Aims

Frozen shoulder is a common, painful condition that results in impairment of function. Corticosteroid injections are commonly used for frozen shoulder and can be given as glenohumeral joint (GHJ) injection or suprascapular nerve block (SSNB). Both injection types have been shown to significantly improve shoulder pain and range of motion. It is not currently known which is superior in terms of relieving patients’ symptoms. This is the protocol for a randomized clinical trial to investigate the clinical effectiveness of corticosteroid injection given as either a GHJ injection or SSNB.

Gel-based autologous chondrocyte implantation (ACI) over the years have shown encouraging results in repairing the articular cartilage. More recently, the use of cultured mesenchymal stem cells (MSC) has represented a promising treatment option with the potential to differentiate and restore the hyaline cartilage in a more efficient way. This study aims to compare the clinical and radiological outcome obtained in these two groups.

Twenty-eight consecutive symptomatic patients diagnosed with full-thickness cartilage defects were assigned to two treatment groups (16 patients cultured bone marrow-derived MSC and 12 patients with gel-type ACI). The MSC group patients underwent microfracture and bone marrow aspiration in the first stage and injection of cultured MSC into the knee in the second stage. Clinical and radiological results were compared at a minimum follow up of five years

There was excellent clinical outcome noted with no statistically significant difference between the two groups. Both ACI and MSC group showed significant improvement of the KOOS, Lysholm and IKDC scores as compared to their preoperative values and this was maintained at 5 years follow up. The average MOCART score for all lesions was also nearly similar in the two groups. The mean T2* relaxation-times for the repair tissue and native cartilage were 27.8 and 30.6 respectively in the ACI group and 28 and 29.6 respectively in the MSC group.

Use of cultured MSC is less invasive, technically simpler and also avoids the need for a second surgery as compared to an ACI technique. With similar encouraging clinical results seen and the proven ability to restore true hyaline cartilage, cultured MSC represent a favorable treatment option in articular cartilage repair.

Chondral defects of the knee are common and often seen in young and active individuals. A novel single stage arthroscopic technique for the treatment of articular cartilage defects in the knee is described. This involves microfracture and application of concentrated bone marrow aspirate cells (BMAC) with fibrin and Hyaluronic Acid as a gel. After a representative preclinical study, the 5 year results of a prospective clinical study are presented.

The pre-clinical study involved two groups of rabbits with standardised lesions treated with microfracture alone and microfracture combined with fibrin/HA/BMAC application. New cartilage from both groups was subjected to staining with H&E for tissue morphology, toluidine blue (collagen) and safranin O (GAG), immunohistochemistry with antibodies for collagen type I and II, and scanning and transmission electron microscopy to analyse the microstructural morphologies. The fibrin/HA/BMAC group scored better than the microfracture group on all tests.

A subsequent prospective clinical study patients (n=60) with symptomatic ICRS grade III/IV chondral defects (lesion size 2–8cm2). The surgical procedure involved debridement of the lesion, micro-fracture and application of fibrin/HA/BMAC gel under CO2 insufflation. Patients underwent morphological evaluation with MRI (T2*-mapping and d-GEMRIC scans). Clinical assessment employed the Lysholm, IKDC and KOOS scores while radiological assessment was performed with MOCART score.

At 5 years, Lysholm score was 78, compared to 51 pre-operatively (p<0.05). KOOS (symptomatic) improved to 90 from 66 (p<0.05). IKDC (subjective) went to 80 from 39 (p<0.05). The mean T2* relaxation-times for the repair tissue and native cartilage were 26 and 29.9 respectively. Average MOCART score for all lesions was 70.

This technique shows encouraging clinical results at 5 year follow-up. The morphological MRI shows good cartilage defect filling and the biochemical MRI suggests hyaline like repair tissue.

Introduction

We describe a single stage arthroscopic procedure for the treatment of articular cartilage defects in the knee. The novel procedure involves microdrilling and application of atellocollagen and fibrin gel. The aim of the study was to evaluate the clinical outcomes at 4 years.

We describe a novel single stage arthroscopic repair procedure for articular cartilage defect in the knee. The aim of the study was to evaluate the clinical and radiological outcomes at two years.

The pre-clinical study involved two groups of New Zealand rabbits, treated with microfracture alone and microfracture combined with fibrin gel and concentrated bone marrow aspirate cells (BMAC) application. New cartilage from both groups was studied with histological staining, immunohistochemistry and electron microscopy. The fibrin gel-BMAC group scored better than the microfracture group on all counts.

