Osteochondral (OC) defects of the knee are associated with pain and significant limitation of activity. Studies have demonstrated the therapeutic efficacy of mesenchymal stem cell (MSC) therapies in treating osteochondral defects. There is increasing evidence that the efficacy of MSC therapies may be a result of the paracrine secretion, particularly exosomes. Here, we examine the effects of MSC exosomes in combination with Hyaluronic Acid (HA) as an injectable therapy on functional osteochondral regeneration in a rabbit osteochondral defect model. Exosomes were purified from human MSC conditioned medium by size fractionation. A circular osteochondral defect of 4.5 mm diameter and 2.5 mm depth was surgically created in the trochlear grooves of 16 rabbit knees. Thereafter, eight knees received three weekly injections of 200 µg of exosomes in one ml of 3% HA, and the remaining eight knees received three weekly injections of one ml of 3% HA only. The rabbits were sacrificed at six weeks. Analyses were performed by macroscopic and histological assessments, and functional competence was analysed via Young Modulus calculation at five different points (central, superior, inferior, medial and lateral) of the repaired osteochondral defect site. MSC exosomes displayed a modal size of 100 nm and expressed exosome markers (CD81, TSG101 and ALIX). When compared to HA alone, MSC exosomes in combination with HA showed significantly better repair histologically and biomechanically. The Young Modulus was higher in 4 out of the 5 points. In the central region, the Young Modulus of MSC exosome and HA combination therapy was significantly higher: 5.42 MPa [SD=1.19, 95% CI: 3.93–6.90] when compared to HA alone: 2.87 MPa [SD=2.10, 95% CI: 0.26–5.49], p < 0 .05. The overall mean peripheral region was also significantly higher in the MSC exosome and HA combination therapy group: 5.87 MPa [SD=1.19, 95% CI: 4.40–7.35] when compared to HA alone: 2.70 MPa [SD=1.62, 95% CI: 0.79–4.71], p < 0 .05. The inferior region showed a significantly higher Young Modulus in the combination therapy: 7.34 MPa [SD=2.14, 95% CI: 4.68–10] compared to HA alone: 2.92 MPa [SD=0.98, 95% CI: 0.21–5.63], p < 0.05. The superior region showed a significantly higher Young Modulus in the combination therapy: 7.31 MPa [SD=3.29, 95% CI: 3.22–11.39] compared to HA alone: 3.59 MPa [SD=2.55, 95% CI: 0.42–6.76], p < 0.05. The lateral region showed a significantly higher Young Modulus in the combination therapy: 8.05 MPa [SD=2.06, 95% CI: 5.49–10.61] compared to HA alone: 3.56 MPa [SD=2.01, 95% CI: 1.06–6.06], p < 0.05. The medial region showed a higher Young Modulus in the combination therapy: 6.68 MPa [SD=1.48, 95% CI: 4.85–8.51] compared to HA alone: 3.45 MPa [SD=3.01, 95% CI: −0.29–7.19], but was not statistically significant. No adverse tissue reaction was observed in all the immunocompetent animals treated with MSC exosomes. Three weekly injections of MSC exosomes in combination with HA therapy results in a more functional osteochondral regeneration as compared to HA alone.
Long bone defects often require surgical intervention for functional restoration. The ‘gold standard’ treatment is autologous bone graft (ABG), usually from the patient’s iliac crest. However, autograft is plagued by complications including limited supply, donor site morbidity, and the need for an additional surgery. Thus, alternative therapies are being actively investigated. Autologous bone marrow (BM) is considered as a candidate due to the presence of both endogenous reparative cells and growth factors. We aimed to compare the therapeutic potentials of autologous bone marrow aspirate (BMA) and ABG, which has not previously been done. We compared the efficacy of coagulated autologous BMA and ABG for the repair of ulnar defects in New Zealand White rabbits. Segmental defects (14 mm) were filled with autologous clotted BM or morcellized autograft, and healing was assessed four and 12 weeks postoperatively. Harvested ulnas were subjected to radiological, micro-CT, histological, and mechanical analyses.Objectives
Methods
Recurrent patellar instability is common in young and active patients. Medial patellofemoral ligament (MPFL) reconstruction with a single bundle hamstring graft is one method of surgical treatment for this problem. This is a retrospective case series of patients who underwent MPFL reconstruction by a single specialist knee surgeon between January 2009 and July 2014. Data was collected prospectively for the purpose of service evaluation. Recorded data included gender, age, length of rehabilitation, complications, Knee Injury and Outcome Score (KOOS) and International Knee Documentation Score (IKDC). Data is expressed as mean (range). 108 knees (103 patients) were identified (56 female, 52 male) with a mean age of 24.5 years (12–58). Mean length of rehabilitation was 3.2 months (0–11 months). Three patients required further revision surgery for recurrent instability. KOOS and IKDC scores improved from 44 (4–86) and 38 (2–81), respectively before surgery, to 77 (49–100) and 69 (37–95) after rehabilitation. MPFL reconstruction with a single bundle hamstring graft produces a marked improvement in knee function with a low recurrence of instability.
