Tranexamic acid (TXA) is an anti-fibrinolytic medication commonly used to reduce peri-operative bleeding. Increasingly, topical administration as an intra-articular injection or peri-operative wash is being administered at concentrations between 10–100mg/ml. This study investigated effects of TXA on human periarticular tissues and primary cell cultures using clinically relevant concentrations.

Tendon, synovium and cartilage obtained from routine orthopaedic surgeries were used ex vivo or cultured for in vitro studies using various concentrations of TXA. They were stained with 5-chloromethylfluorescein diacetate and propidium iodide and imaged using confocal microscopy to identify the proportion of live and dead cells. The in vitro effect of TXA on primary cultured tenocytes, synovial like fibroblast (FLS) cells and chondrocytes was investigated using cell viability assays (MTT), fluorescent microscopy and multi-protein apoptotic arrays for cell death.

There was significant (p<0.01) increase in cell death in all tissue treated with 100mg/ml TXA, ex vivo. MTT assays revealed significant (p<0.05) decrease in cell viability following treatment with 50 or 100mg/ml of TXA within 4 hours of all cell types cultured in vitro. Additionally, there was significant (p<0.05) increase in cell apoptosis detected by fluorescent microscopy within 1 hour of exposure to TXA. Furthermore, multi-protein apoptotic arrays detected increased apoptotic proteins within 1 hour of TXA treatment in tenocytes and FLS cells.

Our study provides evidence of TXA cytotoxicity to human peri-articular tissues ex vivo and in vitro at concentrations and durations of treatment routinely used in clinical environments. Clinicians should therefore show caution when considering use of topical TXA administration.

The aim of this study was to determine if patient reported outcome scores for arthroscopic meniscectomy are adversely affected by the degree of knee osteoarthritis or patient body mass index (BMI).

All patients who underwent arthroscopic meniscectomy within the NHS in Scotland between 6th February and 29th April 2012 were audited as part of the Scottish Government Musculoskeletal Knee Arthroscopy Audit and were eligible for inclusion within this study. A total of 270 patients returned both their pre-operative and post-operative EuroQol 5Q5D5L descriptive questionnaire and Knee injury and Osteoarthritis Outcomes Scores. Patients were stratified according to BMI, degree of osteoarthritis, history of injury, and duration of knee symptoms.

Pre-operative to post-operative EuroQol index scores [0.642±0.253 to 0.735±0.277, median±SD] and Knee injury and Osteoarthrtis Outcome Scores [44.63±18.78 to 62.28±24.94, median±SD] improved across all patients (p<0.0001). This was irrespective of degree of BMI, history of injury, or duration of symptoms. There was no such improvement in patients with moderate to severe osteoarthritis. Those patients with a BMI >35 kg/m2 had lower post-operative scores than the pre-operative scores of those of BMI <30 kg/m2.

Arthroscopic meniscectomy is beneficial regardless of patient BMI, duration of symptoms, history of injury, or in the presence of mild arthritis.

The Medial Patellofemoral Ligament (MPFL) is the main restraining force against lateral patellar displacement. It is often disrupted following patellar subluxation or dislocation. MPFL reconstruction is frequently performed when conservative management fails and the patient experiences recurrent patellar dislocation. Various MPFL reconstruction procedures have been described in the literature and reported outcomes are encouraging. This study analyses the radiographic outcomes following MPFL reconstruction.

From January 2006 to January 2011, 76 consecutive patients (80 knees) with patellar recurrent dislocation underwent medial patellofemoral ligament reconstruction in three large teaching hospitals. Mean follow-up was 31.8 months (range, 13–72). Semitendinosus and gracilis autografts were used for the reconstruction and all procedures were carried out by the senior authors (WL, BR, CW, MB).

Plain radiographs (Anteroposterior (AP), Lateral and Skyline) performed preoperatively and postoperatively were used to compare the sulcus angle, congruence angle, lateral patellofemoral angle, trochlear dysplasia (Dejour classification), trochlear boss height and patellar height (Caton-Deschamps ratio). Plain radiographs (Lateral) performed postoperatively were used to evaluate the femoral tunnel placement used for MPFL reconstruction.

