As arthroplasty demand grows worldwide, the need for a novel cost-effective treatment option for articular cartilage (AC) defects tailored to individual patients has never been greater. 3D bioprinting can deposit patient cells and other biomaterials in user-defined patterns to build tissue constructs from the “bottom-up,” potentially offering a new treatment for AC defects. Novel composite bioinks were created by mixing different ratios of methacrylated alginate (AlgMA) with methacrylated gelatin (GelMA) and collagen. Chondrocytes and mesenchymal stem cells (MSCs) were then encapsulated in the bioinks and 3D bioprinted using a custom-built extrusion bioprinter. UV and double-ionic (BaCl2 and CaCl2) crosslinking was deployed following bioprinting to strengthen bioink stability in culture. Chondrocyte and MSC spheroids were also bioprinted to accelerate cell growth and development of ECM in bioprinted constructs. Excellent viability of chondrocytes and MSCs was seen following bioprinting (>95%) and maintained in culture, with accelerated cell growth seen with inclusion of cell spheroids in bioinks (p<0.05). Bioprinted 10mm diameter constructs maintained shape in culture over 28 days, whilst construct degradation rates and mechanical properties were improved with addition of AlgMA (p<0.05). Composite bioinks were also injected into in vitro osteochondral defects and crosslinked in situ, with maintained cell viability and repair of osteochondral defects seen over a 14-day period. In conclusion, we developed novel composite bioinks that can be triple-crosslinked, facilitating successful chondrocyte and MSC growth in 3D bioprinted scaffolds and in vitro repair of an osteochondral defect model. This offers hope for a new approach to treating AC defects

Objectives. Osteochondral injuries, if not treated adequately, often lead to severe osteoarthritis. Possible treatment options include refixation of the fragment or replacement therapies such as Pridie drilling, microfracture or osteochondral grafts, all of which have certain disadvantages. Only refixation of the fragment can produce a smooth and resilient joint surface. The aim of this study was the evaluation of an ultrasound-activated bioresorbable pin for the refixation of osteochondral fragments under physiological conditions. Methods. In 16 Merino sheep, specific osteochondral fragments of the medial femoral condyle were produced and refixed with one of conventional bioresorbable pins, titanium screws or ultrasound-activated pins. Macro- and microscopic scoring was undertaken after three months. . Results. The healing ratio with ultrasound-activated pins was higher than with conventional pins. No negative heat effect on cartilage has been shown. Conclusion. As the material is bioresorbable, no further surgery is required to remove the implant. MRI imaging is not compromised, as it is with implanted screws. The use of bioresorbable pins using ultrasound is a promising technology for the refixation of osteochondral fractures

Introduction. 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. Methods. 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. Results. 58 MAST procedures in 57 patients were identified in this cohort. The mean follow up was 5 years. There were 20 females and37males, with a mean age of 37 years (SD 9.1). 22 patients had lateral OCLS were and 35 patients had medial OCLs. Of this cohort 32patients had previous surgery and 25 had this procedure as a primary event. 15 patients had one failed previous surgery, 9 patients had two, four patients had three previous surgeries and three patients had four previous surgeries. 12 patients had corrective or realignment procedures at the time of surgery. In terms of complications 3 patients of this cohort went on to have an ankle fusion and two of these had medial malleolar metal work taken out prior to this, 5 patients had additional procedures for arthrofibrotic debridements, 1 patient had a repeat MAST procedure, 1 additional patients had removal of medial malleolar osteotomy screws for pain at the osteotomy site, there were 2 wound complications one related to the ankle and one related to pain at the iliac crest donor site. Conclusion. MAST has demonstrated positive results in lesions which prove challenging to treat, even in a “ failed microfracture” cohort. RCT still lacking in field of orthobiologics for MAST. Longer term follow up required to evaluate durability

