No long-term tunnel enlargement following anterior cruciate ligament reconstruction using autograft hamstring tendon with dual suspensory fixation.

PURPOSE: Bone tunnel widening following anterior cruciate ligament reconstruction (ACLR) is well documented, although the aetiology and clinical significance of this phenomenon remain unclear. At mid-term follow-up, a greater prevalence of tunnel enlargement has been reported with the use of hamstring (HS) grafts. However, there are paucity of data on what happens in the longer term. The aim of this study was to assess the change in femoral and tibial tunnel dimensions 15 years after four-strand HS ACLR. METHODS: This is a retrospective review of 15 patients who underwent arthroscopic ACLR using HS autograft tendon and were followed up radiographically at 4 months, 2 years and 15 years. Suspensory fixation was used for both ends of the graft. The diameters of the bone tunnels on posteroanterior (PA) and lateral radiographs were measured using digital callipers. Repeated measures analysis of variance (ANOVA) was used to examine change in tunnel width over time. RESULTS: Radiographic tunnel width did not significantly change between 4 months and 2 years. However, a significant decrease in width was found for both the femoral and tibial tunnels between the 2- and 15-year follow-up (P < 0.01): the femoral tunnel decreased by 50% and 51% in the PA and lateral views, respectively; the tibial tunnel decreased by 77% and 91% in the PA and lateral views respectively. There was no significant correlation between femoral or tibial tunnel width and flexion and extension deficits or with side to side differences in anterior tibial laxity at 15 years. CONCLUSIONS: This radiographic follow-up study of bone tunnel widening following HS ACLR with suspensory fixation demonstrated that tunnel width did not increase beyond 4 months and in fact had decreased significantly at long-term (15 years) follow-up. There was no correlation between tunnel width changes and clinical assessment of flexion and extension deficits or with side-to-side anterior knee laxity at 15-years. LEVEL OF EVIDENCE: IV.

YouTube provides poor information regarding anterior cruciate ligament injury and reconstruction.

PURPOSE: YouTube is a global medium used predominantly by young adults (aged 18-49 years). This study examined the quality of YouTube information regarding ACL injury and reconstruction. METHODS: YouTube was searched on the 13th of June 2015 for "ACL" and "anterior cruciate ligament" with/without associated terms of "injury", "reconstruction", and "surgery". Videos were evaluated by two independent reviewers [EF (Reviewer 1), (Reviewer 2)] using two recognized information scoring systems (Modified DISCERN (MD) 0-5 and JAMA Benchmark 0-4) and an adaptation of a score designed for written ACL information [ACL Specific Score (ASS) 0-25]. The ASS categorized scores as very good (21-25), good (16-20), moderate (11-15), poor (6-10), and very poor (0-5). Number of views/likes/dislikes, animation, and continent of origin and source (e.g., corporate/educational) were recorded. Correlation of video characteristics with number of views was examined using the analysis of variance (ANOVA) model. Agreement between reviewers was assessed by Interclass Correlation Co-efficient (ICC). RESULTS: Following a filtering process of the 964,770 identified videos, 39 videos were retained. The mean MD score was 2.3 (standard deviation (SD) ±0.9) for Reviewer 1 and 2.2 (SD ±0.9) for Reviewer 2 (ICC = 0.7). The mean JAMA score was 2.5(SD ±0.7) for Reviewer 1 and 2.3 (SD ±0.7) for Reviewer 2 (ICC = 0.8). The mean ASS was 6.3 (SD ±3.5) for Reviewer 1 and 4.6 (SD ±2.9) for Reviewer 2 (ICC = 0.9). Five videos achieved moderate score (13%), while 15 (38%) and 19 (49%) scored as poor and very poor, respectively. There was no correlation between number of views and video quality/video source for any scoring system. CONCLUSION: The majority of videos viewed on YouTube regarding ACL injury and treatment are of low quality.

Incomplete burst fractures of the thoracolumbar spine: a review of literature.

