 1, 2006

Management of Periprosthetic Joint Infections (PJIs), 2017

Multiple difficulties occur during treatment of different orthopedic infections such as biofilm f... more Multiple difficulties occur during treatment of different orthopedic infections such as biofilm formation, osteonecrosis, destruction of bone matrix, and compromised soft tissues and vascularization. Biomaterials can be used to treat the infection and to solve the different treatment difficulties. These biomaterials can elicit local antibacterial therapy, which is necessary for optimal treatment of orthopedic infections. Furthermore, they can also be used as a bone defect filler after debridement surgery. Different types of biomaterials are developed: antibiotic-loaded collagen fleeces and ceramic or composite calcium-based bone graft substitutes as calcium sulfates, calcium phosphates, and hydroxyapatite. Another biomaterial used in treatment of these infections is bioactive glass. In this chapter, the properties of different biomaterials regarding treatment of infection are elucidated and the clinical results of these biomaterials in treatment of chronic osteomyelitis are discussed.

Journal of Biomedical Materials Research Part A, 2017

Calcium phosphate cements (CPCs) are commonly used as bone substitute materials. However, their s... more Calcium phosphate cements (CPCs) are commonly used as bone substitute materials. However, their slow degradation rate and lack of macroporosity hinders new bone formation. Poly(dl‐lactic‐co‐glycolic acid) (PLGA) incorporation is of great interest as, upon degradation, produces acidic by‐products that enhance CPC degradation. Yet, new bone formation is delayed until PLGA degradation occurs a few weeks after implantation. Therefore, the aim of this study was to accelerate the early stage pore formation within CPCs in vitro. With that purpose, we incorporated the water‐soluble porogen sucrose at different weight percentages (10 or 20 wt %) to CPC and CPC/PLGA composites. The results revealed that incorporation of sucrose porogens increased mass loss within the first week of in vitro degradation in groups containing sucrose compared to control groups. After week 1, a further mass loss was observed related to PLGA and CPC degradation. Macroporosity analysis confirmed that macroporosity f...

Spine, 2014

Introduction: Growth-guidance or self-lengthening rod systems are an alternative to subcutaneous ... more Introduction: Growth-guidance or self-lengthening rod systems are an alternative to subcutaneous growing rods and the vertical expandable prosthetic titanium rib (VEPTR) for the surgical treatment of early onset scoliosis (EOS). The main perceived advantage in comparison to growing rods is the marked decrease in subsequent operative procedures. Therefore growthguidance systems are especially suitable for neuromuscular EOS patients, who often suffer from significant comorbidities. The Shilla growth-guidance system and a modern Luque trolley are examples of such systems; both depend on gliding pedicle screws and/or sliding titanium sublaminar wires. However, the unknown consequences of metal-on-metal wear debris are reason for concern in young patients. Another disadvantage of gliding pedicle screws is that thoracic pedicle screw placement can-be difficult due to the distorted vertebral anatomy often seen in scoliosis. Easy placement of sublaminar wires offers surgeons a valuable alternative to pedicle screws in those technically challenging cases. Ultra high molecular weight polyethylene (UHMWPE) or other polymeric sublaminar cables have already been introduced for spinal deformity surgery; the soft and flexible structure of woven UHWMPE wires decreases the risk of neurological injury, while the broad shape distributes contact forces over a greater area, thus allowing for higher correction forces. Despite the increased contact surface, internal data has shown that UHMWPE cables exhibit lower friction during longitudinal sliding along spinal rods as compared to titanium sublaminar wires in an in vitro test setup, indicating the potential for allowing continuation of longitudinal spinal growth. Until now, radiolucency of UHWMPE wires has limited the possibility for postoperative radiological assessment and subsequent clinical use. The development of novel radiopaque UHMWPE wires, with bismuth-oxide particles blended into each fiber, allows for clinical application. The goal of this study consists of two parts: (1) to test the stability and biocompatibility of novel radiopaque UHMWPE wires as sublaminar wire, and (2) to assess the potential of using UHMWPE sublaminar wires in a growth guidance system for EOS. Methods: An intervention group of twelve immature sheep (18 weeks old) received posterior segmental spinal instrumentation; pedicle screws were inserted at L5 and UHWMPE wires were passed sublaminarly at each level between L3 and T11. Dual cobaltchromiun rods were placed along the spine between levels L5 and T11 and fixed by set-screws at the pedicle screw attachment sites. The UHMWPE sublaminar wires were secured used a double-loop sliding knot, tightened to 100N, and secured with multiple granny knots. The control group consisted of four age-matched, unoperated animals in order to determine 'normal' spinal growth.. Lateral radiographs were taken at 4-week intervals to evaluate growth of the instrumented segment. After 24 weeks, the animals were sacrificed and the spines were harvested for histological evaluation and high-resolution peripheral quantitative computed tomography (HR-pQCT) analysis. Prior to HR-pQCT scanning, the spinal rods were removed. The occurrence of spontaneous spinal fusion was assessed by manual palpation. Results: No neurological deficits occurred during the postoperative period. One animal died during follow-up (7 weeks postoperatively) due to unknown cause. At sacrifice, none of the cables had loosened and all instrumentation remained stable. Substantial growth occurred in the instrumented segments (L5-T11) in the intervention group (2.67± 0.16 cm). Spinal growth was slightly higher in the control group, (2.96 ± 0.35cm), but this difference was not statistically significant (p=0.42). Manual palpation revealed a solid, spontaneous fusion across all instrumented levels. HR-pQCT analysis (figure 1) showed interlaminar ossification, possibly a result of periosteal stripping. Typical bone formation encircling the posterior rods coupled with degenerative facet joint changes were also seen. Histological analysis revealed fibrous encapsulation of the novel radiopaque UHMWPE sublaminar wires in the epidural space (typical physiological response to foreign materials), with no evidence of chronic inflammation or wear debris. Discussion: Despite the occurrence of spontaneous fusion in all cases, UHMWPE sublaminar cables allowed for almost normal continued growth of the instrumented spinal segments during follow-up. Extrapolation of these results to the pediatric patient population is difficult due to a much higher growth velocity in animals, but also due to the exaggerated bone formation response typical for quadrupedal animal models in which higher spinal loads lead to stronger mechanical stimuli to form new bone (Smit). Fibrous encapsulation of the cable and preservation of instrumentation stability during the course of this study show that the application of these novel radiopaque UHMWPE sublaminar cables in spinal deformity correction surgery is safe. Further research into the fate of bismuth-oxide particles however is ongoing.

