A cost-effective cell- and matrix-based minimally invasive single-stage chondroregenerative technique developed with validated vertical translation methodology.

Introduction The morbidity and significant health economic impact associated with the chondral lesion has led to a large number of strategies for therapeutic neochondrogenesis. The challenge has been to develop techniques that are cost effective single-stage procedures with minimal surgical trauma that have undergone rigorous preclinical scrutiny and robust reproducible assessment of effectiveness. A biological repair requires the generation of a cellular and matrix composite with appropriate signalling for chondrogenic differentiation. Methods and results A technique was developed that allowed chondrogenic primary (uncultured) cells from bone marrow aspirate concentrate, combined with a composite hydrophilic and fibrillar matrix to be applied arthroscopically to a site of a chondral lesion. The construct was tested in vitro and in animal experiments before clinical trials. Clinical trials involved 60 patients in a prospective study. Symptomatic International Cartilage Repair Society grade 3 and 4a lesions were mapped and treated. Pre- and postoperative clinical assessments showed statistically significant improved outcomes; Lysholm Knee Scoring Scale (mean 52.8 to > 76.4; P < 0.05) International Knee Documentation Committee (mean 39 to > 79 P < 0.05) and Knee injury and Osteoarthritis Outcome Score (64.5 to >89.2 P < 0.05). Postoperative magnetic resonance imaging was evaluated morphologically (magnetic resonance observation of cartilage repair tissue, average MOCART score 72) and qualitatively; the regenerate was comparable to native cartilage. Conclusions This technique is effective, affordable, requires no complex tools and delivers a single-stage treatment that is potentially accessible to any centre capable of performing arthroscopic surgery. Good clinical results were found to be sustained at five years of follow-up with a regenerate that appears hyaline like using multiple magnetic resonance measures.

Accuracy of hand-held ultrasound scanning in detecting meniscal tears.

The diagnosis of a meniscal tear may require MRI, which is costly. Ultrasonography has been used to image the meniscus, but there are no reliable data on its accuracy. We performed a prospective study investigating the sensitivity and specificity of ultrasonography in comparison with MRI; the final outcome was determined at arthroscopy. The study included 35 patients with a mean age of 47 years (14 to 73). There was a sensitivity of 86.4% (95% confidence interval (CI) 75 to 97.7), a specificity of 69.2% (95% CI 53.7 to 84.7), a positive predictive value of 82.6% (95% CI 70 to 95.2) and a negative predictive value of 75% (95% CI 60.7 to 81.1) for ultrasonography. This compared favourably with a sensitivity of 86.4% (95% CI 75 to 97.7), a specificity of 100.0%, a positive predictive value of 100.0% and a negative predictive value of 81.3% (95% CI 74.7 to 87.9) for MRI. Given that the sensitivity matched that of MRI we feel that ultrasonography can reasonably be applied to confirm the clinical diagnosis before undertaking arthroscopy. However, the lower specificity suggests that there is still a need to improve the technique to reduce the number of false-positive diagnoses and thus to avoid unnecessary arthroscopy.

15-year follow-up results of the hydroxyapatite ceramic-coated femoral stem.

PURPOSE: To evaluate the clinical and radiological outcomes following implantation of the Furlong hydroxyapatite ceramic-coated femoral stem in total hip arthroplasty. METHODS: A longitudinal cohort of 116 consecutive patients (134 hips) was followed up prospectively. The follow-up period was at least 13 years (range, 13- 15 years). Clinical and radiological assessments were made using the Merle d'Aubigne and Postel score and Engh score for fixation and stability, respectively. Osteointegration was assessed radiographically by examining the bone implant interface using the method described by Gruen. RESULTS: 22 patients died during the study period and 6 were lost to follow-up. The respective mean Merle d'Aubigne and Postel scores for pain, range of movement, and ability to walk were 2.2, 2.8, and 2.4 preoperatively and 5.8, 4.8, and 5.4 postoperatively. Engh described satisfactory bony ongrowth as 10 points or more; the mean Engh score for fixation and stability was 24.7 (fixation=10, stability=14.7). One femoral stem was revised for a periprosthetic fracture caused by a fall, but none was revised for loosening. This gave a 99% survival at 13 years (95% confidence interval 94-100). CONCLUSION: The long-term results of this hydroxyapatite ceramic-coated femoral prosthesis are very satisfactory.

