The purpose of this study is to clarify optimal timing of anterior cruciate ligament (ACL) reconstruction from the point of view of meniscus injury. One hundred thirty-five ACL injuries (under 40 years of age) were analyzed in this study. All knees had undergone primary reconstruction without other ligament injury, and follow-up arthroscopy. ACL reconstruction was performed by the semitendinosus and gracilis method. The rehabilitation protocol was based on that of Shelbourne. Cases were divided into 4 groups by the period from injury to reconstruction. Nineteen knees were of the acute phase, which is within 1 month from the injury to reconstruction. Thirty-one knees were of the subacute phase, which is from 1 month over to reconstruction. Thirty-one knees were of the subacute phase, which is from 1 month over to 3 months from the injury to reconstruction. Forty knees were of the subchronic phase, which is from 3 months over to 1 year from the injury to reconstruction. Forty-five knees were of the chronic phase, which is over 1 year from the injury to reconstruction. We compared arthroscopic findings as well as clinical follow-up results of each phase. The rate of lateral meniscus injury were 84% in the acute phase, 39% in the subacute phase, 58% in the subchronic phase, and 51% in the chronic phase. The rates of medial meniscus injury were 32% in the acute phase, 29% in the subacute phase, 53% in the sub-chronic phase, and 60% in the chronic phase. Horizontal tear and degenerative tear of the lateral meniscus were increased with time. Osteoarthritic change at follow-up arthroscopy was observed 3 knees in the acute phase, 4 knees In the subacute phase, 8 knees In the subchronic phase, and 13 knees in the chronic phase. There was no difference between clinical results of our ACL reconstruction in the acute phase and chronic phase. ACL reconstruction in the acute phase was the effective method for preventing secondary osteoarthritis after medial meniscus injury

Aims. The ulna is an extremely rare location for primary bone tumours of the elbow in paediatrics. Although several reconstruction options are available, the optimal reconstruction method is still unknown due to the rarity of proximal ulna tumours. In this study, we report the outcomes of osteoarticular ulna allograft for the reconstruction of proximal ulna tumours. Methods. Medical profiles of 13 patients, who between March 2004 and November 2021 underwent osteoarticular ulna allograft reconstruction after the resection of the proximal ulna tumour, were retrospectively reviewed. The outcomes were measured clinically by the assessment of elbow range of motion (ROM), stability, and function, and radiologically by the assessment of allograft-host junction union, recurrence, and joint degeneration. The elbow function was assessed objectively by the Musculoskeletal Tumor Society (MSTS) score and subjectively by the Toronto Extremity Salvage Score (TESS) and Mayo Elbow Performance Score (MEPS) questionnaire. Results. The mean follow-up of patients was 60.3 months (SD 28.5). The mean elbow flexion-extension ROM was 95.8° (SD 21). The mean MSTS of the patients was 84.4 (SD 8.2), the mean TESS was 83.8 (SD 6.7), and the mean MEPS was 79.2 (SD 11.5). All the patients had radiological union at the osteotomy site. Symptomatic osteoarthritic change was observed in three patients (23%), one of whom ended up with elbow joint fusion. Two patients (15.4%) had recurrence during the follow-up period. Surgical complications included two allograft fractures, two plate fractures, three medial instabilities, and two infections. Conclusion. Osteoarticular ulna allograft reconstruction provides acceptable functional outcomes. Despite a high rate of complications, it is still a valuable reconstruction method, particularly in skeletally immature patients who need their distal humerus physis for the rest of hand growth. Cite this article: Bone Jt Open 2024;5(9):749–757

Aims

The optimal management of posterior malleolar ankle fractures, a prevalent type of ankle trauma, is essential for improved prognosis. However, there remains a debate over the most effective surgical approach, particularly between screw and plate fixation methods. This study aims to investigate the differences in outcomes associated with these fixation techniques.

Aims

Therapeutic agents that prevent chondrocyte loss, extracellular matrix (ECM) degradation, and osteoarthritis (OA) progression are required. The expression level of epidermal growth factor (EGF)-like repeats and discoidin I-like domains-containing protein 3 (EDIL3) in damaged human cartilage is significantly higher than in undamaged cartilage. However, the effect of EDIL3 on cartilage is still unknown.

