For degenerative osteoarthritis of the knees, a variety of non-surgical management options have been tried from time to time. Medical management, chondroprotective agents, disease modifying drugs, viscosupplimentation etc. to name a few. Arthroscopic knee lavage with saline also has shown good results, with the effect of cleaning the debries from the joint. Growth Factors Rich Plasma (GFRP) or Platelet Rich Plasma (PRP) is an emerging treatment therapy called “ Orthobiologics”. Alfa granules in platelets contain numerous growth factors which enhance tissue recovery dramatically by catalyzing the body's natural healing response. PRP also attracts Mesenchymal Stem Cells, which differentiate into variety of cell types during tissue repair processes & induce the production of new collagen by the fibroblasts, osteoblasts and chondrocytes as per the need of the parent tissue. Knee lavage is done under local anesthesia using single antero-lateral portal. Four liters of saline is used to lavage the knee and at the end of procedure 80 mg. methyl prednisolone is injected. For GFRP injection, 100 cc of patient's blood is double centrifuged in the refrigerated blood component separator centrifuge in the blood bank giving about 15 cc of buffy layer having GFRP. Since Feb. 2010, more than 1000 knees of different grades of osteoarthritis have been injected with GFRP and the results compared with other different treatment options. Results of few different combination therapies are presented in this study. 1. Knee Lavage Vs Autologous GFRP Injection (100+100 cases) 2. Knee Lavage + Autologous GFRP Injection in 1 knee Vs GFRP Injection only in other knee (200+200 Knees) 3. Visco-supplimentation Vs Autologous GFRP Injection. (10+10cases). Results were analyzed up to 1 year as per VAS scale. Knee Lavage clears the joint of the microscopic and macroscopic debris of the cartilage and synovium which are causing chemical and mechanical irritation resulting in the inflammatory cascade. GFRP injection tries to repair the cartilage by the efficacy of the Growth factors contained therein. It has been observed that Knee Lavage and GFRP Injection have almost similar efficacy at 1 year, though knee lavage starts showing its effects early. GFRP therapy has shown better results compared to visco supplimentation at 1 year. Combination of knee lavage with GFRP injection showed much better results than GFRP injection alone and the results are inversely related to the grade of the osteoarthritis. Viscosupplimentation has very short lived efficacy. It's concluded that Knee Lavage followed by GFRP injection gives the best long term results and this pilot project initiated, hopefully will go a long way in future to change the course of the management for osteoarthritis knees at a minimal cost and may obviate the need for Knee arthroplasty if started in early stages of Osteoartrhritis

A hot swollen joint is a commonly encountered condition in clinical practice. With a broad range of differentials, septic arthritis (SA) is perhaps one of the most concerning. Treated by culture-specific antibiotics and arthroscopic lavage, some patients require multiple washouts. We aimed to determine:. (1) What are the risk factors for development of SA?. (2) What are the risk factors for repeat washout in SA patients?. (3) What are the important clinical differences between a periprosthetic joint infection (PJI) and SA cohort?. All patients presenting to the emergency department, orthopaedic, and rheumatology clinics between January 2020 to January 2021 with a hot, swollen joint were retrospectively evaluated. Patients with previous trauma on the ipsilateral joint, with data missing from their medical records in any of the variables required for analysis, <24 months follow-up were excluded. Variables of interest in the three-month period preceding the diagnosis of SA were compared between SA and non-SA patients. Factors with a p-value of p<0.100 in univariate analysis were included in a stepwise multivariate logistic regression model. Similar analyses were performed to compare SA patients with multiple washouts with those needing one washout. Demographical and clinical data for PJI patients were collected to delineate important differences with SA cohort. 211 patients were included (SA:28;PJI:24;pseudogout:32;gout:26;others:101). Multivariate analysis showed rheumatoid arthritis (RA), skin infection, and liver disease were risk factors for SA. Amongst patients with septic arthritis, multivariate analysis showed that WBC levels above normal limits (3.6-10.5×109 cells/L) and RA were risk factors for multiple washouts. Between the SA and PJI cohorts, BMI (p=0.002) was significantly lower in the former, whilst WBC level (p=0.023) and CRP (p<0.0001) was significantly higher in the former. Early diagnosis of septic arthritis requires understanding the risk factors, namely RA, skin infection, and liver disease. Considering PJI and septic arthritis as the same entity can lead to wrong clinical judgement, and clinicians should be aware of important differences. We believe that the models in this study are of prognostic value to clinicians who are presented with the common presenting compliant of a hot swollen joint

