Osteochondral lesions (OCLs) of the talus are a challenging and increasingly recognized problem in chronic ankle pain. Many novel techniques exist to attempt to treat this challenging entity. Difficulties associated with treating OCLs include lesion location, size, chronicity, and problems associated with potential graft harvest sites. Matrix associated stem cell transplantation (MAST) is one such treatment described for larger lesions >15mm2 or failed alternative therapies. This cohort study describes a medium-term review of the outcomes of talar lesions treated with MAST. A review of all patients treated with MAST by a single surgeon was conducted. Preoperative radiographs, MRIs and FAOS outcome questionnaire scores were conducted. Intraoperative classification was undertaken to correlate with imaging. Postoperative outcomes included FAOS scores, return to sport, revision surgery/failure of treatment and progression to arthritis/fusion surgery.Introduction
Methods
Intra-articular shoulder pathology has been recognised in more detail following widespread use of shoulder arthroscopy. The purpose of this epidemiological study is to present the incidence and exact type of SLAP lesions in our operated population and to correlate them with the presence of other shoulder lesions. Between 2004 and 2010 425 patients underwent shoulder arthroscopy in our department (311 for rotator cuff tears or subacromial impingement, 102 for shoulder instability, 12 for SLAP lesions). Eighty-two SLAP lesions (19.2% overall) were recognized during these procedures. In 44 cases the lesion was SLAP type I (53.6%), in 10 type II (12.2%), in 1 type III (1.2%), in 1 type IV (1.2%), in 24 type V (29.26%) and finally in 2 type VI (2.43%). In more detail SLAP I lesions were associated in 8 patients with subacromial impingement syndrome, in 33 with RC tear and in 3 patients with anterior instability. Type II, III and IV were preoperatively diagnosed, while type V and VI lesions were found in patients with chronic anterior shoulder instability. SLAP lesions are diagnosed more accurately during shoulder arthroscopy rather than with plain shoulder MRI scan. In our study population only 12 cases were accurately diagnosed with a pre-operative MRI scan, while the remaining 70 cases were missed. Additionally, there was significant correlation between rotator cuff problems and SLAP I lesions, while chronic shoulder instability was associated with SLAP V and VI (25.4% of patients with instability). Shoulder arthroscopy not only has changed SLAP lesion diagnosis and treatment but also reveals the correlation of various SLAP lesion types with specific shoulder pathologies.
Adequate perpendicular access to the posterolateral talar dome for osteochondral defect repair is difficult to achieve and a number of different surgical approaches have been described. This cadaveric study examined the exposure available from various approaches to help guide pre-operative surgical planning. Four surgical approaches were performed in a step-wise manner on 9 Thiel-embalmed cadavers; anterolateral approach with arthrotomy, anterolateral approach with anterior talo-fibular ligament (ATFL) release, anterolateral approach with antero-lateral tibial osteotomy, and anterolateral approach with lateral malleolus osteotomy. The furthest distance posteriorly which allowed perpendicular access with a 2mm k-wire to the lateral surface of the talar dome was measured from the anterior aspect of the talar dome. The mean antero-posterior diameter of the lateral talar domes included in this study was 45.1mm. An anterolateral approach to the ankle with arthrotomy provided a mean exposure of the anterior 1/3rd of the lateral talar dome. ATFL release increased this to 43.2%. A lateral malleolus osteotomy provided superior exposure (81.5% vs 58.8%) compared to an anterolateral tibial osteotomy. Only the anterior half of the lateral border of the talar dome could be accessed with an anterolateral approach without osteotomy. A fibular osteotomy provided best exposure to the posterolateral aspect of the talar dome and is recommended for lesions affecting the posterior half of the lateral talar dome.
