The aim of the study is to determine the histological, biochemical, and biomechanical efficacy of fibrin clot and vitamin C in the healing of Achilles tendon ruptures (ATR) in a rat model.52 adult Wistar Albino rats (300–450 g) were used in the study. 12 groups were divided into four groups as Monitor (Group I), Control (Group II), Fibrin Clot (Group III), Fibrin Clot with vitamin C (Group IV). Four rats were used to obtain fibrin clots. Fibroblast Growth Factor (FGF) and Vascular Endothelial Growth Factor (VEGF) were measured in the blood of tail vein (1 cc) on the 3rd, 7th, 14th, and 21st day. Four rats were sacrificed on the 21st day from each group for histological evaluation. The rest of the rats were sacrificed at 42nd day, half for biomechanical and a half for histological evaluation. The 42nd-day HSS scores in group III and group IV were significantly lower than those of group I and group II (p =0.036 and 0.019; respectively). The 42nd-day HSS score of group IV was significantly lower than group III (p =0.036). The Maximum force N value of group III and group IV was significantly higher than those of group I and group II (p <0.05). Group IV showed a significantly higher Maximum force N value than group III (p =0.025). The blood FGF and VEGF levels of group III and group IV on the 3rd, 7th, 14th, and 21st days were higher than those of group I and group II (p <0.05). In the experimentally formed ATR model, fibrin clot and vitamin C produced a stronger tendon structure in terms of biomechanics while providing histological and biochemically better quality tendon healing in the surgical treatment of ATR. We believe that this model can be used to accelerate high-quality tendon healing after ATR

Abstract. Introduction. Augmentation of meniscus repairs with fibrin clot may enhance the healing capacity. Pulling the clot into the tear with a suture ensures that it stays in position. This paper aims to assess the outcome of this technique. Methods. 52 patients over 4 years undergoing suture repair of a meniscus tear with blood clot augmentation were collected from a prospective database. Follow up included outcome scores and a questionnaire. Failure was defined as pain or further surgery secondary to meniscal pathology. Results. There were 32 males and 20 females, mean age of 35 (14–70). The medial meniscus was repaired in 32 knees and the lateral in 20. Complete radial tears were the most common type. Only 2% of tears were in the red-red zone. Follow-up ranged from 12 months to 7 years. Only 1 patient is known to have come to subsequent arthroscopy. Lysholm scores improved from 53.97 (SD 18.14) to 92.08 (SD 8.97), Oxford Knee Scores from 29.84 (SD 9.65) to 45.79 (SD 2.66), KOOS pain scores from 61.49 (SD 22.76) to 93.54 (SD 8.06) and Tegner scores from 4.56 (SD 3.35) to 6.05 (SD 2.41). Conclusions. Pulling a fibrin blood clot into a meniscus tear with a suture ensures that the clot remains in place while the meniscus is repaired. Patients have shown excellent outcomes with 98% survivorship at 45 months. This is a reliable technique for augmenting meniscus repairs especially for tears which otherwise may not have been repaired

This study was proposed to evaluate the efficacy of fibrin clot augmentation in meniscal tear using inside-out meniscal repair. A total of 35 patients with meniscus tears were operated on with inside-out meniscus repair and fibrin clot augmentation. Patients were evaluated preoperatively and postoperatively with clinical criteria, Lysholm knee scoring system, and MRI. Out of the total 35 cases, 5 cases were lost to follow up. Clinical improvement was observed in 29 out of 30 patients (96.6%). The mean Lysholm score improved significantly from 67.63 ± 6.55 points preoperatively to 92.0 ± 2.9 points postoperatively (P < 0.05) in 2 years follow-up. Follow-up MRI in all patients revealed complete healing except in 1 case where the patient presented with recurrence of symptoms such as pain and locking which resolved with partial meniscectomy. Paraesthesia in the anterior part of the knee was observed in 2 cases. (6.6%). We conclude that fibrin clot augmentation is a good cost-effective modality of treatment for repairable meniscus tears to preserve the meniscus and decrease the point contact pressure on the condyles which may prevent the early occurrence of osteoarthritis

Abstract. Introduction. In patients with bilateral unicompartmental knee osteoarthritis, simultaneous bilateral surgery is cost effective, with both patient-specific and wider socioeconomic benefits. There are concerns however regarding higher complication rates with bilateral knee surgery. This study compares simultaneous bilateral unicompartmental knee arthroplasty (UKA), to single side UKA in terms of complications and outcomes. Methodology. This is a retrospective case-control study of single side medial UKA patients (controls) and simultaneous bilateral medial UKA patients (cases). All patients underwent surgery between 2018 and 2022 by a single surgeon. The two cohorts were compared for perioperative blood loss (PBL), length of stay (LOS), complications (infections, blood clots, wound problems), Oxford Knee Score improvement (OKS) and revision surgery, with a follow-up period of up to 5 years. Results. 64 patients were followed up comprising 55 controls and 9 cases. Average length of stay for controls was 1.55 days and 2.22 days for cases (p=0.03). Average haemoglobin drop was 7.5g/l in controls and 12.8g/l in cases (p=0.04). The OKS improvement was comparable in both groups (p=0.95) with no complications and no revision surgery in either group. Conclusion. The statistically significant differences in PBL and LOS were not clinically relevant. There were no blood transfusions and postoperative haemoglobin was within normal range in more than 60% of cases. Simultaneous bilateral unicompartmental knee arthroplasty is a financially favourable and safe option for patients with bilateral knee medial unicompartmental osteoarthritis