Aims. Cartilage injuries rarely heal spontaneously and often require surgical intervention, leading to the formation of biomechanically inferior fibrous tissue. This study aimed to evaluate the possible effect of amelogenin on the healing process of a large osteochondral injury (OCI) in a rat model. Methods. A reproducible large OCI was created in the right leg femoral trochlea of 93 rats. The OCIs were treated with 0.1, 0.5, 1.0, 2.5, or 5.0 μg/μl recombinant human amelogenin protein (rHAM. +. ) dissolved in propylene glycol alginate (PGA) carrier, or with PGA carrier alone. The degree of healing was evaluated 12 weeks after treatment by morphometric analysis and histological evaluation. Cell recruitment to the site of injury as well as the origin of the migrating cells were assessed four days after treatment with 0.5 μg/μl rHAM. +. using immunohistochemistry and immunofluorescence. Results. A total of 12 weeks after treatment, 0.5 μg/μl rHAM. +. brought about significant repair of the subchondral bone and cartilage. Increased expression of proteoglycan and type II collagen and decreased expression of type I collagen were revealed at the surface of the defect, and an elevated level of type X collagen at the newly developed tide mark region. Conversely, the control group showed osteoarthritic alterations. Recruitment of cells expressing the mesenchymal stem cell (MSC) markers CD105 and STRO-1, from adjacent bone marrow toward the OCI, was noted four days after treatment. Conclusion. We found that 0.5 μg/μl rHAM. +. induced in vivo healing of injured articular cartilage and subchondral bone in a rat model, preventing the destructive post-traumatic osteoarthritic changes seen in control OCIs, through paracrine recruitment of cells a few days after treatment. Cite this article: Bone Joint Res 2023;12(10):615–623

Abstract. Introduction. A lipohaemarthrosis seen on Horizontal beam lateral X-ray in acute knee injury is often considered predictive of an intra-articular fracture requiring further urgent imaging. Methodology. We retrospectively searched a five-year X-ray database for the term “lipohaemarthrosis”. We excluded cases if the report concluded “no lipohaemarthrosis” or “lipohaemarthrosis” AND “fracture”. All remaining cases were reviewed by an Orthopaedic Consultant with a special interest in knee injuries (AD) blinded to the report. X-rays were excluded if a fracture was seen, established osteoarthritic change was present, a pre-existing arthroplasty present or no lipohaemarthrosis present. Remaining cases were then studied for any subsequent Radiological or Orthopaedic surgical procedures. Results. 136 cases were identified and reviewed by an Orthopaedic Consultant. 31 were excluded for no lipohaemarthrosis (n= 11), for degenerative change (n=9), for fracture (n=4), for existing arthroplasty (n=4) and for data errors (n=3). The remaining 105 patients had a mean age of 32, and range 5–90 years. 66 patients underwent further imaging in the form of MRI scan (n=47), CT Scan (n=9) repeat x-rays (n=9) and ultrasound (n=1). 27 fractures were identified. Surgery was performed in 12 cases (11%). Two (2%) urgently (One ACL reconstruction plus meniscus repair, one for ORIF of tibial plateau fracture). Ten (10%) had elective surgery (6 for ACL reconstruction, 2 for ACL reconstruction plus meniscus repair, 2 for loose body removal. Conclusion. The presence of a lipohaemarthrosis on x-ray following acute knee injury was a poor predictor of intra-articular fracture (26%) or need for urgent surgery (2%)

Nuclear factor erythroid 2–related factor 2 (Nrf2)/antioxidant response element (ARE) pathway is key in maintaining redox homeostasis and the pathogenesis of osteoarthritis (OA) involves oxidative distress. We thus investigated whether Nrf2/ARE signaling may control expression of key chondrogenic differentiation and hyaline cartilage maintenance factor SOX9. In human C-28/I2 chondrocytes SOX9 expression was measured by RT–qPCR after shRNA-mediated knockdown of Nrf2 or its antagonist the Kelch-like erythroid cell-derived protein with cap “n” collar homology-associated protein 1 (Keap1). Putative ARE-binding sites in the proximal SOX9 promoter region were inactivated, cloned into pGL3, and co-transfected with phRL–TK for dual-luciferase assays to verify whether Nrf2 transcriptionally regulates SOX9. SOX9 promoter activity without and with Nrf2-inducer methysticin were analyzed. Sox9 expression in articular chondrocytes was correlated to cartilage thickness and degeneration in wild-type (WT) and Nrf2-knockout mice. Data were analyzed by one-way ANOVA, a Student's t-test, or Wilcoxon rank-sum test, according to the normal distribution. Statistical significance was set to p < 0.05. While Keap1-specific RNAi increased SOX9 expression, Nrf2-specific RNAi significantly decreased it. Putative ARE sites (ARE. 1. , ARE. 2. ) were identified in the SOX9 promoter region. ARE. 2. mutagenesis significantly reduced SOX9 promoter activity, while truncation of ARE. 1. did not. A functional ARE. 2. site was thus essential for methysticin-mediated induction of SOX9 promoter activity. Knee cartilage of young Nrf2-knockout mice further revealed significantly fewer Sox9-positive chondrocytes as compared to old Nrf2-knockout animals, which further showed thinner cartilage and more severe cartilage erosion. Our data suggest that SOX9 expression in articular cartilage is directly Nrf2-dependent and that pharmacological Nrf2 activation may hold potential to diminish age-dependent osteoarthritic changes in knee cartilage through improving protective SOX9 expression