The sulcus angle improved from 143.2° (122.9–157.7) to 139.3° (115.7–154.6) and the congruence angle improved from 26.7° (−17.5–82.6) to 0.26° (−35.3–7.8). The lateral patellofemoral angle was 7.99° (3.2–19.2) preoperatively and 9.02° (3.2–18.2) postoperatively. The Caton-Deschamps ratio was 1.2 (1.0–1.5) preoperatively and 1.0 (0.8–1.1) postoperatively. Using the Dejour classification of trochlear dysplasia, all preoperative radiographs were considered to be grade C or D and all postoperative radiographs were considered to be grade A or B. Trochlear boss height was 5.9mm (1.8–11.6) preoperatively and 4.7mm (1.6–6.9) postoperatively. 59% of the femoral tunnels were considered to be in a good position on postoperative radiographs.

This study displayed a significant improvement in postoperative radiographic parameters, demonstrating the importance of anatomic restoration when performing MPFL reconstruction.

We report the short term follow up of nineteen consecutive PFC sigma unicompartmental knee replacements carried out in our institution with minimum one year follow up. The PFC Sigma medial unicompartmental knee replacement is a fixed bearing, cemented unicompartmenal knee replacement. There are currently no published reports of follow up for the PFC Sigma medial unicompartmental knee replacement.

Nineteen patients (nineteen knees) underwent PFC sigma medial unicompartmental knee arthroplasty. The pre-operative diagnosis was osteoarthritis in eighteen patients and osteonecrosis in one patient. There were ten males and nine females with a mean age of sixty four years. All patients had clinical and radiological review at one year. All operations were carried out by the two senior authors (BPR and BL).

The mean length of admission was 2.7 days (Range 2–5). There have been no infective or thromboembolic complications to date. The mean oxford scores improved from 41 (Range 26–52) pre-operatively to 18 (15–27) at one year follow-up. The mean range of motion improved from 115 degrees of flexion preoperatively to 125 degrees. All radiographs were satisfactory at one year follow up with no evidence of loosening.

We report the promising early results of a new medial unicompartmental knee replacement with at least one year follow up. No early complications or infections were identified in our cohort of patients.

Aim

We aim to compare post-operative length of stay and cardiopulmonary morbidity in patients randomised to either navigated or conventional total knee arthroplasty (TKA).

Aim

We aim to compare revision rates and functional outcome scores in between two contemporary total knee arthoplasty systems.

Distal radial fractures are amongst the most common trauma referrals, however controversy remains regarding their optimum management. We undertook a retrospective review of the management of distal radial fractures in our department.

The prospectively maintained trauma database was used to identify patients admitted for operative management of a dorsally displaced distal radial fracture between June 2008 and June 2009. Only extra-articular or simple intra-articular fractures were included (AO classification A2/A3/C1/C2). Operation notes were reviewed to determine the method of fixation. Patients were contacted by post and asked to complete a functional outcome score - Disabilities of the Arm, Shoulder and Hand (DASH). A further 12 patients with similar fractures who had been managed conservatively were also asked to complete a DASH score to provide a comparison between operative and non-operative management.

98 patients were identified - 67 female, 31 male. Mean age was 51 years, range 15-85 years. All patients were at least 1 year post-op.

26 patients had manipulation under anaesthesia (MUA). 48 patients had MUA and K-wire fixation, which was supplemented with synthetic bone substitute in 16 cases. 3 patients had MUA and bone graft and 21 patients had open reduction and internal fixation (ORIF) with a volar plate.

34 correctly completed DASH scores were returned. A lower score equates to a better functional outcome. Mean DASH scores were: MUA 14.8; MUA+K-wire 13.1; ORIF 13.6; conservative 47.1.

This data would indicate that patients with a significantly displaced distal radial fracture have a better functional outcome with operative management to improve the fracture alignment. However, all of the methods of fixation used resulted in similar functional outcomes at one year.