Juvenile Osteochondritis dissecans (JOCD) in humans and subchondral cystic lesions (SCL) in horses (also termed radiolucencies) share similarities: they develop in skeletally immature individuals at the same location in the medial femoral condyle (MFC) and their etiology is only partially understood but trauma is suspected to be involved. JOCD is relatively uncommon in people whereas SCLs arise in 6% of young horses leading to lameness. Ischemic chondronecrosis is speculated to have a role in both osteochondrosis and SCL pathogenesis. We hypothesize that MFC radiolucencies develop very early in life following a focal internal trauma to the osteochondral junction. Our aims were to characterize early MFC radioluciencies in foals from 0 to 2 years old. Distal femurs (n=182) from Thoroughbred horses (n=91, 0–2 years old), presented for post-mortem examination for reasons unrelated to this study, were collected. Radiographs and clinical tomodensitometry were performed to identify lesions defined as a focal delay of ossification. Micro-tomodensitometry (m-CT) and histology was then performed on the MFCs (CT lesions and age-matched subset of controls). Images were constructed in 3D. The thawed condyles, following fixation, were sectioned within the region of interest, determined by CT lesion sites. Hematoxylin eosin phloxin and safran (HEPS) and Martius-Scarlet-Blue (MSB) stains were performed. Histological parameters assessed included presence of chondronecrosis, fibrin, fibroplasia and osteochondral fracture. An additional subset of CT control (lesion-free) MFCs (less 6 months old) were studied to identify early chondronecrosis lesions distant from the osteochondral junction. One MFC in clinical CT triages controls had a small lesion on m-CT and was placed in the lesion group. All m-CT and histologic lesions (n=23) had a focal delay of ossification located in the same site, a weight bearing area on craniomedial condyle. The youngest specimen with lesions was less than 2 months old. On m-CT 3D image analysis, the lesions seemed to progressively move in a craniolateral to caudomedial direction with advancing age and development. Seventy-four percent (n=17/23) of the lesions had bone-cartilage separation (considered to be osteochondral fractures) confirmed by the identification of fibrin/clot on MSB stains, representing an acute focal bleed. Fibroplasia, indicating chronicity, was also identified (74%, n=17/23). In four cases, the chondrocytes in the adjacent cartilage were healthy and no chondronecrosis was identified in any sections in the lesions. Nineteen cases had chondronecrosis and always on the surface adjacent to the bone, at the osteochondral junction. None of the subset of control specimens, less than 6 months old (n=44), had chondronecrosis within the growth cartilage. Early subchondral cystic lesions of the medial femoral condyle may arise secondary to focal internal trauma at the osteochondral junction. The presence of fibrin/clot is compatible with a recent focal bleed in the lesion. Medial femorotibial joint internal forces related to geometry could be the cause of repetitive trauma and lesion progression. In the juvenile horse, and potentially humans, the early diagnosis of MFC lesions and rest during the susceptible period may reduce progression and promote healing by prevention of repetitive trauma, but requires further study

