Technological advances and shorter rescue times have allowed early and effective resuscitation after trauma and brought attention to the host response to injury. Trauma patients are at risk of progressive organ dysfunction from what appears to be an uncontrolled immune response. The availability of improved techniques of molecular diagnosis has allowed investigation of the role of genetic variations in the inflammatory response to post-traumatic complications and particularly to sepsis. This review examines the current evidence for the genetic predisposition to adverse outcome after trauma. While there is evidence supporting the involvement of different polymorphic variants of genes in determining the post-traumatic course and the development of complications, larger-scale studies are needed to improve the understanding of how genetic variability influences the responses to post-traumatic complications and pharmacotherapy.
To investigate the appropriate dose and interval for the administration
of triamcinolone acetonide (TA) in treating tendinopathy to avoid
adverse effects such as tendon degeneration and rupture. Human rotator cuff-derived cells were cultured using three media:
regular medium (control), regular medium with 0.1 mg/mL of TA (low
TA group), and with 1.0 mg/mL of TA (high TA group). The cell morphology,
apoptosis, and viability were assessed at designated time points.Objectives
Methods
Frozen shoulder is commonly encountered in general
orthopaedic practice. It may arise spontaneously without an obvious
predisposing cause, or be associated with a variety of local or
systemic disorders. Diagnosis is based upon the recognition of the
characteristic features of the pain, and selective limitation of
passive external rotation. The macroscopic and histological features
of the capsular contracture are well-defined, but the underlying
pathological processes remain poorly understood. It may cause protracted
disability, and imposes a considerable burden on health service
resources. Most patients are still managed by physiotherapy in primary
care, and only the more refractory cases are referred for specialist
intervention. Targeted therapy is not possible and treatment remains predominantly
symptomatic. However, over the last ten years, more active interventions
that may shorten the clinical course, such as capsular distension
arthrography and arthroscopic capsular release, have become more popular. This review describes the clinical and pathological features
of frozen shoulder. We also outline the current treatment options,
review the published results and present our own treatment algorithm.
The October 2014 Research Roundup360 looks at: unpicking syndesmotic injuries: CT scans evaluated; surgical scrub suits and sterility in theatre; continuous passive motion and knee injuries; whether pain at night is melatonin related;
Two types of fracture, early and late, have been
reported following limb lengthening in patients with achondroplasia (ACH)
and hypochondroplasia (HCH). We reviewed 25 patients with these conditions who underwent 72
segmental limb lengthening procedures involving the femur and/or
tibia, between 2003 and 2011. Gender, age at surgery, lengthened
segment, body mass index, the shape of the callus, the amount and
percentage of lengthening and the healing index were evaluated to determine
predictive factors for the occurrence of early (within three weeks
after removal of the fixation pins) and late fracture (>
three weeks
after removal of the pins). The Mann‑Whitney U test and Pearson’s
chi-squared test for univariate analysis and stepwise regression
model for multivariate analysis were used to identify the predictive factor
for each fracture. Only one patient (two tibiae) was excluded from
the analysis due to excessively slow formation of the regenerate,
which required supplementary measures. A total of 24 patients with
70 limbs were included in the study. There were 11 early fractures in eight patients. The shape of
the callus (lateral or central callus) was the only statistical
variable related to the occurrence of early fracture in univariate
and multivariate analyses. Late fracture was observed in six limbs
and the mean time between removal of the fixation pins and fracture
was 18.3 weeks (3.3 to 38.4). Lengthening of the tibia, larger healing
index, and lateral or central callus were related to the occurrence
of a late fracture in univariate analysis. A multivariate analysis
demonstrated that the shape of the callus was the strongest predictor
for late fracture (odds ratio: 19.3, 95% confidence interval: 2.91
to 128). Lateral or central callus had a significantly larger risk
of fracture than fusiform, cylindrical, or concave callus. Radiological monitoring of the shape of the callus during distraction
is important to prevent early and late fracture of lengthened limbs
in patients with ACH or HCH. In patients with thin callus formation,
some measures to stimulate bone formation should be considered as
early as possible. Cite this article:
Failure of bone repair is a challenging problem in the management of fractures. There is a limited supply of autologous bone grafts for treating nonunions, with associated morbidity after harvesting. There is need for a better source of cells for repair. Mesenchymal stem cells (MSCs) hold promise for healing of bone because of their capacity to differentiate into osteoblasts and their availability from a wide variety of sources. Our review aims to evaluate the available clinical evidence and recent progress in strategies which attempt to use autologous and heterologous MSCs in clinical practice, including genetically-modified MSCs and those grown on scaffolds. We have compared various procedures for isolating and expanding a sufficient number of MSCs for use in a clinical setting. There are now a number of clinical studies which have shown that implantation of MSCs is an effective, safe and durable method for aiding the repair and regeneration of bone.
