Aims. Osteochondral lesions of the talus (OLT) are a common cause of disability and chronic ankle pain. Many operative treatment strategies have been introduced; however, they have their own disadvantages. Recently lesion repair using autologous cartilage chip has emerged therefore we investigated the efficacy of particulated autologous cartilage transplantation (PACT) in OLT. Methods. We retrospectively analyzed 32 consecutive symptomatic patients with OLT who underwent PACT with minimum one-year follow-up. Standard preoperative radiography and MRI were performed for all patients. Follow-up second-look arthroscopy or MRI was performed with patient consent approximately one-year postoperatively. Magnetic resonance Observation of Cartilage Repair Tissue (MOCART) score and International Cartilage Repair Society (ICRS) grades were used to evaluate the quality of the regenerated cartilage. Clinical outcomes were assessed using the pain visual analogue scale (VAS), Foot Function Index (FFI), and Foot Ankle Outcome Scale (FAOS). Results. All patients had ICRS grade IV cartilage lesions, except for one (ICRS grade III). The paired MOCART scores significantly improved from 42.5 (SD 1.53) to 63.5 (SD 22.60) (p = 0.025) in ten patients. Seven patients agreed to undergo second-look arthroscopy; 5 patients had grade I (normal) ICRS scores and two patients had grade II (nearly normal) ICRS scores. VAS, FFI, and all subscales of FAOS were significantly improved postoperatively (p ≤ 0.003). Conclusion. PACT significantly improved the clinical, radiological, and morphological outcomes of OLT. We consider this to be a safe and effective surgical method based on the short-term clinical results of this study. Cite this article: Bone Jt Open 2023;4(12):942–947

Aims. In this study, we aimed to visualize the spatial distribution characteristics of femoral head necrosis using a novel measurement method. Methods. We retrospectively collected CT imaging data of 108 hips with non-traumatic osteonecrosis of the femoral head from 76 consecutive patients (mean age 34.3 years (SD 8.1), 56.58% male (n = 43)) in two clinical centres. The femoral head was divided into 288 standard units (based on the orientation of units within the femoral head, designated as N[Superior], S[Inferior], E[Anterior], and W[Posterior]) using a new measurement system called the longitude and latitude division system (LLDS). A computer-aided design (CAD) measurement tool was also developed to visualize the measurement of the spatial location of necrotic lesions in CT images. Two orthopaedic surgeons independently performed measurements, and the results were used to draw 2D and 3D heat maps of spatial distribution of necrotic lesions in the femoral head, and for statistical analysis. Results. The results showed that the LLDS has high inter-rater reliability. As illustrated by the heat map, the distribution of Japanese Investigation Committee (JIC) classification type C necrotic lesions exhibited clustering characteristics, with the lesions being concentrated in the northern and eastern regions, forming a hot zone (90% probability) centred on the N4-N6E2, N3-N6E units of outer ring blocks. Statistical results showed that the distribution difference between type C2 and type C1 was most significant in the E1 and E2 units and, combined with the heat map, indicated that the spatial distribution differences at N3-N6E1 and N1-N3E2 units are crucial in understanding type C1 and C2 necrotic lesions. Conclusion. The LLDS can be used to accurately measure the spatial location of necrotic lesions and display their distribution characteristics. Cite this article: Bone Joint Res 2024;13(6):294–305

Aims. Rotator cuff tear (RCT) is the leading cause of shoulder pain, primarily associated with age-related tendon degeneration. This study aimed to elucidate the potential differential gene expressions in tendons across different age groups, and to investigate their roles in tendon degeneration. Methods. Linear regression and differential expression (DE) analyses were performed on two transcriptome profiling datasets of torn supraspinatus tendons to identify age-related genes. Subsequent functional analyses were conducted on these candidate genes to explore their potential roles in tendon ageing. Additionally, a secondary DE analysis was performed on candidate genes by comparing their expressions between lesioned and normal tendons to explore their correlations with RCTs. Results. We identified 49 genes in torn supraspinatus tendons associated with advancing age. Among them, five age-related genes showed DE in lesioned tendons compared to normal tendons. Functional analyses and previous studies have highlighted their specific enrichments in biological functions, such as muscle development (e.g. myosin heavy chain 3 (MYH3)), transcription regulation (e.g. CCAAT enhancer binding brotein delta (CEBPD)), and metal ion homeostasis (e.g. metallothionein 1X (MT1X)). Conclusion. This study uncovered molecular aspects of tendon ageing and their potential links to RCT development, offering insights for targeted interventions. These findings enhance our understanding of the mechanisms of tendon degeneration, allowing potential strategies to be made for reducing the incidence of RCT. Cite this article: Bone Joint Res 2024;13(9):474–484

Background. It is still controversial whether “labral tear” in the pelvis or “pincer type's femoroacetabular impingement syndrome” should be considered a pathologic lesion, and whether they cause the early onset of osteoarthritis in the pelvis. Hypothesis. The disruption of chondrolabral junction causes degenerative change on hip joint, and the disruption of the vessel tissue to the labrum induces the rapidly progressive degeneration of outside in osteoarthritis changes. Methods. Femoral acetabulum has been escaped from the chondrolabral junction and expanded to the acetabulum inside or outward. Therefore we report the cases. Results. We found cases which has chondrolabral junction disruptive slippage, and disruption of the vessel tissue and inverted or everted labral pathologic lesion, which we named COLADIS, chondrolabral junction disruptive slippage. Conclusion. COLADIS (chondrolabral junction disruptive slippage) caused symptoms on patient's hip, and may be the pre-pathologic lesion of early osteoarthritis

Aims. Osteoarthritis (OA) is a common degenerative joint disease. The osteocyte transcriptome is highly relevant to osteocyte biology. This study aimed to explore the osteocyte transcriptome in subchondral bone affected by OA. Methods. Gene expression profiles of OA subchondral bone were used to identify disease-relevant genes and signalling pathways. RNA-sequencing data of a bone loading model were used to identify the loading-responsive gene set. Weighted gene co-expression network analysis (WGCNA) was employed to develop the osteocyte mechanics-responsive gene signature. Results. A group of 77 persistent genes that are highly relevant to extracellular matrix (ECM) biology and bone remodelling signalling were identified in OA subchondral lesions. A loading responsive gene set, including 446 principal genes, was highly enriched in OA medial tibial plateaus compared to lateral tibial plateaus. Of this gene set, a total of 223 genes were identified as the main contributors that were strongly associated with osteocyte functions and signalling pathways, such as ECM modelling, axon guidance, Hippo, Wnt, and transforming growth factor beta (TGF-β) signalling pathways. We limited the loading-responsive genes obtained via the osteocyte transcriptome signature to identify a subgroup of genes that are highly relevant to osteocytes, as the mechanics-responsive osteocyte signature in OA. Based on WGCNA, we found that this signature was highly co-expressed and identified three clusters, including early, late, and persistently responsive genes. Conclusion. In this study, we identified the mechanics-responsive osteocyte signature in OA-lesioned subchondral bone. Cite this article: Bone Joint Res 2022;11(6):362–370

The management of symptomatic osteochondral lesions of the talus (OLTs) can be challenging. The number of ways of treating these lesions has increased considerably during the last decade, with published studies often providing conflicting, low-level evidence. This paper aims to present an up-to-date concise overview of the best evidence for the surgical treatment of OLTs. Management options are reviewed based on the size of the lesion and include bone marrow stimulation, bone grafting options, drilling techniques, biological preparations, and resurfacing. Although many of these techniques have shown promising results, there remains little high level evidence, and further large scale prospective studies and systematic reviews will be required to identify the optimal form of treatment for these lesions. Cite this article: Bone Joint J 2021;103-B(2):207–212

Aims. The preoperative grading of chondrosarcomas of bone that accurately predicts surgical management is difficult for surgeons, radiologists, and pathologists. There are often discrepancies in grade between the initial biopsy and the final histology. Recent advances in the use of imaging methods have shown promise in the ability to predict the final grade. The most important clinical distinction is between grade 1 chondrosarcomas, which are amenable to curettage, and resection-grade chondrosarcomas (grade 2 and 3) which require en bloc resection. The aim of this study was to evaluate the use of a Radiological Aggressiveness Score (RAS) to predict the grade of primary chondrosarcomas in long bones and thus to guide management. Methods. A total of 113 patients with a primary chondrosarcoma of a long bone presenting between January 2001 and December 2021 were identified on retrospective review of a single oncology centre’s prospectively collected database. The nine-parameter RAS included variables from radiographs and MRI scans. The best cut-off of parameters to predict the final grade of chondrosarcoma after resection was determined using a receiver operating characteristic curve (ROC), and this was correlated with the biopsy grade. Results. A RAS of ≥ four parameters was 97.9% sensitive and 90.5% specific in predicting resection-grade chondrosarcoma based on a ROC cut-off derived using the Youden index. Cronbach’s α of 0.897 was derived as the interclass correlation for scoring the lesions by four blinded reviewers who were surgeons. Concordance between resection-grade lesions predicted from the RAS and ROC cut-off with the final grade after resection was 96.46%. Concordance between the biopsy grade and the final grade was 63.8%. However, when the patients were analyzed based on surgical management, the initial biopsy was able to differentiate low-grade from resection-grade chondrosarcomas in 82.9% of biopsies. Conclusion. These findings suggest that the RAS is an accurate method for guiding the surgical management of patients with these tumours, particularly when the initial biopsy results are discordant with the clinical presentation. Cite this article: Bone Joint J 2023;105-B(7):808–814

Aims. The hypothesis of this study was that bone peg fixation in the treatment of osteochondral lesions of the talus would show satisfactory clinical and radiological results, without complications. Methods. Between September 2014 and July 2017, 25 patients with symptomatic osteochondritis of the talus and an osteochondral fragment, who were treated using bone peg fixation, were analyzed retrospectively. All were available for complete follow-up at a mean 22 of months (12 to 35). There were 15 males and ten females with a mean age of 19.6 years (11 to 34). The clinical results were evaluated using a visual analogue scale (VAS) and the American Orthopaedic Foot and Ankle Society (AOFAS) score preoperatively and at the final follow-up. The radiological results were evaluated using classification described by Hepple et al based on the MRI findings, the location of the lesion, the size of the osteochondral fragment, and the postoperative healing of the lesion. Results. The mean VAS and AOFAS score improved significantly from 6.3 (4 to 8) and 70.6 (44 to 78) preoperatively to 1.6 (0 to 5) and 91.1 (77 to 100) at the final follow-up, respectively (p < 0.001). The classification on MRI was stage 2a in nine patients, stage 3 in 14, and stage 4 in two. The lesion was located on the posteromedial aspect of the dome of the talus in 19 patients, the anterolateral aspect in five, and the centrolateral aspect in one. The mean size of the fragment was 11.2 mm (5 to 20) horizontally, 10.4 mm (7 to 18) vertically, and 5.2 mm (3 to 10) deep, respectively. The postoperative healing state was good in 19 patients and fair in six. Conclusion. Bone peg fixation for osteochondral lesions of the talus showed satisfactory clinical and radiographic results, without complications. This technique could be a good form of treatment for patients with this condition who have an osteochondral fragment. Cite this article: Bone Joint J 2020;102-B(10):1349–1353

A Morel-Lavallee lesion (MLL) is a benign cystic lesion that occurs due to injury to the soft-tissue envelope's perforating vascular and lymphatic systems, resulting in a distinctive hemolymphatic fluid accumulation between the tissue layers. The MLL has the potential to make a significant impact on the treatment of orthopaedic injuries. A 79-year-old male patient community ambulatory with assisting aid (cane) known case of Diabetes mellitus, hypertension, bronchial asthma and ischemic heart disease. He was brought to the Emergency, complaining of right hip discomfort and burning sensation for the last 5 days with no history of recent trauma at all. Patient had history of right trochanteric femur fracture 3 years ago, treated with DHS in a privet service. Clinical and Radiological assessment showed that the patient mostly has acute MLL due to lag screw cut out. We offered the patient the surgical intervention, but he refused despite explaining the risks of complications if not treated and preferred to receive the conservative treatment. Compression therapy management explained to him including biker's shorts (instructed to be worn full-time a day) and regular follow up in clinic. Symptom's improvement was reported by the patient in the subsequent visits. In the polytrauma patient, a delayed diagnosis of these lesions is conceivable due to the presence of more visible injuries. It's located over the greater trochanter more commonly, but sometimes in other areas such as the lower lumbar region, the thigh, or the calf. Incorrect or delayed diagnosis and care can have unfavorable outcomes such as infection, pseudocyst development, and cosmetologically deformity. Magnetic resonance imaging (MRI) and ultrasound will aid in MLL diagnosis. However, the effectiveness of MLL therapy remains debatable. We strongly believe that the MLL caused due to tangential shear forces applied to the soft tissue leads to accumulation of the blood and/or lymph between the subcutaneous and overlying fascia and it often misdiagnosed due to other distracting injuries. Nontheless, in our case we reported MLL occur due to internal pressure on the fascia caused by cut out of DHS lag screw

Aims. The aim of this study was to evaluate the outcome of Monteggia-like lesions at midterm follow-up and to determine whether the surgical treatment of the radial head influences the clinical and radiological results. Patients and Methods. A total of 78 patients with a Monteggia-like lesion, including 44 women and 34 men with a mean age of 54.7 years (19 to 80), were available for assessment after a mean 4.6 years (2 to 9.2). The outcome was assessed using the Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), Mayo Modified Wrist Score (MMWS), and The Disabilities of the Arm, Shoulder and Hand (DASH) score. Radiographs were analyzed for all patients. A total of 12 Mason type I, 16 type II, and 36 type III fractures were included. Surgical treatment consisted of screw fixation for all type II and reconstructable type III fractures, while radial head arthroplasty (RHA) or excision was performed if reconstruction was not possible. Results. The mean MEPS was 88.9 (40 to 100), mean OES was 40.1 (25 to 48), mean MMWS was 88.1 (50 to 100), mean DASH score was 14.7 (0 to 60.2), and mean movement was 114° (. sd. 27) in extension/flexion and 155° (. sd. 37) in pronation/supination. Mason III fractures, particularly those with an associated coronoid fracture treated with RHA, had a significantly poorer outcome. Suboptimal results were also identified in patients who had degenerative changes or heterotopic ossification on their latest radiograph. In contrast, all patients with successful radial head reconstruction or excision had a good outcome. Conclusion. Good outcomes can be achieved in Monteggia-like lesions with Mason II and III fractures, when reconstruction is possible. Otherwise, RHA is a reliable option with satisfactory outcomes, especially in patients with ligamenteous instability. Whether the radial head should be excised remains debatable, although good results were achieved in patients with ligamentous stability and in those with complications after RHA. Cite this article: Bone Joint J 2019;101-B:1512–1519