Although remnant-preserved ACL reconstruction (ACLR) restores knee joint stability and dampens the problem of acute ACL rupture-induced knee pain, an increasing number of patients still develop post-traumatic osteoarthritis (PTOA) after 10 to 15 years of ACLR. We previously found that remnant-preserved ACLR with concomitant medial and lateral meniscus repair may not prevent cartilage degeneration and weaken muscle strength, while the clinical features of PTOA are not clear. We hypothesized that remnant-preserved ACLR with concomitant medial and lateral meniscus tears is related to early cartilage damage, worse function recovery, patient-reported outcomes (PROs) and delayed duration to return to sports. The aim is to evaluate the remnant-preserved ACLR with complicated meniscal injuries in predicting which patients are at higher risk of osteoarthritic changes, worse function and limited activities after ACLR for 12 months. Human ethical issue was approved by a committee from Xi'an Jiaotong University. 26 young and active patients (24 male, 2 female) with ACL injuries (Sherman type I and II) with concomitant medial and lateral meniscus within 2 months were included from January 2014 to March 2022. The average age of the ACLR+ meniscus repair was 26.77±1.52 (8 right, 5 left) and isolated ACLR control was 31.92±2.61 years old (7 left, 6 right). Remnant-preserved ACLR with a 5- to 6-strand hamstring tendon graft was operated on by the same sports medicine specialists. MRI CUBE-T. 2. scanning with 48 channels was conducted by a professional radiologist. The volume of the ACL graft was created through 3 dimensional MRI model (Mimics 19, Ann Arbor). Anterior Cruciate Ligament OsteoArthritis Score (ACLOAS) was applied to score visible cartilage damage. IKDC 2000 score and VAS were assessed by two blinded researchers. Results were presented as mean± SEM of each group. The cross-sectional area and 3D volume of the ACL graft were greater in the remnant-preserved ACLR+meniscus group compared with isolated ACLR (p=0.01). It showed that ACLR+ meniscus group had early signs of joint damage and delayed meniscus healing regarding ACLOAS compared to control group (p=0.045). MRI CUBE-T. 2. prediction of radiographic cartilage degeneration was not obvious in both groups post remnant-preserved ACLR over 12 months (p>0.05). However, higher VAS scores, lower IKDC scores, and long-last joint swelling were reported in the ACLR+ meniscus repair group at the end of 12 months follow-up. Although remnant-preserved ACLR+ meniscus was able to maintain the restore the knee function, it showed delayed timing (>12 months) to return to play at the pre-injury stage, while no difference between the timing of returning to the normal daily routine of their ACLR knee compared to control (p=0.30). The cost of ACLR+ meniscus (average 10,520.76$) was higher than the control group (6,452.92$, p=0.018). Remnants-preserved ACLR with concomitant injured medial and lateral meniscus repair shows a higher risk of cartilage damage, greater cost, worse functional performance, and longer time for young male patients to return to sports after 12-month follow-up compared to isolated ACLR. Further evidence and long-term follow-up are needed to better understand the association between these results and the risk of development of PTOA in this patient cohort

Osteonecrosis (ON) around the knee joint can be spontaneous (primary), without comorbid medical conditions, or secondary. ON is characterized by sudden pain, usually self resolving after six months to a year, night pain, and involving mainly women older than 55 years of age. Twenty seven patients with primary ON were retrospectively reviewed. The patients were evaluated clinically (physical examination and H.S.S. scoring) and radiographically (plain radiographs were done at the beginning and at the end of follow-up and MRI studies). The MRI study included calculations of the area and the volume of the lesion, osteoarthritic changes, bone collapse and meniscal pathologic findings. The majority of the patients, 96% (26/27), complained of sudden pain. Night pain was observed in 46% of the patients. Osteoarthritic changes observed in 60% of the patients and further deterioration (37%) was noted at follow up radiographs. Osteoarthritic changes were more predominant in patients with tibial condyle involvement rather than those with femoral involvement, 61% vs. 43% (p=0.04), respectively. Diagnosis of osteonecrosis by the initial radiographs was more common in patients with femoral involvement (7 femurs vs. 1 tibia). All ON lesions were diagnosed by MRI, from these, 17 meniscal tears (63%) were detected. Several observations were noted in the volumetric analysis: Tibial lesions were larger than femoral lesions (8.1cm. 3. vs. 3.1cm. 3. , respectively, p=0.026). Women had significantly larger lesions in volume and area than men (area – 5.09cm. 2. vs 2.05cm. 2. , p=0.01; and volume – 6.6cm. 3. vs. 1.2cm. 3. , p=0.001). Significant correlation was found between bone collapse and the need for total knee replacement (TKR): 40% collapse in the TKR patients versus 13.6% collapse without TKR (p=0.028). Patients that were diagnosed with collapse at the end of the follow up had a larger area (5.8cm. 2. vs 3.7cm. 2. ) and a lower HSS score (68.5 points vs. 83 points, p=0.02) than those without. A significant correlation was noted between a larger lesion area and lower HSS scoring (p=0.037) at the end of the follow-up. Patients with tibial lesions had more meniscal pathologies involvement, 56.3% vs. 43.8%, however it was not statistically significant (p=0.68). We conclude that MRI study for patients with ON and calculating the area and the volumetric data particularly, is an accurate predictive tool for the natural history of knee ON. The findings presented here may guide us in determining the best possible treatment