$Research paper thumbnail of Assessment of the healing process in distal radius fractures by high resolution peripheral quantitative computed tomography$

Bone, 2014

DOI to the publisher's website. • The final author version and the galley proof are versions of t... more DOI to the publisher's website. • The final author version and the galley proof are versions of the publication after peer review. • The final published version features the final layout of the paper including the volume, issue and page numbers. Link to publication General rights Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. • Users may download and print one copy of any publication from the public portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying the publication in the public portal. If the publication is distributed under the terms of Article 25fa of the Dutch Copyright Act, indicated by the "Taverne" license above, please follow below link for the End User Agreement:

International Journal of Research, 2015

Background The nature of distal femoral osteochondromas in term of size and position in patients ... more Background The nature of distal femoral osteochondromas in term of size and position in patients with hereditary multiple osteochondromas, (HMO) during skeletal growth has never been assessed before. This study was set up to address three specific aims: 1) to assess whether it is possible to reproducibly measure growth of osteochondromas on plain X-rays, 2) to assess which parameters best describe the relationship between growth of the femur and development of osteochondromas, and 3) to assess whether the osteochondromas’ place of origin and its positional relation to the femur changes during skeletal growth. Methods Weretrospectively reviewed X-rays of tenpatients diagnosed withHMO, with sixteen individual osteochondromas and measured: length of the femur from the fossa piriformis to the joint line of the knee, distance from the base of the osteochondroma to the joint line of the knee, the base of the osteochondroma, cross section of the femur at the most proximal part of the base ...

Background: Total ankle arthroplasty is increasingly used as a treatment for endstage ankle arthr... more Background: Total ankle arthroplasty is increasingly used as a treatment for endstage ankle arthropathy. The aim of our study was to report the mid-term clinical function and survival results of Ceramic Coated Implant (CCI) ankle replacements and assess the association between the alignment of the CCI total ankle replacements and early functional outcome and complication incidence.Methods: Data of 61 patients, who received 65 CCI implants between 2010 and 2016, were obtained from a prospectively documented database. Mean follow-up time was 85.2 months (range 27-99 months). Clinical function was assessed with AOFAS questionnaire and passive range of motion (ROM). Survival analysis and elaborate radiographic analysis was performed. Furthermore, complications and re-operations were recorded for all patients Results: Progression in ROM was most seen in the first 10 months from 21.8 degrees of passive range of motion preoperative to 27.6 degrees postoperative (p< 0.001), while the AOF...