Aims. Metal particles detached from metal-on-metal hip prostheses (MoM-THA) have been shown to cause inflammation and destruction of tissues. To further explore this, we investigated the histopathology (aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL) score) and metal concentrations of the periprosthetic tissues obtained from patients who underwent revision knee arthroplasty. We also aimed to investigate whether accumulated metal debris was associated with ALVAL-type reactions in the synovium. Methods. Periprosthetic metal concentrations in the synovia and histopathological samples were analyzed from 230 patients from our institution from October 2016 to December 2019. An ordinal regression model was calculated to investigate the effect of the accumulated metals on the histopathological reaction of the synovia. Results. Median metal concentrations were as follows: cobalt: 0.69 μg/g (interquartile range (IQR) 0.10 to 6.10); chromium: 1.1 μg/g (IQR 0.27 to 4.10); and titanium: 1.6 μg/g (IQR 0.90 to 4.07). Moderate ALVAL scores were found in 30% (n = 39) of the revised knees. There were ten patients with an ALVAL score of 6 or more who were revised for suspected periprosthetic joint infection (PJI), aseptic loosening, or osteolysis. R2 varied between 0.269 and 0.369 for the ordinal regression models. The most important variables were model type, indication for revision, and cobalt and chromium in the ordinal regression models. Conclusion. We found that metal particles released from the knee prosthesis can accumulate in the periprosthetic tissues. Several patients revised for suspected culture-negative PJI had features of an ALVAL reaction, which is a novel finding. Therefore, ALVAL-type reactions can also be found around knee prostheses, but they are mostly mild and less common than those found around metal-on-metal prostheses. Cite this article: Bone Joint Res 2024;13(4):149–156

Introduction. The ankle cartilage has an important function in walking movements, mainly in sports; for active young people, between 20 and 30 years old, the incidence of osteochondral lesions is more frequent. They are also more frequent in men, affecting around 21,000 patients per year in USA with 6.5% of ankle injuries generating osteochondral lesions. The lesion is a result of ankle sprain and is most frequently found in the medial location, in 53% of cases. The main objective of this work was to develop an experimental and finite element models to study the effect of the ankle osteochondral lesion on the cartilage behavior. Materials and Methods. The right ankle joint was reconstructed from an axial CT scan presenting an osteochondral lesion in the medial position with 8mm diameter in size. An experimental model was developed, to analyze the strains and influence of lesion size and location similar to the patient. The experimental model includes two cartilages constructed by Polyjet™ 3D printing from rubber material (young modulus similar to cartilage) and bone structures from a rigid polymer. The cartilage was instrumented with two rosettes in the medial and lateral regions, near the osteochondral region. The fluid considered was water at room temperature and the experimental test was run at 1mm/s. The Finite element model (FE) includes all the components considered in the experimental apparatus and was assigned the material properties of bone as isotropic and linear elastic materials; and the cartilage the same properties of rubber material. The fluid was simulated as hyper-elastic one with a Mooney-Rivlin behavior, with constants c1=0.07506 and c2=0.00834MPa. The load applied was 680N in three positions, 15º extension, neutral and 10º flexion. Results. The experimental strain measured in the cartilage in the rosettes presents similar behavior in all experiments and repetitions. The maximum value observed near the osteochondral lesion was 3014(±5.6)µε in comparison with the intact condition it was 468 (±1.95)µε. The osteochondral lesion increases the strains around 6.5 times and the synovial liquid reduces the intensity of strain distribution. The numerical model presents a good correlation with the experiments (R2 0.944), but the FE model underestimates the values. Discussion and conclusion. As a first conclusion, the size of the osteochondral lesion is important for the strains developed in cartilage. The size of lesion greater than 10mm is critical for the strains concentration. The synovial fluid present an important aspect in the strains measured, it reduces the strains in the external surface of cartilage and induces an increase in the lower part. This phenomenon should be addressed in more studies to evaluate this effect

A number of causes have been advanced to explain the destructive discovertebral (Andersson) lesions that occur in ankylosing spondylitis, and various treatments have been proposed, depending on the presumed cause. The purpose of this study was to identify the causes of these lesions by defining their clinical and radiological characteristics. We retrospectively reviewed 622 patients with ankylosing spondylitis. In all, 33 patients (5.3%) had these lesions, affecting 100 spinal segments. Inflammatory lesions were found in 91 segments of 24 patients (3.9%) and traumatic lesions in nine segments of nine patients (1.4%). The inflammatory lesions were associated with recent-onset disease; a low modified Stoke ankylosing spondylitis spine score (mSASSS) due to incomplete bony ankylosis between vertebral bodies; multiple lesions; inflammatory changes on MRI; reversal of the inflammatory changes and central bony ankylosis at follow-up; and a good response to anti-inflammatory drugs. Traumatic lesions were associated with prolonged disease duration; a high mSASSS due to complete bony ankylosis between vertebral bodies; a previous history of trauma; single lesions; nonunion of fractures of the posterior column; acute kyphoscoliotic deformity with the lesion at the apex; instability, and the need for operative treatment due to that instability. It is essential to distinguish between inflammatory and traumatic Andersson lesions, as the former respond to medical treatment whereas the latter require surgery

Aims. Reconstruction of the acetabulum after resection of a periacetabular malignancy is technically challenging and many different techniques have been used with varying success. Our aim was to prepare a systematic review of the literature dealing with these techniques in order to clarify the management, the rate of complications and the outcomes. Patients and Methods. A search of PubMed and MEDLINE was conducted for English language articles published between January 1990 and February 2017 with combinations of key search terms to identify studies dealing with periacetabular resection with reconstruction in patients with a malignancy. Studies in English that reported radiographic or clinical outcomes were included. Data collected from each study included: the number and type of reconstructions, the pathological diagnosis of the lesions, the mean age and follow-up, gender distribution, implant survivorship, complications, functional outcome, and mortality. The results from individual studies were combined for the general analysis, and then grouped according to the type of reconstruction. . Results. A total of 57 studies met the inclusion criteria and included 1700 patients. Most lesions were metastatic (41%), followed by chondrosarcoma (29%), osteosarcoma (10%), Ewing’s sarcoma (7%), and multiple myeloma (2%). The techniques of reconstruction were divided into seven types for analysis: those involving a Harrington reconstruction, a saddle prosthesis, an allograft and allograft prosthesis composite, a pasteurised autograft, a porous tantalum implant, a custom-made prosthesis and a modular hemipelvic reconstruction. The rate of complications was 50%, with infection (14%) and instability (8%) being the most common. Mortality data were available for 1427 patients (84%); 50% had died of disease progression, 23% were alive with disease, and 27% had no evidence of disease at a mean follow-up of 3.4 years (0 to 34). . Conclusion. Both the rate of complications and mortality are high following resection of oncological periacetabular lesions and reconstruction. Many types of reconstruction have been used with unique challenges and complications for each technique. Newer prostheses, including custom-made prostheses and porous tantalum implants and augments, have shown promising early functional and radiographic outcomes. . Cite this article: Bone Joint J 2018;100-B(1 Supple A):22–30

Osteochondral lesions (OCLs) occur in up to 70% of sprains and fractures involving the ankle. Atraumatic aetiologies have also been described. Techniques such as microfracture, and replacement strategies such as autologous osteochondral transplantation, or autologous chondrocyte implantation are the major forms of surgical treatment. Current literature suggests that microfracture is indicated for lesions up to 15 mm in diameter, with replacement strategies indicated for larger or cystic lesions. Short- and medium-term results have been reported, where concerns over potential deterioration of fibrocartilage leads to a need for long-term evaluation. . Biological augmentation may also be used in the treatment of OCLs, as they potentially enhance the biological environment for a natural healing response. Further research is required to establish the critical size of defect, beyond which replacement strategies should be used, as well as the most appropriate use of biological augmentation. This paper reviews the current evidence for surgical management and use of biological adjuncts for treatment of osteochondral lesions of the talus. . Cite this article: Bone Joint J 2014;96-B:164–71

Aims

Patients with differentiated thyroid carcinomas (DTCs) have a favourable long-term survival. Spinal metastases (SMs) cause a decline in performance status (PS), directly affecting mortality and indirectly preventing the use of systemic therapies. Metastasectomy is indicated, if feasible, as it yields the best local tumour control. Our study aimed to examine the long-term clinical outcomes of metastasectomy for SMs of thyroid carcinomas.

Cartilage lesions occur as a result of joint trauma, and progressively degenerate over time leading to osteoarthritis (OA). Early intervention therapies to repair the initial tissue damage have the potential to delay or prevent the onset of OA. We have developed two acellular treatments; 1) an injectable proteoglycan-like self-assembling hydrogel for the repair of ICRS grade 1 lesions, and 2) a decellularised xenogeneic osteochondral scaffold for surgical grafting in grade 2–4 lesions. We produced an in vitro glycosaminoglycan depleted grade 1 lesion model using porcine cartilage. Peptide-chondroitin sulphate mixture was injected and spontaneously gelled in situ. Cartilage resistance to deformation was increased by 50 %. Decellularised porcine osteochondral scaffolds which maintain the native tissue composition and architecture whilst being immunocompatible were successfully developed and are currently undergoing in vivo assessment in an ovine critical size condylar defect model. Incorporation of the subchondral bone in osteochondral scaffolds is intended to improve osseointegration; implanted decellularised bone-only scaffolds in sheep exhibited superb osteoinductive and osteoconductive properties in a proof-of-concept study. We envisage that our early intervention therapies will be employed clinically to maintain or restore functional hyaline-like cartilage across the whole range of early chondral pathologies and prevent the onset of OA

Aims. The aims of this study were to evaluate the morphology of the ankle in patients with an osteochondral lesion of the talus using 3D CT, and to investigate factors that predispose to this condition. Patients and Methods. The study involved 19 patients (19 ankles) who underwent surgery for a medial osteochondral lesion (OLT group) and a control group of 19 healthy patients (19 ankles) without ankle pathology. The mean age was significantly lower in the OLT group than in the control group (27.0 vs 38.9 years; p = 0.02). There were 13 men and six women in each group. 3D CT models of the ankle were made based on Digital Imaging and Communications in Medicine (DICOM) data. The medial malleolar articular and tibial plafond surface, and the medial and lateral surface area of the trochlea of the talus were defined. The tibial axis-medial malleolus (TMM) angle, the medial malleolar surface area and volume (MMA and MMV) and the anterior opening angle of the talus were measured. Results. The mean TMM angle was significantly larger in the OLT group (34.2°, . sd. 4.4°) than in the control group (29.2°, . sd. 4.8°; p = 0.002). The mean MMA and MMV were significantly smaller in the OLT group than in the control group (219.8 mm. 2. , . sd. 42.4) vs (280.5 mm. 2. , . sd. 38.2), and (2119.9 mm. 3. , . sd. 562.5) vs (2646.4 mm. 3. , . sd. 631.4; p < 0.01 and p = 0.01, respectively). The mean anterior opening angle of the talus was significantly larger in the OLT group than in the control group (15.4°, . sd. 3.9°) vs (10.2°, . sd. 3.6°; p < 0.001). Conclusion. 3D CT measurements showed that, in patients with a medial osteochondral lesion of the talus, the medial malleolus opens distally, the MMA and MMV are small, and the anterior opening angle of the talus is large. This suggests that abnormal morphology of the ankle predisposes to the development of osteochondral lesions of the talus. Cite this article: Bone Joint J 2018;100-B:1487–90

Purpose: To compare the site of lesions in medial and lateral unicompartmental osteoarthritis (OA) of the knee. Methods: Patients with medial (n=35) and lateral (n=15) OA, having unicompartmental knee arthroplasty, were recruited. Intra-operatively, the distance between the anterior, posterior, medial and lateral margins of the full-thickness lesion and reference lines dividing the condyles was measured. The midpoints of lesions were calculated and groups were compared. Lateral radiographs were used to determine the relationship between the lesion site and knee flexion angle (KFA). Results: Femoral lesion: In lateral OA, the midpoint of lesions was 25.0mm (SD:8.8) posterior to the reference line passing transversely through the apex of the inter-condylar notch. This was significantly different (p< 0.001) from midpoint in medial OA, which was 10.7mm (SD:9.4) posterior to the reference line. Tibial lesion: In lateral OA, the midpoint of lesions was 2.0mm (SD:6.5) posterior to the reference line passing through the mid-coronal plane of the resected tibia. This was located significantly more posterior (p=0.038) than midpoint in medial OA, which was 2.2mm (SD:5.7) anterior to the reference line. Knee Flexion Angle: In lateral OA, the midpoint of lesions was on average at 40° flexion and sites of smaller lesions were very variable. The lesion expanded both anteriorly and posteriorly. In medial OA, smaller femoral lesions occurred in full extension and extended further posteriorly with disease progression. No significant difference was demonstrated in medial and lateral localisation of the lesions. Conclusion: Medial OA begins near full extension, progresses in a predictable manner and is perhaps initiated by events occurring at heel strike. Lateral OA begins in flexion in a less predictable manner, at KFA above that seen during the gait cycle. The different sites of lesions in medial and lateral OA suggest different aetiology and pathophysiology. Therefore, prevention and treatment strategies should be different

Our aim in this prospective study was to determine the best diagnostic method for discriminating between patients with and without osteochondral lesions of the talus, with special relevance to the value of MRI compared with the new technique of multidetector helical CT. We compared the diagnostic value of history, physical examination and standard radiography, a 4 cm heel-rise view, helical CT, MRI, and diagnostic arthroscopy for simultaneous detection or exclusion of osteochondral lesions of the talus. A consecutive series of 103 patients (104 ankles) with chronic ankle pain was included in this study. Of these, 29 with 35 osteochondral lesions were identified. Twenty-seven lesions were located in the talus. Our findings showed that helical CT, MRI and diagnostic arthroscopy were significantly better than history, physical examination and standard radiography for detecting or excluding an osteochondral lesion. Also, MRI and diagnostic arthroscopy performed better than a mortise view with a 4 cm heel-rise. We did not find a statistically significant difference between helical CT and MRI. Diagnostic arthroscopy did not perform better than helical CT and MRI for detecting or excluding an osteochondral lesion

