Aims

We introduced a self-care pathway for minimally displaced distal radius fractures, which involved the patient being discharged from a Virtual Fracture Clinic (VFC) without a physical review and being provided with written instructions on how to remove their own cast or splint at home, plus advice on exercises and return to function.

Aims

The aim of this study was to identify the origin and development of the threshold for surgical intervention, highlight the consequences of residual displacement, and justify the importance of accurate measurement.

Purpose: Lower extremity articular fracture treatment requires acccurate diagnosis and anatomic reduction and fixation. As articular injuries, posterior malleolus (PM) fractures are still poorly defined: for example the incidence of associated PM marginal impaction and of free articular fragments is unknown. The purposes of this study were:. to define the articular injuries of PM fractures into clincially relevant groups, as complex articular injuries could require specific surgical steps;. to identify clinical and radiographic parameters which would alert the surgeon to the presence of complex injuries. Method: Our prospectively-collected orthopaedic trauma database (OTDB) query identified 796 ankle fractures treated operatively between 2003–2007. Of these 147 cases involved the posterior malleolus. Four were misclassified leaving 143 cases. We obtained demographic and injury data from the OTDB, and validated the OTDB coded mechanisms of injury by an individual chart review. We reviewed all radiographs to describe the PM injuries (fracture patterns and dimensions) and to identify the associated injuries. Results: Of the 143 cases: Mean age was 50 years (sd=19), 68.5% were female, 51% were right sided injuries, and the median ISS=4 (in fact, 97.5% had ISS=4, most therefore being isolated trauma). The mean post malleolus AP size=11mm (sd=5). We identified recurrent patterns and classified the PM fracture as SIMPLE or COMPLEX (to include marginal impaction or free comminuted fragment, which should be anatomically reduced), 42% of cases (60/143) were COMPLEX (18 were impaction, 42 were free fragment). To help clinicians identify which cases could be COMPLEX we correlated (Chi-sq) the presence of a COMPLEX PM fracture to common clinical and radiographic variables. COMPLEX PM were statistically significantly associated with (p values). an axial loading injury mechanism (.000),. a radiographically captured dislocation (.006),. posteromedial comminution [as defined Tor-netta] (.005). the size of the fragment (.000). For example, axial loading would result in a complex fracture in > 85% of cases. In contrast, there was a statistically significant association between a Weber C fracture and older age and the presence of a SIMPLE PM fracture. These factors being potentially “protective” from joint comminution. Conclusion: We have defined and quantified the PM articular lesions which require anatomic reduction and fixation, beyond what has been published. We have defined clinical and radiographic criteria which, because higly associated with COMPLEX lesions, could. prompt surgeons to order further imaging (CT) to better delineate the lesion, and. draw his/her attention to potentially malaligned fragments at the time surgery

Chondrocyte dysfunction is attributable to the development of osteoarthritis (OA). Deregulation of chondrogenic regulators and deleterious factors, e.g. proteinases, Wnt signalling components, and autophagy repressors lowers chondrogenic activities and ultimately deteriorates cartilage homeostasis. Emerging evidence is that epigenetic pathways, including non-coding microRNAs and histone remodelling switch on/off the expression of joint-deleterious factors. MicroRNAs reduces the expressions of mRNAs through binding to the 3'-untranslation regions of targets. The levels of microRNAs, e.g. miR-29a, miR-128a in serum, synovial fluid, synovium, and cartilage are correlated with the occurrence of OA. Mice overexpressing/deficient microRNAs of interest show minor responses to OA progression. Besides, acetylation and methylation statuses of histones regulate the factors detrimental to chondrocytes through altering the interactions between histones and promoters. Histone deacetylases and demethylases, e.g. HDAC4, SIRT1, and EZH2 contribute to the modification reactions of histones, which modulate cartilage matrix metabolism. An intricate nature is that reciprocal actions between microRNAs and histone deacetylase/demethylase are indispensable in chondrocyte survival and function. Administrations with specific inhibitor/agonists for microRNAs and histone deacetylases/demethylase enable joints to show minor responses to articular injury, which mitigate the pathogenesis of OA. This talk highlights the biological roles and therapeutic advantage of epigenetic microRNAs and histone remodelling in OA

Aims

Focal knee arthroplasty is an attractive alternative to knee arthroplasty for young patients because it allows preservation of a large amount of bone for potential revisions. However, the mechanical behaviour of cartilage has not yet been investigated because it is challenging to evaluate in vivo contact areas, pressure, and deformations from metal implants. Therefore, this study aimed to determine the contact pressure in the tibiofemoral joint with a focal knee arthroplasty using a finite element model.

