Autologous osteochondral transplantation (AOT) is an effective treatment for large Osteochondral Lesions of the Talus (OLT), however little is reported on an athletic population, who are likely to place higher demands on the reconstruction. The aim is to report the outcomes of large OLT (>150mm. 2. ) within an athletic population. The study population was limited to professional or amateur athletes (Tegner score >6) with an OLT of size 150mm. 2. or greater. The surgical intervention was AOT with a donor site from the lateral femoral condyle. Clinical outcomes at a minimum of 24 months included Return to Sport, VAS and FAOS Scores. In addition, graft incorporation was evaluated by MRI using MOCART scores at 12 months post-surgery. 38 athletes including 11 professional athletes were assessed. Mean follow-up was 46 months. Mean lesion size was 249mm. 2. 33 patients returned to sport at their previous level and one did not return to sport (mean return to play 8.2 months). Visual analogue scores improved from 4.53 pre-operatively to 0.63 post-operatively (p=0.002). FAOS Scores improved significantly in all domains (p< 0.001). Two patients developed knee donor site pain, and both had three osteochondral plugs harvested. Univariant analysis demonstrated no association between pre-operative patient or lesion characteristics and ability to return to sport. However, there was a strong correlation between MOCART scores and ability to return to sport (AUC=0.89). Our study suggests that AOT is a viable option in the management of large osteochondral talar defects in an athletic population, with favourable return to sport levels, patient satisfaction, and FAOS/VAS scores. The ability to return to sport is predicated upon good graft incorporation and further research is required to optimise this technique. Our data also suggests that patients should be aware of the increased risk of developing knee donor site pain when three osteochondral plugs are harvested

Lesions of the anterior interosseous nerve in the forearm are rare and often misdiagnosed as tendon injuries. A consecutive series of 13 patients with this condition referred for electrodiagnosis is reviewed. Only three had originally a correct clinical diagnosis and three were initially considered to have tendon ruptures. Five cases were of mechanical origin and seven due to ‘neuritis’. All showed electrophysiological abnormalities, most commonly involving the pronator quadratus. Late spontaneous recovery was common, and only one case had surgical exploration

Aims

A variety of surgical methods and strategies have been demonstrated for Andersson lesion (AL) therapy. In 2011, we proposed and identified the feasibility of stabilizing the spine without curettaging the vertebral or discovertebral lesion to cure non-kyphotic AL. Additionally, due to the excellent reunion ability of ankylosing spondylitis, we further came up with minimally invasive spinal surgery (MIS) to avoid the need for both bone graft and lesion curettage in AL surgery. However, there is a paucity of research into the comparison between open spinal fusion (OSF) and early MIS in the treatment of AL. The purpose of this study was to investigate and compare the clinical outcomes and radiological evaluation of our early MIS approach and OSF for AL.

Optimal treatment for symptomatic talus Osteochondral Lesions (OCLs) where primary surgical techniques have failed has not been established. Recent advances have focussed on biological repair such as Autologous Chondrocyte Implantation (ACI) however funding for this treatment is limited. Stem cell therapy in the ankle has not been assessed. The purpose of this pilot study was to evaluate the safety and efficacy of stem cell therapy in the treatment of ankle OCLs. The study was approved by the new procedures committee. Between January 2015 and December 2016, 26 patients, mean age of 36 years (range 16–58 years) with persisting disabling symptoms underwent Complete Cartilage Regeneration (CCR) using stem cells for failed primary treatment for ankle OCLs. Treatment involved iliac crest bone marrow aspiration, centrifugation to obtain bone marrow concentrate (BMC), and then injection of the BMC combined with hyaluronic acid into the OCL. Any necessary additional procedures, e.g. bone grafting or lateral ligament reconstruction were also undertaken. In 18 patients the lesion was on the medial talar dome, in 5 the lateral talar dome, 2 multiple, 1 tibial plafond. The Manchester-Oxford Foot Questionnaire (MOXFQ) was utilised to assess outcome. Average pre-operative MOXFQ scores were Walking dimension −78, Pain dimension − 65, and Social dimension − 64.2. Average 3 month post-operative MOXFQ scores were Walking − 54.8, Pain − 35.4, Social − 38.9. Average 6 month post-operative MOXFQ scores were Walking − 34.4, Pain − 35.4, Social − 28. Two patients from the beginning of the series had AOFAS scores only which improved from an average of 55 pre-operatively to 76 post-operatively. No early complications were noted. We conclude that CCR treatment is a safe treatment for talus OCLs in patients who have failed primary treatment. The procedure avoids two-stage surgery of ACI in some patients without large cysts. The early clinical outcome is favourable with no complications noted. Longer term follow-up is required

Aims

Osteofibrous dysplasia (OFD) is a rare benign lesion predominantly affecting the tibia in children. Its potential link to adamantinoma has influenced management. This international case series reviews the presentation of OFD and management approaches to improve our understanding of OFD.

