Aims. Complex joint fractures of the lower extremity are often accompanied by soft-tissue swelling and are associated with prolonged hospitalization and soft-tissue complications. The aim of the study was to evaluate the effect of vascular impulse technology (VIT) on soft-tissue conditioning in comparison with conventional elevation. Methods. A total of 100 patients were included in this prospective, randomized, controlled monocentre study allocated to the three subgroups of dislocated ankle fracture (n = 40), pilon fracture (n = 20), and intra-articular calcaneal fracture (n = 40). Patients were randomized to the two study groups in a 1:1 ratio. The effectiveness of VIT (intervention) compared with elevation (control) was analyzed separately for the whole study population and for the three subgroups. The primary endpoint was the time from admission until operability (in days). Results. The mean length of time until operability was 8.2 days (SD 3.0) in the intervention group and 10.2 days (SD 3.7) in the control group across all three fractures groups combined (p = 0.004). An analysis of the subgroups revealed that a significant reduction in the time to operability was achieved in two of the three: with 8.6 days (SD 2.2) versus 10.6 days (SD 3.6) in ankle fractures (p = 0.043), 9.8 days (SD 4.1) versus 12.5 days (SD 5.1) in pilon fractures (p = 0.205), and 7.0 days (SD 2.6) versus 8.4 days (SD 1.5) in calcaneal fractures (p = 0.043). A lower length of stay (p = 0.007), a reduction in pain (p. preop. = 0.05; p. discharge. < 0.001) and need for narcotics (p. preop. = 0.064; p. postop. = 0.072), an increased reduction in swelling (p < 0.001), and a lower revision rate (p = 0.044) could also be seen, and a trend towards fewer complications (p = 0.216) became apparent. Conclusion. Compared with elevation, VIT results in a significant reduction in the time to achieve operability in complex joint fractures of the lower limb. Cite this article: Bone Joint J 2021;103-B(4):746–754

Swelling following an ankle fracture is commonly believed to preclude surgical fixation, delaying operative treatment to allow the swelling to subside. This is in an attempt to achieve better soft tissue outcomes. We aim to identify whether pre-operative ankle swelling influences postoperative wound complications following ankle fracture surgery. This is a prospective cohort study of 80 patients presenting to a tertiary referral centre with operatively managed malleolar ankle fractures. Ankle swelling was measured visually and then quantitatively using the validated ‘Figure-of-eight’ technique. Follow-up was standardised at 2, 6, and 12 weeks post-operatively. Wound complications, patient co-morbidities, operative time, surgeon experience, and hospital stay duration were recorded. The complication rate was 8.75% (n=7), with 1 deep infection requiring operative intervention and all others resolving with oral antibiotics and wound cares. There was no significant difference in wound complication rates associated with quantitative ankle swelling (p=0.755), visual assessment of ankle swelling (p=0.647), or time to operative intervention (p=0.270). Increasing age (p=0.006) and female gender (p=0.049) had a significantly greater probability of wound complications. However, BMI, smoking status, level of the operating surgeon, and tourniquet time were not significantly different. Visual assessment of ankle swelling had a poor to moderate correlation to ‘Figure-of-eight’ ankle swelling measurements ICC=0.507 (0.325- 0.653). Neither ankle swelling nor time to surgery correlates with an increased risk of postoperative wound complication in surgically treated malleolar ankle fractures. Increasing patient age and female gender had a significantly greater probability of wound infection, irrespective of swelling. Visual assessment of ankle swelling is unreliable for quantifying true ankle swelling. Operative intervention at any time after an ankle fracture, irrespective of swelling, is safe and showed no better or worse soft tissue outcomes than those delayed for swelling

Knee swelling is common after injury or surgery, resulting in pain, restricted range of movement and limited mobility. Accurately measuring knee swelling is critical to assess recovery. However, current measurement methods are either unreliable or expensive [1,2]. Therefore, a new measurement method is developed. This wearable (the ‘smart brace’) has shown the ability to distinguish a swollen knee from a not swollen knee using multi-frequency-bio impedance analysis (MF-BIA) [3]. This study aimed to determine the accuracy of this smart brace. The study involved 25 usable measurements on patients treated for unilateral knee osteoartritis with a 5mL injection of Lidocaïne + DepoMedrol (1:4). MF-BIA measurements were taken before and after the injection, both on the treated and untreated knee. The smart brace accurately measured the effect of the injection by a decrease in resistance of up to 2.6% at 100kHz (p<0.01), where commonly used gel electrodes were unable to measure the relative difference. Remarkably, both the smart brace and gel electrodes showed a time component in the MF-BIA measurements. To further investigate this time component, 10 participants were asked to lie down for 30 minutes, with measurements taken every 3 minutes using both gel electrodes and the smart brace on both legs. The relative change between each time step was calculated to determine changes over time. The results showed presence of a physiological aspect (settling of knee fluids), and for the brace also a mechanical aspect (skin-electrode interface) [4]. The mechanical aspect mainly interfered with reactance values. Overall, the smart brace is a feasible method for quantitatively measuring knee swelling as a relative change over time. However, the skin-electrode interface should be improved for reliable measurements at different moments in time. The findings suggest that the smart brace could be a promising tool for monitoring knee swelling during rehabilitation

Abstract. Decellularised porcine superflexor tendon (pSFT) provides an off-the-shelf, cost-efficient option for ACL reconstruction (ACLR). During decellularisation, phosphate buffered saline (PBS) is used for washing out cytotoxic solutes and reagents, maintaining tissue hydration. It has been shown to increase water content in tendon, swelling the tissue reducing mechanical properties. End stage PBS washes in the standard protocol were substituted with alternative solutions to study tissue swelling and its impact on the mechanical behaviour and matrix composition of pSFTs. 25%, 100% Ringers and physiological saline test groups were used (n=6 for all groups). pSFTs were subject to tensile and confined compression testing. Relative hydroxyproline (HYP), glycosaminoglycan (GAG) and denatured collagen content (DNC) were quantified. Modified decellularised tendon groups were compared to tendons decellularised using the standard protocol and native tendons. Specimen dimensions reduced (p=0.004) post-decellularisation only in 25% Ringers group. In all other modified groups, less swelling was apparent but not statistically different from standard group. Only 25% Ringers group had higher linear modulus (p=0.0035) and UTS (p=0.013) compared to standard group. All decellularised groups properties were reduced compared to native pSFTs. Stress relaxation properties showed a significant reduction in decellularised groups compared to native. Compression testing showed no significant differences in peak stress for modified decellularised groups compared to native. A reduction (p=0.036) was observed in standard group. Quantification of GAGs and DNC showed no significant differences between groups. HYP content was higher (p<0.0001) for saline group. A significant reduction in tissue swelling could be related to improved mechanical properties of decellularised pSFTs. Alternative solutions in end stage washes had no significant effect on quantities of matrix components, but altered structure/function could explain the differences in tensile and compressive behaviour, and should be further studied. In all decellularised groups, pSFTs retained suitable mechanical properties for ACLR

Patients awaiting resolution of swelling and oedema prior to ankle surgery can represent a significant burden on hospital beds. Our study assessed whether external pneumatic intermittent compression (EPIC) can reduce delays to surgery. Our prospective randomised controlled trial (n= 20) compared outcomes of patients treated with EPIC vs control group managed with ice and elevation. Included were patients aged <18 years with isolated closed ankle fractures admitted for management of swelling prior to surgery. Excluded were open fractures, injuries to contralateral leg, diabetes, absent pulses, peripheral vascular disease, inability to consent, no requirement for admission. Eligible patients were randomised to active or control arms. All patients were managed initially with reduction and back slab application. Patients in active arm fitted with EPIC (Hydroven 3000) device over the back slab. Assessment by treating team determined the time at which patient is assessed ready for surgery. Patients in the treatment arm were assessed as ready for surgery sooner, (123 hrs vs 168hrs, T score = 1.925, P 0.035) and had a shorter time to surgery (167 hrs vs 216 hrs, T score = 1.748, P 0.047) Length of stay was reduced bud did not reach statistical significance. (259 hrs vs 269 hrs, T score 0.229, P 0.41). Our results showed a statistically and clinically significant reduction in time that patients were assessed ready for surgery and time to surgery in the treatment cohort. We conclude that although further data is needed to achieve an adequately powered study and assess the safety profile of the EPIC, incorporation of EPIC into routine clinical practice has the potential for significant cost savings

Abstract. Objectives. Osteoarthritis (OA) is a complex joint disorder characterised by the loss of extracellular matrix (ECM) leading to cartilage degeneration. Changes to cartilage cell (chondrocyte) behaviour occur including cell swelling, the development of fine cytoplasmic processes and cell clustering leading to changes in cell phenotype and development of focal areas of mechanically-weak fibrocartilaginous matrix. [1]. To study the sequence of events in more detail, we have investigated the changes to in situ chondrocytes within human cartilage which has been lightly scraped and then cultured with serum. Methods. Human femoral heads were obtained with Ethical permission and consent from four female patients (mean age 74 yrs) undergoing hip arthroplasty following femoral neck fracture. Osteochondral explants of macroscopically-normal cartilage were cultured as a non-scraped control, or scraped gently six times with a scalpel blade and both maintained in culture for up to 2wks in Dulbecco's Modified Eagle's Medium (DMEM) with 25% human serum (HS). Explants were then labelled with CMFDA (5-chloromethylfluorescein-diacetate) and PI (propidium iodide) (10μM each) to identify the morphology of living or dead chondrocytes respectively. Explants were imaged using confocal microscopy and in situ chondrocyte morphology, volume and clustering assessed quantitatively within standardised regions of interest (ROI) using Imaris. ®. imaging software. Results. Within 2wks of culture with HS, chondrocyte volume increased significantly from 412±9.3µm. 3. (unscraped) at day 0 to 724±16.6 µm. 3. (scraped) [N(n) = 4(380)] (P=0.0002). Chondrocyte clustering was a prominent feature of HS culture as the percentage of clusters in the cell population increased with scraping from 4.8±1.4% to 14.9±3.9% [N(n) = 4(999)] at week 2 (P=0.0116). In addition, the % of the chondrocyte population within clusters increased from approximately 38% to 60%, and the number of cells per cluster increased significantly from 3.2±0.08 to 4±0.22 (P=0.031). The development of abnormal ‘fibroblastic-like’ chondrocyte morphology demonstrating long (>5µm) cytoplasmic processes also occurred, however the time course of this was more variable. For some samples, clustering occurred before abnormal morphology, but for others the opposite occurred. Typically, by the second week, 17±2.64% of the cell population had processes and this increased to 22±4.02% [N(n) = 4(759)] with scraping. Conclusions. Scraping the cartilage will remove surface constituents including lubricants (e.g. lubricin, hyaluronic acid, phospholipids), extracellular matrix constituents (collagen, proteoglycans – potentially the ‘lamina splendens’) and cells (chondrocytes and mesenchymal stromal cells (MSCs)). Although we do not know which of these component(s) is important, the effect is to dramatically increase the permeation of serum factors into the cartilage matrix and signal the development of cytoplasmic processes, cell clustering and swelling. It is notable that these cellular changes are similar to those occurring in early OA. [1]. This raises the interesting possibility that scraped cartilage cultured with human serum recapitulates some of the changes to in situ chondrocytes during early stages of cartilage degeneration and as such, could be a useful model for following the deleterious changes to matrix metabolism. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Abstract. Objectives. A fibril reinforced multiphasic cartilage model was developed to improve the understanding of the depth-dependent cartilage internal structure and its through thickness biomechanical response. The heterogeneous model of cartilage was validated against full-field strain measurement obtained via Digital Image Correlation (DIC) during free swelling experiments. Methods. Hemi-cylindrical cartilage cores of 5mm diameter were obtained from porcine femoral condyles and humeral heads. The full field behaviour of these samples was monitored using DIC during an osmotic free swelling experiment performed following a standardised protocol [1]. Computational models were created in FEBio (version 2.8, . febio.org. ). The cartilage, submerged in saline solution was represented by a 1×1mm cube [2] with geometry and constrains set up to mimic the experimental conditions. Cartilage was modelled as a multiphasic material represented by one inhomogeneous layer with depth-dependent Young's modulus [3], zonally varied water content and zonally oriented collagen fibrils [4]. Experimental and predicted strain maps were compared to each other both qualitatively and quantitatively. Results. The numerical strain map showed high strain localisation close to the cartilage surface, with strain in this region reaching 40% and 12% for femoral and humeral samples respectively, this finding was confirmed in our experimental results. Strain magnitude gradually decreased with depth, reaching near-zero at around 200μm. This behaviour also matched experimental observations. Conclusions. Both sets of computational strain results exhibited very good agreement with experimental data, both in terms of cartilage through-thickness swelling behaviour and strain magnitude. Our results show the importance of including cartilage structural inhomogeneities and inclusions of collagen fibrils when simulating through-thickness cartilage swelling. These findings highlight the crucial role of collagen fibrils on both tissue solute transport properties as well as the overall biomechanical response of cartilage. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Patients often comment on swelling after foot and ankle surgery. However the relationship between swelling and outcome (pain and function) has not previously been outlined. A recent study by Pinsker and Daniels demonstrated that while swelling was rated as important by patients it was rarely included in outcome scores. The purpose of this paper was to determine the relationship between swelling and outcome after ankle fusion or replacement. A secondary purpose was to determine how this relationship changed in time, how swelling score changed before and after surgery, and determine differences in swelling score between total ankle replacement (TAR), open ankle arthrodesis (OAA) and arthroscopic ankle arthrodesis (AAA). The COFAS prospective ankle arthritis database enrolls patients in 4 centers undergoing surgery by one of 6 surgeons since 2002. The MODEMS outcomes package from AAOS was used, with the validated ankle osteoarthritis score (AOS) score being used to assess outcomes in the pain and disability domains. The swelling score was indexed from 1 to 5, 1 being no swelling and 5 being severe swelling. Outcomes were recorded preoperatively and annually up to 2010. Statistical analysis was performed using 95% confidence intervals and correlations being determined using Pearson's correlation and r2 values. The swelling score was correlated with AOS score with an r2 of 0.13 for postoperative patients. With the swelling score analysed categorically the difference of outcome was significant with a mean AOS score of 15.1 (CI 13.3 to 16.9) for a swelling score of 1, 23 (CI 21.7 to 24.9) for a swelling score of 2, 31 (CI 29.6 to 33.1) for 33.6 (CI 34.9 to 38.8) for 4, and 39 (CI 35.3 to 43.0) for 5. Swelling scores fell outside the 95% confidence intervals for all groups indicating that the AOS outcome of swelling score 5 patients was worse than the 4 group, 4 worse than 3, 3 worse than 2, and 2 worse than 1. Patients with swelling scores of 1 scored 24 points better than those with a swelling score of 5. Swelling scores were the same preoperatively for total ankle arthroplasty, Arthroscopic and open fusions. However swelling scores were lower for arthroscopic fusions after surgery for all time periods at an average of 2.1 (CI 1.9 to 2.2), compared to total ankle arthroplasty (2.5, CI 2.4 to 2.6) and open ankle fusion (2.5, CI 2.4 to 2.6). Swelling has a major relationship with outcome. Swelling may be the cause of poorer outcomes for open ankle fusion compared to arthroscopic. Swelling is an independent factor as swelling scores for TAA were higher compared to AAA despite similar outcomes. Arthroscopic surgery reduces the postoperative swelling. Methods to reduce swelling such as compression stockings, elevation, controlling bleeding may result in better outcomes. Minimising the invasiveness of surgery achieves this goal. Patient education about swelling, elevation and compression stockings would assist in these goals

Aim. Prospectively assess the degree of finger swelling after shoulder arthroscopy, to determine whether rings should be routinely removed prior to surgery. Method and Results. Patients undergoing shoulder arthroscopic procedures had finger diameters measured prior and post surgery, over a three month period. The study was approved by our Research and Development department. Measurements were taken using a finger circumference gauge (Southpointe, Florida, USA) and were all performed by one researcher in a standard technique, to eliminate inter observer variability. Control measurement, using the contralateral hand, were taken. Statistical analysis was performed, using the Mann Whitney U test. 31 patients undergoing shoulder arthroscopy were included in the study and had finger diameters assessed. The median amount of finger swelling on the operated side was 2.8 mm (IQR 4.6) per digit, compared to 0 mm on the contralateral side (IQR 1.6), which was significantly greater (p=0.0003). There was no statistical difference in the amount of finger swelling when patients undergoing short procedures (less than 30 minutes operating time) were compared to patients undergoing long procedures (greater than 60 minutes). Conclusions. These results suggest that patients undergoing shoulder arthroscopy have a significant degree of finger swelling post-operatively and that the amount of swelling cannot be accurately predicted based on the length of procedure alone. This indicates that rings should be routinely removed, prior to shoulder arthroscopy, even if this necessitates cutting of rings for removal

Background. Total knee arthroplasty (TKA) is offered to patients who have end-stage knee osteoarthritis to reduce pain and improve functional performance. Knee edema and pain deteriorate the patients' outcomes after TKA at early period. By quantifying the patients' early outcome deficits and their potential relationships to edema and pain may assist in the design of in-patient rehabilitation programs. Objectives. The aim of this study was to investigate of the effect of knee swelling on early patients' outcomes after primary TKA. Design and Methods. The study group consisted of 61 patients (10 males, 51 females), who underwent primary TKR because of knee arthrosis were included in the study with mean age 65.2±9 years. Patients were evaluated regarding knee circumference (10 cm superior of midpoint of patella, midpoint of patella, 10 cm distal of midpoint of patella), pain (Numeric Pain Rating Scale (NPRS)), knee range of motion (ROM), the day of active straight leg raise, knee function score (Hospital for Special Surgery (HSS)), Functional activities were evaluated using the Iowa Level of Assistance Scale (ILAS) and walking speed was evaluated using the Iowa Ambulation Velocity Scale (IAVS). Results. There were moderate significant correlation between knee circumference (10 cm superior of midpoint of patella; r=0.328, p=0.001, midpoint of patella; r=0.310, p=0.002, 10 cm distal of midpoint of patella; r=0.300, p=0.003) and IAVS. While, significant low correlation was found between pain level and knee ROM (r=−0.272, p=0.008), there was strong significant correlation between pain level and HSS (r=0.866, p<0.001). There was not significant correlation between knee swelling and all the other measurement, and also between pain and all the other measurement (p>0.05). Conclusion. The moderate correlation between knee swelling and IVAS, low correlation between pain and knee ROM, and also strong correlation between pain and HSS suggests that improved postoperative knee swelling and pain could be important to enhance the potential benefits of TKA in early stage. With improvement in knee swelling and pain the patient may obtain good functional outcomes and knee score

The August 2023 Wrist & Hand Roundup360 looks at: Complications and patient-reported outcomes after trapeziectomy with a Weilby sling: a cohort study; Swelling, stiffness, and dysfunction following proximal interphalangeal joint sprains; Utility of preoperative MRI for assessing proximal fragment vascularity in scaphoid nonunion; Complications and outcomes of operative treatment for acute perilunate injuries: a systematic review; The position of the median nerve in relation to the palmaris longus tendon at the wrist: a study of 784 MR images; Basal fractures of the ulnar styloid? A randomized controlled trial; Proximal row carpectomy versus four-corner arthrodesis in SLAC and SNAC wrist; Managing cold intolerance after hand injury: a systematic review

Aims. The aim of this study was to determine whether closed suction drain (CSD) use influences recovery of quadriceps strength and to examine the effects of drain use on secondary outcomes: quadriceps activation, intra-articular effusion, bioelectrical measure of swelling, range of movement (ROM), pain, and wound healing complications. Patients and Methods. A total of 29 patients undergoing simultaneous bilateral total knee arthroplasty (TKA) were enrolled in a prospective, randomized blinded study. Patients were randomized to receive a CSD in one limb while the contralateral limb had the use of a subcutaneous drain (SCDRN) without the use of suction (‘sham drain’). Isometric quadriceps strength was collected as the primary outcome. Secondary outcomes consisted of quadriceps activation, intra-articular effusion measured via ultrasound, lower limb swelling measured with bioelectrical impendence and limb girth, knee ROM, and pain. Outcomes were assessed preoperatively and postoperatively at day two, two and six weeks, and three months. Differences between limbs were determined using paired Student’s t-tests or Wilcoxon’s signed-rank tests. Results. No significant differences were identified between limbs prior to surgery for the primary or secondary outcomes. No significant differences in quadriceps strength were seen between CSD and SCDRN limbs at postoperative day two (p = 0.09), two weeks (primary endpoint) (p = 0.7), six weeks (p = 0.3), or three months (p = 0.5). The secondary outcome of knee extension ROM was significantly greater in the CSD limb compared with the SCDRN (p = 0.01) at two weeks following surgery, but this difference was absent at all other intervals. Secondary outcomes of quadriceps activation, intra-articular effusion, lower limb swelling, and pain were not found to differ significantly at any timepoint following surgery. Conclusion. The use of CSD during TKA did not influence quadriceps strength, quadriceps activation, intra-articular effusion, lower limb swelling, ROM, or pain. These results have limited drain use by the authors in primary uncomplicated TKA. Cite this article: Bone Joint J 2019;101-B (7 Supple C):84–90