Aims

The optimal management of posterior malleolar ankle fractures, a prevalent type of ankle trauma, is essential for improved prognosis. However, there remains a debate over the most effective surgical approach, particularly between screw and plate fixation methods. This study aims to investigate the differences in outcomes associated with these fixation techniques.

Aims

This study uses prospective registry data to compare early patient outcomes following arthroscopic repair or debridement of the acetabular labrum.

We have developed a novel, two-layered, collagen matrix seeded with chondrocytes for repair of articular cartilage. It consists of a dense collagen layer which is in contact with bone and a porous matrix to support the seeded chondrocytes. The matrices were implanted in rabbit femoral trochleas for up to 24 weeks. The control groups received either a matrix without cells or no implant. The best histological repair was seen with cell-seeded implants. The permeability and glycosaminoglycan content of both implant groups were nearly normal, but were significantly less in tissue from empty defects. The type-II collagen content of the seeded implants was normal. For unseeded implants it was 74.3% of the normal and for empty defects only 20%. The current treatments for articular injury often result in a fibrous repair which deteriorates with time. This bilayer implant allowed sustained hyaline-like repair of articular defects during the entire six-month period of observation

Background: Unfortunately ACL injuries are not uncommon in the young: the majority however occurring after skeletal maturity. Aim: To perform an internal audit of the demand, methods and results of ACL reconstruction in young patients at a tertiary referral centre. Methods: Patients were identified through electronic patient records, and all operation notes and follow up records were scrutinised. Results: 84 cases under 20 years of age (range 14–19) were reviewed from 2000–2004 with a minimum follow-up of 6 months. Over 10% had undergone previous surgery or had documented articular injury. 42 cases required further meniscal surgery at the time of reconstruction: 12% repairs (20/168 menisci), 18% partial menisectomy (30/168). The median time to reconstruction from injury was 9 months (range 1–72). No case was delayed for growth plate maturation. Reconstruction methods were partly surgeon dependent, following adult themes. Occasionally tibial fixation was away from the growth plate with low profile screws and washers. We are only aware of 1 failure during this short follow-up. Conclusion: We believe that the use of techniques similar to those used on adults is appropriate for adolescents. However the high comorbidity is of some concern, demonstrating that this age range is as challenging as their older counterparts

Treatment of patellar instability in adolescents is controversial. Some investigators have advocated early repair of the medial structures, whereas others have treated this injury nonoperatively. The medial patellofemoral ligament, is a primary restrictor and stabilizer of the patella, and has acquired a significant role in the treatment of instability in children and adolescents. The authors present a prospective study of 39 consecutive patients (45 knees), without physeal closure, who underwent plasty of the medial patellofemoral ligament for the treatment of symptomatic patellofemoral instability with autologous Gracilis tendon, according to Chassaing’s technique. There were 26 female and 13 male patients with an average age of 15, 9 years. Mean follow-up was 44 months (6–65). All patients presented with clinical evident patellar tilt. This population presented a TA-GT within a normal range (12+/− 5 mm), but presented in 80% of cases a trochlear dysplasia. Clinical functional results were evaluated using the Kujala scale. Arthroscopic evaluation was systematically performed searching for intra articular injuries or patellar tilt. Early rehabilitation protocols were used in all cases. At the last follow up evaluation, 90% of the patients presented good or very good results. Kujala Score was 84, 5 +/−9,7 after surgery compared with 54,9+/−11,8 before surgery (p< 0,0001). There were 3 minor complications: 2 hematomas and 1 superficial infection that resolved without complications. Four patients kept complaining of residual anterior knee pain as result of patellar chondropathy that was diagnosed intra operatively. Three patients complained of graft donor site pain. One patient presented with a patellar dislocation three years after the surgery, and two patients still present clinical instability two years after the procedure. There was no stiffness in the knee in any patient. The technique presented in this study has allowed very good clinical results, with few complications, using a small incision to reconstruct in an isometric fashion, this important patellar stabilizer

