For chondral damage in younger patients, surgical best practice is microfracture, which involves drilling into the bone to liberate the bone marrow. This leads to a mechanically inferior fibrocartilage formed over the defect as opposed to the desired hyaline cartilage that properly withstands joint loading. While some devices have been developed to aid microfracture and enable its use in larger defects, fibrocartilage is still produced and there is no clear clinical improvement over microfracture alone in the long term. Our goal is to develop 3D printed devices, which surgeons can implant with a minimally invasive technique. The scaffolds should match the functional properties of cartilage and expose endogenous marrow cells to suitable mechanobiological stimuli Our novel silica/polytetrahydrofuran/polycaprolactone hybrids were prepared by sol-gel synthesis and scaffolds were 3D printed by direct ink writing. 3D printed hybrid scaffolds with pore channels of ~250 µm mimic the compressive behaviour of cartilage. Our results show that these scaffolds support human bone marrow stem/stromal cell (hMSC) differentiation towards chondrogenesis
The Poole Traction Splint (PTS) is a non-invasive technique that applies dynamic traction to the affected digit using materials readily available in the outpatient department. The primary aim of this study was to document the outcome of the PTS for hand phalangeal fractures. Over a four-year period (2017–2021), suitable patients were reviewed and referred for PTS to the hand physiotherapists. Functional outcome measures included range of motion (ROM), return to work, and a DASH score. In addition, a healthcare cost analysis was carried out. A total of 63 patients were treated with a PTS from 2017 to 2021. Data was analysed for 54 patients with 55 digits. The mean age was 43 years (17–72) and 53.7% (n=29) were female. There were 43 fractures involving the proximal phalanx and 12 involving the middle phalanx. The mean final composite range of movement averaged 209˚ (110–270°), classified as ‘good/excellent’ by ASSH criteria. The mean DASH score was 13.6 (0-43.2; n=45). All patients were able to return to work. Only two (3.7%) digits required conversion to surgical fixation. The PTS resulted in approximate savings of £2,452 per patient. The PTS is a cost-effective non-invasive low risk outpatient treatment method which provides a functional ROM and good functional outcomes in the treatment of complex phalangeal hand fractures, with minimal risk of surgical intervention being required.
A pilon fracture is a severe ankle joint injury caused by high-energy trauma, typically affecting men of working age. Although relatively uncommon (5% to 7% of all tibial fractures), this injury causes among the worst functional and health outcomes of any skeletal injury, with a high risk of serious complications and long-term disability, and with devastating consequences on patients’ quality of life and financial prospects. Robust evidence to guide treatment is currently lacking. This study aims to evaluate the clinical and cost-effectiveness of two surgical interventions that are most commonly used to treat pilon fractures. A randomized controlled trial (RCT) of 334 adult patients diagnosed with a closed type C pilon fracture will be conducted. Internal locking plate fixation will be compared with external frame fixation. The primary outcome and endpoint will be the Disability Rating Index (a patient self-reported assessment of physical disability) at 12 months. This will also be measured at baseline, three, six, and 24 months after randomization. Secondary outcomes include the Olerud and Molander Ankle Score (OMAS), the five-level EuroQol five-dimenison score (EQ-5D-5L), complications (including bone healing), resource use, work impact, and patient treatment preference. The acceptability of the treatments and study design to patients and health care professionals will be explored through qualitative methods.Aims
Methods