Bone is the second most commonly transplanted tissue worldwide, with over four million operations using bone grafts or bone substitute materials annually to treat bone defects. However, significant limitations affect current treatment options and clinical demand for bone grafts continues to rise due to conditions such as trauma, cancer, infection and arthritis. The need for a novel, cost effective treatment option for osteochondral defects has therefore never been greater. As an emerging technology, three-dimensional (3D) bioprinting has the capacity to deposit cells, extracellular matrices and other biological materials in user-defined patterns to build complex tissue constructs from the “bottom up”. Through use of extrusion bioprinting and fused deposition modelling (FDM) 3D printing, porous 3D scaffolds were successfully created in this study from hydrogels and synthetic polymers. Mesenchymal stem cells (MSCs) seeded onto polycaprolactone scaffolds with defined pore sizes and porosity maintained viability over a 7-day period, with addition of alginate hydrogel and scaffold surface treatment with NaOH increasing cell adhesion and viability. MSC-laden alginate constructs produced via extrusion bioprinting also maintained structural integrity and cell viability over 7 days in vitro culture. Growth within osteogenic media resulted in successful osteogenic differentiation of MSCs within scaffolds compared to controls (p<0.001). MSC spheroids were also successfully created and bioprinted within a novel, supramolecular hydrogel with tunable stiffness. In conclusion, 3D constructs capable of supporting osteogenic differentiation of MSCs were biofabricated via FDM and extrusion bioprinting. Future work will look to increase osteochondral construct size and complexity, whilst maintaining cell viability

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

Objectives. Osteochondral ankle defects (OCDs) mainly occur in a young, active population. In 63% of cases the defect is located on the medial talar dome. Arthroscopic debridement and microfracture is considered the primary treatment for defects up to 15 mm. To treat patients with a secondary OCD of the medial talar dome, a 15-mm diameter metal implant (HemiCAP ®) was developed. The set of 15 offset sizes was designed to correspond with the anatomy of various talar dome curvatures. Recently, two independent biomechanical cadaver studies were published, providing rationale for clinical use. The present study was undertaken to evaluate the clinical effectiveness and safety of the metal implantation technique for osteochondral lesions of the medial talar dome in a prospective study. Material and methods. Since October 2007, twenty patients have been treated with the implant. Four patients who did not meet the inclusion criteria and four patients who had less than one-year follow-up at the time of writing were left out of this analysis. Twelve patients are reported with one year (n=8) or two years (n=4) follow-up. All patients had had one or two earlier operations without success. On preoperative CT-scanning, the mean lesion size was 16 × 11 (range, 9–26 × 8–14) mm. Outcome measures were: Numeric Rating Scale pain (NRS) at rest and when walking, Foot Ankle Outcome Score (FAOS), American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, and clinical and radiographic complications. Data are presented as median and range. The Wilcoxon signed ranks test was used to calculate p-values. Results. All patients recovered well from surgery. The NRS at rest improved from 3 (0–7) preoperatively, to 0.5 (0–4) after 1 year and 1 (0–1) after 2 years follow-up (p < 0.05). The NRS when walking was 6.5 (4–8) preoperatively, improving to 1.5 (0–5) at 1 year and 1 (0–2) at 2 years follow-up (p < 0.05). The five subscales of the FAOS improved from 14–64 preoperatively, to 53–91 after 1 year and 63–100 after 2 years (p < 0.05). The AOFAS improved from 70 (42–75) before surgery to 86 (58–100) at 1 year, and 89 (82–90) at 2 years follow-up (p < 0.05). There were no clinical or radiographic complications. Conclusion. The metallic implantation technique appears to be a promising treatment for secondary OCDs of the talus, but more patients and longer follow-up are necessary to draw firm conclusions

