Based on Ilizarov's law of tension-stress principle, distraction histogenesis technique has been widely applied in orthopaedic surgery for decades. Derived from this technique, cranial bone transport technique was mainly used for treating cranial deformities and calvarial defects. Recent studies reported that there are dense short vascular connections between skull marrow and meninges for immune cells trafficking, highlighting complex and tight association between skull and brain. Alzheimer's disease (AD) is a progressive neurodegenerative disease and the most common cause of dementia without effective therapy. Meningeal lymphatics have been recognized as an important mediator in neurological diseases. The augmentation of meningeal lymphatic drainage might be a promising therapeutic target for AD. Our proof-of-concept study has indicated that cranial bone transport can promote ischemic stroke recovery via modulating meningeal lymphatic drainage function, providing a rationale for treating AD using cranial bone maneuver (CBM). This study aims to investigate the effects of CBM on AD and to further explore the potential mechanisms. Transgenic 5xFAD mice model was used in this study. After osteotomy, a bone flap was used to perform CBM without damaging the dura. Open filed test, novel object recognition test and Barn's maze test were used to evaluate neurological functions of 5xFAD mice after CBM treatment. Congo red and immunofluorescence staining were used to evaluate amyloid depositions and Aβ plaques in different brain regions. Lymphangiogenesis and the level of VEGF-C were examined after CBM treatment. OVA-A647 was intra-cisterna-magna injected to evaluate meningeal lymphatic drainage function after CBM treatment. CBM significantly improved memory functions and reduced amyloid depositions and Aβ plaques in the hippocampus of 5xFAD mice. A significant increase of meningeal lymphatic vessels in superior sagittal sinus and transverse sinus, and the upregulation of VEGF-C in meninges were observed in 5xFAD mice treated with CBM. Moreover, CBM remarkably enhanced meningeal lymphatic drainage function in 5xFAD mice (n=5-16 mice/group for all studies). CBM may promote meningeal lymphangiogenesis and lymphatic drainage function through VEGF-C-VEGFR3 pathway, and further reduce amyloid depositions and Aβ plaques and alleviate memory deficits in AD.
To analyze the short-term outcome after medial open-wedge high tibial osteotomy with a 3D-printing technology in early medial keen osteoarthritis and varus malalignment. 32 knees(28 cases) of mOWHTO (fixation with an angular-stable TomoFix implant(Synthes)) with a 3D-printing technology combined with arhtroscopy were prospectively surveyed with regard to functional outcome(Hospital for special knee score [HSS] score). Pre- and postoperative tibial bone varus angle (TBVA), mechanical medial proximal tibial angle (MPTA), and alignment were analyzed with regard to the result.Objective
Design and Method
Hoffa fractures are rare, intra-articular fractures of the femoral condyle in the coronal plane and involving the weight-bearing surface of the distal femur. Surgical fixation is warranted to achieve stability, early mobilisation and satisfactory knee function. We describe a unique type of Hoffa fracture in the coronal plane with sagittal split and intra-articular comminution. There is scant evidence in current literature with regards to surgical approaches, techniques and implants. We report of our case with a review of the literature. A 40 year old male motorcyclist was involved in a high speed road traffic collision. X-rays confirmed displaced unicondylar fracture of the lateral femoral condyle. CT showed sagittal split of the Hoffa fragment and intra-articular comminution. MRI showed partial rupture of the anterior cruciate ligament. The patient underwent definitive surgical treatment via a midline skin incision and lateral parapatellar approach using cannulated screws, headless compression screws and anti-glide plate. Weightbearing was commenced at 8 weeks. Arthroscopy and adhesiolysis was performed at 12 weeks to improve range of motion. The patient was discharged at one year with a pain-free, functional knee.Introduction
Case report
The anterior-posterior (AP) pelvis radiograph is crucial for diagnosis of neck of femur (NOF) fractures, especially as this is one of the commonest fractures in the elderly population. Anecdotally we found that initial AP pelvis radiographs for these suspected fractures did not always exhibit the bones sufficiently. Repeat radiographs were needed, leading to delays in diagnosis, treatment, and repeated radiation exposure. Missed diagnoses can have significant consequences for this patient group. We assessed how many initial AP pelvis radiographs taken for suspected NOF fracture fitted criteria for adequate diagnostic imaging. A retrospective study was carried out assessing the initial AP pelvis radiograph done for each patient presenting to our dedicated NOF unit with suspected NOF fracture for 1st June – 31st July 2014. European Guidelines for Diagnostic Imaging were used as the benchmark. Each radiograph was scored out of six, one for each criteria fulfilled. Guidelines deemed images scoring ≤3 as inadequate.Background
Methods