There is strong current interest to provide reliable treatments for one- and two-compartment arthritis in the cruciate-ligament intact knee. An alternative to total knee arthroplasty is to resurface only the diseased compartments with discrete compartmental components. Placing multiple small implants into the knee presents a greater surgical challenge than total knee arthroplasty, and it is not certain natural knee mechanics can be maintained. The goal of this study was to compare functional kinematics in cruciate-intact knees with either medial unicondylar (mUKA), mUKA plus patellofemoral (mUKA+PF), or bi-unicondylar (biUNI) arthroplasty using discrete compartmental implants with preparation and placement assisted by haptic robotic technology. Nineteen patients with 21 knee arthroplasties consented to participate in an I.R.B. approved study of knee kinematics with a cruciate-retaining multicompartmental knee arthroplasty system. All subjects presented with knee OA, intact cruciate ligaments, and coronal deformity ranging from 7° varus to 4° valgus. All subjects received multicompartmental knee arthroplasty using haptic robotic-assisted bone preparation an average of 13 months (6–29 months) before the study. Eleven subjects received mUKA, five subjects received mUKA+PF, and five subjects received biUKA. Subjects averaged 62 years of age and had an average body mass index of 31. Combined Knee Society Pain/Function scores averaged 102 ± 28 preoperatively and 169 ± 26 at the time of study. Knee range of motion averaged −3° to 120° preoperatively and −1° to 129° at the time of the study. Knee motions were recorded using video-fluoroscopy while subjects performed step-up/down, kneeling and lunging activities. The three-dimensional position and orientation of the implant components were determined using model-image registration techniques (Fig. 1). The AP locations of the medial and lateral condyles were determined by computing a distance map between the femoral condyles and the tibial articular surfaces.INTRODUCTION
METHODS
Traditional Total Knee Arthpolasty (TKA) replaces all 3 compartments of the knee for patients diagnosed with OA. There might be functional benefit to replacing only damaged compartments, and retaining the normal ligamentous structures. There is a long history of performing multi-compartment arthroplasty with discrete components. Laskin reported in 1976 that good pain relief and acceptable clinical results were achieved at two years in patients with bi-unicondylar knee replacement [Laskin 1976]. Other authors also have reported on bi-unicompartmental knee arthroplasty achieving successful clinical outcomes [Stockley 1990; Confalonieri 2005]. Banks et al. reported that kinematics of bi-unicompartmental arthroplasties during gait demonstrated some of the basic features of normal knee kinematics [Banks 2005]. These reports suggest that a modular approach to resurfacing the knee can be successful and achieve satisfactory clinical and functional results. The primary objective of this study is to compare the functional outcomes of three patient groups treated for osteoarthritis.Introduction
Objective
We reports the accuracy of direct Magnetic Resonance Arthrography (MRA) in detecting Triangular Fibrocartilage Complex (TFCC), Scapho-Lunate Ligament (SLL) and Luno-Triquetral Ligament (LTL) tears using wrist arthroscopy as the gold standard. We reviewed the records of all patients who underwent direct wrist MRA and subsequent arthroscopy over a 4-year period between June 2007 and March 2011. Demographic details, MRA findings, arthroscopy findings and the time interval between MRA and arthroscopy were recorded. The scans were performed using a 1.5T scanner and a high resolution wrist coil. All scans were reported by a musculoskeletal radiologist. Sensitivity, specificity, positive and negative predictive values (PPV & NPV) were calculated.Introduction
Methods
There is great interest to provide repeatable and durable treatments for arthritis localized to one or two compartments in the cruciate-ligament intact knee. We report a series of efforts to develop and characterize an implant system for partial knee resurfacing. We studied distal femoral morphology and found that the sagittal-plane relationships between the condylar and trochlear surfaces are highly variable (Figs 1 and 2). In response, we report the design of a multi-compartmental system of implants intended to anatomically resurface any combination of compartments (Fig 3). Finally, we report the results of a pilot fluoroscopic study of the in vivo knee kinematics in patients who received medial, medial plus patellofemoral and bi-condylar knee arthroplasty. The kinematic results suggest these treatments provide a stable knee with intact cruciate ligament function. This work shows various partial knee resurfacing treatments have the potential to provide excellent knee mechanics and clinical outcomes.