Spinal surgery deals with the treatment of different pathological conditions of the spine such as tumors, deformities, degenerative disease, infections and traumas. Research in the field of vertebral surgery can be divided into two main areas: 1) research lines transversal to the different branches; 2) specific research lines for the different branches. The transversal lines of research are represented by strategies for the reduction of complications, by the development of minimally invasive surgical techniques, by the development of surgical navigation systems and by the development of increasingly reliable systems for the control of intra-operative monitoring. Instead, specific lines of research are developed within the different branches. In the field of oncological pathology, the current research concerns the development of in vitro models for the study of metastases and research for the study of targeted treatment methods such as electrochemotherapy and mesenchymal stem cells for the treatment of aneurysmal bone cysts. Research in the field of spinal deformities is focused on the development of increasingly minimally invasive methods and systems which, combined with appropriate pharmacological treatments, help reduce trauma, stress and post-operative pain. Scaffolds based on blood clots are also being developed to promote vertebral fusion, a fundamental requirement for improving the outcome of vertebral arthrodesis performed for the treatment of degenerative disc disease. To improve the management and the medical and surgical treatment of vertebral infections, research has focused on the definition of multidisciplinary strategies aimed at identifying the best possible treatment path. Thus, flow-charts have been created which allow to manage the patient suffering from vertebral infection. In addition, dedicated silver-coated surgical instrumentation and bone substitutes have been developed that simultaneously guarantee mechanical stability and reduce the risk of further local infection. In the field of vertebral traumatology, the most recent research studies have focused on the development of methods for the biostimulation of the bone growth in order to obtain, when possible, healing without surgery. Methods have also been developed that allow the minimally invasive percutaneous treatment of fractures by means of vertebral augmentation with PMMA, or more recently with the use of silicone which from a biomechanical point of view has an elastic modulus more similar to that of bone. It is clear that scientific research has changed clinical practice both in terms of medical and surgical management of patients with spinal pathologies. The results obtained stimulate the basic research to achieve even more. For this reason, new lines of research have been undertaken which, in the oncology field, aim at developing increasingly specific therapies against target receptors. Research efforts are also being multiplied to achieve regeneration of the degenerated intervertebral disc and to develop implants with characteristics increasingly similar to those of bone in order to improve mechanical stability and durability over time. Photodynamic therapies are being developed for the treatment of infections in order to reduce the use of antibiotic therapies. Finally, innovative lines of research are being launched to treat and regenerate damaged nerve structures with the goal, still far from today, of making patients with spinal cord injuries to walk

Menisci are crucial structures for knee homeostasis: they provide increase of congruence between the articular surfaces of the distal femur and tibial plateau, bear loading, shock absorption, lubrication, and proprioception. After a meniscal lesion, the golden rule, now, is to save as much meniscus as possible: only the meniscus tissue which is identified as unrepairable should be excised and meniscal sutures find more and more indications. Several different methods have been proposed to improve meniscal healing. They include very basic techniques, such as needling, abrasion, trephination and gluing, or more complex methods, such as synovial flaps, meniscal wrapping, or the application of fibrin clots. Basic research of meniscal substitutes has also become very active in the last decades. The features needed for a meniscal scaffold are: promotion of cell migration, it should be biomimetic and biocompatible, it should resist forces applied and transmitted by the knee, it should slowly biodegrade and should be easy to handle and implant. Several materials have been tested, that can be divided into synthetic and biological. The first have the advantage to be manufactured with the desired shapes and sizes and with precise porosity dimension and biomechanical characteristics. To date, the most common polymers are polylactic acid (PGA); poly-(L)-lactic acid (PLLA); poly- (lactic-co-glycolic acid) (PLGA); polyurethane (PU); polyester carbon and polycaprolactone (PCL). The possible complications, more common in synthetic than natural polymers are poor cell adhesion and the possibility of developing a foreign body reaction or aseptic inflammation, leading to alter the joint architecture and consequently to worsen the functional outcomes. The biological materials that have been used over time are the periosteal tissue, the perichondrium, the small intestine submucosa (SIS), acellular porcine meniscal tissue, bacterial cellulose. Although these have a very high biocompatibility, some components are not suitable for tissue engineering as their conformation and mechanical properties cannot be modified. Collagen or proteoglycans are excellent candidates for meniscal engineering, as they maintain a high biocompatibility, they allow for the modification of the porosity texture and size and the adaptation to the patient meniscus shape. On the other hand, they have poor biomechanical characteristics and a more rapid degradation rate, compared to others, which could interfere with the complete replacement by the host tissue. An interesting alternative is represented by hydrogel scaffolds. Their semi-liquid nature allows for the generation of scaffolds with very precise geometries obtained from diagnostic images (i.e. MRI). Promising results have been reported with alginate and polyvinyl alcohol (PVA). Furthermore, hydrogel scaffolds can be enriched with growth factors, platelet-rich plasma (PRP) and Bone Marrow Aspirate Concentrate (BMAC). In recent years, several researchers have developed meniscal scaffolds combining different biomaterials, to optimize the mechanical and biological characteristics of each polymer. For example, biological polymers such as chitosan, collagen and gelatin allow for excellent cellular interactions, on the contrary synthetic polymers guarantee better biomechanical properties and greater reliability in the degradation time. Three-dimensional (3D) printing is a very interesting method for meniscus repair because it allows for a patient-specific customization of the scaffolds. The optimal scaffold should be characterized by many biophysical and biochemical properties as well as bioactivity to ensure an ECM-like microenvironment for cell survival and differentiation and restoration of the anatomical and mechanical properties of the native meniscus. The new technological advances in recent years, such as 3D bioprinting and mesenchymal stem cells management will probably lead to an acceleration in the design, development, and validation of new and effective meniscal substitutes