Summary. In a rabbit model of early osteoarthritis, structural changes in femoral condyle cartilage were severer in the lateral compartment and preceded alterations in the underlying bone. In the medial compartment, altered bone properties occurred together with structural changes in cartilage. Introduction. Early osteoarthritic changes in cartilage have been previously studied through anterior cruciate ligament transection (ACLT) in rabbits. However, parallel changes in the structure of subchondral and trabecular bone at 4 weeks after ACLT are not known. Methods. Skeletally mature 14-month old New Zealand white rabbits (n=8) underwent ACLT in the left knee, while right knees were used as controls (CTRL). Femoral condyles (FCs) were harvested at 4 weeks after ACLT. INDENTATION TESTING. Stepwise stress-relaxation tests were performed on medial and lateral FC cartilage (100%/s ramp rate, 3×5% step, 15 min relaxation time). Sinusoidal loading was then applied (amplitude 4% of thickness, 1Hz, 4 cycles). Equilibrium (Eeq) and dynamic (Ed) moduli were derived from stress-relaxation and sinusoidal tests, respectively. STRUCTURAL ANALYSIS OF CARTILAGE. Polarised light microscopy (PLM) and digital densitometry (DD) were used to analyze the collagen orientation angle (COA) and proteoglycan content in the cartilage samples. STRUCTURAL ANALYSIS OF BONE. Distal compartments of FCs were scanned using a high-resolution µCT scanner (Skyscan 1172, Belgium) with an isotropic voxel size of 25 µm. µCT data were imported into Mimics (Materialise, Belgium) for segmentation. 2×2×4 mm. 3. volumes of interest (VOIs) were placed in weight-bearing regions of medial and lateral FCs. Subchondral bone plate thickness (Pt.Th), trabecular volume fraction (BV/TV), trabecular thickness (Tb.Th), structural model index (SMI) and trabecular separation (Tb.Sp) were calculated using the CTAnalyzer software (Skyscan) from the VOIs. STATISTICAL TESTS. Mixed linear model for cartilage parameters and Wilcoxon signed-rank test for bone parameters were used to compare ACLT and CTRL groups (p < 0.05). Results. In both lateral and medial FC compartments, Eeq was significantly smaller in ACLT than in CTRL cartilage. In the medial compartment, also Ed was significantly smaller in ACLT than in CTRL cartilage. As a result of ACLT, significant alterations in the COA extended deeper into cartilage in the lateral than medial compartment, while proteoglycan content was reduced significantly and similarly in both lateral and medial FC cartilages. After ACLT, Pt.Th was significantly reduced in the medial compartment, while no changes were observed in the lateral compartment. Furthermore, only in the medial compartment, both BV/TV and Tb.Th were significantly smaller in the ACLT compared to the CTRL group. Discussion. The study showed that disruption of the collagen architecture in the ACLT joint cartilage extended into the middle zone only in the lateral FC compartment. Instead, thinning of the subchondral bone plate combined with resorption of trabecular bone was observed only in the medial FC compartment. The former finding reflects early osteoarthritic changes, while the latter finding may be indicative of a diminished loading in the medial FC compartment, as caused by ACLT

Abstract. INTRODUCTION. The mechanisms underlying abnormal joint mechanics are poorly understood despite it being a major risk factor for developing osteoarthritis. Glutamate signalling has been implicated in osteoarthritic bone changes and AMPA/kainate glutamate receptor (GluR) antagonists alleviate degeneration in rodent models of osteoarthritis. We investigated whether glutamate signalling molecules are mechanically regulated in a human, cell-based 3D model of bone. METHODS. Human Y201 MSC cells embedded in 3D type I collagen gels (0.05 × 106 cell/gel) differentiated to osteocytes were mechanically loaded in silicone plates (5000 µstrain, 10Hz, 3000 cycles) or not loaded (n=5/group). RNA extracted 1-hr post load was quantified by RTqPCR and RNAseq whole transcriptome analysis (NovaSeq S1 flow cell 2 × 100bp PE reads). Differentially expressed GluRs and glutamate transporters (GluTs) were identified using DEseq2 analysis on normalised count data. Genes were considered differentially expressed if >2 fold change and FDR p<0.05. RESULTS. Cells expressed mature osteocyte markers (E11, sclerostin, DMP-1). DEseq2 analysis, revealed 981 mechanically regulated genes. Mechanical loading upregulated kainate GluRs, GRIK2 (1.6 fold, p=0.024) and GRIK5 (4.2 fold, p=0.045); the NMDA GluR GRIN3B (3.25 fold, p=0.047) and the GluT SLC1A1 (3 fold, p=0.037). Conversely, AMPA GRIA3, NMDA GluRs GRIN2A&C, and the GluT SLC1A2 were down regulated by 50–60%, although not significant. Kainate GRIK3&4; AMPA GRIA2, NMDA GRIN1, and GluTs SLC1A6&A7 were not expressed in control or loaded osteocytes, whereas GluRs (GRIK1, GRIA1&4, GRIN2B&2D&3A) and GluT SLC1A3 were expressed but not regulated by mechanical loading. DISCUSSION. Mechanical loading of human osteocytes in 3D revealed that they regulated expression of glutamate receptors and transporters. This is consistent with our observation that mechanical perturbation after joint injury in rodent models of OA regulates glutamatergic signalling in the bone thus linking mechanical stimuli to inflammatory and nociceptive pathways mediated by glutamate receptors. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