PURPOSE: The purpose of this review was to analyze the biomechanical basis of incomplete burst fractures of the thoracolumbar spine, summarize the available treatment options with evidence from the literature, and to propose a method to differentiate fracture severity. METHODS: The injury pattern, classification, and treatment strategies of incomplete burst fractures of the thoracolumbal spine have been described following a review of the literature. All level I-III studies, studies with long-term results and comparative studies were included and summarized. RESULTS: Details of five randomized control trials were included. Additionally, three comparative studies and two studies with long-term outcomes were detailed in this review. The fracture severity reported in the included studies varied tremendously. Most classification used did not adequately describe the complexity of fracture configuration. A wide variety of treatment strategies were outlined, ranging from non-operative therapy to aggressive surgical intervention with combined anterior-posterior approaches. Thus, the treatment of incomplete burst fractures of the thoracolumbar spine is quite diverse and remains controversial. CONCLUSIONS: Incomplete burst fractures can differ tremendously regarding the degree of instability they confer to the thoracolumbar spine. Based on a detailed review of the literature, it is clear that good results can be obtained with both non-operative and operative strategies to treat these injuries. In the authors' opinion, the intervertebral disc plays a key role in determining the long-term clinical and radiological outcome. Thus, an incorporation of the intervertebral disc pathology into the existing classification systems would be a valuable prognostic factor.

Silver nanoparticles and their orthopaedic applications.

Implant-associated infection is a major source of morbidity in orthopaedic surgery. There has been extensive research into the development of materials that prevent biofilm formation, and hence, reduce the risk of infection. Silver nanoparticle technology is receiving much interest in the field of orthopaedics for its antimicrobial properties, and the results of studies to date are encouraging. Antimicrobial effects have been seen when silver nanoparticles are used in trauma implants, tumour prostheses, bone cement, and also when combined with hydroxyapatite coatings. Although there are promising results with in vitro and in vivo studies, the number of clinical studies remains small. Future studies will be required to explore further the possible side effects associated with silver nanoparticles, to ensure their use in an effective and biocompatible manner. Here we present a review of the current literature relating to the production of nanosilver for medical use, and its orthopaedic applications.

The role of osteoblasts in peri-prosthetic osteolysis.

Peri-prosthetic osteolysis and subsequent aseptic loosening is the most common reason for revising total hip replacements. Wear particles originating from the prosthetic components interact with multiple cell types in the peri-prosthetic region resulting in an inflammatory process that ultimately leads to peri-prosthetic bone loss. These cells include macrophages, osteoclasts, osteoblasts and fibroblasts. The majority of research in peri-prosthetic osteolysis has concentrated on the role played by osteoclasts and macrophages. The purpose of this review is to assess the role of the osteoblast in peri-prosthetic osteolysis. In peri-prosthetic osteolysis, wear particles may affect osteoblasts and contribute to the osteolytic process by two mechanisms. First, particles and metallic ions have been shown to inhibit the osteoblast in terms of its ability to secrete mineralised bone matrix, by reducing calcium deposition, alkaline phosphatase activity and its ability to proliferate. Secondly, particles and metallic ions have been shown to stimulate osteoblasts to produce pro inflammatory mediators in vitro. In vivo, these mediators have the potential to attract pro-inflammatory cells to the peri-prosthetic area and stimulate osteoclasts to absorb bone. Further research is needed to fully define the role of the osteoblast in peri-prosthetic osteolysis and to explore its potential role as a therapeutic target in this condition.

Focal femoral condyle resurfacing.

Focal femoral inlay resurfacing has been developed for the treatment of full-thickness chondral defects of the knee. This technique involves implanting a defect-sized metallic or ceramic cap that is anchored to the subchondral bone through a screw or pin. The use of these experimental caps has been advocated in middle-aged patients who have failed non-operative methods or biological repair techniques and are deemed unsuitable for conventional arthroplasty because of their age. This paper outlines the implant design, surgical technique and biomechanical principles underlying their use. Outcomes following implantation in both animal and human studies are also reviewed.