Introduction. Osteochondral defects (OCDs) of the talus are treated initially by arthroscopic bone marrow stimulation. For both large and secondary defects, current alternative treatment methods have disadvantages such as donor site morbidity or two-stage surgery. Demineralized bone matrix (DBM) was published for the treatment of OCDs of rabbit knees. Autologous platelet-rich plasma (PRP) may improve the treatment effect of DBM. We previously developed a goat model to investigate new treatment methods for OCDs of the talus. The aim of the current study was to test whether DBM leads to more bone regeneration than control OCDs, and whether PRP improves the effectiveness of DBM. Methods. A standardized 6-mm OCD was created in 32 ankles of 16 adult Dutch milk goats. According to a randomized schedule, 8 goats were treated with commercially available DBM (Bonus DBM, Biomet BV, Dordrecht, the Netherlands) hydrated with normal saline, and 8 were treated with the same DBM but hydrated with autologous PRP (DBM+PRP). The contralateral ankles (left or right) were left untreated and served as a control. The goats were sacrificed after 24 weeks and the tali were excised. The articular talar surfaces were assessed macroscopically using the international cartilage repair society (ICRS) cartilage repair assessment, with a maximum score of 12. Histologic analysis was performed using 5-μm sections, and histomorphometric parameters (bone% and osteoid%) were quantified on representative areas of the surface, center, and peripheral areas of the OCDs. Furthermore, μCT-scans of the excised tali were obtained, quantifying the bone volume fraction, trabecular number, trabecular thickness, and trabecular spacing in both the complete OCDs and the central 3-mm cylinders. Results. All goats recovered well and were able to bear full weight within 24 hours after surgery. The mean ICRS-score of the ankles treated with DBM was 8.0 ± 1.0, compared to a score of 8.4 ± 1.5 in the contralateral ankle (NS); those treated with DBM+PRP scored 6.9 ± 2.4, compared to 7.4 ± 2.0 in the contralateral ankle (NS). Histologic analysis showed four different patterns of healing, distributed evenly over the treatment and control groups: type 1 (n = 4), almost completely healed; type 2 (n = 11), restoration of the subchondral bone with a cystic lesion underneath; type 3 (n = 14), superficial defect with regeneration from the margins and bottom; type 4 (n = 3), no healing tendency. Histomorphometry and μCT revealed no statistically significant difference between treatment (DBM or DBM+PRP) and contralateral control or between both treatment groups in any of the parameters investigated. Conclusion. No treatment effect of DBM was found compared to control defects, and the addition of PRP was not beneficial

Aims

Open reduction and plate fixation (ORPF) for displaced proximal humerus fractures can achieve reliably good long-term outcomes. However, a minority of patients have persistent pain and stiffness after surgery and may benefit from open arthrolysis, subacromial decompression, and removal of metalwork (ADROM). The long-term results of ADROM remain unknown; we aimed to assess outcomes of patients undergoing this procedure for stiffness following ORPF, and assess predictors of poor outcome.

Aim. The present study was designed to evaluate the implantation of alginate beads containing human mature allogenic chondrocytes for the treatment of symptomatic cartilage defects in the knee. Methods. A biodegradable, alginate-based biocompatible scaffold containing human mature allogenic chondrocytes was used for the treatment of chondral and osteochondral lesions in the knee. Twenty-one patients were clinically prospectively evaluated with use of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and a Visual Analogue Scale (VAS) for pain preoperatively and at 3, 6, 9, 12, 24 and 36 months of follow-up. Results. A statistically significant clinical improvement became apparent after 6 months and patients continued to improve during the 36 months of follow-up. Adverse reactions to the alginate/fibrin matrix seeded with the allogenic cartilage cells were not observed. Two of the procedures failed. One of the patients had loosening of the periosteal flap, which was attributed to a failure of the surgical procedure. The other failure case was the result of the poor quality and quantity of the repair tissue itself. Discussion. The results of this pilot study show that the alginate-based scaffold containing human mature allogenic chondrocytes is feasible for the treatment of symptomatic cartilage defects in the knee. The described technique provides clinical outcomes equal to those of other cartilage repair techniques

Staphylococcus aureus is a highly virulent pathogen and is implicated in approximately 50% of cases of septic arthritis. Studies investigating other S. aureus-related infections have suggested that alpha (Hla), beta (Hlb) and gamma (Hlg) toxins are key virulence factors. In particular, the ‘pore-forming’ alpha toxin is believed to be most potent. In this study, we have assessed the influence of alpha toxin on in situ chondrocyte viability. Osteochondral explants were harvested from the metacarpophalangeal joints of 3-year-old cows and placed into flasks containing Dulbecco's Modified Eagle's Medium. The flasks were then inoculated with the following isogenic ‘knockout’ strains of S. aureus: DU5946 (Hla+Hlb-Hlg-) or DU1090 (Hla-Hlb+Hlg+). The explants were incubated (37°C) and stained after 18, 24 and 40hrs with chloromethylfluorescein di-acetate and propidium iodide, labelling living chondrocytes green and dead cells red, respectively. Axial sections were imaged by confocal microscopy and the percentage cell death obtained using Volocity 4 software. The alpha toxin-producing S. aureus caused rapid cell death, with 24.8+/−3.7% at 18hrs and 44.6+/−7.2% at 24hrs. At 40hrs, there was significantly more chondrocyte death (87.4+/−3.6%; p<0.001) compared to the alpha toxin knockout strain (4.1+/−1.7%; means +/− SEM; n=4). In situ chondrocyte viability was significantly compromised by alpha toxin, with beta and gamma toxins having minimal effect. Further work will clarify the exact mechanism through which this important toxin induces chondrocyte death. Thereafter, it is hoped that targeted treatments can be developed to reduce the extent of cartilage destruction during, and after, an episode of septic arthritis