Introduction: Hip resurfacing has been increasingly used procedure for physiologically young and active patients. Wear properties of the implants are considered to be excellent. We present a case of tumor like swelling of the thigh following metal on metal hip resurfacing. Case report: 56 year old lady underwent metal on metal hip resurfacing for idiopathic osteoarthritis of right hip. Implant size: 38 mm head with 44 mm cup. After 18 months of successful surgery she presented with short duration (2 weeks) history of thigh swelling with pain and stiffness in hip and knee. Clinically gross circumferential swelling of right thigh from inguinal ligament to the knee joint. She had increased serum cobalt chromium levels. Aspiration of hip revealed high levels of cobalt and chromium. Biopsy and intra operative samples at revision revealed “no infection or tumor but non specific inflammatory reaction.”. The patient underwent revision surgery to ceramic-plastic bearing.(THR). 12 months post operative, the swelling has reduced with painless mobile hip and knee joints. Discussion: The metal on metal hip resurfacing could have produced high metal ion wear reaction leading to swelling. Which could be because of small diameter prosthesis with valgus position of femoral component with open cup angle of 49 degrees

Introduction: Ankle fractures are among the commonest orthopaedic injuries. A delay in operating is often due to the swelling associated with such fractures. On the other hand, the delay in operative fixation beyond 24 h from injury is associated with a lengthening of hospital stay which costs approximately £225 per patient per day for an acute trauma bed. Objectives: The aim of this study was to analyse the relationship between the delay in surgical intervention of open reduction and internal fixation of ankle fractures from presentation due to ankle swelling, and the length of hospital stay and postoperative complications. Patients and Methods: A retrospective study of 145 consecutive patients treated for ankle fractures over a period of 12 months between January and December 2008. results were collated excluding talar and pilon fractures. Emergency department presentation times were noted and time of anaesthetic to determine surgical delay. Notes were reviewed for inpatient stay and postoperative complications. Results: There were 62 male and 83 female patients with a mean age of 49 years. In total, 117 (80%) patients were operated on within 24 hours of presentation (early group). 28 patients’ surgery was delayed beyond 24 hours (delayed group). Of the 117 patients the mean inpatient stay was 3.79 days (± 2.39) whereas in the delayed group the mean stay was 8.57 days (± 6.54). Of the delayed group, 57% of the cases had swelling as the cause of a postponed operation, whereas other causes included lack of theatre time and lack of fitness for surgery. In the early group, 5 patients (4.27%) had wound infections and one patient had a chest infection (0.85%). Four patients (14.28%) from the delayed group developed wound infections all of whom were from patients with ankle swelling. Conclusion: We recommend that policies be put in place to provide early operative intervention for patients with fractured ankles prior to the development of swelling as this would result in improved patient outcome and significant financial savings. If an operation is not feasible within 24 hours of admission and the ankle is swollen resulting in a high operative risk, we recommend sending the patient home for a period of 5–7 days with advice on RICE and anticoagulation which would both permit surgery and cut down costs

Patient specific knee modelling has the potential to help understand the development of the mechanically induced degenerative disease, Osteoarthritis. A full joint contact model of the knee involves modelling the bones, ligaments, articular cartilage (AC) and meniscus, as well as, the kinematics and geometry of real joints. These finite element models will inevitably require great computational resource to run and it is desirable to find resource effective material model formulations which can accurately describe the mechanical behaviour of the soft tissues. Biphasic models (BIMs) have long been established as an effective formulation for modelling AC. However, the swelling behaviour caused by changes in the ionic phase is a major recovery mechanism and is neglected in the BIMs. It is therefore believed that BIMs alone are insufficient to fully describe the mechanical behaviour of AC. Instead, a thermal analogy method which is generically a BIM that includes the swelling behaviour has been thought to be suitable and has been validated against literature data using material parameters optimized to match the numerical and experimental results. To ensure the model is suitable for patient specific modelling where it will have the ability to reflect the individual AC material properties of the patients in the mechanical behaviour it predicts, two experiments have been planned and are currently being carried out using bovine AC. The first experiment is to investigate the diffusivity of the tissue in solutions of different molarity by measuring the change in tissue weight over time. Eleven explants are taken from the same bovine articular joint using a 6mm biopsy punch and are left in 10mM of PBS overnight to ensure ionic equilibrium has been reached before experiments are carried out. The explants are then placed in PBS solutions of molarities ranging from 0mM to 10mM and weighed at regular time intervals. In the final stage, the explants are then lyophilized and weighed for determining the volume of water in the tissues. Using Archimedes principle, the change in porosity of the tissue is found. A preliminary study has shown that explants submerged in a solution of 5mM has an approximately 4% change in weight after the first 24h and a further 1.73% change in the following 24h. Control specimens left in a solution of 10mM had a 0% change in weight. The second experiment is to carry out mechanical loading on the AC specimens while submerged in a solution of different ion concentrations. Experiments with various loading conditions are being investigated to explore their efficacy for validation. Preliminary compression tests have been carried out where steps of 1% strain was applied, giving a total of 10% strain. Between each step, strain was held constant until full relaxation has been achieved. The reaction force measured from the second experiment in conjunction with data collected from the first experiment will be compared to results predicted in the numerical model. This will allow the determination of whether thermal analogy is adequate or whether more complex triphasic models need to be considered. Furthermore, the development of these experimental methods will contribute to the validation of other AC material models in the future

Postoperative leg swelling after a total knee replacement is common complaint amongst patients. We studied leg swelling by constructing a novel, simple and cost water volumeter. A pilot study was conducted on 15 volunteers by two observers and each observer took a total of three readings. The mean intraobserver variation was 0.2 percent and mean interobserver variation was 0.3 percent, indicating a highly acceptable level of accuracy. The water volumeterwas then used in a randomized prospective study was conducted to determine the relationship between postoperative leg swelling and Fraxiparine, a low molecular weight heparin. From the period of 1st January 2000 till 31th October 2000, a total of 36 patients were enrolled in the study. 18 patients in the study group received fraxiparine and 18 patients in the control group did not. The leg volume was measured preoperatively and on postoperative days 5, 7 and 10. We found that both groups developed maximum swelling at postoperative day 5 and this decreased to almost normal at day 10. However the fraxiparine group was statistically less swollen (4%) than the control group (10%) on day 5 and also on day 7 (−0.2% vs 7%). These findings were independent of whether the patient underwent bilateral or unilateral surgery. We conclude that low molecular weight heparins are effective in reducing postoperative leg swelling in total knee replacement

Introduction. Excessive soft tissue swelling will delay surgery for a proportion of patients admitted with ankle fractures. Surgical and anesthetic teams may waste time assessing patients destined to be cancelled due to swelling. The aim of this investigation was to determine factors associated with cancellation. Methods. Case notes of 87 patients (46 male, 41 female), mean age 43 years (range, 13 to 80) who underwent ankle fracture fixation were retrospectively analysed. 31 of 87 ankles (36%) were unsuitable for day after admission surgery due to swelling. Factors investigated included age, gender, mechanism of injury, fracture configuration and necessity for reduction on arrival in the emergency department due to dislocation; each factor was independently analysed for significance using Fisher's exact test. Results. Ankle fractures associated with a higher energy injury such as sports, falls from height and road traffic accidents were significantly more likely than simple slips to be cancelled due to excess swelling the following morning (p = 0.053). Tri- or bi-malleolar ankle injuries and fracture dislocations requiring manipulation in the emergency department were also significant risk factors for cancellation (p = 0.004 and p = 0.002 respectively). Patients presenting with at least two of these factors demonstrated a 71% probability of cancellation the following day (17 of 87 patients). Presence of three risk factors increased the probability of cancellation to 100% (3 of 87 patients). Conclusion. Cancellation on the day of surgery wastes time and causes patient distress. During busy on-call periods patients with all three risk criteria will almost certainly be too swollen for next day surgery. With the proviso that these fractures are immobilised in an acceptable position, patients could be rested with elevation and rebooked for surgery as opposed to being assessed and subsequently cancelled due to soft tissue swelling the day after injury

Range of motion, degree of hemarthrosis and leg circumference was prospectively recorded in one hundred and eighteen consecutive isolated ACL reconstructions. A higher grade of hemarthrosis at one week was associated with a flexion deficit at eight weeks (P=0.002, relative risk 1.93). Increased leg circumference at one week was also associated with a flexion deficit at eight weeks (P=0.007, relative risk 1.37). An extension deficit was not associated with a hemarthrosis (P=0.47) or increased circumference (P=0.07). This prospective review identifies a risk factor for clinicians to be aware of after ACL Reconstruction. These patients merit closer observation and possibly a modified rehabilitation protocol. To determine if increased swelling in the early post operative period is predictive of difficulty in regaining full range of motion after ACL reconstruction. Increased swelling, at one-week post op (presence of a large hemarthrosis or a measured circumference greater than 1.5cm more than the control limb) is associated with flexion loss at eight weeks post surgery. These patients merit closer observation and possibly a modified rehabilitation protocol. Patients with a higher grade of hemarthrosis at one week were more likely to have a flexion deficit at eight weeks (P=0.002, relative risk 1.93). Increased circumference was also associated with a flexion deficit at eight weeks (P=0.007, relative risk 1.37). The presence of a large hemarthrosis was not associated with an extension deficit at (P=0.47) although there was a trend for increased circumference to be associated with extension deficit (P=0.07). One hundred and eighteen consecutive patients were prospectively assessed post ACL reconstruction. Range of motion was measured by goniometer at week one, four and eight. A deficit greater than 10° of flexion or 5° of extension (compared to normal leg) at the eight-week mark was defined as significant. The grade of hemarthrosis and circumference of the leg at the level of the patella were recorded at the same intervals. All patients underwent endoscopic, primary, ACL reconstruction with a standardized post op physio protocol. Exclusion criteria included previous surgery on either knee, significant effusion at the time of surgery or associated ligament injuries

Introduction and Aims: A variety of factors have been associated with difficulty in regaining normal knee motion following anterior cruciate ligament surgery. The purpose of this study was to determine if increased swelling in the early post-operative period is predictive of difficulty in regaining full range of motion after ACL reconstruction. Method: 118 consecutive patients were prospectively assessed post-ACL reconstruction. Range of motion was measured by goniometer at week one, four and eight. A deficit greater than 10 degrees of flexion or five degrees of extension (compared to normal leg) at the eight-week mark were defined as significant. The grade of hemarthrosis and circumference of the leg at the level of the patella were recorded at the same intervals. All patients underwent endoscopic, primary, ACL reconstruction with a standardised post-op physio protocol. Exclusion criteria included previous surgery on either knee, significant effusion at the time of surgery or associated ligament injuries. Results: Patients with a higher grade of hemarthrosis at one week were more likely to have a flexion deficit at eight weeks (P=0.002, relative risk 1.93). Increased circumference was also associated with a flexion deficit at eight weeks (P=0.007, relative risk 1.37). The presence of a large hemarthrosis was not associated with an extension deficit at (P=0.47), although there was a trend for increased circumference to be associated with extension deficit (P=0.07). The patients that had difficulty in regaining full range of motion were similar to the rest of the cohort with regards to patient age, sex, time to surgery, graft type, incidence and treatment of meniscal pathology. Conclusions: Increased swelling, at one-week post-op (presence of a large hemarthrosis or a measured circumference greater than 1.5cm more than the control limb) is associated with flexion loss at eight weeks post-surgery. These patients merit closer observation and possibly a modified rehabilitation protocol

Introduction. Physical disruption of the extracellular matrix influences the mechanical and chemical environment of intervertebral disc cells. We hypothesise that this can explain degenerative changes such as focal proteoglycan loss, impaired cell-matrix binding, cell clustering, and increased activity of matrix-degrading enzymes. Methods. Disc tissue samples were removed surgically from 11 patients (aged 34–75 yrs) who had a painful but non-herniated disc. Each sample was divided into a pair of specimens (approximately 5mm. 3. ), which were cultured at 37°C under 5% CO. 2. One of each pair was allowed to swell, while the other was restrained by a perspex ring. Live-cell imaging was performed with a wide field microscope for 36 hrs. Specimens were then sectioned at 5 and 30 μm for histology and immunofluorescence using a confocal microscope. Antibodies were used to recognise free integrin receptor α5β1, matrix metalloprotease MMP-1, and denatured collagen types I-III. Proteoglycan content of the medium, analysed using the colorimetric DMMB assay, was used to assess tissue swelling and GAG loss. Constrained/unconstrained results were compared using matched-pair t-tests. Results. Time-lapse cinematography revealed small cell movements in unconstrained specimens, for up to 12 hrs. By 36 hrs, unconstrained (free swelling) samples showed greater: loss of GAG's (p<0.003), loss of integrin binding (p<0.02), synthesis of MMP-1 (p<0.03), and collagen denaturation (p<0.009). Cell clustering was evident in all tissues after 36 hrs. Conclusion. Swelling of disrupted disc tissue disturbs cell-matrix binding, increases matrix degradation, and allows increased proteoglycan loss. This sequence of events could follow disc injury or herniation in-vivo

We performed a prospective randomised controlled trial of the A-V Impulse System in 82 patients treated by hemiarthroplasty for subcapital fracture of the femoral neck. The incidence of proximal deep-vein thrombosis as assessed by Doppler ultrasonography was 23% in the control group and 0% in those using the device (p less than 0.01). Calf and thigh circumferences were measured in both groups at seven to ten days after operation. In the treatment group there was a mean relative reduction of postoperative swelling of the thigh by 3.27 cm (p less than 0.001) and of the calf by 1.55 cm (p less than 0.001). The A-V Impulse System appears to be a safe and effective method of reducing the incidence of proximal deep-vein thrombosis, and of postoperative swelling

Giant synovial cyst is commonly seen in association with rheumatoid arthritis. The Baker’s cyst around the knee is the commonest example but it has also been described at the elbow and hip. The possibility of a synovial cyst around the hip is unfamiliar to most clinicians including those who regularly deal with inguinal swellings and those specialising in musculoskeletal conditions. This is often overlooked as a cause of symptoms in inguinal area and lower limb. We present a report on two patients in whom abnormal pulsatile masses in the groin caused diagnostic difficulty. Patients were initially admitted under vascular surgeons with a clinical diagnosis of aneurysm. Ultrasound examination was useful in excluding aneurysm. Detailed clinical examination revealed painful restricted hip movements and an X–ray showed evidence of arthritis in hip joint. CT Scan confirmed it to be a synovial cyst. Computed Arthrotomogram or Arthrography showed communication of the cyst with hip joint. Synovial cysts and iliopsoas bursa enlargement may be more common than previously reported. They may present as a pulsatile mass due to close proximity to femoral vessels and should be considered as a differential diagnosis in patients with unusual inguinal swelling

Following the discovery of a powerful venous pump in the foot that is activated by weight-bearing independently of muscular action, a pneumatic impulse device was developed to actuate this pump artificially. In a multicentre international trial the device was shown to reduce post-traumatic and postoperative swelling; pain also was alleviated. Evidence is also presented that dangerously high compartment pressures may be reduced to acceptable levels and fasciotomy avoided. We present an explanation of the clinical effects of activation of the venous footpump, based on recent improved understanding of the physiology of the microcirculation. The hyperaemic response that follows the liberation of endothelial-derived relaxing factor (EDRF) by sudden changes of pressure after weight-bearing or impulse compression is particularly important

Introduction: Surgery to ankle fractures requiring fixation is often delayed due to swelling. Social circumstances and surgeon preference dictate whether these patients are rested in hospital or at home. The aim of this study was to explore the effectiveness of a discharge and readmit policy for surgical fixation of ankle fractures unsuitable for immediate surgery. Materials and methods: The case notes and radiographs of 87 patients’ who underwent ankle fracture fixation between January 1st 2007 and December 31st 2007 were reviewed for causes of delayed surgery and details of the admission. Results: The sample comprised 46 male and 41 female patents, average age 43 years (range, 13–80). 43 operations were cancelled within 24 hours of admission. These were considered delayed operations. 31 patients were cancelled due to soft tissue swelling. Lack of operating capacity or awaiting the results of further investigations caused the remaining 12 delays. Twenty-three of the delayed procedures were deemed suitable for discharge and re-admission (safe, previously mobile, not living alone). Seven of these patients were discharged and re-admitted through fracture clinic five to seven days later. The remaining 16 were rested as inpatients. Patients treated with traditional inpatient rest and elevation averaged at total inpatient stay of 13 days (range 8–19 days). Patients discharged for rest and elevation had a significantly (p< 0.05) reduced overall inpatient stay of 3.3 days (range, 2–5 days). This approach could have saved our institution an estimated £53,808 (157 inpatient days) for the period January 1st 2007 to December 31st 2007. Conclusion: The re-admission policy for ankle fractures too swollen for early surgery described in this report significantly reduces overall inpatient stay with no identifiable adverse effects. Readmission through outpatient clinics generates administrative costs and as yet un-quantified service pressure which may cause disruption to outpatient services although this approach in undoubtedly a useful practice with careful patient selection

A primary hydatid cyst in the pelvis is rare, and usually presents with pressure symptoms affecting the adjacent abdominal organs. We describe such a cyst which protruded through the sciatic notch and presented as a gluteal swelling with a foot drop due to compression of the lumbosacral nerve roots. Surgical excision and postoperative treatment with albendazole for six weeks were effective in controlling the disease and preventing recurrence

Hip arthrography was performed in 19 patients in the initial stage of Perthes' disease. Sphericity and subluxation were measured and it was found that subluxation was independent of the femoral head deformity. We therefore tried to identify the cause of early subluxation: in seven patients a swollen ligamentum teres was thought to be responsible, and was associated with medial pooling of the contrast medium. A swollen ligamentum teres was seen in another seven cases; the other five arthrograms were normal. These findings were further clarified by enhanced CT scans, which confirmed that ligament swelling may be an important cause of early subluxation

Recently, highly crosslinked polyethylenes have emerged as an alternative bearing surface with tremendous potential for clinical success. However, the term highly cross-linked polyethylene refers to a great many materials, each manufactured under drastically different processing parameters, such as type of irradiation, dose, and warm versus cold state. It has been widely shown in laboratory hip simulator testing, that the wear resistance of UHMWPE improves significantly with increasing cross-link density, but the measurement of this parameter is somewhat controversial. While both swell testing of the polyethylene (direct) and trans-vinylene content (indirect) both yield information regarding the actual degree to which the material is crosslinked, no study to date has examined the exact relationship between these two tests. In evaluating the clinical performance of highly crosslinked polyethylenes, it is crucial that they be characterized according to the specific parameters by which they were manufactured. onship. Micro-Fourier Transform Infrared Spectroscopy (FTIR) and swelling measurements were performed on samples irradiated by either electron beam or gamma sources at varying doses, in both the cold and warm state. The trans-vinylene content was obtained from the ratio of the peaks at 965 cm-1 and 2022 cm-1, while the crosslink density was computed from Flory network theory. The information for crosslink density was plotted versus trans-vinylene content to obtain the precise relationship between these two highly sensitive tests. This information can be used to aid in the clinical evaluation of commercially available highly crosslinked polyethylenes, and to improve our understanding of the very complex relationship between wear and the physical and chemical properties of UHMWPE

Aims. Staphylococcus aureus is a major cause of septic arthritis, and in vitro studies suggest α haemolysin (Hla) is responsible for chondrocyte death. We used an in vivo murine joint model to compare inoculation with wild type S. aureus 8325-4 with a Hla-deficient strain DU1090 on chondrocyte viability, tissue histology, and joint biomechanics. The aim was to compare the actions of S. aureus Hla alone with those of the animal’s immune response to infection. Methods. Adult male C57Bl/6 mice (n = 75) were randomized into three groups to receive 1.0 to 1.4 × 10. 7. colony-forming units (CFUs)/ml of 8325-4, DU1090, or saline into the right stifle joint. Chondrocyte death was assessed by confocal microscopy. Histological changes to inoculated joints were graded for inflammatory responses along with gait, weight changes, and limb swelling. Results. Chondrocyte death was greater with 8325-4 (96.2% (SD 5.5%); p < 0.001) than DU1090 (28.9% (SD 16.0%); p = 0.009) and both were higher than controls (3.8% (SD 1.2%)). Histology revealed cartilage/bone damage with 8325-4 or DU1090 compared to controls (p = 0.010). Both infected groups lost weight (p = 0.006 for both) and experienced limb swelling (p = 0.043 and p = 0.018, respectively). Joints inoculated with bacteria showed significant alterations in gait cycle with a decreased stance phase, increased swing phase, and a corresponding decrease in swing speed. Conclusion. Murine joints inoculated with Hla-producing 8325-4 experienced significantly more chondrocyte death than those with DU1090, which lack the toxin. This was despite similar immune responses, indicating that Hla was the major cause of chondrocyte death. Hla-deficient DU1090 also elevated chondrocyte death compared to controls, suggesting a smaller additional deleterious role of the immune system on cartilage. Cite this article: Bone Joint Res 2022;11(9):669–678