We investigated the incidence of soft-tissue lesions after small head metal-on-metal total hip replacement (MoM THR). Between December 1993 and May 1999, 149 patients (195 hips) underwent primary cementless MoM THR. During the follow-up period, three patients (five THRs) died and eight patients (14 THRs) were lost to follow-up. We requested that all patients undergo CT evaluation. After exclusion of five patients (six THRs) who had undergone a revision procedure, and 22 (28 THRs) who were unwilling to take part in this study, 111 patients (142 THRs) were evaluated. There were 63 men (88 THRs) and 48 women (54 THRs) with a mean age of 45.7 years (37 to 56) at the time of surgery. The mean follow-up was 15.4 years (13 to 19). A soft-tissue lesion was defined as an abnormal peri-prosthetic collection of fluid, solid lesion or asymmetrical soft-tissue mass. At final follow-up, soft-tissue lesions were found in relation to 28 THRs (19.7%), including 25 solid and three cystic lesions. They were found in 20 men and eight women; 26 lesions were asymptomatic and two were symptomatic. The mean maximal diameter of the soft-tissue lesion was 42.3 mm (17 to 135). The relatively high rate of soft-tissue lesions observed with small head MoM THR remains a concern. Cite this article: Bone Joint J 2014;96-B:1594–9

ONFH with large or lateral-located lesion is challenging due to difficulty of regeneration. We introduce novel tissue engineering technique using ex vivo expanded bone marrow stromal cell seeded on calcium metaphosphate (CMP) scaffold to regenerate dead bone for these challenging cases. Ten millilitres of bone marrow was aspirated from iliac crest and mononuclear cells were collected. These cells were expanded and differentiated to osteoblast-lineage cells using osteogenic media and autologous serum for 2–4 weeks ex vivo. Porous bead-form scaffolds were made of CMP and cells were seeded in a density of million/ml³ into 20 to 30 beads for 1 hour. The necrotic area was curetted and the beads were implanted through core tract in 9 hips (Steinberg IIc in 5 hips and IVc in 4 hips which involved greater than 30% of whole head; JIC classification C1 in 4 hips, and C2 in 5 hips which involved weight bearing area). The tract was blocked with a CMP rod. The age of patients ranged from 16 to 37. Associated factors were; steroid in 4, idiopathic in 3, alcoholic in 1 and traumatic in 1 hip, respectively. Kerboul combined necrotic angle was more than 200° in all hips. We compared preoperative and annual radiographs and MRI images to check dome depression of femoral head and signal change of osteonecrotic area. Follow-up period ranged from 8 to 14 years. Two IIc lesions progressed and were converted to THA at two and six years postoperatively. We could get clinical and radiographic success in 7 hips (78%). Follow-up radiographs and MRI showed partial or nearly complete regeneration of necrotic bone, prevention of collapse, and reduction in necrotic lesion. This can be a good strategy for bone regeneration of unmet need as in a human model

Hill-Sachs and reverse Hill-Sachs lesions come in different shapes and sizes, and their effect on “glenoid track” can vary. Small Hill-Sachs lesions that do not engage can be successfully treated with a Bankart repair alone done arthroscopically or open. Moderate, engaging, Hill-Sachs lesions can be treated either with the addition of remplissage to an arthroscopic Bankart or by adding the triple blocking effect of the Bristow-Latarjet procedure. Surface replacements vary in size from the small hemi-cap type of procedure to an entire humeral head replacement (HHR). These devices can be used as opposed to allograft replacement when the risk of post-reconstruction arthritis is high with the aforementioned more conventional treatment techniques. When 45% or more of the humeral head is involved with the lesion, or Outerbridge stage III and IV changes prevail, a HHR is preferred. An oval shaped HHR is the author's preference, and the long diameter can be used to provide coverage anteriorly or posteriorly and is particularly useful in large Hill-Sachs lesions associated with epilepsy

The Hill-Sachs lesion is a bony defect of the humeral head that occurs in association with anterior instability of the glenohumeral joint. Hill-Sachs lesions are common, with an incidence approaching nearly 100% in the setting of recurrent anterior glenohumeral instability. However, the indications for surgical management are very limited, with less than 10% of anterior instability patients considered for treatment of the Hill-Sachs lesion. Of utmost importance is addressing bone loss on the anterior-inferior glenoid, which is highly successful at preventing recurrence of instability even with humeral bone loss. In the rare situation where the Hill-Sachs lesion may continue to engage the glenoid, surgical management is indicated. Surgical strategies are variable, including debridement, arthroscopic remplissage, allograft transplantation, surface replacement, and arthroplasty. Given that the population with these defects is typically comprised of young and athletic patients, biologic solutions are most likely to be associated with decades of sustainable joint preservation, function, and stability. The first priority is maximizing the treatment of anterior instability on the glenoid side. Then, small lesions of less than 10% are ignored without consequence. Lesions involving 10–20% of the humeral head are treated with arthroscopic remplissage (defect filled with repair of capsule and infraspinatus). Lesions greater than 20% that extend beyond the glenoid tract are managed with fresh osteochondral allografts to biologically restore the humeral head. Lesions great than 40% are most commonly associated with advanced arthritis and deformity of the humeral articular surface and are therefore treated with a humeral head replacement. This treatment algorithm maximises our ability to stabilise and preserve the glenohumeral joint

There have been considerable recent advances in the understanding and management of femoroacetabular impingement and associated labral and chondral pathology. We have developed a classification system for acetabular chondral lesions. In our system, we use the six acetabular zones previously described by Ilizaliturri et al. The cartilage is then graded on a scale of 0 to 4 as follows: grade 0, normal articular cartilage lesions; grade 1, softening or wave sign; grade 2, cleavage lesion; grade 3, delamination; and grade 4, exposed bone. The site of the lesion is further classed as A, B or C based on whether the lesion is less than one-third of the distance from the acetabular rim to the cotyloid fossa, one-third to two-thirds of the same distance and greater than two-thirds of the distance, respectively. In order to validate the classification system, six surgeons graded ten video recordings of hip arthroscopy. Our findings showed a high intra-observer reliability of the classification system with an intraclass correlation coefficient of 0.81 and a high interobserver reliability with an intraclass correlation coefficient of 0.88. We have developed a simple reproducible classification system for lesions of the acetabular cartilage, which it is hoped will allow standardised documentation to be made of damage to the articular cartilage, particularly that associated with femoroacetabular impingement

Previously, we showed that case-specific non-linear finite element (FE) models are better at predicting the load to failure of metastatic femora than experienced clinicians. In this study we improved our FE modelling and increased the number of femora and characteristics of the lesions. We retested the robustness of the FE predictions and assessed why clinicians have difficulty in estimating the load to failure of metastatic femora. A total of 20 femora with and without artificial metastases were mechanically loaded until failure. These experiments were simulated using case-specific FE models. Six clinicians ranked the femora on load to failure and reported their ranking strategies. The experimental load to failure for intact and metastatic femora was well predicted by the FE models (R. 2. = 0.90 and R. 2. = 0.93, respectively). Ranking metastatic femora on load to failure was well performed by the FE models (τ = 0.87), but not by the clinicians (0.11 < τ < 0.42). Both the FE models and the clinicians allowed for the characteristics of the lesions, but only the FE models incorporated the initial bone strength, which is essential for accurately predicting the risk of fracture. Accurate prediction of the risk of fracture should be made possible for clinicians by further developing FE models.

We reviewed, retrospectively, 65 patients who had undergone arthroscopic treatment for osteochondral lesions of the talus. The 46 men and 19 women with a mean age at operation of 34.25 years, were followed up for a mean of 3.5 years. The medial aspect was affected in 45 patients and the lateral aspect in 20. All the lateral lesions and 35 (75%) of the medial lesions were traumatic in origin. Medial lesions presented later than lateral lesions (3 v 1.5 years) and had a much greater incidence of cystic change (46% v 8%). At follow-up, 34 patients had achieved a good result, and 17 and 14 fair and poor results, respectively. Of the 14 poor results, 13 involved medial lesions. Cystic lesions had a poor outcome in 53% of patients. Excision and curettage led to better results than excision and drilling of the base. Further arthroscopic surgery for patients with a poor result was disappointing. There was no association between outcome and the patient’s age

Objectives. We have encountered patients who developed large joint fluid collections with massive elevations in chromium (Cr) and cobalt (Co) concentrations following metal-on-metal (MoM) hip arthroplasties. In some cases, retrieval analysis determined that these ion concentrations could not be explained simply by the wear rates of the components. We hypothesized that these effects may be associated with aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL). Patients and Methods. We examined the influence of the ALVAL grade on synovial fluid Co and Cr concentrations following adjustment for patient and device variables, including volumetric wear rates. Initially restricting the analysis to include only patients with one MoM hip resurfacing device, we performed multiple regression analyses of prospectively collected data. We then repeated the same statistical approach using results from a larger cohort with different MoM designs, including total hip arthroplasties. Results. In the resurfacing cohort (n = 76), the statistical modelling indicated that the presence of severe ALVAL and a large fluid collection were associated with greater joint fluid Co concentrations after adjustment for volumetric wear rates (p = 0.005). These findings were replicated in the mixed implant group (n = 178), where the presence of severe ALVAL and a large fluid collection were significantly associated with greater fluid Co concentrations (p < 0.001). Conclusion. The development of severe ALVAL is associated with elevations in metal ion concentrations far beyond those expected from the volumetric loss from the prosthetic surfaces. This finding may aid the understanding of the sequence of events leading to soft-tissue reactions following MoM hip arthroplasties. Cite this article: D. J. Langton, R. P. Sidaginamale, T. J. Joyce, J. G. Bowsher, J. P. Holland, D. Deehan, A. V. F. Nargol, S. Natu. Aseptic lymphocyte-dominated vasculitis-associated lesions are related to changes in metal ion handling in the joint capsules of metal-on-metal hip arthroplasties. Bone Joint Res 2018;7:388–396. DOI: 10.1302/2046-3758.76.BJR-2018-0037

We have previously shown that cytological diagnosis based on fine-needle aspiration biopsy (FNAB) is a safe and efficient method for the discrimination between benign, primary malignant and metastatic bony lesions. We have now studied metastatic lesions to assess the diagnostic accuracy and to ascertain whether FNAB allows identification of the primary lesion. Between 1990 and 1997, 447 patients were referred for diagnosis of skeletal lesions of unknown type. Of these 119 proved to have metastatic disease, either myeloma or lymphoma. Nine were excluded leaving 110 consecutive patients with metastatic carcinoma (80), myeloma (16) or lymphoma (14). FNAB gave a correct diagnosis in 102 of the 110 patients (93%). In eight it was inconclusive. It correctly diagnosed 15 of 16 patients with myeloma, 12 of 14 with lymphoma, and 75 of 80 with metastatic carcinoma. Furthermore, the site and type of malignancy were correctly suggested in two-thirds of patients with metastatic carcinoma. Overall, only seven open biopsies were carried out. We conclude that time-consuming and costly investigations can be reduced by choosing FNAB as the initial diagnostic method for skeletal lesions of unknown origin. The choice of radiological examinations, laboratory tests and surgical biopsies can be determined by using FNAB

The treatment of osteochondral lesions is of great interest to orthopaedic surgeons because most lesions do not heal spontaneously. We present the short-term clinical outcome and MRI findings of a cell-free scaffold used for the treatment of these lesions in the knee. A total of 38 patients were prospectively evaluated clinically for two years following treatment with an osteochondral nanostructured biomimetic scaffold. There were 23 men and 15 women; the mean age of the patients was 30.5 years (15 to 64). Clinical outcome was assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Tegner activity scale and a Visual Analgue scale for pain. MRI data were analysed based on the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring system at three, 12 and 24 months post-operatively. There was a continuous significant clinical improvement after surgery. In two patients, the scaffold treatment failed (5.3%) There was a statistically significant improvement in the MOCART precentage scores. The repair tissue filled most of the defect sufficiently. We found subchondral laminar changes in all patients. Intralesional osteophytes were found in two patients (5.3%). We conclude that this one-step scaffold-based technique can be used for osteochondral repair. The surgical technique is straightforward, and the clinical results are promising. The MRI aspects of the repair tissue continue to evolve during the first two years after surgery. However, the subchondral laminar and bone changes are a concern. Cite this article: Bone Joint J 2015; 97-B:318–23

We evaluated the histological changes before and after fixation in ten knees of ten patients with osteochondritis dissecans who had undergone fixation of the unstable lesions. There were seven males and three females with a mean age of 15 years (11 to 22). The procedure was performed either using bio-absorbable pins only or in combination with an autologous osteochondral plug. A needle biopsy was done at the time of fixation and at the time of a second-look arthroscopy at a mean of 7.8 months (6 to 9) after surgery. The biopsy specimens at the second-look arthroscopy showed significant improvement in the histological grading score compared with the pre-fixation scores (p < 0.01). In the specimens at the second-look arthroscopy, the extracellular matrix was stained more densely than at the time of fixation, especially in the middle to deep layers of the articular cartilage. Our findings show that articular cartilage regenerates after fixation of an unstable lesion in osteochondritis dissecans

The incidence of horizontal cleavage lesions of the menisci was studied in 100 random necropsy examinations. Sixty per cent of subjects had at least one such tear, the incidence being 29 per cent out of the 400 menisci. Eighty-five per cent of the subjects showed changes of osteoarthritis in the patello-femoral or tibio-femoral joint compartments. The coincidence of horizontal cleavage lesion and osteoarthritis was frequent. Horizontal cleavage lesions were commoner in medial or larger menisci and in males. Eighteen per cent of the menisci were calcified and this was twice as common in those menisci with a degenerate tear. Because the horizontal cleavage lesion was so common in the older knee, it must usually remain unrecognised clinically with other factors causing symptoms of night pain and tenderness

Purpose: The purpose of this study is to examine the rate of Buford complex in a consecutive series of patients with arthroscopic Bankart repair and to evaluate the postoperative outcome compared to a group of patients without this anatomical variation. Material and Method: The surgical findings of 138 consecutive shoulder arthroscopies for Bankart lesions were prospective evaluated between January 2005 and January 2007; the mean of age was 25 years old (range 14–52). The criteria used to establish the diagnosis of Buford Complex included: cordlike middle glenohumeral ligament inserted in the superior labrum and attached to the biceps tendon, and complete absence of anterosuperior labrum. Postoperative outcomes were evaluated with Rowe score. Results: Five out of 138 patients (3.6%) presented a Buford complex associated to a Bankart lesion. Four of these patients (80%) presented a type II SLAP lesion. The follow up was 28 months (range 19–40 months). In the group of patients with the Buford complex the Rowe score had a mean of 75 points (range:45–95), 2 patients (40%) presented re-dislocation whereas in the other group the Rowe score had a mean 88 points (range: 25–100) and 9 cases (6.5%) had re-dislocation (P< 0.05). Conclusion: The rate of complex of Buford associated to Bankart lesion was of 3.6%. The presence of complex of Buford in our series was associated to worse functional postoperative outcomes