Aims: Arthroscopic drilling for the treatment of osteo-chondral lesion (OCL) of talus has been able to return earlier to social life resulting from less invasive operation. However, long term results of drilling have not been clear. Results of arthroscopic drilling for OCL which have passed 5 years or longer are reported. Methods: Subjects were 54 feet in 52 patients who had passed more than 5 years who underwent arthroscopic drilling. Age ranged 21 to 52 years with an average of 34 years. Classiþcation based on Berndt & Harty was as follows: 1 foot for stage?, 38 feet for stage?, 8 feet for stage?and 7 feet for stage?. Resdults: No patients showed limited range of motion at the þnal examination. With pain, 2 patients developed pain in the lesion, while no patients showed disturbance in gait, either. With sports, all the patients returned to initial sports, however, in patients with extensive lesion (3 patients), there remained pain causing a decrease in sports level. X-ray þndings revealed osteoarthritic change in three patients. Conclusions: In the present study, in patients of 90 percent or greater, there were no new developed or deterorated pains. However, osteoarthritic change was observed in the cases with lateral ligaments tear or subchondral bone cyst. Thus, it may suggest the limit in the indications of drilling. Furthermore, since there remained pain in the patients with complicated injuries or extensive lesion, it may be difþcult to obtain excellent results with use of arthroscopic drilling alone

Knee osteoarthritis is a common, debilitating condition. Intra articular corticosteroid injections are a commonly used non-operative treatment strategy. Intra articular hip injection with Ketorolac (an NSAID) has proven to be as efficacious as corticosteroids. No prior study compares the efficacy of Ketorolac relative to corticosteroids for relief of discomfort in knee osteoarthritis. The study design was a single centre double blinded RCT. Severity of osteoarthritic changes were graded on plain film weightbearing radiographs using the Kellgren and Lawrence system. Injection was with either 30mg Ketorolac or 40mg Methylprednisolone, given by intra-articular injection, in a syringe with 5mls 0.5% Marcaine. Pre-injection clinical outcomes were assessed using the Numerical Pain Score (NPS), WOMAC, and Oxford knee scores. Patients' NPS scores were assessed at Day 1 and Day 14 post-injection. An assessment of all clinical outcomes took place in clinic at six weeks. There were 72 participants (83 knees) in the study. No patients were lost to follow-up. Mean age was 62.66 years (Range 29–85). 42 knees received a corticosteroid injection, 41 a NSAID injection. Mean Kellgren and Lawrence score was 3.1. There was no significant difference in pre-injection clinical scores in either group. There was a significant improvement of NPS on Day 1 and 14 in both injection groups(p<0.05). These improved pain scores were sustained at 6 weeks in both groups. WOMAC and Oxford Knee Scores showed a statistically significant improvement in the corticosteroid group. WOMAC scores showed significant improvement in the NSAID group, however these improvements didn't achieve statistical significance using the Oxford Knee Score. Corticosteroid or NSAID injectate are a safe and effective non-operative treatment strategy in the patient with knee osteoarthritis. Ketorolac appears to provide effective medium-term improvement of pain and clinical scores. Further follow-up is recommended to investigate if this trend in sustained