We examined the roles of methylmethacrylate (MMA) monomer and cementing technique in the formation, and haemodynamic outcome, of pulmonary fat emboli. The preparation of the femoral canal and the cementing technique were studied in four groups of adult dogs as follows: control (no preparation); lavage; cement pressurisation; and cement pressurisation after lavage. We measured the intramedullary pressure, pulmonary artery pressure (PAP), pulmonary capillary wedge pressure and bilateral femoral vein levels of triglyceride, cholesterol and MMA monomer at rest and after reaming, lavage, and cementing. Femoral vein triglyceride and cholesterol levels did not vary significantly from resting levels despite significant elevations in intramedullary pressure with reaming, lavage and cementing (p = 0.001). PAP was seen to rise significantly with reaming (p = 0.0038), lavage (p = 0.0031), cementing (p = 0.0024) and cementing after lavage (p = 0.0028) while the pulmonary capillary wedge pressure remained unchanged. MMA monomer was detected in femoral vein samples when cement pressurisation was used. Intramedullary lavage before cementing had no significant effect on the MMA level. Haemodynamic evidence of pulmonary embolism was noted with reaming and intramedullary canal preparation, irrespective of the presence of MMA monomer. We found no relationship between MMA monomer level and intramedullary pressure, PAP or pulmonary capillary wedge pressure. Our findings suggest that the presence of MMA monomer in femoral venous blood has no effect on the formation of fat emboli or their pulmonary haemodynamic outcome during cemented hip arthroplasty

Introduction and Objective. Hemorrhagic shock and fractures are the most common injuries within multiple injured patients, inducing systemic and local inflammation in NF-kappaB-dependent manner. Alcohol intoxication, showing a high incidence with severe injuries, has immunomodulatory properties and implicates NF-kappaB downregulation. However, the mechanism is largely unknown. A20 deubiquitinase is a critical negative regulator of NF-kappaB activity and inflammation. Here, we investigate the role of A20 as a modifier of NF-kappaB-driven inflammation and remote lung injury in severely injured and alcohol-intoxicated mice. Materials and Methods. Mice were randomly divided into four groups. Either sodium chloride or ethanol (35%, EtOH) was administrated by intragastral gavage one hour before trauma induction. In the trauma group, the animals underwent an osteotomy with external fracture fixation (Fx) followed by a pressure-controlled hemorrhagic shock (35±5 mmHg; 90 minutes) with subsequent resuscitation (H/R). Sham-operated animals underwent only surgical procedures. Mice were sacrificed at 24 hours. Fatty vacuoles and thus, the alcohol intoxication were evaluated by Oil red O staining of the liver. To assess the lung injury, hematoxylin eosin staining, determination of total protein concentration in bronchoalveolar lavage (BALF) and calculation of the lung injury score (LIS) were performed. Lungs were stained for neutrophil elastase, CXCL1 and active caspase-3 to determine neutrophil invasion, pro-inflammatory changes and apoptosis, respectively. The expression level of A20 was evaluated by immunofluorescence microscopy. Results. EtOH induced significant fatty changes in the liver. Fx+H/R led to trauma-induced lung injury, significantly enhancing the total protein concentration in the BALF and the histomorphological LIS compared to sham animals. In turn, EtOH reduced the lung injury in Fx+H/R. The expression of CXCL1 and activated caspase-3 as well as the pulmonary neutrophil infiltration were significantly enhanced in Fx+H/R vs. sham, whereas A20 protein expression was reduced. EtOH+Fx+H/R caused reduced pulmonary neutrophil invasion, CXCL1 expression, and apoptosis compared to Fx+H/R, whereas the A20 protein expression in the lungs was increased. Conclusions. In murine Fx+H/R trauma model, EtOH ameliorates the extent of the remote lung injury. The immunosuppressive effect may be caused by elevated pulmonary levels of A20 deubiquitase, indicating a suppression of NF-kappaB activation