The aim of this pilot study was to evaluate the accuracy of two different methods of navigated retrograde drilling of talar lesions. Artificial osteochondral talar lesions were created in 14 cadaver lower limbs. Two methods of navigated drilling were evaluated by one examiner. Navigated Iso-C. 3D. was used in seven cadavers and 2D fluoroscopy-based navigation in the remaining seven. Of 14 talar lesions, 12 were successfully targeted by navigated drilling. In both cases of inaccurate targeting the 2D fluoroscopy-based navigation was used, missing lesions by 3 mm and 5 mm, respectively. The mean radiation time was increased using Iso-C. 3D. navigation (23 s; 22 to 24) compared with 2D fluoroscopy-based navigation (14 s, 11 to 17)

The classic Hill-Sachs lesion is a compression or impression fracture of the humeral head in occurrence with anterior glenohumeral instability. The true incidence is unknown but clearly increases with recurrent instability episodes. Recent peer-reviewed literature has highlighted the importance of addressing “significant” humeral and glenoid bone defects in the management of glenohumeral instability. Quantification of the “significance” of a Hill-Sachs lesion with regard to location, size, and depth in relation to the glenoid has helped guide indications for surgical management. Options for managing Hill-Sachs lesions include both humeral-sided techniques (soft tissue, bone, and/or prosthetic techniques) and also glenoid-sided techniques (bone transfers to increase glenoid width). The majority of significant acute or chronic Hill-Sachs lesions can be effectively managed without prosthetic replacement. Is a prosthetic surface replacement ever indicated for the management of Hill-Sachs lesions? The peer-reviewed literature is sparse with the outcomes of this treatment, and significant consideration must be given to both the age of the patient and the need for such management when other effective non-prosthetic options exist. In a patient with more than half of the humeral head involved after instability episodes (perhaps seizure or polytrauma patients), metallic surface replacement arthroplasty may be an option that could require less involved post-operative care while restoring range of motion and stability

Purpose of Study. We report the outcome of five cases of chronic paediatric Monteggia lesion treated with a modified Bell-Tawse procedure. Methods. Five patients with a chronic Monteggia lesion were treated over an eight-year period (2004–2012) at our institution. All underwent a modified Bell-Tawse procedure. The patient medical records were retrospectively analysed. We report the outcome in five patients. Results. Four girls and one boy were treated for a chronic Monteggia lesion in the period studied. The mean age at time of surgery was 8 years old (range 4–14 years). The mechanism of injury was post-traumatic in four of the five cases, while in one case the mechanism was uncertain. All children underwent modified Bell-Tawse procedure. All children ultimately required ulnar osteotomy, while two also required radial osteotomy. At a mean follow-up of 22 months (range 16–38 months), four children had experienced complications. Symptomatic metalwork was removed in one case, two children re-dislocated the affected joint, and one child required revision Bell-Tawse procedure. No nerve palsies were noted on follow-up. Conclusion. Paediatric elbow trauma necessitates early, senior management. We report a series of five patients who underwent modified Bell-Tawse procedure for chronic Monteggia lesion. Four of the five children experienced complications. All required shortening osteotomies. The chronic Monteggia lesion is an unusual but troublesome presentation in the paediatric population. Further research in the area is necessary

The Hill-Sachs lesion is a bony defect of the humeral head that occurs in association with anterior instability of the glenohumeral joint. Hill-Sachs lesions are common, with an incidence approaching nearly 100% in the setting of recurrent anterior glenohumeral instability. However, the indications for surgical management are very limited, with less than 10% of anterior instability patients considered for treatment of the Hill-Sachs lesion. Of utmost importance is addressing bone loss on the anterior-inferior glenoid, which is highly successful at preventing recurrence of instability even with humeral bone loss. In the rare situation where the Hill-Sachs lesion may continue to engage the glenoid, surgical management is indicated. Surgical strategies are variable, including debridement, arthroscopic remplissage, allograft transplantation, surface replacement, and arthroplasty. Given that the population with these defects is typically comprised of young and athletic patients, biologic solutions are most likely to be associated with decades of sustainable joint preservation, function, and stability. The first priority is maximising the treatment of anterior instability on the glenoid side. Then, small lesions of less than 10% are ignored without consequence. Lesions involving 10–20% of the humeral head are treated with arthroscopic remplissage (defect filled with repair of capsule and infraspinatus). Lesions greater than 20% that extend beyond the glenoid tract are managed with fresh osteochondral allografts to biologically restore the humeral head. Lesions great than 40% are most commonly associated with advanced arthritis and deformity of the humeral articular surface and are therefore treated with a humeral head replacement. This treatment algorithm maximises our ability to stabilise and preserve the glenohumeral joint

The diagnosis of Osteochondral Chondral Lesion of the talar dome is ever more regularly made. Though algorithms of management have emerged by recognising the position, size and the most reliable treatment options, the problem of the failed or relapsed case has only been considered in limited publications. When considering the failed case a variety of possibilities have to be considered. The characteristics of the patient have to be considered. The nature of the original presentation and the history of the present as opposed to the past compliant are worth noting. Patients who have no history of trauma do seem to have a different natural history and response to treatment. The young and the old may well respond differently. Factors preventing recovery from surgery such as ongoing instability of the ankle or hindfoot deformity creating on going abnormal pressures on the joint surface should be looked for. The possibility that the surgery undertreated or missed the full nature of the lesion has to be considered. The possibility of an untreated further pathology should be reviewed. The severity of the original lesion and it's likely response to treatment should be considered. Larger cystic lesions would be more likely to have a poorer outcome. Ultimately if there are persistent symptoms and evidence of ongoing unresolved pathology on the joint surface alternative techniques to resurface the joint should be considered

Purpose. The purpose of the present study was to compare functional outcomes of medial unicompartmental knee arthroplasty (UKA) in patients with lateral meniscal lesion (LM (+) group) in the preoperative MRI and those without lateral meniscal pathology (LM (−) group) and to evaluate the effect of lateral meniscus lesion in preoperative MR on functional outcomes after UKA. Methods. The outcomes of 66 knees (LM (+) group) were compared to the outcomes of 54knees(LM (−) group)with a median follow-up of 28 month(range 24–36 months). Clinical outcomes including KS object score, KS pain score, lateral side pain, physical exam for lateral meniscal lesion and squatting ability. Radiological parameters (mechanical axis and component position) were compared and their effects on functional outcomes were evaluated at the final follow-up visits. Result. At final follow-up visits, no significant intergroup difference was found about KS object score, presence of lateral side pain, positive physical examination for meniscal lesion and squatting ability. LM(+) group had a tendency of more varus postoperative mechanical axis and showed better KS pain score and more comfortable feeling during squatting activity. Furthermore, no correlation was found between postoperative mechanical axis and functional outcome variables. Conclusions. The result of UKA for medial unicompartmental knee osteoarthritis was excellent regardless of preoperative lateral meniscal pathology in the MRI, if patient had not symptoms related to lateral meniscus lesion. Mild varus alignment for those who had a lateral meniscal lesion provided satisfactory clinical outcome of medial UKA

This study evaluates the outcome of arthroscopic femoral osteochondroplasty for cam lesions of the hip in the absence of additional pathology other than acetabular chondral lesions. We retrospectively reviewed 166 patients (170 hips) who were categorised according to three different grades of chondral damage. The outcome was assessed in each grade using the modified Harris Hip Score (MHHS) and the Non-Arthritic Hip Score (NAHS). Overall, at the last follow-up (mean 22 months, 12 to 72), the mean MHHS had improved by 15.3 points (95% confidence interval (CI), 8.9 to 21.7) and the mean NAHS by 15 points (95% CI, 9.4 to 20.5). Significantly better results were observed in hips with less severe chondral damage. Microfracture in limited chondral lesions showed superior results. Arthroscopic femoral osteochondroplasty for cam impingement with microfracture in selected cases is beneficial. The outcome correlates with the severity of acetabular chondral damage

We reviewed 28 patients with brachial plexus lesions caused by shoulder dislocation. Contrary to most other reports, we found that the neurological lesions involved the infraclavicular and the supraclavicular brachial plexus. With supraclavicular lesions the involvement was always of the suprascapular nerve, and this always recovered spontaneously. Isolated axillary nerve lesions had the poorest prognosis for spontaneous recovery. We explored all lesions that showed no recovery after three to five months and performed either grafting or neurolysis. We discuss the combinations of nerve lesions, their recovery, the surgical indications, and the operations. We also suggest a new classification for these injuries which is more clinically relevant than the anatomical classification of Leffert and Seddon (1965)

We report positive and negative factors associated with the most commonly-used methods of reconstruction after pathological fracture of the proximal femur. The study was based on 142 patients treated surgically for 146 metastatic lesions between 1996 and 2003. The local rate of failure was 10.3% (15 of 146). Of 37 operations involving osteosynthetic devices, six failed (16.2%) compared with nine (8.3%) in 109 operations involving endoprostheses. Of nine cases of prosthetic failure, four were due to periprosthetic fractures and three to recurrent dislocation. In the osteosynthesis group, three (13.6%) of 22 reconstruction nails failed. The two-year risk of re-operation after any type of osteosynthesis was 0.35 compared with 0.18 after any type of endoprosthetic reconstruction (p = 0.07). Endoprosthetic reconstructions are preferable to the use of reconstruction nails and other osteosynthetic devices for the treatment of metastatic lesions in the proximal third of the femur

Between 2002 and 2008, 130 consecutive ankles were replaced with an hydroxyapatite (HA) and titanium-HA-coated Ankle Evolutive System total ankle prosthesis. Plain radiographs were analysed by two independent observers. Osteolytic lesions were classified by their size and location, with cavities > 10 mm in diameter considered to be ‘marked’. CT scanning was undertaken in all patients with marked osteolysis seen on the plain radiographs. Osteolytic lesions were seen on the plain films in 48 (37%) and marked lesions in 27 (21%) ankles. The risk for osteolysis was found to be 3.1 (95% confidence interval 1.6 to 5.9) times higher with implants with Ti-HA porous coating. Care should be taken with ankle arthroplasty until more is known about the reasons for these severe osteolyses

INTRODUCTION. Loss of joint function is only exploited in osteoarthritis (OA) once severe impairment is apparent. Animal models allow for lesion induction and serial OA progression measures. We recently described an adjustable non-surgical loading model for generating focal cartilage lesions in only the lateral femur joint compartment, in which regimes can be adjusted so that these either do or do not progress spontaneously. Herein, we use ventral plane videographic treadmill gait analysis to determine whether gait changes can be used to discriminate between stable and spontaneously progressing lesions, induced by these two loading regimes. METHODS. Animals encountered normal conditions, except during loading (9N, 40 cycles, 0.1 Hz, 10 sec/ cycle) which was applied to right knees in two groups (n=8) of 8-week-old male CBA mice: i) loaded once; ii) loaded 3 times/week for 2 weeks. Gait (including: brake, propel, stance, stride, stride length, stride frequency, steps and paw area) was assessed 3 times/week for 2 weeks in each mouse using a DigigaitTM treadmill. Thereafter, mice received 5mg/kg carprofen for analgesia and gait analysis repeated on 3 further alternate days. RESULTS. The two loading regimes produced virtually identical gait modifications with delayed onset (apparent on day 3) which remained unchanged for 2 weeks; mice loaded once only showed modified contralateral limb use, but those loaded multiply exhibited additional ipsilateral front limb modifications; no changes in gait were observed in loaded limbs. Intriguingly, the two regimes produced distinct responses to analgesia. Load-induced gait changes were completely rescued by carprofen in mice loaded only once, whilst those in mice loaded repetitively persisted. CONCLUSION. Our findings reveal specific and reproducible, compensatory changes in contralateral, non-loaded limb gait induced by any joint loading which produces focal articular lesions, and modified ipsilateral front limb use only when progressing lesions are induced by repetitive loading. We find that pain relief completely alleviates all gait modifications associated with stable lesions induced by single loading, but not those induced by repetitive loading. Differing responses in mice with stable and progressive articular cartilage load-induced lesions suggests that gait behaviour in a mechanical loading model of OA may predict joint degeneration

A clinical evaluation of the effect of MRI scan to bring about a change in surgical management of elderly patients who present with hip fracture with no history of trauma or a suspicious looking lesion on x-rays. Many of these patients present with or without history of previous malignancy or bone disorder. We evaluated that if the delay in treatment within 36 hours as per national guide lines is justified to benefit patients. Methods. A clinical review of six hundred hip fracture patients where one hundred and four patients who had MRI scan of hip for fracture with either no history of trauma or a fracture with suspected pathological features with or without history of malignancy or bone disorder. The final outcome of hundred patients who had MRI scans 32 male and 68 female with median age of 65 years. Four patients were excluded as were unable to tolerate the MRI scan. Statistical analysis software SAS/STAT® was used to conduct data collation and analyses. A further radiological analysis of MRI scans with positive lesion to the plain X-rays to correlate the finding of a lesion on femoral side on MRI scan to a lesion on acetabular side. Results. Out of hundred patients who had MRI scan for a suspected metastatic or pathological lesion only 12 showed a metastatic lesion despite the fact 31 had previous history of malignancy, CI 4.03; 101.91, P < 0.0003. No primary lesion detected in any patient. We also found if the acetabular side was not seen to be involved on pain x-ray, MRI scan did not detect any acetabular lesion, contingency coefficient 0.5632, P < .0001. Conclusion. Delay in surgery to obtain an MRI scan does not change any management plans and hence best avoided for benefit of patients and compliance with guide lines

Background. Fractures of the radial head result from an axial force that causes impaction against the capitellum. Associated lesions of the capitellum in this pattern of injury have been previously reported in the orthopaedic literature as an uncommon occurrence. Methods. All patients presenting to the clinics of the senior surgeon between 1998-2008 with radial head fractures requiring surgery were included. Data collected included demographics (age, gender, side of injury), mechanism, timing of injury and injury type (Mason classification). Intraoperative findings including evidence of union, capitellar injury, associated joint dislocation, collateral ligament injury, and any other fractures around the elbow were documented. Results. We reviewed 109 consecutive patients presenting with radial head fractures. 67% of the patients were found to have the PLUCCAR lesion, a capitellar slither of cartilage impacted in the radial fracture. Of these, 76.9% of patients with a Mason I injury had a PLUCCAR lesion, 76.7% of patients with Mason II injury had a PLUCCAR lesion, and only 33.3% of patients with Mason III lesion had a PLUCCAR lesion. 13 patients had a pre-existing non-union, 84% of whom had a PLUCCAR lesion. 19 patients were found to have a malunion, 84% of whom were found to have the PLUCCAR lesion. Conclusion. Injury to the capitellum is commonly associated with radial head fracture. We term impaction of a capitellar fragment in the radius a PLUCCAR lesion. There is an increased incidence of this injury in less comminuted radial head fractures, and in patients presenting with non union or malunion of a radial head fracture