Osteocondritis dissecans (OCD) is a relatively common cause of knee pain. Ideal treatment is still controversial. Aim of this exhibit is to describe the outcomes of 5 different surgical techniques in a series of 63 patients. 63patients (age 22.5±7.4 years) affected by OCD of the femoral condyle (45 medial and 17 lateral) were treated by either osteochondral autologous transplantation, autologous chondrocyte implantation with bone graft, biomimetic nanostructured osteochondral scaffold (Maioregen) implantation, bone-cartilage paste graft or bone marrow derived cells transplantation “one-step” technique. Patient evaluation included IKDC score, eq-vas score, X-Rays and MRI preoperatively and at follow-up. Global mean IKDC improved from pre-operative 40.1±14.6 to 77.2±21.3 (p<0.0005) at mean 5.3±4.7 years follow-up, while eq-vas improved from 51.7±17.0 to 83.5±18.3(p<0.0005). No influence of age, size of the lesion, length of follow-up and associated surgeries on the result was found. No differences were found between the results obtained with different surgeries except a slight tendency of better improvement in the result following autologous chondrocyte implantation (p<0.01). Control MRI evidenced a satisfactory repair of cartilaginous layer and subchondral bone. The techniques described were effective in providing good clinical and radiographic results in the treatment of OCD and confirmed the validity of autologous chondrocyte implantation over time. Newer techniques such as Maioregen implantation and “one-step” base on different rationales, the first relying on the characteristics of the scaffold and the second on the regenerative potential of mesenchymal cells. Both of them have the advantages to be minimally invasive surgeries and to require a single operation

Chondral injuries of the knee are extremely common and present a unique therapeutic challenge due to the poor intrinsic healing of articular cartilage. These injuries can lead to significant functional impairment. There are several treatment modalities for articular osteochondral defects, one of which is autologous chondrocyte implantation. Our study evaluates the mid to long term functional outcomes in a cohort of 828 patients who have undergone an autologous chondrocyte implantation procedure (either ACI or MACI), identifying retrospectively factors that may influence their outcome. The influence of factors including age, sex, presence of osteoarthritis and size and site of lesion have been assessed individually and with multivariate analysis. All patients were assessed using the Bentley Functional Score, Visual Analogue Score and the Cincinnati Functional Score. Assessment were performed pre-operatively and of their status in 2010. The majority of patients had several interim scores performed at varying intervals. The longest follow-up was 12 years (range 24 to 153 months) with a mean age of 34 years at time of procedure. The mean defect size was 486 mm2 (range 64 to 2075 mm2). The distribution of lesions was 51% Medial Femoral Condyle, 12.5% Lateral Femoral Condyle, 18% Patella (single facet), 5% Patella (Multifacet) and 6% Trochlea. 4% had cartilage transplant to multiple sites. 30% failed following this procedure at a mean time of 72 months. 52% patients stated a marked improvement in their functional outcomes within the first two years. 49% stated an excellent result following their procedure. High failure rate was noted in those with previous cartilage regenerative procedures, transplants occurring on the patella, particularly if involving multifacets. Multiple site cartilage transplantation was also associated with a high failure rate. Autologous chondrocyte implantation is an effective method of decreasing pain and increasing function, however patient selection plays clear role in the success of such procedure

INTRODUCTION. Fresh bipolar shell osteochondral allograft (FBOA) is a controversial treatment option for post-traumatic ankle arthritis. Immunological response to transplanted cartilage may play a role in failure. Aim of the study is to compare two groups of patients who received FBOA in association or not to immunosuppressive therapy. METHODS. 2 groups, of 20 patients each, underwent FBOA. Only one group (group-B) received immunosuppressive therapy. Pre-operative and follow-up evaluation were clinical (AOFAS) and radiographical (X-Rays, CT- scan, MRI). Bioptic samples harvested during II look were examined by histochemical, immunohistochemical (ICRS II score) and by genetic typing analyses. RESULTS. Group-A pre-operative AOFAS score improved from 28.2 ± 10.9, to 69.9 ± 18.2 at 24 months follow-up(p<0.005), while Group B improved from 26.2 ± 6.8 to 71.4 ± 7.3 (p<0.005). Comparison of clinical outcomes between the groups was non-significant. Group B showed better morphology of the grafts (ICRS II score mean of 68%) compared to Group A (mean of 40%) (p<0.05). Genetic typing showed a mixed recipient/donor DNA presence. Kendall ordinal correlation between groups and ICRS score was found. All the samples rated as 100 were in group B, while all the samples rated 0 were in group A (=0.506, p=0.008). CONCLUSIONS. Although clinical results were comparable in the two groups, better histological score in Group B evidentiated hyaline cartilage significatively better preserved. Genetic typing showed the presence of cells of the host into the transplanted cartilage suggesting a possible colonization of transplanted cartilage by host cells never described before

