Osteoarthritis (OA) is an important cause of
pain, disability and economic loss in humans, and is similarly important in
the horse. Recent knowledge on post-traumatic OA has suggested opportunities
for early intervention, but it is difficult to identify the appropriate
time of these interventions. The horse provides two useful mechanisms
to answer these questions: 1) extensive experience with clinical
OA in horses; and 2) use of a consistently predictable model of
OA that can help study early pathobiological events, define targets
for therapeutic intervention and then test these putative therapies.
This paper summarises the syndromes of clinical OA in horses including
pathogenesis, diagnosis and treatment, and details controlled studies
of various treatment options using an equine model of clinical OA.
The purpose of this study was to evaluate the
long-term functional and radiological outcomes of arthroscopic removal
of unstable osteochondral lesions with subchondral drilling in the
lateral femoral condyle. We reviewed the outcome of 23 patients
(28 knees) with stage III or IV osteochondritis dissecans lesions
of the lateral femoral condyle at a mean follow-up of 14 years (10
to 19). The functional clinical outcomes were assessed using the Lysholm
score, which improved from a mean of 38.1 ( We found radiological evidence of degenerative changes in the
third or fourth decade of life at a mean of 14 years after arthroscopic
excision of the loose body and subchondral drilling for an unstable
osteochondral lesion of the lateral femoral condyle. Clinical and
functional results were more satisfactory.
Low back injuries account for the greatest loss of playing time for professional fast bowlers in cricket. Previous radiological studies have shown a high prevalence of degeneration of the lumbar discs and stress injuries of the pars interarticularis in elite junior fast bowlers. We have examined MRI appearance of the lumbar spines of 36 asymptomatic professional fast bowlers and 17 active control subjects. The fast bowlers had a relatively high prevalence of multi-level degeneration of the lumbar discs and a unique pattern of stress lesions of the pars interarticularis on the non-dominant side. The systems which have been used to classify the MR appearance of the lumbar discs and pars were found to be reliable. However, the relationship between the radiological findings, pain and dysfunction remains unclear.
We describe a 23-year-old woman with neuritis ossificans involving the tibial, common peroneal and lateral sural nerves. She presented with chronic debilitating posterior knee pain. An MRI scan showed masses in these nerves, biopsy of which revealed a histological diagnosis of neuritis ossificans. Treatment with OxyContin and Neurotin for two years resulted in resolution of symptoms. Follow-up MRI demonstrated a resolution of two of the three masses. There was a persistent area of ossification without associated oedema in the common peroneal nerve. Neuritis ossificans has the histological appearance of myositis ossificans and follows a similar clinical course. The success of conservative treatment in this case suggests that the potential complications of surgical excision can be avoided.
Bone defects are occasionally encountered during
primary total knee replacement (TKR) and cause difficulty in establishing
a stable well-aligned bone-implant interface. Between March 1999
and November 2005, 59 knees in 43 patients underwent primary TKR
with a metal block augmentation for tibial bone deficiency. In all,
six patients (eight knees) died less than four years post-operatively,
and four patients (five knees) were lost to follow-up leaving 46 knees
in 33 patients available for review at a mean of 78.6 months (62
to 129). The clinical results obtained, including range of movement,
American Knee Society and Oxford knee scores, and the Western Ontario
and McMaster Universities osteoarthritis index, were good to excellent,
with no failures. Radiolucent lines at the block-cement-bone interface
were noted in five knees (11%) during the first post-operative year,
but these did not progress. Modular rectangular metal augmentation for tibial bone deficiency
is a useful option. No deterioration of the block-prosthesis or
block-cement-bone interface was seen at minimum of five years follow-up.
We retrospectively compared the outcome after
the treatment of giant cell tumours of bone either with curettage alone
or with adjuvant cementation. Between 1975 and 2008, 330 patients
with a giant cell tumour were treated primarily by intralesional
curettage, with 84 (25%) receiving adjuvant bone cement in the cavity.
