Effectiveness of Absorbable Plates for the Treatment of Nasal Septal Cartilage Fractures.

BACKGROUND: Nasal bone fractures are the most common type of facial fracture. Nasal bone fractures often occur in combination with septal cartilage fractures, because the nasal septal cartilage acts as a vertical strut and provides structural support for the nose and bilateral nasal airway. However, the treatment for nasal septal cartilage fracture remains controversial, and if untreated, nasal septal cartilage fracture can lead to various complications, such as nasal obstruction and posttraumatic nasal and septal deformity. This study aimed to evaluate the effectiveness and safety of our procedure in which septal cartilage fractures were treated with septoplasty using an absorbable plate as an internal splint. METHODS: Between January 2017 and November 2020, 21 patients with nasal septal cartilage fractures were treated with septoplasty using an absorbable plate as an internal splint. The severity of the septal cartilage fracture was graded from 0 to 3 according to the computed tomography septal grading system. The numeric graded scale of nasal septal cartilage fracture was evaluated preoperatively and 6 months postoperatively using a computed tomography scan. RESULTS: Of 21 patients with septal cartilage fractures, 12 were treated with a polycaprolactone (PCL) mesh plate, and 9 were treated with a polydioxanone (PDS) plate. In the PDS plate group, the preoperative numeric scale of nasal septal cartilage fracture was 2.50 (2.00-3.00), whereas the postoperative numeric scale was 1.00 (1.00-1.25, P = 0.023). In the PCL mesh plate group, the preoperative numeric scale of nasal septal cartilage fracture was 2.00 (2.00-3.00), whereas the postoperative numeric scale was 1.00 (1.00-1.50, P = 0.034). The effectiveness of the PCL mesh plate and that of the PDS plate group according to the septal grading scale were 1.45 (SD, 0.522) and 1.18 (SD, 0.603), respectively. However, these differences were not statistically significant. CONCLUSIONS: Our study shows that septoplasty using absorbable plates provides satisfactory and safe clinical outcomes in patients with nasal septal cartilage fractures.

[When is cartilage repair successful?] / Wann ist eine Knorpelreparatur erfolgreich?

Focal cartilage lesions are a cause of long-term disability and morbidity. After cartilage repair, it is crucial to evaluate long-term progression or failure in a reproducible, standardized manner. This article provides an overview of the different cartilage repair procedures and important characteristics to look for in cartilage repair imaging. Specifics and pitfalls are pointed out alongside general aspects. After successful cartilage repair, a complete, but not hypertrophic filling of the defect is the primary criterion of treatment success. The repair tissue should also be completely integrated to the surrounding native cartilage. After some months, the transplants signal should be isointense compared to native cartilage. Complications like osteophytes, subchondral defects, cysts, adhesion and chronic bone marrow edema or joint effusion are common and have to be observed via follow-up. Radiological evaluation and interpretation of postoperative changes should always take the repair method into account.

Osteochondral Fractures of the Knee in Skeletally Immature Patients: Short-Term Results of Operative Fixation using Omnitech Screws.

PURPOSE OF THE STUDY: Retrospective case series looking at the use of Omnitech compression screws for the management of osteochondral fractures in skeletally immature patients. MATERIAL AND METHODS: Nine patients with a mean age of 14 were included in the study with a mean follow up of 26 months. RESULTS: The average KOOS, IKDC and Tegner Lysholm Scores were 86.7, 90.34 and 96.1 respectively. CONCLUSION: The use of Omnitech screws in the acute setting for skeletally immature patients shows excellent short-term outcomes.

Application of pulsed electromagnetic fields after microfractures to the knee: a mid-term study.

PURPOSE: Pulsed electromagnetic fields (PEMFs) may improve clinical outcomes following microfractures and prevent their decline over time. METHODS: Sixty-eight patients who underwent partial medial meniscectomy and microfractures to the medial femoral condyle for management of grade III-IV cartilage lesions were randomly divided into two groups using a block randomization procedure. After surgery, 34 patients underwent PEMFs application in the I-ONE group; 34 patients underwent placebo treatment in the placebo group. All patients had the same postoperative rehabilitation protocol. Sixty patients (28 in the I-ONE group, 32 in the placebo group) were assessed at an intermediate follow-up of two years and a minimum follow-up of five years after surgery. RESULTS: The two groups were homogeneous. There was a significant improvement from baseline to the last minimum follow up of two years. At two years, IKDC and Lysholm and Constant scores were significantly improved compared to baseline in both groups with no significant inter-group differences. At the last follow up (minimum five years), clinical and functional outcomes were decreased in both the groups, with significant better outcomes in the I-ONE group. At five years, the percentage of patients still active at the same level they were pre-operatively was greater in the I-ONE group (82% vs 68%, P = 0.28). At radiographic assessment, at the latest evaluation, six patients (21.4%) in the I-ONE group and nine (28.1%) in the placebo group demonstrated grade I-II degenerative changes according to Fairbank grading system (Χ = 0.36, P = 0.55). CONCLUSIONS: PEMFs application can improve the effectiveness of microfracture in the long term.

