Aims

The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach.

Abstract. Introduction. Symptomatic osteochondritis dissecans (OCD) and traumatic osteochondral fractures (OCF) are treated with fixation with either metal or bioabsorbable device. We performed a comparative review of patients with OCD and traumatic OCF stabilised with Bio-Compression screws which are headless absorbable compression screws. Our aim was to determine whether there was a difference in outcomes between presentations. Methods. Retrospective single-centre cohort study of all patients with OCD and OCF treated with Bio-Compression screw between July 2017 and September 2022. All patients followed up until discharge with satisfactory clinical outcome. Primary outcome was return to theatre for ongoing pain or mechanical symptoms. Secondary outcome was evidence of fixation failure on follow-up MRI scan. Results. 20 patients included; 8 OCF and 12 OCD. Average age 21 (OCF), 24 (OCD). The most common location was patella (58%) in OCF or the medial femoral condyle (75%) in OCD. Traumatic defects were smaller (2.6cm2 vs 3.3cm2) although this was not statistically significant (p=0.28). In the OCF group one patient went on to have further surgery. There were no re-operations in the OCD group. Both groups had good outcomes and similar times to discharge. There was no evidence of fixation failure of Bio-Compression screws on MRI scans. Conclusions. Within the limits of this relatively small cohort there is no significant difference between outcomes for OCD or traumatic OCF fixation with Bio-Compression screws. Both groups demonstrate good outcomes irrespective of the location or the aetiology of the fragment

Abstract. Introduction. Fractures of the articular surface of the patella or the lateral femoral condyle usually occur following acute dislocation of the patella. This study looked at the radiological and functional outcomes of fixation of osteochondral fractures. Methods. Twenty-nine patients (18 male, 11 female) sustained osteochondral fractures of the knee following patellar dislocation. All patients had detailed radiographic imaging and MRI scan of the knee preoperatively. An arthroscopic assessment was done, followed by fixation using bio-absorbable pins or headless screws either arthroscopically or mini-open arthrotomy. VMO plication or MPFL repair were done if necessary. MRI scan was done at follow-up to assess for healing of the fixed fragment prior to patient discharge. Results. The mean age of the patients was 21 yrs (9–74), 11 had osteochondral fracture of the patella (38%), while 18 were from the lateral femoral condyle (62%). 13 patients needed additional VMO plication. Mean follow up period was 7.7 years (1 to 12 years). As per Tegner activity scale, all patients returned to their pre-injury activity level (Mean score 7) and sports. None of the patients had a further episode of patellar dislocation. Mean postoperative IKDC score was 86.5 (SD 17.3), Kujala was 91.1(SD 15.5) and Tegner- lysholm was 88.7 (SD 14.4). All patients had statistically significant (p < 0.05) improvement. Post-operative MRI scan showed satisfactory union in all cases (100%). Conclusion. It is extremely important to identify this group of injury and treat them early to have satisfactory knee function and avoid long term complications of arthritis

Aims

Osteonecrosis (ON) can cause considerable morbidity in young people who undergo treatment for acute lymphoblastic leukaemia (ALL). The aims of this study were to determine the operations undertaken for ON in this population in the UK, along with the timing of these operations and any sequential procedures that are used in different joints. We also explored the outcomes of those patients treated by core decompression (CD), and compared this with conservative management, in both the pre- or post-collapse stages of ON.

Aims

The hypothesis of this study was that bone peg fixation in the treatment of osteochondral lesions of the talus would show satisfactory clinical and radiological results, without complications.

Aims

For cementless implants, stability is initially attained by an interference fit into the bone and osteo-integration may be encouraged by coating the implant with bioactive substances. Blood based autologous glue provides an easy, cost-effective way of obtaining high concentrations of growth factors for tissue healing and regeneration with the intention of spraying it onto the implant surface during surgery. The aim of this study was to incorporate nucleated cells from autologous bone marrow (BM) aspirate into gels made from the patient’s own blood, and to investigate the effects of incorporating three different concentrations of platelet rich plasma (PRP) on the proliferation and viability of the cells in the gel.

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

Aims

The aim of this study was to analyze the results of two radiocapitellar prostheses in a large case series followed prospectively, with medium-term follow-up.

The natural history of primary anterior dislocation of the glenohumeral joint in adolescent patients remains unclear and there is no consensus for management of these patients.

The objectives of this study were to report the natural history of primary anterior dislocation of the glenohumeral joint in adolescent patients and to identify the risk factors for recurrent dislocation.