Femoroacetabular impingement due to a reduced femoral head-neck-offset or excessive acetabular coverage will lead to early cartilage lesions of the hip joint. The purpose of the present study was to analyze the relationship between the extent of bony deformity and the presence and extent of cartilage lesions in femoroacetabular impingement. On the radiographs of 92 hip joints in 86 patients with a mean age of 36.5 ± 9.2 years who were operated on for with femoroacetabular impingement by surgical hip dislocation, the acetabular index of the weight-bearing zone, the center-edge-angle, the inclination of the acetabulum, the lateral-head-extrusion-index, retroversion signs of the acetabulum, the neck-shaft-angle, asphericity, superior and anterior alpha angles, and superior and anterior offset and offset ratios were assessed and correlated to the presence and extent of chondromalazia.Background
Methods
Our understanding of the spectrum of pathological lesions of the shoulder anterior capsular-labral complex in anterior instability continues to evolve. In a previous study using magnetic resonance arthrography we have showed three variants of the essential lesion of the anterior capsular-labral complex. This is the first large arthroscopic study to finely evaluate the nature and relative proportions of these three lesions in anterior instability. We studied 122 patients, 101 male and 21 female patients with an average age of 28 (17 to 47 years old), undergoing primary arthroscopic stabilization for anterior instability between 2004 and 2008. The pathoanatomy of the anterior capsule-labral complex was documented. Based on our previous MRI arthrography experience we were able to categorize the lesions seen arthroscopically in three subgroups: the Bankart lesion, the Perthes lesion and the ALPSA (anterior periosteal sleeve avulsion).Purpose
Methods
The purpose of this study was to validate the usefulness of SPECT/CT as an evaluation method for determining treatment and prognosis for patellofemoral cartilage lesions, based on MRI and arthroscopic findings. From August 2009 to February 2010, SPECT/CT was performed on 80 patients (24 male and 56 female, average 53.3 years old) with chronic anterior knee pain who had no degenerative changes or patellar malalignment on plain radiographs. Radioisotope uptake findings on patellofemoral joint from SPECT/CT were classified into three grades by one nuclear medicine specialist. In the patients who demonstrated poor improvements after conservative treatments, MRI and arthroscopy were performed. Patellofemoral cartilage conditions under arthroscopic finding (ICRS grades) were compared with SPECT/CT grading. In all cases, there were increased uptakes on patellofemoral joints. Eighteen cases showed low uptake (Group 1), 22 cases showed medium uptake (Group 2) and 40 cases high uptake (Group 3). At the follow-up examination after mean 1.7 months, 16 cases of Group 1 (89%), 14 cases of Group 2 (64%) and 28 cases of Groups3 (70%) responded positively to the conservative treatments. For those 22 cases showing poor improvement, MRI and arthroscopy were done. Damage or thinning of patellofemoral cartilage, subchondral cyst, edema and fissuring were observed in every case that underwent MRI. Every arthroscopic case was found that there was patellofemoral cartilage damage. Each of ICRS grade I and grade II was found in 2 cases from Group 1. Two cases of grade II, 4 cases of grade III, and 2 cases of grade IV were found in Group 2. Two cases of grade II, 4 cases of grade III, and 6 cases of grade IV were found in Group 3. There was significant difference in the success rate of conservative treatment between SPECT/CT grade 1 and 2 or 3. And there was significant association between SPECT/CT grade and ICRS grade (P=0.034). SPECT/CT could be a useful modality in determining the treatment and prognosis for patellofemoral cartilage lesions compared with MRI and arthroscopic findings.
ACL (anterior cruciate ligament) partial tears include various types of lesions, and an high rate of these lesions evolve into complete tears. Most of the techniques described in literature for the surgical treatment of chronic partial ACL tears, don't spare the intact portion of the ligament. Aim of this study was to perform a prospective analysis of the results obtained by augmentation surgery using gracilis and semitendinosus tendons to treat partial sub-acute lesions of the ACL. This technique requires an “over the top” femoral passage, which enables salvage and strengthening of the intact bundle of ACL. The study included 97 patients treated consecutively at our Institute from 1993 to 2004 with a mean injury-surgery interval of 23 weeks (12–39). Patients were followed up by clinical and instrumental assessment criteria at 3 months, 1 year and 5 years after surgery. Clinical assessment was performed with the IKDC form. Subjective and functional parameters were assessed by the Tegner activity scale. Instrumental evaluation was done using the KT-2000 instrument: the 30 pound passive test and the manual maximum displacement test were performed. We obtained good to excellent results in 95.9% of cases. We didn't observed recurrences in ligamentous laxity. We believe that the described technique has the advantage of being little invasive, compatible with the ACL anatomy, and enables very rapid functional recovery and return to sport.