Abstract. Objectives. Osteoarthritis (OA) is a painful and debilitating disorder of diarthroidal joints. Progressive degeneration of the cartilage extracellular matrix (ECM) together with abnormal chondrocyte characteristics occur leading to a switch to a fibroblast-like phenotype and production of mechanically-weak cartilage. Early changes to chondrocytes within human cartilage have been observed including chondrocyte swelling. [1]. together with the development of thin cytoplasmic processes which increase in number and length with degeneration. [2]. Changes to chondrocyte phenotype in degenerate cartilage are associated with F-actin redistribution and stress fibres (SF) formation, leading to morphologically-dedifferentiated (fibroblast-like) chondrocytes. [3,4]. It is unclear if these processes are a consequence of ‘passive’ cell swelling into a defective ECM or an ‘active’ event driven by changes in cell metabolism resulting in alterations to cell shape. To address this, we have quantified and compared the distribution and levels of F-actin, a key cytoskeletal protein involved in the formation of cytoplasmic processes, within in situ chondrocytes in non-degenerate and mildly degenerate human cartilage. Methods. Human femoral head cartilage was obtained from 21 patients [15 females, 6 males, average age 69.6yrs, (range 47–90yrs)] following femoral neck fracture, with Ethical Approval and patient's permission. Cartilage explants were removed from areas graded non-degenerate grade 0 (G0) or mildly degenerate grade 1 (G1) and cultured for up to 3wks in Dulbecco's Modified Eagle's Medium (DMEM) +/− 25% human serum (HS). In situ chondrocytes were stained with CMFDA (5-chloromethylfluoresceindiacetate, Cell-Tracker Green®) and phalloidin (F-actin labelling) and imaged by confocal microscopy and analysed quantitatively using ImageJ and Imaris® software. Results. There were significant increases in the total amount (TA) of F-actin and its distribution [intense punctuate (IP) and intense areas (IA)] between the whole chondrocyte populations of G0 and G1 cartilage (P=0.0356; 0.0112; 0.016, respectively). Where the volume of chondrocytes was divided into normal (<1000 µm³) and swollen (≥1000 µm³) cells, F-actin TA increased in swollen cells (P=0.036 within G0 and G1, and P=0.0009 between grades) compared to chondrocytes of normal volume in each grade. Moreover, IP and IA within and between G0 and G1 were higher compared to normal chondrocytes (with P<0.0001 for IP and P<0.001 for IA). In addition, tissue culture experiments demonstrated that 90% of chondrocytes with cytoplasmic processes had strong F-actin intensity (either IP or IA with P<0.0001). Furthermore, 83% of this F-actin was associated with cytoplasmic processes, with >65% situated at the base of the process (P<0.0001). Conclusions. The increases in chondrocyte F-actin levels (TA) and its localisation (IP, IA) appear to be associated with cell swelling and development of cytoplasmic processes, which are both characteristics of early OA cartilage. [1]. This suggests the formation of chondrocyte cytoplasmic processes is an ‘active’ event potentially involving changes to matrix metabolism rather than a ‘passive’ cell swelling into a defective extracellular matrix. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Osteochondromas are benign chondrogenic lesions arising on the external surface of the bone with aberrant cartilage (exostosis) from the perichondral ring that may contain a marrow cavity also. In a few cases, depending on the anatomical site affected, different degrees of edema, redness, paresthesia, or paresis can take place due to simple contact or friction. Also, depending on their closeness to neurovascular structures, the procedure of excision becomes crucial to avoid recurrence. We report a unique case of recurrent osteochondroma of the proximal humerus enclosing the brachial artery which makes for an important case and procedure to ensure that no relapse occurs. We report a unique case of a 13-year-old female who had presented with a history of pain and recurrent swelling for 5 years. The swelling size was 4.4 cm x 3.7 cm x 4 cm with a previous history of swelling at the same site operated in 2018. CT reports were suggestive of a large well defined broad-based exophytic diaphyseal lesion in the medial side of the proximal humerus extending posteriorly. Another similar morphological lesion measuring approximately 9 mm x 7 mm was noted involving the posterior humeral shaft. The minimal distance between the lesion and the brachial artery was 2 mm just anterior to the posterio-medial growth. Two intervals were made, first between the tumor and the neurovascular bundle and the other between the anterior tumor and brachial artery followed by exostosis and cauterization of the base. Proper curettage and excision of the tumor was done after dissecting and removing the soft tissue, blood vessels, and nerves so that there were very less chances of relapse. Post-operative X-ray was done and post 6 months of follow-up, there were no changes, and no relapse was observed. Thus, when presented with a case of recurrent osteochondroma of the proximal humerus, osteochondroma could also be in proximity to important vasculature as in this case enclosing the brachial artery. Thus, proper curettage and excision should be done in such cases to avoid recurrence

The extracellular matrix (ECM)-based biomaterials provide a platform to mimic the disc microenvironment in facilitating stem cell transplantation for tissue regeneration. However, little is known about in vitro preconditioning human umbilical cord Wharton Jelly-derived mesenchymal stem cells (MSCs) on 3D hyaluronic acid (HA)/type II collagen (COLII) hydrogel for nucleus pulposus (NP) phenotype and pain modulation. We developed a tuneable 3D HA/COLII by fabricating HA/COLII hydrogel at 2 mg/ml COLII and various weight ratios of HA:COLII, 1:9 and 4.5:9. The hydrogel was characterized for degradability, stability, and swelling capacity. The viability of hWJ-MSC encapsulated on hydrogel supplemented with TGF-β3 was assessed. The implantation of HA/COLII hydrogel was done in surgically induced disc injury model of pain in the rat tail. The general health status in rats was monitored. The nociceptive behaviour in rats was performed for mechanical allodynia using von Frey test. The HA/COLII 4.5:9 hydrogel showed higher swelling capacity than weight ratio 1:9, suggesting that a higher amount of HA can absorb a large amount of water. Both HA/COLII 4.5:9 and 1:9 hydrogel formulations had a similar degradation profile, stable to the hydrolytic process. The hWJ-MSC-encapsulated on hydrogel marked higher cell viability with round morphology shape of cells in vitro. The surgically induced disc injury in the rat tail evoked mechanical allodynia, without affecting general health status in rats. The implantation of HA/COLII 1:9 hydrogel was observed to slightly alleviate injury-induced mechanical allodynia. Fine-tuning HA/COLII-based hydrogel provides the optimal swelling capacity, stability, degradability, and non-cytotoxic, mimicking the 3D NP niche in guiding hWJ-MSCs towards NP phenotype. The HA/COLII hydrogel could be employed as an advanced cell delivery system in facilitating stem cell transplantation for intervertebral disc regeneration targeting pain

INTRODUCTION. Tuberculosis (TB) is a public health challenge. However, musculoskeletal involvement represents 10–15% of all extrapulmonary cases. Upper extremity involvement is extremely rare. The slow progressive course of clinical symptoms and lack of radiological signs lead to difficulties in establishing early diagnosis. Hence, the patients who have tuberculosis of the wrist are usually misdiagnosed. We report 5 cases of tuberculosis of the wrist seen in our unit from the year 2012 to 2021. METHODS. Cases were retrospectively evaluated on demographics, nature of history, clinical presentation, culture finding, and histopathological findings from 2012 to 2021 at our unit. RESULTS. A total of 5 cases were evaluated retrospectively. Three patients were more than 60 years old and two were less than 30 years old. Four of the patients presented with wrist swelling 2 of them had wrist pain and only 1 patient had discharge from the wound. The duration of the symptoms ranges from 2 months to 3 years. Only one of the patients had a history of pulmonary TB contact whereas the others didn't. All patients underwent surgery. All of the patients had positive cultures for Mycobacterium tuberculosis complex and histopathological examination showed necrotizing granulomatous inflammation from specimens taken intraoperatively, which confirmed the diagnosis of tuberculosis of the wrist. DISCUSSIONS. Our cases show that the common presentation of tuberculosis of the wrist was comparable to other literature. Most of the patients presented with chronic wrist swelling with or without wrist pain. The diagnosis of the disease was delayed an average of 10 - 12 months from symptoms onset to diagnosis. S. Bayram et al reported a case where the diagnosis was made 45 months later. Due to its rarity, it often is misdiagnosed, resulting in delays in the proper treatment. CONCLUSION. The diagnosis of the TB wrist remains difficult because of insidious and non-specific. presentation. However, early diagnosis is essential to avoid delays in treatment and complications. Hence, chronic wrist pain, and swelling with or without unexplained bone erosion around the wrist area must be highly suspected of being osteoarticular tuberculosis

The June 2023 Research Roundup. 360. looks at: Characterizing recurrent infections after one-stage revision for periprosthetic joint infection of the knee; Predicted waiting times for orthopaedic surgery: an urgent need to address the deficit in capacity; Vascular impulse technology versus elevation for reducing the swelling of upper and lower limb joint fractures; Desperate patients will accept higher risks; How long does it take to find a positive culture in periprosthetic joint infection?

The direct anterior approach (DAA) is a popular minimally invasive approach for total hip arthroplasty (THA). It usually involves ligation of the lateral femoral circumflex artery's ascending branch (a-LFCA), which contributes to the perfusion of the tensor fasciae latae (TFL) muscle. Periarticular muscle status and clinical outcome were assessed after DAA-THA after a-LFCA preservation versus ligation. We evaluated surgical records of 161 patients undergoing DAA-THA with tentative preservation of the a-LFCA by the senior author between May and November 2021. Among 92 eligible patients, 33 (35 hips) featured successful preservation, of which 20 (22 hips, 13 female) participated in the study. From 59 patients with ligated a-LFCA, 26 (27 hips, 15 female) were enrolled, constituting the control group. MRI and clinical examinations were performed at 17–26 months to analyze volume and fatty infiltration of the TFL, gluteus medius and gluteus minimus muscles relative to the contralateral non-THA hip (15 preserved, 18 ligated). Clinical and radiographic data was retrospectively extracted from patient files. Patient-reported outcomes (PROMs) were added from the THA registry. There was a relative difference in TFL muscle volume of -6.27 cm. 3. (−9.89%, p=0.018) after a-LFCA preservation versus -8.6 cm. 3. (=11.62%, p=0.002) after ligation, without group differences (p>0.340). a-LFCA preservation showed lower relative TFL fatty infiltration (p=0.10). Gluteal muscle status was similar between sides and groups. Coxa valga morphology was more frequent in a-LFCA preservation (83%) than ligation (17%). Clinical outcomes showed high patient satisfaction in both groups, without difference in PROMs, but less anterolateral soft-tissue swelling after a-LFCA preservation (p<0.001). Despite excellent clinical results in both groups, preservation of the a-LFCA was associated with less TFL fatty infiltration and soft tissue swelling. Provided there is no compromise of intraoperative access we recommend a-LFCA preservation for DAA-THA

Abstract. Introduction. The Wells score is commonly used to assess the risk of proximal Deep Vein Thrombosis (DVT) following Knee Arthroplasty (KA). The National Institute for Health and Care Excellence (NICE) guidelines recommend an Ultrasound scan in patients with a Wells score of 2 points or more. We wanted to assess how often this protocol resulted in a scan being done and how many were negative. Methodology. Details of all postoperative Ultrasound scans performed up to 90 days were audited in a high-volume unit between 1st January 2016 and 31st December 2020. This included all Lower Limb Arthroplasty patients. Results. Out of a total of 4955 KA (4506 Total Knee Arthroplasty, 449 Unilateral Knee Arthroplasty), 449 (9.1%) had a total of 561 scans, with 17 (3.0%) scans demonstrating a proximal DVT. Thus 97.0% of Ultrasound scans were negative. Conclusion. The present NICE guidelines with the two-Level DVT Wells score are inappropriate for the management of suspected proximal DVT following KA. We propose that swelling that fails to reduce after 4 hours of elevation, or new swelling after a period of recumbent rest, would be more appropriate indications for a scan and negative scans should not be repeated without a change in symptoms. Unless there are pressing clinical indications, therapeutic anticoagulation should not commence in the absence of a diagnosis

Aims. The rate of day-case total knee arthroplasty (TKA) in the UK is currently approximately 0.5%. Reducing length of stay allows orthopaedic providers to improve efficiency, increase operative throughput, and tackle the rising demand for joint arthroplasty surgery and the COVID-19-related backlog. Here, we report safe delivery of day-case TKA in an NHS trust via inpatient wards with no additional resources. Methods. Day-case TKAs, defined as patients discharged on the same calendar day as surgery, were retrospectively reviewed with a minimum follow-up of six months. Analysis of hospital and primary care records was performed to determine readmission and reattendance rates. Telephone interviews were conducted to determine patient satisfaction. Results. Since 2016, 301/7350 TKAs (4.1%) in 290 patients at our institution were discharged on the day of surgery. Mean follow-up was 31.4 months (6.2 to 70.0). In all, 28 patients (9.3%) attended the emergency department or other acute care settings within 90 days of surgery, most often with wound concerns or leg swelling; six patients (2.0%) were readmitted. No patients underwent a subsequent revision procedure, and there were no periprosthetic infections. Two patients (0.7%) underwent secondary patella resurfacing, and one patient underwent arthroscopic arthrolysis after previous manipulation under anaesthetic (MUA). Three patients (1.0%) underwent MUA alone. Primary care consultation records, available for 206 patients, showed 16 patients (7.8%) contacted their general practitioner within two weeks postoperatively; two (1.0%) were referred to secondary care. Overall, 115/121 patients (95%) telephoned stated they would have day-case TKA again. Conclusion. Day-case TKA can be safely delivered in the NHS with no additional resources. We found low incidence of contact with primary and secondary care in the postoperative period, and high patient satisfaction. Cite this article: Bone Jt Open 2023;4(8):621–627

Aims. The aim of this study was to examine whether tourniquet use can improve perioperative blood loss, early function recovery, and pain after primary total knee arthroplasty (TKA) in the setting of multiple-dose intravenous tranexamic acid. Methods. This was a prospective, randomized clinical trial including 180 patients undergoing TKA with multiple doses of intravenous tranexamic acid. One group was treated with a tourniquet during the entire procedure, the second group received a tourniquet during cementing, and the third group did not receive a tourniquet. All patients received the same protocol of intravenous tranexamic acid (20 mg/kg) before skin incision, and three and six hours later (10 mg/kg). The primary outcome measure was perioperative blood loss. Secondary outcome measures were creatine kinase (CK), CRP, interleukin-6 (IL-6), visual analogue scale (VAS) pain score, limb swelling ratio, quadriceps strength, straight leg raising, range of motion (ROM), American Knee Society Score (KSS), and adverse events. Results. The mean total blood loss was lowest in the no-tourniquet group at 867.32 ml (SD 201.11), increased in the limited-tourniquet group at 1024.35 ml (SD 176.35), and was highest in the tourniquet group at 1,213.00 ml (SD 211.48). The hidden blood loss was lowest in the no-tourniquet group (both p < 0.001). There was less mean intraoperative blood loss in the tourniquet group (77.48 ml (SD 24.82)) than in the limited-tourniquet group (137.04 ml (SD 26.96)) and the no-tourniquet group (212.99 ml (SD 56.35); both p < 0.001). Patients in the tourniquet group showed significantly higher levels of muscle damage and inflammation biomarkers such as CK, CRP, and IL-6 than the other two groups (p < 0.05). Outcomes for VAS pain scores, limb swelling ratio, quadriceps strength, straight leg raising, ROM, and KSS were significantly better in the no-tourniquet group at three weeks postoperatively (p < 0.05), but there were no significant differences at three months. No significant differences were observed among the three groups with respect to transfusion rate, thrombotic events, or the length of hospital stay. Conclusion. Patients who underwent TKA with multiple doses of intravenous tranexamic acid but without a tourniquet presented lower total blood loss and hidden blood loss, and they showed less postoperative inflammation reaction, less muscle damage, lower VAS pain score, and better early knee function. Our results argue for not using a tourniquet during TKA. Cite this article: Bone Joint Res 2020;9(6):322–332

Aims. Osteofibrous dysplasia (OFD) is a rare benign lesion predominantly affecting the tibia in children. Its potential link to adamantinoma has influenced management. This international case series reviews the presentation of OFD and management approaches to improve our understanding of OFD. Methods. A retrospective review at three paediatric tertiary centres identified 101 cases of tibial OFD in 99 patients. The clinical records, radiological images, and histology were analyzed. Results. Mean age at presentation was 13.5 years (SD 12.4), and mean follow-up was 5.65 years (SD 5.51). At latest review, 62 lesions (61.4%) were in skeletally mature patients. The most common site of the tibial lesion was the anterior (76 lesions, 75.2%) cortex (63 lesions, 62.4%) of the middle third (52 lesions, 51.5%). Pain, swelling, and fracture were common presentations. Overall, 41 lesions (40.6%) presented with radiological deformity (> 10°): apex anterior in 97.6%. A total of 41 lesions (40.6%) were treated conservatively. Anterior bowing < 10° at presentation was found to be related to successful conservative management of OFD (p = 0.013, multivariable logistic regression). Intralesional excision was performed in 43 lesions (42.6%) and a wide excision of the lesion in 19 (18.8%). A high complication rate and surgical burden was found in those that underwent a wide excision regardless of technique employed. There was progression/recurrence in nine lesions (8.9%) but statistical analysis found no predictive factors. No OFD lesion transformed to adamantinoma. Conclusion. This study confirms OFD to be a benign bone condition with low rates of local progression and without malignant transformation. It is important to distinguish OFD from adamantinoma by a histological diagnosis. Focus should be on angular deformity, monitored with full-length tibial radiographs. Surgery is indicated in symptomatic patients and predicted by the severity of the initial angular deformity. Surgery should focus more on the deformity rather than the lesion. Cite this article: Bone Joint J 2022;104-B(2):302–308

Introduction and Objective. Guided Bone Regeneration (GBR) uses biodegradable collagen membranes of animal origin tissues (dermis and pericardium). Their barrier effect prevents soft tissues to interfere with the regeneration of alveolar bone. However, their xenogeneic origin involves heavy chemical treatments which impact their bioactivity. Wharton's Jelly (WJ) from the umbilical cord is a recoverable surgery waste. WJ is mostly made from collagen fibers, proteoglycans, hyaluronic acid, and growth factors. WJ with immunologically privileged status and bioactive properties lends credence to its use as an allograft. Nevertheless, low mechanical properties limit its use in bone regenerative strategies. Herein, our objective is to develop a crosslinked WJ-based membrane to improve its strength and thus its potential use as a GBR membrane. Materials and Methods. The umbilical cords are collected after delivery and then stored at −20°C until use. The WJ membranes (1 × 5 × 12 mm) were obtained after the removal of blood vessels and amniotic tissue, washed, lyophilized, and stored at −20°C. WJ membranes were incubated in genipin solutions in decreasing concentrations (0.3 g / 100 mL − 0.03 g / 100 mL) for 24 hours at 37°C. The crosslinking degree was estimated by ninhydrin and confirmed by FTIR (Fourier-transform infrared spectroscopy) assays. The swelling rate was obtained after the rehydration of dry crosslinked WJ-membrane for 10 min in D-PBS. The mechanical properties were assessed in hydrated conditions on a tensile bench. The resistance to the degradation was evaluated by collagenase digestion (1 mg/mL for 60 hours) assay. The cytotoxicity of crosslinked WJ-membrane was evaluated in accordance with the standard ISO.10993-5 (i.e. Mitochondrial activity and Lactate Dehydrogenase release) against Mesenchymal Stem Cells (MSCs). Finally, the MSCs colonization and proliferation were followed after 21 days of culture on crosslinked WJ-membranes. Results. The increase of crosslinking rates from 30% to 90% of the WJ membrane was demonstrated by the ninhydrin assay. FTIR analysis showed a prominent peak at 1732 cm. -1. , confirming the incorporation of genipin in the WJ. The swelling rate of crosslinked WJ-membrane decreased with an increase of the crosslinking rate. An increase in elastic modulus and an increase in the resistance to the collagenase degradation were observed along with an increase in the crosslinking degree. Cytotoxicity investigations did not elicit a harmful effect of the genipin, however, a poor MSCs adhesion on the crosslinked membrane was observed. Conclusions. Our results show that a membrane can be developed from Wharton's jelly. The mechanical and degradation properties can be improved by crosslinking with genipin without inducing any cytotoxicity effect. However, the percentage of crosslinking has an influence on the adhesion of the cells to the membranes. The crosslinked WJ-membrane bioactivity and the osteo-regenerative potential in vitro/in vivo will be evaluate

Ankle fractures are among the most common types of fractures. If surgery is not performed within 12 to 24 hours, ankle swelling is likely to develop and delay the operative fixation. This leads to patients staying longer in the ward waiting and increased hospital occupancy. This prolonged stay has significant financial implication as well as it is frustrating for both patients and health care professionals. The aim was to formulate a pathway for the ankle fracture patients coming to the emergency department, outpatients and planned for operative intervention. To identify whether pre-operative hospital admissions of stable ankle fracture patients are reduced with the implementation of the pathway. We formulated an ankle fracture fixation pathway, which was approved for use in December 2020. A retrospective analysis of 6 months hospital admissions of ankle fracture patients in the period between January to June 2020. The duration from admission to the actual surgery was collected to review if some admissions could have been avoided and patients brought directly on the surgery day. A total of 23 patients were included. Mean age was 60.5 years and SD was 17years. 94% of patients were females. 10 patients were appropriately discharged.7 Patients were appropriately admitted. 6 Patients were unnecessarily admitted. These 6 patients were admitted on presentation to ED. Retrospective analysis of this audit showed that this cohort of patients met the safe discharge criteria and could have been discharged. Duration of unnecessary stay ranged from 1 to 11 days (21 days in total). Total saving could have been £6300. Standards were met in 74% of cases. Preoperative hospital admission could be reduced with the proposed pathway. It is a valuable tool to be used and should be implemented to reduce unnecessary hospital admissions