Background. Injury to the ACL is a significant problem and can cause further damage to the internal structures of the knee. ACL injury is associated with injuries to other structures in the knee such as the meniscus and chondral cartilage. Such intra articular injuries pre-dispose the knee to develop arthritis. This injury is usually seen in young and active people usually related to sporting injuries. There is a paucity of literature on the influence of anthropometric features on the hamstring graft obtained in ACL reconstruction, although there are studies on the sex based differences affecting the hamstring graft. This study was undertaken to assess the influence of anthropometric measurements on the graft thickness obtained at ACL reconstruction surgery within the UK population. Objective. This study was undertaken to assess the influence of anthropometric measurements (body mass index (BMI), height and weight) on the graft thickness obtained at anterior cruciate ligament reconstruction surgery. Materials and methods. Data from 121 consecutive patients who had undergone ACL reconstruction by the same surgeon using quadrupled hamstring grafts were analysed. The body mass index, height and weight of these patients were correlated with the graft thickness obtained during surgery. Regression analysis was undertaken to assess the influence of individual anthropometric variables on the graft thickness. Results. Of the 121 patients there were 108 males and 13 females. Average age of the cohort was 32 years (14–55). There was a statistically significant positive correlation between the height and graft size (r=0.38, p < 0.01) as well as between the body weight and graft size (r=0.29, p < 0.01). However, when body mass index was calculated, the correlation was not statistically significant (r=0.08, p > 0.1). Regression analysis confirmed that BMI was not statistically significant as a predictor of hamstring graft diameter whereas height was statistically the most important predictor (F=20.1; p < 0.01) and yielded the predictive equation from regression analysis. Graft diameter=4.5 + 0.02 × Ht. (in cms) suggesting that people with height less than 125 cms (4′1″) are at greatest risk of a quadrupled graft size of less than 7 mm. Conclusion. Our findings suggest that although body mass index did not significantly correlate, individual anthropometric variables (height and weight) do influence the size of graft thickness in ACL reconstruction and give pre operative information. This may allow surgeons to plan for alternative graft options, if they could predict the possibility of inadequate graft size prior to ACL reconstruction surgery

Introduction A review of the the treatment of supracondylar fractures of the distal femur is presented. Methods The material presented consists of a review of published literature and personal experience. Results The introduction of the Condylar Blade Plate by the AO in the 1960s revolutionized the treatment of this injury. Numerous publications over the last 30 years attest to the superiority of the modern AO methods. The Comprehensive Classification of the supracondylar fractures greatly helps surgeons in decision making. The mid-line medial parapatelar surgical approach is preferred to the classical lateral incision. A lateral parapatellar incision has been in use recently in conjunction with the LISS and CLCP. A detailed understanding of the surgical anatomy of the distal femur prevents technical misadventures in securing stable fixation. Atraumatic reduction techniques have been developed to prevent devitalization of intermediate fragments which permits bridge plating and obviates the need of bone grafting multifragmentary fractures. Previously, failure to bone graft multifragmentary fractures was the commonest cause of failure of fixation. Current fixation devices are the classic condylar plate, the dynamic condylar screw, the condylar buttress plate, and the retrograde supracondylar femoral nail and the most recently developed LISS and the condylar locked compression plate. The choice of implant depends on the specific fracture pattern and associated soft tissue injury, concomitant apendicular and system injuries, the patient’s age and the presence of osteoporosis. The open supracondylar fracture presents unique problems which require careful judgement and staging in reconstruction. Even if they become infected, with proper stabilization 80% will still achieve satisfactory results. The supracondylar fracture in the presence of a total knee replacement is an absolute indication to surgical stabilization. It and osteoporosis present specific challenges which require specialized techniques of fixation for successful resolution. Polytrauma with multisystem injuries and certain specific concomitant articular injuries such as patellar fractures or fractures of the tibial plateau prejudice the outcome of treatment. Conclusions With modern surgical treatment, young patients with isolated Type A, Type B and C1 or C2 fractures can expect a normal knee as the outcome of treatment. Type C3 fractures and open fractures continue to be a challenge and their outcome depends on the degree of initial articular cartilage destruction, the degree of bone fragmentation and displacement, and on the degree of soft tissue damage. Articular cartilage injury and severe osteoporosis continue to be the two most important unsolved problems in fracture surgery

