The management of symptomatic osteochondral lesions of the talus (OLTs) can be challenging. The number of ways of treating these lesions has increased considerably during the last decade, with published studies often providing conflicting, low-level evidence. This paper aims to present an up-to-date concise overview of the best evidence for the surgical treatment of OLTs. Management options are reviewed based on the size of the lesion and include bone marrow stimulation, bone grafting options, drilling techniques, biological preparations, and resurfacing. Although many of these techniques have shown promising results, there remains little high level evidence, and further large scale prospective studies and systematic reviews will be required to identify the optimal form of treatment for these lesions.

Cite this article: Bone Joint J 2021;103-B(2):207–212.

Aims

Periprosthetic joint infections (PJIs) and osteomyelitis are clinical challenges that are difficult to eradicate. Well-characterized large animal models necessary for testing and validating new treatment strategies for these conditions are lacking. The purpose of this study was to develop a rabbit model of chronic PJI in the distal femur.

We have reviewed 12 cases of fracture-separation of the distal humeral epiphysis, three of which were initially misdiagnosed as fractures of the lateral condyle and one as an elbow dislocation. Cubitus varus deformity is as common after this fracture-separation as it is following supracondylar fracture, and is most common in children under two years of age. Closed reduction and simple immobilisation is adequate for the older child, but we recommend for those under two years of age that closed reduction should be followed by percutaneous pinning, so that the carrying angle can be assessed immediately after reduction. If the elbow is then in varus the wires should be removed, reduction repeated and treatment by straight lateral traction used to maintain a valgus carrying angle

Aims

Total knee arthroplasty (TKA) using functional alignment aims to implant the components with minimal compromise of the soft-tissue envelope by restoring the plane and obliquity of the non-arthritic joint. The objective of this study was to determine the effect of TKA with functional alignment on mediolateral soft-tissue balance as assessed using intraoperative sensor-guided technology.

A prospective randomised clinical trial was undertaken to compare biodegradable polyglycolic acid pins with standard Kirschner wires used to fix displaced elbow fractures in children. Twenty-four children were enrolled in the trial; 14 had fractures of the lateral condyle of the humerus, eight of the medial epicondyle and two had olecranon fractures. Eleven fractures were fixed with Kirschner wires and 13 with polyglycolic acid pins. Fracture union with full function occurred in all cases within six months. Kirschner wires caused problems including infection in three cases, soft-tissue ossification in one and they required removal under general anaesthesia in nine cases. No such complications occurred with polyglycolic acid pins but one patient in this group developed avascular necrosis and premature fusion of the medial epicondyle

From an anatomical study and clinical review of fractures of the lateral humeral condyle in children, the following conclusions are drawn. The mechanism of injury is a violent varus force with the elbow in extension, the condyle being avulsed. by the lateral ligament and the extensor muscles. If the fracture is incomplete, with an intact hinge of pre-osseous cartilage medially, the fragment will not be displaced. If the fracture is complete the fragment may be displaced, and open reduction with internal fixation is mandatory. The results of open reduction more than three weeks after the fracture are no better than those of no treatment at all, and may kill the lateral condylar fragment by damaging its blood supply. The major problem of a neglected fracture is tardy ulnar nerve palsy; to avoid this, immediate anterior transposition of the nerve is recommended, operation for the fracture itself being of no benefit

Upper limb amputations, ranging from transhumeral to partial hand, can be devastating for patients, their families, and society. Modern paradigm shifts have focused on reconstructive options after upper extremity limb loss, rather than considering the amputation an ablative procedure. Surgical advancements such as targeted muscle reinnervation and regenerative peripheral nerve interface, in combination with technological development of modern prosthetics, have expanded options for patients after amputation. In the near future, advances such as osseointegration, implantable myoelectric sensors, and implantable nerve cuffs may become more widely used and may expand the options for prosthetic integration, myoelectric signal detection, and restoration of sensation. This review summarizes the current advancements in surgical techniques and prosthetics for upper limb amputees.

Cite this article: Bone Joint J 2021;103-B(3):430–439.

