The Poller Screw Technique: A Method of Fine-Tuning the Reduction in Locked Nailing.

Intramedullary nailing is the treatment of choice for diaphyseal fractures in long bones. However, nailing of long bone fractures at the metaphyseodiaphyseal junction is technically difficult and can cause malalignment because of the mismatch in the diameter of the bone. One of the most common and recently described methods of correcting deformity during nailing is the poller screw technique. We describe a modified technique to correct malreduced fractures with the nail in situ, which we have used successfully in 3 patients.

Comparison of Electrophysiological Properties and Gene Expression between Human Chondrocytes and Chondroprogenitors Derived from Normal and Osteoarthritic Cartilage.

OBJECTIVES: Bone-marrow mesenchymal stem cells (MSCs) and chondrocytes are currently used for cell-based therapy in cartilage repair. Chondroprogenitors (CPs), resident cells of articular cartilage, demonstrate likeness to stem cells. Reports suggest that chondrocytes phenotype is altered in culture, thus making differentiation between the two cell populations difficult. Our objectives were to electrophysiologically assess chondrocytes and CPs, compare their mRNA expression with that of ionic channels already reported in MSCs, and to observe the effect of time in culture and osteoarthritic damage on cells. DESIGN AND RESULTS: Chondrocytes and CPs at passages 0 (p0) and 5 (p5) derived from normal and osteoarthritic (OA) knee joints were used. Ionic currents were recorded by subjecting cells to depolarizing voltage pulses, and reverse transcriptase-polymerase chain reaction (RT-PCR) was used for studying ion channel expression. Our results demonstrated that both chondrocytes and CPs showed the presence of similar currents belonging to voltage-gated potassium channel subfamily, with RT-PCR confirming high mRNA expression of Maxi K, HKv1.1, HKv1.4, HKv4.2, and hEAG1 channels. Our finding also suggested that CPs were comparatively more sensitive to increased time in culture and inflammatory processes as observed in OA, as was evidenced by the significant decrease in mean current density (p0 normal CP: 183.171 ± 50.80 pA/pF; p5 normal CP: 50.225 ± 17.63 pA/pF; P = 0.0280) and significant increase in cellular size (p0 normal CP: 21.564 ± 2.98 pF; p0 OA CP: 37.939 ± 3.55 pF; P = 0.0057). CONCLUSION: Both cell types appear to be optimal candidates for cell-based therapy although initial seeding density, cell source (normal vs. OA), and time in culture are matters of concern, prior to cell-type selection.

Management of Chronic Infected Intra-Articular Fractures of the Proximal Tibia with Ilizarov Ring Fixation.

Infected nonunion and malunion of tibial plateau are rare injuries with no standardized protocols for treatment. This study assessed the outcome of chronic infected intra-articular proximal tibial fractures with and without metaphyseal bone loss managed with the Ilizarov ring fixator. A series of six patients of intra-articular infected nonunion of the tibial plateau and two patients with malunited plateau with metaphyseal nonunion were treated in a tertiary care hospital. Three of these eight patients had a metaphyseal bone loss or bone gap after debridement and underwent internal transport with distal corticotomy to obtain the bone length. The remaining five patients underwent static ring fixation after correction of the articular deformity. Clinical evaluation was done by Knee Society Score, Rasmussen radiological and Association for the Study and Application of Methods of Ilizarov scores. All patients but one achieved union with the ring fixator. The average follow-up was 33 months (range, 12-120 months). Average time to achieve union was 11.5 months (range, 3-30). The scores were good in four patients and poor in the rest four, out of which three had undergone internal transport. Proximal tibia intra-articular infected nonunion and malunion with or without metaphyseal bone loss can be treated successfully with the Ilizarov fixator. Malunion of the tibial plateau has to be addressed in cases with varus alignment of the limb or articular step-off of ≥ 5mm between the two tibial surfaces. Patients with associated metaphyseal bone loss tend to have complications and take a longer duration to heal. Single-stage treatment avoids intra-articular malunion and loss of limb alignment.

Saving the ankle in distal fibular giant cell tumour - A case report.

Distal Fibula Giant cell tumour (GCT) is a rare condition. The described methods of treatment for distal fibula GCT include excision of tumour and ankle arthrodesis, replacement of distal fibula with ipsilateral proximal fibula and autograft or allograft reconstruction. This case report describes treatment of distal fibula grade 3 GCT with involvement of syndesmosis with tumour excision, proximal fibular slide and reconstruction of ankle joint. With this technique the ankle joint movements are preserved and stability is maintained.