The extracellular matrix (ECM) is the non-cellular structural support that provides cells with a network of biochemical and biomechanical factors for cellular processes. The ECM regulates cell function, differentiation and homeostasis. Here, we present a proteomics characterization of three commonly used additive manufactured polymers: polylactic acid (PLA), polyactive (PEOT/PBT) and polycaprolactone (PCL). We cultured human mesenchymal stromal cells (hMSCs) and make them undergo chondrogenic and osteogenic differentiation on 3D printed PCL, PEOT/PBT and PLA scaffolds. hMSCs were cultured in basal, chondrogenic and osteogenic media (200000 cells/scaffold) and analyzed after 35 days of culture. Differentiation was proved through biochemical assays, immunofluorescence and histology. The protein content was explored using label free liquid chromatography mass spectrometry (LC-MS), which revealed upregulated proteins and their related pathways. A higher difference was found among different media compared to the scaffold type through principal component analysis (PCA). Interestingly, in all three materials, chondrogenesis was characterized by a lower but more diverse amount of proteins. PCL induced ECM production in both differentiation media, but it led to more apoptosis and GAG degradation in the chondrogenic medium compared to the osteogenic one. During chondrogenesis in PEOT/PBT and PLA, cell differentiation resulted in the activation of stress response cascades, collagen formation and ECM remodelling. On the other hand, in osteogenesis, PCL enhanced insulin-like growth factor pathway and fibrin clot related pathways

We studied twelve parameters (physical appearance, mucin clot, fibrin clot, white cell count, differential count, red blood cell count, gram stain for bacteria, crystal microscopy, aerobic bacterial culture, anaerobic bacterial culture and ratio between synovial sugar and blood sugar) in over 300 samples of synovial fluid from patients with a variety of suspected pathologies (e.g. infection, inflammatory disease, infection adjacent to a joint, aseptic loosening of a prosthesis). The diagnosis of infection was further established using clinical signs, radiological features, full blood count, C-reactive protein and iron profile. Many of the patients came to surgery. This of course created further opportunity to establish or rule out the diagnosis of infection with greater certainty. Nine of the features of synovial fluid were analysed statistically, including turbidity, diminished viscosity, mucin clot, fibrin clot, total white cell count, polymorphs greater than 60%, bacteria observed on direct microscopy, bacteria yielded by culture and concentration of synovial sugar less than 40% of the simultaneous blood sugar. The positive or negative features of infection were determined to be true or false in the light of the cumulative overall features of infection. The data so obtained was analysed to establish sensitivity, specificity, positive predictive value, negative predictive value and accuracy. The mass of data so obtained cannot be meaningfully expressed in such a brief abstract. Important examples are when culturing synovial fluid there were 44% false negatives or no growth and 56% true positives. Looking at the ratio between synovial sugar and blood sugar we found that taking 40% as the critical value, this was 62% sensitive, the specificity was 89%, the accuracy was 73%, the positive predictive value was 89%, the negative predictive value was 62.4%. However we went further and separated those who were definitely infected or probably infected i.e. Groups 4 & 5 from those who were probably or definitely NOT infected according to the sum of clinical laboratory and radiological parameters. When thus separated the predictive value of a positive result was 100% in Group 4 & 5 and 0% in Group 1 & 2. The predictive value of a negative result in Group 1 & 2 was 98.7% accurate and 22.4% in Group 4 & 5

The clinical success of revision THA combined with impaction morcelised bone graft is completely dependent on healing of the bone graft. Both the platelets inside a fibrin clot contained in the graft bed, and the row bone surfaces of bone graft pieces leak bone morpogenetic proteins essential for healing. Pre operatively in the state of aseptically loosening when osteolysis is the predominant metabolism, there are also a bone healing activity present in the endosteum, as could be visualised studying Flouride-uptake in a Positron Emission Tomography scan. One day after revision THA using a Lubinus SP II stem with impacted morcelised fresh frozen and fat reduced allografts, no bone healing activity could be detected using PET. 8 days after the same kind of surgery an intense bone healing activity detected as an elevated Flouride-PET uptake was seen. 3 weeks after the same kind of surgery, histological analyses of human biopsies from the graft beds surrounding femoral stems revealed an intense state of healing. A fibrin clot, invaded by inflammatory cells, predominantly granulocytes, was surrounded the necrotic graft pieces. Fibroblasts creating a granulation tissue with newly formed capillaries were also seen in the graft bed. This is the healing scenario normally seen at periostal callus formation. Occasionally bone formation with osteoide was seen in the periphery of the graft beds at this early stage. 3–4 months after surgery histological analyses showed the fibrous healing to have reached 3–5 mm inside the graft beds. Bone healing was somewhat slower; it had reached 2–4 mm. At this stage a continuously high bone healing activity could be confirmed using PET. 6 months post operatively the fibrous and bone healing had advanced further 2–3 mm. 10 months after surgery, the superficial 3-mm of the graft beds were mainly bone healed as seen by histology. Also the deeper layers of the graft beds were now in an intense state of bone healing. The secondary stage of bone healing, creating new Haversian canals and trabeculares in the direction of load, visible in plain radiographs, is not yet present at this time. 1 year compared to 1 week after surgery PET scans revealed the maximal bone forming activity to have advanced from the surface of the graft beds (which is in the interface to the endosteum) to the deep graft area close to the cement mantle surrounding the stem. 1 1/2 year after surgery is the earliest stage, to my knowledge, when new trabecular formation inside the graft bed can be detected at plain radiographs. Predominantly first visible in the most loaded Gruen zones. If new trabecular formation is not detected after 3 years it is unlikely to become present at al. Cortical repair however may be detected after half a year. The course of healing described here is to my knowledge predominant. Less good healing scenarios do however occur. Whole or parts of the graft bed may remain necrotic, as has been described in the literature. In case of non-healing, the stem and the cement mantle is bound to a slow but continuos subsidence. Pain is not likely to occur until the tip of such a stem is in contact with the cortex