Isolated osteochondral fracture of the metatarsal head of lesser toes.

Isolated fracture of the metatarsal head is very rare and no consensus has been reached regarding their best management. We reported four cases of isolated osteochondral fracture of the metatarsal head with different method of treatment to achieve the common goal of restoration of the congruity of the metatarsal head.

Fixation of chondral fracture of the weight-bearing area of the lateral femoral condyle in an adolescent.

Purely chondral fractures of the distal femur associated with patellar dislocation are uncommon, and treatment varies from fixation to debridement and marrow stimulation techniques. The unusual case reported here involves an adolescent who underwent fixation of a purely chondral fracture involving a large weight-bearing portion of the lateral femoral condyle. Chondral fracture healing was confirmed on follow-up magnetic resonance imaging and arthroscopic examination. This case suggests that fixation of purely chondral fractures can be successful in weight-bearing areas of the knee. Level of evidence V.

[Complex fracture of the larynx caused by a horse kick]. / Komplexe Larynxverletzung durch Pferdetrittverletzung.

Every blunt laryngeal trauma requires examination by an ENT physician and may necessitate observation for a number of hours. The literature shows a heterogeneous picture regarding airway management (tracheotomy vs. intubation). Extremely violence forces such as horse kicks require a tracheotomy, as demonstrated by case studies. In such cases, a high level of responsibility lies with the emergency physician providing the initial treatment. We present the case of a 37-year-old horse trainer, who suffered a horse kick to the larynx with a complex laryngeal fracture. Intubation of the patient by the emergency physician would most probably have led to incorrect placement of the tube or complete displacement of larynx and trachea. In addition to securing a vital airway by tracheotomy, a timely reconstruction of the airways, where necessary by employing the temporary insertion of a tracheal stent, is the treatment of choice. The latter therapy should be applied within the first 6 hours following the accident.

Transplantation of aggregates of synovial mesenchymal stem cells regenerates meniscus more effectively in a rat massive meniscal defect.

Transplantation of mesenchymal stem cells (MSCs) derived from synovium is a possible therapy for meniscus regeneration. We have previously reported that intraarticular injection of 5 million synovial MSCs promoted meniscal regeneration in rat meniscal defects. However, if a similar cell number per body weight were required, preparation of required human MSCs would not be practical in a clinical situation. The use of aggregates of MSCs may be one of the solutions. Here, we investigated whether the use of aggregates of synovial MSCs regenerated meniscus more effectively in a rat meniscectomized model. The total number of synovial MSCs was adjusted to 25,000 cells, and aggregates consisting of MSCs or 25,000 MSCs suspended in PBS were placed on the meniscal defects. Five million MSCs suspended in PBS were also used as another control. For the regenerated menisci, the area was larger and the histological findings were closer to that of the normal meniscus in the aggregate groups than to that in the suspension groups at 4 weeks. The effects of transplantation of aggregates were still observed at 12 weeks. Luminescence intensity remained higher at 3 weeks and thereafter in the aggregate group than in the suspension group when the same number of luciferase expressing MSCs were transplanted. We confirmed that MSCs transplanted as aggregates existed in the regenerated meniscus focally and partially. Transplantation of aggregates of synovial MSCs regenerated meniscus more effectively in a rat massive meniscal defect.

In vivo MRI of fresh stored osteochondral allograft transplantation with delayed gadolinium-enhanced MRI of cartilage: protocol considerations and recommendations.

The protocol for delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) was adapted for the evaluation of transplanted osteochondral allograft cartilage. Eight patients with focal grade 4 cartilage defects of the femoral condyle were treated with single cylindrical osteochondral allografts. At 1 and 2 years, dGEMRIC image sequences were acquired and regions of interest (ROIs) were drawn in repair and native control cartilage. Mean T1 values of region of interest were used to calculate established dGEMRIC metrics. The correlation was measured between the ΔR1 and R1 -Post metrics for repair and native cartilage. T1 times were measured in deep and superficial zones of cartilage. A strong correlation was identified between full-thickness, deep, and superficial ΔR1 and R1 -Post values for native cartilage and repair cartilage for all years (range: 0.893-1.0). The mean T1 times and ΔR1 rate between deep and superficial regions of articular cartilage were statistically different for all regions of the distal femora analyzed at 1 year and 2 years after osteochondral allograft transplantation (P<0.05). The dGEMRIC pre-Gadolinium scan is unnecessary when evaluating transplanted osteochondral allograft cartilage. The observation of stratified T1 and ΔR1 values indicates a need to re-evaluate the methodology behind the placement of region of interest in dGEMRIC.