Similar regeneration of articular cartilage defects with autologous & allogenic chondrocytes in a rabbit model.

Background & objectives: Articular cartilage defects in the knee have a very poor capacity for repair due to avascularity. Autologous chondrocyte transplantation (ACT) is an established treatment for articular cartilage defects. Animal studies have shown promising results with allogenic chondrocyte transplantation since articular cartilage is non-immunogenic. In addition to being economical, allogenic transplantation has less morbidity compared to ACT. This study was undertaken to compare ACT with allogenic chondrocyte transplantation in the treatment of experimentally created articular cartilage defects in rabbit knee joints. Methods: Cartilage was harvested from the left knee joints of six New Zealand white rabbits (R1-R6). The harvested chondrocytes were cultured to confluence and transplanted onto a 3.5 mm chondral defect in the right knees of 12 rabbits [autologous in 6 rabbits (R1-R6) and allogenic in 6 rabbits (R7-R12)]. After 12 wk, the rabbits were euthanized and histological evaluation of the right knee joints were done with hematoxylin and eosin and safranin O staining. Quality of the repair tissue was assessed by the modified Wakitani histological grading scale. Results: Both autologous and allogenic chondrocyte transplantation resulted in the regeneration of hyaline/mixed hyaline cartilage. The total histological scores between the two groups showed no significant difference. Interpretation & conclusions: Allogenic chondrocyte transplantation seems to be as effective as ACT in cartilage regeneration, with the added advantages of increased cell availability and reduced morbidity of a single surgery.

Comparison of human articular chondrocyte and chondroprogenitor cocultures and monocultures: To assess chondrogenic potential and markers of hypertrophy.

BACKGROUND AND OBJECTIVE: In the field of cartilage repair, use of two or more cell populations such as mesenchymal stem cells with chondrocytes in an in-vitro co-culture synergistic environment has been attempted to evade limitations of monoculture systems and promote/induce chondrogenesis. Articular cartilage-derived chondroprogenitors (CPs), considered to have stem-cell like characteristics have been proposed as a potential contender for neocartilage development. Our objective was to assess whether co-cultures using different ratios of chondrocytes(C) and CPs would demonstrate better results in terms of growth kinetics, surface marker expression, chondrogenic potential, tendency for hypertrophy and glycosaminoglycan deposition than monocultures. STUDY DESIGN: Human chondrocytes and CPs (fibronectin adhesion assay) from the same cartilage source were isolated. Passage 2 cells were subjected to monolayer/pellet cultures and were grown as monocultures and cocultures at the following percentage ratios(C:CP) 80:20, 65:35, 50:50, 35:65 and 20:80. RESULTS: Analysis of data acquired from population doubling, flow cytometry, RT-PCR and Safranin O uptake demonstrated similar results in all monoculture and co-culture groups with no significant inter-group variation, even when reported specific markers of identification (CD54 and CD44:chondrocyte markers) and isolation (CD29 and CD49e: forming heterodimeric fibronectin receptor for CP sorting) were examined. CONCLUSION: In conclusion, this study suggests the need for improved sorting techniques based on a characteristic differentiating biomarker for selection of cells which are true representatives of CPs possessing properties of enhanced chondrogenesis and reduced hypertrophy.

Comparison of Reverse Sural Artery Flap Healing for Traumatic Injuries Above and Below the Ankle Joint.

The reverse sural artery (RSA) flap is popular among trauma surgeons to cover the distal third of the leg to the foot. However, flaps that inset in the foot seem to have a high necrosis rate. This study compared the healing of RSA flaps performed for defects proximal to the ankle versus defects distal to the ankle. Patient data were collected retrospectively between January 2005 and December 2009. Eighty-five patients with the lower leg, ankle, and traumatic foot injuries were divided into 2 groups. Group 1 (49 patients) had RSA flap cover for soft tissue and bony defect proximal and up to the ankle joint line, and group 2 (36 patients) had RSA flap cover distal to the ankle joint line. The time to healing and type of healing were compared between the groups. The demographics between the 2 groups were similar. The successful RSA flap healing rate was 65% in group 1 (32 of 49) and 42% in group 2 (15 of 36). The average time to flap healing between the groups was similar (p = .16). Group 1 had predominantly primary healing compared with group 2 (p = .03). Group 2 had a higher reoperation rate for wound necrosis, which was significant (p = .001). The success of the RSA flap is higher when used for proximal to ankle joint line defects. Surgeons should be aware of the chances of flap necrosis when undertaking RSA flap cover distal to the ankle joint line.