We reviewed prospectively-collected clinical and radiological data on 133 adolescent patients diagnosed with a primary anterior dislocation of the glenohumeral joint who had been managed non-operatively at our hospital between 1996 and 2008. There were 115 male (86.5%) and 18 female patients (13.5%) with a mean age of 16.3 years (13 to 18) and a mean follow-up of 95.2 months (1 to 215).

During follow-up, 102 (absolute incidence of 76.7%) patients had a recurrent dislocation. The median interval between primary and recurrent dislocation was ten months (95% CI 7.4 to 12.6). Applying survival analysis the likelihood of having a stable shoulder one year after the initial injury was 59% (95% CI 51.2 to 66.8), 38% (95% CI 30.2 to 45.8%) after two years, 21% (95% CI 13.2 to 28.8) after five years, and 7% (95% CI 1.1 to 12.9) after ten years. Neither age nor gender significantly predicted recurrent dislocation during follow-up.

We conclude that adolescent patients with a primary anterior dislocation of the glenohumeral joint have a high rate of recurrent dislocation, which usually occurs within two years of their initial injury: these patients should be considered for early operative stabilisation.

Cite this article: Bone Joint J 2015;97-B:520–6.

The February 2014 Foot & Ankle Roundup³⁶⁰ looks at: optimal medial malleolar fixation; resurfacing in the talus; predicting outcome in mobility ankles; whether mal-aligned ankles can be successfully replaced; cartilage colonisation in bipolar ankle grafts; CTs and proof of fusion; recalcitrant Achilles tendinopathy; and recurrent fifth metatarsal stress fractures.

Objectives. Osteochondral injuries, if not treated adequately, often lead to severe osteoarthritis. Possible treatment options include refixation of the fragment or replacement therapies such as Pridie drilling, microfracture or osteochondral grafts, all of which have certain disadvantages. Only refixation of the fragment can produce a smooth and resilient joint surface. The aim of this study was the evaluation of an ultrasound-activated bioresorbable pin for the refixation of osteochondral fragments under physiological conditions. Methods. In 16 Merino sheep, specific osteochondral fragments of the medial femoral condyle were produced and refixed with one of conventional bioresorbable pins, titanium screws or ultrasound-activated pins. Macro- and microscopic scoring was undertaken after three months. . Results. The healing ratio with ultrasound-activated pins was higher than with conventional pins. No negative heat effect on cartilage has been shown. Conclusion. As the material is bioresorbable, no further surgery is required to remove the implant. MRI imaging is not compromised, as it is with implanted screws. The use of bioresorbable pins using ultrasound is a promising technology for the refixation of osteochondral fractures

Introduction. Osteochondral defects of the knee may occur following patella dislocation or following direct trauma or twisting injuries to the knee in adolescents. Often a diagnostic and therapeutic challenge, if these lesions are left, posttraumatic osteoarthritis may occur. This retrospective single centre study presents the short-term results following operative fixation of osteochondral fragments of the knee using Omnitech ® screws. Method. All skeletally immature patients presenting with an osteochondral fracture of their femur or patella confirmed on xray and MRI were identified. Arthroscopic evaluation of the osteochondral defect was performed followed by open reduction and internal fixation of the osteochondral fragment using Omnitech ® screws. A standard postoperative rehabilitation protocol was followed. Patients were evaluated at follow-up using a Knee Injury and Osteoarthritis Outcome Score (KOOS). Results. Eight patients were identified. The mean age at time of injury was 15 years (range 14–16) for two girls and 14.4 years (range 13–16) for six boys. The lateral femoral condyle was involved in six cases and patella in two cases. At mean follow up of 14 months (range 1–38) there was no revision for failure and no postoperative complications. The KOOS score (out of 100) at final follow up was subdivided as follows; Pain, 93 (range 81–100), other symptoms, 77 (range 36–100), function in daily living (ADL), 97 (range 84–100), function in sport and recreation, 84 (range 55–100) and knee related quality of life, 79 (range 44–100). Discussion. The short-term results of using Omnitech® screws are promising. Subchondral screw placement with adequate compression of the osteochondral fragment is achievable with Omnitech ® screws. Seven patients are back to their pre-injury sporting activity and one patient is currently undergoing postoperative rehabilitation, one month following surgery

Dislocation of the shoulder may occur during seizures in epileptics and other patients who have convulsions. Following the initial injury, recurrent instability is common owing to a tendency to develop large bony abnormalities of the humeral head and glenoid and a susceptibility to further seizures. Assessment is difficult and diagnosis may be missed, resulting in chronic locked dislocations with protracted morbidity. Many patients have medical comorbidities, and successful treatment requires a multidisciplinary approach addressing the underlying seizure disorder in addition to the shoulder pathology. The use of bony augmentation procedures may have improved the outcomes after surgical intervention, but currently there is no evidence-based consensus to guide treatment. This review outlines the epidemiology and pathoanatomy of seizure-related instability, summarising the currently-favoured options for treatment, and their results.