Adolescent patellar osteochondral fracture following patellar dislocation.

PURPOSE: Patellar dislocations in adolescents may cause osteochondral fractures of the patella. The aim of this study was to review the outcomes of adolescent patients who underwent surgical intervention for patellar osteochondral fracture following patellar dislocation. METHODS: Nine patients who underwent surgery for osteochondral fracture of the patella following dislocation were identified retrospectively. Following arthroscopic examination, if the fragment was large enough to support fixation, headless screws or bioabsorbable pins were used. Otherwise, the loose body was excised, and the donor site was managed with a microfracture. Postoperatively, patients were assessed using the International Knee Documentation Committee (IKDC) and Knee injury and Osteoarthritis Outcome Score (KOOS) outcome measures. RESULTS: The average age of the patients was 14.6 with average follow-up 30.2 months. Four of the nine patients underwent fixation, while five patients underwent removal of loose body with microfracture. The average defect size in the nonfixation group was 1.2 cm(2) compared with 3.2 cm(2) in the fixation group. The IKDC scores for fixation and nonfixation groups were 63.9 (SD = 18) and 76.1 (SD = 11.7), respectively. The KOOS subscale scores for symptoms, function in sports and recreation, and knee-related quality of life were higher for the nonfixation group when compared to the fixation group. CONCLUSIONS: This is the first known series examining surgical outcomes of osteochondral fractures of the patella following patellar dislocations in the adolescent population. While patients without fixation were less symptomatic in this series, this may be attributable to more severe injuries in patients undergoing fracture fixation. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

[The bovine cartilage punch model: a tool for the in vitro analysis of biomaterials and cartilage regeneration]. / Das bovine Knorpelstanzenmodell : Ein Werkzeug zur In-vitro-Analyse von Biomaterialien und Knorpelregeneration.

BACKGROUND: The limited regeneration capacity of hyaline articular cartilage requires detailed studies concerning the tissue integration of cartilage transplants with meaningful but time and/or resource-consuming and in part ethically problematic animal models or, alternatively, with in vitro test systems for implant materials. MATERIAL AND METHODS: The present study describes a regeneration model with bovine cartilage rings (outer Ø 6 mm, central defect Ø 2 mm) for insertion, cultivation and biomechanical or histological testing of cartilage replacement materials (HE and safranin O staining). In this study, resorbable polymers composed of polyglycolic acid (PGA) were analyzed. RESULTS: Biomechanical testing showed a continuous decrease of the push-out force for the PGA inserts from the cartilage rings, probably due to the resorbability of the material. Histologically, clear immigration of cells into cell-free PGA was observed even after 4 weeks of culture, but in particular after 10 weeks. In addition, storage of proteoglycans was interpreted as an initial sign of the formation of new matrix. CONCLUSION: Thus, the new regeneration model is in principle suitable for the testing of biomaterials, but shows limitations in assessing the "lateral bonding" of resorbable materials.

[Defect models for the regeneration of articular cartilage in large animals]. / Defektmodelle für die Gelenkknorpelregeneration im Großtier.

BACKGROUND: Several animal models are available for the analysis of regeneration of articular cartilage in large animals, such as sheep, pigs, goats, dogs and horses. The subchondral bone lamella must be considered when ACT and MACT techniques are examined in order to protect the implant against migration of cells from the bone marrow, although recruitment of cells is often desirable in the regeneration of human cartilage. MATERIAL AND METHODS: The defects are mainly positioned at the condyles and the trochlea often bilaterally and spontaneous healing should be excluded. The follow-up period for assessment of the effectiveness of cartilage regeneration is 6-12 months. Shorter observation times up to 12 weeks can be used for pilot studies. Scores based on histological, immunohistological and biochemical staining are mostly used for assessing the regenerated tissue. Biomechanical tests with destructive features need isolated specimens from the animal but modern slice imaging techniques can reflect the progression of the healing processes over the time span of the study in vivo. CONCLUSION: Approaches to standardize the evaluation of the regeneration of articular cartilage have been sporadically described whereas they are required from the point of view of the approval of new concepts for therapy and the protection of animals.