Introduction and Objective. Joint malleolar fractures have been estimated around 9% of all fractures. They are characterized by different both early and late complications. Among the latter, arthrofibrosis and early secondary arthrosis represent the two most common ones. Moreover, these two complications could be considered related to each other. Their real cause is still under investigation, even if residual post-operative hematoma and acute post-traumatic synovitis appear to be the most accredited. Supporting this hypothesis, joint debridement and the evacuation of the post-operative hematoma could represent a possible solution. The aim of this prospective study is to evaluate the role of arthroscopic lavage and debridement during internal fixation in order to prevent late joint complications. Materials and Methods. Sixty consecutive patients who reported dislocated articular ankle fractures with surgical indication of open reduction and internal fixation (ORIF) have been included in this study. 27 patients underwent ORIF surgery associated with arthroscopic washout and debridement, while 33 patients, representing the control group, underwent just internal reduction and osteosynthesis. Patients with pure dislocations, non-articular fractures, polytrauma, previous local trauma, metabolic and connective pathologies were excluded. Follow-up was performed at 40 days (T1), 3 (T2) and 6 months (T3) after trauma for all patients. If necessary, some have been re-evaluated 12 months after the trauma. Efficacy of the treatment was evaluated through the VAS scale, Maryland scale, search for local complications such as dehiscence or infections, and finally radiographic evaluation. T-Student was estimated in order to individuate statistical significance. Results. VAS scale showed higher values for the case group than the control group with mean values of 2.7 and 4.2 at T1 and 2.1 and 3.8 at T2, respectively. At 6 months follow-up, the VAS values resulted similar with 2.6 for the case group and 2.8 for the control group. The same projections were found for the Maryland scale, with values of 61.5 and 40.7 at T1, 80.8 and 68.0 at T2 and 87.8 and 85.0 with no significant differences at T3 respectively. No significant differences were detected for complications or radiographic evaluation. Conclusions. Our study has shown significance differences in terms of pain and time for recovery only in the very short term follow up. Although our study, due to the specific limits, cannot be considered diriment, on the basis of the data, we could hypothesize that the aforementioned hypothesis may remain valid for the non-acute hematoma or that the cause of the arthrofibrosis should be sought somewhere else. However, evidence is low, and further research is needed

High-pressure lavage produces greater visible damage to bone at a macroscopic and microscopic level when compared with low-pressure lavage and can result in delay in the healing of fractures. Osteoblasts and adipocytes are derived from mesenchymal stem cells. Conditions which lead to bone loss often involve a switch from the osteoblast to adipocyte lineage. We have therefore examined the effect of high- and low-pressure irrigation on the differentiation of adipocytes. Calvaria-derived bone cells were exposed to either low-pressure or high-pressure irrigation with normal saline. After 14 days the cells were fixed and the osteoblasts and adipocytes quantified using Oil Red O to stain cytoplasmic lipid droplets (triglycerides) in the cells. Osteoblasts were quantified using a commercially available alkaline-phosphatase staining assay. A standard quantitative reverse transcription-polymerase chain reaction (RT-PCR) was performed. Messenger RNA levels for osteocalcin, a marker of osteoblasts, and PPARγ2, a marker of adipocytes, were measured. High-pressure lavage resulted in an increase in adipogenesis of 50% when compared with low-pressure lavage. Our findings suggest that high-pressure lavage may promote differentiation of mesenchymal stem cells towards the adipoctye lineage. This may have clinical significance in the development of delayed and nonunion after treatment of fractures of long bones

Aim. To determine if systemic toxicity occurs after the use of antibiotic loaded calcium sulphate in the treatment (1) of bone and soft tissue infection. Although antibiotic loaded calcium sulphate is increasingly used for the local treatment of bone and soft tissue infection, there is little data to demonstrate that systemic levels generated by local release of antibiotics are safe. For this reason, we routinely assay systemic levels of antibiotics. Methods. Patients with osteomyelitis or soft tissue infection underwent surgical debridement and lavage of the infected tissue in routine fashion. Patients with osteomyelitis were graded with the Cierny-Mader classification. Bone cavities and soft tissue dead spaces were packed with antibiotic loaded calcium sulphate (10–40 cc) loaded with Vancomycin (1–4 g) and Gentamicin (240–960 mg). The wounds were closed over the antibiotic loaded calcium sulphate. Patients underwent serial assays of Vancomycin and Gentamicin levels on the day of surgery and the first two post-operative days. Renal function was also measured. Results. 12 limbs in 10 patients were treated for osteomyelitis or soft tissue infection. There was 1 Cierny-Mader grade 1, 3 Cierny-Mader grade 3, and 2 Cierny-Mader grade 4. Two had deep soft tissue infection alone. There were 3 type A hosts and 7 type B hosts. The patients age ranged from 24 to 89 (mean 54). In patients without renal dysfunction, the systemic levels were either unmeasurable at the first assay, or below the acceptable trough level. (Mean 2.4 and 1.8 for Vancomycin and Gentamycin respectively). They had unmeasurable systemic levels at the third assay. In patients with renal dysfunction, systemic levels were in the therapeutic range determined for systemically administered antibiotics, but these levels remained high and did not decrease until patients had undergone their routine dialysis. Conclusions. In patients treated with antibiotic loaded Stimulan, antibiotic assays are not necessary in patients who have normal renal function, as they clear the systemic absorption as quickly as it is generated. Patients with impaired renal function should have lower doses of antibiotic used for their topically applied carrier, and should undergo assays regularly to ascertain if levels are remaining below the accepted range determined for systemically administered antibiotics. If they remain high, the antibiotic loaded calcium sulphate could be removed. * Stimulan (Biocomposites, Keele, UK)