This is a prospective study of 30 patients with symptomatic ICRS grade III/IV chondral defects, ranging from 2–8 cm², which were assessed clinically and radiologically. The surgical procedure involved debridement of the lesion, microfracture and arthroscopic application of concentrated BMAC with fibrin gel under CO₂ insufflation. Patients underwent morphological MRI, quantitative T2*-mapping and d-GEMRIC scan. Clinical assessment was carried out using the Lysholm, IKDC and KOOS scores while radiological assessment used the MOCART score.

At 2 year follow-up, Lysholm score was 80.1, as compared to 50.8 pre-operatively (p < 0.05). KOOS (symptomatic) was 92.1, as compared to 65.7 pre-operatively. IKDC (subjective) was 83, up from 39 preoperatively. The mean T2* relaxation-times for the repair tissue and native cartilage were 29.1 and 29.9 respectively. Average MOCART score for all lesions was 72.

Our technique shows encouraging clinical and radiological results. The morphological MRI shows good cartilage defect filling and the biochemical MRI (T2*-mapping) suggests hyaline like repair tissue.

Introduction

Nerve conduction studies are considered to be the investigation of choice for the diagnosis of Carpal Tunnel Syndrome. However they are expensive and can be painful.

We scored patients based on a ten point scoring system; four symptoms (Katz Hand Diagram – Classic and Probable pattern for tingling and numbness, nocturnal paresthesia, bilateral symptoms), four signs (weak thumb abduction test, Tinel sign, Phalen sign, Hypoalgesia in median nerve territory) and two risk factors (age more than 40 years and female sex). This was done in an effort to predict the severity of carpal tunnel syndrome and to correlate it with nerve conduction studies.

The most appropriate bearings in young patients remain highly debated. The aim of this metaanalysis was to summaries the best available evidence on relative success of the three most popular bearings [metal-on-poly (MOP), metal-on-metal (MOM) and ceramic-on-ceramic (COC)] used in total hip replacement (THR) in young active patients.

All the relevant studies published in the English language were retrieved. Studies with THR in patients with mean age less than 55 years of age were selected. The survivorship analysis for the three important bearings at 10 years was evaluated.

Ten-year survival rates suggest that MOM bearings performed significantly better than MOP (p=0.01) and COC (p=0.001). MOP revealed higher survival rates than COC bearings (p=0.05).

Our findings support the use of MOM bearings in the management of the young arthritic hip. These findings, largely based upon observational studies should be taken in context to the limitations of such non-randomized study designs.

Aim: To assess whether stable undisplaced ankle fractures treated conservatively with a below knee non weight bearing cast ever displace.

Methods: Retrospective case notes analysis was performed. Between August 2007 and August 2009, one hundred and twenty one patients sustained a stable undisplaced ankle fracture which was treated conservatively. Their age range was from 16 to 86 years. Male to female ratio was 74:47. The mean number of clinic follow ups was 3.7. These patients were classified according to the Danis-Weber Classification for analysis. Thirty (25%) patients had Weber A1 fractures, seventy two (60%) had Weber B1 fractures, five patients (4%) had Weber B2 fractures, three patients (2%) had Weber C1 fractures, ten patients (8%) had isolated medial malleolus fracture and one patient suffered an isolated posterior malleolus fracture.

Results: An average of 4.7 x-rays were performed on each patient from the time of diagnosis to discharge from clinic. None of these fractures displaced on follow up x-rays.

Conclusion: Stable undisplaced ankle fractures treated conservatively with a below knee non weight bearing cast do not displace. Hence these patients do not require to be followed up frequently with serial x-rays as they may be exposed to unnecessary harmful radiation and follow up appointments thereby saving time, money and resources.

Background: The worst fear of a joint replacement surgeon is infection. Many factors are known to contribute to the development of infection in a surgical set up. Post-operative wound soakage is one of them. Wet wounds lead to repeated dressings, exposing the wound for contamination, risk of infection and increased length of hospital stay. Therefore, any measure to avoid postoperative wound problems is desirable. We wish to report our experience of the use of occlusive, sterile sanitary napkin dressings in routine total hip and knee replacement wounds.

Method: In a prospective randomized study, we compared the use of occlusive, sterile sanitary napkin dressings with standard ward gauze dressings in routine hip and knee replacement wounds. We studied 27 patients in two groups (standard dressings and sanitary napkin dressings) for the number of dressing changes required due to wound soakage. Our results showed that use of sanitary napkin dressings reduced the number of dressings, significantly, before staples removal (p= 0.0001).

