The UK and Australian clinical experience of an implantable load absorber was reviewed for knee OA patients who have exhausted conservative care, but are not ideal candidates for HTO or arthroplasty due to age, activity level, obesity, or disinclination. The load absorber was implanted in 58 patients, with the longest duration exceeding two years. Patients included younger OA sufferers (31-68 years), and had a mean BMI > 30kg/m2. Early surgical experience and adverse events with the device were recorded and clinical outcomes using validated patient reported outcomes tools were collected at baseline, post-op, 2 and 6 weeks, and 3, 6, 12 and 24 month timepoints. All patients were successfully implanted with a mean surgical time of 76.4 minutes (range 54-153). After a mean hospital stay of 1.7 days (range 1-3), patients resumed full weight bearing within 1-2 weeks and achieved normal range of motion by 6 weeks. Mean WOMAC pain (0-100 scale) improved from 42.4 to 16.1 (p<0.001); mean WOMAC function (0-100 scale) improved from 42.0 to 14.7 (p<0.001). Most patients reported “no or mild” pain (85%) or “no or mild” functional impairment (90%) at last follow-up (9.5 ± 3.5 months). Patients reported high satisfaction with the implant. Initial UK results mirror the positive Australian experience: reduced pain, improved function, and high satisfaction. Complications arising in the early surgical experience were effectively resolved through revised surgical technique and minor design modifications.Statement of Purpose
Methods and Results
Patellofemoral replacement is an established intervention in selected patients with severe isolated patellofemoral osteoarthritis. FPV (Wright Medical, UK) is a third generation patellofemoral arthroplasty implant and is the second most used after AVON in National Joint Registry for England and Wales. Reports of survivorship and functional of this implant are scarce in literature. Evaluation of functional outcome and survivorship following FPV patellofemoral arthroplasty.Background
Aim
Hyaline cartilage defects are a significant clinical problem for which a plethora of cartilage repair techniques are used. One such technique is cartilage replacement therapy using autologous chondrocyte or mesenchymal stem cell (MSC) implantation (ACI). Mesenchymal stem cells are increasingly being used for these types of repair technique because they are relatively easy to obtain and can be expanded to generate millions of cells. However, implanted MSCs can terminally differentiate and produce osteogenic tissue which is highly undesirable, also, MSCs generally only produce fibrocartilage which does not make biomechanically resilient repair tissue, an attribute that is crucial in high weight-bearing areas. Tissue-specific adult stem cells would be ideal candidates to fill the void, and as we have shown previously in animal model systems [ At present, research focused on isolating tissue-specific stem cells from articular cartilage has met with modest success. Our results demonstrate that using differential adhesion it is possible to easily isolate articular cartilage progenitor populations from human hyaline cartilage and that these cells can be subsequently expanded In conclusion, we propose the identification and characterisation of a novel articular cartilage progenitor population, resident in human cartilage, which will greatly benefit future cell-based cartilage repair therapies.