Outcome of screw post fixation of neglected posterior cruciate ligament bony avulsions.

BACKGROUND: Contrary to acute posterior cruciate ligament (PCL) bony tibial avulsions, surgical management of chronic injuries is technically challenging and appears to be controversial. We sought to assess the outcome of a novel screw post augmentation technique in neglected cases. METHODS: 16 patients were followed up in a tertiary single-center retrospective study. The bony fragment was fixed using a lag screw with a spiked washer and an additional screw post through an open posterior approach. The pre- and postoperative knee range of movement (ROM), laxity, and modified Tegner-Lysholm (TL) scores were compared. RESULTS: The median time from injury to surgery was 10 weeks (range, 3-260). The mean clinical follow-up time was 24.25 ± 9.21 months. At the final follow-up, the mean knee ROM flexion was 130° ± 11.55° with no extension lag. 3 patients had grade 1 laxity. The TL grade was predominantly excellent, and the overall median score improved from 76 preoperatively to 95 postoperatively (p < 0.0004). Bony union was achieved in all cases. CONCLUSION: The described screw post fixation technique results in an excellent outcome for these rare injuries. LEVEL OF EVIDENCE: Level IV, case series.

Allogeneic platelet rich plasma serves as a scaffold for articular cartilage derived chondroprogenitors.

Limited self-restorative ability of the cartilage has necessitated the use of cell and tissue engineering based therapies. Recent advances in the isolation, expansion and characterization of articular cartilage derived chondroprogenitors(CPs) has gained popularity in its role for cartilage repair. Platelet rich plasma (PRP) is a reliable biological scaffold for in-vitro and in-vivo studies with reported therapeutic applications in cartilage and bone pathologies. The aim of this study was to evaluate whether human allogeneic PRP could serve as a biological scaffold for chondroprogenitors (CPs) in cartilage repair. CPs were isolated from the superficial layer of three osteoarthritic knee joints by fibronectin adhesion assay and characterized using flow cytometric analysis. Allogeneic citrated blood was harvested from three subjects to obtain PRP. CPs at a concentration of one million cells per ml were gelled with PRP using calcium chloride. The PRP-CP scaffolds were subjected for adipogeneic, osteogenic, chondrogeneic differentiation and processed for post differentiation-staining studies (Oil Red O, Von Kossa, Alcian blue staining), immunofluorescence (collagen II) and live dead assays (Calcein AM-Ethidium Homodimer). We show that PRP was able to sustain CP cell viability and differentiate towards adipogenic, osteogenic and chondrogenic lineage under appropriate culture conditions. We also noted positive extracellular matrix production in PRP-CP scaffolds cultured without chondrogenic supplementation. Our results suggest that PRP could be a promising bio-active scaffold due to its synergistic effect in supporting cell proliferation, maintaining cell viability and favoring extracellular matrix production. PRP can be used as biological scaffold for the delivery of CPs in cartilage healing.

Reserve or Resident Progenitors in Cartilage? Comparative Analysis of Chondrocytes versus Chondroprogenitors and Their Role in Cartilage Repair.

Introduction Articular cartilage is made up of hyaline tissue embodying chondrocytes, which arise from mesenchymal stromal cells (MSCs) and specialized extracellular matrix. Despite possessing resident progenitors in and around the joint primed for chondrogenesis, cartilage has limited intrinsic capacity of repair and cell turnover. Advances in isolation, culture, and characterization of these progenitors have raised the possibility for their use in cell-based cartilage repair. Chondroprogenitors (CPCs) have been classified as MSCs and have been postulated to play a vital role in injury response and are identified by their colony forming ability, proliferative potential, telomere dynamics, multipotency, and expression of stem cell markers. The combined presence of CPCs and chondrocytes within the same tissue compartments and the ability of chondrocytes to dedifferentiate and acquire stemness during culture expansion has obscured our ability to define and provide clear-cut differences between these 2 cell populations. Objective This review aims to evaluate and summarize the available literature on CPCs in terms of their origin, growth kinetics, molecular characteristics, and differential and therapeutic potential with emphasis on their difference from daughter chondrocytes. Design For this systematic review, a comprehensive electronic search was performed on PubMed and Google Scholar using relevant terms such as chondrocytes, chondroprogenitors, and surface marker expression. Results and Conclusion Our comparative analysis shows that there is an ill-defined distinction between CPCs and chondrocytes with respect to their cell surface expression (MSC markers and CPC-specific markers) and differentiation potential. Accumulating evidence indicates that the 2 subpopulations may be distinguished based on their growth kinetics and chondrogenic marker.