[Biomechanics of cartilage tissue engineering constructs : Sensitive test procedure for assessment of biomechanical functionality and further development after in vivo transplantation]. / Biomechanik von Knorpel-Tissue-Engineering-Konstrukten : Sensitives Testverfahren zur Beurteilung deren biomechanischer Funktionalität und ihrer Weiterentwicklung nach In-vivo-Transplantation.

Specific biomechanical properties represent important quality markers of cartilage tissue engineering (TE) constructs. The aim of the study was to identify a sensitive biomechanical test to assess mechanical properties of cartilage TE constructs. Biomechanical testing of in vitro cultivated constructs following the very low rubber hardness (VLRH) principle illustrated significant differences between constructs cultured under chondrogenic conditions over various periods of time. An increase in proteoglycan and collagen type II deposition corresponded to increasing VLRH hardness values. Although a decrease in proteoglycan was detected after ectopic implantation of constructs into SCID mice, no reduction in biomechanical hardness values was observed. A functional estimation of TE constructs requires determination of biomechanical and biochemical parameters as quality features.

Ultrasonic Pin Placement for Resorbable Rigid Fixation of a Thyroid Cartilage Fracture.

OBJECTIVE: To present the first use of an ultrasonic pin resorbable plate fixation system for rigid fixation of a laryngeal fracture. METHODS: Presentation of a 20-year-old male with a high velocity injury to his neck, via a lacrosse ball, resulting in a displaced laryngeal cartilage fracture. RESULTS: Intraoperatively, a Poly-D, L-Lactic Acid (PDLLA) polymer plate was contoured in-situ, bridging the fracture, and secured with ultrasonically placed resorbable pins. He was extubated on post-op day one and had return to vocal baseline one-month post-op. CONCLUSION: Ultrasonic pin placement systems for resorbable rigid fixation of a thyroid cartilage fracture optimizes recovery of respiratory and phonatory functions. Laryngoscope, 133:1470-1472, 2023.

Evaluation of chondral repair using quantitative MRI.

Various quantitative magnetic resonance imaging (qMRI) biomarkers, including but not limited to parametric MRI mapping, semiquantitative evaluation, and morphological assessment, have been successfully applied to assess cartilage repair in both animal and human studies. Through the interaction between interstitial water and constituent macromolecules the compositional and structural properties of cartilage can be evaluated. In this review a comprehensive view of a variety of quantitative techniques, particularly those involving parametric mapping, and their relationship to the properties of cartilage repair is presented. Some techniques, such as T2 relaxation time mapping and delayed gadolinium-enhanced MRI of cartilage (dGEMRIC), are well established, while the full potential of more recently introduced techniques remain to be demonstrated. A combination of several MRI techniques is necessary for a comprehensive characterization of chondral repair.

Current treatments of isolated articular cartilage lesions of the knee achieve similar outcomes.

BACKGROUND: Many surgical techniques, including microfracture, periosteal and perichondral grafts, chondrocyte transplantation, and osteochondral grafts, have been studied in an attempt to restore damaged articular cartilage. However, there is no consensus regarding the best method to repair isolated articular cartilage defects of the knee. QUESTIONS/PURPOSES: We compared postoperative functional outcomes, followup MRI appearance, and arthroscopic examination after microfracture (MF), osteochondral autograft transplantation (OAT), or autologous chondrocyte implantation (ACI). METHODS: We prospectively investigated 30 knees with MF, 22 with OAT, and 18 with ACI. Minimum followup was 3 years (mean, 5 years; range, 3-10 years). We included only patients with isolated cartilage defects and without other knee injuries. The three procedures were compared in terms of function using the Lysholm knee evaluation scale, Tegner activity scale, and Hospital for Special Surgery (HSS) score; modified Outerbridge cartilage grades using MRI; and International Cartilage Repair Society (ICRS) repair grade using arthroscopy. RESULTS: All three procedures showed improvement in functional scores. There were no differences in functional scores and postoperative MRI grades among the groups. Arthroscopy at 1 year showed excellent or good results in 80% after MF, 82% after OAT, and 80% after ACI. Our study did not show a clear benefit of either ACI or OAT over MF. CONCLUSIONS: Owing to a lack of superiority of any one treatment, we believe MF is a reasonable option as a first-line therapy given its ease and affordability relative to ACI or OAT. LEVEL OF EVIDENCE: Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Hemi-bucket-handle tears of the meniscus: appearance on MRI and potential surgical implications.

