A Randomized Trial of Autologous Chondrocyte Implantation Versus Alternative Forms of Surgical Cartilage Management in Patients With a Failed Primary Treatment for Chondral or Osteochondral Defects in the Knee.

BACKGROUND: There are limited randomized controlled trials with long-term outcomes comparing autologous chondrocyte implantation (ACI) versus alternative forms of surgical cartilage management within the knee. PURPOSE: To determine at 5 years after surgery whether ACI was superior to alternative forms of cartilage management in patients after a failed previous treatment for chondral or osteochondral defects in the knee. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: In total, 390 participants were randomly assigned to receive either ACI or alternative management. Patients aged 18 to 55 years with one or two symptomatic cartilage defects who had failed 1 previous therapeutic surgical procedure in excess of 6 months prior were included. Dual primary outcome measures were used: (1) patient-completed Lysholm knee score and (2) time from surgery to cessation of treatment benefit. Secondary outcome measures included International Knee Documentation Committee and Cincinnati Knee Rating System scores, as well as number of serious adverse events. Analysis was performed on an intention-to-treat basis. RESULTS: Lysholm scores were improved by 1 year in both groups (15.4 points [95% CI, 11.9 to 18.8] and 15.2 points [95% CI, 11.6 to 18.9]) for ACI and alternative, with this improvement sustained over the duration of the trial. However, no evidence of a difference was found between the groups at 5 years (2.9 points; 95% CI, -1.8 to 7.5; P = .46). Approximately half of the participants (55%; 95% CI, 47% to 64% with ACI) were still experiencing benefit at 5 years, with time to cessation of treatment benefit similar in both groups (hazard ratio, 0.97; 95% CI, 0.72 to 1.32; P > .99). There was a differential effect on Lysholm scores in patients without previous marrow stimulation compared with those with marrow stimulation (P = .03; 6.4 points in favor of ACI; 95% CI, -0.4 to 13.1). More participants experienced a serious adverse event with ACI (P = .02). CONCLUSION: Over 5 years, there was no evidence of a difference in Lysholm scores between ACI and alternative management in patients who had previously failed treatment. Previous marrow stimulation had a detrimental effect on the outcome of ACI. REGISTRATION: International Standard Randomised Controlled Trial Number: 48911177.

Patient-specific instruments: advantages and pitfalls.

Patient-specific instruments (PSI) aim to improve the accuracy of total knee replacement (TKR) based on computer-assisted preoperative planning. In this work, the authors describe the advantages and pitfalls of PSI based on their clinical experience. The main conclusion of this work is that PSI has direct impact on the logistical and technical features of TKR with some advantages and pitfalls.

The 2-0 Ethilon test.

Tight closure, which is a sign of ischemia secondary to tension, can lead to tissue necrosis. This article describes a simple and reliable test to help avoid excessive tension during skin closure.

The Long Gamma Nail for stabilisation of existing and impending pathological fractures of the femur: an analysis of 48 cases.

The results in a series of 42 patients with 48 impending or complete pathological femur fractures stabilised with the Long Gamma nail (Howmedica-Osteonics, Rutherford, NJ,USA) are presented. Twenty two impending and 26 completed pathological femoral fractures treated between 1995 and 1999 were retrospectively analysed. The mean age of the patients was 65.7 yrs (range: 40 to 88). All patients were treated with an 11-mm diameter Long Gamma Nail, inserted through a 5-cm incision proximal to the greater trochanter using the antegrade reaming technique. The mean surgical time was 98 minutes (range: 65 to 225). Reliable stability was achieved in all cases and pain relief was excellent. Complications included 2 superficial and 1 deep wound infections, 4 chest infections, 2 urinary tract infections, and 2 deaths in the recovery. Implant failure occurred in one patient and needed revision to a long stemmed total hip prosthesis. The Long Gamma nail offers the advantage of a technically less demanding percutaneous insertion through the tip of the greater trochanter, secure proximal femoral fixation and the ability to allow immediate or early weight-bearing ambulation. Because of these advantages, we recommend the use of the Long Gamma nail for stabilisation of pathologic and impending pathologic fractures of the femur.

