We treated 26 patients with 27 aneurysmal bone cysts by curettage and cryotherapy and evaluated local tumour control, complications and functional outcome. The mean follow-up time was 47 months (19 to154). There was local recurrence in one patient. Two patients developed deep wound infections and one had a postoperative fracture. We compared our results with previous reports in which several different methods of treatment had been used and concluded that curettage with adjuvant cryotherapy had similar results to those of marginal resection, and that no major bony reconstruction was required. We recommend the use of cryotherapy as an adjuvant to the surgical treatment of aneurysmal bone cysts. It provides local tumour control. Combination with bone grafting achieved consolidation of the lesion in all our patients

This edition of the Cochrane Corner looks at the three reviews that were published in the second half of 2023: surgical versus non-surgical interventions for displaced intra-articular calcaneal fractures; cryotherapy following total knee arthroplasty; and physical activity and education about physical activity for chronic musculoskeletal pain in children and adolescents

The February 2023 Oncology Roundup. 360. looks at: Is the number of national database research studies in musculoskeletal sarcoma increasing, and are these studies reliable?; Re-excision after unplanned excision of soft-tissue sarcoma is associated with high morbidity; Adjuvant radiation in atypical lipomatous tumours; The oncological outcomes of isolated limb perfusion and neoadjuvant radiotherapy in soft-tissue sarcoma patients - a nationwide multicentre study; Can low-grade chondrosarcoma be treated with intralesional curettage and cryotherapy?; Efficacy and safety of carbon ion radiotherapy for bone sarcomas: a systematic review and meta-analysis; Doxorubicin-polymeric meshes prevent local recurrence after sarcoma resection while avoiding cardiotoxicity; How important are skip lesions in Ewing’s sarcoma?; Improving outcomes for amputees: the health-related quality of life and cost utility analysis of osseointegration prosthetics in transfemoral amputees

[Purpose]. There have been only a few reports about the efficacy of postoperative cryotherapy following total hip arthroplasty (THA), and past studies have described that local cooling is efficacy for pain relief. The purpose of this study is whether the continuous local cooling following THA is effective for pain relief and the reduction of blood loss, swelling, and the duration of hospital stay. [Materials and Methods]. Thirty-eight patients (39 hips) underwent primary cementless THA for osteoarthritis and were divided into a cryotherapy group (30 subjects; from Apr. 2013 to Oct. 2013) and a control group (9 subjects; from Nov. 2012 to Mar. 2013). In the cryotherapy group, a continuous cooling pad was applied on the surgical wound and the thigh with a cloth anchor band (CF-3000, Sigmax, Japan) with the cooling temperature set to a constant 5°C for 72 hours immediately after surgery. Blood was collected on postoperative days 1,4,7,14, and 21 to determine Hb, CK, and CRP levels. Postoperative pain of the hip was scored by using a visual analog scale questionnaire on postoperative days 1 to 28. Total doses of selecoxib and dicrofenac sodium used for pain relief were measured. The circumference of patellar superior border was measured on postoperative days 4,7,14, and 28. The unpaired t-test was used for blood tests as well as for comparisons between the cryotherapy and control groups, and the Mann-Whitney U test was used for the analysis of age, BMI, approach of the surgery, analgesic use, pain scores, the circumference of the thigh and the duration of hospital stay. [Results]. There were no significant differences in age (p = 0.605), BMI (p = 0.790), approach of the surgery (p = 0.572), duration of the surgery (p = 0.117), blood loss during surgery (p = 0.739), or hospital stay (p = 0.169) between the cryotherapy and the control. There were no significant differences between the 2 groups in CK, CRP levels, or pain scores. However, Hb levels measured postoperatively in only day 4 and the total dose of selecoxib was used for pain relief were significantly lower for the cryotherapy group than for the control group, respectively (p = 0.028, p = 0.003), and the total dose of dicrofenac sodium was tend to be significant lower for the cryotherapy group. (p = 0.070). The circumference of patellar superior border measured postoperatively in only day 4 was significantly lower for the cryotherapy group than for the control group (p = 0.010). No complications such as skin problems or neuroparalysis were observed. [Discussion]. This study found the reduction of blood loss, swelling on the patellar superior border, and the total dose of selecoxib for the patients undergoing cryotherapy. However, the pain-relief efficacy of postoperative cryotherapy has not been recognized. Postoperative continuous cryotheraapy is a simple, noninvasive, and effective approach for the reduction of blood loss and swelling following THA

