Total knee arthroplasty (TKA) is considered as one of the most successful and cost-effective medical interventions yet it is consistently reported that up to 20% of patients are dissatisfied with their outcomes. Patient satisfaction is correlated with the fulfillment of expectations and an important aspect of this involves good surgeon-patient communication, which itself is a contributor to TKA satisfaction. The purpose of this study was to develop and test a checklist intended to enhance the quality of surgeon-patient communication by optimizing the surgeon's role in helping patients set (or reset) and manage post-TKA expectations that are realistic, achievable, and most importantly, patient-specific.

In this prospective mixed methods study, a communication checklist was developed from the analysis of interviews with patients who were between six weeks and six months post-TKA. Four orthopaedic surgeons then used the checklist to guide discussions with patients about post-operative expectations and outcomes during follow-up visits between six weeks and six months. A visual analogue scale was used to survey two groups of patients on five measures of satisfaction: the standard of care communication group and the intervention group who had received the checklist. The mean scores of the two groups were compared using independent t-tests. The duration of follow-up visits was also tracked to determine if the checklist took significantly more time in practice.

Themes from the qualitative analysis of eight patient interviews incorporated into the checklist included pain management, medication, physiotherapy, and general concerns and questions. The quantitative study comprised 127 participants, 67 in the standard of care communication group and 60 in the checklist group. There were no significant group differences in gender, BMI, comorbidities, post-operative complications, marital or occupational status, however the standard of care group was older by six years (p < .001). The checklist group reported significantly greater satisfaction on four of the five measures of satisfaction: TKA satisfaction and expectations met (p = .017), care and concern shown by the surgeons (p = .011), surgeons' communication ability (p = .008), and satisfaction with time surgeons spent with patients during follow-up visits (p < .001). Satisfaction with the TKA for relieving pain and restoring function was not significant (p = .064). Although the checklist increased the average clinic visit time by only 1 minute, 51 seconds, it was significantly greater (p = .001). The impact of age and gender on satisfaction was explored using a two-way analysis of variance. No significant effects or interactions were observed.

Checklists have been shown to decrease medical errors and improve overall standards of patient care but no published research to date has used a communication checklist to enhance orthopaedic surgeon-patient communication. The present findings indicate that this simple tool can significantly increase patient satisfaction. This has practical significance because patient satisfaction is a metric that is increasingly used as a key performance indicator for surgeons and health care institutions alike. Increased TKA satisfaction will benefit patients, surgeons, and the health care system overall.

Purpose: Despite a number of recently published reports on the success of meniscal repair devices, there are no anatomic studies documenting their safety. The purpose of this cadaveric and radiographic study was to anatomically determine the proximity of a common commercially available meniscal repair device to the popliteal neurovascular structures

Methods: Five human cadaveric knees were obtained and procured from the medical school anatomy lab. Two Biostingers (Linvatec) measuring 16mm in length were placed in the posterior one third of the medial meniscus. Each specimen was then placed prone with the knee extended to expose the posterior aspect of the knee. The distance to the neurovascular bundle for each device was then measured with a ruler calibrated to the nearest 0.1cm. To validate our anatomic dissection results, fifty calibrated human knee MRI scans were reviewed by two independent radiologists. The distances measured were from the popliteal artery to the closest point at the lateral meniscus periphery/capsule and the medial meniscus periphery/capsule. The average distance as measured by the two radiologists was calculated as was the average for the entire population of fifty subjects

Results: The mean distance in the cadaveric study was 15.6mm (14.0–18.0mm) between the tip of the repair device needle and the neurovascular bundle. The mean distance on MRI from the popliteal neurovascular bundle to the closest point in the posterior medial meniscus was 20.0 mm (13.0 mm–28.7 mm). The mean distance from the popliteal structures to the posterior lateral meniscus was 9.4 mm (3.2 mm–16.5 mm).

Conclusions: Considering the potential for significant morbidity, we recommend medial meniscal repair should be performed carefully with repair devices. Specifically, one should limit posterior capsule penetrations to less than 15 mm based on these findings.

Purpose: There is increasing evidence that surgical reconstruction of the ACL deficient knee in active patients over the age of 40 is the treatment of choice. The purpose of this study was to compare the objective and subjective outcomes of patients over 40 years old with those of a group of younger patients, all of whom underwent arthroscopic ACL reconstruction with quadruple hamstring autograft.

Methods: Forty patients were enrolled in this retrospective case-control study. Twenty patients over 40 years of age were compared to twenty patients under the age of 40 from our database. Both groups underwent single incision ACL reconstruction using hamstrings autograft and had a minimum of one year followup. Each patient underwent subjective questioning, radiographic and physical examination by 2 independent clinical reviewers. Subjectively, the groups were then compared using the IKDC (International Knee Documentation Committee) subjective questionnaire, Lysholm Knee score, Tegner activity level, and SF-36 general health survey. Objectively, they were compared using the IKDC objective questionnaire and KT-1000 arthrometry.