In order to investigate the osteoinductive properties of allograft used in impaction grafting and the effect of strain during impaction on these properties, we designed an We have shown that BMP-7 is released from fresh-frozen femoral head cancellous bone in proportion to the strain applied to the bone. This suggests that the impaction process itself may contribute to the biological process of remodelling and bony incorporation.
Heterotopic ossification (HO) is perhaps the
single most significant obstacle to independence, functional mobility, and
return to duty for combat-injured veterans of Operation Enduring
Freedom and Operation Iraqi Freedom. Recent research into the cause(s)
of HO has been driven by a markedly higher prevalence seen in these
wounded warriors than encountered in previous wars or following
civilian trauma. To that end, research in both civilian and military
laboratories continues to shed light onto the complex mechanisms
behind HO formation, including systemic and wound specific factors,
cell lineage, and neurogenic inflammation. Of particular interest,
non-invasive
Our objective in this article is to test the hypothesis that
type 2 diabetes mellitus (T2DM) is a factor in the onset and progression
of osteoarthritis, and to characterise the quality of the articular
cartilage in an appropriate rat model. T2DM rats were obtained from the UC Davis group and compared
with control Lewis rats. The diabetic rats were sacrificed at ages
from six to 12 months, while control rats were sacrificed at six
months only. Osteoarthritis severity was determined via histology
in four knee quadrants using the OARSI scoring guide. Immunohistochemical
staining was also performed as a secondary form of osteoarthritic
analysis.Objectives
Methods
Invasive group A streptococcus (iGAS) is the most common cause of monomicrobial necrotising fasciitis. Necrotising infections of the extremities may present directly to orthopaedic surgeons or by reference from another admitting specialty. Recent epidemiological data from the Health Protection Agency suggest an increasing incidence of iGAS infection in England. Almost 40% of those affected had no predisposing illnesses or risk factors, and the proportion of children presenting with infections has risen. These observations have prompted the Chief Medical Officer for the Central Alerting System in England to write to general practitioners and hospitals, highlighting the need for clinical vigilance, early diagnosis and rapid initiation of treatment in suspected cases. The purpose of this annotation is to summarise the recent epidemiological trends, describe the presenting features and outline the current investigations and treatment of this rare but life-threatening condition.
The goal of this study was to determine whether intra-articular
administration of the potentially anti-fibrotic agent decorin influences
the expression of genes involved in the fibrotic cascade, and ultimately
leads to less contracture, in an animal model. A total of 18 rabbits underwent an operation on their right knees
to form contractures. Six limbs in group 1 received four intra-articular
injections of decorin; six limbs in group 2 received four intra-articular
injections of bovine serum albumin (BSA) over eight days; six limbs
in group 3 received no injections. The contracted limbs of rabbits
in group 1 were biomechanically and genetically compared with the
contracted limbs of rabbits in groups 2 and 3, with the use of a
calibrated joint measuring device and custom microarray, respectively.Objectives
Methods
The December 2013 Research Roundup360 looks at: Inflammation implicated in FAI; Ponseti and effective teaching; Unicompartmental knee design and tibial strain; Bisphosphonates and fracture healing; Antibiosis in cement; Zoledronic acid improves primary stability in revision?; Osteoporotic fractures revisited; and electroarthrography for monitoring of cartilage degeneration
Osteochondral lesions (OCLs) occur in up to 70%
of sprains and fractures involving the ankle. Atraumatic aetiologies have
also been described. Techniques such as microfracture, and replacement
strategies such as autologous osteochondral transplantation, or
autologous chondrocyte implantation are the major forms of surgical
treatment. Current literature suggests that microfracture is indicated
for lesions up to 15 mm in diameter, with replacement strategies
indicated for larger or cystic lesions. Short- and medium-term results
have been reported, where concerns over potential deterioration
of fibrocartilage leads to a need for long-term evaluation. Biological augmentation may also be used in the treatment of
OCLs, as they potentially enhance the biological environment for
a natural healing response. Further research is required to establish
the critical size of defect, beyond which replacement strategies
should be used, as well as the most appropriate use of biological augmentation.
