The June 2012 Knee Roundup360 looks at: ACI and mosaicplasty; ACI after microfracture; exercise therapy and the degenerate medial meniscal tear; intra-articular bupivacaine or ropivacaine at knee arthroscopy; lateral trochlear inclination and patellofemoral osteoarthritis; bone loss and ACL reconstruction; assessing stability using the contralateral knee; tranexamic acid and a useful review of knee replacement.
To assess the effectiveness of a modified tibial tubercle osteotomy
as a treatment for arthroscopically diagnosed chondromalacia patellae. A total of 47 consecutive patients (51 knees) with arthroscopically
proven chondromalacia, who had failed conservative management, underwent
a modified Fulkerson tibial tubercle osteotomy. The mean age was
34.4 years (19.6 to 52.2). Pre-operatively, none of the patients
exhibited signs of patellar maltracking or instability in association
with their anterior knee pain. The minimum follow-up for the study
was five years (mean 72.6 months (62 to 118)), with only one patient
lost to follow-up.Objectives
Methods
We compared the quality of debridement of chondral lesions performed by four arthroscopic (SH, shaver; CU, curette; SHCU, shaver and curette; BP, bipolar electrodes) and one open technique (OPEN, scalpel and curette) which are used prior to autologous chondrocyte implantation (ACI). The The most vertical walls with the least adjacent damage to cartilage were obtained with the OPEN technique. The CU and SHCU methods gave inferior, but still acceptable results whereas the SH technique alone resulted in a crater-like defect and the BP method undermined the cartilage wall. The subchondral bone was severely violated in all the equine samples which might have been peculiar to this model. The predominant depth of the debridement in the adult human samples was at the level of the calcified cartilage. Some minor penetrations of the subchondral end-plate were induced regardless of the instrumentation used. Our study suggests that not all routine arthroscopic instruments are suitable for the preparation of a defect for ACI. We have shown that the preferred debridement technique is either open or arthroscopically-assisted manual curettage. The use of juvenile equine stifles was not appropriate for the study of the cartilage-subchondral bone interface.
The April 2014 Knee Roundup360 looks at: mobile compression as good as chemical thromboprophylaxis; patellar injury with MIS knee surgery; tibial plateau fracture results not as good as we thought; back and knee pain; metaphyseal sleeves may be the answer in revision knee replacement; oral tranexamic acid; gentamycin alone in antibiotic spacers; and whether the jury is still out on unloader braces.
Treatment strategies for osteoarthritis most commonly involve the removal or replacement of damaged joint tissue. Relatively few treatments attempt to arrest, slow down or reverse the disease process. Such options include peri-articular osteotomy around the hip or knee, and treatment of femoro-acetabular impingement, where early intervention may potentially alter the natural history of the disease. A relatively small proportion of patients with osteoarthritis have a clear predisposing factor that is both suitable for modification and who present early enough for intervention to be deemed worthwhile. This paper reviews recent advances in our understanding of the pathology, imaging and progression of early osteoarthritis.
The April 2012 Research Roundup360 looks at who is capable of being an arthroscopist, bupivacaine, triamcinolone and chondrotoxicity, reducing scarring in injured skeletal muscle, horny Goat Weed and the repair of osseous defects, platelet-derived growth factor and fracture healing, the importance of the reserve zone in a child’s growth plate, coping with advanced arthritis, hydroxyapatite and platelet-rich plasma for bone defects, and calcium phosphate and bone regeneration
The February 2014 Oncology Roundup360 looks at: suspicious lesions; limb salvage in pelvic sarcomas; does infection affect oncological survival?; cancer patient pathways; radiological arthritis with cement augmentation in GCT; and post-chemotherapy increase in tumour volume as a predictor of poor prognosis.
Post-traumatic arthritis is a frequent consequence of articular fracture. The mechanisms leading to its development after such injuries have not been clearly delineated. A potential contributing factor is decreased viability of the articular chondrocytes. The object of this study was to characterise the regional variation in the viability of chondrocytes following joint trauma. A total of 29 osteochondral fragments from traumatic injuries to joints that could not be used in articular reconstruction were analysed for cell viability using the fluorescence live/dead assay and for apoptosis employing the TUNEL assay, and compared with cadaver control fragments. Chondrocyte death and apoptosis were significantly greater along the edge of the fracture and in the superficial zone of the osteochondral fragments. The middle and deep zones demonstrated significantly higher viability of the chondrocytes. These findings indicate the presence of both necrotic and apoptotic chondrocytes after joint injury and may provide further insight into the role of chondrocyte death in post-traumatic arthritis.