In recent years tribological development of knee replacement impants has beeen introduced with several benefits. However, concomitant problems were noticed following widespread use. High-flexion total knee replacement (PFC RPF DePuy) has been developed with a view to improve flexion and the design is expected to have a better patello-femoral biomechanics. However, high secondary patella resurfacing rate has been noticed in the current series. We have retrospectively reviewed 119 knees in 96 patients who underwent RPF knee replacement with selective patellar resurfacing from 2006 to 2010 by the senior author. 71 were performed without primary resurfacing while 48 in knees patella was resurfaced primarily due to significant symptomatic arthritic changes. Majority were females (57 versus 39 males). Average follow-up period was 37 (12-62) months. Twelve (16.9%) knees were subjected to secondary resurfacing due to continuing anterior knee pain. Average time from primary total knee replacement to secondary resurfacing was 18 months (8-35). Most of the patients were satisfied following the secondary resurfacing. Mean Oxford Knee Score in the group where the patella was resurfaced primarily was 33.1 (9-48), in the group where the patella was not resurfaced 32.8 (11-47), in the secondary resurfacing group 31.8 (14-43) and in the revision group 20.5 (16-25). RPF knee replacements in our series have a considerably higher rate of secondary patellar resurfacing as compared with published literature. We recommend primary patellar resurfacing of all RPF knee replacements to avoid this problem. Further analysis of the prosthetic design would be beneficial in relation to clinical outcome. No of patients-96 Total no of knee-118 Av age-66.5 Females-57 Males-39 Patella not resurfaced- 73 Resurfaced-45 Revised-10(13.7%) Revision to TKR (TC3) for different reason-3(2.54%) Average time from primary to secondary resurfacing-
Glutamate is a neurotransmitter that transmits mechanical signals in bone (1) and activates glutamate receptors and transporters, in bone, cartilage, meniscus and synovium (2). Glutamate receptor activation influences inflammatory, degenerative and nociceptive pathways in arthritic joints (2). Thus glutamate signalling is a mechanism whereby mechanical load can directly influence joint pathology and pain. We have investigated components of glutamate signalling in the subchondral bone of patients with osteoarthritis to determine which are expressed and whether this varies in anatomical regions subject to different loads. Subchondral bone was sampled from tibial cuts derived from total knee arthroplasty (n=2, TKR, Kellgren Lawrence grade 3) and from tibial drill hole sites from high tibial osteotomy (n=5, HTO, KL grades 2 and 3) for osteoarthritis. RNA was extracted, reverse transcribed and RT-PCR performed for a housekeeping gene GAPDH, a glutamate transporters (EAAT-1, EAAT1ex9skip), glutamate receptors (NR2A and KA1), a bone matrix protein, osteocalcin, and signaling molecules (osteoprotegerin [OPG], RANKL). We found differential mRNA expression in different regions of subchondral bone. In one TKR patient, EAAT-1 expression was significantly reduced in the anterior zone versus the middle or posterior zones of the tibial plateau (ANOVA, p<0.001). HTO bone cores were subdivided medial/lateral and anterior/posterior. Good quality RNA was obtained from bone cores removed from drill holes during HTO surgery, with GAPDH, osteocalcin, EAAT-1, EAAT1ex9skip, NR2A, KA1, OPG and RANKL mRNA expression detected. In one patient, comparison of gene expression in bone cores obtained pre and post HTO revealed that EAAT1ex9skip was rarely detected in post-op bone whereas KA1 was rare in pre-op bone. This differential mRNA expression may be due to the altered loading through the joint caused by the osteotomy, although these on/off differences need to be quantified to confirm this. We have shown that glutamate transporters and receptors are expressed in human subchondral bone. Activation of these receptors and transporters by the increased synovial fluid concentrations of glutamate released in arthritis will influence pathological changes and nociception. In some patients, glutamate transporter mRNA expression appears to vary with anatomical location in bone, or after HTO surgery, consistent with our original discovery of this transporter as mechanically-regulated in bone (1). If glutamatergic signaling is mechanically regulated in the human knee, this will vary during arthritic disease progression and after joint realignment, providing a direct mechanism linking mechanical loading through the joint to pathology and pain in arthritis.
The simple dictum of the late Prof. Alf Nachemson was that ‘surgery should very rarely, if ever, be performed in adult scoliotic patients for lumbar curves when pain is the most serious problem’. Today, the complexity of intercurrent neural symptoms, the advancing age of the population and the increasing demands and expectations of modern living require a somewhat more flexible approach to this increasingly common problem. Treatment of adult deformity has improved along with our understanding of the radiological features of the condition most likely to be associated with disabling pain and also with our appreciation of the adverse significance of patient co-morbidity. In those patients where conservative measures have failed and where an acceptable quality of life has been lost, surgical management may be undertaken, but must address all the symptomatic aspects of the deformity in one episode of care. Primary objectives include the restoration of satisfactory sagittal plane correction using the minimum number of operated levels whilst providing adequate spinal stability. Meticulous preoperative planning from a clinical and radiological perspective maximises the possibility of a satisfactory outcome and in this regard patient expectation is of prime importance. The questions of operative approach and levels of fixation are ever present and recent advances in our understanding of distal end fixation are worthy of consideration. Finally, exemplary cases and our series of 23 patients undergoing surgical treatment of adult scoliosis will be presented. Mean coronal curve correction by anteroposterior approach was 60.4% and by posterior only approach 40.3%. Patient satisfaction was 77.8% by combined approach and 58.9% by posterior only approach. The rate of reoperation was 66.7% for posterior surgery alone and 11.1% for combined approach corrections.