Aims

The aim of this study is to define a core outcome set (COS) to allow consistency in outcome reporting amongst studies investigating the management of orthopaedic treatment in children with spinal dysraphism (SD).

Syndesmotic ankle lesions involve disruption of the osseous tibiofibular mortise configuration as well as ligamentous structures stabilizing the ankle joint. Incomplete diagnosis and maltreatment of these injuries is frequent, resulting in chronic pain and progressive instability thus promoting development of ankle osteoarthritis in the long term. Although the pathogenesis is not fully understood, abnormal mechanics has been implicated as a principal determinant of ankle joint degeneration after syndesmotic ankle lesions. Therefore, the focus of this presentation will be on our recent development of a computationally efficient algorithm to calculate the contact pressure distribution in patients with a syndesmotic ankle lesion, enabling us to stratify the risk of OA development in the long term and thereby guiding patient treatment.

Abstract

Ramp lesions are meniscocapsular or meniscosynovial tears associated with chronic ACL injury and are postulated to occur because of disruption of meniscotibial ligament.

Various techniques have been described in literature for their diagnosis and repair. Each of the described techniques have had some concerns. The authors, hereby, describe a novel technique for RAMP repair.

Purpose: The morphology and mechanical function of the metatarsosesamoid joint plays an important role in metatarsal head stability. The position of the sesamoids during the development of hallux valgus was evaluated by Inges, Haines and Tourne who distinguished three stages. Cartilage lesions in the context of hallux valgus have not been analysed with precision. The purpose of our work was to identify metatarsosesamoid lesions on anatomic specimens in patients who had undergone hallux valgus surgery. Material and methods: We dissected 12 metatarsosesa-moid joints (4 right, 13 left) from laboratory specimens and evaluated the degenerative lesions. For each specimen, we noted the metatarsophalangial angle and the AADM. We also examined 17 metatarsal specimens to determine the persistence or absence of the median crest as a sign of wear. Using the same protocol, we examined the joints surfaces and determined degenerative lesions during 20 SCARF procedures for hallus valgus. Results: For the twelve laboratory specimens, we observed: for the plantar joint surface of M1, the joint surfaces were perfectly intact in 2 specimens, the sagittal crest was worn away in 4, degenerative lesions appeared on the medial surface in 4, and on the lateral surface in 2. For the sesamoids, the degenerative lesions involved both sesamoids in 1 specimen, the lateral sesamoid in 2, the medial sesamoid in 4, and none in 3. Lesions of the metatarsophalangial joint were diffuse in 1 case, localised in 5 and absent in 6. For the 17 metatarsals, for an AADM between 4 and 12, no lesion was found in 6 cases, degenerative lesions involving both sesamoids in 1, the lateral sesamoid in 1 and the medial sesamoid in 2. For an AADM greater than 12, the metatarso-sesamoid joints surfaces were intact in 1 case, the sagittal crest was worn off in 4, and degenerative lesions involved the medial surface in 4 and the lateral surface in 1. Conclusion: This anatomy study demonstrated the precise topography of degenerative lesions of the metata-sosesamoid joint. This data base should be useful for evaluating functional outcome as a function of the meta-tarsosesamoid lesions in the treatment of hallux valgus

