Aims

Periprosthetic joint infection (PJI) is a debilitating condition with a substantial socioeconomic burden. A novel autologous blood glue (ABG) has been developed, which can be prepared during surgery and sprayed onto prostheses at the time of implantation. The ABG can potentially provide an antimicrobial coating which will be effective in preventing PJI, not only by providing a physical barrier but also by eluting a well-known antibiotic. Hence, this study aimed to assess the antimicrobial effectiveness of ABG when impregnated with gentamicin and stem cells.

We split 100 porcine flexor tendons into five groups of 20 tendons for repair. Three groups were repaired using the Pennington modified Kessler technique, the cruciate or the Savage technique, one using one new device per tendon and the other with two new devices per tendon. Half of the tendons received supplemental circumferential Silfverskiöld type B cross-stitch. The repairs were loaded to failure and a record made of their bulk, the force required to produce a 3 mm gap, the maximum force applied before failure and the stiffness. When only one device was used repairs were equivalent to the Pennington modified Kessler for all parameters except the force to produce a 3 mm gap when supplemented with a circumferential repair, which was equivalent to the cruciate. When two devices were used the repair strength was equivalent to the cruciate repair, and when the two-device repair was supplemented with a circumferential suture the force to produce a 3 mm gap was equivalent to that of the Savage six-strand technique

Aims

Preoperative talar valgus deformity ≥ 15° is considered a contraindication for total ankle arthroplasty (TAA). We compared operative procedures and clinical outcomes of TAA in patients with talar valgus deformity ≥ 15° and < 15°.

We studied 57 patients with isolated lunotriquetral injuries treated by arthrodesis, direct ligament repair, or ligament reconstruction. The outcomes were compared by using written questionnaires, the Disabilities of the Arm, Shoulder and Hand (DASH) score, range of movement, strength, morbidity and rates of reoperation. Isolated lunotriquetral injury was confirmed by arthroscopy or arthrotomy. The mean age of the patients was 30.7 years (15.4 to 53.7) and the injuries were subacute or chronic in 98.2%. Eight patients underwent lunotriquetral reconstruction using a distally-based strip of the tendon of extensor carpi ulnaris, 27 had lunotriquetral repair and 22 had lunotriquetral arthrodesis. The mean follow-up was 9.5 years (2 to 22). The probability of remaining free from complications at five years was 68.6% for reconstruction, 13.5% for repair, and less than 1% for arthrodesis. Of the lunotriquetral arthrodeses, 40.9% developed nonunion and 22.7% developed ulnocarpal impaction. The probability of not requiring further surgery at five years was 68.6% for reconstruction, 23.3% for repair and 21.8% for arthrodesis. The DASH scores for each group were not significantly different. Objective improvements in strength and movement, subjective indicators of pain relief and satisfaction were significantly higher in the lunotriquetral repair and reconstruction groups than in those undergoing arthrodesis

We used a biodegradable mesh to convert an acetabular defect into a contained defect in six patients at total hip replacement. Their mean age was 61 years (46 to 69). The mean follow-up was 32 months (19 to 50). Before clinical use, the strength retention and hydrolytic in vitro degradation properties of the implants were studied in the laboratory over a two-year period. A successful clinical outcome was determined by the radiological findings and the Harris hip score. All the patients had a satisfactory outcome and no mechanical failures or other complications were observed. No protrusion of any of the impacted grafts was observed beyond the mesh. According to our preliminary laboratory and clinical results the biodegradable mesh is suitable for augmenting uncontained acetabular defects in which the primary stability of the implanted acetabular component is provided by the host bone. In the case of defects of the acetabular floor this new application provides a safe method of preventing graft material from protruding excessively into the pelvis and the mesh seems to tolerate bone-impaction grafting in selected patients with primary and revision total hip replacement

The intermittent administration of parathyroid hormone (PTH) increases the formation of bone by stimulating osteoblastic activity. Our study evaluates the possibility that intermittent treatment with PTH (1-34) may also enhance the implant-bone fixation of stainless-steel screws. Twenty-eight rats received one screw in either one (n = 8) or in both (n = 20) proximal tibiae. We administered either PTH (1-34) in a dosage of 60 μg/kg/day (n = 14) or vehicle (n = 14) over a period of four weeks. At the end of this time, the degree of fixation was assessed by measuring the removal torque on one screw in each rat (n = 28) and the pull-out strength on the contralateral screw (n = 20). PTH increased the mean removal torque from 1.1 to 3.5 Ncm (p = 0.001) and the mean pull-out strength from 66 to 145 N (p = 0.002). No significant differences in body-weight or ash weight of the femora were seen. Histological examination showed that both groups had areas of soft tissue at the implant-bone interface, but these appeared less in the PTH group. These results indicate that intermittent treatment with PTH may enhance the early fixation of orthopaedic implants