Tapping the radial side of the wrist normally elicits a reflex contraction producing elbow flexion, wrist extension and wrist radial deviation. An abnormal response, consisting of finger flexion when performing this manoeuvre is known as the inverted radial (supinator) reflex (IRR). The significance of this reflex in asymptomatic subjects is unknown. To document the frequency of the IRR in an asymptomatic population and to identify any presymptomatic pathology in those subjects. The study group consisted of patients and staff at the senior author's institution. Patients were taken from clinics where the complaints were of lower limb symptoms. Subjects were excluded if they had any history of neck pain or stiffness or if they had any subjectively abnormal sensation. The radial reflex was elicited with a tendon hammer. Those subjects with an IRR were asked to attend for a MRI scan of the cervical spine to investigate for any abnormality. 47 subjects were studied. There were 8 subjects who displayed an IRR. In 4 subjects the IRR was unilateral and in 4 bilateral. Seven subjects consented to further investigation by MRI. The average age of these patients was 36 years. The MRI scans revealed normal appearances in 6 cases. There was no cord signal abnormality in any case. The IRR occurred with a frequency of 17% in the study group. There was no significant cervical pathology identified in these subjects. In young asymptomatic patients, the presence of an inverted radial reflex is of no diagnostic relevance.
AO Spine Reference Centre & Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, Australia Traumatic spinal cord injury (SCI) is a devastating condition with no curative therapy. Pro-inflammatory therapy has been suggested recently to try and reduce the inhibitory glial scar and promote neural regeneration and healing. The aim of this study is to investigate the potential of sustained delivery of angiogenic/pro-inflammatory growth factors to reduce the secondary degeneration after spinal cord injury. Adult male Wistar Kyoto rats (200-300g; 12-16weeks old) were subjected to cord hemisections via a T10 laminectomy. Animals were randomised to treatment or control groups after the spinal cord injury had been induced. Treatment consisted of implantation of a mini-osmotic pump capable of delivering 5 micrograms vascular endothelial growth factor (VEGF) and 5 micrograms platelet-derived growth factor (PDGF), via a catheter, to the site of the lesion, over 7 days(n=6). Control animals were subjected to either cord lesion only (n=6) or lesion plus mini-pump delivering PBS (phosphate-buffered saline) solution (n=6). Rats were sacrificed at one month and the spinal cords were harvested and examined by immunohistology, using anti-neurofilament-200 and anti-Glial Acidic Fibrillary Acidic Protein (GFAP) antibodies. RESULTS: Active treatment spinal cords showed a higher level with aboration of the axonal filament through the defect and more dense neurofilament-200 staining at the lesion site compared to both control groups. The treatment also showed the elevated presence of activated microglia in the lesion, whilst distal to the lesion the microglia and astrocytes retained an unreactive phenotype. Pro-inflammatory therapy in the rat spinal cord-injury model showed favourable histological findings after sustained delivery of PDGF and VEGF
We undertook a prospective randomised trial to determine the outcome of locked intramedullary fixation vs. plating of displaced shortened mid-shaft clavicle fractures. The primary outcome measure was the Constant shoulder score, while secondary outcome measures included the Oxford shoulder score, union rate, and complication rates. Thirty-two patients were recruited to the trial; 17 randomised to locked intramedullary fixation and 15 randomised to plating. Mean age was 29.3years (13 to 53 years). Mean follow-up was 12.4 months (5 to 28 months). There was no significant difference in Constant scores (p = 0.365) and no significant difference in Oxford scores (p = 0.686). There was 100% union in both groups. In the intramedullary group, there was one case of soft tissue irritation that settled after the pin was removed, one pin backed out and had to be revised with another pin. There were three superficial wound infections resulting in plate removal and 8 plates (53%) were removed. Locked intramedullary fixation and plating are equally effective in the management of shortened displaced mid-shaft clavicle fractures.