The objective was to seek evidence of hypoxia in early human tendinopathy and thereafter, to explore mechanisms whereby tissue hypoxia may regulate apoptosis, inflammatory mediators and matrix regulation in human tenocytes.

Fifteen torn supraspinatus tendon (established pathology) and matched intact subscapularis tendon (representing ‘early pathology’) biopsies were collected from patients undergoing arthroscopic shoulder surgery. Control samples of subscapularis tendon were collected from 10 patients undergoing arthroscopic stabilisation surgery. Markers of hypoxia were quantified by immunohistochemical methods. Human tendon-derived primary cells were derived from hamstring tendon tissue obtained during hamstring tendon ACL reconstruction. The impact of hypoxia upon tenocyte biology ex vivo was measured using quantitative RT-PCR, multiplex cytokine assays, apoptotic proteomic profiling, immunohistochemistry and annexin V FACS staining.

Increased expression of HIF 1a, Bcl-2 and clusterin (hypoxic and apoptotic markers) was detected in subscapularis tendon samples compared to both matched torn samples and non matched control samples (p<0.01). Hypoxic tenocytes exhibited increased production of proinflammatory cytokines (p<0.001), altered matrix regulation (p<0.01) with increased production of Collagen type III operating through a MAPK dependent pathway. Finally, hypoxia increased expression of several mediators of apoptosis and thereby promoted tenocyte apoptosis.

Hypoxia promotes expression of proinflammatory cytokines, key apoptotic mediators and drives matrix component synthesis towards a collagen type III profile by human tenocytes. We propose hypoxic cell injury as a critical pathophysiological mechanism in early tendinopathy offering novel therapeutic opportunities in the management of tendon disorders.

We aim to compare post-operative length of stay and cardiopulmonary morbidity in patients randomised to either navigated or conventional total knee arthroplasty (TKA).

Patients undergoing primary TKA for osteoarthritis were prospectively assigned randomly to either navigation-guided or control groups and blinded to this.

All patients received a PFC implant (DePuy, Warsaw, IN). In the control group the standard femoral intramedullary and tibial extramedullary alignment rod was used. In the navigation group, the BrainLab (Munich, Germany) navigation system was used. All operations were carried out by one of two consultant orthopaedic knee surgeons.

Length of post operative hospital stay and the development of cardiopulmonary complication were recorded and groups compared.

100 patients were recruited (55 control vs 45 navigated). Patient demographics were similar in both groups.

Mean length of stay was 7 days in the control group (range 3-101), 5 days in the navigation group (range 3-10). The mode was 4 days in both groups.

7 patients (13%) stayed for >7 days in the control group, 3 patients (7%) stayed >7 days in the navigation group(p=0.339).

4 patients(7%) required >10 days inpatient stay in the control group, 0 patients required to stay in hospital for longer than 10 days in the navigation group(p=0.069).

The causes for the length of stay exceeding 10 days were pulmonary embolus in 3 patients, and chest infection in 1 patient.

Patients undergoing navigation-guided TKA required shorter post-operative inpatient stays than those undergoing arthroplasty using conventional techniques. Fewer patients in the navigation group required stays longer than 7 or 10 days. The difference in post-operative stay was associated with fewer respiratory complications in the navigated group.

Introduction

Previous studies comparing cruciate retaining (CR) and cruciate sacrificing - posterior stabilised (PS) TKRs have failed to demonstrate a difference in outcomes based on numbers of patients recruited.

This large study compares clinical outcomes in groups having PS and CR TKR and reports the results at 1 and 2 years post-operatively.

Summary: This study compares the outcomes of a large series of 683 cruciate sacrificing (PS) and cruciate retaining (CR) TKRs at minimum 2 years follow-up. Patients with a PS component showed a greater improvement in the pain and knee components of the American Knee Society Score at both 1 and 2 years post-operatively and also demonstrated a greater improvement in knee flex-ion at both time points.

Introduction: Excellent clinical results have been reported with both PS and CR TKR designs. A number of randomised trials comparing the two techniques have failed to demonstrate a difference in outcomes based on the numbers of patients recruited.