Regulation of articular cartilage homeostasis is a complex process in which biologic and mechanical factors are involved. Hyperactivation of Wnt signaling, associated with osteoarthritis (OA), could jeopardize the protective anabolic effect of physiological loading. Here, we investigated the role of excessive Wnt signalling in cartilage molecular responses to loading. Human cartilage explants were harvested from hips of donors without OA. The Wnt agonist CHIR99021 was used to activate Wnt signalling 24 hours before cartilage explants were subjected to a loading protocol consisting of 2 cycles of 1 hour of 10% compression at 1 Hz, followed by 1-hour free swelling. Mechano-responsiveness was evaluated using the expression of type II collagen, aggrecan and MMP-13. Expression of known target genes TCF-1 and c-JUN was evaluated as positive control for Wnt and mechanical stimulation, respectively. In the absence of loading, CHIR99021 decreased the expression of the cartilage anabolic genes type II collagen and aggrecan, and increased the levels of MMP-13, corroborating that Wnt hyperactivation disrupts cartilage homeostasis. In the absence of Wnt hyperactivation, the applied loading protocol, representative for a physiologic stimulation by mechanical loading, led to an increase in type II collagen and aggrecan levels. However, when cartilage explants were subjected to mechanical stimulation in the presence of CHIR99021, the expression of cartilage anabolic genes was decreased, indicating changes to the cells’ mechano-responsiveness. Interestingly, mechanical stimulation was able to reduce the expression levels of MMP-13 compared to the condition of CHIR stimulation without loading. Hyperactivation of Wnt signaling switches the anabolic effect of physiologic compressive loading towards a potential catabolic effect and could contribute to the development and progression of OA

Biofabrication is a popular technique to produce personalized constructs for tissue engineering. In this study we combined laponite (Lap), gellan gum (GG) with platelet-rich plasma (PRP) aiming to enhance the endothelial regeneration through the synergistic effects of their individual properties. Laponite has the ability to form porous three-dimensional networks mimicking the extracellular matrix structure, and PRP delivery of growth factors stimulates the endothelial cell proliferation and migration, offering a composite bioink for cell growth and support. The sustained release of these growth factors from the GG-laponite-PRP composite material over time provides a continuous source of stimulation for the cells, leading to more effective tissue engineering strategies for endothelial tissue regeneration. Four blend compositions comprising 1% w/v GG and 0.5 or 1% w/v Lap and 25% v/v PRP were combined with Wharton jelly mesenchymal stem cells (WJ-MSCs) and bioprinted into vessel-like structures with an inner diameter of 3 mm and a wall thickness of 1 mm. Stress/strain analysis revealed the elastomeric properties of the hydrogels with Young modulus values of 10 MPa. Increasing the Lap concentration led to a non-significant decrease of swelling ratio from 93 to 91%. Live/dead assay revealed cell viability of at least 76%, with the 0.5%Lap-GG viability exceeding 99% on day 21. Gradual increase of glycosaminoglycans accumulation and collagen production indicate promotion of ECM formation. The expression and membranous localization of PECAM-1 from day 7 and the granular intracellular localization of vWF after 2 weeks demonstrate in vitro endothelial functionality. In vivo subcutaneous implantation indicated the absence of any adverse immunological reactions. The results reveal the expression of both vWF and PECAM-1 by WJ-MSCs entrapped in all four construct compositions with significantly higher expression of vWF in the presence of PRP

Tendoscopy in the treatment of peroneal tendon disorders is becoming an increasingly safe, reliable, and reproducible technique. Peroneal tendoscopy can be used as both an isolated procedure and as an adjacent procedure with other surgical techniques. The aim of our study was to review all peroneal tendoscopy that was undertaken at the AOC, by the senior authors (IGW, SH), and to determine the safety and efficacy of this surgical technique. Methods. From 2000 to 2017 a manual and electronic database search was undertaken of all procedures by the senior authors. Peroneal tendoscopy cases were identified and then prospectively analysed. Results. 51 patients (23 male, 28 female) were identified from 2004–2017 using a manual and electronic database search. The mean age at time of surgery was 41.5 years (range 16–83) with a mean follow-up time post operatively of 11.8 months (range 9–64 months). The main indications for surgery were lateral and/or postero-lateral ankle pain and lateral ankle swelling. The majority of cases showed unstable peroneal tendon tears that were debrided safely using tendoscopy. Of the 51 patients, 23 required an adjacent foot and ankle operation at the same time, 5 open and 17 arthroscopic (12 ankle, 5 subtalar). Open procedures included 2 first ray osteotomies, 2 open debridements of accessory tissue, one PL to PB transfer. One patient also had an endoscopic FHL transfer. Complication rates to date have been low: 2 superficial wound infections (4%) and one repeat tendoscopy for ongoing pain. A small proportion of patients with ongoing pain were treated with USS guided steroid injections with good results. Conclusion. Our series of peroneal tendoscopy has a low complication rate with high patient satisfaction at discharge. Results of tendoscopic treatment are similar to open techniques, however its advantages make tendoscopic procedures an excellent method to treat peroneal tendon disorders

This study investigates the relationships between Intervertebral Disc (IVD) morphology and biomechanics using patient-specific (PS) finite element (FE) models and poromechanical simulations. 169 3D lumbar IVD shapes from the European project MySpine (FP7-269909), spanning healthy to Pfirrmann grade 4 degeneration, were obtained from MRIs. A Bayesian Coherent Point Drift algorithm aligned meshes to a previously validated structural FE mesh of the IVD. After mesh quality analyses and Hausdorff distance measurements, mechanical simulations were performed: 8 and 16 hours of sleep and daytime, respectively, applying 0.11 and 0.54 MPa of pressure on the upper cartilage endplate (CEP). Simulation results were extracted from the anterior (ATZ) and posterior regions (PTZ) and the center of the nucleus pulposus (CNP). Data mining was performed using Linear Regression, Support Vector Machine, and eXtreme Gradient Boosting techniques. Mechanical variables of interest in DD, such as pore fluid velocity (FLVEL), water content, and swelling pressure, were examined. The morphological variables of the simulated discs were used as input features. Local morphological variables significantly impacted the local mechanical response. The local disc heights, respectively in the mid (mh), anterior (ah), and posterior (ph) regions, were key factors in general. Additionally, fluid transport, reflected by FLVEL, was greatly influenced (r2 0.69) by the shape of the upper and lower cartilage endplates (CEPs). This study suggests that disc morphology affects Mechanical variables of interest in DD. Attention should be paid to the antero-posterior distribution and local effects of disc heights. Surprisingly, the CEP morphology remotely affected the fluid transport in NP volumes around mid-height, and mechanobiological implications shall be explored. In conclusion, patient-specific IVD modeling has strong potential to unravel important correlations between IVD phenotypes and local tissue regulation. Acknowledgments: European Commission: Disc4All-MSCA-2020-ITN-ETN GA: 955735; O-Health-ERC-CoG-2021-101044828

Bone is a dynamic tissue that undergoes continuous mechanical forces. Mechanical stimuli applied on scaffolds resembling a part of the human bone tissue affects the osteogenesis [1]. Poly(3,4-ethylenedioxythiophene) (PEDOT) is a piezoelectric material that responds to mechanical stimulation producing an electrical signal, which in turn promotes the osteogenic differentiation of bone-forming cells by opening voltage-gated calcium channels [2]. In this study we examined the biological behavior of pre-osteoblastic cells seeded onto lyophilized piezoelectric PEDOT-containing scaffolds applying uniaxial compression. Two different concentrations of PEDOT (0.10 and 0.15% w/v) were combined with a 5% w/v poly(vinyl alcohol) (PVA) and 5% w/v gelatin, casted into wells, freeze dried and crosslinked with 2% v/v (3-glycidyloxypropyl)trimethoxysilane and 0.025% w/v glutaraldehyde. The scaffolds were physicochemically characterized by FTIR, measurement of the elastic modulus, swelling ratio and degradation rate. The cell-loaded scaffolds were subjected to uniaxial compression with a frequency of 1 Hz and a strain of 10% for 1 h every second day for 21 days. The loading parameters were selected to resemble the in vivo loading situation [3]. Cell viability and morphology on the PEDOT/PVA/gelatin scaffolds was determined. The alkaline phosphatase (ALP) activity, the collagen and calcium production were determined. The elastic modulus of PEDOT/PVA/gelatin scaffolds ranged between 1 and 5 MPa. The degradation rate indicates a mass loss of 15% after 21 days. The cell viability assessment displays excellent biocompatibility, while SEM images display well-spread cells. The ALP activity at days 3, 7 and 18 as well as the calcium production are higher in the dynamic culture compared to the static one. Moreover, energy dispersive spectroscopy analysis revealed the presence of calcium phosphate in the extracellular matrix after 14 days. The results demonstrate that PEDOT/PVA/gelatin scaffolds promote the adhesion, proliferation, and osteogenic differentiation of pre-osteoblastic cells under mechanical stimulation, thus favoring bone regeneration

Aims. The STRYDE nail is an evolution of the PRECICE Intramedullary Limb Lengthening System, with unique features regarding its composition. It is designed for load bearing throughout treatment in order to improve patient experience and outcomes and allow for simultaneous bilateral lower limb lengthening. The literature published to date is limited regarding outcomes and potential problems. We report on our early experience and raise awareness for the potential of adverse effects from this device. Methods. This is a retrospective review of prospective data collected on all patients treated in our institution using this implant. We report the demographics, nail accuracy, reliability, consolidation index, and cases where concerning clinical and radiological findings were encountered. There were 14 STRYDE nails implanted in nine patients (three male and six female) between June 2019 and September 2020. Mean age at surgery was 33 years (14 to 65). Five patients underwent bilateral lengthening (two femoral and three tibial) and four patients unilateral femoral lengthening for multiple aetiologies. Results. At the time of reporting, eight patients (13 implants) had completed lengthening. Osteolysis and periosteal reaction at the junction of the telescopic nail was evident in nine implants. Five patients experienced localized pain and swelling. Macroscopic appearances following retrieval were consistent with corrosion at the telescopic junction. Tissue histology was consistent with effects of focal metallic wear debris. Conclusion. From our early experience with this implant we have found the process of lengthening to be accurate and reliable with good regenerate formation and consolidation. Proposed advantages of early load bearing and the ability for bilateral lengthening are promising. We have, however, encountered concerning clinical and radiological findings in several patients. We have elected to discontinue its use to allow further investigation into the retrieved implants and patient outcomes from users internationally. Cite this article: Bone Joint J 2021;103-B(6):1168–1172

Tissue engineering and regenerative medicine (TERM) hold the promise to provide therapies for injured tendons despite the challenging cues of tendon niche and the lack of specific factors to guide regeneration. The emerging potential of magnetic responsiveness and magnetic nanoparticles (MNPs) functionalities offers new perspectives to tackle TERM challenges. Moreover, pulsed electromagnetic field (PEMF) is FDA approved for orthopaedics with potential to control inflammation upon injury. We previously demonstrated that magnetic cell-sheets assisted by PEMF trigger the inflammation resolution by modulating cytokine-enriched environments [1]. To further understand the potential of magnetically assisted living patches, we have recently conducted in vivo studies using a rat patellar defect model. After labeling of human adipose stem cells with iron oxide MNPs for 16h, magCSs were cultured up to 3 days in α-MEM medium under non-magnetic or PEMF conditions. MagCSs were evaluated by immunocytochemistry, and real time RT-PCR for tendon markers. Cell metabolic activity was also assessed by MTS and ECM proteins quantified by Sirius Red/Fast Green. The MagCSs effect in ameliorating healing was assessed after implantation in window defects created in the patellar tendon of rats. PEMF was externally applied (3mT, 70Hz) 3d/week for 1h (magnetotherapy). After 4 and 8w, tendons were histologically characterized for immune-detection of tendon and inflammatory markers, and for Perls van Gieson and HE stains. Blood and detoxification organs were screened for inflammatory mediators and biodistribution of MNPs, respectively. In vitro results suggest that PEMF stimulates cellular metabolic activity, influences protein synthesis and the deposition of collagen and non-collagenous proteins is significantly increased compared to non-magnetic conditions. No adverse reactions, as infection or swelling, were observed after surgery or during follow-up. After 8w, magCSs remained at the implantation site and no MNPs were detected on detoxification organs. Plasma levels of IL1α, β, IL6 and TNFα assessed by multiplex assay were below detectable values (<12.5pg/ml). Thus, the combination of cell sheets and magnetic technologies hold promise for the development of living tendon substitutes. Acknowledgement to ERC-COG MagTendon772817, H2020 Achilles 810850, FCT - 2020.01157.CEECIND

Introduction. Aneurysmal bone cysts commonly found in lower limbs are locally aggressive masses that can lead to bony erosion, instability and fractures. This has major implications in the lower limbs especially in paediatric patients, with potential growth disturbance and deformity. In this case series we describe radical aneurysmal bone cyst resection and lower limb reconstruction using cable transport and syndesmosis preservation. Materials & Methods. Case 1 - A 12-year-old boy presented with a two-week history of atraumatic right ankle pain. An X-ray demonstrated a distal tibia metaphyseal cyst confirmed on biopsy as an aneurysmal bone cyst. The cyst expanded on interval X-rays from 5.5cm to 8.5cm in 9 weeks. A wide-margin en-bloc resection was performed leaving a 13.8cm tibial defect. A cable transport hexapod frame and a proximal tibial osteotomy was performed, with syndesmosis screw fixation. The transport phase lasted 11 months. While in frame, the boy sustained a distal femur fracture from a fall. The femur and the docking site were plated at the same sitting and frame removed. At one-year post-frame removal he is pain-free, with full ankle dorsiflexion but plantarflexion limited to 25 degrees. He has begun graduated return to sport. Results. Case 2 - A 12-year-old girl was referred with a three-month history of lateral left ankle swelling. X-ray demonstrated an aneurysmal bone cyst in the distal fibula metaphysis. The cyst grew from 4.2 × 2.3cm to 5.2 × 3.32cm in 2 months. A distal fibula resection (6.2cm) with syndesmosis fixation and hexapod cable transport frame were undertaken. The frame was in situ for 13 weeks and during this time she required an additional osteotomy for premature consolidation and had one pin site infection. After 13 weeks a second syndesmosis screw was placed, frame removed, and a cast applied. 3 months later she had fibular plating, BMAC and autologous iliac crest bone graft for slow union. At 3 years post-operative she has no evidence of recurrence, is pain-free and has no functional limitation. Conclusions. We describe two cases of ankle syndesmosis preservation using cable transport for juxta-articular aneurysmal bone cysts. This allows wide resection to prevent recurrence while also preserving primary ankle stability and leg length in children. Both children had a minor complication, but both had an excellent final outcome. Cable bone transport and prophylactic syndesmosis stabilization allows treatment of challenging juxta-articular aneurysmal bone cysts about the ankle. These techniques are especially useful in large bone defects

Introduction. Chronic recurrent multifocal osteomyelitis (CRMO) is a rare condition characterised by bony pain and swelling which may be initially mistaken for bacterial osteomyelitis. The episodic course of the disease may confound the diagnosis and potentially be mistaken for a partial response to antimicrobial therapy. It is an orphan disease and consequently results in many unclear aspects of diagnosis, treatment and follow up for patients. The aim of this study is to evaluate a national tertiary centre's experience with the clinical condition and present one of the largest cohorts to date, emphasizing the vast array of clinical spectrum, course and response to treatment. Methods. We retrospectively evaluated all children identified with CRMO from the period 2000–2022 within Wales. Demographic data and clinical parameters were selectively identified through the utilisation of a national clinical platform (Welsh Clinical Portal). The diagnosis was based on clinical findings, radiological images, histopathological and microbiological studies. Results. A total of 21 patients were identified as suitable for inclusion. The mean age of diagnosis was 9.4 ±2 years. The age range of children being diagnosed was 6–14 years. Of the 21 patients, only 2 reported feeling unwell prior to their first presentation with generalized coryzal illness reported. The most common presenting site for CRMO was knee (33%) followed by back pain (28%). 19% of the included cases at initial presentation had localised warmth and had nocturnal pain. 4 of the patients went on to have dermatological conditions of which psoriasis was the most common (14%). Bilateral symptoms developed in 38% of the included patients. Biochemical investigations revealed only 19% of patients had a raised C-reactive protein level and erythrocyte sedimentation rate whilst 9/21 patients went on to have a bone biopsy to aid diagnosis. 100% of patients had MRI whilst whole body MRI was utilised in 8/21 patients. NSAID's were utilised for 81%, Pamidronate for 33% and methotrexate for 14%. Biologics were utilised for a further 24% of the total population in failed medical therapy. Surgical intervention was utilised for a single individual in this cohort of patients in the form of posterior spinal stabilisation. The most common referring speciality for these patients was Rheumatology (71%) followed by Orthopaedics (33%). Discussion. CRMO represents a challenging diagnosis to make with such varied clinical and biochemical presentations for this condition. The absence of diagnostic Radiological features on X-ray could argue over early MRI imaging. The utilisation of whole body-MRI can now identify multifocal disease burden which may facilitate a timely diagnosis and ensure that effective medical treatment is started promptly without delay. This study is the largest cohort of CRMO patients conducted in this country. Future work will serve to build upon a framework and national referral pathway so that these patients can be seen by the appropriate specialist in a timely manner

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

A significant portion of ankle arthroplasty and ankle arthrodesis procedures performed in British Columbia are funded by the public medical services plan (MSP). However, some patients are treated privately through self-pay or by the workers compensation board (WCB), with the latter two groups being more likely to receive treatment sooner. The potential effect of payer on patient-reported outcomes and reoperation rates has not been previously explored. A retrospective chart review was performed using data from the Canadian Orthopaedic Foot and Ankle Society Prospective Ankle Reconstruction Database. N=443 patients (393 MSP, 26 self-pay, 24 WCB), treated with total ankle replacement or ankle arthrodesis by three subspecialty-trained surgeons in Vancouver from 1999–2003, were analyzed. Outcomes were compared, by payer, preoperatively and at long-term follow-up (6.3 years, range 2–14 years). Function was assessed using the Ankle Osteoarthritis Scale (AOS) Total score (primary outcome) and the AOS Pain and Difficulty subscores. Expectation and satisfaction with symptoms was assessed using the Musculoskeletal Outcomes Data Evaluation and Management Scale, and physical and emotional quality of life was assessed using the Short Form-36 (SF-36) Health Survey in terms of the mental component summary (MCS) and physical component summary (PCS). Swelling and reoperation rates were also compared. AOS Total score was not significantly different between payers. WCB patients had significantly worse preoperative AOS Difficulty scores (73, 95%CI 65–80) compared to MSP (65, CI 63–67) and self-pay patients (56, CI 49–63)(p < 0 .008). Their SF-36 MCS scores were also significantly worse pre- and postoperatively (WCB: 43, CI 38–49, 45, CI 40–50, MSP: 51, CI 50–52, 51, CI 50–52, self-pay: 51, CI 46–56, 54, CI 49–58)(p < 0 .03). AOS Pain scores and SF-36 PCS scores were not different. Pre- and postoperatively, MSP patients reported more satisfaction with symptoms (1.31, CI 1.24–1.38, 3.21, CI 3.07–3.35), compared to WCB (1.13, CI 0.84–1.41, 2.83, CI 2.26–3.41) and self-pay patients (1.19, CI 0.91–1.47, 2.88, CI 2.33–3.44). Preoperatively, WCB patients had the lowest expectations (76, CI 69–84), the worst AOS Total (64, CI 57–71) and SF-36 scores (MCS 43, CI 38–49, PCS 28, CI, 25–32), and the most swelling (3.5, CI 3.1–4). Conversely, self-pay patients had the highest preoperative expectations (88, CI 81–95), the best AOS Total (53, CI 46–60) and SF-36 scores (MCS 51, CI 46–56, PCS: 34, CI 30–37) and the least swelling (3, CI 2.6–3.4). Postoperatively, WCB and self-pay patients had lower expectations met (35, CI 23–47 and 40, CI 28–51) and worse AOS Total scores (36, CI 27–45 and 35, 26–43), compared to MSP patients (Expectations: 29, CI 26–32, AOS Total: 31, CI 29–33). Reoperation rates were similar among groups. WCB patients had significantly more difficulty with symptoms prior to surgery and worse SF-36 MCS scores pre- and postoperatively. The preoperative expectations of WCB patients were lowest, while those of self-pay patients were highest. Both groups had lower expectations met postoperatively

Introduction. Closed suction intraarticular drain (CSD) use after total knee arthroplasty (TKA) has been studied with regards to wound healing and range of motion, however, no data exist on how CSD use impacts knee joint effusion and quadriceps strength. The primary purpose of this study was to determine whether CSD use influences recovery of quadriceps strength. Secondary outcomes examined effects of CSD on intraarticular effusion, lower limb swelling, knee range of motion (ROM), pain and wound healing complications. Methods. Twenty-nine patients undergoing same-day bilateral TKA were enrolled in a prospective, randomized blinded study. Subjects were randomized to receive a CSD on one lower extremity while the contralateral limb had the use of a subcutaneous drain (SCDRN) without the use of suction. Isometric quadriceps strength was collected as the primary outcome. Secondary outcomes consisted of quadriceps muscle activation, intraarticular effusion measured via ultrasound, lower extremity swelling measured with bioelectrical impendence, lower extremity girth, ROM, and pain. Outcomes were assessed preoperatively and postoperatively at day 2, 2 and 6 weeks and 3 months. Differences in limbs were determined using paired t-tests or Wilcoxon signed rank tests. Results. No significant differences were identified between limbs prior to surgery for the primary or secondary outcomes. No significant differences in quadriceps strength were seen between CSD and SCDRN limbs at postoperative day 2 (p = 0.09), two weeks (p=0.7), six weeks (p=0.3), or three months (p=0.5). Secondary outcomes, of quadriceps activation battery, intraarticular effusion, lower extremity swelling, ROM, and pain were not found to significantly differ at any time point following surgery. Conclusion. The use of CSD during TKA did not influence quadriceps strength, quadriceps activation, intraarticular effusion, bioelectrical measure of swelling, ROM, or pain. The results of this study have limited drain use by the authors in primary uncomplicated TKA