OBJECTIVES: To describe a type of meniscus flap tear resembling a bucket-handle tear, named a "hemi-bucket-handle" tear; to compare its imaging features with those of a typical bucket-handle tear; and to discuss the potential therapeutic implications of distinguishing these two types of tears. MATERIALS AND METHODS: Five knee MR examinations were encountered with a type of meniscus tear consisting of a flap of tissue from the undersurface of the meniscus displaced toward the intercondylar notch. A retrospective analysis of 100 MR examinations prospectively interpreted as having bucket-handle type tears yielded 10 additional cases with this type of tear. Cases of hemi-bucket-handle tears were reviewed for tear location and orientation, appearance of the superior articular surface of the meniscus, presence and location of displaced meniscal tissue, and presence of several classic signs of bucket-handle tears. RESULTS: A total of 15/15 tears involved the medial meniscus, had tissue displaced toward the notch, and were mainly horizontal in orientation. The superior surface was intact in 11/15 (73.3%). In 1/15 (6.7%) there was an absent-bow-tie sign; 6/15 (40%) had a double-PCL sign; 14/15 (93.3%) had a double-anterior horn sign. CONCLUSION: We describe a type of undersurface flap tear, named a hemi-bucket-handle tear, which resembles a bucket-handle tear. Surgeons at our institution feel this tear would likely not heal if repaired given its predominantly horizontal orientation, and additionally speculate the tear could be overlooked at arthroscopy. Thus, we feel it is important to distinguish this type of tear from the typical bucket-handle tear.

Tension band wire fixation for anterior cruciate ligament avulsion fracture: biomechanical comparison of four fixation techniques.

PURPOSE: The purpose of this study is to design a new fixation method to treat tibial eminence fractures and assess its stability compared with conventional fixation methods. METHODS: Eighty fresh porcine knees were stripped of all soft tissue, leaving intact only the femur-anterior cruciate ligament (ACL)-tibia complex. A standardized type III fracture was simulated at the anterior cruciate ligament attachment region using an osteotome. Then, the 80 specimens were randomly divided into 4 groups consisting of 20 knees each. The bony fragments were, respectively, fixed with sutures, steel wire, screws, and the newly designed tension band wire. All specimens were subsequently tested on a Material Testing Machine at a load rate of 60 mm/min. The statistically significant difference between the methods in terms of ultimate failure load, yield load, and displacement of the fragment under single-cycle loading and cyclic loading were analysed. RESULTS: Steel wire encircling K-wire fixation showed significantly higher maximum loads, yield loads, and less displacement than all the other fixation methods tested. Specimens fixed with steel wire had the second highest maximal load followed by fixation with the cannulated screw. The lowest maximal load was observed in the group using PDS II suture. CONCLUSIONS: The ultimate strength of tension band wire fixation of tibial eminence fractures in these specimens was significantly greater than those of the other three fixation methods. Tension band wire fixation of eminence fractures appears to provide biomechanical advantages over the other three fixation methods; hence, it is a practical alternative to conventional fixation techniques.

Revision of severe nasal trauma.

Facial trauma commonly includes injury to the nose and perinasal area. In this review, we will focus on the sequelae of severe nasal trauma and provide examples of correction of the severely deviated nose, the severely collapsed nose, and revision of a traumatic deformity after prior rhinoplasty. We will then discuss coexistent deformities of perinasal regions in addition to functional and posttraumatic nasal correction, including posttraumatic periorbital deformities.

Osteochondral autograft transplantation for juvenile osteochondritis dissecans of the knee: a series of twelve cases.

PURPOSE: The purpose of this study was to evaluate the clinical outcomes of osteochondral autograft transplantation (OAT) for juvenile osteochondritis dissecans (JOCD) lesions of the knee, especially time to return to sports. METHODS: Twelve knee JOCD lesions with OCD grade 3 and 4 categorised by magnetic resonance imaging (MRI) were treated with OAT. Nine male and two female skeletally immature patients averaging 13.7 years old were included. The OCD lesions were assessed arthroscopically and then fixed in situ using multiple osteochondral plugs harvested under fluoroscopy from the distal femoral condyle without damaging the physis. International Cartilage Repair Society (ICRS) score and Lysholm score were assessed pre- and postoperatively. RESULTS: After a mean follow-up of 26.2 ± 15.1 months, the International Knee Documentation Committee (IKDC) subjective score significantly improved (p < 0.01). According to the IKDC score, objective assessment showed that ten of 12 (83 %) had excellent results (score: A) after OAT and significantly improved (p < 0.01). Based on ICRS criteria, results were satisfactory in all patients. No patients experienced complications at the graft harvest site. All patients returned to their previous level of athletic activity at an average of 5.7 months after the surgery. CONCLUSIONS: OAT for JOCD of the knee provided satisfactory results in all patients at a mean follow-up of 26.2 months.