Cryotherapy is often applied after injuries of synovial joints. Although positive clinical effects on periarticular swelling and pain are well known, the effects on molecular processes of cartilage and synovial cells remained largely unknown so far. Therefore, the hypothesis was tested that hypothermia alleviates the synovial reaction and prevents chondrocyte death as well as cartilage destructive processes after blunt trauma. Human articular cartilage and synovial tissue was obtained with informed consent from patients undergoing knee joint replacement. Cartilage explants from macroscopically intact cartilage were impacted by a drop-tower apparatus with defined energy (0.59J) and cultivated for 24h or 7d at following temperature conditions: 2h, 16h or throughout at 27°C and afterwards or throughout at 37°C. Furthermore, human fibroblast-like synoviocytes (FLS) were stimulated with conditioned medium from traumatized cartilage (t-CM) and cultivated as indicated above up to 4d. Effects of hypothermia were evaluated by live/dead assay, gene expression (RQ-PCR), and type II collagen synthesis/cleavage as well as release of MMP-2, MMP-13 and IL-6 on protein level (ELISA, gelatin zymography). Statistical analysis was performed by 2-way ANOVA. The experimental study was performed in the research laboratory of the Orthopedic Department, University Hospital Ulm, Germany. Hypothermic treatment significantly improved chondrocyte viability 7d after blunt cartilage trauma (2h: p=0.016; 16h: p=0.036; throughout: p=0.039). 2h posttraumatic hypothermia attenuated expression of MMP-13 (m-RNA: p=0.012; protein: p=0.024). While type II collagen synthesis was significantly increased after 16h hypothermia, MMP-13 expression (mRNA: p=0.003; protein: p<0.001) and subsequent cleavage of type II collagen (p=0.049) were inhibited. Continuous hypothermia for 7d further significantly suppressed MMP release (proMMP-2, active MMP-2 and MMP-13) and type II collagen breakdown. On day 4 t-CM stimulated FLS revealed significantly suppressed gene expression of matrix-destructive enzymes (16h: ADAMTS-4; throughout: ADAMTS-4, MMP-3, MMP-13) and by trend reduced IL-6 expression in case of 16h or continuous hypothermia. Overall, hypothermia for only 2h and/or 16h after blunt cartilage trauma exhibited significant cell- and matrix-protective effects and promoted anabolic activity of surviving chondrocytes. Expression of matrix-destructive enzymes by FLS stimulated with Danger Associated Molecular Patterns (DAMPs) released from traumatized cartilage was attenuated by more prolonged hypothermia. These findings suggest that an optimized cryotherapy management after cartilage trauma might have the potential to ameliorate early molecular processes usually associated with the pathogenesis of posttraumatic osteoarthritis