Unlike hyaline cartilage, mandibular condylar cartilage can respond to injury by complete healing. We have used the reparative potential of mandibular cartilage to promote repair of defects in a hyaline cartilage joint surface. In 12 adult marmosets, articular fibrocartilage from the mandibular condyles was transplanted into full-thickness defects created in the femoral condyles. Additional defects acted as an ungrafted control group. The grafted defects showed good incorporation of the transplant with restoration of the articular surface within six months. Repair was by proliferation of the fibrocartilaginous graft and chondrogenesis of hyaline cartilage. The repopulating cells were distributed in a matrix of maturing collagen and sulphated glycosaminoglycans. Ungrafted control defects were only partly repaired with fibrous tissue, leaving articular deficiencies. We conclude that transplanted mandibular fibrocartilage can promote reconstitution of wounded hyaline cartilage joint surfaces in primates

We have studied 27 tibial prostheses retrieved from knee replacements after 1 to 9 years. In 22 the femoral components were of cobalt-chrome, in five polyacetal. The design of the components gave a nominal contact area of 320 mm2 on each condyle. The tibial component was of high-density polyethylene (HDP) at least 6 mm thick, and not heat-treated. In the metal/HDP prostheses the average wear rate was 0.025 mm/year. The relative wear on the medial and lateral sides was related to the leg axis. None of the retrieved prostheses showed any severe disruption of their surface. The polyacetal/HDP prostheses showed similar wear with a statistically insignificant trend towards slower penetration. We conclude that the rate of wear of HDP in a conforming tibiofemoral bearing with a fixed tibial component at least 6 mm thick and not heat-treated is slow enough to be safe in clinical practice

1. Sixty-eight crush fractures of the articular surface of the lateral tibial condyle have been analysed. 2. Follow-up examination at a minimum of three years after injury was carried out in all cases. 3. The only factors which appeared to influence the results were the extent of the original depression, and if this was severe, the degree of restoration obtained by the treatment. Prolonged plaster fixation was avoided. 4. At review, no patient complained of symptoms which were attributable to damage to ligaments or menisci and no patient had symptoms of late onset. 5. The results suggest that there is nothing to be gained by open reduction if the lateral condyle is depressed by less than 10 millimetres, as conservative treatment gives good results. If the depression is more severe, however, a good result can only be assured if the articular surface is successfully reconstituted, but this is sometimes difficult to achieve. It is not possible to reconstitute the surface by non-operative means

1. The movements of flexion and extension at the knee joint take place above the menisci; the movements of rotation take place below the menisci. 2. The popliteus muscle consists of two halves, one being attached by tendon to the femur, the other by aponeurosis to the lateral meniscus. The action of the muscle is to rotate the knee and retract the posterior arch of the lateral meniscus. The flexing action of the muscle is quite negligible. 3. The effects of rotation of the knee joint on the two menisci are dissimilar. The medial meniscus is distorted during rotation; its horns move with the tibia, but the intervening arch moves with the femur, and the distortion renders it liable to injury during rotation. The lateral meniscus does not become distorted during rotation; it follows the lateral condyle of the femur by reason of the attachments of the ligaments of Humphry and Wrisberg and the popliteus muscle. It is thus relatively immune from injury daring rotation

This is a prospective study of 105 knees in 91 patients with idiopathic osteonecrosis of the femoral condyles, with an average follow-up of five years in 101 knees. Forty-eight of the 75 patients in whom the body weight was studied were obese and four of the 33 patients in whom a densitometry study was done showed decreased bone density. Prognosis is unfavourable if the lesion is larger than five square centimetres and if its width is more than 40 per cent of that of the condyle. Of the 22 patients followed up after conservative treatment 80 per cent were satisfactory. Of the 11 knees treated by arthrotomy alone 55 per cent were satisfactory. Of the 31 knees treated by osteotomy (21 with associated arthrotomy) 87 per cent were satisfactory. Arthrotomy did not significantly improve the results of osteotomies. The ideal correction was to 10 degrees of valgus. Of the 37 knees treated with replacement 95 per cent were satisfactory, and the best results were obtained with the total-condylar prosthesis

