Arthritic knees, for the purpose of surgical correction during arthroplasty, are generally thought to be either varus knees or valgus knees and soft tissue releases are done in accordance with the same concept. This view is dependent on the clinical deformity in extended knee and the plain AP radiograph of the extended knee. This concept is now challenged by the observations from our study of the arthritic knee kinematics using computer aided navigation when performing total knee replacement arthroplasty. We performed 283 total knee replacements with computer aided navigation. Imageless navigation was used with Stryker and Orthopilot systems. Bone trackers were fixed to the bones and through real time infrared communication the data was collected. The knee kinematics were recorded before and at the end of surgery. This included measurement of biomechanical axis with the knee extended and then gradually flexed. The effect of flexion on the coronal alignment was recorded real time on the computer. The results were then analysed and compared with plain radiographic deformity on long leg films.

Majority of the knees did not behave in a true varus or valgus fashion. We classified the deformity into different groups depending on the behavior of the knee in coronal plane as it moves from extension to flexion. 2 degree was taken as minimum deviation to signify change, as the knee bends from full extension to flexion. The classification system is as follows

Neutral

Deformity - Varus/Valgus to start with in extension

Gp1

Deformity remains the same as the knee flexes

Gp2

Decreasing deformity but does not reach neutral in flexion

Gp3

Decreasing deformity and crosses to opposite (Varus to valgus or valgus to varus) deformity in flexion

Gp4

Deformity first increases and then decreases but does not reach neutral

Traditional releases of medial or lateral structures without realising the true picture of what happens when the knee is flexed, may not be correct. From our study it is clear that not all arthritic varus or valgus knees behave in the same way. Some of the releases we perform conventionally may not be required or need to be modified depending on the knee kinematics.

Aims: For the scaphoid, several views are needed to visualise the whole bone. These sets of views are routinely called “scaphoid views”. However certain views are better than others for imaging particular parts of the scaphoid. The authors believe that asking for scaphoid views from the radiology department often leads to a wide variety and number of radiographic views being taken, even when a protocol is in place. Methods: 50 radiographers from 4 London teaching hospitals were asked which and how many views of the scaphoid they would take, at initial presentation and in the outpatient setting. They were also asked to describe and demonstrate exactly how they would take the view(s) chosen. Results: We found a wide variation in the descriptive terms used by radiographers for particular views. There was also little agreement on how many and which views to take despite protocols being in place. Conclusion: Not only is their complete lack of agreement on what “scaphoid views” should be, it was also discovered that there was little agreement on the nomenclature of the individual views themselves. This can lead to loss of information from the wrong views being taken as well as unnecessary radiation exposure. The lack of nomenclature also leads to confusion between radiologists, radiographers and surgeons

The study of the chondrocyte maturation cycle and endochondral ossification showed that the developing vascular supply has appeared to play a key role in determining the cortical or trabecular structure of the long bones. The chondrocyte maturation cycle and endochondral ossification were studied in human, foetal cartilage anlagen and in postnatal meta-epiphyses. The relationship between the lacunar area, the inter territorial fibril network variations and CaP nucleation in primary and secondary ossification centres were assessed using light microscopy and SEM morphometry. The anlage topographic, zonal classification derived from the anatomical nomenclature of the completely developed long bone (diaphysis, metaphyses and epiphyses) allowed to follow the development of long bones cartilage model. A significant increase in chondrocyte lacunar area (p<0.001) was documented from the anlage epiphyseal zone 4 and 3 to zone 2 (metaphysis) and zone 1 (diaphysis), with the highest variation from zone 2 to zone 1. An inverse reduction in the intercellular matrix area (p<0.001) and matrix interfibrillar empty space (p<0.001) was also documented. These findings are consistent with the osmotic passage of free cartilage water from the interfibrillar space into the swelling chondrocytes, raising ion concentrations up to the critical threshold for mineral precipitation in the matrix. The mineralised cartilage served as a scaffold for osteoblasts apposition both in primary and secondary ossification centres and in the metaphyseal growth plate cartilage, but at different periods of bone anlage development and with distinct patterns for each zone. They all shared a common initial pathway, but it progressed with different times, modes and organisation in diaphysis, metaphysis and epiphysis. In the ossification phase the developing vascular supply has appeared to play a key role in determining the cortical or trabecular structure of the long bones