Pain, swelling and inflammation are expected during the recovery from total knee arthroplasty (TKA) surgery. The severity of these factors and how a patient copes with them may determine the ultimate outcome of a TKA. Cryotherapy and compression are frequently used modalities to mitigate these commonly experienced sequelae. However, their effect on range of motion, functional testing, and narcotic consumption has not been well-studied. A prospective, multi-center, randomised trial was conducted to evaluate the effect of a cryopneumatic device on post-operative TKA recovery. Patients were randomised to treatment with a cryopneumatic device or ice with static compression. A total of 280 patients were enrolled at 11 international sites. Both treatments were initiated within three hours post-operation and used at least four times per day for two weeks. The cryopneumatic device was titrated for cooling and pressure by the patient to their comfort level. Patients were evaluated by physical therapists blinded to the treatment arm. Range of motion (ROM), knee girth, six minute walk test (6MWT) and timed up and go test (TUG) were measured pre-operatively, two- and six-weeks post-operatively. A visual analog pain score and narcotic consumption was also measured post-operatively. At two weeks post-operatively, both the treatment and control groups had diminished ROM and function compared to pre-operatively. Both groups had increased knee girth compared to pre- operatively. There was no significant difference in ROM, 6MWT, TUG, or knee girth between the 2 groups. We did find a significantly lower amount of narcotic consumption (509 mg morphine equivalents) in the treatment group compared with the control group (680 mg morphine equivalents) at up to two weeks postop, when the cryopneumatic device was being used (p < 0.05). Between two and six weeks, there was no difference in the total amount of narcotics consumed between the two groups. At six weeks, there was a trend toward a greater distance walked in the 6MWT in the treatment group (29.4 meters versus 7.9 meters, p = 0.13). There was a significant difference in the satisfaction scores of patients with their cooling regimen, with greater satisfaction in the treatment group (p < 0.0001). There was no difference in ROM, TUG, VAS, or knee girth at six weeks. There was no difference in adverse events or compliance between the two groups. A cryopneumatic device used after TKA appeared to decrease the need for narcotic medication from hospital discharge to 2 weeks post-operatively. There was also a trend toward a greater distance walked in the 6MWT. Patient satisfaction with the cryopneumatic cooling regimen was significantly higher than with the control treatment.

Background of study. Total Knee Replacement (TKR) is one of the commonest elective arthroplasty operations. Crepe dressings are used following TKR by most surgeons as it may provide comfort and hemostasis through external pressure however, may reduce early range of motion (ROM). Avoiding crepe dressings after TKR saves operating time, avoids bulky dressings (which may reduce ROM) and allows interventions such as cryotherapy in the early post-operative period. There are no published studies comparing the use of crepe dressing after TKR with an impermeable dressing alone. Materials and Methods. We did a retrospective study, analysing patients who had a TKR with the use of crepe dressings compared with patients who had an impermeable dressing alone. All patients had cruciate retaining PFC Implants through the medial para-patellar approach. We compared ROM (at initial physio contact and on discharge), rate of wound leakage, opioid requirements and duration of inpatient stay. Results. Data from 40 patients with similar demographics was analysed; 20 in each group. There was no significant difference in; the ROM at initial physiotherapy contact and at discharge (P< 0.01), rate of wound leakage, opioid use and pain score during inpatient stay. The duration of inpatient stay was shorter in patients in whom a crepe dressing was not used. Conclusion. Avoiding the use of Crepe dressings after TKR does not improve early ROM, pain scores, opioid use or wound leakage in the immediate post-operative period. The duration of inpatient stay was shorter without a crepe dressing. Therefore, both practices can be safely used in clinical practice

Aims

We performed a systematic literature review to define features of patients, treatment, and biological behaviour of multicentric giant cell tumour (GCT) of bone.

The August 2023 Oncology Roundup360 looks at: Giant cell tumour of bone with secondary aneurysmal bone cyst does not have a higher risk of local recurrence; Is bone marrow aspiration and biopsy helpful in initial staging of extraskeletal Ewing’s sarcoma?; Treatment outcomes of extraskeletal Ewing’s sarcoma; Pathological complete response and clinical outcomes in patients with localized soft-tissue sarcoma treated with neoadjuvant chemoradiotherapy or radiotherapy; Long-term follow-up of patients with low-grade chondrosarcoma in the appendicular skeleton treated by extended curettage and liquid nitrogen; Cancer-specific survival after limb salvage versus amputation in osteosarcoma; Outcome after surgical treatment of dermatofibrosarcoma protuberans: does it require extensive follow-up, and what is an adequate resection margin?; Management of giant cell tumours of the distal radius: a systematic review and meta-analysis.