The local recurrence rate for curettage alone was 29.7% (73 of 246)
compared with 14.3% (12 of 84) for curettage and cementation (p
= 0.001). On multivariate analysis both the stage of disease and
use of cement were independent significant factors associated with
local recurrence. The use of cement was associated with a higher
risk of the subsequent need for joint replacement. In patients without
local recurrence, 18.1% (13 of 72) of those with cement needed a
subsequent joint replacement compared to 2.3% (4 of 173) of those
without cement (p = 0.001). In patients who developed local recurrence,
75.0% (9 of 12) of those with previous cementation required a joint
replacement, compared with 45.2% (33 of 73) of those without cement
(p = 0.044).
The purpose of this study was to report the outcome
of ‘isolated’ anterior cruciate ligament (ACL) ruptures treated with
anatomical endoscopic reconstruction using hamstring tendon autograft
at a mean of 15 years (14.25 to 16.9). A total of 100 consecutive
men and 100 consecutive women with ‘isolated’ ACL rupture underwent
four-strand hamstring tendon reconstruction with anteromedial portal
femoral tunnel drilling and interference screw fixation by a single
surgeon. Details were recorded pre-operatively and at one, two,
seven and 15 years post-operatively. Outcomes included clinical
examination, subjective and objective scoring systems, and radiological
assessment. At 15 years only eight of 118 patients (7%) had moderate
or severe osteo-arthritic changes (International Knee Documentation
Committee Grades C and D), and 79 of 152 patients (52%) still performed
very strenuous activities. Overall graft survival at 15 years was
83% (1.1% failure per year). Patients aged <
18 years at the
time of surgery and patients with >
2 mm of laxity at one year had
a threefold increase in the risk of suffering a rupture of the graft
(p = 0.002 and p = 0.001, respectively). There was no increase in
laxity of the graft over time. ACL reconstructive surgery in patients with an ‘isolated’ rupture
using this technique shows good results 15 years post-operatively
with respect to ligamentous stability, objective and subjective
outcomes, and does not appear to cause osteoarthritis.
We evaluated the long-term outcome of isolated endoscopically-assisted posterior cruciate ligament reconstruction in 26 patients using hamstring tendon autografts after failure of conservative management. At ten years after surgery the mean International Knee Documentation Committee subjective knee score was 87 ( At ten years endoscopic reconstruction of the posterior cruciate ligament with hamstring tendon autograft is effective in reducing knee symptoms. Of the series, 22 patients underwent radiological assessment for the development of osteoarthritis using the Kellgren-Lawrence grading scale. In four patients, grade 2 changes with loss of joint space was observed and another four patients showed osteophyte formation with moderate joint space narrowing (grade 3). These findings compared favourably with non-operatively managed injuries of the posterior cruciate ligament. This procedure for symptomatic patients with posterior cruciate ligament laxity who have failed conservative management offers good results.
This review discusses the pathogenesis and surgical treatment of tears of the rotator cuff.
We performed a comprehensive systematic review of the literature to examine the role of hemiarthroplasty in the early management of fractures of the proximal humerus. In all, 16 studies dealing with 810 hemiarthroplasties in 808 patients with a mean age of 67.7 years (22 to 91) and a mean follow-up of 3.7 years (0.66 to 14) met the inclusion criteria. Most of the fractures were four-part fractures or fracture-dislocations. Several types of prosthesis were used. Early passive movement on the day after surgery and active movement after union of the tuberosities at about six weeks was described in most cases. The mean active anterior elevation was to 105.7° (10° to 180°) and the mean abduction to 92.4° (15° to 170°). The incidence of superficial and deep infection was 1.55% and 0.64%, respectively. Complications related to the fixation and healing of the tuberosities were observed in 86 of 771 cases (11.15%). The estimated incidence of heterotopic ossification was 8.8% and that of proximal migration of the humeral head 6.8%. The mean Constant score was 56.63 (11 to 98). At the final follow-up, no pain or only mild pain was experienced by most patients, but marked limitation of function persisted.
We attempted to characterise the biological quality
and regenerative potential of chondrocytes in osteochondritis dissecans
(OCD). Dissected fragments from ten patients with OCD of the knee
(mean age 27.8 years (16 to 49)) were harvested at arthroscopy.
