Meniscus allograft and synthetic meniscus scaffold (Actifit®) transplantation have shown promising outcomes for symptoms relief in patients with meniscus deficient knees. Untreated chondral defects can place excessive load onto meniscus transplants and cause early graft failure. We hypothesised that combined ACI and allograft or synthetic meniscus replacement might provide a solution for meniscus deficient individuals with co-existing lesions in cartilage and meniscus. We retrospectively collected data from 17 patients (16M, 1F, aged 40±9.26) who had ACI and meniscus allograft transplant (MAT), 8 patients (7M, 1F, aged 42±11) who underwent ACI and Actifit® meniscus scaffold replacement. Other baseline data included BMI, pre-operative procedures and cellular transplant data. Patients were assessed by pre-operative, one-year and last follow-up Lysholm score, one-year repair site biopsy, MRI evaluations.Abstract
Objectives
Methods
The current study aims to ascertain the outcome of ACI with simultaneous transplantation of an autologous bone plug for the restoration of osteoarticular defects in the femoral condyle of the knee (‘Osplug’ technique). Seventeen patients (mean age of 27±7 years), twelve with Osteochondritis dissecans (OD) and five with an osteochondral defect (OCD) was treated with unicortical autologous bone graft combined with ACI (‘Osplug’ technique). Functional outcome was assessed with Lysholm scores obtained for 5 years post-operatively. The repair site was evaluated with the Oswestry Arthroscopy Score (OAS), MOCART MRI score and ICRS II histology score. The mean defect size was 4.5±2.6 SD cm² and mean depth was 11.3±5 SD mm. A significant improvement of Lysholm score from 45 (IQR 24, range 16–79) to 77 (IQR 28, range 41–100) at 1 year (p-value 0.001) and 70 (IQR 35, range 33–91) at 5 years (p-value 0.009). The mean OAS of the repair site was 6.2 (range 0–9) at a mean of 1.3 years. The mean MOCART score was 61 ± 22SD (range 20–85) at 2.6 ± 1.8SD years. Histology demonstrated generally good integration of the repair cartilage with the underlying bone. Poor lateral integration of the bone graft on MRI and low OAS were significantly associated with a poor outcome and failure. The Osplug technique shows significant improvement of functional outcome for up to 5 years. This is the first report describing the association of bone graft integration with functional outcome after such a procedure.
Randomised controlled study evaluating new bone formation Regenerating new bone by cell therapy could provide therapeutic options in many conditions such as fracture non-unions and osteo-chondral defect regeneration in advance OA. In this randomised controlled study we evaluated the efficacy of new bone formation by bone marrow derived stromal cells (BMSC) in patients with non-union.Summary
Introduction
To evaluate the efficacy of bone marrow derived stromal cells (BMSC) for the treatment of non-unions in fractures. An ethically approved single centre randomised control trial recruited 35 patients for treatment of non-unions with BMSC during 2006–2010. Autologous BMSC were culture expanded at the Good Manufacturing Practice (GMP) standard Oscell® laboratory in the hospital. Following Aim
Methods
Meniscus deficiency leads to the development of early arthritis. Total knee replacement may be the only available treatment option in certain situations. However it is generally best avoided in young patients. We hypothesized that a combination of the two procedures, Allograft Meniscal Transplantation (AMT) and Autologous Chondrocyte Implantation (ACI) would be a solution to treat bone-on-bone arthritis in meniscal deficient knees and postpone the need for a total knee replacement (TKR). 12 consecutive patients who underwent both ACI and AMT between 1998 and 2005 were followed up prospectively. The patients were assessed by a self-assessed Lysholm score prior to the procedure and yearly thereafter. All operations were performed by the senior author (JBR). ACI procedure was performed according to the standard technique. Frozen meniscal allograft with bone plugs at either ends secured by sutures in the bone tunnels. Post operatively all patients underwent a strict Oscell Rehabilitation protocol. A repeat procedure or progression to a TKR was taken as a failure.Introduction
Materials/Methods
Regenerative medicine is a rapidly expanding discipline. However due to a lack of validated outcome measures, clinical trials have been far few. This study aims to assess the validity, inter-observer reliability and intra-observer reproducibility of experimental fracture healing assessment on plain radiographies. This technique involves implantation of mesenchymal stem cell (MSC) seeded constructs on only one side of the fracture after randomisation. We examined inter/intraobserver agreement on the area and “bridging length” of callus formed on opposite sides of the fracture. Among 16 orthopaedic surgeons with trauma commitments (8 consultants, 8 registrars) on two separate occasions (average 52 days apart). They independently assessed the radiographs (AP or lateral) of 28 patients with fractures of the tibial or femoral shaft. The fractures chosen included non-unions treated with MSC/constructs and fresh fractures at 4–9 months. For each radiograph the assessor assigned which side (medial or lateral) is there more callus. Chase-corrected agreement using Fleiss kappa was used to compare opinions. Digital analysis software (Image-J) was used to quantify extent/bridging callus and correlate it with surgeons opinion.Introduction