Background. Processing of allografts, which are used to fill bone defects in orthopaedic surgery, includes chemical cleaning as well as gamma irradiation to reduce the risk of infection. Viable bone cells are destroyed and denaturing proteins present in the graft the osteoconductive and osteoinductive characteristics of allografts are altered. The aim of the study was to investigate the mechanical differences of chemical cleaned allografts by adding blood, clotted blood, platelet concentrate and platelet gel using a uniaxial compression test. Methods. The allografts were chemically cleaned, dried and standardized according to their grain size distribution. In group BL 4 ml blood, in CB 4 ml blood and 480 μl of 1 mol calcium chloride to achieve clotting, in PC 4 ml of concentrated platelet gel, in PG 4 ml of concentrated platelets and 666 μl of 1 mol calcium chloride were added. Uniaxial compression test was carried out for the four groups before and after compating the allografts. Results. No statistically significant decrease of the initial density was observed after compaction for BL and PC. In CB a statistical significant decrease of the initial density by 10% was observed, while PG decreased its initial density after compaction by 13%. Considering the density at the yield limit before and after compaction BL showed a statistically significant decrease of 13% and PG of 14%. In CB and PC no statistically significant decrease of the density at the yield limit could be observed. All groups showed a statistical significant difference when comparing the yield limit before and after compaction. BL and PC showed a ∼35% higher yield limit after compaction, while in the groups with the activation liquid CB and PG the yield limit increased by 15% for CB and 20% for PG. No statistically significant difference between groups was found for the density at the yield limit before compaction (p=0.157), for the initial density (p=0.523), the density at the yield limit (p=0.681) and the yield limit itself (p=0.423) after compaction. A statistically significant difference between the groups under investigation was found for the initial density before compaction (p=0.041) and for the yield limit before compaction (p=0.041). BL had a statistically significant lower initial density than PG (p=0.048). All other pairwise comparisons between groups did not reach statistically significance for the initial density before compaction. Conclusion. Adding blood, PRP or PC in allografts has shown in different studies to enhance bone ingrowth. The authors recommend to chemical clean allografts for large defects, optimize their grain size distribution and add platelet concentrate or platelet rich plasma for enhancing as well primary stability as well bone ingrowth. The recommended processing procedure has to be tested in an in-vivo study

Purpose: The purpose of this study was to use the thromboelastogram to determine whether autologous blood transfusion following primary total knee replacement surgery results in an alteration to systemic coagulation. Methods: 44 patients were randomised to receive either Hartmann’s solution alone postoperatively (control group), or Hartmann’s solution and autologous blood at six hours (ABT group). Thromboelastogram measurements of systemic blood clotting were performed pre-operatively, and post operatively at 6h just prior to the commencement of the ABT, 6h 30mins, and 8h. Results: At 8h post operation (2h post ABT), the ABT group when compared with the control group showed an earlier onset of coagulation (3.83 minutes versus 4.49 minutes, p=0.003) and the formation of a stronger clot as assessed by the TEG maximum amplitude (maximum clot strength 83.9mm versus 75.9mm, p< 0.001). Conclusion: The transfusion of drained autologous blood following total knee replacement may lead to an exaggerated hypercoagulable postoperative state. Further investigation of this potentially serious consequence of autologous blood transfusion is required