A sample of cartilage from the intercondylar notch was taken from
the same joint and from the notch of ten patients with a traumatic
cartilage defect (mean age 31.6 years (19 to 52)). Chondrocytes
were extracted and subsequently cultured. Collagen types 1, 2, and
10 mRNA were quantified by polymerase chain reaction. Compared with
the notch chondrocytes, cells from the dissecate expressed similar
levels of collagen types 1 and 2 mRNA. The level of collagen type
10 message was 50 times lower after cell culture, indicating a loss
of hypertrophic cells or genes. The high viability, retained capacity
to differentiate and metabolic activity of the extracted cells suggests
preservation of the intrinsic repair capability of these dissecates.
Molecular analysis indicated a phenotypic modulation of the expanded
dissecate chondrocytes towards a normal phenotype. Our findings
suggest that cartilage taken from the dissecate can be reasonably
used as a cell source for chondrocyte implantation procedures.
We investigated the eventual diagnosis in patients referred to a tertiary centre with a possible diagnosis of a primary bone malignancy. We reviewed our database from between 1986 and 2010, during which time 5922 patients referred with a suspicious bone lesion had a confirmed diagnosis. This included bone sarcoma in 2205 patients (37%), benign bone tumour in 1309 (22%), orthopaedic conditions in 992 (17%), metastatic disease in 533 (9%), infection in 289 (5%) and haematological disease in 303 (5%). There was a similar frequency of all diagnoses at different ages except for metastatic disease. Only 0.6% of patients (17 of 2913) under the age of 35 years had metastatic disease compared with 17.1% (516 of 3009) of those over 35 years (p <
0.0001). Of the 17 patients under 35 years with metastatic disease, only four presented with an isolated lesion, had no past history of cancer and were systematically well. Patients under the age of 35 years should have suitable focal imaging (plain radiography, CT or MRI) and simple systemic studies (blood tests and chest radiography). Reduction of the time to biopsy can be achieved by avoiding an unnecessary investigation for a primary tumour to rule out metastatic disease.
The direct anterior approach in total hip replacement anatomically offers the chance to minimise soft-tissue trauma because an intermuscular and internervous plane is explored. This motivated us to abandon our previously used transgluteal approach and to adopt the direct anterior approach for total hip replacement. Using MRI, we performed a retrospective comparative study of the direct anterior approach with the transgluteal approach. There were 25 patients in each group. At one year post-operatively all the patients underwent MRI of their replaced hips. A radiologist graded the changes in the soft-tissue signals in the abductor muscles. The groups were similar in terms of age, gender, body mass index, complexity of the reconstruction and absence of symptoms. Detachment of the abductor insertion, partial tears and tendonitis of gluteus medius and minimus, the presence of peri-trochanteric bursal fluid and fatty atrophy of gluteus medius and minimus were significantly less pronounced and less frequent when the direct anterior approach was used. There was no significant difference in the findings regarding tensor fascia lata between the two approaches. We conclude that use of the direct anterior approach results in a better soft-tissue response as assessed by MRI after total hip replacement. However, the impact on outcome needs to be evaluated further.
We undertook a prospective study to analyse the
outcome of 48 malunited pronation-external rotation fractures of the
ankle in 48 patients (25 females and 23 males) with a mean age of
45 years (21 to 69), treated by realignment osteotomies. The interval
between the injury and reconstruction was a mean of 20.2 months
(3 to 98). In all patients, valgus malalignment of the distal tibia and
malunion of the fibula were corrected. In some patients, additional
osteotomies were performed. Patients were reviewed regularly, and
the mean follow-up was 7.1 years (2 to 15). Good or excellent results were obtained in 42 patients (87.5%)
with the benefit being maintained over time. Congruent ankles without
a tilted talus (Takakura stage 0 and 1) were obtained in all but
five cases. One patient required total ankle replacement.