Methods
Autologous Chondrocyte Implantation (ACI) is frequently used to treat chondral defects in the knee with a good long-term outcome. This is contraindicatd in meniscal deficient knees. Allogenic Menicsal Transplantation (AMT) has been shown to give good symptomatic relief in meniscus deficient knees. However this is contraindicated in advanced cartilage degeneration. We hypothesized that combination of these two might be a solution for bone-on-bone arthritis in young individuals. We studied a consecutive series of 12 patients who underwent combined ACI and AMT between 1998 and 2005. Pre operative and post operative comparisons of lysholm scores were recorded. Magnetic Resonance Imaging was performed to assess the integration ACI & AMT. Arthroscopy was performed at one year for assessment and obtain biopsy for histological examination.Background
Methods
Thrust plate prosthesis (TPP) is a bone conserving prosthesis in use for over thirty years. TPP is a stemless and uncemented femoral prosthesis fixed at the lateral femoral cortex with a bolt, plate and screw. This has a metal-on-metal articulation with a 28mm Metasul head and Allofit press fit acetabular cup. Our study aimed to assess the functional outcome of this prosthesis. In our institution 234 TTPs were implanted between 1995 and 2005. All patients completed a self-assessed questionnaire of Harris Hip Score at 2 months, 1 year, and then yearly. Only those who had a follow up was within the last two years were included in the analysis. 76 patients who had failed to satisfy the criteria were excluded. Of the 158 hips in the study 75 hips were in male patients and 83 were in female patients. The median age of patients was 52 years (range 15 to 82). 75 hips were on the right side and 83 on the left. All patients were operated by the senior author or a senior trainee under his supervision (seven hips). Revision of the implant or decision to revise was taken as the end point of our study.Background
Methods
Autologous Chondrocyte Implantation (ACI) is a procedure which is gaining acceptance for the treatment of cartilage defects in the knee with good results and a long term durable outcome. Its use in other joints has been limited, mainly to the ankle. We aimed to assess the outcome of ACI in the treatment of chondral and osteochondral defects in the hip. Fifteen patients underwent ACI for chondral or osteochondral defects in the femoral head with a follow up of upto 8 years (mean of 2 years) in our institution with a mean age of 37 years at the time of operation. Pre-operatively hip function was assessed by using the Harris Hip Score and MRI. Post-operatively these were repeated at 1 year and hip scores repeated annually. Failure was defined as a second ACI to the operated lesion or a conversion to a hip resurfacing or replacement.Background
Methods
Hip resurfacing has resurged in the last decade due to a renewed interest in metal on metal bearing. One of the proposed advantages is ease of revision of the femoral component. Short term functional results after femoral revision are similar to those after conventional total hip replacement. Survival and function after revision of the acetabular component only or of both components have not been reported. We aimed to assess hip function and implant survival after revision of the acetabular component for failed Birmingham hip resurfacing (BHR). The Oswestry Outcome Centre collected data prospectively on 5000 patients who underwent hip resurfacing between 1997 and 2002. Of these, 182 hips were revised: 42% had revision of the femoral component only, 8% revision of the acetabular component only, and 50% revision of both components. This study analyzed patients who had revision of the acetabular component, either in isolation or in combination with the femoral component.Background
Methods
Thrust plate prosthesis (TPP) is a bone conserving prosthesis in use for over thirty years. TPP is a stemless and uncemented femoral prosthesis fixed at the lateral femoral cortex with a bolt, plate and screw. This has a metal-on-metal articulation with a 28mm Metasul head and Allofit press fit acetabular cup. Our study aimed to assess the survival of this prosthesis. At Oswestry 234 TTP's were implanted between 1995 and 2005. All patients completed a self-assessed questionnaire of Harris Hip Score pre-operatively and post-operatively at 2 months, 1 year, and then yearly. Only those who had a follow up was within the last two years were included in the analysis. 76 patients who had failed to satisfy the criteria were excluded. Of the 158 hips in the study 75 hips were in male patients and 83 were in female patients. The median age of patients was 52 years (range 15 to 82). 75 hips were on the right side and 83 on the left. All patients were operated by the senior author or a senior trainee under his supervision (seven hips). Revision of the implant or decision to revise was taken as the end point of our study. The median time to follow up was 7 years (range 1 to 15). The median pre-operative hip score was 43 (range 3 to 77) which rose to 83 points (range 11 to 100) at the latest follow up. Median hip score in females improved from 39 to 82 points and in males from 52 to 85 points. Twelve patients (5.1%) underwent revision surgery either for infection or aseptic loosening. The Thrust Plate Prosthesis had a good outcome with an increase in hip score of 40 points and 94.9 % survival at a median of 7 years.