The June 2012 Children’s orthopaedics Roundup³⁶⁰ looks at; open reduction for DDH; growing rod instrumentation for scoliosis; acute patellar dislocation; management of the relapsed clubfoot; clubfoot in Iran; laughing gas and fracture manipulation; vascularised periosteal fibular grafting for nonunion; slipped upper femoral epiphysis; intramedullary leg lengthening and orthopaedic imaging and defensive medicine.

Osteochondral fracture of the femoral head is an uncommon injury with a high potential for a poor functional outcome. Management is often challenging with limited options. We present two cases in which osteochondral fractures of the femoral head were treated with partial resurfacing using the HemiCAP System (Arthrosuface, Franklin MA, USA). Patient 1. A 22-year-old male professional motorbike rider presented with an anterior left hip dislocation that occurred during a race. A CT scan after a closed reduction revealed a large osteochondral impaction fracture/defect that was addressed via partial resurfacing using the HemiCAP System. Patient 2. A 34-year-old male presented with an anterior left hip dislocation after a motor vehicle accident and underwent a closed reduction. CT showed a loose osteochondral fragment, that was fixed back with headless screws, and an adjacent defect was addressed with a HemiCAP implant. Both patients were kept non weight-bearing for two months and had an uneventful recovery. Patient 1 was last reviewed at our institution one month post-operatively with a pain-free hip. His follow-up is being continued interstate and at telephone interview, 18 months after surgery, he had returned to full function and resumed riding on the professional racing circuit. Patient 2, at three-month review, had a pain-free hip with a full range of motion. CT scan showed excellent joint surface congruity at the implant articular surface junction. We report the use of the HemiCAP System as a novel method of treating osteochondral defects, which has never been reported before. There has only been one other reported case of using a HemiCAP in an osteoarthritic femoral head. This is a short follow-up with only two patients treated; however we are encouraged by the results so far, as there are no other satisfactory alternative treatment options

The expansion of arthroscopic treatment to serious and catastrophic injuries to the weightlifters of the Hellenic National Weightlifting Team. The evaluation of the results of this specific arthroscopic treatment. 45 athletes (36 male, 9 female) with shoulder injuries 2000–2009. 15 yrs – 35 yrs, average: 27 yrs. One 3-times Golden Olympic. One Bronze medalist, Two Silver Olympic, Three Olympic winners, Five World championsetc. Clinical examination and musculoskeletal ultrasound. Plain X-rays. E.M.G, M.R.I.-arthrography, 3DC/T when that was required. Strength measurement with Nottingham McMecin Myometer for ipsi-contro lateral shoulder. Full ROM was necessary for the operated shoulder before starting exercise for a competition. All 48 underwent arthroscopic treatment (3 mini-open). Arthroscopic stabilization using absorbable or non anchors. 45 athletes, 48 shoulders operated,(3 bilat-erally).36 RC tears, 6 bony-bankart, 2 posterior and 28 anterior labrum detachment, 3 avulsion osteochondral fractures, 2 AMBRII, 4 deranged LH of biceps, 4 underwent SSN release. All patient returned at same sport level except one with AMBRII and cervical spine pathology. Rehabilitation time for basic weightlifting exercise was 3.5 months and for competition level was 4,5 -6 months. The shoulder demands during the snatch, clean and jerk of the weightlifters provoke often shoulder injuries. The arthroscopic surgery gives thorough and broad knowledge of their shoulder injuries. The minimal detachment, less postoperative joint stiffness and decreased shoulder pain are encouraging factors for the arthroscopic treatment. Additionally, the returning time for training and competition combining with a proper rehabilitation seems to be less than open surgery