Neglected Anterior Dislocation of the Knee with Common Peroneal Palsy.

Knee dislocations usually follow high velocity injuries and are increasingly being treated with immediate reduction and staged repair of the ligaments. Neglected knee dislocations are rare and more difficult to treat with inferior outcomes. We present a rare case of neglected anterior dislocation of the knee treated by surgical arthrodesis.

Can tibial plateau fractures be reduced and stabilised through an angiosome-sparing antero-lateral approach?

INTRODUCTION AND AIM: Tibial plateau fractures (TPFs) are an independent, non-modifiable risk factor for surgical site infections (SSIs). Current antero-lateral approaches to the knee dissect through the anterior tibial angiosome (ATA), which may contribute to a higher rate of SSIs. The aim of this study was to develop an angiosome-sparing antero-lateral approach to allow reduction and fixation of lateral TPFs and to investigate its feasibility in a consecutive cohort. METHODS: Twenty cadaveric knees were dissected to define the position of the vessels supplying the ATA from the lateral tibial condyle to the skin perforators. Based on these results, an angiosome-sparing surgical approach to treat lateral TPFs was developed. Fifteen consecutive patients were subsequently treated through this approach. Clinical outcomes included assessment of SSI and Lysholm score. Fracture healing and stability were assessed using the Rasmussen score and radiostereometric analysis (RSA). RESULTS: At the latest follow-up between 1 and 4 years, there was no report of SSI. Nine patients (60%) had good or excellent Lysholm scores. The mean Rasmussen score at final follow-up was 17 (median 18, range 14-18) with 10 patients (66%) graded as excellent. Fracture fragment migration measured using RSA was below 2mm in all cases. DISCUSSION: This study has demonstrated that an angiosome-sparing antero-lateral approach to the lateral tibial plateau is feasible. Adequate stability of these fracture types was achieved by positioning a buttress plate away from the bone and superficial to the regional fascial layer as an 'internal-external fixator'. CONCLUSION: The angiosome-sparing approach developed was able to be used in a prospective cohort and the clinical results to date are encouraging. Future clinical studies need to investigate the potential benefits of this surgical approach when compared with the previously described antero-lateral approaches.

The efficacy of single-stage open intramedullary nailing of neglected femur fractures.

BACKGROUND: Neglected femur fractures are not rare in the developing world. Treatment options include single-stage open reduction and intramedullary nailing, or open release, skeletal traction, and then second-stage open intramedullary nailing, with bone grafting. Single-stage procedures have the potential advantage of avoiding neurovascular complications secondary to acute lengthening, but they require a second operation, with potentially increased resource use and infection risk. QUESTIONS/PURPOSES: We sought to determine the (1) likelihood of union, (2) complications and reoperations, and (3) functional results with single-stage open intramedullary nailing without bone grafting in patients with neglected femur fractures. METHODS: Between January 2003 and December 2007, 17 consecutive patients presented to our practice with neglected femoral shaft fractures. All were treated with single-stage nailing without bone grafting. There were 15 men and two women with a median age of 27 years. The average time from fracture to treatment was 13 weeks (range, 4-44 weeks). Eleven patients underwent open nailing with interlocked nails and six were treated with cloverleaf Kuntscher nails. Patients were followed for a minimum of 6 months (mean, 33 months; range, 6-72 months). The mean preoperative ROM of the knee was 28° (range, 10°-150°) and femoral length discrepancy was 3.1 cm (range, 1-5 cm). RESULTS: All fractures united and the mean time to union was 16 weeks (range, 7-32 weeks). There were no neurologic complications secondary to acute lengthening. The mean postoperative ROM of the knee was 130° (range, 60°-150°). All patients were able to return to preinjury work. Sixteen patients regained their original femoral length. CONCLUSIONS: One-stage open intramedullary nailing of neglected femoral diaphyseal fractures without bone grafting was safe and effective, and obviated the need for a two-stage approach. Although the findings need to be replicated in larger numbers of patients, we believe this technique may be useful in treating patients with this injury, and may offer advantages in resource-constrained environments.