Good quality RNA was obtained from bone cores removed from drill holes during HTO surgery, with GAPDH, EAAT-1, NR2A and KA1 expression detected. Osteocalcin expression was high indicating RNA was derived from osteoblasts and osteocytes, but did not vary with anatomical site or disease status. End-stage RT-PCR indicated differential expression of EAAT-1 between medial and lateral bone samples in total knee arthroplasty, however these differences were not significant by quantitative RT-PCR. In one patient, EAAT-1 expression was significantly reduced in the anterior zone versus the middle or posterior zones (ANOVA, p<
0.001). EAAT-1ex9skip represented a significant proportion of the total EAAT-1 mRNA expression in bone from TKR patients, but appeared less abundant in HTO samples.
Good quality RNA was obtained from bone cores removed from drill holes during HTO surgery, with GAPDH, EAAT-1, NR2A and KA1 expression detected. Osteocalcin expression was high indicating RNA was derived from osteoblasts and osteocytes, but did not vary with anatomical site or disease status. End-stage RT-PCR indicated differential expression of EAAT-1 between medial and lateral bone samples in total knee arthroplasty, however these differences were not significant by quantitative RT-PCR. In one patient, EAAT-1 expression was significantly reduced in the anterior zone versus the middle or posterior zones (ANOVA, p<
0.001). EAAT-1ex9skip represented a significant proportion of the total EAAT-1 mRNA expression in bone from TKR patients, but appeared less abundant in HTO samples.
Human meniscus expressed GAPDH, type 1 collagen, EAAT-1, EAAT-1ex9skip, NR2A, AMPA GluR3 and KA1 mRNAs. Levels of EAAT-1 expression, normalised to GAPDH, did not differ between the inner and outer halves, or in the anterior, middle or posterior regions of menisci from the less affected compartments of arthritic knees. EAAT-1 expression appeared greater in the 2 painful, compared with the single non-painful meniscus. Interestingly, EAAT-1ex9skip was significantly more common within the outer zones (ANOVA, P=0.040) and in the posterior horns of the menisci (ANOVA, p=0.038).
Traditional management of spinal metastases has been for the most part palliative. In this decade however there has been a gradual shift towards extirpative treatment of spinal secondary malignancy in certain circumstances. The techniques of en bloc vertebral resection have gained more widespread acceptance improving the chances of successful wide or marginal resection of both primary and secondary tumours of the spine. Those metastatic lesions which are solitary and associated with a long period of latency from treatment of the primary lesion have a greater likelihood of improved survival with en bloc resection. Although technically demanding, these same techniques coupled with advances in spinal implantation may allow complete excision of extended primary malignancy of the spine previously considered unresectable. This presentation examines the indications for en bloc resection of secondary and extended primary malignancy of the spine. A case for early referral of solitary metastatic spinal lesions is presented in the hope of adding extirpative surgical techniques to the traditional armamentarium of theoncologist.
plain x-ray plain xray and flexion/extension x-rays and plain x-ray and flexion/extension x-rays and CT scan. These results were correlated with a fusion rate based on the micro CT. The specificity and sensitivity of these radiological measures in diagnosing pseudarthrosis and inter-rater reliability using Fleiss’ Kappa scores for each method were calculated.
Patient’s charts and radiology findings were reviewed with special attention to operative notes and preoperative knee MR imaging. Patients with knee symptoms prior to presenting injury were excluded. The mechanism of injury, the time elapsed from the original injury to anterior cruciate ligament reconstruction, associated meniscal injury, and quality of cartilage in the knee- at the time of MR imaging and ACL reconstruction were noted. Degenerative cartilage changes were graded upon reconstruction using the Outerbridge classification. The average time from Injury to MR imaging and MR to ACL reconstruction was 4.85 and 12.65 months respectively. We found a direct relationship between the time elapsed after the ACL injury and the severity of the chondral lesion (p<
0.05). Furthermore, a significant worsening in chondral degeneration of the involved knee was seen when the MR imaging and ACL reconstruction were more than 12 months apart (p<
0.01).
Early reconstruction may protect the knee from chondral wear and subsequent degenerative arthritis.