High flexion knee arthroplasties have been designed to allow up to 155 degrees flexion and enable high flexion activities such as kneeling and squatting. To date randomised controlled trials have shown no difference in range of movement (ROM) between high flexion and standard designs. The aim of this study was to determine if there is a difference in functional outcome and ROM between the standard and high flexion design of the PFC Sigma TKA system.Introduction
Objectives
Anterior cruciate ligament (ACL) injuries are being seen with increasing frequency in children. Treatment of the ACL deficient knee in skeletally immature patients is controversial. To determine the outcome of anatomic transphyseal ACL reconstruction in tanner stage 1 and 2 patients with open growth plates at a minimum of 2 years after surgery. Between 2007–2008, 16 prepubescent skeletally immature patients underwent anatomic transphyseal ACL reconstruction using soft tissue grafts. All patients were tanner stage 1 and 2 and all had open growth plates. Outcomes were assessed at a minimum of 2 years after surgery and included: limb alignment, limb length, instrumented testing with KT-1000 and International Knee Documentation Committee (IKDC) score. Mean age at the time of surgery was 12 years (8–14). Graft choices included: living-related donor hamstring tendon allograft (n=14), hamstring tendon autograft (n=1) and fresh frozen allograft (n=1). Mean IKDC subjective score was 96 (84–100). Sixty-two percent of patients had <3mm side-to-side difference on instrumented KT-1000 testing and 88% had a negative pivot shift. At 2 years after surgery, all patients had returned to strenuous activities and normal or nearly normal overall IKDC score was documented in 94% of patients. There were no cases of limb malalignment or growth arrest. We present a large series of anatomic transphyseal ACL reconstruction in tanner stage 1 and 2 patients with open growth plates at a minimum of 2 years following surgery. Excellent clinical outcomes were obtained with high levels of return to desired activities. Importantly, no growth disturbances were seen in this series of patients.
The National Institute for Health and Clinical Effectiveness recommends both low molecular weight heparin (LMWH) and Rivaroxaban for venous thromboembolic (VTE) prophylaxis following lower limb arthroplasty. Despite evidence in the literature that suggests Rivaroxaban reduces VTE events, there are emerging concerns from the orthopaedic community regarding an increase in wound complications following its use. Through the orthopaedic clinical directors forum, Trusts replacing LMWH with Rivaroxaban for lower limb arthroplasty thromboprophylaxis during 2009 were identified. Prospectively collected Hospital episode statistics (HES) data was then analysed for these units so as to determine rates of 90-day symptomatic deep venous thrombosis (DVT), pulmonary embolism (PE), major bleed (cerebrovascular accident or gastrointestinal haemorrhage), all-cause mortality, and 30-day wound infection and readmission rates before and after the change to Rivaroxaban. 2752 patients prescribed Rivaroxaban following TKR or THR were compared to 10358 patients prescribed LMWH. Data was analysed using odds ratios (OR).Background
Methods
The National Institute for Health and Clinical Effectiveness recommends both low molecular weight heparin (LMWH) and Rivaroxaban for venous thromboembolic (VTE) prophylaxis following lower limb arthroplasty. Despite evidence in the literature that suggests Rivaroxaban reduces VTE events, there are emerging concerns from the orthopaedic community regarding an increase in wound complications following its use. Through the orthopaedic clinical directors forum, Trusts replacing LMWH with Rivaroxaban for lower limb arthroplasty thromboprophylaxis during 2009 were identified. Prospectively collected Hospital episode statistics (HES) data was then analysed for these units so as to determine rates of 90-day symptomatic deep venous thrombosis (DVT), pulmonary thromboembolism (PTE), major bleed (cerebrovascular accident or gastrointestinal haemorrhage), all-cause mortality, and 30-day wound infection and readmission rates before and after the change to Rivaroxaban. 2752 patients prescribed Rivaroxaban following TKR or THR were compared to 10358 patients prescribed LMWH. Data was analysed using odds ratios (OR).Introduction