Objectives

Infection of implants is a major problem in elective and trauma surgery. Heating is an effective way to reduce the bacterial load in food preparation, and studies on hyperthermia treatment for cancer have shown that it is possible to heat metal objects with pulsed electromagnetic fields selectively (PEMF), also known as induction heating. We therefore set out to answer the following research question: is non-contact induction heating of metallic implants effective in reducing bacterial load in vitro?

Objectives

Surgeons face a substantial risk of infection because of the occupational exposure to blood-borne pathogens (BBPs) from patients undergoing high-risk orthopaedic procedures. This study aimed to determine the seroprevalence of four BBPs among patients undergoing joint arthroplasty in Shanghai, China. In addition, we evaluated the significance of pre-operative screening by calculating a cost-to-benefit ratio.

Objectives

Mesenchymal stem cells have the ability to differentiate into various cell types, and thus have emerged as promising alternatives to chondrocytes in cell-based cartilage repair methods. The aim of this experimental study was to investigate the effect of bone marrow derived mesenchymal stem cells combined with platelet rich fibrin on osteochondral defect repair and articular cartilage regeneration in a canine model.

The treatment of chronic osteomyelitis often includes surgical debridement and filling the resultant void with antibiotic-loaded polymethylmethacrylate cement, bone grafts or bone substitutes. Recently, the use of bioactive glass to treat bone defects in infections has been reported in a limited series of patients. However, no direct comparison between this biomaterial and antibiotic-loaded bone substitute has been performed.

In this retrospective study, we compared the safety and efficacy of surgical debridement and local application of the bioactive glass S53P4 in a series of 27 patients affected by chronic osteomyelitis of the long bones (Group A) with two other series, treated respectively with an antibiotic-loaded hydroxyapatite and calcium sulphate compound (Group B; n = 27) or a mixture of tricalcium phosphate and an antibiotic-loaded demineralised bone matrix (Group C; n = 22). Systemic antibiotics were also used in all groups.

After comparable periods of follow-up, the control of infection was similar in the three groups. In particular, 25 out of 27 (92.6%) patients of Group A, 24 out of 27 (88.9%) in Group B and 19 out of 22 (86.3%) in Group C showed no infection recurrence at means of 21.8 (12 to 36), 22.1 (12 to 36) and 21.5 (12 to 36) months follow-up, respectively, while Group A showed a reduced wound complication rate.

Our results show that patients treated with a bioactive glass without local antibiotics achieved similar eradication of infection and less drainage than those treated with two different antibiotic-loaded calcium-based bone substitutes.

Cite this article: Bone Joint J 2014; 96-B:845–50.

We have studied the effects of bupivacaine on human and bovine articular chondrocytes in vitro. Time-lapse confocal microscopy of human articular chondrocytes showed > 95% cellular death after exposure to 0.5% bupivacaine for 30 minutes. Human and bovine chondrocytes exposed to 0.25% bupivacaine had a time-dependent reduction in viability, with longer exposure times resulting in higher cytotoxicity. Cellular death continued even after removal of 0.25% bupivacaine. After exposure to 0.25% bupivacaine for 15 minutes, flow cytometry showed bovine chondrocyte viability to be 41% of saline control after seven days. After exposure to 0.125% bupivacaine for up to 60 minutes, the viability of both bovine and human chondrocytes was similar to that of control groups.

These data show that prolonged exposure 0.5% and 0.25% bupivacaine solutions are potentially chondrotoxic.