Menisci are crucial structures for knee homeostasis: they provide increase of congruence between the articular surfaces of the distal femur and tibial plateau, bear loading, shock absorption, lubrication, and proprioception. After a meniscal lesion, the golden rule, now, is to save as much meniscus as possible: only the meniscus tissue which is identified as unrepairable should be excised and meniscal sutures find more and more indications. Several different methods have been proposed to improve meniscal healing. They include very basic techniques, such as needling, abrasion, trephination and gluing, or more complex methods, such as synovial flaps, meniscal wrapping, or the application of fibrin clots. Basic research of meniscal substitutes has also become very active in the last decades. The features needed for a meniscal scaffold are: promotion of cell migration, it should be biomimetic and biocompatible, it should resist forces applied and transmitted by the knee, it should slowly biodegrade and should be easy to handle and implant. Several materials have been tested, that can be divided into synthetic and biological. The first have the advantage to be manufactured with the desired shapes and sizes and with precise porosity dimension and biomechanical characteristics. To date, the most common polymers are polylactic acid (PGA); poly-(L)-lactic acid (PLLA); poly- (lactic-co-glycolic acid) (PLGA); polyurethane (PU); polyester carbon and polycaprolactone (PCL). The possible complications, more common in synthetic than natural polymers are poor cell adhesion and the possibility of developing a foreign body reaction or aseptic inflammation, leading to alter the joint architecture and consequently to worsen the functional outcomes. The biological materials that have been used over time are the periosteal tissue, the perichondrium, the small intestine submucosa (SIS), acellular porcine meniscal tissue, bacterial cellulose. Although these have a very high biocompatibility, some components are not suitable for tissue engineering as their conformation and mechanical properties cannot be modified. Collagen or proteoglycans are excellent candidates for meniscal engineering, as they maintain a high biocompatibility, they allow for the modification of the porosity texture and size and the adaptation to the patient meniscus shape. On the other hand, they have poor biomechanical characteristics and a more rapid degradation rate, compared to others, which could interfere with the complete replacement by the host tissue. An interesting alternative is represented by hydrogel scaffolds. Their semi-liquid nature allows for the generation of scaffolds with very precise geometries obtained from diagnostic images (i.e. MRI).

Promising results have been reported with alginate and polyvinyl alcohol (PVA). Furthermore, hydrogel scaffolds can be enriched with growth factors, platelet-rich plasma (PRP) and Bone Marrow Aspirate Concentrate (BMAC). In recent years, several researchers have developed meniscal scaffolds combining different biomaterials, to optimize the mechanical and biological characteristics of each polymer. For example, biological polymers such as chitosan, collagen and gelatin allow for excellent cellular interactions, on the contrary synthetic polymers guarantee better biomechanical properties and greater reliability in the degradation time. Three-dimensional (3D) printing is a very interesting method for meniscus repair because it allows for a patient-specific customization of the scaffolds. The optimal scaffold should be characterized by many biophysical and biochemical properties as well as bioactivity to ensure an ECM-like microenvironment for cell survival and differentiation and restoration of the anatomical and mechanical properties of the native meniscus. The new technological advances in recent years, such as 3D bioprinting and mesenchymal stem cells management will probably lead to an acceleration in the design, development, and validation of new and effective meniscal substitutes.

Purpose: Osteochondritis dissecans (OCD) of the capitellum most commonly affects adolescent pitchers and gymnasts, and presents with pain and mechanical symptoms. Fragment excision is the most commonly employed surgical treatment; however, patients with larger lesions have been reported to have poorer outcomes. It’s not clear whether this is due to increased contact pressures on the surrounding articular surface, or if fragment excision causes instability of the elbow. The purpose of this study was to determine if fragment excision of simulated OCD lesions of the capitellum alters kinematics and stability of the elbow. Method: Nine fresh-frozen cadaveric arms were mounted in an upper extremity joint motion simulator, with cables attaching the tendons of the major muscle tendons to motors and pneumatic actuators. Electromagnetic receivers attached to the radius and ulna enabled quantification of the kinematics of both bones with respect to the humerus. Three-dimensional CT scans were used to plan lesions of 12.5% (mean 0.8cm2), 25%, 37.5%, 50%, and 100% (mean 6.2cm2) of the capitellar surface, which were marked on the capitellum using navigation. Lesions were created by burring through cartilage and subchondral bone. The arms were subjected to active and passive flexion in both the vertical and valgus-loaded positions, and passive forearm rotation in the vertical position. Results: No significant differences in varus-valgus or rotational ulnohumeral kinematics were found between any of the simulated OCD lesions and the elbows with an intact articulation with active and passive flexion, regardless of forearm rotation and the orientation of the arm (p> 0.7). Radiocapitellar kinematics were not significantly affected during passive forearm rotation with the arm in the vertical position (p=0.07–0.6). Conclusion: In this in-vitro biomechanical study even large simulated OCD lesions of the capitellum did not alter the kinematics or laxity of the elbow at either the radiocapitellar or ulnohumeral joints. These data suggest that excision of capitellar fragments not amenable to fixation can be considered without altering elbow kinematics or decreasing stability. Further study is required to examine other factors, such as altered contact stresses on the remaining articulation, that are thought to contribute to poorer outcomes in patients with larger lesions