Methods
Stable ankle fractures can be successfully treated non-operatively with a below knee plaster cast. In some European centres it is standard practice to administer thromboprophylaxis, in the form of low molecular weight heparin, to these patients in order to reduce the risk of deep venous thrombosis (DVT). The aim of our study was to assess the incidence of DVT in such patients in the absence of any thromboprophylaxis. We designed a prospective study, which was approved by the local ethics committee. We included 100 consecutive patients with ankle fractures treated in a below knee plaster cast. At the time of plaster removal (6 weeks), patients were examined for signs of DVT. A colour doppler duplex ultrasound scan was then performed by one of the two experienced musculoskeletal ultrasound technicians. We found that 5 patients developed a DVT. Two of these were above knee, involving the superficial femoral vein and popliteal vein respectively. The other three were below knee. None of the patients had any clinical symptoms or signs of DVT. None of the patients developed pulmonary embolism. Of these five patients, four had some predisposing factors for DVT. The annual incidence of DVT in the normal population is about 0.1%. This can increase to about 4.5% by the age of 75. DVT following hip and knee replacement can occur in 40-80% of cases. Routine thromboprophylaxis may be justified in these patients. However, with a low incidence of 5% following ankle fractures treated in a cast, we believe that routine thromboprophylaxis is not justified.
High tibial valgus osteotomy is now well established in management of medial knee osteoarthritis. While conventional closing osteotomies are usually within 2 cm of the knee joint, opening wedges typically pivot more distally from the joint line; theoretically the same angular correction will cause greater linear shift of the tibial plateau away from the tibial long axis. We hypothesise that this may lead to an increased incidence of problems with future knee replacement where tibial stem augments are needed, and to evaluate this we used a computerbased templating system with web-based component templates for sizing and implant position planning. We studied 10 knees that had undergone opening wedge osteotomy. Pre-operative and postoperative mechanical and anatomical axes, and corrections achieved, were measured radiologically. Computer-based knee arthroplasty templating was then performed with the TraumaCad digital templating software (Orthocrat, Israel), using Depuy PFC tibial component templates with 75 mm stem augments. Cases were analysed for impingement of tibial stem augments when added to a well-placed tibial tray, and conversely for the need for tibial tray downsizing to avoid tray overhang if stem augments were placed centrally.
Logistic regression model was used to investigate the relationship between mortality and re-operation at six months and case mix variables (age, ASA grade, fracture types, pre-fracture residence, and mobility and activity level), and management variables (days to operation, the grade of the surgeon and supervision level). Mann-Whitney test was used to compare the level of experience among trainees in the group of patients who died or required re-operation at six months.
The logistic regression model used to predict six months mortality was highly significant (X2=166.6 [24df], p<
0.0001). It showed that age, ASA grade and pre-fracture activity level were strongly associated with mortality at six months. Patients operated on by a trainee without the consultant being scrubbed were 1.8 times (p<
0.05) more likely to die at 6 months. (Odds ratio of 1.8 with 95% confidence interval of 1.15 to 2.75). Re-operation at six months could not be predicted by these factors. Regarding patients operated on by trainees, there was no significant difference in the level of experience among trainees who operated on patients who died or who required re-operation at six months compared to those who did not.