Acutrak fixation of comminuted distal radial fractures.

The authors describe a new technique of fixation of comminuted displaced distal radial fractures in young adults. A 40-year-old man fell from a ladder and injured his wrist. He sustained a comminuted fracture of the distal radius. The fracture was opened through a volar incision and the three rotated, unreduced fragments were reduced and fixed with three Acutrak (Acumed Inc., Beaverton, OR, USA) screws. A removable splint was applied to the wrist for one week, following which the wrist was mobilised. Six months later at a routine follow-up the patient had full functional use of the wrist. The purpose of this technical note is to discuss the fracture, the fixation technique, and the management of this subtype of distal radial fractures in young adults.

Phalangeal intraosseous epidermoid cyst.

The authors describe two cases of phalangeal intraosseous epidermoid cyst. Two theories try to explain their origin. One theory sees traumatic implantation of epidermal cells as causative. A second theory is based on faulty embryogenesis.

The 30 ml cement test.

We describe a simple and reliable test which can be used while performing hip arthroplasty as an indicator of the size and volume of the femoral canal to roughly estimate the volume of cement required to fill the femoral canal for cementing the femoral prosthesis.

Implant removal on an outpatient basis. A patient satisfaction survey.

Unstable fractures of the distal radius can be stabilised with Kirschner wires. The K wires need to be removed after five to six weeks. The authors surveyed 100 consecutive patients with distal radial fractures treated with percutaneous Kirschner wires that were left buried under the skin. Group A had 50 patients who had such wires removed under local anaesthetic in the orthopaedic outpatient department. Group B comprised of patients who had the wires removed in the operating theatres under a short general anaesthetic. A questionnaire was designed to assess the satisfaction of these 100 patients. The survey showed that the patient satisfaction for this minor procedure carried out in the outpatient clinic was poor. Patient information and senior surgical input could increase the satisfaction.

A biomechanical analysis of four different methods of harvesting bone-patellar tendon-bone graft in porcine knees.

BACKGROUND: Anterior cruciate ligament reconstruction with use of bone-patellar tendon-bone graft is commonly performed to treat functional instability of the knee after injury of the anterior cruciate ligament. Patellar fracture is an underreported complication of this procedure, yet it may be a career-ending injury for a professional athlete. The purpose of this study was to design a new technique to procure the patellar bone plug when reconstructing the cruciate ligament with use of patellar tendon. METHODS: Fifty-eight knees were harvested from eighteen to twenty-four-month-old pigs. Bone plugs of four geometrical shapes were cored out of the patellae from forty knees (four plug shapes for each of ten knees). Ten knees had no graft removed. Fifty knees were tested for the effects of a single impact. Eight knees (two plug shapes for each of four knees) were tested for the effects of repeated impacts. Data were analyzed statistically with use of an ordinal logistic model. The probability of impact failure of the patella at different energy levels was calculated. RESULTS: Impact energy has been shown to have a significant effect on the outcome (p < 0.001). When controlling for energy level, there was a significant difference between the sharp and round corners (p < 0.01). The ordinal logistic model was found to be very good for predicting the outcome of impact testing. The impact energy required to create a 1% probability of complete fracture was 7 J for a patella with a sharp-cornered plug defect, 17 J for a patella with a trapezoidal plug, 22 J for a patella with a sharp-cornered defect with a drill-hole at the corner, 40 J for a patella with a round-cornered defect, and about 49 J for a normal patella. Repeat impact testing substantially damaged the patellae with sharp-cornered defects, as they failed earlier at a lower energy and after a lower number of impacts than did the patellae with round-cornered defects. CONCLUSIONS: We propose the use of the round-cornered patellar bone plug when bone-patellar tendon-bone graft is harvested for anterior cruciate ligament reconstruction, to further reduce the small likelihood of a patellar fracture occurring intraoperatively or in the early postoperative rehabilitation phase.