While classically bone tumors were classified according to the differentiation and cellular morphology at the light microscopical level, it has become clear that over the past decade the array of knowledge which became available on the cytogenetic and molecular genetic level should influence tumor classification. This lead to an integrated approach in drafting the 2002 WHO nomenclature for bone tumors in which morphology was combined with the evolving genetic information. With regard to bone tumorigenesis distinct patterns can be recognized with regard to underlying genetics:. balanced translocations such as in Ewing sarcoma, or aneurysmal bone cysts. numerical chromosomal abnormalities like in adamantinoma. complex karyotypes with as yet no identified starting point from a genetic point of view such as in osteosarcomas or central chondrosarcomas. single gene events such as in fibrous dysplasia or osteochondroma. These different pathways in oncogenesis open an array of possibilities for studying the drivers in oncogenesis. Especially those pathways essential in keeping the proliferative state as opposed to the ones governing differentiation might proof to be potential targets for tailored drug treatment. Here high throughput screens focusing on kinase activity appear especially of interest. Within the EuroBoNeT consortium (. www.eurobonet.eu. ) several working groups act transnationally together in unraveling these events. Important key elements of study are the molecular-genetic networks involved in skeletogenesis as well, which amongst others are studied within the consortium using in vitro systems as well as in vivo models using xenografted mouse models, mesenchymal stem cell models and models exploring zebrafish development

Aims

Multiligament knee injuries (MLKI) are devastating injuries that can result in significant morbidity and time away from sport. There remains considerable variation in strategies employed for investigation, indications for operative intervention, outcome reporting, and rehabilitation following these injuries. At present no study has yet provided a comprehensive overview evaluating the extent, range, and overall summary of the published literature pertaining to MLKI. Our aim is to perform a methodologically rigorous scoping review, mapping the literature evaluating the diagnosis and management of MLKI.

Aims

The aim of this study was to investigate the global and local impact of fat on bone in obesity by using the diet-induced obese (DIO) mouse model.

Aims

This systematic review aims to identify 3D predictors derived from biplanar reconstruction, and to describe current methods for improving curve prediction in patients with mild adolescent idiopathic scoliosis.

The study aimed to develop and assess a new classification system for Segmentation Defects of the Vertebrae (SDV), a frequent cause of congenital scoliosis. Existing nomenclature for the wide range of SDV phenotypes is inadequate and confusing eg ‘Jarcho-Levin syndrome’. A multidisciplinary group of the International Consortium for Vertebral Anomalies and Scoliosis (ICVAS) met to formulate a new classification system, based primarily on radiology. SDV are identified by number affected, contiguity, and spinal region(s). The size, shape and symmetry of the thoracic cage, and rib number, symmetry and fusion are included, and familiar vertebral morphology terms retained, together with accepted syndrome names. The terms spondylocostal and spondylothoracic dysostosis apply only to phenotypes typified by the monogenic disorders due to mutated DLL3, MESP2, LNFG and HES7 genes. Five ICVAS members (Group 1) then independently assessed 10 new cases, inter-observer reliability assessed using kappa. Seven independent radiologists (Group 2) then assessed the same cases before and after introduction to the new system. Inter-observer reliability for Group 1 yielded a kappa value of 0.21 (95% confidence intervals (CI) 0.052, 0.366, p=0.0046). For Group 2, before introduction to the new system, 1/70 responses (1.4%) agreed with the Group 1 consensus,12 different diagnoses were offered, and 38/70 (54.3%) responses were ‘Unknown’. After introduction to the new system 47/70 responses (67.1%; 95% CI 55.5, 77.0) agreed with Group 1 consensus, a 65.7% improvement (95% CI 52.5, 75.6, p< 0.00005). The system was well received by 6/7 radiologists. The new system was found to be reliable and acceptable. Ethics approval: None. Interest Statement: None

The use of artificial intelligence (AI) is rapidly growing across many domains, of which the medical field is no exception. AI is an umbrella term defining the practical application of algorithms to generate useful output, without the need of human cognition. Owing to the expanding volume of patient information collected, known as ‘big data’, AI is showing promise as a useful tool in healthcare research and across all aspects of patient care pathways. Practical applications in orthopaedic surgery include: diagnostics, such as fracture recognition and tumour detection; predictive models of clinical and patient-reported outcome measures, such as calculating mortality rates and length of hospital stay; and real-time rehabilitation monitoring and surgical training. However, clinicians should remain cognizant of AI’s limitations, as the development of robust reporting and validation frameworks is of paramount importance to prevent avoidable errors and biases. The aim of this review article is to provide a comprehensive understanding of AI and its subfields, as well as to delineate its existing clinical applications in trauma and orthopaedic surgery. Furthermore, this narrative review expands upon the limitations of AI and future direction.