Our aim was to analyse the effect of avascularity on the morphology and mechanical properties (tensile strength, viscoelasticity) of human bone-patellar-tendon-bone (BPTB) grafts in vitro. These were harvested at postmortem and stored submerged in denaturated human plasma at a constant pH, pO. 2. , pCO. 2. , temperature and humidity under sterile conditions. Mechanical testing was performed two and four weeks after removal of the graft. The mean ultimate strength was 1085.7 ± 255.8 N (control), 1009.0 ± 314.9 N (two weeks cultured) and 1076.8 ± 414.8 N (four weeks cultured). There was no significant difference in linear stiffness or deformation to failure between the groups. There was a difference in viscoelasticity between the control group and the avascular grafts and the latter had significant lower peak load-to-load ratios after 15 minutes compared with the control group. After two and four weeks the graft contained viable fibroblasts. There was regular cellularity in the superficial layers and decreased cellularity in the midportion. The structure of the collagen including the crimp pattern appeared to be normal in polarised light. We conclude that avascularity does not significantly affect ultimate failure loads or stiffness of BPTB grafts. Slight changes in viscoelasticity were induced, but the significance of the increased stress relaxation is not fully understood

A total of 20 pairs of fresh-frozen cadaver femurs were assigned to four alignment groups consisting of relative varus (10° and 20°) and relative valgus (10° and 20°), 75 composite femurs of two neck geometries were also used. In both the cadaver and the composite femurs, placing the component in 20° of valgus resulted in a significant increase in load to failure. Placing the component in 10° of valgus had no appreciable effect on increasing the load to failure except in the composite femurs with varus native femoral necks. Specimens in 10° of varus were significantly weaker than the neutrally-aligned specimens. The results suggest that retention of the intact proximal femoral strength occurs at an implant angulation of ≥ 142°. However, the benefit of extreme valgus alignment may be outweighed in clinical practice by the risk of superior femoral neck notching, which was avoided in this study

We reviewed 23 patients who had had 25 Darrach procedures for traumatic or post-traumatic disorders of the wrist at a mean follow-up of 75.5 months (36 to 121). The mean age at the time of operation was 61.1 years (34 to 82). All patients were reviewed in person. Assessment included a history, a questionnaire on patient satisfaction and a detailed physical examination. Standardised radiographs of both wrists were taken with the patient’s hands in a resting position and during maximal grip. Convergence of the distal ulnar stump towards the distal radius during maximal grip (dynamic radio-ulnar convergence) was seen in 14 wrists including five with actual contact (dynamic radio-ulnar impingement), but this produced symptoms in only two cases. The presence of dynamic radio-ulnar convergence did not correlate with grip strength, pinch strength, range of movement or wrist score, but was associated with increased length of excision of the distal ulna. Nineteen of the 23 patients were satisfied with the procedure. Dynamic radio-ulnar convergence is common after the Darrach procedure, but is rarely symptomatic; resection of the distal ulna remains a reliable procedure in the older patient with pain and loss of movement. Excision of the lower end of the ulna should be restricted to the least required to restore full rotation

Aims

The James Lind Alliance aims to bring patients, carers, and clinicians together to identify uncertainties regarding care. A Priority Setting Partnership was established by the British Association for Surgery of the Knee in conjunction with the James Lind Alliance to identify research priorities related to the assessment, management, and rehabilitation of patients with persistent symptoms after knee arthroplasty.

Forty-two consecutive patients with suspected lumbar disc protrusions were studied prospectively to compare the diagnostic accuracy of low-field strength MRI with that of radiculography. Thirty patients subsequently underwent surgical exploration at 33 levels and the operative findings were compared to both methods of diagnostic imaging. All patients had MRI studies, whilst 29 patients also had radiculography. Both studies were evaluated without prior knowledge of the clinical signs, operative findings or the results of other imaging techniques. MRI predicted the correct diagnosis in 29 of the 33 levels explored, an accuracy of 88%. All discs proven to be abnormal demonstrated a reduced signal from the nucleus pulposus. There were two false positive results and two doubtful cases but no false negatives. Radiculography predicted the correct diagnosis in 24 of 32 levels explored, an accuracy of 75%. There were two false positive results, five doubtfuls and one false negative. The overall accuracy when both tests were considered rose to 94%. Of the remaining 12 patients all except one showed good correlation between the MRI and radiculographic findings. These results indicate that low field strength MRI is slightly better than radiculography in diagnosing lumbar disc protrusions

Aims

Perthes’ disease is a condition which leads to necrosis of the femoral head. It is most commonly reported in children aged four to nine years, with recent statistics suggesting it affects around five per 100,000 children in the UK. Current treatment for the condition aims to maintain the best possible environment for the disease process to run its natural course. Management typically includes physiotherapy with or without surgical intervention. Physiotherapy intervention often will include strengthening/stretching programmes, exercise/activity advice, and, in some centres, will include intervention, such as hydrotherapy. There is significant variation in care with no consensus on which treatment option is best. The importance of work in this area has been demonstrated by the British Society for Children’s Orthopaedic Surgery through the James Lind Alliance’s prioritization of work to determine/identify surgical versus non-surgical management of Perthes’ disease. It was identified as the fourth-highest priority for paediatric lower limb surgery research in 2018.