Impaction bone grafting of segmental bone defects in femoral non-unions.

Impaction bone grafting shows encouraging early results as a method of immediately restoring leg length, while allowing weight-bearing as tolerated, in the treatment of large segmental femoral defects after femoral shaft and metaphyseal non-unions. The operative technique followed is described in three consecutive cases and the effectiveness of impaction bone grafting for femoral non-unions with associated large segmental bone defects has been demonstrated. Between 80 and 120 cm3 of coarsely milled irradiated bone allograft was used to reconstruct the defects, which were contained in malleable metal mesh. All three patients were fully weight-bearing by three months postoperatively. At two years follow-up, plain radiographs demonstrated maintenance of reduction and healing in all three cases.

Functional outcome of biological condylar blade plating of subtrochanteric fractures.

BACKGROUND: The aim of this study was to review high-energy subtrochanteric fractures treated biologically with the 95° angled blade plate, to assess the time to union and return to work, and to perform a functional evaluation using the traumatic hip rating scale. PATIENTS AND METHODS: This study is a retrospective review of 22 patients with 23 fractures. Twenty-one patients (96%) with 22 fractures were available for analysis. The average age was 33 years (range 18-47). There were seventeen males and four females. The right side was involved in fifteen patients, the left in five patients, and one patient had bilateral fractures. Motor vehicle accident was the predominant mode of injury in eleven patients. Seven patients had other associated injuries. 32B2.1 (40%) was the commonest fracture pattern according to the OTA classification. RESULTS: The average follow-up period was 29 months (range 12-49). The mean time to fracture healing was 16 weeks (range 12-32). All patients returned to their pre-fracture occupation (100%). Eighteen patients (86%) healed without any additional surgery. The outcome according to the hip rating scale was excellent in ten patients and good in eleven patients. Two patients (9%) required additional surgery. CONCLUSIONS: Biological fixation of subtrochanteric fractures using 95° CBP results in a high union rate with low morbidity and good functional outcome.

Incidence and radiologic outcome of intraoperative lateral wall fractures in OTA 31A1 and A2 fractures treated with cephalomedullary nailing.

OBJECTIVES: To determine the incidence of intraoperative lateral wall fracture in OTA 31A1 and A2 fractures treated with a cephalomedullary nail and to determine whether this contributed to the failure of treatment. DESIGN: Retrospective review. SETTING: University hospital. PATIENTS/PARTICIPANTS: A cohort of 291 patients (31.A1/A2-231, A3-60) was assessed with pre- and postoperative radiographs. Patients with intact lateral wall fractures were included in the study. One hundred sixty-five of 231 patients (77%) completed radiologic follow-up. They were divided into 2 groups. Group 1 (129 patients, 78%) consisted of patients with an intact lateral wall postoperatively. Group 2 (36 patients, 22%) consisted of patients who sustained lateral wall fracture intraoperatively (FLW). INTERVENTION: Closed reduction and intramedullary nail insertion. MAIN OUTCOME MEASUREMENTS: Rate of failure/reoperation and collapse were compared between the groups. RESULTS: The incidence of intraoperative lateral wall fracture was 21% (48 of 165). Fracture collapse and failure rate were not statistically significant in either groups (group 1: 1%, group 2: 5%). CONCLUSIONS: The incidence of intraoperative lateral wall fracture in OTA 31A1 and A2 pertrochanteric fractures after cephalomedullary nailing is similar to sliding hip screws. The presence of lateral wall fracture did not adversely affect healing of pertrochanteric fractures. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A simple solution for wound coverage by skin stretching.

Viscoelastic properties of skin, ie, creep and stress relaxation, allow it to stretch beyond its normal state within a short period of time. Presented here is a technique of "wound coverage by skin stretching" that uses this principle. Kirschner wires were passed through the skin edges on either side of the wound margins. Dynamic traction was applied with traction bands improvised by the surgeon from surgical glove wrist rings. We used this method in eight patients to close 10 wounds that were not feasible to close with direct methods. We have found that this simple, economic, and effective method provides rapid functional wound closure when bone and other structures are exposed. It does not require specialized training or devices. Careful attention to the described surgical technique gives good results and few complications.