The presentation of this huge monoinstitutional cumulative experience in bone tumor cryosurgery serves as an illustration of our basic phylosophycal concent: “No man-made implants are even close to God’s natural implants yet”. The result is the concept of conservation surgery in which cryotherapy plays the major role. Materials and Methods: During the period of 1/88 to 12/02 (15 years, FUT 2→17 years, median=6 years) 440 cryosurgical procedures were performed in 405 people. There were 214 male and 191 female patients. The age range was 5 to 80 years but most were between 20 and 59 years. 2/3 of the series included a variety of primary benign aggressive and low grade malignant lesions and 1/3 included primary high grade and metastatic bone tumors. The anatomical location is highly variable and includes almost every bone of the skeleton. Two methods of bone cryosurgery will be presented (including combinations of them and other adjuvants or techniques): The open system according to Marcove and our Closed System. Results and Complications: Overall local recurrence (LR) rate=8%, fractures=1%, infections=2%, skin burns= 1.3%. There were 3 cases of temporary nerve palsies and 2 cases of late OA of an adjacent joint. Functional outcome in 372 NED patients is almost 100% good and excellent (AMSTS, Enneking’s scoring system). Summary: Bone cryosurgery is a safe, reliable and inexpensive technique of conservative limb, joint and even epiphysis sparing surgery in the suitable types of bone tumors, eliminating temporarily or permanently the need for resection surgery

Anterior knee instability associated with rupture of ACL is a disabling clinical problem, especially in the athletic individual. The gracilis and semitendinosus tendon (T4) represent an alternative autograft donor material for reconstruction of the ACL. The aim of our study was to elaborate a CPG to assist physiotherapists in decision making and to improve the efficacy and uniformity of care for patients with ACL reconstruction with T4. The CPG was developed according to international methods of guideline development. To identify “best evidence” a structured search was performed. When no evidence was available, consensus between experts (physiotherapist and orthopaedic surgeons) was achieved to develop the guideline. To identify “best clinical experience” and “physiopathology reasoning” focus group of practicing physiotherapists was used. They reviewed the clinical applicability and feasibility of the guideline, and their comments were used to improve it. CPG include three phases determined from the evidence, physiopathology reasoning and the biological process of autograft (weeks after the surgery: 2. a. –6. a. , 6. a. –10. a. and 10. a. –16. a. ). The recommendations included: In postoperative weeks (2. a. –6. a. ) physiotherapy focused on early range of motion of the knee; manual therapy (passive range of motion (PROM) 0–120° and miofascial techniques), pulsed ultrasound of low intensity with a power of 0.3w/cm2 (1MHz) during 10min/day in tibial tunnel, early active hamstring beginning with static weight bearing co-contractions (closed-kinetic-chain) and adductors, partial weight bearing with crutches, exercises in the swimming pool and cryotherapy to pain control (30 mi/4 hours). In weeks 6 to 10, full weight bearing, manual therapy (PROM 0–140° and miofascial techniques), hamstring strengthening progress complexity and repetitions of co-contractions, electrotherapy hamstring and quadriceps co-contractions. Starting at week 10, progress to more dynamic activities/movements, proprioceptive work, open-kinetic-chain, stationary bike and Theraband squats. In week 12, progress jogging program and plyometric type activities. The patients performed sports-specific exercises by about 3½ months postoperative

Cite this article: Bone Joint J 2024;106-B(1):6–8.

Aims:This study: a)revisits the effectiveness of preoperative embolization alone for hypervascular lesions of the thoracolumbar spine and b) compares its action with intraoperative cryotherapy alone or in conjunction with embolization. Methods:14 patients underwent 15 surgeries for hypervascular spinal tumors. Ten of the surgeries were augmented by preoperative embolization alone. Four surgeries involved intraoperative cryocoagulation, and one surgery used a combination of preoperative embolization and intraoperative cryocoagulation for tumor resection. When cryocoagulation was used, its extend was controlled by intraoperative ultrasound or by establishing physical separation of the spinal cord from the tumor. Results:Among cases treated with embolization alone, 50% still had intraoperative blood-loss in excess of 3 liters. Mean blood-loss was of 2.8 liters/patient. One patient bled excessively (over 8000ml) terminating the surgery prematurely and resulted in suboptimal tumor resection. All procedures using cryo-coagulation achieved adequate hemostasis with average blood-loss of only 500 ml/patient by far better than embolization (P< 000.1). Conclusions:Preoperative embolization alone may not always be satisfactory for surgery of hypervascular tumors of the thoracolumbar spine. Although experience with cryocoagulation is limited, its use, with or without embolization, suggests its effectiveness in limiting blood-loss. Cryocoagulation may also assist resection by preventing tumor spillage, facilitating more radical excision of the tumor and enabling spinal reconstruction that eventually may contribute to improve survival. The extent of cryocoagulation could be controlled adequately with ultrasound. Somatosensory evoked potentials may provide early warning of cord cooling. No new neurological deþcits were attributable to the use of cryocoagulation