A new surgical hybrid technique involving the combination of autologous bone plug(s) and autologous chondrocyte implantation (AOsP-ACI) was used and evaluated as a treatment option in 15 patients for repair of large osteochondral defects in knee (N=12) and hip joints (N=3). Autologous Osplugs were used to contour the articular surface and the autologous chondrocytes were injected underneath a biological membrane covering the plug. The average size of the osteochondral defects treated was 4.5cm2. The average depth of the bone defect was 26mm. The patients had a significant improvement in their clinical symptoms at 12 months with significant increase in the Lysholm Score and Harris Hip Score (p = 0.031). The repaired tissue was evaluated using Magnetic Resonance Imaging, Computerised Tomography, arthroscopy, histology and immunohistochemistry (for expression of type I and II collagen). Magnetic Resonance Imaging, Computerised Tomography and histology at 12 months revealed that the bone plug became well integrated with the host bone and repair cartilage. Arthroscopic examination at 12 months revealed good lateral integration of the AOsP-ACI with the surrounding cartilage. Immunohistochemistry revealed mixed fibro-hyaline cartilage. We conclude that the hybrid AOsP-ACI technique provides a promising surgical approach for the treatment of patients with large osteochondral defects. This study highlights the use of this procedure in two different weightbearing joints and demonstrates good early results which are encouraging. The long term results need to be evaluated.
Hip resurfacing with metal-on-metal in patients with osteonecrosis (ON) raises concerns of early failure. This study addresses the hypothesis that osteonecrosis as a pre-operative diagnosis significantly increases the risk of failure following hip resurfacing. We analyzed data of 202 hips that underwent metal-on-metal hip resurfacing. In group 1 were 101 hips with a pre-operative diagnosis of osteonecrosis. In group 2 were 101 hips with other pre-operative diagnosis of osteoarthritis. Survival analysis with Cox regression was used to compare the revision risks of both groups. The mean age at operation was 42 years in osteonecrotic and 43 years in osteoarthritic group. The preoperative and postoperative hip scores were 62 and 96 for osteonecrotic group and 58 and 95 for osteoarthritic group, respectively. Survival analysis with revision for any reason as the endpoint was performed on the two groups which had identical follow-up periods. Survival at 10 years was 97.7% for osteonecrosis and 95.0% for osteoarthritis. The revision risk for patients with osteonecrosis was lower (0.37, 95% CI 0.07 – 1.82, Cox regression) but the difference was not significant (p = 0.19). Our study found no difference in revision risk in patients with osteonecrosis as compared to those with osteoarthritis
We aimed to assess the long term results of patients who underwent Autologous Chondrocyte Implantation (ACI) for osteochondral lesions of the talus. Between 1998 and 2006, 28 patients underwent ACI for osteochondral lesions of the talus. All these patients were prospectively reviewed and assessed for long term results. Outcomes were assessed using satisfaction scores, Mazur ankle score and the AOFAS score, and Lysholm knee score for donor site morbidity. The 28 patients who underwent the procedure included 18 males and 10 females. Follow up ranged from 1–9 years. In all patients, there was an improvement in the Mazur and AOFAS ankle scores and the Lysholm scores showed minimal donor site morbidity. Improvement in ankle score was independent of age and gender. The better the pre-op score the less the difference in post-op ankle scores. Patients were unlikely to benefit with pre-op ankle scores over 75. The mid to long term results of ACIs in the treatment of localised, contained cartilage defects of the talus are encouraging and prove that it is a satisfactory treatment modality for symptomatic osteochondral lesions of the talus. Complications are limited. However, in view of limited number of patients, a multi-centre randomised controlled study is required for further assessment.