Various studies have demonstrated that menisci heal in the vascular region but do not heal in the avascular area. Experimental studies of the promotion of meniscal healing in the avascular area have involved the application of fibrin clot, fibrin glue to the injured area, as well as the construction of an access chanel to the vascular regiòn, all of them with poor results. The multilineage potential of adult stem cells has been characterized extensively. The adipose tissue has been described as a useful source of adult stem cells. We try to show that the use of stem cells from the adipose tissue may promete meniscal healing in the avascular area. Twelve New Zealand white rabbits with a mean weight of 3 kg were used. The medial meniscus of both knees was aproached, and was performed a longitudinal tear in the avascular area in the anterior horn with a mean length of 0.5 cm. All the tears were sutured with one vertical stitch of nonabsorbable suture. In each rabbit a solution with 1 00 000–1 000 000 stem cells from the fat was introduced in one of the knees, and the other one was used as a control. The rabbits were killed at 12 weeks, and a macro-microscopic study of the meniscus was done, and also a inmunohistochemistry study for the stem cells. The incidence of healing was better in those menisci with the stem cells solution. Three total and three partial healing was obtained in the stem cells group and none in the control group. The inmunohistochemistry showed that the stem cells were in the repair zone. We think that stem cells will be very useful in the treatment of the lesion in the avascular area of the meniscus

Sutures are the strongest and the only time proven technique for meniscal repair. Sutures are safe and without surprises as long as the peroneal and the saphenus nerves are protected and avoided. Sutures can be placed via arthrotomy or under arthroscopic view. In pure suture techniques a sling holds the meniscus parts together or refixes the meniscus to the capsule. The orientation of the sling can be vertical, horizontal or oblique, but should always either catch the circumferential fibre bundles of the meniscal tissue or part of the densely woven meniscal surface. Suture related techniques make use of a thread but do not strive to form a sling. The earliest of these was the knot-end technique, the latest one is the Fastfix? repair. Either absorbable or non-absorbable material has been recommended but most would favour non-absorbable threads of 0 or 1–0 USP sizes. Depending on the course of the needle inside-out, outside-in and all-inside techniques have been described. For repair of intrasubstance tears the sutures have to be supplemented by measures to enhance healing as trephination of the meniscal periphery or addition of a fibrin clot to the repair side. There are regions of the menisci that are close to impossible to reach for the suture cannulas. For these it seems better to do a non-suture reconstruction with some of the innovative devices compared to leaving them alone or do meniscectomy instead of repair. Hybrid meniscal rapair, combining the advantages of sutures and new repair devices are in frequent use

Aim: This study was undertaken to assess the incidents of Deep Vein Thrombosis (DVT) and/or Pulmonary Embolus (PE) in orthopaedics outpatients who were immobilised in lower limb casts. Materials and Methods: We retrospectively analysed the incidents of DVT/PE in a district general hospital over a one year period in orthopaedic outpatients who had their lower limb immobilised. Only patients who were no already on anti-coagulants were included and patients with co-morbidity associated with a higher risk of thrombosis were excluded. The diagnosis of DVT was made by ultrasound scan and PE confirmed with a CT pulmonary angiogram. The details of patients who were found to have a clot were cross checked with the outpatient plaster room register. The relevant case notes were then studied. Results: There were three hundred and eighty patients who had lower limb casts, six of whom developed a blood clot during the period of immobilisation. All patients were male -and four patients presented with a DVT and two patients presented with a pulmonary embolism, all patients survived. There were two smokers and one patient was very overweight. Discussion: Incidents of DVT among patients with lower limb casts are low. At present there is no guideline on the use of DVT prophylaxis in orthopaedic outpatients. Our results show that even though the number of proven DVTs is low, the potential of developing a fatal pulmonary embolus in these patients is present. Conclusion: DVT prophylaxis could be considered for orthopaedic outpatients who are treated with lower limb casts and who have additional risk factors. A larger prospective survey is required before guidelines regarding prophylaxis can be drawn up

Patients with a thrombotic history are thought to be at greater risk for developing blood clots following total hip arthroplasty (THA) or total knee arthroplasty (TKA). The incidence of venous thromboembolism and risk factors associated with clot development in this population of patients, however, are not well defined. From the years 2002 to 2008, 547 patients undergoing elective joint arthroplasty with a history of thrombotic disease, defined by prior history of deep venous thrombosis (DVT) or pulmonary embolism (PE), were followed prospectively for a minimum of one month after TKA or THA. Patients received prophylactic anticoagulation with coumadin starting on POD 1 with or without bridge therapy with low molecular weight heparin (LMWH). Patients were compared for the following risk factors: advanced age (> 70 years old), inherited or acquired thrombophilia, time elapsed since prior episode, association of prior episode with surgery, and method of anticoagulation. Of the 547 patients, 72 (13.2%) developed symptoms consistent with DVT or PE. Thirty-two thromboembolic events (5.9%, 26 DVT, 6 PE) were confirmed by lower extremity Doppler ultrasound, spiral computerized tomography or ventilation-perfusion scanning. 60% of events occurred before POD 3, and the average INR at the time of diagnosis was 1.67. The incidence of thromboembolism was 14.6% and 9.9% for unilateral TKA and THA, respectively and 27.6% and 25% for bilateral TKA and THA, respectively. The institutional rate of DVT during that same time frame is 1.9%. History of inherited or acquired thrombophilia (p< 0.01), time elapse since prior thrmoboembolic event (p=0.04), and association of prior events with surgery (p=0.02) significantly increase the risk of thromboembolism in this population. Bridge therapy with LMWH of any dose did not significantly reduce the risk of DVT or PE, however, there was a trend towards significance (p=0.17). Eight patients (1.5%) experienced bleeding complications; 6 were major in nature (gastrointestinal bleeding and joint hematoma). Patients with a thrombotic history are at increased risk for developing DVTs after joint arthroplasty. These patients share the same risk factors for development of DVT or PE then patients without a history of prior events. Furthermore, thromboembolic events tend to occur early following surgery in these patients and treatment with LMWH may help reduce the risk of developing clots when used in combination with coumadin