Introduction A review of the the treatment of supracondylar fractures of the distal femur is presented. Methods The material presented consists of a review of published literature and personal experience. Results The introduction of the Condylar Blade Plate by the AO in the 1960s revolutionized the treatment of this injury. Numerous publications over the last 30 years attest to the superiority of the modern AO methods. The Comprehensive Classification of the supracondylar fractures greatly helps surgeons in decision making. The mid-line medial parapatelar surgical approach is preferred to the classical lateral incision. A lateral parapatellar incision has been in use recently in conjunction with the LISS and CLCP. A detailed understanding of the surgical anatomy of the distal femur prevents technical misadventures in securing stable fixation. Atraumatic reduction techniques have been developed to prevent devitalization of intermediate fragments which permits bridge plating and obviates the need of bone grafting multifragmentary fractures. Previously, failure to bone graft multifragmentary fractures was the commonest cause of failure of fixation. Current fixation devices are the classic condylar plate, the dynamic condylar screw, the condylar buttress plate, and the retrograde supracondylar femoral nail and the most recently developed LISS and the condylar locked compression plate. The choice of implant depends on the specific fracture pattern and associated soft tissue injury, concomitant apendicular and system injuries, the patient’s age and the presence of osteoporosis. The open supracondylar fracture presents unique problems which require careful judgement and staging in reconstruction. Even if they become infected, with proper stabilization 80% will still achieve satisfactory results. The supracondylar fracture in the presence of a total knee replacement is an absolute indication to surgical stabilization. It and osteoporosis present specific challenges which require specialized techniques of fixation for successful resolution. Polytrauma with multisystem injuries and certain specific concomitant articular injuries such as patellar fractures or fractures of the tibial plateau prejudice the outcome of treatment. Conclusions With modern surgical treatment, young patients with isolated Type A, Type B and C1 or C2 fractures can expect a normal knee as the outcome of treatment. Type C3 fractures and open fractures continue to be a challenge and their outcome depends on the degree of initial articular cartilage destruction, the degree of bone fragmentation and displacement, and on the degree of soft tissue damage. Articular cartilage injury and severe osteoporosis continue to be the two most important unsolved problems in fracture surgery

Hip arthroscopy has gradually evolved over the past two decades. Recently hip arthroscopy has an increasing role in diagnosis and treatment for specific intra articular and extra articular hip injuries and especially for soft tissue injuries. February 2002 – May 2009. 18 athletes. 5 football players. 8 basketball players. 2 weight lifters. 3 gymnasts. Mean age: 32 y.o. (19–39 y.o.). Undiagnosed hip pain, Osteoarthritis, Labral pathology, Loose bodies, Osteochondral defects, Sepsis, Liga-mentum Teres, Trauma, Synovitis. Symptoms: Deep dull ache pain during hip flexion and external or internal rotation. Decreased R.O.M. 12/18 Cam sign + (positive), 11/18 Pincher sign + (positive), 14/18 Impingement syndrome in adduction and in flexion. Instrumentation and Equipment: 30°, 70°, 4,5mm arthroscope, High flow rate mechanical pump, 15 gauge 6" cardiac needle, Convex full radius chondroplasty blades, Special electrocautery (Philippon), Distraction apparatus, Mechanical water pump unit, Image intensifier. Surgery: Standard orthopaedic traction table, Supine position, Hip is extended and abducted 25°. Portals: Anterior, Anterolateral, Posterolateral. Intraoperative Findings – Results. Detachment of the labrum, 2/18 erosion of the articular cartilage of the acetabulum and drilling of the bare area, 12/18 Cam sign excision. The athletes with symptoms of an internal hip pain and impingement signs after a clinical exam of their hip will get a benefit from an arthroscopic procedure for treating any existing cetabulo-femoral pathology, especially for the athletes with femoraloacetabular impingement syndrome (FAI)

Slipped capital femoral epiphysis (SCFE) may lead to symptomatic femoroacetabular impingement (FAI). We report our experience of arthroscopic treatment, including osteochondroplasty, for the sequelae of SCFE.