One of the most important factors influencing therapeutical decisions in orthopaedic surgery are long-term results. Although, osteochondritis dissecans (o.c.d.) of the femoral condyles is the most often occurring location little is known about long-term results. Furthermore, it is of interest to see the time course of such patients regarding the development of secondary osteoarthritis. Thus, it was the aim of our study to re-analyse patients suffering from o.c.d. of the femoral condyle which had been operated have been followed up after a medium time-intervall. Material & methods: 97 of 147 with o.c.d. of the femoral condyles which were operated using different surgical techniques depending on the stage were followed-up clinically (Lysholm-Score) & radiologically (Arcq- classification/Tapper- & Hoover-score for OA). Results were analysed depending on the age, stage and surgical technique. In 2nd follow-up ten years after the first follow-up patients were reexamined with the same clinical and radiological scores. Results: At 1st follow-up we found a median Lysholm-Score of 83.7 (21–100, SD 19.6) pts.. Regarding the OA-changes in 56.3% no changes, in 21.9 % 1°-changes, in 3.1% 3°-changes, in 6.3 % 3°-changes & in 12.5 % 4° changes. The mean stage postop. was 0.97 SD 1.4. Ten years later similar results were found: in 56.3% no osteoarthritic changes were seen. 1°-changes were found in 21.9%, 2°-changes in 3.1% and 3°-changes in 6.3% and severe OA 4°-changes were found in 12.5%. In comparison to the 1st follow-up at the 2nd follow-up no individual changes could be detected in 73 %, a slight impairment in 11.5 % & a slight improvement in 15.4%. In most of the patients osteoarthritic changes were slight & did not show a severe impairment after a mean of 20.3 years. Depending on the age (the stage of the growth plate open vs. closed) adolescents exhibited no or slight oa-changes in 83.3% & moderate changes in 16.7%. Severe oa-changes were not detectable. Adults exhibited a distinct higher incidence of oa (no o.-a.: 37.5%/1°: 25%/2°: 12.5% 3°:/12.5%/4°:12.5%). Regarding the surgical technique retrograde technique leaving the cartilage layer intact resulted in distinct better results than those perforating the cartilage layer. Conclusion: Best long-term results with a low incidence of OA are to obtain in cases with o.c.d. with intact cartilage layer not necessitating cartilage damage. Worst results are seen in adult patients with 4°-lesions

The purpose of this study was to present the long team functional results after conservative treatment of intraarticular calcaneal fractures. Nine patients with 11 fractures (mean age at accident 52 years old) were reevaluated. Mean follow-up was 8 years (6–15). 5 fractures were tongue type, 5 were compression fractures and 1 with comminution according to Essex Lopresti classification. These patients were clinically and functionally evaluated with the Ankle-Hind foot scale (Kitaoka, 1994). They were submitted to radiographic testing (foot AP, ankle lateral, axial and medial axial views). Osteoarthritic (OA) changes, calcaneal dimensions (height, width) and Bohler’s – Gissane’s angles were recorded. According to Ankle Hind foot score (highest 100) our patients scored a mean 77 points (48–90). OA changes were recorded in 7 cases in the ankle joint and in all cases in taloscaphoid, calcanocuboid (severe in 8) and subtalar joints (severe in 5). We found width reduction in 6 patients and height reduction in 2, compared to the healthy side. Bohler’s angle was abnormal in 6 cases (−21°to 52°) while Gissane’s angle was abnormal in 9 (84° to 115°). Treatment of intraarticular calcaneal fractures is still controversial. Recent studies show a tendency for surgical treatment. In the present study a distinction between clinical and radiographic findings was made. Patients had satisfactory functional results although severe osteoarthritic changes were recorded

Joint degeneration may make a total knee arthroplasty (TKA) a requirement for pain relief and function. However, the presence of ipsilateral limb osteomyelitis (OM) makes surgical management extremely challenging. We report the experience of a high volume revision knee surgeon managing ipsilateral limb multi resistant OM and the outcome of subsequent TKA. Four consecutive patients were identified who had either ipsilateral femoral or tibial chronic osteomyelitis treated prior to undergoing TKA. Surgery to eradicate the osteomyelitis involved a Lautenbach compartmental debridement, and where necessary, healing by secondary intention. The decision to proceed to a TKA was based on history, clinical examination and radiological findings of advanced osteoarthritic change. The patients had a mean age of 50 years. They had a background of multi-organism OM and underwent single-stage TKAs at an average of 63 months following eradication of the underlying OM. Three patients did well but had complications associated with poor skin and soft tissues, and abnormal bone anatomy. One patient developed an infection and following a re-revision had an arthrodesis. The results for the four cases are summarised in Table 1. We have highlighted that patients with ipsilateral limb multi resistant OM are a difficult cohort to manage