This review describes the development of arthroscopy of the hip over the past 15 years with reference to patient assessment and selection, the technique, the conditions for which it is likely to prove useful, the contraindications and complications related to the procedure and, finally, to discuss possible developments in the future.
In 1999, we developed a technique for biological
reconstruction after excision of a bone tumour, which involved using
autografts of the bone containing the tumour treated with liquid
nitrogen. We have previously reported the use of this technique
in 28 patients at a mean follow up of 27 months (10 to 54). In this study, we included 72 patients who underwent reconstruction
using this technique. A total of 33 patients died and three were
lost to follow-up, at a mean of 23 months (2 to 56) post-operatively,
leaving 36 patients available for a assessment at a mean of 101
months 16 to 163) post-operatively. The methods of reconstruction included
an osteo-articular graft in 16, an intercalary in 13 and, a composite
graft with prosthesis in seven. Post-operative function was excellent in 26 patients (72.2%),
good in seven (19.4%), and fair in three (8.3%) according to the
functional evaluation system of Enneking. No recurrent tumour occurred
within the grafts. The autografts survived in 29 patients (80.6%),
and the rates of survival at five and ten years were 86.1% and 80.6
%, respectively. Seven of 16 osteo-articular grafts (44%) failed
because of fracture or infection, but all the composite and intercalary
grafts survived. The long-term outcomes of frozen autografting, particularly using
composite and intercalary grafts, are satisfactory and thus represent
a good method of treatment for patients with a sarcoma of bone or
soft tissue. Cite this article:
Trochlear dysplasia is an important anatomical abnormality in symptomatic patellar instability. Our study assessed the mismatch between the bony and cartilaginous morphology in patients with a dysplastic trochlea compared with a control group. MRI scans of 25 knees in 23 patients with trochlear dysplasia and in 11 patients in a randomly selected control group were reviewed retrospectively in order to assess the morphology of the cartilaginous and bony trochlea. Inter- and intra-observer error was assessed. In the dysplastic group there were 15 women and eight men with a mean age of 20.4 years (14 to 30). The mean bony sulcus angle was 167.9° (141° to 203°), whereas the mean cartilaginous sulcus angle was 186.5° (152° to 214°; p <
0.001). In 74 of 75 axial images (98.7%) the cartilaginous contour was different from the osseous contour on subjective assessment, the cartilage exacerbated the abnormality. Our study shows that the morphology of the cartilaginous trochlea differs markedly from that of the underlying bony trochlea in patients with trochlear dysplasia. MRI is necessary in order to demonstrate the pathology and to facilitate surgical planning.
The purpose of this study was to assess whether
the use of a joint-sparing technique such as curettage and grafting was
successful in eradicating giant cell tumours of the proximal femur,
or whether an alternative strategy was more appropriate. Between 1974 and 2012, 24 patients with a giant cell tumour of
the proximal femur were treated primarily at our hospital. Treatment
was either joint sparing or joint replacing. Joint-sparing treatment
was undertaken in ten patients by curettage with or without adjunctive
bone graft. Joint replacement was by total hip replacement in nine patients
and endoprosthetic replacement in five. All 11 patients who presented
with a pathological fracture were treated by replacement. Local recurrence occurred in five patients (21%): two were treated
by hip replacement, three by curettage and none with an endoprosthesis.
Of the ten patients treated initially by curettage, six had a successful
outcome without local recurrence and required no further surgery.
Three eventually needed a hip replacement for local recurrence and
one an endoprosthetic replacement for mechanical failure. Thus 18
patients had the affected joint replaced and only six (25%) retained
their native joint. Overall, 60% of patients without a pathological
fracture who were treated with curettage had a successful outcome. Cite this article:
Most hip fractures treated with modern internal
fixation techniques will heal. However, failures occasionally occur and
require revision procedures. Salvage strategies employed during
revision are based on whether the fixation failure occurs in the
femoral neck, or in the intertrochanteric region. Patient age and
remaining bone stock also influence decision making. For fractures
in young patients, efforts are generally focused on preserving the
native femoral head via osteotomies and repeat internal fixation.