A total of 11 patients (12 knees) with stable lesions of osteochondritis dissecans of the knee underwent arthroscopic fixation of the fragments using polylactide bioabsorbable pins. The site of the lesion was the medial femoral condyle in ten knees and the lateral femoral condyle in two. The mean age of the patients was 14.8 years (12 to 16). At a mean follow-up of 32.4 months (13 to 38 months) all fragments had MRI evidence of union. One patient developed early transient synovitis, which resolved with non-steroidal anti-inflammatory medication. All patients returned to sporting activities within eight months of operation and did not require a period of immobilisation

We have assessed the final strength of the deltoid in 121 patients who had repair of isolated or combined lesions of the axillary (circumflex) nerve and were available for statistical analysis. Successful or useful results were achieved in 85% after grafting of isolated lesions. The strength was statistically better when patients had grafting of the axillary nerve within 5.3 months from the time of injury. The dramatic decrease in the rate of success seen with longer delays suggests that surgery should be undertaken within three months of injury. A statistically significant downward trend of the rate of success was noted with increasing age. The force and level of injury to the shoulder play an important role in the type, combination and level of nerve damage and the incidence of associated rotator-cuff, vascular and other injuries to the upper limb. Management of isolated and combined lesions of the axillary nerve after injury to the shoulder needs to be thorough and systematic

Subacromial bursa fibrosis are linked to rotator cuff lesion with shoulder stiffness; however, the mechanism underlying this shoulder disorder remain elusive. MicroRNA-29s (miR-29s) are emerging fibrosis inhibitor targeting fibrogenic matrices during tissue fibrosis. This study is aimed to investigate clinical relevance and function of miR-29 signalling to subacromial bursa homeostasis in shoulder stiffness. Subacromial bursa in patients with rotator cuff lesion with or without shoulder stiffness who required open acromioplasty were harvested for assessing fibrosis histopathology using Manson's trichrome staining. Expressions of proinflammatory cytokines, fibrotic matrices, and miR-29s were quantified using RT-PCR and in situ hybridization. Range of motion and pain scores of the stiffness group were higher than those of non-stiffness group. Upregulated proinflammatory cytokines (IL-1β, IL-6, and TNF-α) and fibrotic matrices (collagen 1α1, 3α1, and 4α1) but decreased miR-29a and b expression existed in the stiffness group. Affected tissues exhibited severe fibrotic matrix accumulation, synovial hyperangiogenesis, hyperplasia, and strong miR-29a transcripts. In vitro, IL-1β rather than IL-6 and TNF-α decreased miR-29a expression of subacromial bursa fibroblasts. miR-29a knockdown escalated fibrotic matrix expression, whereas forced miR-29a expression alleviated the IL-1β-induced fibrotic matrix expression. Of interest, miR-29a transgenic mice displayed moderate responses to supraspinatus and infraspinatus tenotomy-induce fibrosis and gait irregularity of affected shoulders. Weak miR-29 signalling causes excessive fibrosis and remodelling in subacromial bursa and ultimately increases the prevalence of shoulder stiffness. This study reveals a new mechanistic underlying shoulder stiffness and highlights that sustained miR-29a potentially ameliorates the severity and function of stiff shoulder

We reviewed 19 patients who presented with aggressive granulomatosis around the femoral stem after hip replacement. All had experienced stress pain and had required revision arthroplasty on average 8.8 years after the primary operation. Fifteen patients were men and four were women; none had rheumatoid arthritis. One patient had an uncemented Moore hemiprosthesis; the others all had cemented total hip replacements. When first detected, the granulomatous lesions were multifocal in 13 patients. The first granuloma was in the region of the lesser trochanter in 10, and near the tip of the stem in only two. Speed of growth varied but on average there was doubling of the area on anteroposterior films in 2.2 years (range 6 months to 4.6 years). Aggressive granulomatous lesions in replaced hips are a distinct condition, different from simple loosening or infection; the lesions may grow rapidly, so revision surgery is indicated soon after diagnosis

The recognition, investigation and management of osteoid osteoma has been well documented. Treatment can either be medical or surgical, studies have shown both options to have almost equal long term outcomes. However only surgical treatment involving complete excision of the lesion allows for confirmatory tissue diagnosis of osteoid osteoma especially important in cases where symptoms and signs are atypical. Several methods of surgical treatment with varying degrees of success have been described in literature. Here we describe a surgical techniques for the treatment of osteoid osteoma which enables removal of the lesion in a precise manner using a precision bone graft trephine with minimal excision of bone. This technique will be very useful in the excision of lesions in areas in which excessive excision of bone can lead to an unstable bony structure which can predispose to fracture. To our knowledge this surgical technique in the management of osteoid osteoma has not been described in the literature

We reviewed lesions of the femoral condyles seen in 5,000 knee arthroscopies, recording the findings and the age and sex of the patients. We were able to distinguish the characteristics of developing and late osteochondritis dissecans, acute and old osteochondral fractures, chondral separations, chondral flaps and idiopathic osteonecrosis, and suggest that these are separate distinct conditions. Haemarthrosis was associated only with acute osteochondral fractures. The characteristic feature of osteochondritis dissecans was an expanding concentric lesion at the 'classical' site on the medial femoral condyle which appeared during the second decade of life and progressed to a concave steep-sided defect in the mature skeleton. Caffey's (1958) classification of epiphyseal dysplasias could not be applied to osteochondritis dissecans, which appeared to have a gradual onset without acute trauma. Much of the controversy about the cause of osteochondritis dissecans is the result of imprecise nomenclature

We describe six patients with aggressive granulomatous lesions around cementless total hip prostheses. Two patients previously had a cemented prosthesis in the same hip. The Lord prosthesis was used in five patients, the PCA in one. Both prostheses were made of chrome-cobalt alloy. Pain on weight-bearing occurred on average 3.2 years after the cementless arthroplasty, and at that time radiography revealed aggressive granulomatosis around the proximal femoral stem and the acetabular component in five of the patients; one had a large solitary granuloma in the proximal femur. Revision was performed on average 4.8 years after the cementless arthroplasty. At that time all granulomas had grown large in size; while waiting for revision operation, two femoral stem components fractured. All the granulomas showed a uniform histopathology, which included histiocytosis; the cause for these lesions was thought to be plastic debris from the acetabular socket

The treatment of osteochondral lesions of the talus has evolved with the development of improved imaging and arthroscopic techniques. However, the outcome of treatment for large cystic type-V lesions is poor, using conventional grafting, debridement or microfracture techniques. This retrospective study examined the outcomes of 50 patients with a cystic talar defect who were treated with arthroscopically harvested, cored osteochondral graft taken from the ipsilateral knee. Of the 50 patients, 45 (90%) had a mean good to excellent score of 80.3 (52 to 90) in the Karlsson-Peterson Ankle Score, at a mean follow-up of 36 months (24 to 83). A malleolar osteotomy for exposure was needed in 26 patients and there were no malleolar mal- or nonunions. One patient had symptoms at the donor site three months after surgery; these resolved after arthroscopic release of scar tissue. This technique is demanding with or without a malleolar osteotomy, but if properly performed has a high likelihood of success

Total hip replacement in patients with advanced osteonecrosis of the femoral head is often complicated by early loosening of the femoral component. Recent evidence has suggested that abnormal bone extending into the proximal femur may be responsible for the early failure of the femoral component. We aimed to identify which patients were at high risk of early failure by evaluating gadolinium-enhanced MR images of histologically-confirmed osteonecrotic lesions beyond the femoral head. Although the MR signal intensity has been shown to correlate well with osteonecrosis in the femoral head, it was found to be relatively insensitive at identifying lesions below the head, with a sensitivity of only 51% and a predictive value of a negative result of only 48%. However, the specificity was 90%, with the predictive value of a positive MRI finding being 86%. Only those patients with osteonecrosis of the femoral head secondary to sickle-cell disease, who are known to be at high risk of early loosening, had changes in the MR signal in the greater trochanter and the femoral shaft. This observation suggests that changes in the MR signal beyond the femoral head may represent osteonecrotic lesions in areas essential for the fixation of the femoral component. Pre-operative identification of such lesions in the neck of the femur may be important when considering hip resurfacing for osteonecrosis of the femoral head, following which early loosening of the femoral component and fracture of the neck are possible complications

Background. Cartilage lesions in chronic lateral ligament deficiency are common with the incidence rates mentioned in the previous literature up to 30%. However, other intra-articular pathologies in the unstable ankle have received little attention. Anterolateral impingement associated with synovitis and scarring is a less recognised feature in the treatment of chronic instability. The aim of our study was to ascertain the incidence of chondral and anterolateral impingement lesions in the symptomatic lateral ligament complex deficiency. Methods. We performed a retrospective study of all consecutive patients who underwent modified Brostrom repair for symptomatic recurrent instability of the ankle. All patients underwent a MRI scan prior to surgery. Arthroscopy was performed in all the patients before lateral ligament reconstruction. Seventy seven patients with 78 ankles were included in the study. Patients who had previous ankle surgery or inflammatory arthropathy were excluded. Data was obtained from clinical and radiological records. Arthroscopic findings were recorded in detail during the surgery. Results. The mean age was 29.8 years (Range 18.2–58 yrs). There were 44 females and 34 males in the study. The incidence of chondral lesions were 11.5% (9 out of 78 ankles). The commonest site for chondral defect was the anteromedial talar dome. The incidence of anterolateral impingement which required arthroscopic debridement was 48.7 %(38 ankles). A further 10 ankles revealed non-specific synovitis and scarring which was debrided. The sensitivity and specificity of the MRI scans in the assessment of chondral lesions is 91% and 100%. Conclusion. The incidence of chondral lesions in chronic ankle instability is lower than previously published literature. However, soft tissue impingement lesions have a much higher incidence and require debridement. Arthroscopic examination and debridement of impingement prior to lateral ligament reconstruction of the ankle is quintessential in the management of chronic anterolateral instability

The oblique sagittal diameter of the lumbar spinal canal was measured by diagnostic ultrasound in seventy-three patients with symptomatic disc lesions, and compared with measurements from 200 asymptomatic subjects. Results suggest that the available space in the spinal canal is highly significant in the symptomatology of disc lesions, and in the patient's response to treatment

A patient with recurrent dislocation of the hip is described. The initial injury had been a posterior dislocation without associated fracture of the acetabular wall, and the hip had not been immobilised or protected from weight-bearing during treatment. Exploration of the hip for recurrence revealed disruption of the posterosuperior acetabular labrum with formation of a pouch between the posterior acetabular wall and the short rotator muscles. We have found no previous report of this lesion, which resembles a Bankart lesion of the shoulder. Repair using a bone block is described

INTRODUCTION. Osteochondral lesions of the knee are relatively common both in young and senior population. The very disabling clinical symptoms, in association to the scarce regenerative capacity of the articular cartilage and the increased risk of developing a secondary osteoarthritis make an effective treatment mandatory. MATERIALS AND METHODS. From December 2008 to January 2013, 34 patients (35 knees), 24 males and 10 females (mean age 36.2 years range 14–66) underwent implant of Maioregen® (Finceramica Faenza S.P.A, Italy) biomimetic osteochondral scaffold. In 17 cases the osteochondral lesion was cause by an osteochondritis dissecans (acute or sequela), in 13 cases by a spontaneous osteonecrosis and in 4 cases the etiology was traumatic. Patients were evaluated with subjective IKDC and Tegner Lysholm scores, VAS and Tegner Activity Scale before surgery and at regular follow up (mean follow up 38.4 months, range 13 months max 63 months). RESULTS. Both Lysholm and IKDC Subjective scores significantly increased from 57.5 and 48.2 before surgery to 89.7 and 76.3 at 1 year follow up. Mean VAS scale score decreased from 6.3 to 2 at 1 year follow up. At 3 years follow up 20 evaluated patients showed an increment on both scales (Lysholm 92.38, IKDC 84.7). Only 4 patients were evaluated at 5 years follow up with mean subjective IKDC 92.5, Lysholm 98.75 and VAS 1. DISCUSSION. Maioregen ® biomimetic osteochondral scaffold showed very good results as surgical treatment option in treating ICRS grade 3–4 osteochondral lesions whatever the etiology. In particular, the implant showed good results also in treatment of osteonecrosis and could provide an alternative to unicompartimental arthroplasty in young and active patients

We report our experience of treating 17 patients with benign lesions of the proximal femur with non-vascularised, autologous fibular strut grafts, without osteosynthesis. The mean age of the patients at presentation was 16.5 years (5 to 33) and they were followed up for a mean of 2.9 years (0.4 to 19.5). Histological diagnoses included simple bone cyst, fibrous dysplasia, aneurysmal bone cysts and giant cell tumour. Local recurrence occurred in two patients (11.7%) and superficial wound infection, chronic hip pain and deep venous thrombosis occurred in three. Pathological fracture did not occur in any patient following the procedure. We conclude that non-vascularised fibular strut grafts are a safe and satisfactory method of treating benign lesions of the proximal femur

Introduction: The progression of the collapse is influenced by the extent and location of the necrotic focus of the necrotic femoral head. The authors studied the extent of the necrotic focus on the joint surface by conventional antero-posterior radiographs in neutral position, and antero-posterior radiographs at the 45 degrees flexion position. The differences of the lesions in these two types of radiographs were analyzed. Materials and Methods: The conventional antero-posterior radiographs of the neutral position, and the antero-posterior radiographs at the 45 degrees flexion positions in 115 hip joints of 86 patients with non-traumatic osteonecrosis of the femoral head were obtained for this study. These 115 hips showed extensive lesions and could be divided into two groups: Type C-1 or C-2 by classification of the Specific Disease Investigation Committee under the auspices of the Japanese Ministry of Health Labor and Welfare. Type C1 lesions occupy more than the medial 2/3 of the femoral head and C2 lesions extend laterally to the acetabular edge. Results: At the neutral position, Type C-1 lesions were noted in 42 joints (36%). In these 42 hips, 13 showed Type C-1 (30%) at the 45 degrees flexion position. In contrast, 29 joints (70%) were Type C-2. Type C-2 lesions in 73 joints (64%) were shown in the neutral position. In these 73 hips, Type C-2 lesions were disclosed on 69 joints (95%) in the 45 degrees flexion position and Type C-1 was noted on 4 hips (5%). Conclusions: Based on these results, the authors propose that location of the lesion on the joint surface varies with different hip positions

Two consecutive cases of chronic dislocation of the head of the radius after missed Bado type-I Monteggia lesions are presented. Reduction was successfully achieved in both patients after ulnar corticotomy, gradual lengthening and angulation of the ulna using an external fixator. Open reduction or reconstruction of the radio-ulnar capitellar joint was not undertaken. The age at injury was seven years in the older and two years in the younger patient. The time from injury to treatment was five years in the older and three months in the younger child. At follow-up, nine years after completion of treatment in the older and eight months in the younger patient, both show satisfactory movement, function of the forearm and reduction of the head of the radius. This technique may be considered in missed Monteggia lesions before open procedures on the radio-ulnar capitellar joint are undertaken