Results: The average age of the older group was 50 while the younger group age was 28. The two groups were also similar in terms of sex distribution, follow-up, and meniscal injury at reconstruction. Two patients in the over 40 group had postoperative infection. One patient in the under 40 group suffered a deep abrasion secondary to the tourniquet.|We found no significant difference between the 2 groups in regards to IKDC Subjective score, Lysholm Knee Score, Tegner Activity Level, and SF-36 General Health Survey. Also we found no significant difference between the groups objectively with IKDC scores, KT-1000 measurement and complication rates.

Conclusions: These results indicate that ACL reconstruction using hamstrings tendon autograft in patients older than 40 years old is comparable with that of a younger cohort. Age alone should not be used to determine whether surgical management of patients with ACL deficiency is necessary.

Introduction and Aims: The radiographic appearance of fractures is often used as an evaluative tool when assessing the status of healing fractures. The aim of this study was in the first instance to assess the reliability of orthopaedic surgeons to measure the area of periosteal callus and secondly to compare the area with the biomechanical strength of the fractures.

Method: Thirty-seven sheep underwent a transverse osteotomy of the right radius. All sheep were managed in a plaster cast and splint to ensure non weight-bearing during rehabilitation. Nineteen of the sheep were ran-domised to receive cyclic loading by the application of a pressure cuff around the muscles of the proximal forearm deep to the cast. The other 18 sheep acted as controls. Sheep from both groups were sacrificed at either four or six weeks. Fractures were x-rayed and subjected to biomechanical testing following sacrifice. X-rays were transferred to a Labview program from which the area of callus was measured. Biomechanical testing of the fractures was a torsional test to failure. The peak torque, stiffness and energy absorbed over the first 10 degrees of torsion were measured for each fracture.

Results: The two orthopaedic surgeons who measured the area of callus showed a positive correlation (r = 0.85). When the four-week fractures that were treated with cyclic loading were compared with the four-week control fractures, the periosteal callus measurement along with the peak torque, fracture stiffness and energy absorbed over the first 10 degrees of torsion all showed a significant difference (p < 0.05). In addition, when the six-week fractures that were treated with cyclic loading were compared with the six-week control fractures, the periosteal callus measurement along with the peak torque, fracture stiffness and energy absorbed over the first 10 degrees of torsion were not significantly different (p > 0.05).

Conclusion: The results show that the area of periosteal callus on radiographs can be related to the biomechanical status of a healing fracture. Further research is required to determine if other characteristics of the periosteal callus plus quantification of the callus area is able to accurately predict fracture strength.

Introduction Experimental heterotopic bone formation in the canine urinary bladder has been observed for more than seventy years without revealing the origin of the osteoinductive signals. In 1931, Huggins demonstrated bone formation in a fascial transplant to the urinary bladder. Through an elaborate set of experiments, it was found that proliferating canine transitional epithelial cells from the urinary system act as a source of osteoinduction.

Urist performed a similar series of experiments in guinea pigs as Huggins did in his canine model. After two weeks, mesenchymal cells condensed against the columnar epithelium and membranous bone with haversian systems and marrow began to form juxtapose the basement membrane. At no time was cartilage formation noted, only direct membranous bone formation. They also demonstrated the expression of BMP’s in migrating epithelium and suggested that BMP is the osteoinductive factor in heterotopic bone formation.

Method This study was approved by Institutional Animal Ethics Committee. Six dogs underwent a mid-line laparotomy incision followed by mobilisation of a right sided myoperitioneal vascularised flap based on an inferior epigastric artery pedicle. A sagittal cystotomy is made in the dome of the bladder and the vascularised flap was sutured in place with acryl absorbable, continuous suture. The animals were sacrificed at 6 weeks. The bladder samples were removed and assessed by histology and immunohistochemistry. Sections were incubated with optimal dilution of primary antibody for type I collagen, type III collagen, alkaline phosphatase (ALP), bone morphogenetic protein (BMP)-2 and –4, osteocalcin (OCN), osteopontin (OPN), bone sialoprotein (BSP).

Results The mechanism for bone formation induced by the epithelial-mesenchymal cell interactions is not clear. We were able to demonstrate mature lamellar bone formation 6 weeks after transplanting a portion of the abdominal smooth muscle into the bladder wall. The bone formed immediately adjacent to the proliferating transitional uroepithelium, a prerequisite for bone formation in Huggins’ model. Here we report evidence of cartilage formation and therefore endochondral ossification as well as membranous bone formation. This is very similar histologically to the process of endochondral ossification at the growth plate in the growing skeleton. We propose a mechanism for the expression of BMP by epithelial cells.

Discussion This study demonstrates transitional epithelium induced formation of chondrocytes and osteoblasts in muscle tissue. The sequential expression of bone matrix proteins was related to cell proliferation, differentiation and formation of endochondral and membranous bone. Further information regarding the molecular mechanism of bone formation induced by epithelial-mesenchymal cell interactions will improve understanding of cell differentiation during osteogenesis.