There were 159 CHS procedures and 146 IMHS procedures. 137 CHS and 123 IMHS procedures fulfilled the blood testing and transfusion criteria. Haemoglobin levels were used as an indication for blood loss attributable to surgery. The difference between the last level of haemoglobin checked preoperatively and the first post operative level performed between 12–48 hours postoperatively is calculated. Cases where blood transfusion was carried out preoperatively without further preoperative haemoglobin check were excluded, so were cases receiving intra or post operative blood transfusion prior to the defined postoperative haemoglobin check was carried out.
The surgeons’ grades were classified into three groups as: Consultants, Registrars and Senior House Officers. Levene’s test again proved the variances of haemoglobin drop within each group to be homogeneous. Hence a One-Way ANOVA test was carried out showing that the differences in haemoglobin drop were not statistically significant when comparing the three groups of surgeons to each other. This was true for both IMHS and CHS procedures. Conclusion: Patients undergoing a CHS procedure drop their haemoglobin levels by 0.64 g/dl less than those undergoing an IMHS procedure. The surgeon’s seniority does not make difference to the amount of haemoglobin level drop following either of the two procedures. We recommend the use of CHS for stable fractures and reserve the IMHS for the unstable ones due to the increased blood loss with IMHS procedures.
Idiopathic anterior knee pain (AKP) is common in adolescents and young adults. Most believe that the origin of the problem lies in the patello-femoral joint. Hamstring tightness has also been attributed as an important cause. The aim of our study was to compare biometric parameters in patients with idiopathic AKP and controls. We also wanted to assess whether there was a difference in the relative electromyographic (EMG) onset times of the medial and lateral hamstrings. We prospectively recruited patients with idiopathic anterior knee pain in the age group 11 to 25. Patients, but not the control population, had AP, lateral and skyline radiographs taken to rule out other pathology. We had 34 patients (60 knees) with a minimum one year follow up. There was no difference in the symptoms of patients who attended physiotherapy as compared to those who did not. Patients with knee pain had significantly more hip external rotation (63 deg) as compared to the control (47 deg) group (p=0.001). Patients also had significantly more hamstring tightness (p=0.04). Surface EMG was recorded (17 patients and controls each) from the medial and lateral hamstrings during 3 repetitions of a maximal voluntary isometric contraction exercise with the knee at 45° of flexion. The lateral hamstrings contracted 48.7 m.sec earlier than the medial hamstrings in patients as compared to controls. AKP is a multifactorial and self-limiting disorder. Earlier contraction of the lateral hamstrings may cause tibial external rotation and contribute to the symptoms. Our data suggests that physiotherapy did not significantly alter the course of the condition. We believe that increased hip external rotation may contribute to the symptoms by increasing medial facet stress.
The purpose of this study was to determine the prevalence of non-accidental injury in toddlers (birth to two years old) presenting with a femur fracture to a single institution within a Western Canadian population. There are currently no Canadian studies that investigate this association in the medical literature. A retrospective case-control study was performed for children less than or equal to two years of age with a diagnosis of femur fracture who presented to a single institution from 1994 to 2005. Patients with associated pathological or metabolic bone disorders were excluded. The primary outcome measure was the prevalence of non-accidental injury associated with femur fracture. Secondary outcome measures included: patient demographics, injury characteristics, radiologic and other work-up, and suspicion of abuse. Statistical analysis was performed using tests of analysis of variance and multivariate analysis to identify independent and significant risk factors associated with non-accidental injury. One hundred twenty-seven children that met the inclusion criteria were identified. The overall prevalence of non-accidental injury was 11% (14/127 patients) and 17% (10/60 patients) in children under twelve months. Mean age was twelve months in the abused group and sixteen months in the accidental group. Forty-three percent of the abused group had delayed presentation compared to 8% of the accidental group. In the abused group, 43% had unknown, unwitnessed, inconsistent histories versus 4% in the accidental group. No specific fracture pattern or location suggestive for non-accidental injury was identified. Forty-three percent (6/14 patients) of the abused group and 12% (13/113 patients) of the accidental group had other injuries. Multivariate analysis determined that delayed presentation (p=0.001), mechanism of injury (p=0.02) and other associated injuries (p=0.003) were the only independently significant risk factors for abuse. Toddlers who present with femoral fracture are at risk for associated non-accidental injury though perhaps this risk is not as high as previously thought. Regardless, a high index of suspicion is mandatory when these children are encountered and careful screening with a thorough history, physical examination, and other investigations where indicated, are warranted to rule out associated child abuse.