One out of nine Canadian males would suffer prostate cancer (PC) during his lifetime. Life expectancy of males with PC has increased with modern therapy and 90% live >10 years. However, 20% of PC-affected males would develop incurable metastatic diseases. Bone metastases (BM) are present in ~80% of metastatic PC patients, and are the most severe complication of PC, generating severe pain, fractures, spinal cord compression, and death. Interestingly, PC-BMs are mostly osteoblastic. However, the structure of this newly formed bone and how it relates to pain and fracture are unknown. Due to androgen antagonist treatment, different PC phenotypes develop with differential dependency on androgen receptor (AR) signaling: androgen-dependent (AR+), double negative (AR-) and neuroendocrine. How these phenotypes are related to changes in bone structure has not been studied. Here we show a state-of-the-art structural characterization of PCBM and how PC phenotypes are associated to abnormal bone formation in PCBM.

Cadaveric samples (n=14) obtained from metastases of PC in thoracic or lumbar vertebrae (mean age 74yo) were used to analyze bone structure. We used micro-computed tomography (mCT) to analyze the three-dimensional structure of the bone samples. After imaging, the samples were sectioned and one 3mm thick section was embedded in epoxy-resin, ground and polished. Scanning electron microscopy (SEM)/energy-dispersive X-ray spectroscopy (EDS) and quantitative backscattering electron (qBSE) imaging were used to determine mineral morphology and composition. Another section was used for histological analysis of the PC-affected bone. Collagen structure, fibril orientation and extracellular matrix composition were characterized using histochemistry. Additionally, we obtained biopsies of 3 PCBM patients undergoing emergency decompression surgery following vertebral fracture and used them for immunohistological characterization.

By using mCT, we observed three dysmorphic bone patterns: osteolytic pattern with thinned trabecula of otherwise well-organized structures, osteoblastic pattern defined as accumulation of disorganized matrix deposited on pre-existing trabecula, and osteoblastic pattern with minimum residual trabecula and bone space dominated by accumulation of disorganized mineralized matrix. Comparing mCT data with patho/clinical parameters revealed a trend for higher bone density in males with larger PSA increase. Through histological sections, we observed that PC-affected bone, lacks collagen alignment structure, have a higher number of lacunae and increased amount of proteoglycans as decorin.

Immunohistochemistry of biopsies revealed that PC-cells inside bone organize into two manners: i) glandular-like structures where cells maintain their polarization in the expression of prostate markers, ii) diffuse infiltrate that spreads along bone surfaces, with loss of cell polarity. These cells take direct contact with osteoblasts in the surface of trabecula. We define that PCBM are mostly composed by AR+ with some double negative cells. We did not observe neuroendocrine phenotype cells.

PCBMs generate predominantly osteoblastic lesions that are characterized by high lacunar density, lack of collagen organization and elevated proteoglycan content. These structural changes are associated with the infiltration of PC cells that are mostly androgen-dependent but have lost their polarization and contact directly with osteoblasts, perhaps altering their function. These changes could be associated with lower mechanical properties that led to fracture and weakness of the PCBM affected bone.

The purpose of this study was to identify aetiological that may determine prognosis in ulnar nerve lesions and to evaluate the role of non-operative treatment. 148 consecutive patients (100 male) with 170 electrophysiologically proven (by nerve conduction and electromyography) ulnar nerve lesions were identified from the departmental records. Patient details, symptoms, known aetiology and treatment profile were recorded. Each patient was then contacted by telephone and/or questionnaire 1–6 (median 3. 8) years following electrodiagnosis to determine clinical progress and outcome. In patients with sensory symptoms alone or non-progressive painless motor symptoms, non-operative treatment was commenced. This involved advice on activity modifications and protection with a tubipad bandage or night spin. 12. 9% and 8. 8% of lesions were due to injury and intra-operative pressure respectively. Other causes included deformity and/or synovitis from arthritis of the elbow, repeated pressure, medial epicondylitis and benign space occupying lesions. 58. 2% were idiopathic with no clinical aetiological factor. 22 patients had expected bilateral lesions whereas 15 had contralateral lesions that were not symptomatic. 89. 4% and 4. 7% of lesions occurred at the elbow and wrist respectively. 83% of patients received non-operative first line treatment. 21% of these required operative intervention following further clinical and electrophysiological assessment. Partial or complete recovery occurred in 80%, 67% and 52% of the intra-operative, idiopathic and injury cases respectively (P< 0. 05). We conclude lesions of the ulnar nerve predominate in males and can be treated non-operatively providing clinical and electrophysiological monitoring is possible. Bilaterality is not uncommon and should be excluded. Lesions due to injury have a worse prognosis than those caused by direct continuous or repeated pressure or where no aetiological factor exists

The incisura fibularis (IF) provides intrinsic stability to the ankle joint complex by interlocking the distal tibia and fibula. Despite a high frequency of ligamentous ankle injuries, scant attention has been given to the morphology of the IF morphology incisura fibularis in the onset and development of these lesions. Therefore, we systematically reviewed the relation between ligamentous ankle disorders and the morphometrics of the IF.