Purpose. The purpose of this study is to analyse regional differences in the microstructural and mechanical properties of the distal femur depending on osteoarthritic changes using micro-images based on finite element analysis. Materials and Methods. Distal femur specimens were obtained from ten donors composed of 10 women with OA (mean age of 65 years, ranging from 53 to 79). As controls, the normal distal femur was sampled from age and gender matched donors consisting of 10 women(mean age of 67 years, ranging from 58 to 81). The areas of interest were six regions of the condyles of the femur(Lateral-Anterior, Middle, Posterior; Medial=Anterior, Middle, Posterior). A total of 20 specimens were scanned using the micro-CT system. Micro-CT images were converted to micro-finite element model using the mesh technique, and micro-finite element analysis was then performed for assessment of the mechanical properties. Results. Trabecular bones from the distal femur in control and OA groups exhibited different microstructural and mechanical properties in the same region. BV/TV, Tb.N, Tb.S and Yield strength were different between LA and MMsignificantly (p=0.005). In control group, the lateral anterior region of the distal femur reflected subchondral trabecular remodeling, while in advanced OA group, the medial middle region showed prominent changes in the microstructural and mechanical properties. Conclusion. The authors concluded that with aging and the progress of primary OA, changes of patello-femoral reaction force induced subchondral trabecular changes of the anterolateral region initially, and then progressed to the medial middle and posterior region in advanced OA

Purpose. The purpose of this study is to investigate the relationship between the angles made by the reference axes on the computerized tomography (CT) images and comparison of the knee alignment between healthy young adults and patients who is scheduled to have total knee arthroplasty. Materials and Methods. This study was conducted in 102 patients with osteoarthritis of knee joint who underwent preoperative computerized tomography (CT). The control group included 50 patients having no arthritis who underwent CT of knee. Axial CT image of the distal femur were used to measure the angles among the the anteroposterior (AP) axis, the posterior condylar axis (PCA), clinical transepicondylar axis (cTEA) and the surgical transepicondylar axis (sTEA). Then, the differences in amounts of rotation between normal and osteoarthritic knee was evaluated. Results. The mean angle between cTEA and PCA in the osteoarthritis group was 5.0°±2.2, whereas that in the control group was 5.5°±2.0. The mean angle between cTEA and sTEA in the osteoarthritis group was 3.7°±0.8, whereas that in the control group was 4.3°±0.6. The mean angle between AP axis and PCA in the osteoarthritic group was 93.25°±2.0, whereas in the control group was 96.3°±1.9. There was significant differences in angles between AP axis and PCA. But, no significant difference was seen in angles between cTEA and PCA, cTEA and sTEA in two groups. Conclusion. In result of this study, the angle between cTEA and PCA showed an average external rotation of 5.0° in osteoarthritic group. More external rotation was needed for the femoral component alignment than 3° recommended in usual total knee arthroplasty. The angle between AP axis and PCA is decreased in osteoarthritic knee compared with normal knee. But, osteoarthritic change of knee joint had no significant effect on the relationships of other axes

DDH with or without previous treatment is the most frequent source of early hip OA in adolescents. Others are hip joint deformation following Legg-Calve-Perthes disease, slipped capital epiphysis or trauma. Secondary OA after rheumatoid arthritis, bacterial infection or as result of an hemophilic hip joint are relatively infrequent. The choice of treatment depends on the type of the deformity and the severity of osteoarthritic changes. Osteotomies are favorably performed in adolescents. Arthrodesis is rarely accepted in this age group. In selected individuals THR is the matter of choice. Pain, limping gait, restricted joint motion and sometimes clicking phemomena are the usual complains. Pain is usually aggravated by running and other sports activities. Residual dysplasia of the hip with a spherical femoral head is best treated by a triple periacetabular osteotomy. The Bernese ostetomy of Ganz (. 3. ) and the triple osteotomy of Tönnis (. 9. ) are popular procedures. They mobilise an acetabular fragment, then reorient and stabilise the fragment in an optimal position. Internal fixation with screws provides stability and allows early mobilisation with partial weight bearing. Chiari’s osteotomy is a supracetabular rotatory displacement osteotomy. Femoral head and joint capsule are medialised and covered by the osteomised iliac bone. The joint capsule in the weight bearing zone is transformed into fibrous cartilage by time. Congruent remodelling of the acetabular roof and fibrous tissue transformation into cartilage are biased by inproper height and orientation of the osteotomy (. 5. ). There is still an indication in severe DDH with subluxation of the femoral head and those with a severely deformed femoral head. In pathomorphologies with aspherical femoral heads femoral osteotomies, usually valgus osteotomies, are required additionally in order to optimize the joint congruency. A dysplastic hip in a high dislocation and moderate to severe OA are contraindications. Radiographic work up includes pelvic ap view and faux profil view. Assessment of the anterior and posterior acetabular rim indicate orientation of the acetabulum in terms of anteversion / retroversion. Orientation of the subchondral sclerosis over the femoral head is an indicator of femoral head coverage as CE-angle and AC-angle. 20°–30° abduction view in neutral rotation mimikes the postoperative acetabulum / femoral head relation. From CT-scans acetabular orientation ( ante-version / retroversion ), degenerative bone cysts, posteroinferior joint space and femoral head deformities and femoral neck osteophytes are depicted. Labrum pathology is dedectable by MRT and MRT-arthrography. After treatment of DDH deformation of the femoral head and neck due to ischaemic necrosis develop in an incidence up to 20 %, depending on the method. Premature closure of the epiphyseal plate can also follow trauma, septic arthritis and Legg-Calve-Perthes disease. Most often an combination of acetabular dysplasia and coxa magna with short femoral neck and a high-standing greater trochanter are typical deformities. Specchiulli’s classification (. 8. ) is very helpful for deformations after avascular necrosis in DDH. Limping gait due to femoral shortening and insufficient strength of the abductor muscels are the major complains of adolescents. Symptoms exacerbate during walking of longer distances and restrict sports activities. Valgus osteotomy, Y-osteotomy, transfer of the greater trochanter alone or in combination with valgus osteotomy are appropiate methods to restore a better function and improve alignment of the mechanical axis to the knee joint. Femoral neck lengthening osteotomies (. 1. ,. 4. ) with distal-lateral transfer of the greater trochanter are advocated by several authors. Restoration of almost normal anatomy muscle function of the hip joint are realistic aims of these methods. If the abductor muscel deficit is dominant and only a minor leg length discrepancy is in slight deformities, e.g. some Specchiulli’s type B2, we do not always need such complex procedures. Isolated transfer of the greater trochanter also improves the lever arm of the abductor muscles and therefore joint function, but does not influence leg length discrepancy. Disappearance of the Tren-delenburg-type gait is the most visible improvement of this procedure (. 7. ). Total hip replacement (=THR) is rarely indicated in adolescents, but sometimes necessary for restoration of a almost normal quality of life. Especially in severe symptomatic OA after septic arthritis or trauma in some individuals remain only two options : arthrodesis or arthroplasty. Arthrodesis is a permanent solution for many years or even life time. Gait function is compromised remarkable (. 6. ) and specific compensatory mechanisms are adopted when walking. Excessive motion in the lumbar spine and ipsilateral knee provokes back and knee pain as well as osteoarthritic changes on the long run. THR in young patients includes the risk of several revisions over life time , due to wear problems particularly in physically active individuals. A deficient acetabular bone stock as usual in severe acetabular dysplasia or poor bone quality after trauma or septic arthritis may compromize primary stability and secondary osteointegration. Nevertheless functional results and outcome (. 2. ) in terms of life quality are superior compared with various non-substituting procedures