It is hypothesised that cruciate retention in total knee arthroplasty may result in improved kinematics of the knee by maintaining the femoral rollback seen in the normal knee, resulting in improved function. This study compares clinical outcomes in groups having PS and CR total knee arthroplasty and report the results at 1 and 2 years post-operatively.

Methods: A total of 683 patients undergoing TKR surgery were consecutively enrolled in a prospective multi-centre study with 2 arms. In the first arm patients receiving a PS component were randomised to receive either a mobile bearing (176 patients) or fixed bearing (176 patients) implant. In the second arm, patients receiving a CR component were randomised to receive either a mobile bearing (161 patients) or fixed bearing (170 patients) implant. All patients were assessed pre-operatively and at one and two years postoperatively using standard tools (Oxford, AKSS, Patellar Score) by independent nurse specialists. The data from the 2 arms of the trial were then analysed to compare differences between PS and CR implants.

Results: Patients with a PS component showed a greater improvement in the pain component of the AKSS at 1 year (p=0.0003) and at 2 years (p=0.0085) post-op.

Patients with a PS also showed a greater improvement in the AKSS knee score at 1 (p=0.0001) and 2 (p=0.001) years.

Knee flexion improvement was also greater in the PS group at 1 (p=0< 0.0001) and 2 (p=0.0035) years.

PS knees also achieved better outcomes in these variables in the mobile and fixed subgroups.

There were no other significant differences in the scores between the two groups at any stage.

Conclusion: This study reports on a large prospective multi-centre series of PS and CR TKRs. Improvements in pain and knee components of the AKSS score and knee flexion at both 1 and 2 years follow-up were greater in PS knees. Although this difference was statistically significant, differences in real terms were relatively small.

We performed a prospective audit to assess radiological and clinical sequelae of using injectable calcium sulphate in the management of distal radial fractures.

All patients in a 4-month period who were treated with injectable calcium sulphate for distal radial fracture were included in the audit. Initial data was collected on demographics; AO classification and degree of deformity; method of fixation and surgical complications. Follow up consisted of clinical and radiological assessment of fracture healing at standard fracture clinic intervals with a final assessment of subjective functional recovery. 16 patients were included in the audit, all of whom were followed up for a minimum of 8 weeks. We observed a low incidence of secondary displacement, and did not observe the problem of increased pain and erythema that has been observed with other bone graft substitutes.

We conclude that injectable calcium sulphate is a useful adjunct to conventional management of these fractures that is safe, helps maintain fracture reduction and is not associated with product specific complications.

A prospective randomised study was carried out to compare two methods of pain control following arthroscopically assisted ACL reconstruction.

Twenty patients each were randomly recruited to receive either femoral nerve block with 0.5% Bupivicaine or an intra-articular injection with the same. Both groups were prescribed Diclofenac regularly and Coproxamol as required. Visual analogue scores (VAS) were used to assess pain levels preoperatively, four hours postoperatively and on the morning after. The duration between surgery and the first dose of PRN analgesia was recorded, along with the total quantity of analgesia required before discharge. Patients with associated PCL or collateral ligament injuries were excluded beforehand.

Both groups were evenly matched for age (t-test p< 0.05). Tourniquet time did not differ significantly between the groups (t-test p:0.24). The VAS pain levels were not significantly different at four hours and the first morning postoperatively in both groups. Femoral block (Ave VAS: 21 & 25) did not confer a significant advantage (t-test p: 0.69, 0.7) over intra-articular injections of Bupivicaine (Ave VAS: 25 & 22). The total quantity of Coproxamol consumed did not vary significantly (p=0.99). There was no correlation between tourniquet time and postoperative pain (r=0.19, 0.08). All but one patient was discharged home on the first postoperative morning.

Our study demonstrates that pain levels can be sufficiently controlled by intra-articular infiltration of Bupivicaine coupled with oral analgesia. The level of pain relief achieved could allow this procedure to be increasingly performed in a day surgery setting without the need for femoral block thereby allowing for quicker mobilisation.