Data were prospectively collected on patients undergoing arthroscopy of the hip for the sequelae of SCFE between March 2007 and February 2013, including demographic data, radiological assessment of the deformity and other factors that may influence outcome, such as the presence of established avascular necrosis. Patients completed the modified Harris hip score (mHHS) and the non-arthritic hip score (NAHS) before and after surgery.

In total, 18 patients with a mean age of 19 years (13 to 42), were included in the study. All patients presented with pain in the hip and mechanical symptoms, and had evidence of FAI (cam or mixed impingement) on plain radiographs.

The patients underwent arthroscopic osteoplasty of the femoral neck. The mean follow-up was 29 months (23 to 56).

The mean mHHS and NAHS scores improved from 56.2 (27.5 to 100.1) and 52.1 (12.5 to 97.5) pre-operatively to 75.1 (33.8 to 96.8, p = 0.01) and 73.6 (18.8 to 100, p = 0.02) at final follow-up, respectively. Linear regression analysis demonstrated a significant association between poorer outcome scores and increased time to surgery following SCFE (p < 0.05 for all parameters except baseline MHHS).

Symptomatic FAI following (SCFE) may be addressed using arthroscopic techniques, and should be treated promptly to minimise progressive functional impairment and chondrolabral degeneration.

Take home message: Arthroscopy of the hip can be used to treat femoroacetabular impingement successfully following SCFE. However, this should be performed promptly after presentation in order to prevent irreversible progression and poorer clinical outcomes.

Cite this article: Bone Joint J 2016;98-B:21–7.

Aims

Between 2002 and 2011, 81 patients with a traumatic total brachial plexus injury underwent reconstruction by double free muscle transfer (DFMT, 47 cases), single muscle transfer (SMT, 16 cases) or nerve transfers (NT, 18 cases).

Injury to the anterior cruciate ligament (ACL) is one of the most devastating and frequent injuries of the knee. Surgical reconstruction is the current standard of care for treatment of ACL injuries in active patients. The widespread adoption of ACL reconstruction over primary repair was based on early perception of the limited healing capacity of the ACL. Although the majority of ACL reconstruction surgeries successfully restore gross joint stability, post-traumatic osteoarthritis is commonplace following these injuries, even with ACL reconstruction. The development of new techniques to limit the long-term clinical sequelae associated with ACL reconstruction has been the main focus of research over the past decades. The improved knowledge of healing, along with recent advances in tissue engineering and regenerative medicine, has resulted in the discovery of novel biologically augmented ACL-repair techniques that have satisfactory outcomes in preclinical studies. This instructional review provides a summary of the latest advances made in ACL repair.

Cite this article: Bone Joint Res 2014;3:20–31.

Hyaline articular cartilage has been known to be a troublesome tissue to repair once damaged. Since the introduction of autologous chondrocyte implantation (ACI) in 1994, a renewed interest in the field of cartilage repair with new repair techniques and the hope for products that are regenerative have blossomed. This article reviews the basic science structure and function of articular cartilage, and techniques that are presently available to effect repair and their expected outcomes.

Fractures of the distal radius occurring in young adults are treated increasingly by open surgical techniques, partly because of concern that failure to restore the alignment of the fracture accurately may cause symptomatic post-traumatic osteoarthritis in future years. We reviewed 106 adults who had sustained a fracture of the distal radius between 1960 and 1968 and who were below the age of 40 years at the time of injury. We carried out a clinical and radiological assessment at a mean follow-up of 38 years (33 to 42).

No patient had required a salvage procedure. While there was radiological evidence of post-traumatic osteoarthritis after an intra-articular fracture in 68% of patients (27 of 40), the disabilities of the arm, shoulder and hand (DASH) scores were not different from population norms, and function, as assessed by the Patient Evaluation Measure, was impaired by less than 10%. Ordinal logistic regression analysis showed a significant relationship between narrowing of the joint space and extra-articular malunion (dorsal angulation and radial shortening) as well as intra-articular injury. Multivariate analysis revealed that grip strength had fallen to 89% of that of the uninjured side in the presence of dorsal malunion, but no measure of extra-articular malunion was significantly related to either the Patient Evaluation Measure or DASH scores.

While anatomical reduction is the principal aim of treatment, imperfect reduction of these fractures may not result in symptomatic arthritis in the long term, and this should be considered when counselling patients on the risks and benefits of the many treatment options available.