For failures in older patients, some kind of hip replacement is
usually selected. Disuse osteopenia, deformity, bone loss, and stress-risers
from previous internal fixation devices all pose technical challenges
to successful reconstruction. Attention to detail is important in
order to minimise complications. In the majority of cases, good
outcomes have been reported for the various salvage strategies. Cite this article:
There are several reports clarifying successful results following
open reduction using Ludloff’s medial approach for congenital (CDH)
or developmental dislocation of the hip (DDH). This study aimed
to reveal the long-term post-operative course until the period of
hip-joint maturity after the conventional surgical treatments. A long-term follow-up beyond the age of hip-joint maturity was
performed for 115 hips in 103 patients who underwent open reduction
using Ludloff’s medial approach in our hospital. The mean age at
surgery was 8.5 months (2 to 26) and the mean follow-up was 20.3
years (15 to 28). The radiological condition at full growth of the hip
joint was evaluated by Severin’s classification.Objectives
Methods
Young adults with hip pain secondary to femoroacetabular
impingement (FAI) are rapidly being recognised as an important cohort
of orthopaedic patients. Interest in FAI has intensified over the
last decade since its recognition as a precursor to arthritis of
the hip and the number of publications related to the topic has
increased exponentially in the last decade. Although not all patients
with abnormal hip morphology develop osteoarthritis (OA), those
with FAI-related joint damage rapidly develop premature OA. There
are no explicit diagnostic criteria or definitive indications for
surgical intervention in FAI. Surgery for symptomatic FAI appears
to be most effective in younger individuals who have not yet developed
irreversible OA. The difficulty in predicting prognosis in FAI means
that avoiding unnecessary surgery in asymptomatic individuals, while
undertaking intervention in those that are likely to develop premature
OA poses a considerable dilemma. FAI treatment in the past has focused
on open procedures that carry a potential risk of complications. Recent developments in hip arthroscopy have facilitated a minimally
invasive approach to the management of FAI with few complications
in expert hands. Acetabular labral preservation and repair appears
to provide superior results when compared with debridement alone.
Arthroscopic correction of structural abnormalities is increasingly becoming
the standard treatment for FAI, however there is a paucity of high-level
evidence comparing open and arthroscopic techniques in patients
with similar FAI morphology and degree of associated articular cartilage damage.
Further research is needed to develop an understanding of the natural
course of FAI, the definitive indications for surgery and the long-term
outcomes. Cite this article:
Total hip replacement (THR) after acetabular
fracture presents unique challenges to the orthopaedic surgeon.
The majority of patients can be treated with a standard THR, resulting
in a very reasonable outcome. Technical challenges however include
infection, residual pelvic deformity, acetabular bone loss with
ununited fractures, osteonecrosis of bone fragments, retained metalwork,
heterotopic ossification, dealing with the sciatic nerve, and the
difficulties of obtaining long-term acetabular component fixation.
Indications for an acute THR include young patients with both femoral
head and acetabular involvement with severe comminution that cannot
be reconstructed, and the elderly, with severe bony comminution.
The outcomes of THR for established post-traumatic arthritis include
excellent pain relief and functional improvements. The use of modern
implants and alternative bearing surfaces should improve outcomes
further. Cite this article:
To study the effect of hyaluronic acid (HA) on local anaesthetic
chondrotoxicity Chondrocytes were harvested from bovine femoral condyle cartilage
and isolated using collagenase-containing media. At 24 hours after
seeding 15 000 cells per well onto a 96-well plate, chondrocytes
were treated with media (DMEM/F12 + ITS), PBS, 1:1 lidocaine (2%):PBS,
1:1 bupivacaine (0.5%):PBS, 1:1 lidocaine (2%):HA, 1:1 bupivacaine (0.
5%):HA, or 1:1 HA:PBS for one hour. Following treatment, groups
had conditions removed and 24-hour incubation. Cell viability was
assessed using PrestoBlue and confirmed visually using fluorescence
microscopy.Objective
Methods
Smoking is known to have an adverse effect on wound healing and musculoskeletal conditions. This case-controlled study looked at whether smoking has a deleterious effect in the outcome of autologous chondrocyte implantation for the treatment of full thickness chondral defects of the knee. The mean Modified Cincinatti Knee score was statistically significantly lower in smokers (n = 48) than in non-smokers (n = 66) both before and after surgery (p <
0.05). Smokers experienced significantly less improvement in the knee score two years after surgery (p <
0.05). Graft failures were only seen in smokers (p = 0.016). There was a strong negative correlation between the number of cigarettes smoked and the outcome following surgery (Pearson’s correlation coefficient −0.65, p = 0.004). These results suggest that patients who smoke have worse pre-operative function and obtain less benefit from this procedure than non-smokers. The counselling of patients undergoing autologous chondrocyte implantation should include smoking, not only as a general cardiopulmonary risk but also because poorer results can be expected in smokers following this procedure.