Cite this article: Bone Joint Res 2023;12(7):447–454.

Aims

Is it feasible to conduct a definitive multicentre trial in community settings of corticosteroid injections (CSI) and hydrodilation (HD) compared to CSI for patients with frozen shoulder? An adequately powered definitive randomized controlled trial (RCT) delivered in primary care will inform clinicians and the public whether hydrodilation is a clinically and cost-effective intervention. In this study, prior to a full RCT, we propose a feasibility trial to evaluate recruitment and retention by patient and clinician willingness of randomization; rates of withdrawal, crossover and attrition; and feasibility of outcome data collection from routine primary and secondary care data.

Significant controversy exists with regard to the nomenclature, treatment and outcome of a group of well-differentiated lipomatous tumours sometimes labeled as atypical lipomas. The purpose of this paper is to attempt to clarify these controversies by reporting our experiences with this lesion. The clinical features and follow-up of seventy patients with the diagnosis deep atypical lipoma (DAL) and a minimum two-year follow-up were examined. Sixty- one patients were treated here with their primary lesion. Thirty-three were female and 28 were male. Ages ranged from 11 to 83 years (mean 57 years). They typically presented with a long history (four weeks to ten years, mean 91 weeks) and a large mass (4 to 30 centimetres, mean 18 centimetres). Most lesions were located in the thigh. Following treatment by marginal excision alone, five patients had a local recurrence (8.2%). Three recurred once and two recurred twice. No patient had a metastasis or died as a result of the tumour. No lesion dedifferentiated. Eight of the nine patients seen here with a presumed recurrence actually had a recurrent atypical lipoma. All recurrences were treated by further marginal resections and one went on to have a further recurrence. None of these patients had a metastasis and no lesion dedifferentiated. The final patient with a suspected recurrence most likely had a radiation-induced sarcoma nine years following radiotherapy after the marginal excision of a recurrent atypical lipoma. We believe the term atypical lipoma is appropriate for these tumours, as they appear not to have any metastatic potential, merely a propensity to recur locally. The chance of dedifferentiation is small and the role of radiotherapy in the causation of dedifferentiation is uncertain. We suggest that a simple marginal resection (shelling-out) is adequate treatment for these lesions. Radiotherapy should not be used

Introduction: The knee joint in congenital longitudinal deformities of the lower extremity shows a large variety of pathological findings. Valgus deformity is found in most cases and is described as being juxta- articular. To describe the true anatomic pathology we performed a radiographic analysis of the knee joint in congenital longitudinal deformities. Patients and Method: Between 1985 and 2001 we treated 102 patients presenting with congenital longitudinal deformities. Inclusion criteria for this study were diagnoses of fibular hemimelia (FBH) and/or congenital femoral deficiency (CFD), an age between 5 and 16 years, unilateral affection and availability of long standing X-rays, whereas bilateral affection or previous operations on the lower extremities were defined as exclusion criteria. Twenty-four parameters were defined on the femur and tibia respectively and a nomenclature was created. The mean values including standard deviation were calculated and we statistically compared the parameters of the affected to those of the non-affected knee. Furthermore, MRI scans of the knee joint of 20 of these patients were evaluated. Results: Thirty- nine patients (19 female, 20 male) met the inclusion criteria. The average age at the time of evaluation was 8.87 years (3.1 SD). A combined deficiency of femur and tibia was found in 35 patients. The predominant diagnosis was CFD in 13, fibular hemime-lia in 13 and fibular aplasia in 9 cases. The anatomic lateral distal femoral angle (ALDFA) measured 75.4° (2.5 SD) on the affected, and 81.6° (1.6 SD) on the non-affected knee. The lateral distal femoral metaphyseal angle of the affected side and of the non-affected side showed no significant difference. The distal lateral femoral epiphyseal width (DLFEW) was decreased in the affected limb compared to the non affected limb, whereas the distal medial femoral epiphyseal width (DMFEW) of the affected and non-affected side showed only a minor difference. In the tibia we found no significant difference between the variables for the medial proximal tibial angle (MPTA) and for the medial proximal tibial metaphyseal angle (MPTMA) of the affected and the non-affected limb. A significant difference was found between the proximal lateral tibial epiphyseal width of the affected and the non-affected side. Analysis of the MRI scans revealed aplasia of the anterior cruciate ligament in 18 cases and aplasia of the posterior cruciate ligament in 8 of the 20 cases. The defect of ossification of the lateral tibial epiphysis as seen in plain X-rays is visible in the MRI scans as cartilage anlage. (Only the most important findings are summarized). Conclusions: In our patient population only four patients had FBH or CFD but 35 cases presented combined defects; we assume that the femur is affected to some extent in almost all cases of FBH. The hypoplasia was only found in the lateral aspects of femur and tibia and was primarily located within the femoral epiphysis. The metaphysis was not or only minimally affected in the evaluated longitudinal deficiencies. Awareness of sagittal instability, due to ACL and/or PCL aplasia, is necessary to avoid subluxation or dislocation when lengthening procedures are performed