Introduction: Bone-marrow stimulating techniques like microfracturing for focal chondral defects of the knee joint are widespread utilizing mesenchymal stem cells (MSC) for an autogenous reparation process. Microfracturing shows good results for smaller defects up to 2cm. 2. while larger defects tend to an early secondary degeneration. Autologous Matrix Induced Chondrogenesis (AMIC®) combines microfracturing with application of a porcine collagen type-I/III bilayer matrix to host the MSC and to stabilize the blood clot. Methods: 32 patients (25m, 7f, mean age 37.4y (18–52y)) with 35 focal chondral defects of the knee joint (ICRS III–IV°) of the condyle, trochlea and/or patella were treated by standardized microfracturing and application of a collagen matrix (Geistlich Biomaterials, Wolhusen, Switzerland). The outcome was evaluated prospectively by clinical scores and MRI with a follow-up of 6 to 24 months. The mean defect size was 3.86 cm. 2. (1.0 – 6.8 cm. 2. ). 22 patients (68%) had at least one operation (1–8) on the knee before. 9 defects were caused by trauma. All 7 patients with osteochondritis dissecans had an autologous bone grafting. In 5 patients an ACL stabilization was performed simultaneously. Results: All patients considered their knee as abnormal (ICRS III° (70%)) or severely abnormal (ICRS IV° (30%)) preoperatively according to the ICRS functional status. The Cincinnati-Score improved from 52.9 to 81.1 points while the Lysholm-Score rose from 60.4 to 85.9 points (each p< 0.001). Pain decreased significantly from 6.1 to 2.2 (10=max.) on the visual analogue scale. 4 biopsies (4–21 months) revealed reasonable results with regard to surface formation, filling and integration in the Brittberg score (∅10.25 pts., 12 pts.=max.) The MRI follow-ups showed an adequate filling of the defect, no prolonged effusion occured. Conclusion: Microfracturing in combination with a collagen matrix (AMIC®) is a minimal invasive, effective technique for the repair of focal cartilage defects of the knee joint. Not using cultured chondrocytes it can be performed cost-effectively as a single-step procedure. Both primary and secondary treatments are possible. The first results concerning clinical functional improvement, pain reduction and patients’ satisfaction as well as defect filling in MRI are promising

This study reports our long-term results of arthroscopically assisted meniscal suture using an inside-out technique. Between January 1990 and July 1997, 112 patients underwent 121 meniscal repairs in 112 knees. The average follow-up is 8.7 years (range 5.4 to 12.9 years). Repairs consisted of interrupted sutures using 2.0 PDS. Sutures were placed arthroscopically using a suture shuttle system and tied behind the capsule after making a small postero-medial or posterolateral incision. The meniscus and bed was prepared using a Rasp or hand-held instruments. Fibrin clot techniques were not used. 79% of patients had associated ACL reconstruction in addition to meniscal suture. All surgery was carried out by our senior author (PTM). Rehabilitation involved non-weight-bearing in an extension splint for 3 weeks and partial weight-bearing for a further 3 weeks followed by a progressive rehabilitation programme. The average age at surgery was 23.9 years (range 12.2 to 57.7 years). The average time from injury to surgery was 13.5 months (range 0 to 60 months). There were 74 males and 38 females. 51% of patients were professional or semi-professional athletes. Repair involved 79 medial menisci, 42 lateral menisci. The average number of sutures used was 3.8 (range 1 to 12). Operative findings and procedure were entered prospectively into a database. Patients were assessed clinically until recovery and long-term follow-up consisted of a detailed postal questionnaire. The average Lysholm scores were 86.4, with 59% excellent, 16% good, 17% fair and 8% poor. IKDC subjective scores averaged 82.0, with 40% excellent, 21% good, 27% fair and 12% poor. Confirmed failure of meniscal repair (as indicated by MRI or re-arthros-copy) has been identified in 11.8% of patients. A further 10.8% have a probable failure based on a recurrence of mechanical symptoms. Of the failures 73% were professional or semi-professional sportsman. Their average return to sport after surgery was 9.5 months (range 3 to 18 months). Failure was reported at an average of 29.3 months after surgery (range 0 to 84 months). With an aggressive approach towards meniscal preservation we have achieved a success rate of 77.4% at an average follow-up of 8.7 years. The majority of these tears are vertical posterior horn or large bucket handle and associated with an ACL reconstruction. The majority of patients are young and involved in a high level of sporting activity