Total hip arthroplasty (THA) is regarded as one of the most successful surgeries in medicine. However, recent studies have revealed that ideal acetabular cup implantation is achieved less frequently than previously thought, as little as 50% of the time. It is well known that malalignment of the acetabular component in THA may result in dislocation, reduced range of motion, or accelerated wear. This study reports accuracy of a tactile robotic arm system to ream the acetabulum and impact an acetabulur cup compared to manual instrumentation. 12 fresh frozen cadaveric acetabulae were pre-operatively CT scanned and 3D templating was used to plan the center of rotation, and anteversion and inclination of the cup. Each specimen received THA, six prepared manually and six prepared with robotic arm guidance. Tactile, visual, and auditory feedback was provided through robotic guidance as well as navigated guided reaming and cup impaction. The robotic guidance constrained orientation of instruments thus constraining anteversion, inclination, and center of rotation for reaming, trialing, and final cup impaction. Post-operative CT scans were taken of each specimen to determine final cup placement for comparison to the pre-operative plans.INTRODUCTION
METHODS
Symptomatic hip disorders associated with cam deformities are routinely treated with surgery, during which the deformity is resected in an effort to restore joint range of motion, reduce pain, and protect the joint from further degeneration. This is a technically demanding procedure and the amount of correction is potentially critical to the success of the procedure: under-resection could lead to continued progression of the OA disease process in the joint, while over-resection puts the joint at risk for fracture. This study compares the accuracy of a new robotically assisted technique to a standard open technique. Sixteen identical Sawbones models with a cam type impingement deformity were resected by a single surgeon simulating an open procedure. An ideal final resected shape was the surgical goal in all cases. 8 procedures were performed manually using a free-hand technique and 8 were performed using robotic assistance that created a 3-dimensional haptic volume defined by the desired post-operative morphology. All of 16 sawbones, including uncut one as well, were scanned by Roland LPX-600 Laser scanner with 1mm plane scanning pitch and 0.9 degree of rotary scanning. Post-resection measurements included arc of resection, volume of bone removed and resection depth and were compared to the pre-operative plan.INTRODUCTION
METHODS
We present the results of a bi-centre, retrospective study examining the clinical, functional and radiological outcomes of distal radius fracture fixation with the Aptus locking plates and Tri-Lock® variable angle locking screws. We assessed 61 patients with distal radius fractures with a minimum of six months follow-up. Functional assessment was made using the DASH score. We measured wrist range of movement and grip strength, and reviewed radiographs to assess restoration of anatomy, fracture union and complications. All fractures united within six weeks. Mean ranges of movement and grip strength were only mildly restricted compared to the normal wrist. The mean DASH score was 18.2. Seven patients had screws misplaced outside the distal radius although 3 of these remained asymptomatic. Five other patients developed minor complications. Variable angle locking systems benefit from flexibility of implant positioning and may allow enhanced inter-fragmentary reduction for accurate fixation of intra-articular fractures. However, variable-angle systems may lead to increased rates of screw misplacement.
Pre-operative urine screening is accepted practice during pre-operative assessment in elective orthopaedic practice. There is no evidence surrounding the benefits, effects or clinical outcomes of such a practice. A series of 558 patients undergoing elective admission were recruited during pre-assessment for surgery and were screened for UTIs according to a pre-existing trust protocol. All patients had their urine dipstick tested and positive samples were sent for culture and microscopy. Patients with a positive urine culture were treated prior to surgery and were admitted to the elective centre where strict infection control methods were implemented. The patients were followed up after their surgery and divided into three clinical groups: uneventful surgery; Suspected wound infection; Confirmed wound infectionIntroduction
Methods
The CMI pyrocarbon implant is a unipolar arthroplasty for trapeziometacarpal joint arthritis which is implanted in to the thumb metacarpal. Previous case series have shown these implants provide significant pain relief and good patient satisfaction. We report the first cases of pyrocarbon hemiarthroplasty from Peterborough. Seventeen cases in fifteen patients were retrospectively reviewed. The average patient age was 59.7 years (range 47–72). 7 patients were men and 8 were women. Five were discharged with good outcome at a mean of 11.5 months (range 6–19). One failed to attend follow up. Most patients in whom the implant survived were afforded good pain relief by the procedure and had a good functional range of thumb movement. Radiologically 8 implants were subluxed by at least 50%. One implant was revised after dislocation and loosening of the prosthesis which was associated with trauma. She made excellent clinical progress after revision of the prosthesis. One of the thirteen cases dislocated and was revised to a trapeziumectomy after 11 months. Preliminary results suggest that this implant affords good pain relief and functional improvement in managing OA at the TMC joint. Longer term follow up will be required to correlate clinical and radiological outcomes.