In total knee arthroplasty (TKA), both intravenous (IV) and/or intra-articular (IA) administration of tranexamic acid (TXA) were showed to reduce blood loss. Moreover, research suggesting TXA decreases postoperative knee swelling, but it is unknown whether this results in improved postoperative rehabilitation outcome. Thus, the aim of this study was to evaluate whether combined IV and IA administration of TXA would associate with improved early rehabilitation outcomes. In this institutional review board approved randomized controlled trial, 179 patients scheduled for unilateral TKA were randomized to one of three regimens: (1) IA administration of 1gm TXA at end of procedure only, (2) additional preoperative IV dose of 15 mg/kg 30min before tourniquet inflation, and (3) additional postoperative dose 4hrs after preoperative dose. Primary outcomes included knee range of motion, Knee Society Score (KSS) at 6-month postoperatively, haemoglobin drop at day-2 post-operatively, and transfusion rate. Secondary outcome was venous thromboembolism (VTE) complications. Baseline characteristics were comparable between the allocation groups. Patients in regimen (3) showed statistically significant better knee extension range (6.2°, 5.9°, 2.9°, p=0.01), and KSS (88.5, 89.9, 93.0, p=0.02) at 6-month postoperatively, and lesser drop in haemoglobin at day-2 post-operatively (2.72, 2.47, 1.75 g/dL, p=0) when compared with patients in other regimens. No patients required transfusion, or complicated by VTE. The combined administration of IA and IV TXA, including both preoperative and postoperative doses, associated with statistically significantly improved early rehabilitation outcomes. The improvement may be related to higher haemoglobin level and decreased knee swelling in patients having regimen (3). For any reader queries, please contact . cpk464@yahoo.com.hk

Aim. Extraspinal osteoarticular tuberculosis (TOA-ER) is a rare form of extra-pulmonary tuberculosis. It remains a topical problem not only in underdeveloped countries but also in developed countries due to cases of immune deficiency. Through a study of 40 cases, we specify the current diagnostic aspects of TOA-ER and detail their therapeutic and evolutionary modalities. Method. The mean age of our patients was 40 years with a clear predominance of females observed (SR = 0.66). 76.31% of the cases were from a rural setting. The impairment was single-focal in 72.5%. Associated tuberculosis location was found in 59% of cases. Pain and swelling were the main clinical symptoms. Signs of tuberculous impregnation were found in less than half of the cases. The IDR was positive in 67%. All patients underwent an appropriate radiological exploration consisting of a standard x-ray (30 cases), CT (21 cases) and MRI (23 cases). technetium-99m bone scintigraphy, performed in 15 cases, detected 5 infra-clinical osteoarticular locations. 77.5% of patients had formal pathological and / or bacteriological confirmation of the diagnosis. All patients had adequate anti-tuberculosis chemotherapy with a mean duration of 18 months. 67% of patients had a surgical debridement procedure. Results. After a mean follow-up of 5 years, the outcome was favourable in 75.2% of cases. A microbiological cure at the cost of serious functional sequelae was noted in 12.8% of cases. The outcome was unfavourable with relapse observed in 4.8% of cases and death in 7.2% of cases. Conclusions. Extraspinal osteoarticular tuberculosis is a fairly common condition in our country. Its insidious clinical course is the cause of diagnostic and therapeutic delay. Its treatment is mainly medical. The surgery keeps some indications. Good therapeutic adherence and early diagnosis are the best guarantees of good therapeutic results

Introduction and Objective. Total shoulder replacement is a common elective procedure offered to patients with end stage arthritis. While most patients experience significant pain relief and improved function within months of surgery, some remain unsatisfied because of residual pain or dissatisfaction with their functional status. Among these patients, when laboratory workup eliminates infection as a possibility, corticosteroid injection (CSI) into the joint space, or on the periprosthetic anatomic structures, is a common procedure used for symptom management. However, the efficacy and safety of this procedure has not been previously reported in shoulder literature. Materials and Methods. A retrospective chart review identified primary TSA patients who subsequently received a CSI into a replaced shoulder from 2011 – 2018 by multiple surgeons. Patients receiving an injection underwent clinical exam, laboratory analysis to rule out infection, and radiographic evaluation prior to CSI. Demographic variables were recorded, and a patient satisfaction survey assessed the efficacy of the injection. Results. Of the 43 responders, 48.8% remembered the injection. The average time from index arthroplasty to injection was median 16.8 months. Overall, 61.9% reported decreased pain, 28.6% reported increased motion, and 28.6% reported long term decreased swelling. Improvement lasted greater than one month for 42.9% of patients, and overall 52.4% reported improvement (slight to great) in the shoulder following CSI. No patient developed a periprosthetic joint infection (PJI) within 2 years of injection. Conclusions. This study suggests that certain patients following TSA may benefit from a CSI. However, this should only be performed once clinical, radiographic, and laboratory examination has ruled out conditions unlikely to improve long term from a CSI. Given these findings, further study in a large, prospective trial is warranted to fully evaluate the benefits of CSI following TSA

As the intervertebral disc is largely avascular, needle injection is the most practical method for delivery of therapeutic agents used in treatments for degenerative disc disease. Intradiscal pressure increases during injection, and insufficient recovery time prior to needle retraction may result in injectate leakage. In order to determine the maximum pressure and post-injection recovery time for a given injection volume and rate, an analytical model of intradiscal injection was developed and calibrated experimentally. A governing equation was derived defining intradiscal pressure as a function of effective permeability, initial elastic stiffness, nonlinear stiffness term, and injection rate. The equation was solved using a fourth order Runge-Kutta routine with a 0.05s time step and a ramp-dwell injection. The model was calibrated by performing controlled intradiscal injections on five bovine caudal intervertebral discs. Three had adjacent vertebrae intact, while two were separated from vertebrae and constrained between porous stainless steel platens. A syringe driven by a linear actuator was used to inject phosphate buffered saline through a 21g hypodermic needle inserted radially into the disc to a depth of one half of the disc diameter. Injection was performed at a rate of 75μL/s to a volume of 250μL followed by a 240s dwell. Fluid pressure was recorded during both the injection phase and subsequent recovery phase. For each experimental pressure vs time trace, model parameters were varied in order to obtain an optimal fit. The model was run with the average parameter values across a grid of possible injection protocols, with injection volume ranging from 30 to 300μL and injection time ranging from 0.1 to 5s. For each case, peak pressure and time required to reach a 1kPa threshold were recorded. Experimentally measured peak pressure ranged from 68 to 88kPa. Pressure at the end of the 240s dwell ranged from 49 to 69kPa. There was no apparent difference between discs with and without endplates. Leakage of fluid following needle retraction was observed in all specimens. Experimental data were well fit by the analytical model, which predicted higher peak pressure and longer recovery time with increasing volume, from approximately 1500s at 30μL to nearly 3000s at 300μL. The model was nearly insensitive to injection rate. The experimental data confirm pressurization of the disc during injection and injectate leakage resulting from insufficient recovery time. The model predicts that the time required to recover to below threshold leakage pressure is impractically long for both laboratory and clinical injection protocols. Similar behavior with and without endplates confirms that fluid flow is limited by permeability of the tissue itself, not the boundary conditions. Slow recovery is likely attributable to the fact that peak injection pressures were lower than the hydraulic swelling pressure of the nucleus pulposus, which has been reported to be approximately 140kPa. Due to the high swelling pressure of the nucleus pulposus, it is unlikely that intradiscal injection procedures can be performed without substantial injectate leakage following needle retraction

Introduction and Objective. Lower limb fractures are amongst the most common surgically managed orthopaedic injuries, with open reduction and internal fixation (ORIF) as the conventional method of treatment of the fibula. In recent years, dedicated intramedullary implants have emerged for fibula fixation in tandem with the move towards minimally invasive surgery in high-risk patients. This is the largest multicentre review to date with the aim of establishing the clinical outcomes following intramedullary nail (IMN) fixation of the fibula and to identify the absolute indication for fibula IMN fixation. Materials and Methods. A retrospective study of adult patients in all UK hospitals, who underwent fibula nail fixation between 01/01/2018 and 31/10/2020 was performed. Primary outcome measures included time to union, infection rate, other post-operative complications associated with the fixation and length of hospital stay. The secondary outcome measure was to identify the indication for fibula nailing. Data tabulation was performed using Microsoft Excel and analysis was performed using SPSS Version 23 (SPSS Statistics). Results. 2 Major Trauma Centres (MTCs) and 9 Trauma Units (TUs) were eligible for inclusion. 102 patients were included and 91% were classified as ankle fractures of 68% (n=69) were Weber B, 24% (n=24) Weber C and 8% (n=9) were either distal tibial fractures with an associated fibula fracture or pilon fractures. The mean age was 64 years of which 45 were male patients and 57 were female. The average BMI was 30.03kg/m. 2. and 44% of patients were ASA 3. 74% of patients had poor pre-op skin condition including swelling and open wounds. The calculated infection rate for fibula nail was 4.9% and metal-work complication rate was 4.9%. The average time to union was 13 weeks and length of inpatient stay was 15 days (SD +/− 12 days). Conclusions. MEFNO has demonstrated that fibula nail is an ideal implant in patients who have a physiologically higher risk of surgery, poor skin condition and a complex fracture pattern. The time to union, complication and infection risks are lower than that reported in literature for ankle ORIFs

Introduction and Objective. Nonunion is incomplete healing of fracture and fracture that lacks potential to heal without further intervention. Nonunion commonly presents with persistent pain, swelling, or instability. Those symptoms affect patient quality of life. It is known that using low intensity pulsed ultrasound (LIPUS) for fresh fractures promotes healing. However, effectiveness of LIPUS for nonunion is still controversial. If LIPUS is prove to be effective for healing nonunion, it can potentially provide an alternative to surgery. In addition, we can reduce costs by treating nonunion with LIPUS than performing revision surgery. Materials and Methods. The two authors carried out a systematic search of PubMed, Ovid MEDLINE, and the Cochrane Library. Meta-analysis of healing rate in nonunion and delayed union patients who underwent LIPUS was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) instruction method using a random effects model. Results. The initial search identified 652 articles. Of these, 541 were excluded on the basis of the title because they were either a review paper or covered an unrelated topic. The abstracts of the remaining 111 articles were examined further. That review resulted in a sample of 12 articles. We performed a meta-analysis with a random effects model using Open Meta Analyst software. The result of pooled effect size of healing rate was 73.4% (95%CI: 65.3–81.6%). Due to the fact that nonunion lacks potential to heal without further intervention, we suggest that the therapeutic effect of 73.4% from LIPUS is sufficiently effective. As far as we know, there are no trials comparing the therapeutic effectiveness of surgery and LIPUS, so it cannot be said which is more advantageous. However, the healing rate of revision surgery was reported between 68–96%; therefore, our result is within that range. Thus, if surgery is difficult due to complications, we can recommend LIPUS. Conclusions. Meta-analysis of healing rate of nonunion treated by low-intensity pulsed ultrasound is 73.4%, which suggests sufficient therapeutic effectiveness. Furthermore, we can say that LIPUS may provide an alternative treatment for nonunion patients who cannot tolerate revision surgery due to complications

Introduction. Articular cartilage injuries have a limited potential to heal and, over time, may lead to osteoarthritis, an inflammatory and degenerative joint disease associated with activity-related pain, swelling, and impaired mobility. Regeneration and restoration of the joint tissue functionality remain unmet challenges. Stem cell-based tissue engineering is a promising paradigm to treat cartilage degeneration. In this context, hydrogels have emerged as promising biomaterials, due to their biocompatibility, ability to mimic the tissue extracellular matrix and excellent permeability. Different stimulation strategies have been investigated to guarantee proper conditions for mesenchymal stem cell differentiation into chondrocytes, including growth factors, cell-cell interactions, and biomaterials. An interesting tool to facilitate chondrogenesis is external ultrasound stimulation. In particular, low-intensity pulsed ultrasound (LIPUS) has been demonstrated to have a role in regulating the differentiation of adipose mesenchymal stromal cells (ASCs). However, chondrogenic differentiation of ASCs has been never associated to a precisely measured ultrasound dose. In this study, we aimed to investigate whether dose-controlled LIPUS is able to influence chondrogenic differentiation of ASCs embedded in a 3D hydrogel. Materials and Methods. Human adipose mesenchymal stromal cells at 2∗10. 6. cells/mL were embedded in a hydrogel ratio 1:2 (VitroGel RGD®) and exposed to LIPUS stimulation (frequency: 1 MHz, intensity: 250 mW/cm. 2. , duty cycle: 20%, pulse repetition frequency: 1 kHz, stimulation time: 5 min) in order to assess its influence on cell differentiation. Hydrogel-loaded ASCs were cultured and differentiated for 2, 7, 10 and 28 days. At each time point cell viability (Live&Dead), metabolic activity (Alamar Blue), cytotoxicity (LDH), gene expression (COL2, aggrecan, SOX9, and COL1), histology and immunohistochemistry (COL2, aggrecan, SOX9, and COL1) were evaluated respect to a non-stimulated control. Results. Histological analysis evidenced a uniform distribution of ASCs both at the periphery and at the center of the hydrogel. Live & Dead test evidenced that the encapsulated ASCs were viable, with no signs of cytotoxicity. We found that LIPUS induced chondrogenesis of ASCs embedded in the hydrogel, as demonstrated by increased expression of COL2, aggrecan and SOX9 genes and proteins, and decreased expression of COL1 respect to the non-stimulated control. Conclusions. These results suggest that the LIPUS treatment could be a valuable tool in cartilage tissue engineering, to push the differentiation of ASCs encapsulated in a 3D hydrogel

Introduction and Objective. Low back pain (LBP) is a major cause of long-term disability in adults worldwide and it is frequently attributed to intervertebral disc (IVD) degeneration. So far, no consensus has been reached regarding appropriate treatment and LBP management outcomes remain disappointing. Spine unloading or traction protocols are common non-surgical approaches to treat LBP. These treatments are widely used and result in pain relief, decreased disability or reduced need for surgery. However, the underlying mechanisms -namely, the IVD unloading mechanobiology- have not yet been studied. The aim of this first study was to assess the feasibility of IVD unloading in a large animal organ culture set-up and evaluate its impact on mechanobiology. Materials and Methods. Bovine tail discs (diameter 16.1 mm ± 1.2 mm), including the endplates, were isolated and prepared for culture. Beside the day0 sample that was processed directly, three other discs were cultured for 3 days and processed on day4. One disc was loaded in the bioreactor according to a previously established physiological (compressive) loading protocol (2h/day, 0.2Hz). The two other discs were embedded in biocompatible resin, leaving the cartilage endplate free to permit nutrient diffusion, and fitted in the traction holder; one of these discs was kept in free swelling conditions, whereas the second was submitted to cyclic traction loading (2h/day, 0.2Hz) corresponding to 30% of the animal body weight corrected for organ culture. Results. The cell viability assessed on lactate dehydrogenase and ethidium homodimer stained histological slides was not different between the three cultured discs. This means that the disc viability was not affected neither by the embedding, nor by the traction itself. Compared to the physiologically loaded disc, the gene expression of COL1, COL2 and ACAN was higher in the nucleus pulposus and inner annulus fibrosus of the traction treated disc. In the outer annulus fibrosus of this disc TAGLN and MKX were higher expressed upon traction than in the physiologically loaded disc. Conclusions. Based on these preliminary data, we can conclude that large animal organ culture allows effective unloading of the disc, while preserving cell viability and modulating cellular gene expression responses. This sets the ground for future experiments and opens the door to an evidence-based improvement of clinical spine traction protocols and LBP management overall

Total knee arthroplasty (TKA) is becoming more prevalent as the average age of the general population increases and is generally considered to be a very effective and successful surgery. However, functional recovery post-surgery can often be less than optimal. Neuromuscular electrical stimulation (NMES) is a beneficial therapy proven to improve haemodynamics and muscle strength and may be of great benefit in improving functional recovery in the acute phase post-TKA. The objective of the study was to assess functional recovery in the period immediately following TKA and hospital discharge in response to a home-based NMES programme. Twenty-six TKA patients were randomized into a NMES stimulation or placebo-controlled group. All participants were given a research muscle stimulator to use at home post-discharge for 90 minutes per day over a period of 5 weeks. In the stimulation group, application of stimulation resulted in an electrically activated contraction of the soleus muscle. Patients in the placebo-controlled group received sensory stimulation only. Outcome measures were physical activity levels, joint range of motion and lower limb swelling, which were measured pre-surgery and on a weekly basis post-discharge up until the sixth post-surgical week. 90 minutes per day NMES stimulation significantly increased the Activity Time (P = 0.029 week 1 post-discharge) and the number of Stepping Bouts (P < 0.05 weeks 1 to 4 post-discharge) in the early post-discharge phase. While there was a trend towards a greater knee flexion with use of NMES, this did not reach statistical significance (P = 0.722). No effect of NMES was observed on swelling (P > 0.05 for all measures). Compliance to the NMES therapy was measured by an on-board SIM card in the NMES device, with a 95% and 94% time compliance rate for the stimulation and placebo-controlled groups respectively. The results of this study suggest that NMES may be very useful in improving functional recovery through increasing physical activity levels in the early post-TKA discharge phase. The results of this study warrant further investigation into the use of an optimized NMES protocol whereby improvements in knee range of motion and swelling may also be observed

Introduction and Objective. Septic arthritis is an acute infective presentation of the joint calling for urgent intervention, thus making the differential diagnosis process difficult. An increase in temperature in the area containing the suspected septic arthritis is one of the clinically important findings. In this study, it was aimed to investigate whether or not the temperature changes obtained through thermal camera can be used as a new additional diagnostic tool in the differential diagnosis of septic arthritis. Materials and Methods. The study was approved by the local ethics committee as a prospective cohort. A total of 49 patients, 15 septic and 34 non-septic ones, both male and female ones from all ages admitted to the emergency room or evaluated with the consultation of another clinics who were also present with a pre-diagnosis of arthritis (septic or non-septic) in the knee (with complaints of redness, swelling, pain, effusion, increased temperature, edema, and inability to walk) were included in the study. The patients with non-joint inflammatory problems and a history of surgery in the same joint were excluded from the study. The temperature increase in the joint area with suspected septic arthritis was observed, and the difference in temperature changes of this suspicious area with the joint area of the contralateral extremity was compared after which the diagnosis of septic arthritis was confirmed by taking culture with routine intra-articular fluid aspiration, which is the gold standard for definitive diagnosis. Results. The mean age of the patients was 39.89 ± 27.65°C. A significant difference was found between the group with and without septit arthritis in terms of ASO, sedimentation, and leukocyte increase in the analysis of joint fluid (p <0.05). When the thermal measurements were compared, the mean temperature was 37.93°C in the septic group, while it was 36.79°C in the non-septic group, which showed a significant difference (p <0.000∗). The mean temperature difference in both joints was 3.40°C in the septic group, while 0.94°C in the non-septic group (p <0.000∗). While the mean temperature was 37.10°C in the group with septit arthritis, it was measured to be 35.89 °C in the group without (p <0.020). A very strong positive correlation was found between the difference between the mean temperatures of both groups and the values of the hottest and coldest temperature points (r = 0.960, r = 0.902). Conclusions. In the diagnosis of septic arthritis, a thermal imager can be used as a non-invasive diagnostic tool. With the help of this device, a quantitative value, in addition to palpation, can be given to the local temperature increase in the joint, which is an important finding in the clinic of septic arthritis. In future studies, specially designed thermal devices developed with special software for septic arthritis can be developed

Introduction. Critical limb ischemia (CLI) is the reduced blood flow in the arteries of the lower extremities. It is a serious form of peripheral arterial disease, or PAD. If left untreated the complications of CLI will result in amputation of affected limb. The treatment experience of diabetic foot with transverse tibial transport was carried out by Ilizarov technique. Madura foot ulcer is not a common condition. It disturbs the daily activities of the patient. Pain swelling with multiple nodules with discharging sinus with discoloration(blackening) of the affected area is the main problem. Materials and Methods. We treated total case: 36 from Jan. 2003 – Jan. 2020 (17yrs.). Among these-. TAO- 20. Limb Ishchemia- 5. Diabetic Foot- 9. Mycetoma pedis- 2. Infected sole and dorsum of the foot- 5. Results. Transverse corticotomy and wire technique followed by distraction increases blood circulation of the lower limbs, relieving the pain. The cases reported here were posted for amputation by the vascular surgeons, who did not have any other option for treatment. Hence we, re-affirm that Academician Prof. Ilizarov's method of treatment does help some patients suffering from these diseases. Conclusions. By Ilizarov compression distraction device for TAO, modura foot ulcer, diabetic foot ulcer, mycetoma pedis ulcer, infected sole and dorsum of the foot ulcer were treated by introducing K/wires through the bones with proper vertical corticotomy. Application of this noble device will bring angeogenesis within the reach of all deserving patients

The aim of this retrospective multicentre study was to report the continued occurrence of compartment syndrome secondary to paediatric supracondylar humeral fractures in the period 1995 to 2005. The inclusion criteria were children with a closed, low-energy supracondylar fracture with no associated fractures or vascular compromise, who subsequently developed compartment syndrome. There were 11 patients (seven girls and four boys) identified from eight hospitals in three countries. Ten patients with severe elbow swelling documented at presentation had a mean delay before surgery of 22 hours (6 to 64). One patient without severe swelling documented at presentation suffered arterial entrapment following reduction, with a subsequent compartment syndrome requiring fasciotomy 25 hours after the index procedure. This series is noteworthy, as all patients had low-energy injuries and presented with an intact radial pulse. Significant swelling at presentation and delay in fracture reduction may be important warning signs for the development of a compartment syndrome in children with supracondylar fractures of the humerus