Prevalence and surgical significance of a high-origin anterior tibial artery.

PURPOSE: To assess the prevalence of proximal high-origin anterior tibial artery and its surgical significance. METHODS: 100 knees were prospectively studied using colour Doppler ultrasonography. No patient had a history of lower-limb arterial pathology or previous knee surgery. All ultrasound images were assessed by a single experienced vascular technician to eliminate inter-observer variability. RESULTS: The mean age of the patients was 56 years (range, 21-96 years). Prevalence of the high-origin anterior tibial arterial pattern was 6%, greater than that reported by previous angiographic or cadaveric studies. In all patients with high-origin anterior tibial artery, the artery was in direct contact with the posterior cortex of the tibia. CONCLUSION: This highlights the danger of using sharp instruments in knee procedures that involve extension of osteotomy to the posterior tibial cortex, particularly high-tibial osteotomy and total knee replacement. Knowledge of the anatomical variations in the branching of the popliteal artery is important because damage to its branches can be limb- or life-threatening.

Results of a hydroxyapatite-coated (Furlong) total hip replacement: a 13- to 15-year follow-up.

We describe the survival of 134 consecutive JRI Furlong hydroxyapatite-coated uncemented total hip replacements. The mean follow-up was for 14.2 years (13 to 15). Patients were assessed clinically, using the Merle d'Aubigné and Postel score. Radiographs were evaluated using Gruen zones for the stem and DeLee and Charnley zones for the cup. Signs of subsidence, radiolucent lines, endosteal bone formation (spot welds) and pedestal formation were used to assess fixation and stability of the stem according to Engh's criteria. Cup angle, migration and radiolucency were used to assess loosening of the cup. The criteria for failure were revision, or impending revision because of pain or loosening. Survival analysis was performed using a life table and the Kaplan-Meier curve. The mean total Merle d'Aubigné and Postel score was 7.4 pre-operatively and 15.9 at follow-up. During the study period 22 patients died and six were lost to follow-up. None of the cups was revised. One stem was revised for a periprosthetic fracture following a fall but none was revised for loosening, giving a 99% survival at 13 years. Our findings suggest that the long-term results of these hydroxyapatite-coated prostheses are more than satisfactory.

A safe zone for the passage of screws through the posterior tibial cortex in tibial tubercle transfer.

In tibial tubercle transfer, surgery drills and screws can put the popliteal vessels at risk if the posterior cortex is breached. This complication can be devastating. We have looked at arteriograms of 50 knees and identified a safe zone through which an instrument can be passed with more confidence. In our study we found no vessels directly posterior to the supero-medial aspect of the proximal metaphysis in any knee. Whilst care must still be taken, this area will allow surgeons greater confidence to obtain a stronger bicortical hold with any fixation device.

Popliteal artery entrapment syndrome: an unusual presentation of a fibular osteochondroma.

This report describes a fibular neck osteochondroma presenting as popliteal artery entrapment syndrome.

Comparing wound complication rates following closure of hip wounds with metallic skin staples or subcuticular vicryl suture: a prospective randomised trial.

PURPOSE: To compare 2 methods of wound closure-metallic staples or 3-0 undyed vicryl-according to postoperative wound complication rates. METHODS: Patients who underwent surgery for proximal femoral fractures were randomised to have wound closure with metallic staples or with subcuticular vicryl suture. Wounds were regularly examined postoperatively and only those with positive wound swabs were regarded as wound infections. RESULTS: Five infections and one superficial wound dehiscence occurred in the patients who had wound closure with metallic staples. The complication rate was significantly higher for this group compared with the group who had wound closure with subcuticular vicryl suture (p<0.025). CONCLUSION: Superficial wound complication rates are higher for wounds closed with metallic staples compared to wounds closed with subcuticular vicryl.