We carried out weight-bearing video radiological studies on 40 patients with a total knee arthroplasty (TKA), to determine the presence and magnitude of femoral condylar lift-off. Half (20) had posterior-cruciate-retaining (PCR) and half (20) posterior-cruciate-substituting (PS) prostheses. The selected patients had successful arthroplasties with no pain or instability. Each carried out successive weight-bearing knee bends to maximum flexion, and the radiological video tapes were analysed using an interactive model-fitting technique. Femoral lift-off was seen at some increment of knee flexion in 75% of patients (PCR TKA 70%; PS TKA 80%). The mean values for lift-off were 1.2 mm with a PCR TKA and 1.4 mm with a PS TKA. Lift-off occurred mostly laterally with the PCR TKA, and both medially and laterally with the PS TKA. Separation between the femoral condyles and the articular surface of the tibia was recorded at 0°, 30°, 60° and 90° of flexion. Femoral condylar lift-off may contribute to eccentric polyethylene wear, particularly in designs of TKA which have flatter condyles. Coronal conformity is an important consideration in the design of a TKA

Introduction

In response to the COVID-19 pandemic, there was a rapidly implemented restructuring of UK healthcare services. The The Royal National Orthopaedic Hospital, Stanmore, became a central hub for the provision of trauma services for North Central/East London (NCEL) while providing a musculoskeletal tumour service for the south of England, the Midlands, and Wales and an urgent spinal service for London. This study reviews our paediatric practice over this period in order to share our experience and lessons learned. Our hospital admission pathways are described and the safety of surgical and interventional radiological procedures performed under general anaesthesia (GA) with regards to COVID-19 in a paediatric population are evaluated.

Aims

Modern total knee arthroplasty (TKA) prostheses are designed to restore near normal kinematics including high flexion. Kneeling is a high flexion, kinematically demanding activity after TKA. The debate about design choice has not yet been informed by six-degrees-of-freedom in vivo kinematics. This prospective randomized clinical trial compared kneeling kinematics in three TKA designs.

Aims

Fibrinolysis plays a key transition step from haematoma formation to angiogenesis and fracture healing. Low-magnitude high-frequency vibration (LMHFV) is a non-invasive biophysical modality proven to enhance fibrinolytic factors. This study investigates the effect of LMHFV on fibrinolysis in a clinically relevant animal model to accelerate osteoporotic fracture healing.

Aims

To compare patients undergoing total knee arthroplasty (TKA) with ≤ 80° range of movement (ROM) operated with a 2 mm increase in the flexion gap with matched non-stiff patients with at least 100° of preoperative ROM and balanced flexion and extension gaps.

Foreign-body reaction to polyglycolide (PGA) implants has been described in man. Many animal experiments have verified the mechanical properties of fixation devices made from PGA, but a significant foreign-body reaction has not been described. We studied the effect of PGA rods in 12 sheep with standardized osteochondral fractures of the medial femoral condyle fixed with uncoloured, self-reinforced PGA rods (Biofix). Radiographs were taken at intervals ranging from two weeks to two years, and the sheep were killed at intervals ranging from six to 24 months. All knees were examined histologically. Eleven of the 12 fractures healed radiologically and histologically. Moderate to severe osteolysis was seen at four to six weeks with maximum changes at 12 weeks in ten animals. Six knees showed fistula-like connections between the implant site and the joint space. Three developed synovitis, one with inflammatory changes involving the whole cartilage and one with destruction of the medial condyle. Although in our study osteochondral fractures fixed with PGA rods healed reliably, there were frequent, significant foreign-body reactions. Caution is needed when considering the use of PGA fixation devices in vulnerable regions such as the knee

Aims

This study aimed to evaluate the association between the sagittal alignment of the femoral component in total knee arthroplasty (TKA) and new Knee Society Score (2011KSS), under the hypothesis that outliers such as the excessive extended or flexed femoral component were related to worse clinical outcomes.

Aims

It remains controversial whether patellofemoral joint pathology is a contraindication to lateral unicompartmental knee arthroplasty (UKA). This study aimed to evaluate the effect of preoperative radiological degenerative changes and alignment on patient-reported outcome scores (PROMs) after lateral UKA. Secondarily, the influence of lateral UKA on the alignment of the patellofemoral joint was studied.