We prospectively assessed the diagnostic accuracy of the gravity stress test and clinical findings to evaluate the stability of the ankle mortise in patients with supination–external rotation-type fractures of the lateral malleolus without widening of the medial clear space. The cohort included 79 patients with a mean age of 44 years (16 to 82). Two surgeons assessed medial tenderness, swelling and ecchymosis and performed the external rotation (ER) stress test (a reference standard). A diagnostic radiographer performed the gravity stress test. For the gravity stress test, the positive likelihood ratio (LR) was 5.80 with a 95% confidence interval (CI) of 2.75 to 12.27, and the negative LR was 0.15 (95% CI 0.07 to 0.35), suggesting a moderate change from the pre-test probability. Medial tenderness, both alone and in combination with swelling and/or ecchymosis, indicated a small change (positive LR, 2.74 to 3.25; negative LR, 0.38 to 0.47), whereas swelling and ecchymosis indicated only minimal changes (positive LR, 1.41 to 1.65; negative LR, 0.38 to 0.47). . In conclusion, when gravity stress test results are in agreement with clinical findings, the result is likely to predict stability of the ankle mortise with an accuracy equivalent to ER stress test results. When clinical examination suggests a medial-side injury, however, the gravity stress test may give a false negative result. Cite this article: Bone Joint J 2015; 97-B:1126–31

Introduction. The STRYDE nail is an evolution of the PRECICE Intramedullary Limb Lengthening System, with unique features regarding its composition. It is designed for load bearing throughout treatment in order to improve patient experience and outcomes and allow for simultaneous bilateral lower limb lengthening. The literature published to date is limited with regards to both outcomes and potential issues. In this paper we report on our early experience and raise awareness for the potential of adverse effects from this device. Materials and Methods. This is a review of all patients treated in our institution using this implant. Data were prospectively recorded. We report on demographics, nail accuracy, reliability, consolidation index and cases where concerning clinical and radiological findings were encountered. Results. 14 Stryde nails were implanted in nine patients (three males and six females) between June 2019 and September 2020. Mean age at surgery was 33 years old (14–65 years old). Five patients underwent bilateral lengthening (two femoral and three tibial) and four patients unilateral femoral lengthening for multiple aetiologies. By the time of this report eight patients (13 implants) had completed lengthening. Osteolysis and periosteal reaction at the junction of the telescopic nail was evident in nine implants. Five patients experienced localised pain and swelling. Macroscopic appearances following retrieval were consistent with corrosion at the telescopic junction. Tissue histology was consistent with effects of focal metallic wear debris. Conclusions. From our early experience with this implant we have found the process of lengthening to be accurate and reliable with good regenerate formation and consolidation. Proposed advantages of early load bearing and the ability for bilateral lengthening are promising. We have, however, encountered cases with concerning clinical and radiological findings. We have elected to discontinue its use to allow further investigation into the retrieved implants and patient outcomes from users internationally

Purpose of Study: To discuss on Clinical presentations, Investigations, Histopathology, Differential diagnosis and Treatment options based on a series of six Lipoblastomas that we encountered in our paediatric orthopaedic practice. Materials and Methods: This series consists of six children with lipoblastoma who attended Alder Hey Hospital between 2000 and 2006. Mean age 17 months. Mean follow up was 26 months. The youngest was a six month old infant with a swelling on his right instep. The second patient was a three year old girl who presented with a limp and swelling in her foot, the third patient was an 18 month old boy with a swelling on the dorsum of his left forearm, fourth patient had a swelling of his left thigh and two patients had swellings in their back. They were investigated appropriately with MRI, CT or USG and surgical excision planned accordingly. Results: Male to female ratio was 5:1. Age groups; 2 patients were of less than 12 months of age, another two of them was between 12 to 24 months and the last two were under 36 months at the time of diagnosis. Anatomically three patients had swellings in the lower limb, 2 had swellings over dorsum of their trunk one patient had a forearm swelling. Investigations include MRI for one patient and CT for another USG was done for the remaining four. There was no post op complication for any of them. None of them have shown any recurrence during the follow-up. Discussion: Lipoblastomas are uncommon, benign tumour of embryonal mesenchymal cells. It is a rare tumour but occurs mostly during infancy and early childhood. It most often presents on the extremities, back, head and neck. Histology: cellular neoplasm composed of lipoblasts in different stages of maturation and fine vascular network, with well defined septa. Cytogenetic evaluation often shows chromosomal anomalies of tumour cells like abnormalities of the long arm of chromosome 8, leading the rearrangement of the PLAG1 gene. Biopsy of the lesion is recommended, as clinical and radiological diagnoses can be misleading. These tumours tend to spread locally and may recur in case of incomplete resection; metastatic potential has not been reported. Differential diagnosis includes myxoid liposarcoma, welldiffrentiated liposarcoma, spindle cell lipoma, typical lipoma and soft tissue sarcoma. Conclusion: All patients were originally thought to have simple lipomas or soft tissue swellings. This is primarily because lipoblastoma is a rare tumour and is rarely encountered in orthopaedic training. It is important that we orthopaedic surgeons be aware that lipoblastoma is in fact the most likely diagnosis of a fatty lump in a child of less than two years of age. Lipoblastomas needs through imaging and if possible cytogenetic evaluation for accurate diagnosis before surgery because complete surgical resection is mandatory to prevent a likely local recurrence

Meniscus has many important functions in the knee joint such as load bearing, shock absorption, joint stability, joint lubrication and proprioception. In the recent years, meniscus injuries have been the focus of orthopaedic surgeons and musculoskeletal tissue engineering applications because of its avascular nature. In this study, we aimed to compare the regeneration capacities of two composite scaffolds in a New Zealand Rabbit meniscal defect model. The first scaffold consists Poly-Lactic Acid (PLA) + chitosan + loofah and the second PLA + Hydroxyapatite (HAp) + loofah. In order to produce these scaffolds; 4% chitosan, 4% PLA and 4% HAp solutions were seperately prepared. The loofah pieces were saturated with these solutions and vacuum-dried for 14 days and sterilized with ethylene oxide. There were several characterizations performed such as Fourier Transform Infrared Spectroscopy (FTIR) for the investigation of chemical structure, Scanning Electron Microscopy (SEM) for morphological analysis, thermogravimetric differential thermal analysis (TGA/DTA) for thermal properties, mechanical compression and swelling ratio analysis. Moreover, in order to investigate biocompatibility of the scaffolds, WST-1 colorimetric assay at days 3, 7, 10, 14 and 21 was conducted. After these biocompatibility analysis, a 1.5-mm cylindrical defect was created in the avascular portion of the anterior horn of the medial meniscus in 14 New Zealand rabbits (2.5–3 kg weight) which were randomly grouped in two. The scaffolds were implanted at the defect site with the help of a freshly prepared fibrin glue. 8 weeks after the operation, the rabbits were sacrificed and their tissues were kept for further mechanical, radiological and histological analysis. In conclusion, we succeeded to produce a new meniscus scaffold. The proliferation ability of PLA + chitosan + loofah scaffold is higher than PLA + HAp + loofah scaffold. However, there was no statistically significant difference among them

Bone fractures are highly observed clinical situation in orthopaedic treatments. In some cases, there might be non-union problems. Therefore, recent studies have focused on tissue engineering applications as alternative methods to replace surgical procedures. Various biopolymer based scaffolds are produced using different fabrication techniques for bone tissue engineering applications. In this study, hydroxyapatite (HAp) and loofah containing carboxymethyl chitosan (CMC) scaffolds were prepared. In this regard, first 4 ml of CMC solution, 0.02 g of hydroxyapatite (HAP) and 0.06 g of poly (ethylene glycol) diglycidyl ether (PEGDE) were mixed in an ultrasonic bath until the HAp powders were suspended. Next, 0.04 g of loofah was added to the suspension and with the help of PEGDE as the cross-linking agent, then, the mixture was allowed to cross-link at 40. o. C overnight. Finally, the three-dimensional, porous and sponge-like scaffolds were obtained after lyophilization (TELSTAR - LyoQuest −85) at 0.1 mbar and −25°C for 2 days. Morphologies, chemical structures and thermal properties of the scaffolds were characterized by scanning electron microscopy (SEM), Fourier Transform infrared spectroscopy (FT-IR) and thermogravimetric differential thermal analysis (TGA/DTA), respectively. In addition, swelling behavior and mechanical properties of the scaffolds under compression loading were determined. In order to investigate biocompatibility of the scaffolds, WST-1 colorimetric assay at days 0, 1, 3, 5 and 7 was conducted by using human dermal fibroblast. Also, histological and morphological analysis were performed for cell attachment at day 7. In conclusion, the produced scaffolds showed no cytotoxic effect. Therefore, they can be considered as a candidate scaffold for bone tissue regeneration. Further studies will be performed by using bone marrow and periosteum derived mesenchymal stem cells with these scaffolds

Background. Hoffa pad in Total knee replacement is a mystery. Very few studies have been carried out and no obvious results have been achieved. Aim. Our aim was to compare the clinical value of the Hoffa pad including blood loss, range of motion, anterior knee pain and swelling post total knee replacement. Method. this study has been designed as prospective randomized control trial, with involvement of 4 surgeons, with no exclusion criteria and no special preparation for the patients. Results. with 100 patients results, it has been found that by leaving the Hoffa pad well alone, there were increase of range of motion post TKR by 5 to 10 degrees, there were decrease of blood loss by 50%, no difference in swelling, and most patients with Hoffa pad had almost no anterior knee pain. Conclusion. the study is in a very early stage to draw a concrete conclusion, however early results showed that Hoffa pad can play a huge role in lubrication, anterior knee pain and finally in reducing blood loss

Introduction. Recovery after total knee arthroplasty (TKA) may take longer than patients expect. Furthermore, there are a subset of patients who still experience pain and dissatisfaction despite normal physical examination, radiographs, and laboratory analysis. Corticosteroid injection (CSI) is commonly used nonsurgical treatment for painful knee arthritis. However, the efficacy of CSI in patients with a painful TKA remains unknown. Methods. A retrospective charge review was performed to identify a cohort of patients who had a primary TKA performed between 2015 and 2016 and later received a CSI. All TKAs and CSIs were performed by a fellowship-trained arthroplasty surgeon. Patients receiving a CSI underwent a clinical exam, laboratory analysis to rule out infection, and radiographic evaluation prior to injection. Patient variables were recorded and a survey assessed the efficacy of the injection. The survey response rate was 63.6%. Results. Of the 119 responders, 81.5% remembered the injection. The average time from index arthroplasty injection was 16.9 months (range 1–133) and patients received 1.3 averaged CSIs (range 1–4). Overall, 77.3% reported decreased pain, 54.6% reported increased motion, and 60.8% reported decreased swelling. The relief lasted greater than three months for 53.6% of patients, and 84.6% reported improvement (slight to great) in the knee. The rate of patient reported adverse events was 5.0% and included pruritus, pain, decreased energy, swelling, and clicking. No patients developed PJI as a result of the injection. Conclusions. The results of this survey suggest that patients with a painful and/or swollen TKA may benefit from a CSI. However, this should only be performed once clinical, radiographic, and laboratory examination has ruled out recognizable etiologies (i.e. infection, loosening, instability). This study certainly has its limitations but it is the only study of its kind. The authors hope that this provides impetus for further research regarding this investigation

Surgical microfracture is considered a first line treatment for talar osteochondral defects. Pain reduction, functional improvement and patient satisfaction are described to be 61–86% in both primary and secondary osteochondral defects. However, limited research is available whether improvement of the surgical technique is possible. We do know that the current rigid awls and drills limit the access to all locations in human joints and increase the risk of heat necrosis of bone. Application of a flexible water jet instrument to drill the microfracture holes can improve the reachability of the defect without inducing thermal damage. The aim of this study is to determine whether water jet drilling is a safe alternative compared to conventional microfracture awls by studying potential side effects and perioperative complications, as well as the quality of cartilage repair tissue in a caprine model. 6 mm diameter talar chondral defects were created bilaterally in 6 goats (12 samples). One defect in each goat was treated with microfracture holes created with conventional awls. The contralateral defect was treated with holes created with 5 second water jet bursts at a pressure of 50 MPa. The pressure was generated with a custom-made setup using an air compressor connected to a 300 litre accumulator that powered an air driven high-pressure pump (P160 Resato, Roden, The Netherlands, . www.resato.com. ). Postoperative complications were recorded. After 24 weeks, analyses were performed using the ICRS macroscopic score and the modified O'Driscoll histological score. Wilcoxon ranked sum tests were used to assess significant differences between the two instrument groups using each goat as its own control (p ≤ 0.05). One postoperative complication was signs of a prolonged wound healing with swelling and reluctance to weight bearing starting two days after surgery on the water jet side. Antibiotics were administered which resolved the symptoms. The median total ICRS score for the tali treated with water jets was 9,5 (range: 6–12) and 9 (range 2–11) for Observer 1 and 2 respectively; and for the tali treated conventionally this was 9,5 (range 5–11) and 9 range (2–10). The median total Modified O'Driscoll score for the tali treated with water jets was 15 (range: 7–17) and 13 (range: 3–20) for Observer 1 and 2 respectively; and for the tali treated conventionally was 13 (range: 11–21) and 15 (range: 9–20). No differences were found in complication rate or repair tissue quality between the two techniques. The results suggest that water jet drilling can be a safe alternative for conventional microfracture treatment. Future research and development will include the design of an arthroscopic prototype of the water jet drill. The focus will be on stability in nozzle positioning and minimized sterile saline consumption to further the decrease the risk of soft tissue damage

Cobalt-chrome alloys are widely used in dentistry and Orthopaedic implant industry. Vitallium is a similar alloy which contains 60% cobalt, 20% chromium, 5% molybdenum along with traces of other substances. It has been in use along with stainless steel for the last century because of its lightweight, favourable mechanical properties and resistance to corrosion. We present an unusual case of synovial cyst formation following Vitallium plating mimicking a sarcoma. To our knowledge, we are the first to report a delayed tissue reaction to Vitallium plating 40 years after its implantation. A 78 yrs old man had a right femoral intertrochanteric fracture 40 years ago, which was fixed with a Vitallium nail plate. His postoperative recovery was uneventful and he regained full function of his leg. 3 years prior to excision, he presented with a painless swelling around his right upper thigh to our unit. Aspiration of the swelling and investigations were requested but patient was lost to follow up due to social reasons. Seven months prior to excision, he represented as the swelling had increased to the extent that it was involving the anterior and posterior aspect of the upper thigh with pressure necrosis of skin posteriorly. Examination revealed painless, transilluminable, fluctuant multilobular swelling over the right proximal femur overlying the healed surgical scar. Compression of the larger lobe in the buttock clearly forced fluid into the anterior compartment of the thigh where again swelling was extensive. Surprisingly he had full range of movements at the hip joint. Radiograph of the hip showed a soft tissue swelling with a healed fracture and Vitallium implant insitu. Cytology was negative. MRI scan showed multiloculated cystic lesions extending anteriorly, laterally and posteriorly into the intermuscular and subcutaneous planes around the right proximal femur. Multiple small dependent foci likely representing debris or synovial proliferation was seen within loculations. Excision of the cystic lesions with removal of metal work was performed. The old incision was reopened in the lateral position and a large cystic lesion with a thick capsule was dissected down to the metal work. The lesion was lying superficial to the vastus lateralis but was communicating with metal work. The metal work was removed with difficulty, no visible metallosis. A second cystic lesion was located more posteriorly but its neck was communicating with the thin hole into the first lesion. The lesion was excised completely. Macroscopic examination showed two cysts 9×8×5.5cm and 20×10×7.5cm with a smooth external surface and the lumen appeared trabecular containing numerous loose (rice) bodies. Microscopy showed a dense fibrotic cyst wall with lumen with multiple small nodules containing organised fibrinous and eosinophilic material. Several foci of cellular debris including lymphocytes and macrophages were scattered in nodules best representing a synovial cyst with loose/rice bodies. No malignancy was seen. We recommend early removal of metal work if it shows any signs of local reaction provided fracture is united. Be aware of large foreign body/ hypersensitivity reaction and incompatible equipment for removal

Post-operative swelling and wound ooze following primary Total Knee Replacement (TKR) can lead to complications such as wound infection, and delays in achieving adequate range of motion. The aim of the study is to examine the effectiveness of using an additional layer of a self-adherent elastic wrap (CobanTM) in reducing post-operative swelling and wound ooze after Primary TKR. Seventeen pairs of patients who had had a primary TKR were studied in a prospective, age and gender-matched cohort study. Half of the patients had wool and crepe dressing (Group A) and the other half with an additional layer of CobanTM dressing (Group B), applied to the wound. Limb circumference was measured at three levels (below knee, knee and above knee) preoperatively and 3 consecutive days post-operatively. The area of wound ooze was measured using AutoCAD software. Group B showed a significant reduction difference in the mean of post-operative limb circumference at above knee level (3.2 vs 4.9 cm. p =0.023). This trend in reduction was seen at below knee and knee levels, though not statistically significant. There is a clinical difference in the wound ooze measured area of 17.8cm2 Vs 22.9 cm2, in Group B and A, respectively. Within the relative small size of this study, there appeared a significant reduction in post-operative limb swelling and wound ooze when using CobanTM in TKR. It is promising preliminary results, however the study groups must be extended

Total Knee Arthroplasty (TKA) necessitates disruption of well-vascularised tissue during exposure and soft tissue release as well as from the cutting of bone, and thus bleeding into the joint space routinely occurs to some degree following TKA. Defining a complication from bleeding is not necessarily straightforward, but includes 3 different conditions: hemarthrosis, hematoma, and bloody wound drainage. All of these conditions can be seen in the normal postoperative setting, and when mild, may be simply observed. However, persistent swelling resulting in clinical symptoms should be appropriately treated. A hemarthrosis is defined as blood being contained in the knee capsule. Although some bleeding is expected, “excessive” hemarthrosis results in increased pain limiting or difficulty regaining motion. If high levels of fluid pressure are present, rupture of the arthrotomy may occur. A hematoma occurs when intra-articular blood escapes the arthrotomy and drains into the overlying soft tissues. This may occur following performance of a large lateral release or an insufficient arthrotomy closure or simply secondary to a large hemarthrosis under tension. Symptoms include ecchymosis, soft tissue swelling, and potential skin complications. Increased pain and limited range of motion frequently accompany these symptoms. Wound drainage may present as a knee that continues to have bloody or serous drainage that continues long after the first or second dressing change. It is this continued wound drainage that is most worrisome, with increased wound infection rates when prolonged drainage is allowed to persist. While excessive bleeding during the early postoperative period is most common, isolated or recurrent hemarthrosis may occur long after recovery from surgery. The incidence of postoperative hemarthrosis is not well studied, but the need for surgical treatment is uncommon. Recurrent hemarthrosis is also relatively rare after TKA and has been reported at rates between 0.3% and 1.6%. The etiology of this complication can be systemic or local, and initial workup should include coagulation studies to rule out any underlying systemic coagulopathy. Conservative therapy including rest, cooling, and elevation is the preferred treatment for mild cases. If conservative treatment is not successful, or the acute hemarthrosis is clinically tense, interfering with recovery, or threatening wound healing, drainage may be the preferable option. This can be done by opening the arthrotomy in the operating room or through large bore arthroscopy cannulae. Careful attention to debridement of clotted blood must be followed by a meticulous search for potential sources of bleeding which should be managed appropriately. Recurrent hemarthrosis may occur at any time but is not commonly diagnosed until the patient has left the early recovery period. Repeated bleeding episodes may lead to an inflammatory cascade that propagates bleeding events more readily. If coagulation studies are normal, the most common source is the impingement of proliferative synovium or other retained soft tissue between the articulating components of the knee prosthesis. Other causes may be multifactorial and synergistic but are not well understood, making diagnosis and treatment more difficult. If symptoms persist, classical treatment has consisted of open or arthroscopic synovectomy. Over the past decade angiography and angiographic embolization of the source of bleeding has been successful. In a recent meta-analysis including 99 patients, technical success rates of 99% were noted, though 2 cases became infected and 10 cases suffered recurrent bleeding episodes. Radio-active synovectomy has also been successful