Purpose: In this study we comprehensively evaluate a cohort of profoundly affected adults with Cerebral Palsy. We document hip disability and pain and statistically evaluate the effect of demographic, physical examination (PE) and radiographic parameters on pain and function of the hip. Methods: We evaluated 77 institutionalized patients with cerebral palsy. Medical history, level of function, pain, and analgesic requirements were obtained from record review and through caregiver interview. Range of motion (ROM), degree of spasticity, decubitus ulcers were documented as well as changes in vital signs and the FLACC pain scale during PE. Radiographs of the pelvis and spine were blindly evaluated without knowledge of the above data. Statistical analysis was performed in order to identify correlations between subjective and objective findings from the history and PE with radiographic parameters in these patients. Results: Participants included 38 men and 39 women with a mean age of 40 years (range, 22-81), 94 % had severe spastic quadriplegia. Fifteen percent of hips were dislocated and radiographic evidence of arthritis was noted in 23 %. Eighteen percent of hips were definitely painful and 45 % were definitely not painful. Higher rates of dislocation and arthritis were noted in older patients (p<
.05). Increased hip pain and perineal care problems were noted in patients with decreased hip abduction (p=.01), windswept hip deformities (p=.02) or flexion contractures (p=.07). Increased spasticity was associated with higher rates of arthrosis, dislocation, pain and decubiti. Hip dislocation and subluxation sig-nificantly correlated with osteoarthritis (p<
.0001) but not hip pain. Patients with lower CE (<
20°) or higher Sharps (>
40°) angles were more likely to have a history of hip pain (p=.02). No radiographic parameter correlated with increased analgesic use, or change in FLACC score or vital signs during PE of the hip. Conclusions: From these adult cerebral palsy patients we document pain and poor perineal care in patients with diminished hip range of motion and windswept hip posture. Hip dislocation and arthritis was noted in 15 and 23 % of hips, with definite pain noted in 18 %. Ace-tabular dysplasia was statistically associated with hip pain; however, in this study we could not correlate hip displacement or arthritis with a history of hip pain or diminished function. Because the incidence of hip pain is low and does not correlate with dislocation or arthritis, we suggest that surgical treatment of hips in severely affected immature patients with cerebral palsy be based on presence of pain or contractures and not on radiographic signs of hip displacement.
We performed a retrospective study of the factors affecting the outcome of Weber type-C ankle fractures in 43 patients reviewed at two to nine years after injury. We determined the functional result in relation to the use of a diastasis screw, the accuracy of reduction, the presence of tibiotalar dislocation, and of injury to the medial side of the ankle by medial malleolar fracture or deltoid ligament rupture. We assessed the use of a diastasis screw as appropriate or inappropriate on the basis of an anatomical study performed by Boden et al (1989). The diastasis screw was used unnecessarily in 19 of the 31 patients so treated, but this did not appear to affect the final functional result. The worse functional results were in ankles dislocated at the initial injury, and in those with medial malleolar fractures as opposed to those with deltoid ligament ruptures. The best results were after accurate reduction of the fibula and the syndesmosis, and greater increase in the width of the syndesmosis was associated with a worse result. Our results suggest that an increase of more than 1.5 mm in syndesmosis width is unacceptable. We recommend that when the deltoid ligament is ruptured, a diastasis screw should be used if the fibular fracture is more than 3.5 cm above the top of the syndesmosis. When a medial malleolar fracture has been rigidly repaired a diastasis screw is required if the fibular fracture is more than 15 cm above the syndesmosis.
We report a case of neonatal separation of the distal humeral epiphysis in which non-invasive ultrasonic examination provided clear definition of the injury.
Unilateral Colles' fractures in 187 patients over the age of 55 years were studied in a randomised prospective trial: 97 fractures were minimally displaced and were treated either conventionally or in a crepe bandage; 90 displaced Colles' fractures were reduced and of these 47 were treated conventionally while 43 were encouraged to mobilise the wrist in a cast which restricted extension. Early wrist movement hastened functional recovery and led to earlier resolution of wrist swelling. Discomfort was no greater than in patients who were treated conventionally. The bony deformity, which recurred irrespective of the method of treatment, was not adversely affected by early mobilisation.