We found no significant difference between the groups in the EMG intensity of vastus lateralis relative to biceps femoris, or vastus medialis relative to vastus lateralis, during the balance test or during the step up task (Mann Whitney U test all p>
0.05). We did not find any difference in the proprioceptive abilities of the two groups
The aim of this study was to determine whether there is a difference in the functional outcome between fixed and mobile bearings in total knee arthroplasty. 120 patients were randomized (computer generated) to receive either a fixed or mobile bearing P.F.C. Sigma total knee replacement. 96 patients were needed to detect a 20° difference in range of motion (ROM) with a significance level of 0.05 and a test power of 0.97. Oxford knee score (OKS) and ROM were assessed independently before and one year after surgery. Mean ROM and Oxford knee score before and at one year after surgery for both groups are shown as preliminary results for 70 patients (follow-up expected to be completed by March 2006): There is no statistically significant difference in the mean ROM at one year and in change in ROM between the two groups (p=0.53 and p=0.21 respectively). The findings were similar for Oxford Knee Score at one year and change in Oxford Knee Score (p=0.45 and p=0.82). There was no early aseptic loosening in either group. The one year results suggest that there is no significant difference in functional outcome measured as ROM and Oxford Knee Score between the two types of bearing. Further follow-up will be carried out to detect any differences in the long term outcome.
The purpose of this study was to determine contact patterns in cementless acetabular cups using a novel computed tomography (CT) scan analysis technique. Eighteen embalmed cadaveric hemipelvis specimens were randomly assigned to receive one of three cup designs. A custom CT platform was designed to optimize imaging of the acetabular cups. After cup implantation, specimens were mounted on the platform and imaged in a spiral CT scanner. Contact analysis was preformed using custom-developed imaging software. The hemisphere, dual geometry and spiked cup designs analyzed using this CT analysis technique demonstrate differences in the amount and distribution of bone pros-thesis contact. The purpose of this study was to determine contact patterns in cementless acetabular cups using computed tomography (CT) scan analysis. Eighteen embalmed cadaveric hemipelvis specimens were randomly assigned to receive a hemispherical cup, a dual geometry cup, or a spiked cup. After radiographic templating, an experienced orthopaedic team prepared the specimens and implanted the acetabular cups. A custom CT platform was designed to optimize imaging of the acetabular cups. After cup implantation, specimens were mounted on the platform and imaged in a spiral CT scanner. Contact analysis was preformed using custom-developed imaging software. Contact was defined as a bone-prosthesis distance of 0.5 mm or less. The mean amount of cup contact was 40.4% (SD=8.2%) in the hemisphere group, 24.7% (SD=2.3%) in the dual geometry group, and 29.7% (SD=9.5%) in the spiked group. Colour mapping of the bone-prosthesis gap was used to identify contact/non-contact regions along the acetabular contour for all cup designs. Preliminary work with this CT analysis technique demonstrates differences in the amount and distribution of contact in the acetabular cup designs. Future work will involve development of an imaging phantom to clarify error, use of the technique with different cup designs and reaming techniques, and comparison of this technique with conventional CT scan techniques. This study outlines a novel CT analysis technique for quantitatively determining bone-prosthesis contact for cementless acetabular cups. The hemisphere, dual geometry and spiked cup designs analyzed using this CT analysis technique demonstrate differences in the amount and distribution of bone prosthesis contact.
The sensitivity of clinical diagnosis for medial and lateral meniscus and ACL lesions was found to be less than 90%. Clinical impression was found to be significantly specific for lesions of ACL and the articular cartilage. The negative predictive value of the MRI scan was found to be significantly high (>
95%), for lesions of the medial and lateral meniscus and the ACL.