Purpose: Coronal shear fractures of the humerus include the Kocher-Lorenz fracture, an osteochondral fracture of the capitellar articular surface, the Hahn-Steinthal fracture, a substantial shear fragment, extension into the trochlea, and complete involvement of the capitellum and trochlea. If the fracture proves irreparable, it is not known what the impact of fragment excision would have on the biomechanics of the elbow. The purpose of this study was to examine the effect of the sequential loss of the capitellum and trochlea on the kinematics and stability of the elbow. Method: Eight fresh-frozen cadaveric arms were mounted in an upper extremity joint testing system, with cables attaching the tendons of the major muscles to motors and pneumatic actuators. Electromagnetic receivers attached to the radius and ulna enabled quantification of the kinematics of both bones with respect to the humerus. The distal humeral articular surface was sequentially excised to replicate clinically relevant coronal shear fractures while leaving the collateral ligaments intact. Active flexion in both the vertical and valgus-loaded positions, and passive rotation in the vertical position was conducted for each excision. Results: Excision of the capitellum had no effect on ulnohumeral stability or kinematics in both the vertical or valgus positions (p=1.0). Excision of the entire capitellum and trochlea led to significant valgus instability with the arm in the valgus position (p=0.01), while excision of the lateral trochlea led to increased valgus instability with pronated flexion in the valgus position (p=0.049). Progressive loss of the articular surface led to posterior, inferior, and medial displacement of the radial head with respect to the capitellum and increased external rotation of the ulna with respect to the humerus in the vertical position (p< 0.05). Conclusion: Excision of the capitellum did not result in valgus or rotational instability, while excision of the trochlea resulted in multiplanar instability. The radial head displaced medially because it is constrained to the ulna by the annular ligament, and the ulna pivoted into valgus and external rotation on the residual trochlea and medial collateral ligament. In patients with coronal shear fractures, the trochlea must be reconstructed to prevent instability and the potential for secondary degenerative change

We evaluated the histological changes before and after fixation in ten knees of ten patients with osteochondritis dissecans who had undergone fixation of the unstable lesions. There were seven males and three females with a mean age of 15 years (11 to 22). The procedure was performed either using bio-absorbable pins only or in combination with an autologous osteochondral plug. A needle biopsy was done at the time of fixation and at the time of a second-look arthroscopy at a mean of 7.8 months (6 to 9) after surgery.

The biopsy specimens at the second-look arthroscopy showed significant improvement in the histological grading score compared with the pre-fixation scores (p < 0.01). In the specimens at the second-look arthroscopy, the extracellular matrix was stained more densely than at the time of fixation, especially in the middle to deep layers of the articular cartilage.

Our findings show that articular cartilage regenerates after fixation of an unstable lesion in osteochondritis dissecans.

Between 1995 and 2000, nine patients between the ages of 12 and 15 years were treated for very large osteochondral fractures of the lateral femoral condyle with internal fixation of the displaced osteochondral fragment with bioabsorbable pins. Initial healing in these patients has been assessed with either follow up arthroscopy or MRI scanning. Early results suggested very good healing of the detached fragments. The aim of this study was to review these patients at greater than five years follow up to assess how the healed articular cartilage has survived and performed. Eight of the nine patients were able to be followed up for clinical assessment, IKDC rating, Noyes Cincinnati Knee rating, radiologic and MRI assessment. Under the IKDC Knee Scoring system, five patients scored a final grade of A, two patients scored a grade of B and one patient scored C. Under the Noyes Cincinnati Knee Scoring system, three of the eight patients scored excellent, two scored good and three had a final rating of fair. There were no poor results. X-rays, including weight bearing views, were assessed for evidence of lateral compartment degeneration. Six patients had normal knee x-rays. Two patients had subchondral bony irregularity in the lateral compartment with subtle lateral compartment narrowing. We found that MRI scanning with specific cartilage sequences was an accurate way to assess healing and integrity of the articular cartilage at greater than 5 years. All patients had intact articular cartilage in the lateral compartment with no area of full thickness articular cartilage loss. Six of the eight patients had a small abnormal cleft-like signal corresponding to the likely posterior margin of the initial fracture fragment. Two patients had no cleft-like signal. The meniscii appeared normal in all patients. No evidence of pin tracts remained. Our five-year follow up results suggest that the majority of the reattached articular cartilage does survive and these young, active patients’ knees have functioned well. The outcome in the longer term remains guarded. We recommend that internal fixation of these fragments with bioabsorbable pins, or other appropriate means of fixation, is a worthwhile procedure

The administration of intra-articular local anaesthetic is common following arthroscopy of the knee. However, recent evidence has suggested that bupivacaine may be harmful to articular cartilage. This study aimed to establish whether infiltration of bupivacaine around the portals is as effective as intra-articular injection.

We randomised 137 patients to receive either 20 ml 0.5% bupivacaine introduced into the joint (group 1) or 20 ml 0.5% bupivacaine infiltrated only around the portals (group 2) following arthroscopy. A visual analogue scale was administered one hour post-operatively to assess pain relief. Both patients and observers were blinded to the treatment group. A power calculation was performed.

The mean visual analogue score was 3.24 (sd 2.20) in group I and 3.04 (sd 2.31) in group 2. This difference was not statistically significant (p = 0.62).

Infiltration of bupivacaine around the portals had an equivalent effect on pain scores at one hour, and we would therefore recommend this technique to avoid the possible chondrotoxic effect of intra-articular bupivacaine.