Introduction. There is a challenge to detect partial tear of the ACL, the number of bundle injured and the proportion of fibers torn. The MRI was shown efficient to individualize the two anteromedial (AM) and posterolateral (PL) bundles of the ACL. The purpose of this study was to assess the ability of the MRI to detect partial tears of the ACL on axial views to display the AM and PL bundles. Materials and methods. This retrospective study included 48 patients (19 partial tears of the ACL, 16 complete rupture of the ACL and 13 normal knee) who underwent both arthroscopy and MRI examinations of the knee. The conventional MRI protocol included one sagittal T1- weighted sequence and 3 proton-density fat sat. The images from MRI were analysis by a radiologist specialized in musculoskeletal imaging who was blinding to the arthroscopic findings. The criteria for the analysis of MRI were divided into primary (those involving the ACL himself) and secondary signs (associated abnormalities). The primary signs included the horizontalisation of the ACL (ACL axis), the global ACL signal intensity and the signal intensity of each AM and PL bundle. The secondary signs included bone bruise, osteochondral impaction, popliteus muscle injury, medial collateral ligament injury and joint effusion. The ACL was classified as normal, partially or totally torn. The rupture of the AM and PL bundle was specified. Results. In our study, MRI was found to have a 75% sensitivity and a 73% specificity for the diagnosis of partial tears of the ACL. The sensitivity to detect AM bundle lesion was 88% but the specificity was 50%. The lack of horizontalisation of the ACL was a very good sign, for partial tears of the ACL, with a sensitivity of 84% and a specificity of 81% (p<0.05). Regarding the secondary signs, there was no significant difference to distinguish partial and complete tear. However, we found that there was a greater probability to find a partial tear of the ACL with the lack of joint effusion, bone bruise and medial collateral ligament injury. Quantifying the proportion of injured fibers was unsuccessful and was found as a failure of the MRI. Conclusions. MRI exhibited lower sensitivity and specificity for partial tear than for complete rupture of the ACL. However 3 important arguments can guide us: the lack of horizontalisation of the ACL, a continuous ACL signal, the display of one of two bundles on the axial view

PURPOSE. Osteochondral talar defects (OCDs) are sometimes located so far posteriorly that they may not be accessible by anterior arthroscopy, even with the ankle joint in full plantar flexion, because the talar dome is covered by the tibial plafond. It was hypothesized that computed tomography (CT) of the ankle in full plantar flexion could be useful for preoperative planning. The dual purpose of this study was, firstly, to test whether CT of the ankle joint in full plantar flexion is a reliable tool for the preoperative planning of anterior ankle arthroscopy for OCDs, and, secondly, to determine the area of the talar dome that can be reached by anterior ankle arthroscopy. METHODS. In this prospective study, CT-scans with sagittal reconstructions were made of 46 consecutive patients with their affected ankle in full plantar flexion. In the first 20, the distance between the anterior border of the OCD and the anterior tibial plafond was measured both on the scans and during anterior ankle arthroscopy as the gold standard. Intra- and interobserver reliability of CT as well as agreement between CT and arthroscopy were assessed by intraclass correlation coefficients (ICCs) and a Bland and Altman graph. Next, the anterior and posterior borders of the talar dome as well as the anterior tibial plafond were marked on all 46 scans. Using a specially written computer routine, the anterior proportion of the talar dome not covered by the tibial plafond was calculated, both lateral and medial, indicating the accessible area. RESULTS. The distance between the anterior border of the OCD and the anterior tibial plafond ranged from −3.1 to 9.1 mm on CT and from −3.0 to 8.5 on arthroscopy. The intra- and interobserver reliability of the measurements made on CT-scans were excellent (ICC > 0.99, p < 0.001). Likewise, agreement between CT and arthroscopy was excellent (ICC=0.97; p < 0.001); only one patient showed a difference of more than 2.0 mm. The anterior 47.3 ± 6.8% (95%CI, 45.2–49.3) of the lateral talar dome, and 47.7 ± 7.0% (95%CI, 45.7–49.8) of the medial talar dome was not covered by the tibial plafond. CONCLUSIONS. Computed tomography of the ankle joint in full plantar flexion is an accurate preoperative planning method to determine the arthroscopic approach for treatment of OCDs of the talus. Almost half of the talar dome is directly accessible by anterior ankle arthroscopy

