Two-stage revision anterior cruciate ligament reconstruction: Our experience using allograft bone dowels.

The incidence of anterior cruciate ligament reconstruction (ACLR) is continuously increasing. As a result so has the need for revision ACLR, which unfortunately has worse functional outcomes and rate of return to sport. Revision ACLR can be performed as a single stage or in two stages. The latter is recommended in the presence of enlarged and/or malpositioned tunnels. We describe our surgical technique, experience and outcome of our first 19 patients in whom we used allograft bone dowels in the first stage of revision ACLR.

Diagnosis and management of chondral delamination injuries of the knee.

BACKGROUND: Chondral delamination with intact articular surface is an under-recognised entity with no previous reports on how it should be managed. The purpose of this article is to increase awareness of this entity and make recommendations for its management. METHODS: We present a small case series of three patients who presented with knee pain and subsequent MRI scans revealed chondral delamination with intact articular surface as the only explanation of symptoms. RESULTS: Two of the lesions were located in the patella and one on the lateral aspect of the medial femoral condyle. All three were treated with bioabsorbable pin fixation. The delaminated area was easily recognised at arthroscopy by its bogginess on probing. All three patients made an excellent recovery and the lesions healed on MRI. CONCLUSION: Chondral delamination with intact articular surface is best managed with bioabsorbable pin fixation so that it can be salvaged in order to optimise patient outcomes and avoid deterioration to a full thickness chondral lesion once the articular surface has separated.

Can the radiopaque marker in surgical swabs scratch orthopaedic implant surfaces?

AIMS: To determine whether the radiopaque marker strip, which is woven in surgical swabs, causes measureable wear on metal implants at pressures typically used to wipe off fluid from their surface. MATERIALS AND METHODS: Finger pressure used to wipe a surface was measured and used as a reference pressure for further testing. A tribological wear rig was then used to analyse the wear caused on polished titanium plates by a cobalt chromium pin (the control test), the pin covered by a surgical swab and the pin covered by a radiopaque marker strip. RESULTS: It was found that the cotton part or the radiopaque marker of surgical swabs on polished medical grade titanium plates caused no significant wear. In contrast severe scratching was observed from the cobalt chromium pin on its own. CONCLUSION: To our knowledge, this is the first study in the literature analysing the wear caused by the surgical swabs and radiopaque strip on metal implants. The results suggest that surgical swabs are safe to use on metallic implants at pressures typical of a wiping motion.

A Novel Arthroscopic Technique for Intraoperative Mobilization of Synovial Mesenchymal Stem Cells.

BACKGROUND: Mesenchymal stem cells (MSCs) have emerged as a promising candidate for tissue regeneration and restoration of intra-articular structures such as cartilage, ligaments, and menisci. However, the routine use of MSCs is limited in part by their low numbers and the need for methods and procedures outside of the joint or surgical field. PURPOSE: To demonstrate feasibility of a technique in which minimally manipulated synovial MSCs can be mobilized during knee arthroscopy, thereby showing proof of concept for the future evaluation and clinical use of native joint resident MSCs in single-stage joint repair strategies. STUDY DESIGN: Descriptive laboratory study. METHODS: Patients (n = 15) undergoing knee arthroscopy who were free from synovitis or active inflammation were selected. Three samples of irrigation fluid were collected from each patient at inception of the procedure, after an initial inspection of the joint, and after agitation of the synovium. MSC numbers were evaluated by colony forming unit-fibroblastic assay. The phenotype of synovial fluid resident and synovial-mobilized MSCs was determined by flow cytometry, and their functionality was determined by trilineage differentiation. Adhesion of culture-expanded mobilized MSCs to fibrin scaffolds was also evaluated to ascertain whether mobilized MSCs might concentrate at sites of bleeding. RESULTS: Normal irrigation during arthroscopy depleted resident synovial fluid MSCs (4-fold decrease, n = 15). Numbers of MSCs mobilized through use of a purpose-made device were significantly higher (105-fold) than those mobilized through use of a cytology brush (median of 5763 and 54 colonies, respectively; P = .001; n = 15). The mobilized cellular fraction contained viable MSCs with proliferative potential and trilineage differentiation capacity for bone, cartilage, and fat lineages, and cultured daughter cells exhibited the standard MSC phenotype. Following culture, mobilized synovial MSCs also adhered to various fibrin scaffolds in vitro. The technique was simple and convenient to use and was not associated with any complications. CONCLUSION: Numbers of functional MSCs can be greatly increased during arthroscopy through use of this technique to mobilize cells from the synovium. CLINICAL RELEVANCE: This study highlights a novel, single-stage technique to increase joint-specific, synovial-derived MSCs and thereby increase the repair potential of the joint. This technique can be undertaken during many arthroscopic procedures, and it supports the principle of integrating mobilized MSCs into microfracture sites and sites of bleeding or targeted repair through use of fibrin-based and other scaffolds.

