Tissue engineering strategies to heal critical-size bone defects through direct bone formation are limited by incomplete integration of grafts with host bone and incomplete vascularisation. An alternative strategy is the use of cartilage grafts that undergo endochondral ossification. Endochondral cartilages stimulate angiogenesis and are remodeled into bone, but are naturally found in only small quantities. We sought to develop engineered endochondral cartilage grafts using human osteoarthritic (OA) articular chondrocytes. Study approval was obtained from our human and animal ethics review committees. Human OA cartilage was obtained from discarded tissues from total knee replacements. Scaffold-free engineered grafts were generated by pelleting primary or passaged chondrocytes, followed by culture with transforming growth factor-β1 (TGF-β1) and bone morphogenetic protein 4. Samples were transplanted into immunocompromised mice either subcutaneously or into critical-size tibial defects. Grafts derived from passaged chondrocytes from either of two patients (64 year old and 68 year old men) where implanted into tibial defects in five mice. Bone formation was assessed with histology after four weeks of implantation.Background
Methods
We evaluated the long-term benefits of steroid injection in 20 consecutive patients (25 shoulders) with primary acromioclavicular arthritis using the Constant score. All patients were followed up for a minimum of 5 years. The average age of the patients was 55 years. The mean pre-injection Constant score was 61 points. At six months this improved to 81 points, (mean difference – 19.36) which was highly statistically significant (p<
0.01). There was further improvement at 12 months, on the 6-month score, mean 86 points that also showed a significant improvement on the 6-month score (p = 0.001). At 5 years the mean score was 81 points and this was a significant detoriation compared with the 12-month score (p=0.01) but still a significant improvement when compared to the preinjection scores (p<
0.0005). In addition, the younger the patients, the greater the improvement in the objective score which measures range of movement and power (r= − 0.47; p= 0.01). Female patients also had a greater improvement (r=0.405; p=0.05). We conclude that local steroid injection is an effective method of treatment for primary isolated acromioclavicular arthritis and improvement continues for at least 12 months and the benefit is felt up to 5 years though the pain relief tends to tail off long-term.
Day case surgery is commonplace in the field of orthopaedic surgery, being suitable for a wide range of both trauma &
elective procedures. It became apparent within our unit that an unacceptably high number of cases were being cancelled for a variety of reasons. We set out to identify these reasons and thereby develop a simple screening process to reduce the number of cancellations. Initial audit over a 1 year period showed 25% of the 907 day case patients were being cancelled. We subdivided the reasons for these cancellations at both pre-operative assessment and on the day of surgery into avoidable [e.g. no carer / telephone, uncontrolled BP, high BMI and ischaemic heart disease] and unavoidable [e.g. surgery no longer required, patient unwell, list cancelled for emergencies, patient DNA]. The majority of our cancellations fell into the “avoidable” category, predominantly at pre-operative assessment. Accordingly, we devised a simple screening questionnaire to be used by clinicians in out-patients at the time of listing for surgery, based on the RCS guidelines (1985). If any of the questions were answered “Yes”, the patient was not suitable for day case surgery. The patient information letter was also changed, informing patients that non-attendance would result in their removal from the waiting list. Re-audit of 727 patients over the next 12 months showed a fall in cancellations to only 11%, with the majority of these being for unavoidable reasons. Cancellations are a source of inconvenience, distress and frustration to both clinician and patient, are a waste of hospital time and resources, and lead to an increase in waiting lists. Our study demonstrates the value of closing the loop in audit, leading to a dramatic reduction in cancellations. Audit is a useful tool to improve patient care, and is not merely a “number-crunching” exercise.
The effectiveness of steroid injection in the treatment of primary osteoarthritis of the acromioclavicular joint (ACJ) has been questioned. We prospectively evaluated the outcome of 20 consecutive patients (25 shoulders) with clinical and radiological evidence of primary ACJ arthritis after steroid injections. All patients were evaluated using the Constant score after a minimum of 12 months follow up. Only patients with a negative provocative test after injection of 2ml of depomedrone and lignocaine were included in the study. Eleven females (14 shoulders) and 9 males (11 shoulders) were included. The average age was 53.9 years. The mean preinjection score was 61.6 points (SD 13.12) and at 6 months this improved to 81 points, mean difference of 19.36 (CI = 14.19 – 24.53), p<
0.01, which was highly statistically significant. There was further improvement at 12 months, on the 6 month score, mean 88.4 points, mean difference of 7.4 (CI = 3.55 – 11.25), p = 0.001 which was also statistically significant. In addition, the younger the patient, the greater the improvement in the objective score which measures the range of movement and power (r = −0.47; p = 0.01). We conclude that local steroid injection is an effective method of treatment for primary isolated acromioclavicular arthritis and improvement continues for at least 12 months, but may require more than one injection.
We present the mid term results of 267, 3M Capital hip replacement performed in a single institution from 1991 to 1994. Patients were recalled back to clinic in April 1998 after the reported high failure rate of 3M hips. Fifty- nine hips were excluded from this study for various reasons. Average follow-up was 68.8 months. Nine (4.2%) have been revised for aseptic loosening at the time of review and further 10(4.8%) of the stems are radiologically loose. There was no statistical significant difference between hips that failed, regarding grade of the operating surgeon, surgical approach: trochanteric osteotomy or Hardinge, or type of prosthesis used: monoblock (stainless steel) or modular (titanium). Acetabular wear rate, width of medial cement mantle or cancellous bone at level of neck at Gruen zone7, or stems with canal fill index less than 50%, 7 cm below the level of the collar also showed no statistical difference. Male patients had higher incidence of loosening (p=0.001) which was statistically significant. Both varus and valgus alignment of the stem had higher failure rate which was significant. We could no find any obvious reason for failure in 10 of the 18 patients. The stem was either in varus or there was an inadequate cement mantle in 8 of the failed hips on the initial postoperative radiograph. A feature of this study was high incidence of endosteolysis and debonding of prosthesis from cement in the failed cases. The present series showed considerably lower revision and loosening rate of 3M stems compared to the published series, the reason for which is not clear. Only Palacos cement was used in this series, which may partly account for the lower failure rate. Surface finish of the stem leading to debonding of the prosthesis from cement along with different modulus of elasticity probably accounts for the higher rate. Technical failure is partly to blame for the higher failure rate.