In a rabbit model we investigated the efficacy of a silk fibroin/hydroxyapatite (SF/HA) composite on the repair of a segmental bone defect. Four types of porous SF/HA composites (SF/HA-1, SF/HA-2, SF/HA-3, SF/HA-4) with different material ratios, pore sizes, porosity and additives were implanted subcutaneously into Sprague-Dawley rats to observe biodegradation. SF/HA-3, which had characteristics more suitable for a bone substitite based on strength and resorption was selected as a scaffold and co-cultured with rabbit bone-marrow stromal cells (BMSCs). A segmental bone defect was created in the rabbit radius. The animals were randomised into group 1 (SF/HA-3 combined with BMSCs implanted into the bone defect), group 2 (SF/HA implanted alone) and group 3 (nothing implanted). They were killed at four, eight and 12 weeks for visual, radiological and histological study. The bone defects had complete union for group 1 and partial union in group 2, 12 weeks after operation. There was no formation of new bone in group 3. We conclude that SF/HA-3 combined with BMSCs supports bone healing and offers potential as a bone-graft substitute

We investigated the effect of mitomycin-C on the reduction of the formation of peritendinous fibrous adhesions after tendon repair. In 20 Wistar albino rats the tendo Achillis was cut and repaired using a modified Kessler technique. The rats were divided into two equal groups. In group 1, an injection of mitomycin-C was placed between the tendon and skin of the right leg. In group 2, an identical volume of sterile normal saline was injected on the left side in a similar fashion. All the rats received mitomycin-C or saline for four weeks starting from the day of operation. The animals were killed after 30 days. The formation of peritendinous fibrous tissue, the inflammatory reaction and tendon healing were evaluated. The tensile strength of the repaired tendons was measured biomechanically. Microscopic evidence of the formation of adhesions and inflammation was less in group 1. There was no significant difference in the tensile load required to rupture the repaired tendons in the two groups. Mitomycin-C may therefore provide a simple and inexpensive means of preventing of post-operative adhesions

We performed a biomechanical and histological study to clarify the effect of stress enhancement on the in situ frozen-thawed patellar tendon of the rabbit as a tendon autograft model. We used 48 Japanese White rabbits divided into three groups. In group 1, the patellar tendon underwent in situ freeze-thaw treatment with liquid nitrogen to kill intrinsic fibroblasts. In group 2, after similar treatment, the medial and lateral portions were resected so that the cross-sectional area was reduced by a third. In group 3, after treatment, the cross-sectional area was reduced by a half. In groups 2 and 3, the stress in the tendon was calculated theoretically to be 150% and 200% of the physiological stress during locomotion. Eight rabbits in each group were killed at three and six weeks, respectively. At three weeks, the mean values for the tensile strength of groups 2 and 3 were 113.7% and 75.7% of that of group 1, and at six weeks 101.2% and 57.4%, respectively. The tensile strength in group 3 was significantly lower than that in groups 1 and 2. The histological findings in group 2 were similar to those in group 1, although an acellular area appeared to be wider in the core portion compared with group 1 at each period. In group 3, the collagen bundles of the tendon were less organised than those of groups 1 and 2. Our findings showed that stress enhancement affects the remodelling of the frozen-thawed patellar tendon and that excessively high stress reduces the mechanical properties of the tendon. This indicates that high stress on the patellar tendon autograft should be avoided during ligament reconstruction

Aims

To assess if congenital foot deformity is a risk factor for developmental dysplasia of the hip (DDH).

Aims

Vitamin E-infused highly cross-linked polyethylene (E1) has recently been introduced in total knee arthroplasty (TKA). An in vitro wear simulator study showed that E1 reduced polyethylene wear. However there is no published information regarding in vivo wear. Previous reports suggest that newly introduced materials which reduce in vitro polyethylene wear do not necessarily reduce in vivo polyethylene wear. To assist in the evaluation of the newly introduced material before widespread use, we established an in vivo polyethylene wear particle analysis for TKA. The aim of this study was to compare in vivo polyethylene wear particle generation between E1 and conventional polyethylene (ArCom) in TKA.

Aims

The purpose of this study was to: review the efficacy of the induced membrane technique (IMT), also known as the Masquelet technique; and investigate the relationship between patient factors and technique variations on the outcomes of the IMT.

Background

Due to the overwhelming demand for trauma services, resulting from increasing emergency department attendances over the past decade, virtual fracture clinics (VFCs) have become the fashion to keep up with the demand and help comply with the BOA Standards for Trauma and Orthopaedics (BOAST) guidelines. In this article, we perform a systematic review asking, “How useful are VFCs?”, and what injuries and conditions can be treated safely and effectively, to help decrease patient face to face consultations. Our primary outcomes were patient satisfaction, clinical efficiency and cost analysis, and clinical outcomes.