Aims

Our objective was to conduct a systematic review and meta-analysis, to establish whether differences arise in clinical outcomes between autologous and synthetic bone grafts in the operative management of tibial plateau fractures.

Aims

Psychoeducative prehabilitation to optimize surgical outcomes is relatively novel in spinal fusion surgery and, like most rehabilitation treatments, they are rarely well specified. Spinal fusion patients experience anxieties perioperatively about pain and immobility, which might prolong hospital length of stay (LOS). The aim of this prospective cohort study was to determine if a Preoperative Spinal Education (POSE) programme, specified using the Rehabilitation Treatment Specification System (RTSS) and designed to normalize expectations and reduce anxieties, was safe and reduced LOS.

Aims

Metal allergy in knee arthroplasty patients is a controversial topic. We aimed to conduct a scoping review to clarify the management of metal allergy in primary and revision total knee arthroplasty (TKA).

Aims

The present study investigates the effectiveness of platelet-rich plasma (PRP) gel without adjunct to induce cartilage regeneration in large osteochondral defects in a rabbit model.

Aims

A comprehensive classification for coronal lower limb alignment with predictive capabilities for knee balance would be beneficial in total knee arthroplasty (TKA). This paper describes the Coronal Plane Alignment of the Knee (CPAK) classification and examines its utility in preoperative soft tissue balance prediction, comparing kinematic alignment (KA) to mechanical alignment (MA).

Aims

To explore the clinical relevance of joint space width (JSW) narrowing on standardized-flexion (SF) radiographs in the assessment of cartilage degeneration in specific subregions seen on MRI sequences in knee osteoarthritis (OA) with neutral, valgus, and varus alignments, and potential planning of partial knee arthroplasty.

Cell therapies hold significant promise for the treatment of injured or diseased musculoskeletal tissues. However, despite advances in research, there is growing concern about the increasing number of clinical centres around the world that are making unwarranted claims or are performing risky biological procedures. Such providers have been known to recommend, prescribe, or deliver so called ‘stem cell’ preparations without sufficient data to support their true content and efficacy. In this annotation, we outline the current environment of stem cell-based treatments and the strategies of marketing directly to consumers. We also outline the difficulties in the regulation of these clinics and make recommendations for best practice and the identification and reporting of illegitimate providers.

Cite this article: Bone Joint J 2020;102-B(2):148–154

Aims

Platelet concentrates, like platelet-rich plasma (PRP) and platelet lysate (PL), are widely used in regenerative medicine, especially in bone regeneration. However, the lack of standard procedures and controls leads to high variability in the obtained results, limiting their regular clinical use. Here, we propose the use of platelet-derived extracellular vesicles (EVs) as an off-the-shelf alternative for PRP and PL for bone regeneration. In this article, we evaluate the effect of PL-derived EVs on the biocompatibility and differentiation of mesenchymal stromal cells (MSCs).