Tourniquet use in total knee arthroplasty is convenient for the surgeon and provides a bloodless field for expeditious surgery and a dry field for cementation, but can best be described as an orthopaedic tradition. It is logical for complex anatomy of ligament, nerve, and vessel surgery but it may not be necessary for total knee replacement. In one recent randomised trial, the absence of the tourniquet was not found to affect the quality of cement fixation. There are numerous potential downsides to the use of a tourniquet including decrease range of motion, delayed recovery, increased pain, wound complications, micro-emboli, neuropathy, and increased VTE. There are also a number of complications associated with the use of a tourniquet including arterial thrombosis, skin irritation below the tourniquet, post-operative hyperemia, blood loss, less accurate intra-operative assessment, and it complicates intravenous drug administration. Studies of range of motion have shown that when there is a difference noted, the range of motion is consistently better without tourniquet use. When a tourniquet is utilised it has been found to be advantageous to only use of tourniquet for a minimal amount of the case, typically when cementing is performed. Functional strength has also been found to be improved without the use of a tourniquet. This was attributed to muscle damage, tourniquet-induced ischemia, and compressive injury. Increased peri-operative pain has also been reported in randomised trials associated with the use of a tourniquet. Edema, swelling, and limb girth issues have also been noted to be associated with tourniquet use. Exsanguinating a limb will result in swelling approximately 10% of the original volume half due to a return of blood, and half due to reactive hyperemia. Longer tourniquet times are also associated with increased wound drainage and more wound hypoxia. Tourniquet use has also been associated with embolic phenomenon with several times greater risk of large emboli associated with tourniquet use. A number of complications have been associated with tourniquet use including thromboembolic complications. In one study where quantitative MRI was utilised on both thighs after unilateral total knee replacement with and without a tourniquet, the tourniquet group showed more atrophy with a loss of 20% of the volume compared to the normal side in total knees performed with a tourniquet which also performed clinically worse. There is a small but substantial risk of arterial thrombosis particularly in patients that have atherosclerotic plaque. Ironically there is a risk of increased post-operative blood loss due to the post-tourniquet “blush” as the blood pressure and pain increase hours after a surgical procedure is completed. There is also difficulty in identifying and coagulating posterior and lateral geniculate vessels with the components in place. Utilizing a tourniquet also interferes with intra-operative assessment of patella tracking, range of motion, ligament stability, and gap balancing. Randomised clinical trials have concluded that there is less pain and quicker recovery without the use of a tourniquet. There have also been reports of less swelling, increased range of motion, less analgesic use and better clinical outcome when a tourniquet is not utilised. A meta-analysis of systematic reviews favored not utilizing a tourniquet due to the decrease in complication rate and the improvement in clinical results. While it is standard practice in the US to utilise a tourniquet, the strong consensus of the literature on the subject favors either not using a tourniquet or minimizing the use of a tourniquet for the period of time necessary for a very dry field for cement fixation

For a meaningful evaluation of biomaterials, in vitroenvironments that mimic the physiological properties of the in vivoenvironment are desirable with relevant control of key factors. For faster screening and reduction of time and costs, combination and control of different critical parameters are needed. Commercial Hyalograft® and ChondroGide® scaffolds were compared to a new experimental recombinant human collagen-PLA (rhCo-PLA) [1] and pure PLA scaffolds under BEST protocol [2] in pseudostatic (creep), dynamic (frequency scans, strain sweeps), and combined conditions (simulated operative periods) relevant for orthopaedic applications. Temperatures 25–37°C, dry and fully immersed wet (water, 0.9% NaCl) conditions were analysed and aggregate, complex dynamic moduli and loss factor were obtained. Additionally a method was developed for estimation of the swelling pressure under variable compression. ChondroGide and rhCo-PLA were compared in vivoin earlier experiments [1]. All scaffold materials have a non-linear and non-uniform behaviour when immersed in a fluid, accompanied by rapid change in starting porosity (down for Hyalograft® and ChondroGide®, up for PLA), but nearly stable for rhCo-PLA. Too hydrophilic materials exhibited partial non-wetting (dry spots) under a slight compression eventually by closure of the specimen rim due to elastocapillary effect, where as hydrophobic (PLA) shown substantial expansion. The swelling pressure of PLA was measured of ∼1 kPa (water, 25°C). Observed creeping cannot be reliably fit with simple viscoelastic models, but can be approximated with biphasic theory with variable complex moduli and permittivity values. No significant differences were observed in creep for 1 h and 5 h runs, showing that a shorter time is sufficient to catch the main effects in these biomaterials. No substantial differences were observed between water and NaCl solution at 37°C, except for ChondroGide® which swells in NaCl more than in water. Besides of some differences in swelling, no significant differences observed between 25 and 37°C tests for creep. For dynamic conditions all materials undergo densification and “stiffening” (50% and more) upon cyclic strain deformation, with the effect being higher at 37°C than at 25°C. rhCo-PLA scaffolds exhibit relatively stable modulus in water and loss factor with physiologically-compatible behaviour (∼0.1 with a minimum values range around 1 Hz) at frequency scans (0.01–20 Hz). On the contrary, ChondroGide® has the highest loss factor (up to 0.6–0.7). Water at 25°C seems to be sufficient to rapidly test these kinds of materials for biomechanical screening, unless additions or specific effects are of interest. The applied deformation level is more important to predict materials properties in dynamic conditions than experiment time. This means that better in vitrodata can be obtained in shorter runs. The animal studies have also exhibit rhCo-PLA producing better quality (ICRS median score 12.5 vs. 8.5 for ChondroGide®)

Purpose of Study: To present the clinical features, investigations, histopathology, differential diagnosis and treatment options for lipoblastoma, based on a series of six encountered in our paediatric orthopaedic practice. Method: The records of six children with lipoblastoma who attended Alder Hey Hospital between 2000 and 2006 were reviewed. Mean age was 17 months and mean follow up was 26 months. Results: The youngest was a six month old infant with a swelling on his right instep. The second patient, a three year old girl, presented with a limp and swelling in her foot. The third patient was an 18 month old boy with a swelling on the dorsum of his left forearm. The fourth patient had a swelling of his left thigh and two patients had swellings in their backs. Each was investigated by MRI (1), CT (1) or US (4) and surgical excision planned accordingly. There were no post operative complications. None has shown recurrence during follow-up. Conclusions: All patients were originally thought to have simple lipomata or soft tissue swellings. This is primarily because lipoblastoma is a rare tumour, yet lipoblastoma is the most likely diagnosis of a fatty lump in a child aged less than two. Differential diagnoses include myxoid liposarcoma, well-differentiated liposarcoma, spindle cell lipoma, typical lipoma and soft tissue sarcoma. Lipoblastomata need thorough imaging. Cytogenetic evaluation of tumour cells often reveals chromosomal anomalies, such as abnormalities of the long arm of chromosome 8 leading to rearrangement of the PLAG1 gene. Biopsy of the lesion is recommended for accurate diagnosis, as clinical and radiological diagnoses can be misleading. Lipoblastomata tend to spread locally and may recur after incomplete resection; metastatic potential has not been reported. Complete surgical resection is mandatory to prevent recurrence

Autologous micro-fragmented adipose tissue (MFAT) for the treatment of symptomatic knee osteoarthritis (OA) is gaining interest although there is still a lack of supportive data on safety and clinical efficacy. This study primarily aimed to identify patient- and pathology-related parameters to tighten patient selection criteria for future clinical MFAT application. Secondly, the overall (1) therapeutic response rate (TRR), (2) short-term clinical effect, (3) effect durability and (4) therapeutic safety was investigated at a minimal follow-up of 1 year. Sixty-four subjects (91 knees) with symptomatic knee OA (mild-severe on MRI) were enrolled in a prospective single-centre case series. Ethical approval was obtained from the local and academic ethical committee (#B300201733775). After liposuction, the adipose tissue was mechanically processed in a Lipogem® device which eventually produced 6–9cc MFAT. Subjects were clinically assessed by means of the KOOS, NRS, UCLA and EQ-5D at baseline and 1, 3, 6 and 12 months after injection. Adverse events were meticulously recorded. The TRR was defined according to the OMERACT-OARSI criteria. A baseline MRI was scored following the MOAKS system. Paired sample t-tests, independent t-test and Fischer's exact test were applied on appropriate variables. Multiple regression models were fit separately for patient-and pathology-specific factors. Significance level was set at α=0.05. The overall TRR was 66% at 3 months and 50% at 12 months after injection. Subgroup analysis revealed that specifically patients with no-mild bone marrow lesions (BML) had a TRR of 88% at 3 months and 75% at 12 months after MFAT injection. Therapy responders at these timepoints improved with 29.3±14.1 points and 30.8±15.3 points on KOOS pain, while non-responders deteriorated mildly. All clinical scores were significantly higher at follow-up compared to baseline (p<0.05). BMI (factor 0.17, p=0.002) and age (factor −0.48, p=0.048) were prognosticators for the TRR% at 1 month and for absolute KOOS pain improvement at 6 months, respectively. Posterior horn lesions (PHL) in the medial meniscus (p<0.001) and bone marrow lesions (p=0.003) were negative prognosticators for the TRR at respectively 6 and 12 months post-injection. An inflammatory reaction (pain, swelling or stiffness) to MFAT was reported in 79% knees and resolved spontaneously within 16.6±13.5 days after administration. The study showed a durable and satisfying TRR (up to 75% at 1 year in selected patients without BML) and clinical improvement after a single intra-articular injection with autologous MFAT. The availability of an index knee MRI is mandatory to select MFAT patients, preferably with no or mild BML and without PHL of the medial meniscus. High BMI and younger age are associated with better early outcomes. In comparison to other injection therapies such as cortisone, hyaluronic acid and PRP, MFAT appears very attractive with an effect durability of at least 1 year

Up to one-third of patients experience limited benefit following surgical intervention for LS-OA. Thus, identifying contributing factors to this is important. People with OA often have multijoint involvement, yet this has received limited attention in this population. We documented the occurrence and evaluated the influence of multijoint symptoms on outcome following surgery for LS-OA. 141 patients undergoing decompression surgery+/−fusion for LS-OA completed the Oswestry Disability Index (ODI) pre- and 12-months post-surgery. Also captured pre-surgery: age, sex, education, BMI, smoking, depressive symptoms and comorbidities. Any joints with “pain/stiffness/swelling most days of the month” were indicated on a homunculus. A symptomatic joint site count (e.g. one/both knees= one site), excluding the back, was derived (range zero to nine) and considered as a predictor of magnitude of ODI change, and likelihood of achieving minimally clinically important improvement in ODI (MCID=12.8) using multivariable adjusted linear and log-Poisson regression analyses. Mean age: 66 years (range:42–90), 46% female. 76% reported one+ joint site other than the back, 43% reported three+, and nearly 10% reported six+. (< MCID) for those with three sites, and four units for those with six+ sites. Associated with a greater likelihood of not achieving MCID were increasing joint count (11% increase per site (p=0.012)), higher BMI, current/former smoker, and worse baseline ODI tertile. Results suggest there is more than just the back to consider to understand patient-reported back outcomes. Multijoint symptoms directly contribute to disability, but there is potential they may contribute to systemic, largely inflammatory, effects in OA as well

Hip simulator studies with ceramic-on-metal (COM) predicted less wear than metal-on-metal (MOM: Isaac. 2009). While clinical evidence is scant, two COM case reports described pseudotumors with adverse cup positioning (Deshmukh 2012, Koper 2014). It would appear that our Korean case report is the first to describe pseudotumor formation in well-positioned COM arthroplasty and including detailed failure analysis. A 50-year old female (active salesperson) had bilateral avascular necrosis of her femoral heads. A left metal-on-polyethylene (MPE) hip was performed at outside institution in 2003. At our 3-yrs evaluation, radiographs showed well-functioning MPE hip. Five years later she complained of gradual left-hip pain (2011). Radiographs and CT scan demonstrated wear, osteolysis and loosening of both components. The revision in 2011 was by COM (Fig. 1), using S-ROM stem/sleeve, 36mm ceramic head (Biolox-delta), a CoCr liner and 54mm shell (Pinnacle: Depuy Inc). Cup inclination and anteversion were considered appropriate at 45° and 20° respectively; femoral anteversion of 15° was also appropriate. At 1-yr follow-up patient complained of mild discomfort in left COM hip (2012). Range of motion was painless and normal. Examination revealed a soft, non-tender swelling (2×3cm) in left inguinal region with no inflammation and radiographs were normal (Fig. 1a). One month later the patient complained of left hip pain, the previously noted swelling had increased in size, and she started to limp. Radiographs showed cup migration with increased inclination. CT scans showed a circumscribed lesion extending into iliopsoas region (Fig 2). Serum cobalt and chromium levels were high at 2.4 and 22.5µg/ L, respectively. At revision the pseudotumor and surrounding inflamed synovium was excised. The cystic soft-tissue swelling (stained black) extended into the joint (Fig. 2a). The ceramic head showed a large “black stripe” across the dome (Fig 2b). The cup was loose while the femoral stem was well fixed. Operative cultures of soft tissues and joint fluid were negative for infection while histopathology was consistent for metallosis (Fig. 3). Aggressive debridement was carried out, acetabular defects were filled with bone graft. Revision incorporated 32mm ceramic head (Biolox-delta), highly cross-linked liner and 52mm trabecular-metal shell (Depuy). Functionally the patient has continued to improve. By 6 months, serum ion concentrations decreased to Co:1.3 and Cr:2.54µg/ L with most recent ion levels lower still (Co:0.66 and Cr:0.42µg/ L). Ceramic head surfaces showed normal wear appearance. The large gray stripe identified on the highly polished dome contained Co and Cr metal-transfer from the CoCr liner (Fig. 2b). Thin gray stripes on equatorial head regions (x4 rougher than dome) represented contamination by Ti, Al and V, typical of adverse impingement against Ti6Al4V neck (Clarke 2013). There was a 100–150um defect on rim of CoCr liner as a result of impingement. Cup out-of-roundness was 476um compared to only 7um for ceramic head, thus cup wear dominated at 25–30mm. 3. volume. This case report was illustrative of the unpredictable and seldom diagnosed risk of habitual cup-to-neck impingement and the risk of relying on pristine simulator studies to predict outcomes in novel THA bearings. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Evaluation of different biomaterials is being performed with various methods trying to simulate the closest hostile-like in vitro environments. However the complexity of the conditions usually limits practically feasible combination of most relevant chemical, biological, biomechanical parameters in one single test. Many biomaterials and tissue engineering developments rely on high-throughput screening to multiply number of specimens and thus to gather sufficient data. The price to be paid for these methods is limited number of physical readouts, increased inter-specimens scatter, and unavoidable spatial constrains driving the conditions away of the clinical scenarios. For orthopaedic biomaterials this is of a particular concern, as implantation site conditions cannot be squeezed too much without lost of natural-mimicking stimuli. Here we are presenting another approach based on high-output screening of biomaterials, which is based on the strategy of raising the number of readouts obtainable from every specimen at more clinically-relevant conditions. On the contrary to common methods like ISO 10993 or simplified biomechanical tests, the biomaterials enhanced simulation testing (BEST) evaluates specimens without pre-selected biomaterial model, assessing the whole specimen as would happen in the implantation site. Besides reducing the risk of improper conclusions caused by wrong material model choice, the data processing with non-local method intrinsically includes the test history bypassing common challenges usually seen with hereditary integration. For properly designed experiment, readouts might include invariant moduli, viscous stiffness, fluidity, fluid permittivity and diffusivity (without need for pressure-driven separate tests), fluid source, effective channel size, and swelling pressure (if swelling is present) in addition to conventional biomechanical parameters. New solutions in advanced and consistent evaluations for biomaterials allow better risks control, shorten lead development time and costs, and compliant with 3R-strategy (2010/63/EC) and new regulatory requirements (2012/0266/COD in EU and FY2017 regulatory priorities by FDA). The approach shown is able to combine scientifically based tests with multi-purpose protocols to secure patient safety by screening of biomaterials under proper conditions. The authors thank Finnish Agency for Innovations (Tekes) for providing partial financial support

Tourniquet use in total knee arthroplasty (TKA) is convenient for the surgeon and provides a bloodless field for expeditious surgery and a dry field for cementation, but can best be described as an orthopaedic tradition. It is logical for complex anatomy of ligament, nerve, and vessel surgery but it may not be necessary for TKA. In one recent randomised trial, the absence of the tourniquet was not found to affect the quality of cement fixation. There are numerous potential downsides to the use of a tourniquet including decrease range of motion, delayed recovery, increased pain, wound complications, micro-emboli, neuropathy, and increased VTE. There are also a number of complications associated with the use of a tourniquet including arterial thrombosis, skin irritation below the tourniquet, post-operative hyperemia, blood loss, less accurate intra-operative assessment, and it complicates intravenous drug administration. Studies of range of motion have shown that when there is a difference noted, the range of motion is consistently better without tourniquet use. When a tourniquet is utilised it has been found to be advantageous to only use the tourniquet for a minimal amount of the case, typically when cementing is performed. Functional strength has also been found to be improved without the use of a tourniquet. In a recent randomised trial, tourniquet use was associated with decreased quad strength at 3 weeks that persisted at 3 months. This was attributed to muscle damage, tourniquet-induced ischemia, and compressive injury. Increased peri-operative pain has also been reported in randomised trials associated with the use of a tourniquet. Edema, swelling, and limb girth issues have also been noted to be associated with tourniquet use. Exsanguinating a limb will result in swelling approximately 10% of the original volume half due to a return of blood, and half due to reactive hyperemia. Longer tourniquet times are also associated with increased wound drainage and more wound hypoxia as measured by transcutaneous oxygen levels. Tourniquet use has also been associated with embolic phenomenon with several times greater risk of large emboli. In one study where quantitative MRI was utilised on both thighs after unilateral total knee replacement with and without a tourniquet, the tourniquet group showed more atrophy with a loss of 20% of the volume compared to the normal side in total knees performed with a tourniquet which also performed clinically worse. There is a small but substantial risk of arterial thrombosis particularly in patients that have atherosclerotic plaque. Ironically there is a risk of increased post-operative blood loss due to the post-tourniquet “blush” as the blood pressure and pain increase hours after a surgical procedure is completed. There is also difficulty in identifying and coagulating posterior and lateral geniculate vessels with the components in place. Utilizing a tourniquet also interferes with intra-operative assessment of patella tracking, range of motion, ligament stability, and gap balancing. Randomised clinical trials have concluded that there is less pain and quicker recovery without the use of a tourniquet. There have also been reports of less swelling, increased range of motion, less analgesic use and better clinical outcome when a tourniquet is not utilised. A meta-analysis of systematic reviews favored not utilizing a tourniquet due to the decrease in complication rate and the improvement in clinical results. While it is standard practice in the US to utilise a tourniquet, the strong consensus of the literature on the subject favors either not using a tourniquet or minimizing the use of a tourniquet for the period of time necessary for a very dry field for cement fixation

Introduction: In the growth plate, chondrocyte swelling (hypertrophy) is a crucial event during endochondral ossification and bone lengthening, accounting for ~80% of the increase in bone length (. 1. ,. 3. ). The swelling is dramatic (~10x) and closely regulated. Failure of chondrocyte hypertrophy may underlie the chondrodysplasias of the vertebrate skeleton (. 1. ). However, the mechanisms which control cell swelling are poorly understood although there must be a key role for chondrocyte osmolyte transporters which are sensitive to an increase in cell volume. We have used confocal scanning laser microscopy (CLSM) to study volume regulation by living in situ growth plate chondrocytes at varying degrees of hypertrophy. Methods: Bovine growth plates were taken from the ends of young (~12d) bovine ribs. In situ growth plate chondrocytes at the proliferative through to hypertrophic stages were fluorescently-labelled (calcein-AM; 5μM), imaged (Zeiss CLSM510) and volumes determined quantitatively as described (. 2. ). An acute osmotic challenge (280-140mOsm) was delivered by perfusion to determine volume-regulatory capacity by cells in the various zones. Results: The resting volumes of proliferative and hypertrophic cells were 550±63μm. 3. and 5227±1974μm. 3. respectively. Reducing osmolarity resulted in a rapid (within ~1min) cell swelling, proliferative and hypertrophic chondrocytes increasing in volume by 126±2% and 146±5% (n=5) respectively. Chondrocytes within the proliferative zone then recovered in volume by ~60% over the following 20mins (p=0.04), whereas no volume recovery was detected in hypertrophic cells (p=0.94). Conclusions: For the increase in growth plate chondrocyte volume to produce hypertrophy it is essential that the membrane transporters which normally prevent cell swelling are suppressed, otherwise the increase in volume will be compromised. These results suggest that chondrocyte hypertrophy is associated with reduced activity of the swelling-stimulated osmolyte transporter whereas the pathway is active in proliferating chondrocytes. Changes in the activity of this pathway are likely to be an important component in the control of chondrocyte hypertrophy. It is clear that the contributions of other membrane transporters in mediating chondrocyte swelling must be identified in order to understand the overall hypertrophic process

Aims. Fretting and corrosion at the modular head/neck junction, known as trunnionosis, in total hip arthroplasty (THA) is a cause of adverse reaction to metal debris (ARMD). We describe the outcome of revision of metal-on-polyethylene (MoP) THA for ARMD due to trunnionosis with emphasis on the risk of major complications. Patients and Methods. A total of 36 patients with a MoP THA who underwent revision for ARMD due to trunnionosis were identified. Three were excluded as their revision had been to another metal head. The remaining 33 were revised to a ceramic head with a titanium sleeve. We describe the presentation, revision findings, and risk of complications in these patients. Results. The patients presented with pain, swelling, stiffness, or instability and an inflammatory mass was confirmed radiologically. Macroscopic material deposition on the trunnion was seen in all patients, associated with ARMD. Following revision, six (18.2%) dislocated, requiring further revision in four. Three (9.1%) developed a deep infection and six (18.2%) had significant persistent pain without an obvious cause. One developed a femoral artery thrombosis after excision of an iliofemoral pseudotumor, requiring a thrombectomy. Conclusion. The risk of serious complications following revision MoP THA for ARMD associated with trunnionosis is high. In the presence of extensive tissue damage, a constrained liner or dual mobility construct is recommended in these patients. Cite this article: Bone Joint J 2018;100-B:720–4