Concussion among under 20 rugby union players in Ireland: incidence, attitudes and knowledge.

INTRODUCTION: The aim of this study was to determine the incidence of concussion among a cohort of male under 20 rugby players and assess basic knowledge and attitudes. METHODS: Under 20 age group, players were recruited from local clubs as well as the national academy system. Players were asked to report on their history of concussion as well as a number of factors regarding their recognition of symptoms and behaviours regarding the diagnosis of concussion. RESULTS: 133 players responded (95% response rate). Players could list a mean of 2.6 concussion related symptoms. 64 reported sustaining at least one concussion (average 2.25) and 36 sought medical attention following a concussion. 61 said that they would report suffering a concussion to their coach while 32 would report it to a 'team physiotherapist' or doctor. 114 believed that concussion is as serious as other rugby injuries and 100 believe that playing on while concussed could lead to long-term medical problems. CONCLUSIONS: Further educational efforts are required in this age group of rugby union players to reduce the risk of unnecessary secondary injury. Coaches, managers and players alike need to be targeted in any educational program.

Design, implementation and prospective evaluation of a new interactive musculoskeletal module for medical students in Ireland.

BACKGROUND: We designed, implemented and assessed an interactive musculoskeletal teaching module for fourth-year medical students. Over a 2-week period, students followed a programme of alternating lectures, interactive tutorials, case discussions, clinical examination and 'how to do' sessions using patients and clinical models. METHODS: Over a 4-month period, 140 fourth-year medical students rotated for 2 weeks through a new interactive musculoskeletal teaching module in an elective orthopaedic hospital. To assess the impact of our module, a basic-competency examination in musculoskeletal medicine was developed and validated. Each student completed the examination on the first and last days of the module. We also assessed musculoskeletal basic knowledge in students from a different medical school, receiving a classic lecturing programme. RESULTS: In the pre-course assessment, only 20 % of students achieved an overall pass rate. The pass rate increased to 85 % in post-course examination. Students found particularly beneficial the interactive tutorial approach, with 48 % finding this to be the single most effective teaching method. When compared with students who completed a classic lecturing programme, students attending our interactive module scored higher in all aspects of musculoskeletal knowledge. SIGNIFICANCE: This study highlights the benefits and need for more interactive teaching of musculoskeletal medicine in medical schools.

Cobalt ions induce chemokine secretion in primary human osteoblasts.

Chemokines are major regulators of the inflammatory response and have been shown to play an important role in periprosthetic osteolysis. Titanium particles have previously been shown to induce IL-8 and MCP-1 secretion in osteoblasts. These chemokines result in the chemotaxis and activation of neutrophils and macrophages, respectively. Despite a resurgence in the use of cobalt-chromium-molybdenum alloys in metal-on-metal arthroplasty, cobalt and chromium ion toxicity in the periprosthetic area has been insufficiently studied. In this study we investigate the in vitro effect of cobalt ions on primary human osteoblast activity. We demonstrate that cobalt ions rapidly induce the protein secretion of IL-8 and MCP-1 in primary human osteoblasts. This elevated chemokine secretion is preceded by an increase in the transcription of the corresponding chemokine gene. Using a Transwell migration chemotaxis assay we also demonstrate that the chemokines secreted are capable of inducing neutrophil and macrophage migration. Furthermore, cobalt ions significantly inhibit osteoblast function as demonstrated by reduced alkaline phosphatase activity and calcium deposition. In aggregate these data demonstrate that cobalt ions can activate transcription of the chemokine genes IL-8 and MCP-1 in primary human osteoblasts. Cobalt ions are not benign and may play an important role in the pathogenesis of osteolysis by suppressing osteoblast function and stimulating the production and secretion of chemokines that attract inflammatory and osteoclastic cells to the periprosthetic area.