Interfacial defects between the cement mantle and a hip implant may arise from constrained shrinkage of the cement or from air introduced during insertion of the stem. Shrinkage-induced interfacial porosity consists of small pores randomly located around the stem, whereas introduced interfacial gaps are large, individual and less uniformly distributed areas of stem-cement separation. Using a validated CT-based technique, we investigated the extent, morphology and distribution of interfacial gaps for two types of stem, the Charnley-Kerboul and the Lubinus SPII, and for two techniques of implantation, line-to-line and undersized.

The interfacial gaps were variable and involved a mean of 6.43% (sd 8.99) of the surface of the stem. Neither the type of implant nor the technique of implantation had a significant effect on the regions of the gaps, which occurred more often over the flat areas of the implant than along the corners of the stems, and were more common proximally than distally for Charnley-Kerboul stems cemented line-to-line. Interfacial defects could have a major effect on the stability and survival of the implant.

The role of vacuum mixing on the reduction of porosity and on the clinical performance of cemented total hip replacements remains uncertain. We have used paired femoral constructs prepared with either hand-mixed or vacuum-mixed cement in a cadaver model which simulated intra-operative conditions during cementing of the femoral component. After the cement had cured, the distribution of its porosity was determined, as was the strength of the cement-stem and cement-bone interfaces.

The overall fraction of the pore area was similar for both hand-mixed and vacuum-mixed cement (hand 6%; vacuum 5.7%; paired t-test, p = 0.187). The linear pore fractions at the interfaces were also similar for the two techniques. The pore number-density was much higher for the hand-mixed cement (paired t-test, p = 0.0013). The strength of the cement-stem interface was greater with the hand-mixed cement (paired t-test, p = 0.0005), while the strength of the cement-bone interface was not affected by the conditions of mixing (paired t-test, p = 0.275). The reduction in porosity with vacuum mixing did not affect the porosity of the mantle, but the distribution of the porosity can be affected by the technique of mixing used.

A complete cement mantle is important for the longevity of a total hip replacement. In the minimally-invasive direct anterior approach used at the Innsbruck University hospital, the femoral component has to be inserted into the femoral canal by an angulated movement. In a cadaver study, the quality and the extent of the cement mantle surrounding 13 Exeter femoral components implanted straight through a standard anterolateral transgluteal approach were compared with those of 13 similar femoral components implanted in an angulated fashion through a direct anterior approach. A third-generation cementing technique was used. The inner and outer contours of the cement mantles was traced from CT scans and the thickness and cross-sectional area determined.

In no case was the cement mantle incomplete. The total mean thickness of the cement mantle was 3.62 mm (95% confidence interval 3.59 to 3.65). The mean thickness in the group using the minimally-invasive approach was 0.16 mm less than that in the anterolateral group. The distribution of the thickness was similar in the two groups. The mean thickness was less on the anteromedial and anterolateral aspect than on the posterior aspect of the femur.

There is no evidence that the angulated introduction of Exeter femoral components in the direct anterior approach in cadavers compromises the quality, extent or thickness of the cement mantle.

Several experimental models have been used to produce intravascular fat embolism. We have developed a simple technique to induce fat embolism using corn oil emulsified with distilled water to form fatty micelles. Fat embolism was produced by intravenous administration of these fatty micelles in anaesthetised rats, causing alveolar oedema, haemorrhage and increased lung weight.

Histopathological examination revealed fatty droplets and fibrin thrombi in the lung, kidney and brain. The arteriolar lumen was filled with fatty deposits. Following fat embolism, hypoxia and hypercapnia occurred. The plasma phospholipase A₂, nitrate/nitrite, methylguidanidine and proinflammatory cytokines were significantly increased. Mass spectrometry showed that the main ingredient of corn oil was oleic acid.

This simple technique may be applied as a new animal model for the investigation of the mechanisms involved in the fat embolism syndrome.

The complications of impaction bone grafting in revision hip replacement includes fracture of the femur and subsidence of the prosthesis. In this in vitro study we aimed to investigate whether the use of vibration, combined with a perforated tamp during the compaction of morsellised allograft would reduce peak loads and hoop strains in the femur as a surrogate marker of the risk of fracture and whether it would also improve graft compaction and prosthetic stability.

We found that the peak loads and hoop strains transmitted to the femoral cortex during graft compaction and subsidence of the stem in subsequent mechanical testing were reduced. This innovative technique has the potential to reduce the risk of intra-operative fracture and to improve graft compaction and therefore prosthetic stability.