Objective. We have been using continuous epidural block and local infiltration cocktail for the pain management after TKA since 2005, and good pain control has been acquired with this method. During the past few years we have changed our protocol of postoperative pain management. We have stopped the administration of Loxoprofen starting next morning of the operation, instead Celecoxib was given starting before the operation. We have started mixing steroid to the intraoperative local infiltration cocktail to reduce acute pain as well as swelling. We also have stopped using suction drain, and delayed the timing of CPM start from day 2 to day 3. Methods. This is case control study, and 78 cases of unilateral TKA were investigated for the study. All cases were anesthetized with continuous epidural block with intravenous dosage of phentanyl and propofol. Compositions of local infiltration cocktail are 40ml 0.75% Ropivacaine, 60ml saline, 0.5ml epinephrin. Group1 (n=40) used this cocktail independently, and Group2 (n=38) used this cocktail with addition of 40mg of triamcinolone(Fig.1). Local infiltration cocktail was used during operation, which was injected to the whole joint capsule. In group1 Loxoprofen was given starting next morning, in group 2 Celecoxib was given starting at 7am on the day of operation. In group1 suction tube was left for 2 days, where as in group2 no suction tube was used postoperatively, and continuous epidural block catheter was removed on postoperative day 2 in both groups. CPM was started at postoperative day 2 in group 1 and postoperative day 3 in group 2. Numerical Rating Scale (NRS) was used to analyze the pain. Circumferences of knee and thigh, as well as ROM of knee joint were measured periodically. Results. Preoperative demographics showed no statistical difference between two groups(Fig. 2). Group 2 showed significantly less pain at 6am next morning postoperatively (Fig.3&4). Group 2 showed significantly lower NRS on motion at postoperative day1, 3, 5 and 7 (Fig.5). Group 2 also showed significantly less swellings of knees and thighs at postoperative day 7 (Fig.6). The ROM of the knee joints at postoperative day 7, 14 and 21 were better in group2(Fig.7). Discussions. Our new method of multimodal pain control is effective. It significantly decreased the pain at 6am next morning postoperatively, which is due to preoperative administration of Celecoxib. The pain on motion during 1 st week was significantly decreased which is probably due to the addition of steroid to the cocktail. Suction drain was not needed, if you use steroid in the cocktail and delay the timing to start CPM. The swelling was significantly reduced by steroid injection and delay in ROM exercise. As a result better ROM at postoperative day 7,14 and 21 were obtained. To view tables/figures, please contact authors directly

Introduction: Surgical injury induces a systemic inflammatory response proportional to the severity of the insult. An appropriate response maintains homeostasis and allows wound healing while an excessive response may trigger an inflammatory cascade resulting in the systemic inflammatory response syndrome (SIRS). Tissue injury results in cytokine release, which in turn stimulates the production of acute phase proteins such as C-reactive protein (CRP), fibrinogen, complement C3 and haptoglobin. Serum CRP levels rise following total hip arthroplasty (THA), peaking on the second to third post-operative day. Local effects of the inflammatory response manifest as the cardinal signs of inflammation, which include swelling. One of the potential benefits cited for minimally invasive THA is reduced soft tissue trauma resulting in less post-operative pain, less swelling and earlier mobilisation. Objective evidence, from well designed prospective studies, for these benefits remains lacking. The aim of this study was to investigate whether a minimally invasive technique in THA results in a reduced acute phase response and reduced post-operative swelling compared to THA performed through a standard incision of 16cm. Materials and Methods: 219 patients were randomised to either a minimally invasive (less than or equal to 10cm) or standard (16cm) incision group. Patients were blinded to their incision length. Anaesthetic and postoperative analgesic protocols were standardised. A single surgeon performed all operations using an uncemented cup and a cemented stem. Baseline CRP levels were measured pre-operatively and re-measured on the second post-operative day to determine whether there was any difference in the magnitude of the inflammatory response between the two patient groups. Pre-operative measurements were also made of the mid-thigh circumference on the affected side. The mid-thigh circumference was re-measured at 48 hours to assess postoperative swelling. Results: There was no statistically significant difference in the mean serum CRP levels at 48 hours, which were 135.7mg/L (SD 51.2) for the mini-incision group and 125.6mg/L (SD 59.4) for the standard group (p=0.20). With respect to post-operative swelling, the mean increase in mid-thigh circumference at 48 hours was 4.3cm for the mini-incision group and 3.7cm for the standard group. The difference between the two groups was not statistically significant (p=0.30). Conclusion: THA performed through a single incision minimally invasive approach does not result in reduced post-operative swelling or a reduced acute phase response, as measured from post-operative CRP rise, compared to THA performed through a standard incision of 16cm

Introduction and Aims: Cold therapy is known to reduce pain and swelling after surgical procedures on the knee. We hypothesised that if cold therapy is started earlier, then there would be a reduction in pain and swelling in patients undergoing arthroscopic anterior cruciate ligament [ACL] reconstruction. Method: We prospectively randomised 40 patients undergoing arthroscopic ACL reconstruction with hamstring autograft, to receive either room temperature [19° C] or cold [4° C] arthroscopy irrigation fluid. Patients were then assessed over the following seven days, with regard to pain [measured on a visual analogue scale], and swelling [measured with limb girth at four points around the knee]. Results: Pain scores were consistently reduced in the cold fluid group compared to the room temperature group throughout the post-operative period, and this difference was significant [p< =0.05] from six hours until seven days post-operatively. At day seven, the swelling measured at 5cm below the joint and 5cm above the joint were significantly lower in the cold group compared with the room temperature group. Drainage from the intra-articular drain was significantly lower in the cold group. Conclusion: The use of cold irrigation fluid is a simple and safe measure by which pain and swelling (at day 7) can be reduced in the early post-operative period for arthroscopic ACL reconstruction

Introduction Cold therapy is known to reduce pain and swelling after surgical procedures on the knee. We hypothesised that if cold therapy is started earlier, then there would be a reduction in pain and swelling in patients undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction. Methods We prospectively randomised 40 patients undergoing arthroscopic ACL reconstruction with hamstring autograft, to receive either room temperature (19°C) or cold (4°C) arthroscopy irrigation fluid.Patients were then assessed over the following 7 days, with regard to pain (measured on a visual analogue scale), and swelling (measured with limb girth at 4 points around the knee). Results Pain scores were consistently reduced in the cold fluid group compared to the room temperature group throughout the post operative period, and this difference was significant (p< =0.05) from 6 hours until 7 days post-operatively. At day 7 the swelling measured at 5cm below the joint and 5cm above the joint were significantly lower in the cold group compared with the room temperature group. Drainage from the intra-articular drain was significantly lower in the cold group. Conclusion The use of cold irrigation fluid is a simple and safe measure by which pain and swelling (at day 7), can be reduced in the early post-operative period for arthroscopic ACL reconstruction

Total Knee Arthroplasty (TKA) necessitates disruption of well vascularised tissue during exposure and soft tissue release as well as from the cutting of bone, and thus bleeding into the joint space routinely occurs to some degree following TKA. Defining a complication from bleeding is not necessarily straightforward, but includes 3 different conditions: hemarthrosis, hematoma, and bloody wound drainage. All of these conditions can be seen in the normal post-operative setting, and when mild may be simply observed. However, persistent swelling resulting in clinical symptoms should be appropriately treated. A hemarthrosis is defined as blood being contained in the knee capsule. Although some bleeding is expected, “excessive” hemarthrosis results in increased pain limiting or difficulty regaining motion. If high levels of fluid pressure are present, rupture of the arthrotomy may occur. A hematoma occurs when intra-articular blood escapes the arthrotomy and drains into the overlying soft tissues. This may occur following performance of a large lateral release or an insufficient arthrotomy closure or simply secondary to a large hemarthrosis under tension. Symptoms include ecchymosis, soft tissue swelling, and potential skin complications. Increased pain and limited range of motion frequently accompany these symptoms. Wound drainage may present as a knee that continues to have bloody or serous drainage that continues long after the first or second dressing change. It is this continued wound drainage that is most worrisome with increased wound infection rates when prolonged drainage is allowed to persist. The incidence of post-operative hemarthrosis as a clinical problem is not well studied, but the need for surgical treatment is uncommon. Recurrent hemarthrosis is also relatively rare after total knee arthroplasty and has been reported at rates between 0.3% and 1.6%. The etiology of this complication can be systemic or local, and initial work-up should include coagulation studies to rule out any underling systemic coagulopathy. Conservative therapy including rest, cooling, and elevation is the preferred treatment for mild cases. If conservative treatment is not successful, or the acute hemarthrosis is clinically tense, interfering with recovery, or threatening wound healing, drainage may be the preferable option. This can be done by opening the arthrotomy in the operating room or through a large bore arthroscopy cannulae. Careful attention to debridement of clotted blood must be followed by a meticulous search for potential sources of bleeding which should be managed appropriately. Recurrent hemarthrosis may occur at any time after surgery. Repeated bleeding episodes may lead to an inflammatory cascade that propagates bleeding events more readily. If coagulation studies are normal, the most common source is the impingement of proliferative synovium or other retained soft tissue between the articulating components of the knee prosthesis. Other causes include damage to the geniculate or popliteal vessels with pseudo aneurysm formation. Mild to moderate clinical knee instability may be associated with bloody synovial effusions but limited clinical complaint specific to instability. Other causes may be multifactorial and synergistic but are not well understood, making diagnosis and treatment more difficult. If symptoms persist, and the resulting disability is sufficient, classical treatment has consisted of open or arthroscopic synovectomy. Over the past decade angiography and angiographic embolization of the source of bleeding has been shown to be successful. Radio-active synovectomy has also been successful

Introduction. The aim of this study was to compare the results and length of stay of patients of early (within 12 hours) versus conventional (after 48 hours) ankle fixation our hospital. Methods of study. It was a retrospective study over 18 month period (July 2004 - Dec 2005) including 200 Patients (aged 16 or more). We looked into age, place of living, Weber classification, mechanism of injury, comorbidities especially diabetes, addictions mainly smoking, etc. Overlying skin condition, the amount of swelling at presentation, associated ankle dislocation or talar shift, acute medical comorbidities, injury types-open or closed were classified accordingly. Results. Out of 200 patients, only twenty-two had surgery done within 12 hours (mean length of stay, 3.3 days), and sixty-seven of these had surgery within 48 hours (mean length of stay, 4.9 days), while 111 had surgery after 48 hours (mean length of stay, 9.4 days). Finally we calculated the extra cost (784 bed days - £235,000) incurred to the trust in terms of extra bed occupancy and treating the complications as a result of wait. Main reasons for delay in theatre and discharge were swelling and blisters, delay in transit from Bournemouth A&E, delayed presentation, unavailability of theatre time or cancellation, further imaging required or senior opinion awaited. Conclusion. This study shows that initial delay may cause swelling and blistering to develop which mandates a further delay. Our message about ankle fractures is not to miss the boat and operate before the swelling appears. We want to emphasise on the ‘Window of Opportunity’ ie initial 12 hours to fix the ankle fractures to decrease overall morbidity and cost

[Purpose]. There have been only a few reports about the efficacy of postoperative cryotherapy following total hip arthroplasty (THA), and past studies have described that local cooling is efficacy for pain relief. The purpose of this study is whether the continuous local cooling following THA is effective for pain relief and the reduction of blood loss, swelling, and the duration of hospital stay. [Materials and Methods]. Thirty-eight patients (39 hips) underwent primary cementless THA for osteoarthritis and were divided into a cryotherapy group (30 subjects; from Apr. 2013 to Oct. 2013) and a control group (9 subjects; from Nov. 2012 to Mar. 2013). In the cryotherapy group, a continuous cooling pad was applied on the surgical wound and the thigh with a cloth anchor band (CF-3000, Sigmax, Japan) with the cooling temperature set to a constant 5°C for 72 hours immediately after surgery. Blood was collected on postoperative days 1,4,7,14, and 21 to determine Hb, CK, and CRP levels. Postoperative pain of the hip was scored by using a visual analog scale questionnaire on postoperative days 1 to 28. Total doses of selecoxib and dicrofenac sodium used for pain relief were measured. The circumference of patellar superior border was measured on postoperative days 4,7,14, and 28. The unpaired t-test was used for blood tests as well as for comparisons between the cryotherapy and control groups, and the Mann-Whitney U test was used for the analysis of age, BMI, approach of the surgery, analgesic use, pain scores, the circumference of the thigh and the duration of hospital stay. [Results]. There were no significant differences in age (p = 0.605), BMI (p = 0.790), approach of the surgery (p = 0.572), duration of the surgery (p = 0.117), blood loss during surgery (p = 0.739), or hospital stay (p = 0.169) between the cryotherapy and the control. There were no significant differences between the 2 groups in CK, CRP levels, or pain scores. However, Hb levels measured postoperatively in only day 4 and the total dose of selecoxib was used for pain relief were significantly lower for the cryotherapy group than for the control group, respectively (p = 0.028, p = 0.003), and the total dose of dicrofenac sodium was tend to be significant lower for the cryotherapy group. (p = 0.070). The circumference of patellar superior border measured postoperatively in only day 4 was significantly lower for the cryotherapy group than for the control group (p = 0.010). No complications such as skin problems or neuroparalysis were observed. [Discussion]. This study found the reduction of blood loss, swelling on the patellar superior border, and the total dose of selecoxib for the patients undergoing cryotherapy. However, the pain-relief efficacy of postoperative cryotherapy has not been recognized. Postoperative continuous cryotheraapy is a simple, noninvasive, and effective approach for the reduction of blood loss and swelling following THA

Aims

Adenosine, lidocaine, and Mg²⁺ (ALM) therapy exerts differential immuno-inflammatory responses in males and females early after anterior cruciate ligament (ACL) reconstruction (ACLR). Our aim was to investigate sex-specific effects of ALM therapy on joint tissue repair and recovery 28 days after surgery.

The accessory navicular (AN) is a separate ossification center for the tuberosity of the navicular that is present in approximately 5–14% of the general population. It produces a firm prominence on the plantar-medial aspect of the midfoot. There may be a co-existent flexible flatfoot, but there is no conclusive evidence of a cause-and-effect relationship between the two conditions. It is usually not symptomatic, and few cases necessitate operative intervention. When symptoms require surgical treatment, excision of the AN, with or without advancement of the posterior tibial tendon, usually is considered. To describe new technique of AN excision and tibialis posterior tendon advancement (TPTA) using a bio-absorbable tenodesis screw and to investigate the outcome of this cohort in comparison to conventional simple excision. Retrospective 2 Cohort study. Single surgeon series from single institution. All patients younger than 18 years from Jan 2000 to Aug 2012 undergoing simple excision (SE) or excision with TPTA were identified from the prospectively collected database. Case notes were reviewed and data regarding demographics, indications for surgery, presence of Pes Planus, time from presentation to surgery, length of follow-up, patient satisfaction and complications were recorded. Pain and functional outcome were measured using Visual Analogue Score (VAS) and patient reported outcome measure- Oxford Ankle Foot Questionnaire- Child and Teenager Version. There were 6 patients in SE group. There were 3 males and 3 females. Mean age at surgery was 13.9 years. Surgical indication was painful swelling in all patients and in addition 1 had pes planus. There were 7 in SE & TPTA group. There were 3 males and 4 females. The mean age at surgery was 13.1 years. Surgical indication was painful swelling in all patients and in addition 1 had hind foot rigidity and 3 had pes planus. Postoperative protocol involved weight bearing with or without cast in SE group and non-weight bearing in cast for 6 weeks in TPA group. All patients reported excellent to good outcome. There were no complications and no reoperations after tendon advancement. In conclusion, based on our study findings, we think AN excision and TP advancement is a safe and effective technique for symptomatic pain relief. It is a novel technique which achieved excellent to good outcome in our series

Background:. Role of intra-articular Tranexamic acid in total knee replacement arthroplasty. Materials and methods. Prospective evaluation was done to see the effect of intra-articular Tranexamic acid on blood loss in 60 patients (120 knees) undergoing total knee arthroplasty. All the patients were operated by one surgeon with same technique by using same implants. Patients were randomly injected 1500 mg/20 ml of Tranexamic acid on one side of the knee only. Nothing was injected on the contra lateral knee. Evaluation was done for swelling and the amount of blood loss in the drain. Results:. Average blood loss in the drain on Tranexamic side was 140 ml and the opposite side was 390 ml. Swelling was more observed on the non Tranexamic side. Average time for drain removal on Tranexamic side was 36 hours while it was 48 hours on non Tranexamic side. Early mobilization and weight bearing was less painful in Tranexamic side. No patient had systemic complications of Tranexamic acid. Conclusion:. Intra-articular injection of Tranexamic acid reduces blood loss, swelling around the knee without systemic side effects and allows early weight bearing and mobilization of the joint

Ultrasound screening has shown that the shoulder joint is almost always involved in rheumatoid arthritis. But only few of rheumatoid patients suffering from omarthritis are in considerable pain. Loss of strength and mobility is often compensated by the adjacent joints. Low patients demands, as pain and swelling can be treated often temporarely successfully by corticoid injections and the need of a wide exposure of the shoulder joint when performing an open synovectomy are the reasons of the low rate of synovectomies performed in rheumatoid shoulder joints. The clinical outcome after synovectomies in rheumatoid omarthritis is generally superior to those of knee synovectomies and shows a reliable reduction of pain, swelling and an increase of ROM. The surgical trauma in open synovectomy of the shoulder results in an impairment of the complex muscle co-ordination of the shoulder and a painful long-lasting aftertreatment. This disadvantages can be prevented when using arthroscopic techniques. The advantages of the arthroscopic technique are mostly obvious in the shoulder joint. The reduced surgical trauma of the periarticular tissue leaving the proprioreception intact results in reduced postoperative pain, allowing early mobilisation and shorter rehabilitation. Arthroscopic surgery of the shoulder is performed with the patient in beach- chair position under general anesthesia. We use a standard 5mm arthroscope and a motorised synovial resector. To prevent bleeding it is advantageous to utilise cooled non-ionic irrigation solution with epinephrin in addition pressurised by a roller pump. Synovectomy of the glenohumeral joint and of the subacromial bursa is performed via four portals. Potential hazards like injury to the periarticular vessels and nerves or damage of the joint cartilage especially in stiff shoulders can only be prevented with careful proceeding. Active and passive physiotherapy starts on the first postoperative day. Our first series of 12 shoulder arthroscopies done 1989–1991 was followed 3. 8 years postoperatively. Swelling and pain at rest disappeared rapidly after surgery. Pain during motion took longer to subside. At the end of follow-up patients reported slight pain on motion in five shoulders. Postoperatively all patients reported improvement of pain. There was one recurrence of swelling due to bursitis. In this patient no bursectomy was done during shoulder arthroscopy, which is now done as a routine. There was subjectively and objectively an increase of strength postoperatively. ROM showed immediate postoperative improvement, although a slight reduction was noticed during the follow-up period. In 1990–1999 we performed 52 arthroscopical synovectomies of rheumatoid shoulders. 31 shoulders could be followed by questionnaire at a mean of 6. 5years postoperatively. Pain at rest and pain on motion was improved in about 80% and 74% respectively. Recurrence of swelling was reported by 26% of the patients. Five patients has to be operated again. The clinical outcome compare favourably with the results published about open shoulder synovectomy. Five patients with large humeral cysts were treated with arthroscopic synovectomy, arthroscopically assisted curettage and bone grafting of the cyst via a small incision at the major tuberculum. Until now none of the patients suffered from humeral collaps, no shoulder has to be replaced. In painful rheumatoid omarthritis swelling and pain can be improved reliably with arthroscopic synovectomy. The reduced surgical trauma of minimal invasive synovectomy should raise the rate of early preventive surgery

Aims

While internet search engines have been the primary information source for patients’ questions, artificial intelligence large language models like ChatGPT are trending towards becoming the new primary source. The purpose of this study was to determine if ChatGPT can answer patient questions about total hip (THA) and knee arthroplasty (TKA) with consistent accuracy, comprehensiveness, and easy readability.

Aims

The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients.

1. Two cases of swelling in the popliteal fossa due to a local hypertrophy of the semimembranosus muscle are described and two further cases thought to be of similar nature are noted. 2. The swelling was soft, not tender, fairly well circumscribed, and without signs of inflammation. Its most characteristic feature was an increase in size and hardening of the swelling during active flexion of the knee. 3. This condition should be considered in differential diagnosis of swellings of the popliteal fossa

Paravertebral anaesthesia is a particularly effective, safe and reliable option in scoliosis patients undergoing anterior release in whom percutaneous epidural placement may be difficult to perform. A recent systematic review and meta-analysis of randomized trials has demonstrated that whilst paravertebral block and thoracic epidural insertion provide comparable pain relief after thoracic surgery, paravertebral block placement is associated with a better side effect profile, including a reduction in pulmonary complications, hypotension, nausea and vomiting and urinary retention. We describe a case of a 16 year old female patient who underwent staged correction of her thoracolumbar scoliosis. A paravertebral catheter was inserted under direct vision for continuous infusion post operative analgesia following the anterior release. 48 hours after surgery a swelling was noted in the groin, which was confirmed with ultrasonography as a fluid collection. The swelling resolved upon removing the paravertebral catheter. This suggests that it was caused by the local anaesthetic fluid tracking along the psoas muscle. Retroperitoneal infections, venous thrombosis, femoral hernia, femoral artery aneurysm and inguinal lymphadenopathy are other differentials. Ultrasonography was a fast and sensitive investigation to rule out these differentials and determined that fluid communicating with the abdominal cavity was the cause for this swelling. The infused local anaesthetic had tracked down into the femoral triangle and the swelling resolved upon cessation of the infusion