Thirty-five patients were followed prospectively from their referral to the Problem Fracture Service with chronic osteomyelitis of diaphyseal bone between November 1994 and June 1999. The patients were treated using a closed double-lumen suction irrigation system following reaming and arthroscopic debridement of the intramedullary canal; this is a modified system based on the work of Charles Lautenbach. Results of these procedures were regularly followed up in clinic, and between June and July 2007 the whole cohort was reviewed via postal questionnaire, telephone and case note review. At a mean follow up of 101 months, 26 were living with no evidence of recurrence, 4 had died of unrelated causes with no evidence of recurrent infection. Four patients had persisting problems with sinus discharge requiring intermittent antibiotic therapy and 1 patient had his limb amputated for recurrent metaplastic change. These results gave this cohort an 86% clearance of infection, with recurrence in 12%, which is comparable to the Papineau and Belfast techniques with significantly less surgical insult to the patient.
Conversion of failed femoral components of total hip resurfacing to conventional hip replacement is reportedly a straightforward procedure. There is little published to qualify this and what is available suffers from small study numbers and various combinations pre and post-operative implants. Between 1997 and 2002, the Oswestry Outcome Centre prospectively collected data on 5000 Birmingham Hip Resurfacings (BHRs) performed by 141 surgeons, at 87 hospitals. To date 4526 have survived, 135 died and 165 are lost to follow-up. 174 have been revised, of which 60 were failures of the femoral component. We reviewed modes of failure and post-revision clinical outcomes in this sub-group. Isolated femoral component failure accounted for 60 hips (1.2%). 28 femoral neck fractures, 14 femoral head collapses, 13 femoral component loosenings, 3 avascular necroses (AVN), 1 femoral loosening followed by fracture and 1 dislocation. Mean time to revision surgery was 2.6 years (1.8 years for neck fracture; 3.4 years femoral loosening, head collapse and AVN). All acetabular components were left in situ. At revision surgery 25 cemented, 25 uncemented and 10 unknown femoral prostheses were used with 56 BHR modular heads, 2 custom-made Exeter heads and 2 Thrust Plate heads. 47 patients completed outcome scores post-revision surgery. Median modified Harris Hip Score was 82 (IQ range=63–93) and Merle d’Aubigne score was 14 (IQ= 9.5–15) at a mean follow up of 3.9 years post-revision. The 4526 surviving resurfacings had a median hip score of 96 (IQ=87–100) p≤4.558x10-8 and median Merle score of 17 (IQ=14–18) p≤1.827x10-7. Mean 7.0 years follow up. There was no difference in outcomes between cemented and un-cemented revision components nor were there differences between fractured neck of femur and femoral loosening, head collapse or AVN. Following revision of the femoral component to a conventional hip replacement, function is significantly worse than surviving resurfacings.
Three patients presented with Perthes and five with AVN. Four had chondral loss following trauma and one presented with an area of bone loss in a hip with congenital dysplasia. Defect size was a mean 6.2 cm2. Pre-operatively hip function was assessed by the patient using the Harris Hip Score and MRI. Postoperatively these were repeated at 1 year and hip scores repeated annually. Hip arthroscopy and cartilage biopsy provided Cells for culture in a GMP laboratory where passage numbers were limited to two. Three weeks later by open surgery, all unstable cartilage was excised, the base was debrided or excised and bone graft applied, and suture of a membrane of periosteum or collagen membrane over the defect undertaken. A mean 5.2 million chon-drocytes were inserted beneath this patch following a test of the seal.
174 have been revised, of which 60 were failures of the femoral component. We reviewed modes of failure and post-revision clinical outcomes in this sub-group.
All acetabular components were left in situ. At revision surgery 25 cemented, 25 uncemented and 10 unknown femoral prostheses were used with 56 BHR modular heads, 2 custom-made Exeter heads and 2 Thrust Plate heads. 47 patients completed outcome scores post-revision surgery. Median modified Harris Hip Score was 82 (IQ range=63–93) and Merle d’Aubigne score was 14 (IQ= 9.5–15) at a mean follow up of 3.9years post-revision. The 4526 surviving resurfacings had a median hip score of 96 (IQ=87–100) p≥4.558x10-8 and median Merle score of 17 (IQ=14–18) p≥1.827x10-7. Mean 7.0 years follow up. There was no difference in outcomes between cemented and uncemented revision components nor were there differences between fractured neck of femur and femoral loosening, head collapse or AVN.
We observed similar effect in individual domains of pain, mobility and range of motion. Survival of the implant at nine years with revision due to any reason was 93.5%. We observed a significant difference in survival of procedures done by pioneer surgeons and by non pioneering surgeons (p <
0.01) (log rank test). There were 119 complications of which there were 30 fractures, 21 occurring within the first six months of operation.
The incidence of cancer needs to be interpreted with caution and can only be ascertained by a prospective study.