The role of elastomeric pumps in postoperative analgesia in orthopaedics and factors affecting their flow rate.

Elastomeric pumps are mechanical devices composed of an elastomeric balloon reservoir into which the drug to be infused is stored, a protective casing (used by some manufacturers), a flow controller and a wound catheter. In orthopaedics they are used to provide continuous local infiltration analgesia. In this way patients rely less on other routes of analgesia and thus avoid their systemic side effects. Studies have shown good response to analgesia with these pumps for the first 24 hours but their benefit is not as clear at 48 and 72 hours. There are numerous factors that affect the flow rate of elastomeric pumps. Some are inherent to all elastomeric pumps such as: the pressure exerted by the elastomeric balloon, catheter size, the vertical height of the pump in relation to the wound, viscosity and partial filling. There are also other factors which vary according to the manufacturer such as: the optimal temperature to obtain the desired flow rate as this directly affects viscosity, the dialysate that the analgesic drug is mixed with (ie normal saline or 5% dextrose), and the storage conditions of the fluid to be infused. It is thus essential to follow the clinical guidelines provided by the manufacturer in order to obtain the desired flow rate.

Factors affecting short- and long-term outcomes of manipulation under anaesthesia in patients with adhesive capsulitis of the shoulder.

BACKGROUND: The present study aimed to evaluate and determine the factors that affect short- and long-term outcome following manipulation under anaesthesia (MUA) of patients with adhesive capsulitis. METHODS: Patients recruited from January 1999 to January 2010 were retrospectively analyzed and classified as having primary or secondary adhesive capsulitis. All patients were assessed for range of movement (ROM) and Oxford Shoulder Scores (OSS) before and immediately postoperatively, as well as for OSS more than 1 year post MUA. RESULTS: In total, 295 patients (315 shoulders) were sequentially recruited, and information was collected at baseline, as well as at a mean follow-up of 28 days and 3.6 years. A significant improvement in OSS and ROM was noted 1 month post MUA (p < 0.0001) with females benefiting more than males (p < 0.0025). Long-term follow-up revealed that the improvement in OSS was maintained (p < 0.0001). Secondary adhesive capsulitis significantly reduced the efficacy of MUA as assessed by ROM (p < 0.0001). Other factors (age, initial ROM and OSS, and length of symptoms prior to MUA) did not significantly affect the outcome over the short- or long-term. CONCLUSIONS: The findings of the present study show that all patient groups had a significantly improved ROM and OSS in the short-term with long-term maintenance of improved OSS.

Is there a learning curve in foot and ankle surgery?

BACKGROUND: Previous studies of orthopaedic learning curves have largely described the introduction of new techniques to experienced consultants. End points have usually involved technical considerations. A paucity of evidence surrounds foot and ankle surgery. This study investigates the learning curve during a foot and ankle surgeon's first year, defined by functional outcome. METHODS: 150 patients underwent elective foot or ankle surgery during the whole period. Preoperative and 6 month postoperative functional scores were compared between the first and second 6 month groups. RESULTS: Functional improvement was greater, approaching significance, in the second group (p=0.0605). There was no difference for forefoot cases (p=0.345). Functional improvement was significantly greater in the second group with forefoot cases removed (p=0.0333). CONCLUSIONS: A learning curve exists in the first year of practice of foot and ankle surgery, demonstrated by functional outcome. This is confined to ankle, hindfoot and midfoot, but not forefoot surgery.