Introduction: (OCD) is characterized by bone necrosis and softening of the overlying cartilage, which may separate and displace. It is thought to be secondary to trauma, ischaemia or abnormal epiphyseal ossification. Management remains controversial during the early stages of the disease. Surgery for advanced chondral lesions with loose bodies however remains a challenge. Options that include periosteal graft and autologous chondrocyte transplantation have been used with variable degrees of success. This study investigates the efficacy of these techniques and the use of mesenchymal stem cells to treat advanced chondral lesions found in OCD in animal models. Materials and Methods: A full thickness articular cartilage defect (6mm long, 3mm wide and 1mm deep) was created in the weight-bearing surface of medial femoral condyle in 22-week old NZW rabbits. A total of 90 knees were randomly divided into 3 groups as follows: 1) Transfer of cultured chondrocytes 2) Transfer of cultured periosteum-derived MSCs and 3) Repair by periosteal graft with their contralateral knees as control. The rabbits were allowed to move freely in their cages. The rabbits were sacrificed at 2, 6, 12, 24 and 36 weeks post-operatively. The healing of the defects was assessed by gross examination and histological grading and subjected biomechanical testing. Results: Gross and histological examination at 36 weeks post operation (Wakitani et al grading), the mean score for Group 1 is 2.5, Group 2 is 2.3 and Group 3 is 4.5 with control group of 8.9 in terms of cell morphology, matrix staining, surface regularity, thickness of repaired cartilage and integration of cartilage to adjacent host. Biomechanically by indentation test, Group1 had value of 0.22 MPa, Group 2 0.20 MPa, Group 3 0.16 MPa and Control group of 0.12 MPa. Conclusion: The findings suggested that cultured chondrocytes and mesenchymal stem cells had comparable enhancing effect of the repair of chondral defect in advanced OCD
Clinical investigations and tests need to be validated by studying their inter-observer and intra-observer errors, but there has been no documentation of such verification in diagnostic knee arthroscopy. We performed a prospective study to find out to what extent the findings in knee arthroscopy differ between two different surgeons. Two senior specialist registrars (M.S. and A.J.) who took part in this study worked with the senior author (ACW) for a period of eight and seven months respectively. A total of 78 knee arthroscopies admitted from routine waiting list were studied. The specialist registrar first performed arthroscopy when the supervising consultant stayed away from the operating room. His findings were recorded on a proforma by an independent third person before the consultant returned to the operating room and repeated the EUA and arthroscopy without prior knowledge of the trainee findings. Findings from the consultant arthroscopy were then recorded separately on the same proforma. The following findings were recorded:
Examination under anaesthesia Meniscal pathology ACL pathology Articular surface pathology (more than 1 Outer-bridge grade) The inter-observer variations in diagnostic knee arthroscopy were found to be high. Given the seniority and experience of the two trainee senior registrars involved in the study, and allowing for the Hawthorne effect, the results of the study cast doubt on this procedure being performed un-supervised. It also questions the validity of any therapeutic intervention based on the findings of un-supervised arthroscopies.
Video-assisted thoracoscopic surgery (VATS) has been in use since the 1980s for surgery of the spine. Initially it was used for anterior release of the thoracic spine in order to facilitate posterior instrumentation. With increasing experience, it has been applied to perform definitive correction and instrumentation. Video-assisted thoracoscopic spine surgery allows the surgeon to perform anterior thoracic spine operations with fewer levels of instrumentation, reducing the crankshaft effect and removing the morbidity associated with thoracotomy. From 1996 to November 2000, our center performed 19 such operations. 18 of them were completed successfully endoscopically and one was converted to an open procedure. An initial group of 10 patients underwent thoracoscopic anterior release and fusion followed by same day posterior instrumentation and fusion. Subsequently, 6 patients underwent anterior discectomies, fusion with instrumentation via thoracoscopic approach. For the initial 10 patients, the average operative time was 190 minutes. The average post-operative correction was 62 % and blood loss was 350 mLs. For the 6 patients who underwent anterior discectomies, fusion and instrumentation via the thoracoscopic approach, the average operative time was 360 minutes; average post-operative correction was 70% and blood loss was 400 mLs. Complications encountered were minor and included one case ofcontralateral pneumothorax, one patient complained of transient limb numbness which resolved within 6 weeks. It is our conclusion that thoracoscopic anterior spinal surgery, though with learning curve, a safe and effective procedure.