A systematic literature search was conducted on following databases: PubMed, Embase and Web of Science. Search terms consisted of ‘ankle trauma’, ‘ankle injury’, ‘ankle sprain’, ‘ankle fracture’, ‘tibiofibular’, ‘fibular notch’, ‘fibular incisura’, ‘incisura fibularis’, ‘morphometric analysis’, ‘ankle syndesmosis’, ‘syndesmotic stability’. The evaluation instrument developed by Hawker et al. was used to assess the quality of the selected studies. This protocol was performed according to the PRISMA guidelines and is registered on PROSPERO (CRD42021282862).

Nineteen studies were included and consisted of prospective cohort (n=1), retrospective comparative (n=10), and observational (n=8) study design. Comparative studies have found certain morphological characteristics in patients with ankle instability. Several studies (n=5) have correlated a shallow IF depth with a higher incidence of ankle injury. A significant difference has also been found concerning the incisura height and angle (n=3): a shorter incisura and more obtuse angle have been noted in patients with ankle sprains. The mean Hawker score was 28 out of 36 (range=24-31).

A shallower IF is associated with ligamentous ankle lesions and might be due to a lower osseous resistance against tibiofibular displacement. However, these results should be interpreted in light of moderate methodological quality and should always be correlated with clinical findings. Further prospective studies are needed to further assess the relation between the incisura morphometrics and ligamentous disorders of the ankle joint.

Keywords: ankle instability, ankle injury, incisura fibularis, fibular notch, tibiofibular morphometrics, ankle syndesmosis

Abstract

Abstract

The purpose of this study was to identify aetiological factors that may determine prognosis in ulnar nerve lesions at the elbow and to evaluate the role of non-operative treatment. One hundred and thirty consecutive patients (92 male) with 152 electrophysiologically proven (by nerve conduction and electromyography) ulnar nerve lesions at the elbow were identified from the departmental records. Patient details, symptoms, known aetiology and treatment profile were recorded. Each patient was then contacted by telephone and / or questionnaire between one and six years after electrodiagnosis to determine clinical progress and outcome. In patients with sensory symptoms alone or non-progressive painless motor symptoms, non-operative treatment was commenced. This involved advice on activity modification and protection with a tubipad bandage or night splint with continued clinical and electrophysiological surveillance. Sixty-one percent of lesions were idiopathic with no clinical aetiological factor. Defined causes included deformity and/or synovitis from arthritis of the elbow (11.2%), injudicious intra-operative pressure (9.2%), injury/trauma (8.5%) repeated pressure (4.1%), medial epicondylitis (2.9%) and benign space occupying lesions (2.9%). Twenty-two patients had expected bilateral lesions whereas 15 had contralateral lesions that were not symptomatic. Eighty-three percent of patients received non-operative first line treatment. Twenty-one percent of these required operative intervention (simple decompression) following further clinical and electrophysiological assessment. Partial or complete recovery occurred in 88%, 80%, 67% and 52% of the arthritis, intra-operative, idiopathic and injury cases respectively (P< 0.05). We conclude lesions of the ulnar nerve at the elbow predominate in males and the majority can be treated non-operatively providing clinical and electrophysiological monitoring is possible. Bilaterality is not uncommon and should be excluded. Lesions due to injury have a worse prognosis than those caused by arthritis of the elbow, direct continuous or repeated pressure or where no aetiological factor exists

Introduction

Autologous Matrix Induced Chondrogenesis (AMIC) for surgical treatment of osteochondral lesions of the talus (OCLT) has shown excellent clinical and radiological results at short term follow up two years after surgery. However, no mid-term follow up data is available.

Abstract

Introduction

The purpose of this study was to examine trends in patient characteristics and clinical outcomes that occur with age as a statistical variable when performing autologous osteochondral transplantation (AOT) for the treatment of osteochondral lesions of the talus (OLT).