Tennis elbow--outcome following the Garden procedure: a retrospective study.

PURPOSE: From 1993 to 1999, 17 patients (18 elbows) underwent the Garden procedure for clinically diagnosed tennis elbow. Non-operative treatment was ineffective for these patients. METHODS: The study group consisted of 10 men and 7 women, with a mean age of 49.6 years. Follow-up duration ranged from 18 months to 6 years, with a mean of 37 months. Patients' pain, activity level, and hand grip strength were evaluated postoperatively. RESULTS: 14 (77.8%) elbows had an excellent or good result, 2 elbows had a fair result, and another 2 elbows had a poor result and required revision surgery. Most patients had immediate relief of elbow pain, returned to work early, and did not notice any weakness of hand grip strength or radial wrist extension. There were no significant complications. CONCLUSION: The Garden procedure produced good results for tennis elbow with minimal morbidity in an unselected group of patients. This retrospective study supports the view that the underlying lesion in tennis elbow is in the origin of extensor carpi radialis brevis.

Scaphoid views: a need for standardisation.

AIMS: Several views are needed to visualise the scaphoid. These are routinely called 'scaphoid views'. The authors believe that asking for scaphoid views from the radiology department often leads to a wide variety and number of radiographic views being taken. METHODS: 50 radiographers were asked which and how many views of the scaphoid they would take, in the acute setting and then in the out-patient department. RESULTS: We found a wide variation in the descriptive terms used by radiographers for particular views. There was also little agreement on how many and which radiographic views to take when asked for 'scaphoid views'. CONCLUSIONS: Not only is there complete lack of agreement on what 'scaphoid views' should be, it was also discovered that there was little agreement on the nomenclature of the individual views themselves. Loss of information can result from the wrong views being taken and unnecessary radiation exposure. We recommend five particular views, which together visualise all areas of the scaphoid.

The effect of knee flexion on the popliteal artery and its surgical significance.

Total knee replacement and high tibial osteotomy are common orthopaedic operations with low complication rates. Such surgery is in close proximity to the popliteal artery (PA), the behaviour of which during flexion of the knee is poorly understood. We used Duplex ultrasonography to determine the distance of the PA from the posterior tibial surface at 0 degrees and 90 degrees of flexion in 100 knees. When the knee was flexed the PA was closer to the posterior tibial surface at 1 to 1.5 cm below the joint line in 24% and at 1.5 to 2 cm below the joint line in 15%. There was a high branching anterior tibal artery in 6% of knees. We provide an anatomical account to help to explain our findings by using cadaver dissections, arteriography and static MRI studies.

An unusual case of a postoperative bone cyst.

We describe an unusual case of a postoperative bone cyst resulting from a retained fragment of surgical glove. We highlight some of the problems associated with gloves and suggest ways of safeguarding against similar complications.

Heterotopic ossification after uncemented hydroxyapatite-coated primary total hip arthroplasty.

A total of 134 patients who had a cementless hydroxyapatite-coated total hip arthroplasty (THA) and had no recognized risk factors for heterotopic ossification (HO) were reviewed retrospectively. The average follow-up period was 83 months. Pharmacologic or radiotherapeutic prophylaxis against HO was not used. HO was seen in 90 (67.2%) of the 134 patients reviewed. HO was rated as Brooker class I in 68 (50.7%) patients, class II in 17 (12.7%) patients, class III in 3 (2.2%) patients, and class IV in 2 (1.5%) patients. The average Merle d' Aubigne score in patients with mild forms of HO (Brooker classes I and II) was 16 compared with 13.2 in patients with severe HO (Brooker classes III and IV). A statistically significant negative correlation was found between the presence of HO and the postoperative hip score. Based on our study findings and on a comparison with data in the literature, hydroxyapatite-coated cementless THA alone does not seem to increase the likelihood of HO over other types of THA. The presence of a hydroxyapatite coating does not result in more class III or IV HO, which are the only classes of HO with real clinical significance. Fear of HO should not be a factor in the choice of fixation for THA.