Focal resurfacing can treat localised articular damage of the knee not appropriate for arthroplasty or biological repair. Independent results on these implants are limited. We previously published early results showing significantly improved Knee Injury & Osteoarthritis Outcome Score (KOOS4) without complication or re-operation, demonstrating this system gives good analgesia and functional improvement in selected patients. We present long-term follow-up of these patients. We prospectively evaluated medium- to long-term results in patients with localised, full-thickness articular cartilage defects of the knee undergoing HemiCAP resurfacing. All procedures were performed by one consultant surgeon. Post-operative rehabilitation was standardised. Outcome measures were KOOS4 score, visual analogue score (VAS), Kellgren and Lawrence arthritis grade, and re-operation rates.Background
Methods
Radial head fractures are the commonest fractures involving the elbow. The goals of treatment are to restore stability, preserve motion, and maintain the relative length of the radius. Fortunately, most simple uncomplicated fractures can be treated non-operatively. Choosing between fixation and radial head replacement for comminuted fractures remains difficult. Excision of radial head fractures is not an ideal option in unstable elbow injuries. The purpose of this systematic review was to search for and critically appraise articles directly comparing functional outcomes and complications for fixation (open reduction internal fixation, ORIF) versus arthroplasty for comminuted radial head fractures (Mason type 3) in adults. A comprehensive search of Medline, Embase and Cochrane databases using specific search terms and limits was conducted. Strict eligibility criteria were applied to stringently screen resultant articles. Three comparative studies were identified and reviewed.Background
Method
Osteonecrosis of the femoral head is a complex pathologic process with many aetiological factors. Factors most often mentioned in the literature are mechanical disruption (hip trauma or surgery), steroid use, smoking, haemoglobinopathies and hyperlipidaemia.1 Our case depicts a rare association of crack cocaine related to osteonecrosis of the femoral head which has never been reported in the available literature. Case Report: A 32 year old man was referred to our Orthopaedic clinic with right hip pain. He had a 9 pack-year history of cigarette smoking and had also smoked crack cocaine between ages 20 to 28; shortly after this the hip pain started. He denied antecedent injury. He had undergone a steroid injection into his right ankle abroad for swelling one year before referral, which was after onset of hip pain. MRI of his hip previously performed abroad had been normal. The patient had an indoor job and was otherwise fit and well. On examination he had reduced of movement in his right hip with 5–10 degrees of fixed flexion deformity. Plain radiography demonstrated cyst formation and sclerosis of both femoral heads. Repeat MRI confirmed bilateral osteonecrosis, worse on the right with risk of head collapse. The patient underwent bilateral core decompressions. Subsequent follow-up demonstrated a mobile patient with no need for arthroplasty and he was discharged after two years. Osteonecrosis is caused by the coagulation of the intra-osseous microcirculation leading to thrombosis formation and eventual reduction in osseous blood supply. Steroid use is associated with increased risk of osteonecrosis to the femoral head, however in these cases the patients often undergo either direct local or systemic infiltration of steroid. In this case steroid was administered after symptoms began to a far distant site and therefore cannot be the cause. Cigarette smoking is also known to cause osteonecrosis. Our patient had smoked cigarettes for fourteen years without problems, and it was after he ceased to smoke crack cocaine that his symptoms began. Cocaine blocks voltage-gated sodium-channels causing vasospasm. It is known to cause nasal and facial bone osteonecrosis due to its common intranasal method of delivery. We postulate that in this case crack cocaine was a synergistic factor towards development of femoral head osteonecrosis.
We performed a systematic review to compare outcomes of cemented versus uncemented trapezio-metacarpal joint (TMCJ) replacement for treatment of base-of-thumb arthritis. We assessed improvements in pain and function, range of movement (ROM), strength, complications and need for revision surgery. A thorough literature search was performed. A total of 481 studies were identified from the literature search (179 Medline, 253 Embase, 27 CINAHL, 22 Cochrane). Of 43 relevant titles 28 were selected for full-text review after assessment of the abstracts. Duplicate studies were removed. 18 studies met inclusion criteria on full-text review. All studies were of level IV evidence. There were no randomised controlled trials or meta-analyses. The studies were critically appraised using a validated scoring system. Most studies reported good outcomes for pain and strength, and functional outcome was comparable for both groups. ROM was generally improved for both prosthetic types, however statistical calculation was lacking in many studies. Trapezial component loosening was the main problem for both cemented and uncemented prostheses, however radiological loosening did not necessarily correlate with implant failure. This systematic review has found that both cemented and uncemented replacements generally give good outcomes for the treatment of TMCJ arthritis, however young, male, patients with manual occupations and with disease in the dominant hand and patients with poor trapezial bone stock appear to be at higher risk for implant failure due to cup loosening. We recommend the construction of a joint registry to record implantation and revision rates.