Discussion: Using hydrofibre dressings have been reported to be effective in reducing the number of dressings in patients with lower limb arthroplasty. However, these dressings are expensive and require special manufacturing techniques. The use of sterile, occlusive sanitary napkin dressing in our set up has facilitated us to manage the joint replacement wounds very effectively. This method is simple, inexpensive and reduces the number of man hours and, we believe, reduces the overall cost of the treatment.

Conclusion: Convinced by the impressive performance of this dressing in joint replacement wounds, the authors recommend this method, highly, for routine primary and revision joint replacements.

Introduction: There are a number of publications in the literature on managing post-operative pain and early rehabilitation after primary total hip replacement (THR). However, there has been very little work in the literature to study the influence of the anaesthetic technique used on the post-operative length of hospital stay following primary THR. We, therefore, wished to particularly study the influence of anaesthetic technique and the anaesthetist concerned on the length of hospital stay, as well as the effect of age and body mass index (BMI).

Methods: We studied 121 consecutive THRs in 109 patients. All procedures in our study were performed by the same surgeon using the same posterolateral approach, the same prosthetic design and the same physiotherapy protocol for all patients. Patients received either general anaesthesia alone (50 THRs) or a combination of general and local anaesthesia (lumbar plexus block; 71 THRs) from three separate anaesthetists. The mean age at the time of operation was 66.5 years (33 to 88). The influence of anaesthetist, anaesthetic technique, age of the patient and BMI on length of stay after primary THR was assessed separately.

Results: Our analysis showed that the length of hospital stay was greatly influenced by the anaesthetic technique used, those patients who received a lumbar plexus block having a shorter median length of hospital stay (3 days) than those who received general anaesthesia alone (5 days; p < 0.0001). The age of the patient was also critical (p = 0.003) as was the anaesthetist concerned (p = 0.01). BMI was unimportant.

Conclusions: For those surgeons who believe that a reduction in the length of hospital stay after primary THR is a worthwhile objective, we have one over-riding observation–the anaesthetic technique used is critical.

Background: Pathological medial plica is known to cause anteromedial knee pain. However, clinical diagnosis of pathological medial plica is poorly defined in the literature and therefore, arthroscopic diagnosis remains gold standard. We report a system of clinical diagnosis based on the criteria set by us for these painful conditions of the knee.

Methods: We prospectively studied forty-eight symptomatic patients (sixty-six knees) with clinical suspicion of pathological medial plica based on five “essential” and four “desirable” criteria set by us. All patients were subjected to arthroscopic examination, to confirm or disprove our clinical diagnosis and, for treatment.

Results: Arthroscopic examination confirmed our clinical diagnosis of medial plicae in forty-four (sixty-two knees) of these patients showing a diagnostic accuracy of 91.7% (95% confidence interval: 80.0%, 97.7%), sensitivity of 100% (95% CI: 92.0%, 100.0%) with our method. Those with pathological medial plicae at arthroscopy (forty-four patients; sixty-two knees), were treated by arthroscopic resection. Thirty-nine patients (fifty-five knees) showed satisfactory outcome (95% CI: 75.4%, 96.2%) after arthroscopy.

Conclusions: We believe that our method of clinical diagnosis of pathological medial plica is simple, non-invasive, economic and reliable. Symptomatic medial plica can be successfully treated by arthroscopy. This study has changed our clinical practice and also allowed us to decrease substantially the cost of diagnostic imaging.

Introduction: Although there are a number of publications in the literature on managing post-operative pain and early rehabilitation after surgery in general, there has been little work on the influence of anaesthetic technique on the post-operative length of hospital stay following primary total hip replacement (THR). We wished to particularly study the influence of anaesthetic technique and the anaesthetist concerned on the length of hospital stay, as well as the effect of age and body mass index (BMI).

Methods: We studied 121 consecutive THRs in 109 patients. All procedures were performed by the same surgeon using the same posterolateral approach, prosthetic design and the same physiotherapy protocol. Patients received either general anaesthesia alone (50 THRs) or a combination of general and local anaesthesia (lumbar plexus block; 71 THRs) from three separate anaesthetists. The influence of anaesthetist, anaesthetic technique, age, and BMI on length of stay after primary THR was assessed separately.

Results: Our analysis showed that the length of hospital stay was greatly influenced by the anaesthetic technique used (p < 0.0001), those patients who received a lumbar plexus block having a shorter median length of hospital stay (3 days) than those who received general anaesthesia alone (5 days). The age of the patient was also critical (p = 0.003) as was the anaesthetist concerned (p = 0.01). BMI was unimportant.

Discussion: For those surgeons who believe that a reduction in the length of hospital stay after primary THR is a worthwhile objective, we have one over-riding observation – the anaesthetic technique used, and the anaesthetist involved, are critical.