Specific radiological features identified by Brandser and Marsh were selected for the analysis of acetabular fractures according to the classification of Letournel and Judet. The method employs a binary approach that requires the observer to allocate each radiological feature to one of two groups. The inter- and intra-observer variances were assessed. The presence of articular displacement, marginal impaction, incongruity, intra-articular fragments and osteochondral injuries to the femoral head were analysed by a similar method. These factors were termed ‘modifiers’ and are generally considered when planning operative intervention and, critically, they may influence prognosis. Six observers independently assessed 30 sets of plain radiographs and CT scans on two separate occasions, 12 weeks apart. They were asked to determine the presence or absence of specific radiological features. This simple binary approach to classification yields an inter- and intra-observer agreement which ranges from moderate to near-perfect (κ = 0.49 to 0.88 and κ = 0.57 to 0.88, respectively). A similar approach to the modifiers yields only slight to fair inter-observer agreement (κ = 0.20 to 0.34) and slight to moderate intra-observer agreement (κ = 0 to 0.55)

Aims

The primary aim of this study was to address the hypothesis that fracture morphology might be more important than posterior malleolar fragment size in rotational type posterior malleolar ankle fractures (PMAFs). The secondary aim was to identify clinically important predictors of outcome for each respective PMAF-type, to challenge the current dogma that surgical decision-making should be based on fragment size.

Objectives

The aim of this systematic literature review was to assess the clinical level of evidence of commercially available demineralised bone matrix (DBM) products for their use in trauma and orthopaedic related surgery.

Over a five-year period, adult patients with marginal impaction of acetabular fractures were identified from a registry of patients who underwent acetabular reconstruction in two tertiary referral centres. Fractures were classified according to the system of Judet and Letournel. A topographic classification to describe the extent of articular impaction was used, dividing the joint surface into superior, middle and inferior thirds. Demographic information, hospitalisation and surgery-related complications, functional (EuroQol 5-D) and radiological outcome according to Matta’s criteria were recorded and analysed. In all, 60 patients (57 men, three women) with a mean age of 41 years (18 to 72) were available at a mean follow-up of 48 months (24 to 206). The quality of the reduction was ‘anatomical’ in 44 hips (73.3%) and ‘imperfect’ in 16 (26.7%). The originally achieved anatomical reduction was lost in12 patients (25.8%). Radiologically, 33 hips (55%) were graded as ‘excellent’, 11 (18.3%) as ‘good’, one (1.7%) as ‘fair’ and 15 (25%) as ‘poor’. A total of 11 further operations were required in 11 cases, of which six were total hip replacements.

Univariate linear regression analysis of the functional outcome showed that factors associated with worse pain were increasing age and an inferior location of the impaction. Elevation of the articular impaction leads to joint preservation with satisfactory overall medium-term functional results, but secondary collapse is likely to occur in some patients.

Cite this article: Bone Joint J 2013;95-B:230–8.

Our aim was to evaluate the efficacy of a two-level reconstruction technique using subchondral miniscrews for the stabilisation of comminuted posterior-wall marginal acetabular fragments before applying lag screws and a buttress plate to the main overlying posterior fragment. Between 1995 and 2003, 29 consecutive patients with acute comminuted displaced posterior-wall fractures of the acetabulum were treated operatively using this technique.

The quality of reduction measured from three standard plain radiographs was graded as anatomical in all 29 hips. The clinical outcome at a mean follow-up of 35 months (24 to 90) was considered to be excellent in five patients (17%), very good in 16 (55%), good in six (21%) and poor in two (7%). The use of the two-level reconstruction technique appears to provide stable fixation and is associated with favourable results in terms of the incidence of post-traumatic osteoarthritis and the clinical outcome. However, poor results may occur in patients over the age of 55 years.