A new anterior intrapelvic approach for the surgical
management of displaced acetabular fractures involving predominantly
the anterior column and the quadrilateral plate is described. In
order to establish five ‘windows’ for instrumentation, the extraperitoneal
space is entered along the lateral border of the rectus abdominis
muscle. This is the so-called ‘Pararectus’ approach. The feasibility
of safe dissection and optimal instrumentation of the pelvis was
assessed in five cadavers (ten hemipelves) before implementation
in a series of 20 patients with a mean age of 59 years (17 to 90),
of whom 17 were male. The clinical evaluation was undertaken between
December 2009 and December 2010. The quality of reduction was assessed
with post-operative CT scans and the occurrence of intra-operative
complications was noted. In cadavers, sufficient extraperitoneal
access and safe instrumentation of the pelvis were accomplished.
In the patients, there was a statistically significant improvement
in the reduction of the fracture (pre- versus post-operative:
mean step-off 3.3 mm (. sd. 2.6) vs 0.1 mm
(. sd. 0.3), p <
0.001; and mean gap 11.5 mm (. sd. 6.5) vs 0.8 mm
(. sd. 1.3), p <
0.001).
Introduction. Telangiectatic osteosarcoma (TOS) is a rare subtype of osteosarcoma. We review our experience to characterize its prevalence, treatment, relapse and survivorship at long term follow-up. Methods. Eighty-seven patients aged from 4 to 60 years (mean 20 years), were treated from 1985 to 2008.
Introduction.
We have evaluated prospectively the arthroscopic findings in acute fractures of the ankle in 288 consecutive patients (148 men and 140 women) with a mean age of 45.6 years. According to the AO-Danis-Weber classification there were 14 type-A fractures, 198 type B and 76 type C.
Fractures of the distal third of the humerus may be complicated by complete lesions of the radial nerve which may be entrapped or compressed by bone fragments. Indirect reduction and internal fixation may result in a permanent nerve lesion. We describe the treatment of these lesions by insertion of a bridge plate using the minimally-invasive percutaneous technique. Six patients were operated on and showed complete functional recovery. Healing of the fractures occurred at a mean of 2.7 months (2 to 3) and complete neurological recovery by a mean of 2.3 months (1 to 5). In one patient infection occurred which resolved after removal of the implant.
Surgical dislocation of the hip in the treatment of acetabular fractures allows the femoral head to be safely displaced from the acetabulum. This permits full intra-articular acetabular and femoral inspection for the evaluation and potential treatment of cartilage lesions of the labrum and femoral head, reduction of the fracture under direct vision and avoidance of intra-articular penetration with hardware. We report 60 patients with selected types of acetabular fracture who were treated using this approach. Six were lost to follow-up and the remaining 54 were available for clinical and radiological review at a mean follow-up of 4.4 years (2 to 9). Substantial damage to the intra-articular cartilage was found in the anteromedial portion of the femoral head and the posterosuperior aspect of the acetabulum. Labral lesions were predominantly seen in the posterior acetabular area. Anatomical reduction was achieved in 50 hips (93%) which was considerably higher than that seen in previous reports. There were no cases of avascular necrosis. Four patients subsequently required total hip replacement. Good or excellent results were achieved in 44 hips (81.5%). The cumulative eight-year survivorship was 89.0% (95% confidence interval 84.5 to 94.1). Significant predictors of poor outcome were involvement of the acetabular dome and lesions of the femoral cartilage greater than grade 2. The functional mid-term results were better than those of previous reports. Surgical dislocation of the hip allows accurate reduction and a predictable mid-term outcome in the management of these difficult injuries without the risk of the development of avascular necrosis.
We have evaluated the functional, clinical and radiological outcome of patients with simple and complex acetabular fractures involving the posterior wall, and identified factors associated with an adverse outcome. We reviewed 128 patients treated operatively for a fracture involving the posterior wall of the acetabulum between 1982 and 1999. The Musculoskeletal Functional Assessment and Short-Form 36 scores, the presence of radiological arthritis and complications were assessed as a function of injury, treatment and clinical variables. The patients had profound functional deficits compared with the normal population. Anatomical reduction alone was not sufficient to restore function. The fracture pattern, marginal impaction and residual displacement of >
2 mm were associated with the development of arthritis, which related to poor function and the need for hip replacement. It may be appropriate to consider immediate total hip replacement for patients aged >
50 years with marginal impaction and comminution of the wall, since 7 of 13 (54%) of these required early hip replacement.