Journal of biomedical materials research. Part B, Applied biomaterials, Jan 27, 2017

Polymeric sublaminar cables have a number of advantages over metal cables in the field of spinal ... more Polymeric sublaminar cables have a number of advantages over metal cables in the field of spinal deformity surgery, with decreased risk of neurological injury and potential for higher correction forces as the two most predominant. However, currently available polymer cables are radiolucent, precluding postoperative radiological assessment of instrumentation stability and integrity. This study provides a preclinical assessment of a woven UHMWPE cable made with radiopaque UHMWPE fibers. Our primary goal was to determine if the addition of a radiopacifier negatively affects the mechanical properties of UHMWPE woven cables. Tensile mechanical properties were determined and compared to suitable controls. Radiopacity was evaluated and radiopacifier leaching was assessed in vitro and in vivo. Finally, in vivo bismuth organ content was quantified after a 24-week implantation period in sheep. Results show that the mechanical properties of woven UHMWPE cables were not deleteriously affected b...

BMC medical imaging, Feb 27, 2017

Carbon-fiber-reinforced poly-ether-ether-ketone (CFR-PEEK) has superior radiolucency compared to ... more Carbon-fiber-reinforced poly-ether-ether-ketone (CFR-PEEK) has superior radiolucency compared to other orthopedic implant materials, e.g. titanium or stainless steel, thus allowing metal-artifact-free postoperative monitoring by computed tomography (CT). Recently, high-resolution peripheral quantitative CT (HRpQCT) proved to be a promising technique to monitor the recovery of volumetric bone mineral density (vBMD), micro-architecture and biomechanical parameters in stable conservatively treated distal radius fractures. When using HRpQCT to monitor unstable distal radius fractures that require volar distal radius plating for fixation, radiolucent CFR-PEEK plates may be a better alternative to currently used titanium plates to allow for reliable assessment. In this pilot study, we assessed the effect of a volar distal radius plate made from CFR-PEEK on bone parameters obtained from HRpQCT in comparison to two titanium plates. Plates were instrumented in separate cadaveric human fore-a...

Journal of Biomechanics, 2016

Bioactive Glass (BAG) granules are osteoconductive and possess unique antibacterial properties fo... more Bioactive Glass (BAG) granules are osteoconductive and possess unique antibacterial properties for a synthetic biomaterial. To assess the applicability of BAG granules in load-bearing defects, the aim was to compare mechanical behaviour of graft layers consisting of BAG granules and morselized cancellous bone allograft in different volume mixtures under clinically relevant conditions. The graft layers were mechanically tested, using two mechanical testing modalities with simulated physiological loading conditions: highly controllable confined compression tests (CCT) and more clinically realistic in situ compression tests (ISCT) in cadaveric porcine bone defects. Graft layer impaction strain, residual strain, aggregate modulus, and creep strain were determined in CCT. Graft layer porosity was determined using micro computed tomography. The ISCT was used to determine graft layer subsidence in bone environment. ANOVA showed significant differences (p<0.001) between different graft layer compositions. True strains absolutely decreased for increasing BAG content: impaction strain -0.92 (allograft) to -0.39 (BAG), residual strain -0.12 to -0.01, and creep strain -0.09 to 0.00 respectively. Aggregate modulus increased with increasing BAG content from 116 to 653MPa. Porosity ranged from 66% (pure allograft) to 15% (pure BAG). Subsidence was highest for allograft, and remarkably low for a 1:1 BAG-allograft volume mixture. Both BAG granules and allograft morsels as stand-alone materials exhibit suboptimal mechanical behaviour for load-bearing purpose. BAG granules are difficult to handle and less porous, whereas allograft subsides and creeps. A 1:1 volume mixture of BAG and allograft is therefore proposed as the best graft material in load-bearing defects.