Introduction: We investigated the necrotic area and its shrinkage on stage 1 femoral head necrosis with band pattern low intensity on MRI. Materials and Methods: Eleven femoral heads (6 patients) with a history of steroid treatment were studied. In heads, band pattern was detected by MRI. The mean age was 40 years. The location of the lesion shown by the band pattern low intensity was determined by Japanese investigation committee as follows. Type A lesion occupies the medial one-third or less; Type B occupies the medial two-thirds or less; Type C-1 occupies more than the medial two-thirds; and Type C-2 extends laterally to the acetabular edge at the neutral position. Types were observed on initial and final MRIs. The mean follow up was 4 years and 3 months. For the repair patterns, the direction was observed in the anterior and posterior slices of MRIs. Results: Initial MRIs showed types were Types A, B, C-1, and C-2 in 3, 3, 3, and 2 femoral heads, respectively. At the final observation, no band pattern was noted on the weight-bearing surface in 3 Type-A femoral heads. The femoral head surface was repaired, and the lesion was present only in the non-weight-bearing region. In all of the 3 Type-B femoral heads and 5 Type-C1 and -C-2 femoral heads, the lesion shrank to Type A. The articular surface was covered with normal intensity area from the posterior direction in all femoral heads. Discussion: We believe that the repair occurred during the disease process in stage 1 necrosis

The type II Monteggia (posterior) lesion is a rare injury which is sometimes associated with ulnohumeral instability. We have reviewed 23 of 28 patients with this injury. A clinical and radiographic assessment was undertaken at follow-up. Functional outcome scores, including the Broberg and Morrey Index and the Disabilities of the Arm, Shoulder or Hand (DASH), were used. The results from the six patients with associated posterior ulnohumeral dislocation were compared with 17 without ulnohumeral injury. Those with dislocation had reduced movement of the elbow and had outcome scores indicative of greater disability compared to those without associated dislocation

Osteonecrosis of the femoral head can be caused by a variety of disorders and affects the relatively young patient. Most studies have concentrated on the femoral changes; the sites of early lesions of the labrum and acetabular cartilage have not been recorded. We studied 17 hips with osteonecrosis and a wide congruent joint space on radiographs and by direct inspection of the femoral head, labrum and acetabular cartilage during surgery. All of the femoral heads had some anterosuperior flattening which reduced the head-neck ratio in this area. A consistent pattern of damage to the labrum and the acetabular cartilage was seen in all hips. Intraoperatively, impingement and the cam-effect with its spatial correlation with lesions of the labrum and acetabular cartilage were observed. These findings could be helpful when undertaking conservative surgery for osteonecrosis, since the recognition of early radiologically undetectable acetabular lesions may require modification of the surgical technique

Matrix-induced autologous chondrocyte implantation (MACI) is an established technique used to treat osteochondral lesions in the knee. For larger osteochondral lesions (> 5 cm. 2. ) deeper than approximately 8 mm we have combined the use of two MACI membranes with impaction grafting of the subchondral bone. We report our results of 14 patients who underwent the ‘bilayer collagen membrane’ technique (BCMT) with a mean follow-up of 5.2 years (2 to 8). There were 12 men and two women with a mean age of 23.6 years (16 to 40). The mean size of the defect was 7.2 cm. 2. (5.2 to 12 cm. 2. ) and were located on the medial (ten) or lateral (four) femoral condyles. The mean modified Cincinnati knee score improved from 45.1 (22 to 70) pre-operatively to 82.8 (34 to 98) at the most recent review (p < 0.05). The visual analogue pain score improved from 7.3 (4 to 10) to 1.7 (0 to 6) (p < 0.05). Twelve patients were considered to have a good or excellent clinical outcome. One graft failed at six years. The BCMT resulted in excellent functional results and durable repair of large and deep osteochondral lesions without a high incidence of graft-related complications

Introduction: Pseudoarthrosis in Ankylosing spondylitis is often misdiagnosed as infection. It is a slow progressing lesion resulting in a kyphosis and slow onset weakness of the lower limbs. We are presenting our strategy and experience in treating 9 patients with such a lesion. Method: 9 patients age range from 40–55 years who presented with pseudoarthrosis of the ankylosed spine underwent back-front surgery during 2001–204. 6 patients had dorsal spine lesion, 2 had dorso-lumbar junctional lesion and 1 had cervico-dorsal junctional lesion. 8/9 patients had insidious onset with progressive weakness of both lower limb. 1 patient had an acute onset with deformity. 7/9 patients had neurodeficit (Frankel C) 1/9 had complete paraplegia. All patients underwent posterior kyphosis correction and decompression of the spinal cord. During posterior decompression 8/9 patients had an incidental dural tear due to adherence fractured lamina. The dura was repaired primarily or patch graft. 5/9 patients had single stage back and front surgery. The rest of the patients had staged surgery. The front surgery was excision of the tough fibrotic psuedoarthosis and reconstruction using strut graft/cage. Results: Average duration of surgery was 4 ½ hours (3 ½ to 6 hours). Blood loss was 800 ml (600–1300 ml). All patients required blood transfusion. Primary dural repair was done in 7/8 cases, patch graft in 3/8 cases, ceiling with fusion glue and fat graft in 1 patient. 5 patients who had less that 1000 ml blood loss during posterior surgery had same stage anterior reconstruction. Rest of the patient had 2 staged surgery. 4/9 patients had previous THR B/L. All patients showed rapid improvement in the neurological status and at 3 months follow up all were Frankel E. Conclusion: The surgical outcome of the ankylosing spondylitis patients with Andersson lesion with neurological deficit is encouraging. Excision of the pseudoarthroses anteriorly and posterior spinal stabilization resulted in full recovery of the deficit. However there were difficulties encountered during the posterior decompression due to adhesions of the posterior elements to the dura

Purpose. Osteochondral lesions of the knee are relatively common both in young and senior population. The very disabling clinical symptoms, in association to the scarce regenerative capacity of the articular cartilage and the increased risk of developing a secondary osteoarthritis make an effective treatment mandatory. Methods and Materials. From December 2008 to January 2013, 34 patients (35 knees), 24 males and 10 females (mean age 36.2 years range 14–66) underwent implant of Maioregen® (Finceramica Faenza S.P.A, Italy) biomimetic tri-layer osteochondral scaffold. In 17 cases the osteochondral lesion was cause by an osteochondritis dissecans (acute or sequela), in 13 cases by a spontaneous osteonecrosis and in 4 cases the etiology was traumatic. Patients were evaluated with subjective IKDC and Tegner Lysholm scores, VAS and Tegner Activity Scale before surgery and at regular follow up (mean follow up 38.4 months, range 13 months max 63 months). Results. Both Lysholm and IKDC Subjective scores significantly increased from 57.5 and 48.2 before surgery to 89.7 and 76.3 at 1 year follow up. Mean VAS scale score decreased from 6.3 to 2 at 1 year follow up. At 3 years follow up 20 evaluated patients showed an increment on both scales (Lysholm 92.38, IKDC 84.7). Only 4 patients were evaluated at 5 years follow up with mean subjective IKDC 92.5, Lysholm 98.75 and VAS 1. Conclusion. Maioregen® biomimetic osteochondral scaffold showed very good results as surgical treatment option in treating ICRS grade 3–4 osteochondral lesions whatever the etiology. In particular, the implant showed good results also in treatment of osteonecrosis and could provide an alternative to unicompartimental arthroplasty in young and active patients

We have treated osteochondral lesions of the talus using cortical bone pegs. We examined 27 ankles (27 patients) after a mean follow-up of 7.0 years (2 to 18.8). The mean age of the patients was 27.8 years (12 to 62). An unstable osteochondral fragment or osteosclerotic changes in the bed of the talus were regarded as indications for the procedure. The clinical results were good in 24 ankles (89%) and fair in three (11%); none had a poor result. There was also radiological improvement in 24 ankles. Repair of the articular surface and stability of the lesion can be achieved even in unstable chronic lesions

Introduction: There is controversy over whether the lesions of osteonecrosis of the femoral head (ONFH) will spontaneously decrease. This study reports a longitudinal study of lesion volume using high-resolution serial MRI and recently developed techniques for image registration to realign serial images. Materials and Methods: Baseline and follow-up (minimum one year later) MRI scans were carried out on 15 patients (18 hips). Accurate subvoxel registration was performed and subtraction images were produced to reveal areas of regional necrotic lesion change. Volume-to-femoral head ratio (VFR) was calculated to normalize the measured volume to the total femoral head volume. Results: Three of 18 hips showed spontaneous reductions in the size of the lesions. They were all related to steroid use and were within one year after initial steroid treatment The mean volume decrease of these 3 hips was 3.4 ± 2.0 cm. 3. (SD) and its VFR was 6.8 ± 3.1 % (SD). Mean necrotic lesion volumes at baseline of decreasing lesions and unchanged lesions were 4.6 ± 2.5 cm. 3. (VFR, 9.1 ± 3.9 %) and 7.5 ± 5.5 cm. 3. (VFR, 16.7 ± 12.4 %), respectively. There was no statistically significant difference in baseline lesion volume between decreasing lesions and unchanged lesions. Discussion: In conclusion, some early lesions within one year after onset can decrease in size on MRI, regardless their size at baseline

Osteochondral lesions (OCL) of the talus occur in 38% of the patients with supination external rotation type IV ankle fractures and 6 % of ankle sprains. Osteoarthritis is reported subsequently in 8–48% of the ankles. Several marrow stimulation methods have been used to treat the symptomatic lesion, including arthroscopic debridement and micro fracture. Encouraging midterm results have been reported, but longterm outcome is unknown in relation to more invasive treatments such as transfer of autologous osteoarticular tissue from the knee or talus (OATS), autologous chondrocyte implantation (ACI), frozen and fresh allograft transplantation. Aim. The aim of our study was to review our long term results of arthroscopic treatment of osteochondral lesions of the talus. Materials and methods. 65 patients underwent arthroscopic treatment of the OCL between 1993 and 2000. There were 46(71%) men and 19(29%) women. The mean age at surgery was 34.2 years. The right side was affected in 43 patients and the left side in 22 patients. Results. 40/65(61.5%) patients who underwent arthroscopic treatment of the OCL were followed up. The mean follow-up was 13.1 years (9 to 18 years). The average age at final follow was 49.6 years (25–80 years). 15 (39.5%) patients reported poor, 14 (36.8%) fair, 9 (23.6%) good outcomes based on the Berndt and Harty criteria. 20/40 patients (50 %) needed further surgery. This appears a significant deterioration since this cohort were studied at 3.5 years, when the clinical results were 21.3% poor, 26.2% fair and 52.3% good, although losses to followup make exact comparison impossible. Conclusion. Arthroscopic treatment of osteochondral lesions of the talus gives medium term improvement in the majority of patients, but it appears that results deteriorate with time. Recurrence of symptoms sufficient to require further surgical intervention occurred in half the patients studied

In this study a combination of autologous chondrocyte implantation (ACI) and the osteochondral autograft transfer system (OATS) was used and evaluated as a treatment option for the repair of large areas of degenerative articular cartilage. We present the results at three years post-operatively. Osteochondral cores were used to restore the contour of articular cartilage in 13 patients with large lesions of the lateral femoral condyle (n = 5), medial femoral condyle (n = 7) and patella (n = 1). Autologous cultured chondrocytes were injected underneath a periosteal patch covering the cores. After one year, the patients had a significant improvement in their symptoms and after three years this level of improvement was maintained in ten of the 13 patients. Arthroscopic examination revealed that the osteochondral cores became well integrated with the surrounding cartilage. We conclude that the hybrid ACI/OATS technique provides a promising surgical approach for the treatment of patients with large degenerative osteochondral defects

Ten cases of missed Monteggia lesions were reviewed following treatment. Four cases were treated with an ulnar osteotomy, open reduction of radial head and annular ligament reconstruction (Group A). In six cases only an open reduction of the radial head was performed with an ulnar osteotomy (Group B). No annular ligament reconstruction was done in Group B. The mean age seven in both groups (range 4-12 years). The children presented three months to 24 months after the initial injury. Nine patients were classified as Bado type I, and one with Bado type III injury. The mean follow-up was 20 months (8-26 months) after surgery. In both groups the ulnar osteotomy healed uneventfully. In group A, there was one superficial infection, the mean loss of pronation was 12 degrees and in one case the radial head re-subluxed. In group B, the mean loss of pronation was 10 degrees. Elbow flexion was comparable to Group A. No radial head subluxation was seen in this group. No child in either group had any functional limitation in activities. Thus, in chronic Monteggia lesion, annular ligament reconstruction is not always required to restore radio-capitellar alignment. Open reduction of radial head with an ulnar osteotomy and stable fixation will suffice. Ligament reconstruction will not stabilise an inadequately reduced radial head

We compared the quality of debridement of chondral lesions performed by four arthroscopic (SH, shaver; CU, curette; SHCU, shaver and curette; BP, bipolar electrodes) and one open technique (OPEN, scalpel and curette) which are used prior to autologous chondrocyte implantation (ACI). The ex vivo simulation of all five techniques was carried out on six juvenile equine stifle joints. The OPEN, SH and SHCU techniques were tested on knees harvested from six adult human cadavers. The most vertical walls with the least adjacent damage to cartilage were obtained with the OPEN technique. The CU and SHCU methods gave inferior, but still acceptable results whereas the SH technique alone resulted in a crater-like defect and the BP method undermined the cartilage wall. The subchondral bone was severely violated in all the equine samples which might have been peculiar to this model. The predominant depth of the debridement in the adult human samples was at the level of the calcified cartilage. Some minor penetrations of the subchondral end-plate were induced regardless of the instrumentation used. Our study suggests that not all routine arthroscopic instruments are suitable for the preparation of a defect for ACI. We have shown that the preferred debridement technique is either open or arthroscopically-assisted manual curettage. The use of juvenile equine stifles was not appropriate for the study of the cartilage-subchondral bone interface