There has been evidence of association between femoral shaft fractures and prolonged bisphosphonate therapy. We present a case series of bisphosphonate-associated fractures and invaluable lessons we have learnt. Over the last three years at our unit we have collected a case series of eight patients who have had atypical femoral fractures whilst on bisphosphonate therapy. We present illustrative cases, a summary of key findings, and invaluable lessons we have learnt. There was a long period of prodromal pain for two years before incomplete fractures developed. We speculate this is a warning sign of impending fracture. This may have been prevented with screening. Between incomplete fracture and complete fracture there was a short window of one month. Five patients presented with complete fracture, and three with thigh pain +/- evidence of incomplete fracture. Of the latter group all but one went on to develop complete fractures. The one patient who did not progress died six years after diagnosis. Of those five patients who presented with initial complete fracture, three patients recall thigh pain before fracture on further questioning. Despite being diaphyseal femoral fractures, there is a higher risk of neck of femur fractures in this patient cohort (both patients with initial interlocked nails subsequently developed neck of femur fractures soon after and were revised to cephalomedullary nails). Excluding one death from unrelated cause, only one patient has signs of complete fracture healing. All other patients are still receiving follow-up (mean 490 days). Three patients reported bilateral symptoms (pain). Two had had bilateral symptoms for one year. Both had visible incomplete fractures on further radiographic scrutiny; one underwent prophylactic cephalomedullary nailing, one was managed with active surveillance. We suggest that improved pain and radiographic changes of cortical healing may be misleading and should not be relied upon. Cephalomedullary nailing is the treatment of choice in these fractures due to higher risk of neck of femur fractures in this cohort. We suggest prompt prophylactic cephalomedullary nailing when radiographic incomplete fractures are identified due to a short window before progression to complete fracture, and the need to consider contralateral prophylactic nailing in patients describing bilateral symptoms. We speculate that thigh pain is a warning sign of impending fracture and fracture-progression can be prevented with appropriate screening.
Contrary to NICE guidance there remains a role for Austin-Moore hemiarthroplasty (AM) for patients with significant pre-existing comorbidities who are at higher risk of death and complications following cemented hemiarthroplasty. We analysed prospectively-collected data comparing uncemented AM hemiarthroplasty in frail, poorly-mobile patients, and cemented hemiarthroplasty. We analysed age, pre-operative morbidity, duration of operation, death rate and complication rate. AM patients were significantly older with significantly higher ASA grades. It took significantly longer to optimise them before surgery. AM was significantly shorter to perform. There was no significant difference in complications requiring re-operation. Twice as many AM patients developed post-operative pneumonia despite absence of cement. Twice as many AM patients died after surgery and a significant proportion died within the first month despite no increased risk of repeat operation, shorter operating time and no risk of cement-disease. We infer that these patients would likely have fared badly had they undergone a longer, cemented procedure. A modern cemented prosthesis costs £691 more than AM. There exists a subset of patients within the neck of femur cohort who are significantly more unwell. Contrary to guidelines, we suggest that the cheaper, user-friendly Austin-Moore can be a reasonable prosthesis to use for this cohort.
Wear of polymeric glenoid components has been identified as a cause of loosening and failure of shoulder implants1,2 in vivo. A small number of shoulder joint simulators have been built for in vitro wear testing, however none have been capable of testing with physiological motion patterns in three axes and with physiological loading. The Newcastle Shoulder Wear Simulator was designed with three axes of motion, which are programmable so that different activities of daily living might be replicated. The simulator uses three pneumatic cylinders with integral position encoders to move five shoulder prostheses simultaneously in the flexion-extension, abduction-adduction, and internal-external rotation axes. Axial loading is applied with pneumatic cylinders supplied from a pneumatic proportional valve via a manifold, which also supplies a sixth static control station. In order to establish if that the machine can actually perform as intended, commissioning trials were conducted replicating lifting a 0.5 Kg weight to head height as a daily living activity. During the commissioning trials JRI Orthopaedics Reverse VAIOS shoulder prostheses were tested in 50% bovine serum at ambient temperature. The results show that the shoulder joint wear simulator can satisfactorily reproduce a daily living activity deliberately selected for having a large range of motion and loading. Other daily activities, such as drinking from a mug, are less demanding in the ranges of motion and loading and represent no difficulty in being reproduced on the simulator. Now successfully commissioned, this new multi-station shoulder wear simulator can wear test current and new designs of shoulder prosthesis in vitro