Medial meniscus tear has been proposed as a potential etiology of spontaneous osteonecrosis of the knee (SONK). Disruption of collagen fibers within the meniscus causes meniscal extrusion, which results in alteration in load distribution in the knee. A recent study has demonstrated high incidence of medial meniscus extrusion in the knee with SONK. Our purpose was to determine whether the extent of medial meniscus extrusion correlates with the severity of SONK in the medial femoral condyle. Anteroposterior and lateral knee radiographs were taken with the patients standing. Limb alignment was expressed as the femorotibial angle (FTA) obtained from the anteroposterior radiograph. The stage of progression of SONK was determined according to the radiological classification system described by Koshino. After measurement of anteroposterior, mediolateral, and superoinferior dimensions of the hypointense T1 signal intensity lesion of MRI, its ellipsoid volume was calculated with the three dimensions. Meniscal pathology (degeneration, tear, and extrusion) were also evaluated by MRI. Of the 18 knees with SONK, we found 5 knees at the radiological stage 2 lesions, 9 knees at the stage 3, and 4 knees at the stage 4. Whereas the ellipsoid volume of SONK lesion significantly increased with the stage progression, the volume was significantly greater at stage 4 than stage 2 or 3. All the 18 knees with SONK in the present study showed substantial extrusion (> 3mm) and degeneration of the medial meniscus. While medial meniscal extrusion increased with the stage progression, medial meniscus was significantly extruded at stage 3 or 4 compared with stage 2. A significant increase in FTA was found with the stage progression. FTA was significantly greater at stage 4 than stage 2 or 3. Multiple linear regression analysis revealed that medial meniscus extrusion and FTA were useful predictors of the volume of SONK lesion. This study has clearly shown a significant correlation between the extent of medial meniscus extrusion and the stage and volume of SONK lesion. Degeneration and tears of the medial meniscus in combination with extrusion may result in loss of hoop stress distribution in the medial compartment, which could increase the load in the medial femoral condyle. In addition to meniscal pathology, knee alignment can influence load distribution in the medial compartment biomechanically. Multiple linear regression analysis indicates that an increase in FTA concomitant with a greater extrusion of medial meniscus could result in greater lesion and advanced radiological stage of SONK. Taken together, alteration in compressive force transmission through the medial compartment by meniscus extrusion and varus alignment could develop subchondral insufficiency fractures in the medial femoral condyle, which is considered to be one of the main contributing factors to SONK development. There was high association of medial meniscus extrusion and FTA with the radiological stage and volume of SONK lesion. Increased loading in the medial femoral condyle with greater extrusion of medial meniscus and varus alignment may contribute to expansion and secondary osteoarthritic changes of SONK lesion