The October 2024 Oncology Roundup³⁶⁰ looks at: Composite reconstruction: is it the answer for pelvic resections?; Can the cartilaginous thickness determine the risk of malignancy in pelvic cartilaginous tumours, and how accurate is the preoperative biopsy of these tumours?; Incidence and survival outcomes of patients with high-grade appendicular bone sarcoma and isolated regional lymph node metastasis; Improved metastatic-free survival after systematic re-excision following complete macroscopic unplanned excision of limb or trunk soft-tissue sarcoma; UK guidelines for the management of soft-tissue sarcomas; Current management of desmoid tumours: a review.

Desmoid tumours are a rare fibroblastic proliferation of monoclonal origin, arising in deep soft-tissues. Histologically, they are characterized by locally aggressive behaviour and an inability to metastasize, and clinically by a heterogeneous and unpredictable course. Desmoid tumours can occur in any anatomical site, but commonly arise in the limbs. Despite their benign nature, they can be extremely disabling and sometimes life-threatening, causing severe pain and functional limitations. Their surgical management is complex and challenging, due to uncertainties surrounding the biological and clinical behaviour, rarity, and limited available literature. Resection has been the first-line approach for patients with a desmoid tumour but, during the last few decades, a shift towards a more conservative approach has occurred, with an initial ‘wait and see’ policy. Many medical and regional forms of treatment are also available for the management of this condition, and others have recently emerged with promising results. However, many areas of controversy remain, and further studies and global collaboration are needed to obtain prospective and randomized data, in order to develop an appropriate shared stepwise approach.

Cite this article: Bone Joint J 2023;105-B(7):729–734.

The December 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: A comprehensive nonoperative treatment protocol for developmental dysplasia of the hip in infants; How common are refractures in childhood?; Femoral nailing for paediatric femoral shaft fracture in children aged eight to ten years; Who benefits from allowing the physis to grow in slipped capital femoral epiphysis?; Paediatric patients with an extremity bone tumour: a secondary analysis of the PARITY trial data; Split tibial tendon transfers in cerebral palsy equinovarus foot deformities; Liposomal bupivacaine nerve block: an answer to opioid use?; Correction with distal femoral transphyseal screws in hemiepiphysiodesis for coronal-plane knee deformity.

Aims

The epiphyseal approach to a chondroblastoma of the intercondylar notch of a child’s distal femur does not provide adequate exposure, thereby necessitating the removal of a substantial amount of unaffected bone to expose the lesion. In this study, we compared the functional outcomes, local recurrence, and surgical complications of treating a chondroblastoma of the distal femoral epiphysis by either an intercondylar or an epiphyseal approach.

The June 2023 Foot & Ankle Roundup³⁶⁰ looks at: Nail versus plate fixation for ankle fractures; Outcomes of first ray amputation in diabetic patients; Vascular calcification on plain radiographs of the ankle to diagnose diabetes mellitus; Elderly patients with ankle fracture: the case for early weight-bearing; Active treatment for Frieberg’s disease: does it work?; Survival of ankle arthroplasty; Complications following ankle arthroscopy.

Aims

To assess the cost-effectiveness of a two-layer compression bandage versus a standard wool and crepe bandage following total knee arthroplasty, using patient-level data from the Knee Replacement Bandage Study (KReBS).