This paper reviews the current evidence for surgical management
and use of biological adjuncts for treatment of osteochondral lesions
of the talus. Cite this article:
The aim of this study was to determine the effect
of radial extracorporeal shock-wave therapy (rESWT) on patients with
chronic tendinitis of the rotator cuff. This was a randomised controlled
trial in which 82 patients (mean age 47 years (24 to 67)) with chronic
tendinitis diagnosed clinically were randomly allocated to a treatment
group who received low-dose rESWT (three sessions at an interval
10 to 14 days, 2000 pulses, 0.11 mJ/mm2, 8 Hz) or to
a placebo group, with a follow-up of six months. The patients and
the treating orthopaedic surgeon, who were both blinded to the treatment,
evaluated the results. A total of 44 patients were allocated to
the rESWT group and 38 patients to the placebo group. A visual analogue
scale (VAS) score for pain, a Constant–Murley (CMS) score and a simple
shoulder test (SST) score significantly improved in both groups
at three and six months compared with baseline (all p ≤ 0.012).
The mean VAS was similar in both groups at three (p = 0.43) and
six months (p = 0.262). Also, the mean CMS and SST scores were similar
in both groups at six months (p = 0.815 and p = 0.834, respectively). It would thus seem that low-dose rESWT does not reduce pain or
improve function in patients chronic rotator cuff tendinitis compared
with placebo treatment. Cite this article:
In this study of 41 patients, we used proteomic, Western blot and immunohistochemical analyses to show that several reactive oxygen species scavenging enzymes are expressed differentially in patients with primary osteoarthritis and those with non-loosening and aseptic loosening after total hip replacement (THR). The patients were grouped as A (n = 16, primary THR), B (n = 10, fixed THR but requiring revision for polyethylene wear) and C (n = 15, requiring revision due to aseptic loosening) to verify the involvement of the identified targets in aseptic loosening. When compared with Groups A and B, Group C patients exhibited significant up-regulation of transthyretin and superoxide dismutase 3, but down-regulation of glutathione peroxidase 2 in their hip synovial fluids. Also, higher levels of superoxide dismutase 2 and peroxiredoxin 2, but not superoxide dismutase 1, catalase and glutathione perioxidase 1, were consistently detected in the hip capsules of Group C patients. We propose that dysregulated reactive oxygen species-related enzymes may play an important role in the pathogenesis and progression of aseptic loosening after THR.
We reviewed the literature on the currently available
choices of bearing surface in total hip replacement (THR). We present
a detailed description of the properties of articulating surfaces
review the understanding of the advantages and disadvantages of
existing bearing couples. Recent technological developments in the
field of polyethylene and ceramics have altered the risk of fracture
and the rate of wear, although the use of metal-on-metal bearings has
largely fallen out of favour, owing to concerns about reactions
to metal debris. As expected, all bearing surface combinations have
advantages and disadvantages. A patient-based approach is recommended,
balancing the risks of different options against an individual’s
functional demands. Cite this article:
The patellofemoral joint is an important source of symptoms in osteoarthritis of the knee. We have used a newly designed surgical model of patellar strengthening to induce osteoarthritis in BALB/c mice and to establish markers by investigating the relationship between osteoarthritis and synovial levels of matrix metalloproteinases (MMPs). Osteoarthritis was induced by using this microsurgical technique under direct vision without involving the cavity of the knee. Degeneration of cartilage was assessed by the Mankin score and synovial tissue was used to determine the mRNA expression levels of MMPs. Irrigation fluid from the knee was used to measure the concentrations of MMP-3 and MMP-9. Analysis of cartilage degeneration was correlated with the levels of expression of MMP. After operation the patellofemoral joint showed evidence of mild osteoarthritis at eight weeks and further degenerative changes by 12 weeks. The level of synovial MMP-9 mRNA correlated with the Mankin score at eight weeks, but not at 12 weeks. The levels of MMP-2, MMP-3 and MMP-14 mRNA correlated with the Mankin score at 12 weeks. An increase in MMP-3 was observed from four weeks up to 16 weeks. MMP-9 was notably increased at eight weeks, but the concentration at 16 weeks had decreased to the level observed at four weeks. Our observations suggest that MMP-2, MMP-3 and MMP-14 could be used as markers of the progression of osteoarthritic change.