Abnormal knee kinematics following reconstruction
of the anterior cruciate ligament may exist despite an apparent resolution
of tibial laxity and functional benefit. We performed upright, weight-bearing
MR scans of both knees in the sagittal plane at different angles
of flexion to determine the kinematics of the knee following unilateral reconstruction
(n = 12). The uninjured knee acted as a control. Scans were performed
pre-operatively and at three and six months post-operatively. Anteroposterior
tibial laxity was determined using an arthrometer and patient function
by validated questionnaires before and after reconstruction. In
all the knees with deficient anterior cruciate ligaments, the tibial
plateau was displaced anteriorly and internally rotated relative
to the femur when compared with the control contralateral knee,
particularly in extension and early flexion (mean lateral compartment displacement:
extension 7.9 mm ( Our results show that despite improvement in laxity and functional
benefit, abnormal knee kinematics remain at six months and actually
deteriorate from three to six months following reconstruction of
the anterior cruciate ligament.
We reviewed 234 benign solitary schwannomas treated between 1984 and 2004. The mean age of the patients was 45.2 years (11 to 82). There were 170 tumours (73%) in the upper limb, of which 94 (40%) arose from the brachial plexus or other nerves within the posterior triangle of the neck. Six (2.6%) were located within muscle or bone. Four patients (1.7%) presented with tetraparesis due to an intraspinal extension. There were 198 primary referrals (19 of whom had a needle biopsy in the referring unit) and in these patients the tumour was excised. After having surgery or an open biopsy at another hospital, a further 36 patients were seen because of increased neurological deficit, pain or incomplete excision. In these, a nerve repair was performed in 18 and treatment for pain or paralysis was offered to another 14. A tender mass was found in 194 (98%) of the primary referrals. A Tinel-like sign was recorded in 155 (81%). Persistent spontaneous pain occurred in 60 (31%) of the 194 with tender mass, impairment of cutaneous sensibility in 39 (20%), and muscle weakness in 24 (12%). After apparently adequate excision, two tumours recurred. No case of malignant transformation was seen.
Over recent years hip arthroscopic surgery has
evolved into one of the most rapidly expanding fields in orthopaedic surgery.
Complications are largely transient and incidences between 0.5%
and 6.4% have been reported. However, major complications can and
do occur. This article analyses the reported complications and makes recommendations
based on the literature review and personal experience on how to
minimise them.
Genu varum in the achondroplastic patient has a complex and multifactorial aetiology. There is little mention in the literature of the role of fibular overgrowth. Using the ratio of fibular to tibial length as a measurement of possible fibular overgrowth, we have related it to the development of genu varum. Full-length standing anteroposterior radiographs of 53 patients with achondroplasia were analysed. There were 30 skeletally-immature and 23 skeletally-mature patients. Regression analysis was performed in order to determine if there was a causal relationship between fibular overgrowth and the various indices of alignment of the lower limb. Analysis showed that the fibular to tibial length ratio had a significant correlation with the medial proximal tibial angle and the mechanical axial deviation in the skeletally-immature group. We conclude that there is a significant relationship between fibular overgrowth and the development of genu varum in the skeletally-immature achondroplastic patient.
This study reports the application of a novel method for quantitatively determining differences in the mechanical properties of healthy and torn rotator cuff tissues. In order to overcome problems of stress risers at the grip-tendon interface that can obscure mechanical measurements of small tendons, we conducted our investigation using dynamic shear analysis. Rotator cuff tendon specimens were obtained from 100 patients during shoulder surgery. They included 82 differently sized tears and 18 matched controls. We subjected biopsy samples of 3 mm in diameter to oscillatory deformation under compression using dynamic shear analysis. The storage modulus (G’) was calculated as an indicator of mechanical integrity. Normal tendons had a significantly higher storage modulus than torn tendons, indicating that torn tendons are mechanically weaker than normal tendons (p = 0.003). Normal tendons had a significantly higher mean shear modulus than tendons with massive tears (p <
0.01). Dynamic shear analysis allows the determination of shear mechanical properties of small tissue specimens obtained intra-operatively that could not be studied by conventional methods of tensile testing. These methods could be employed to investigate other musculoskeletal tissues. This pilot study provides some insight into mechanisms that might contribute to the failure of repair surgery, and with future application could help direct the most appropriate treatment for specific rotator cuff tears.