Most of surgical methods, suggested for habitual shoulder instability treatment provide almost similar percentage of successful results, being 90–95%. However, some investigations show unequal efficiency of standard methods in dependence on bone-cartilage lesions presence. It is revealed that redislocations number after arthroscopic Banckart operation in group of patients with insignificant bone-cartilage lesions is 4%, however, in group of patients with significant lesion this figure becomes 67%. In this case – an actual problem is to find new treatment procedure for patients with habitual shoulder instability with bone-cartilage lesion. We aimed to demonstrate our results of treatment of patients with habitual anterior shoulder instability and arthroscopically revealed bone-cartilage lesions using rotational osteotomy by Saha-Weber. In 99 patients with massive bone-cartilage lesion of back surface of humeral head (arthroscopically proved), we have applied rotational osteotomy of the humerus with subscapularis tendon transposition (male/female ratio - 3:1, middle age - 34.6 years). Average duration of disease before the operation was 4.2 years (from 1.2 years to 24 years). In each clinical case the quantity of shoulder dislocations exceeded 6. Long-term result of treatment is studied at 55 patients. Good and excellent clinical results have been reached at 48 patients (87.2%). The moderate functional disorders are revealed in 6 patients (10.9 %). There was one case of redislocation after repeated trauma. There were no cases of nonunion, evident contracture or avascular necrosis of humeral head. These data were compared with the results of surgical technique of strengthening of anterior wall of shoulder joint according to Boychev-I in treatment of 56 patients with an anterior habitual shoulder dislocation with clinical manifestations of bone- cartilage lesion (high number of dislocations with signs of severe instability, average term of supervision - 7 years). Insufficiency of applied technique almost at each third patient is determined. The unsatisfactory result of treatment (redislocation) is found in 4 cases (7.1%), satisfactory (the moderate and expressed functional deficiency) - in 12 (21.4%). Rotational osteotomy of a humerus with subscapularis tendon transposition is an effective operation with rather simple postoperative conducting and low frequency of complications. Obtained data show its advantages in comparison with soft-tissue operations. This operation can be recommended in cases of pronounced Hill-Sacks lesion with severe instability of humeral joint and after failed plastic procedures on the soft tissues

Several studies showed the efficacy of arthroscopic repair for Type II SLAP lesions without other associated lesions, but the only data reported on the association of arthroscopic repair of Type II SLAP lesion and rotator cuff tears involve young and active patient. To our knowledge, no studies have focused on patients over 50. We evaluated the results of a randomized controlled trial of arthroscopic repair in patients over 50 with rotator cuff tears and Type II SLAP lesion in whom the repair was effected repairing the two lesions, or repairing the rotator cuff tears and performing a tenotomy of the long head of the biceps. We recruited 63 patients. In 31 patients, we repaired the rotator cuff and the Type II SLAP lesion (Group 1). In the other 32 patients, we repaired the rotator cuff and tenotomized the long head of the biceps (Group 2). 7 patients (2 in the group 1 and 5 in the group 2) were lost to final follow up. A modified UCLA shoulder rating scale was used to evaluate pre-operative and post-operative shoulder pain, function, active forward flexion, strength and patient satisfaction. Of 63 patients randomized to one of the two treatments, 5.2 year results were available for 56. 7 patients (2 in the group 1 and 5 in the group 2) did not return at the final follow up. Statistically significant differences were seen with respect to the UCLA score and ROM values at final follow-up In Group 1 (SLAP repair and rotator cuff repair), the UCLA showed a statistically significant improvement from a pre-operative average rating of 10.4 (range 6 to 14) to an average of 27.9 (24–35) postoperatively (P< 0.001). In Group 2 (biceps tenotomy and rotator cuff repair), the UCLA showed a statistically significant improvement from a pre-operative average rating of 10.1 (range 5 to 14) to an average of 32.1 (range 30 to 35) post-operatively (P< 0.001) There was statistically significant difference in total post-operative UCLA scores and ROM when comparing the two groups post-operatively (P< 0.05). Arthroscopic management has been recommended for some SLAP lesions, but no studies have focused on patients over 50 with rotator cuff tear and Type II SLAP lesion. We compared the clinical outcome of patients over 50 affected with rotator cuff tears and Type II SLAP lesion in whom both the defects were repaired, or the rotator cuff tear was repaired and the long head of the biceps tendon was tenotomized. In our hands, the association of rotator cuff repair and biceps tenotomy provides better clinical outcome compared with repair of Type II SLAP lesion and of the rotator cuff. The repair of the two defects, in fact, can lead to worst clinical results compared with association Rotator cuff repair alone is sufficient to determine a good post-operative outcome, allowing to avoid post-operative stiffness of the shoulder

Introduction: In cases of small and middle size osteonecrosis on conventional antero-posterior (AP) radiographs, we studied the extent of the lesion on AP radiographs at the 45 degrees flexion position for lesions of the anterior area of the femoral head. Materials and Methods: Classification of Japanese organizing committee was applied for the extent of the lesion on joint surface. Type A lesions occupy the medial one-third or less; Type B, the medial two-thirds or less; Type C-1 occupies more than the medial two-thirds; and Type C-2 extends laterally to the acetabular edge at the neutral position on conventional AP radiographs. Thirty-three hips (25 patients) with small or middle size lesions (Type A;11, Type B;22) were studied. On AP radiographs taken at the 45 degrees flexion position, the extent of the lesion was studied in 33 hips. Results: Seven of 11 hips of Type A on neutral position showed Type A lesions. For the remaining 4 hips, 2 were Type B, 2 were on Type C-1 at 45 degrees flexion position. For 22 hips with Type B on neutral position, 6 were Type B, 12 were Type C-1, 4 were Type C-2 found at the 45 degrees flexion position. Discussion: AP radiographs at the 45 degrees flexion position revealed more extensive necrotic area in cases of small and middle size lesions comparing with the neutral position. This finding may be related to progression of the disease

Introduction: The foot is an unusual site for presentation of Ewings tumour. Haemangioma of the vertebra is a common finding in adults, but is rarely reported in children. 1. Although rarely symptomatic, the lesion may cause diagnostic confusion particularly in the presence of comorbidity. A previous case report details an adult patient with a ‘pseudohaemangioma’ that was subsequently found to be an Ewings tumour. 2. Methods: A review of the literature and a case report is presented of a boy with a Ewing’s sarcoma of the foot presenting with an asymptomatic lytic lesion in the spine. Results: The 12-year-old male initially presented with pain and swelling in the right foot. Subsequent investigation and biopsy confirmed a diagnosis of Ewing’s sarcoma in the second metatarsal. The child received 5 cycles of combined chemotherapy, and the primary tumour was excised from the metatarsal with fibular graft reconstruction. Part of the clinical work up had included an isotope bone scan, which revealed a focal area of increased uptake in the L1 vertebra. On MRI, the vertebral lesion had a ‘halo’ of high intensity signal with infraction of the upper vertebral endplate. There were no clinical symptoms arising from the vertebral lesion. The differential diagnosis of the L1 lesion suggested was either a meta-static Ewing’s tumour or an aggressive haemangioma. Given the possibility of a multifocal or metastatic lesion, a vertebrectomy and reconstruction with femoral allograft was performed. A second stage posterior stabilisation from T12 to L2 was performed. Histological examination of the resected vertebra revealed a benign capillary haemangioma. On recent review one year after treatment, the patient remains in remission from his tumour and has successful graft incorporation with minimal symptoms from his spine. Discussion: Haemangioma is a benign tumour commonly found in the vertebral body. Asymptomatic spinal haemangiomas do not require surgical excision. Clinico-pathological distinction between vertebral haemangioma and metastatic disease can be difficult, particularly in children where the haemangiomata may be in a ‘blastic’ phase. The combination of an extremely unusual age of presentation and the presence of a separate malignant primary bone tumour in this patient introduced a significant clinical dilemma in treatment

To prospectively evaluate patient outcome in terms of stability, function and satisfaction following an arthroscopic anterior Bankart repair in order to identify patient characteristics, surgical technique or instrumentation linked to poor outcomes. These findings can then be used to refine selection criteria such that patient benefit from the shoulder instability repair is maximised. Between April 2002 and June 2004 thirty-seven arthroscopic anterior Bankart lesion repairs were performed by a single orthopaedic surgeon. Data on concomitant shoulder pathology, surgical technique utilised and instrumentation used was recorded for each patient. Reoccurrence rate, patient satisfaction and range of motion were evaluated pre-operatively, and then six weeks, three months, six months, twelve months and twenty-four months post-operatively. Four of thirty-seven patients (10.8%) experienced at least one post-operative reoccurrence defined as a subluxation or dislocation. There was a statistically significant association between the presence of an inverted pear-shaped glenoid and increased incidence of reoccurrence (p < 0.05). Patients’ satisfaction with their shoulders increased significantly from 43% pre-operatively to 71% at the two-year follow-up, as measured by the Western Ontario Shoulder Instability (WOSI) scale. There were no significant differences in range of motion between the patients’ surgically repaired and unaffected shoulders. An arthroscopic repair of an anterior Bankart lesion can yield good-to-excellent results for the majority of patients with respect to stability, function and satisfaction. The presence an inverted pear-shaped glenoid is mostly strongly correlated with an increased incidence of reoccurrence. Patients should be screened pre-operatively to identify this bony abnormality such that it can be addressed appropriately during surgery

We investigated 29 cases, diagnosed clinically as having Morton’s neuroma, who had undergone MRI and ultrasound before a neurectomy. The accuracy with which pre-operative clinical assessment, ultrasound and MRI had correctly diagnosed the presence of a neuroma were compared with one another based on the histology and the clinical outcome. Clinical assessment was the most sensitive and specific modality. The accuracy of the ultrasound and MRI was similar and dependent on size. Ultrasound was especially inaccurate for small lesions. There was no correlation between the size of the lesion and either the pre-operative pain score or the change in pain score following surgery. Reliance on single modality imaging would have led to inaccurate diagnosis in 18 cases and would have only benefited one patient. Even imaging with both modalities failed to meet the predictive values attained by clinical assessment. There is no requirement for ultrasound or MRI in patients who are thought to have a Morton’s neuroma. Small lesions, < 6 mm in size, are equally able to cause symptoms as larger lesions. Neurectomy provides an excellent clinical outcome in most cases

Arthroscopic management has been recommended for some SLAP lesions, but no studies have focused on patients over 50 with rotator cuff tear and Type II SLAP lesion. Our hypothesis was that there was no difference in clinical outcome between repairing of the Type II SLAP lesion and tenotomy of the long head of the biceps tendon after having repaired the rotator cuff tear. This was a randomized controlled clinical trial. We recruited 63 patients. In 31 patients, we repaired the rotator cuff and the Type II SLAP lesion (Group 1). In the other 32 patients, we repaired the rotator cuff and tenomized the long head of the biceps (Group 2). 7 patients (2 in the group 1 and 5 in the group 2) were lost to final follow up. At the 5.2 year follow-up, statistically significant differences were seen with respect to the UCLA score and ROM values. In Group 1 (SLAP repair and rotator cuff repair), the UCLA showed a statistically significant improvement from a pre-operative average rating of 10.4 (range 6 to 14) to an average of 27.9 (24–35) postoperatively (P< 0.001). In Group 2 (biceps tenotomy and rotator cuff repair) the UCLA showed a statistically significant improvement from a pre-operative average rating of 10.1 (range 5 to 14) to an average of 32.1 (range 30 to 35) post-operatively (P< 0.001) There was statistically significant difference in total post-operative UCLA scores and ROM when comparing the two groups post-operatively (P< 0.05). There are no advantages in repairing a Type II SLAP lesion when associated with a rotator cuff tear in patients over 50. Rotator cuff repair alone is sufficient to produce a good post-operative outcome, allowing to avoid post-operative stiffness of the shoulder

A group of patients were studied 10 years after stopping work in a high-pressure environment. Radiographs of their long bones showed little change during the period, but only two of 12 scintigrams were normal. The 10 abnormal scintigrams contained 18 "hot-spots" which were not always associated with an abnormal radiographic appearance; the findings suggest that some lesions may never become visible on a radiograph. A reactive or repair process associated with these lesions may be prolonged and may not be beneficial, as structural failure of the joint may subsequently occur. Prognosis should therefore be guarded

Aims: Arthroscopic drilling for the treatment of osteo-chondral lesion (OCL) of talus has been able to return earlier to social life resulting from less invasive operation. However, long term results of drilling have not been clear. Results of arthroscopic drilling for OCL which have passed 5 years or longer are reported. Methods: Subjects were 54 feet in 52 patients who had passed more than 5 years who underwent arthroscopic drilling. Age ranged 21 to 52 years with an average of 34 years. Classiþcation based on Berndt & Harty was as follows: 1 foot for stage?, 38 feet for stage?, 8 feet for stage?and 7 feet for stage?. Resdults: No patients showed limited range of motion at the þnal examination. With pain, 2 patients developed pain in the lesion, while no patients showed disturbance in gait, either. With sports, all the patients returned to initial sports, however, in patients with extensive lesion (3 patients), there remained pain causing a decrease in sports level. X-ray þndings revealed osteoarthritic change in three patients. Conclusions: In the present study, in patients of 90 percent or greater, there were no new developed or deterorated pains. However, osteoarthritic change was observed in the cases with lateral ligaments tear or subchondral bone cyst. Thus, it may suggest the limit in the indications of drilling. Furthermore, since there remained pain in the patients with complicated injuries or extensive lesion, it may be difþcult to obtain excellent results with use of arthroscopic drilling alone

In order to clarify how intra-articular lesions influence the survival of a periacetabular osteotomy in patients with dysplasia of the hip, we performed an observational study of 121 patients (121 hips) who underwent a transposition osteotomy of the acetabulum combined with an arthroscopy. Their mean age was 40.2 years (13 to 64) and the mean follow-up was 9.9 years (2 to 18). Labral and cartilage degeneration tended to originate from the anterosuperior part of the acetabulum, followed by the femoral side. In all, eight hips (6.6%) had post-operative progression to Kellgren–Lawrence grade 4 changes, and these hips were associated with the following factors: moderate osteoarthritis, decreased width of the joint space, joint incongruity, and advanced intra-articular lesions (subchondral bone exposure in the cartilage and a full-thickness labral tear). Multivariate analysis indicated subchondral bone exposure on the femoral head as an independent risk factor for progression of osteoarthritis (p = 0.003). In hips with early stage osteoarthritis, femoral subchondral bone exposure was a risk factor for progression of the grade of osteoarthritis. . Although the outcome of transposition osteotomy of the acetabulum was satisfactory, post-operative progression of osteoarthritis occurred at a high rate in hips with advanced intra-articular lesions, particularly in those where the degenerative process had reached the point of femoral subchondral bone exposure