The Spine Journal, 2013

BACKGROUND CONTEXT: Numerous prenatal, systemic, or local procedures have been described that hav... more BACKGROUND CONTEXT: Numerous prenatal, systemic, or local procedures have been described that have created an experimental scoliosis within different animal species. Compressionbased fusionless scoliosis correction devices have been used to induce scoliosis (inverse approach) as an indication for their potential corrective efficacy in large animals. Deformities that most closely approximate the three-dimensional nature of an idiopathic-like scoliosis have been created in large animals using a posterior spinal tether. Fusionless scoliosis correction devices have subsequently been tested in these models. PURPOSE: To provide an overview of large animal models used for preclinical testing of fusionless scoliosis correction devices and to describe recent advances in the creation of an idiopathic-like scoliosis large animal model. STUDY DESIGN: Literature review of large animal models in fusionless scoliosis correction research. METHODS: MEDLINE electronic database was searched for studies in which large animal models for spinal or vertebral growth modulation or the creation of an experimental scoliosis were described. The literature search was limited to articles written in the English language. RESULTS: The pig appears to be the most suitable animal species for preclinical testing of fusionless scoliosis correction devices because of its large growth potential and the possibility for early weaning. With the inverse approach, it is difficult to gain insight into the possible corrective efficacy of the tested device, and therefore, a two-step approach is preferred. Using a posterior spinal tether, persistent spinal deformities are attained when the deformity has approximately doubled in comparison to the postoperative measure in a time span of approximately 12 weeks. Sufficient tether midline offset is required to render rib procedures unnecessary. CONCLUSIONS: An idiopathic-like scoliosis animal model can be created using a posterior spinal tether in a fully reversible procedure. Experimental results will need to be reproduced to establish a standard idiopathic-like scoliosis large animal model.

The Journal of bone and joint surgery. American volume, Jan 2, 2016

High-resolution peripheral quantitative computed tomography (HR-pQCT) is a promising tool to asse... more High-resolution peripheral quantitative computed tomography (HR-pQCT) is a promising tool to assess the fracture-healing process at the microscale in vivo. Since casts are often used during fracture treatment, they might affect the assessment of bone density, microarchitectural, and biomechanical parameters and the short-term reproducibility of those parameters, e.g., as a result of beam-hardening. The aim of this study was to assess the effect of a plaster-of-Paris and/or fiberglass cast on bone parameters and on the short-term reproducibility of the HR-pQCT measurements of those parameters. The effects of a cast on HR-pQCT-derived bone parameters were evaluated by comparing HR-pQCT scans of fifteen human cadaveric distal radial specimens from one male and fourteen female donors (median age, eighty-four years [range, sixty-two to ninety years] at the time of death) in three conditions: with a plaster-of-Paris cast, with a fiberglass cast, or without a cast. Short-term reproducibili...

INTRODUCTION Growth-guidance constructs are an alternative to growing rods for the surgical treat... more INTRODUCTION Growth-guidance constructs are an alternative to growing rods for the surgical treatment of early onset scoliosis (EOS). In growth-guidance systems, free-sliding anchors preserve longi...

Journal of Bone and Mineral Research, 2014

Fracture healing is an active process with early changes in bone and inflammation. We performed a... more Fracture healing is an active process with early changes in bone and inflammation. We performed an exploratory study evaluating the association between early changes in densitometric, structural, biomechanical, and biochemical bone parameters during the first weeks of fracture healing and wrist-specific pain and disability at 12 weeks in postmenopausal women with a conservatively treated distal radius fracture. Eighteen patients (aged 64 ± 8 years) were evaluated at 1 to 2 and 3 to 4 weeks postfracture, using high-resolution peripheral quantitative computed tomography (HR-pQCT), micro-finite element analysis, serum procollagen type-I N-terminal propeptide (P1NP), carboxy-terminal telopeptide of type I collagen (ICTP), and high-sensitive C-reactive protein (hsCRP). After 12 weeks, patients rated their pain and disability using Patient Rated Wrist Evaluation (PRWE) questionnaire. Additionally, Quick Disability of the Arm Shoulder and Hand (QuickDASH) questionnaire and active wrist range of motion was evaluated. Linear regression models were used to study the relationship between changes in bone parameters and in hsCRP from visit 1 to 2 and PRWE score after 12 weeks. A lower PRWE outcome, indicating better outcome, was significantly related to an early increase in trabecular bone mineral density (BMD) (β -0.96 [95% CI -1.75 to -0.16], R(2) = 0.37), in torsional stiffness (-0.14 [-0.28 to -0.004], R(2) = 0.31), and to an early decrease in trabecular separation (209 [15 to 402], R(2) = 0.33) and in ICTP (12.1 [0.0 to 24.1], R(2) = 0.34). Similar results were found for QuickDASH. Higher total dorsal and palmar flexion range of motion was significantly related to early increase in hsCRP (9.62 [3.90 to 15.34], R(2) = 0.52). This exploratory study indicates that the assessment of early changes in trabecular BMD, trabecular separation, calculated torsional stiffness, bone resorption marker ICTP, and hsCRP after a distal radius fracture provides valuable information regarding the 12-week clinical outcome in terms of pain, disability, and range of motion and validates its use in studies on the process of early fracture healing. © 2014 American Society for Bone and Mineral Research.

Journal of Materials Science: Materials in Medicine, 2019

The Journal of Bone and Joint Surgery