Introduction: Meniscal tears are common in young athletes, usually result from a twisting injury during sport and may occur in the anterior or posterior horns. Injured menisci may be treated arthroscopically by excision of the torn fragments. However, in patients with peripheral meniscal detachment, located at the “vascular zone”, operative repair is feasible and usually successful. Meniscal repair may be done by open direct suture of peripheral tears or by arthroscopic techniques as “Outside-In”, “Inside-Out” or “All-Inside”. We present our experience with arthroscopic suture of completely detached menisci. Patients & Methods: This study consisted of 33 male patients (14-48Y; mean 25Y; Follow-up: 2-6Y; mean 3.5Y). Inside-Out technique was used in 31 patients and Outside-In technique in two patients. 16/33 patients had detachment of the peripheral half of the meniscus (14-medial; 2-lateral); 13/33 patients had peripheral detachment of almost two thirds of meniscus (10-medial; 3-lateral) and 4/33 patients had detachment of one third of the meniscus (3-lateral; 1-medial injuries; all combined with fractures of the tibial plateau). 15 patients with medial meniscus detachment had complete (5 Pts) or partial (10 Pts) tear of ACL. Two other patients with medial meniscus detachment had associated small radial tears of the affected meniscus. Two of the patients with complete ACL tear had later been operated upon for reconstruction of ACL. Results were assessed by the Knee Society Knee score and by Lysholm Scoring Scale. Results: 25/33 patients (76%) had good and excellent results. Four of them developed re-tear and detachment of medial meniscus during other later additional sport injuries, usually between 1–2 years following initial treatment. Four other patients had a “second” arthroscopic look 1–2 years later following another sport twisting injury and in all of them a stable peripheral attachment of the sutured menisci was observed. Results were better in patients who had ACL reconstruction a few months following meniscal repair. 5 patients had fair results (15%) and 3 patients had poor results (9%). Conclusions: Based on this study it is suggested that meniscal suturing for peripheral tears is a satisfactory procedure. Meniscal tears suitable for repairs are those within the vascular zones (the outer third of the menis-cus), unstable on probing, are longer than 7mm and without major surgical damaging. Tears of posterior segments are the most difficult to suture and often require open arthrotomy. ACL reconstruction combined with meniscal repair appears to increase the healing rate of the meniscus. There are also adjuvant techniques for meniscal repair such as: fibrin clot or laser (both are weaker than suture alone) and adhesives. However, there is still not enough data

This study reports our long-term results of arthroscopically assisted meniscal suture using an inside-out technique. Between January 1990 and July 1997, 112 patients underwent 121 meniscal repairs in 112 knees. The average follow up is 8.7 years (range 5.4 to 12.9 years). Repairs consisted of interrupted sutures using 2.0 PDS. Sutures were placed arthroscopically using a suture shuttle system and tied behind the capsule after making a small posteromedial or posterolateral incision. The meniscus and bed was prepared using a Rasp or hand-held instruments. Fibrin clot techniques were not used. 79% of patients had associated ACL reconstruction in addition to meniscal suture. All surgery was carried out by our senior author (PTM). Rehabilitation involved non-weight bearing in an extension splint for 3 weeks and partial weight bearing for a further 3 weeks followed by a progressive rehabilitation program. The average age at surgery was 23.9 years (range 12.2 to 57.7 years). The average time from injury to surgery was 13.5 months (range 0 to 60 months). There were 74 males and 38 females. 51% of patients were professional or semi-professional athletes. Repair involved 79 medial menisci, 42 lateral menisci. The average number of sutures used was 3.8 (range 1 to 12). Operative findings and procedure were entered prospectively into a database. Patients were assessed clinically until recovery and long-term follow up consisted of a detailed postal questionnaire. The average Lysholm scores were 86.4, with 59% excellent, 16% good, 17% fair and 8% poor. IKDC subjective scores averaged 82.0, with 40% excellent, 21% good, 27% fair and 12% poor. Confirmed failure of meniscal repair (as indicated by MRI or re-arthroscopy) has been identified in 11.8% of patients. A further 10.8% have a probable failure based on a recurrence of mechanical symptoms. Of the failures 73 % were professional or semi-professional sportsman. There average return to sport after surgery was 9.5 months (range 3 to 18 months). Failure was reported at an average of 29.3 months after surgery (range 0 to 84 months). With an aggressive approach towards meniscal preservation we have achieved a success rate of 77.4% at an average follow-up of 8.7 years. The majority of these tears are vertical posterior horn or large bucket handle and associated with an ACL reconstruction. The majority of patients are young and involved in a high level of sporting activity