Femoral head collapse due to avascular necrosis (AVN) is a relatively rare occurrence following intertrochanteric fractures; however, with over thirty-thousand intertrochanteric fractures per year in England and Wales alone, and an incidence of up to 1.16%, it is still significant. Often patients are treated with a hip fixation device, such as a sliding hip screw or X-Bolt. This study aimed to investigate the influence of three factors on the likelihood of head collapse: (1) implant type; (2) the size of the femoral head; and (3) the size of the AVN lesion. Finite element (FE) models of an intact femur, and femurs implanted with two common hip fixation designs, the Compression Hip Screw (Smith & Nephew) and the X-Bolt (X-Bolt Orthopaedics), were developed. Experimental validation of the FE models on 4. th. generation Sawbones composite femurs (n=5) found the peak failure loads predicted by the implanted model was accurate to within 14%. Following validation on Sawbones, the material modulus (E) was updated to represent cancellous (E=500MPa) and cortical (E=1GPa) bone, and the influence of implant design, head size, and AVN was examined. Four head sizes were compared: mean male (48.4 mm) and female (42.2 mm) head sizes ± two standard deviations. A conical representation of an AVN lesion with a lower modulus (1MPa) was created, and four different radii were studied. The risk of head collapse was assessed from (1) the critical buckling pressure and (2) the peak failure stress. The likelihood of head collapse was reduced by implantation of either fixation device. Smaller head sizes and greater AVN lesion size increased the risk of femoral head collapse. These results indicate the treatment of intertrochanteric fractures with a hip fixation device does not increase the risk of head collapse; however, patient factors such as small head size and AVN severity significantly increase the risk

We report a hitherto undescribed type of peripheral nerve lesion in which pressure results in mechanical demyelinisation of a length of nerve with interruption of conduction. On release of the pressure, early recovery may follow the return of the myelin insulation

Background. The aim of this prospective study was to assess the effectiveness of a single ultrasound-guided steroids injection in the treatment of Morton's neuromas and whether the response to injection correlates with the size of neuroma. Methods. Forty three patients with clinical features of Morton's neuroma underwent ultrasound scan assessment. Once the lesion was confirmed in the relevant web space, a single corticosteroids injection was given using 40 mg Methylprednisolone along with 1% Lidocaine. All scans and injections were performed by a single musculoskeletal radiologist. Patients were divided into two groups based on the size of the lesion measured on the scan. Group 1 included patients with neuromas of 5mm or less and Group 2 patients had neuromas larger than 5mm. The Visual Analogue Scale (Scale:0 to 10), the American Orthopaedic Foot and Ankle Society score (AOFAS) and the Johnson satisfaction scale were used to assess patients prior to injection and then at 6 weeks, 6 months and 12 months following the injection. Results. Thirty nine patients had confirmed neuromas. Group 1 (lesion ≤5mm) included 17 patients (mean age, 30 years) (7 males, 10 females) and Group 2 (lesion >5mm) had 22 patients (mean age, 33 years) (8 males, 14 females). VAS scores, AOFAS scores and Johnson scale improved significantly in both groups at 6 weeks (p < 0.0001). At 6 months post-injection, this improvement remained significant only in group 1 with regards to all scores (p < 0.001). At 12 months, there was no difference between both groups and outcome scores nearly approached pre-injection scores. The need for surgical treatment for persistent symptoms was similar in both groups (p = 0.6). Conclusion. A single ultrasound-guided corticosteroids injection offers generally a short-term pain relief for symptomatic Morton's neuromas. The effectiveness of the injection is likely to be more significant and long-lasting for lesions smaller than 5mm

Two patients presented with pain in the arm and a radiographic lesion of the upper humerus which warranted surgical exploration and excision biopsy. In both cases the pathology was inflammatory and involved the insertion of pectoralis major. Tendinitis of the pectoralis major with an associated lesion of the humerus has not previously been described

We examined the relationship between the size of the femoral cam in femoroacetabular impingement (FAI) and acetabular pathomorphology to establish if pincer impingement exists in patients with a femoral cam. CT scans of 37 symptomatic impinging hips with a femoral cam were analysed in a three-dimensional study and were compared with 34 normal hips. The inclination and version of the acetabulum as well as the acetabular rim angle and the bony acetabular coverage were calculated. These measurements were correlated with the size and shape of the femoral cams. While the size of the femoral cam varied characteristically, the acetabular morphology of the two groups was similar in terms of version (normal mean 23° (. sd. 7°); cam mean 22° (. sd.  9°)), inclination (normal mean 57° (. sd. 5°); cam mean 56° (. sd. 5°)), acetabular coverage (normal mean 41% (. sd. 5%); cam mean 42% (. sd. 4%)) and the mean acetabular rim angle (normal mean 82° (. sd. 5°); cam mean 83° (. sd. 4°)). We found no correlation between acetabular morphology and the severity of cam lesion and no evidence of either global or focal over-coverage to support the diagnosis of ‘mixed’ FAI. The femoral cam may provoke edge loading but removal of any acetabular bearing surface when treating cam FAI might induce accelerated wear. Cite this article: Bone Joint J 2013;95-B:314–19

Twenty-five patients with 30 chondral lesions of the knee were treated with an autogenous strip of costal perichondrium. The graft was fixed to the subchondral bone with Tissucol (Immuno, Vienna), a human fibrin glue. The leg was then immobilised for two weeks followed by two weeks of continuous passive motion. Weight-bearing was permitted after three months. The mean knee score (Ranawat, Insall and Shine 1976) changed from 73 before operation to 90 one year after; in 14 patients evaluated after two years there was no decrease. In 28 cases the defect was completely filled with tissue resembling articular cartilage. We conclude that in most cases perichondral arthroplasty of cartilage defects of the knee gives excellent results

We investigated the changes seen on serial metal artefact reduction magnetic resonance imaging scans (MARS-MRI) of metal-on-metal total hip arthroplasties (MoM THAs). In total 155 THAs, in 35 male and 100 female patients (mean age 70.4 years, 42 to 91), underwent at least two MRI scans at a mean interval of 14.6 months (2.6 to 57.1), at a mean of 48.2 months (3.5 to 93.3) after primary hip surgery. Scans were graded using a modification of the Oxford classification. Progression of disease was defined as an increase in grade or a minimum 10% increase in fluid lesion volume at second scan. A total of 16 hips (30%) initially classified as ‘normal’ developed an abnormality on the second scan. Of those with ‘isolated trochanteric fluid’ 9 (47%) underwent disease progression, as did 7 (58%) of ‘effusions’. A total of 54 (77%) of hips initially classified as showing adverse reactions to metal debris (ARMD) progressed, with higher rates of progression in higher grades. Disease progression was associated with high blood cobalt levels or an irregular pseudocapsule lining at the initial scan. There was no association with changes in functional scores. Adverse reactions to metal debris in MoM THAs may not be as benign as previous reports have suggested. Close radiological follow-up is recommended, particularly in high-risk groups. Cite this article: Bone Joint J 2015;97-B:1328–37

We reviewed 42 consecutive children with a supination deformity of the forearm complicating severe birth lesions of the brachial plexus. The overall incidence over the study period was 6.9% (48 of 696). It was absent in those in Narakas group I (27.6) and occurred in 5.7% of group II (13 of 229), 9.6% of group III (11 of 114) and 23.4% of group IV (18 of 77). Concurrent deformities at the shoulder, elbow, wrist and hand were always present because of muscular imbalance from poor recovery of C5 and C7, inconsistent recovery of C8 and T1 and good recovery of C6. Early surgical correction improved the function of the upper limb and hand, but there was a tendency to recurrence. Pronation osteotomy placed the hand in a functional position, and increased the arc of rotation of the forearm. The supination deformity recurred in 40% (17 of 42) of those treated by pronation osteotomy alone, probably because of remodelling of the growing bone. Children should be followed up until skeletal maturity, and the parents counselled on the likelihood of multiple operations

The effects of gamma irradiation on the growth plate have been studied in nineteen rabbits with a 1,000 rads/skin dose. The rabbits were killed after one to ninety days. The growth plates were studied by microscopic examination, thymidine-H3 autoradiography, and fluorescence with radiographic measurement. Changes were already detected after twenty-four hours at the cell mitosis level, which showed the sensitiveness of the chondrocyte itself. The lesions were clearly seen with the optical microscope after seven days, and they were most advanced between the fourteenth and twenty-first day after irradiation. Regeneration of the cartilage began in the fourth week and the histological appearance became normal after seventy days. Fluorescence with tetracycline showed a temporary retardation of growth, with consequent shortening of the affected limb

1. Two cases of fracture-dislocation of the spine at the lumbo-sacral level are reported. 2. One patient was treated conservatively and survived, with a cauda equina lesion which is now recovering. One patient was treated by operative decompression and died offat embolism. 3. The lumbo-sacral joint is locked in the dislocated position

Autologous chondrocyte implantation (ACI) and mosaicplasty are methods of treating symptomatic articular cartilage defects in the knee. This study represents the first long-term randomised comparison of the two techniques in 100 patients at a minimum follow-up of ten years. The mean age of the patients at the time of surgery was 31.3 years (16 to 49); the mean duration of symptoms pre-operatively was 7.2 years (9 months to 20 years). The lesions were large with the mean size for the ACI group being 440.9 mm. 2 . (100 to 1050) and the mosaicplasty group being 399.6 mm. 2. (100 to 2000). Patients had a mean of 1.5 previous operations (0 to 4) to the articular cartilage defect. Patients were assessed using the modified Cincinnati knee score and the Stanmore-Bentley Functional Rating system. The number of patients whose repair had failed at ten years was ten of 58 (17%) in the ACI group and 23 of 42 (55%) in the mosaicplasty group (p < 0.001). The functional outcome of those patients with a surviving graft was significantly better in patients who underwent ACI compared with mosaicplasty (p = 0.02)

Purpose: Appropriate management of complex trauma of the upper limb (CTUL) is a significant therapeutic challenge. The main difficulty is to determine in an emergency situation when ambitious conservative surgery is legitimate and when amputation in necessary. We propose a prognostic lesion score to determine the best option in the emergency setting. Material and methods: This study included 48 patients operated on between 1987 and 1997. These patients presented total or partial amputation (n=23), devascularising injury with continuous limb (=7), complex non-devascularising injury with continuous limb (n=18) (Gustilo IIIa and IIIb). Isolated hand trauma was excluded. Each patient was attributed retrospectively a lesion score taking into account each tissue (bone, vessels, nerves, muscles, skin). At minimum two-year follow-up, the outcome was evaluated for the amputated or non-amputated limb. For each non-amputated patient, a more precise outcome was established using the Chen classification. Operative procedures used the same protocol for all patients. Results: Considering the functional results, the statistical analysis enabled identifying prognostic factors for amputation among the five variables studied. Analysis using a classification tree enabled development of a decisional algorithm based on the muscle, nerve and skin injuries which provided 64.7% sensitivity and 100% specificity with a 100% positive predictive value and an 83.8% negative predictive value. A multiple logistic model was used to confirm these results and led to the selection of the same variables. Discussion: The CTUL score is easy to use and is the only one in the literature using only variables statistically proven to have significant prognostic value for CTUL. Surgical experience is however indispensable for appropriate decision making in these emergency situations. This score thus provides an important therapeutic aid useful in borderline cases where amputation is discussed. Conclusion: A prospective study including a larger number of patients would be helpful to better detail indications and preserve the 100% specificity for an irreversible therapeutic decision

In 16 patients we used uncemented Lord prostheses at revision operations for aggressive granulomatosis after cemented hip arthroplasties; in 12 bone grafts also were used. In 13 hips the granulomatous lesions were multifocal, and in one the acetabular component was involved. There was no evidence of infection in any case: all the patients had normal ESR and CRP levels. The revision operation was performed on average 9.4 years after the primary replacement; the mean age at revision was 64 years. On radiographs, the bone around the prosthesis had consolidated by an average of 16 months. At follow-up, two to six years later (mean 3.5 years) there had been no recurrences, nine patients had an excellent Mayo hip score, five were good and two fair

The purpose of this study was to report the results of the vertical apical suture Bankart lesion repair. Fifty-nine patients (52 men and seven women) with a mean age of twenty-seven years (range, 16–53 years) underwent this procedure. The mean duration of instability was 4 years and mean follow-up was 42 months (minimum of two years). A laterally based T-shape capsular incision is performed with the horizontal component directed towards the glenoid neck and into the Bankart lesion. A vertical apical suture through the superior and inferior flaps of the Bankart lesion, tighten the anterior structures to allow them to snug onto the convex decorticated surface of the anterior glenoid. At final review, according to the system of Rowe et al., 94.9% (56 patients) had a rating of good or excellent. Three patients had a recurrent dislocation due to further trauma. The mean loss of forward elevation was 1 degree, external rotation with the arm at the side was 2.4 degrees and external rotation in 90 degrees abduction was 2.2 degrees. Of forty-four patients participating in sport, thirty-five (79.5%) returned to the same sport at the same level of activity, even returned to the same sport at a reduced level of activity and two patients did not return to sport. The vertical apical suture repair offers a 94.9 percent success rate in terms of stability, a maintained range of motion and a 79.5% return to pre-injury level of sporting activity. It is technically less demanding than the Bankart procedure. All sutures used are absorbable. Complications related to non-absorbable implants and absorbable anchors and tacks are avoided

We have reviewed 41 patients with pustulotic arthro-osteopathy (PAO), all having both the typical skin rash of pustulosis palmaris et plantaris and bone lesions. The most common bones affected were the clavicle, sternum and ribs. Changes in the clavicle started, not as an enthesopathy, but with periosteal bone formation, indicative of a bone marrow disorder. About 30% of the patients also had lesions in the spine, sacroiliac region or the peripheral joints. Bone and joint lesions followed a variable and intermittent clinical course over a long period of time. Biopsies in eight cases showed similar inflammatory changes in skin, bone and synovium, with infiltration of lymphocytes and polymorphonuclear leucocytes. This suggests that there is a common pathogenesis in the three tissues

Introduction: We performed rotational open wedge osteotomy ( ROWO ) for Perthes’ disease with an extensive lesion. With this technique, the femoral head was rotated anteriorly, the postero-lateral viable segment was moved below the lateral acetabular roof consequently with the intertrochanteric osteotomy. We reviewed the results of this procedure radiographically. Materials and Methods: Twenty two cases over 2 years follow up were investigated. Nineteen hips (19 patients) were boys and 3 hips (3 patients) were girls. The patients’ mean age at the time of the operation was 7 years and 9 months and the mean follow-up was 6.5 years. There were 15 hips in fragmentation stage and 7 hips in healing stage. In Catterall Grouping, 19 hips were in Group III and 3 hips were in Group IV. The mean rotation angle was 36 degrees, and the mean varus angle was 21 degrees. We analyzed Stulberg classification and Mose’ rating at the final X-ray. Results By the Stulberg classification on final X-ray, 3 hips were in class I, 17 hips were in class II, 2 hips were in class III, and class IV and V were not seen. In Mose’ rating, all cases had good or fair results. Discussion: We conclude that rotational open wedge osteotomy is a beneficial procedure for Perthes’ disease with extensive lesions