"Meniscal" scar as a landmark for the joint line in revision total knee replacement.

AIM: To determine whether tissue identified at the joint line was actually remnant "meniscal" scar tissue or not. METHODS: Nine patients undergoing revision knee surgery following informed consent had meniscal scar tissue sent to the histology department for analyses. All revisions were performed where joint line had been raised or lowered at earlier surgery. Although preoperative radiographic evaluations suggested that the joint line had been altered, intraoperatively there was scar tissue at the level of the recreated joint line. This scar tissue has traditionally been described as meniscal scar, and to identify the origins of this tissue, samples were sent for histological analyses. The tissue samples were stored in formalin, and embedded and sectioned before undergoing histochemical staining. All samples underwent macroscopic and microscopic examination by a histopathologist who was blind to the study aims. The specific features that were examined included tissue organisation, surface and central composition, cellular distribution including histiocytes, nuclear ratio and vasculature. Atypical and malignant features, inflammation and degeneration were specifically looked for. A statistical review of the study was performed by a biomedical statistician. RESULTS: The histological findings for the nine patients showing the macroscopic and microscopic findings, and the conclusion are outlined in a Table. The histological analyses were reviewed to determine whether the tissue samples were likely to be meniscal scar tissue. The response was yes (2, 22%), no (6, 67%) and maybe (1, 11%) based on the conclusions. The results were "yes" when on macroscopy, firm cream tissue was identified. In these two "yes" samples, microscopic analyses showed organised fibrous tissue with focal degenerative areas with laminated pattern associated with histiocytes peripherally but no inflammation. The "no" samples were assessed macroscopically and microscopically and were deemed to have appearances representing fibrous synovial tissue and features in keeping with degenerate scar tissue or connective tissue. One sample was indeterminate and microscopically contained fibro-collagenous tissue with synovial hyperplasia. It also contained some degenerate hyalinised tissue that may represent cartilage, but the appearances were not specific. CONCLUSION: Based on our pilot study, we recommend reliance on a number of markers to identify the joint line as outlined above, and to exercise caution in using the "meniscal" scar.

Bilateral suprascapular nerve entrapment by ganglion cyst associated with superior labral lesion.

Suprascapular nerve compression is a rare cause of shoulder pain. We report the clinical features, radiological findings, arthroscopic management and outcome of three patients with suprascapular nerve compression caused by labral ganglion cyst associated with SLAP lesion. We performed simultaneous suture anchor SLAP repair and cyst decompression with a blunt probe. Upon a two-year follow-up, patients recovered full shoulder function without pain or limitations in activities of daily living.

Growth factors and stem cells for the management of anterior cruciate ligament tears.

The anterior cruciate ligament (ACL) is fundamental for the knee joint stability. ACL tears are frequent, especially during sport activities, occurring mainly in young and active patients. Nowadays, the gold standard for the management of ACL tears remains the surgical reconstruction with autografts or allografts. New strategies are being developed to resolve the problems of ligament grafting and promote a physiological healing process of ligamentous tissue without requiring surgical reconstruction. Moreover, these strategies can be applicable in association surgical reconstruction and may be useful to promote and accelerate the healing process. The use of growth factors and stem cells seems to offer a new and fascinating solution for the management of ACL tears. The injection of stem cell and/or growth factors in the site of ligamentous injury can potentially enhance the repair process of the physiological tissue. These procedures are still at their infancy, and more in vivo and in vitro studies are required to clarify the molecular pathways and effectiveness of growth factors and stem cells therapy for the management of ACL tears. This review aims to summarize the current knowledge in the field of growth factors and stem cells for the management of ACL tears.

Osteoarthritis: new insights in animal models.

Osteoarthritis (OA) is the most frequent and symptomatic health problem in the middle-aged and elderly population, with over one-half of all people over the age of 65 showing radiographic changes in painful knees. The aim of the present study was to perform an overview on the available animal models used in the research field on the OA. Discrepancies between the animal models and the human disease are present. As regards human 'idiopathic' OA, with late onset and slow progression, it is perhaps wise not to be overly enthusiastic about animal models that show severe chondrodysplasia and very early OA. Advantage by using genetically engineered mouse models, in comparison with other surgically induced models, is that molecular etiology is known. Find potential molecular markers for the onset of the disease and pay attention to the role of gender and environmental factors should be very helpful in the study of mice that acquire premature OA. Surgically induced destabilization of joint is the most widely used induction method. These models allow the temporal control of disease induction and follow predictable progression of the disease. In animals, ACL transection and meniscectomy show a speed of onset and severity of disease higher than in humans after same injury.

Tissue engineered strategies for pseudoarthrosis.

Numerous classification systems of non-union have been proposed based on: presence or absence of infection, radiographic features, clinical findings, biologic activity, location and shape. The management of pseudarthrosis is strongly related to the type of non-union (infected versus uninfected, atrophic versus hypertrophic). Surgical management of pseudarthrosis is generally effective with a success rate ranging from 75 to 100%. Nevertheless, in a relatively high number of instances several combined treatments are required for the fracture healing. The current gold standard to stimulate the bone regeneration is represented by the revision surgery with the application of autologous bone grafts. However, several approaches have been described to promote and enhance the bone tissue regeneration, including extracorporeal shock wave therapy (ESWT), ultrasound, electromagnetic, bone morphogenic proteins (BMPs) and platelet-rich-plasma (PRP).The aim of the present study was to perform a systematic review of the literature evaluating the current therapies to promote and enhance the bone tissue healing. The systematic review was performed according to PRISMA guidelines with a PRISMA checklist and algorithm.Limitations of the present systematic review are mainly related to the scanty quality of the studies available in the literature. Although the therapies previously described for the management of patients with non-unions seems to be effective, the limitations of the included studies, especially the extensive clinical heterogeneity, make not possible to provide clear recommendations regarding the application of these approaches. The problems remain the need to better understand the most effective treatment options, subject to surgical stabilization as a first step.

A novel method of diagnosing autonomic dysfunction in carpal tunnel syndrome: measuring skin capacitance.

Carpal Tunnel Syndrome (CTS) is normally diagnosed via its sensory and motor manifestations. The associated autonomic dysfunction has not been exploited to its full potential as a diagnostic tool due to the difficulties in quantifying it. We aim to demonstrate that autonomic dysfunction of CTS can be quantified by measuring skin capacitance. Fifty-one patients with clinical signs and electrophysiological evidence of CTS in 89 hands were recruited. Skin capacitance was measured using Corneometer CM825 (C&K Electronic, GmbH) from the palmar aspect of the distal phalanx of the index and little finger of the affected hand. Healthy gender- and age-matched individuals were recruited as controls. The mean ratio of hydration of the index to the little finger was 0.82. The mean difference was 10.98 arbitrary units. The control group consisted of 151 subjects (80 Male & 71 Female) and 302 hands with an average age of 40.1 years (18-81 years). The mean ratio of hydration of the index to the little finger was 0.87. The mean difference was 8.67 arbitrary units. The measurement ratios (index to little finger skin hydration) between the two groups was compared directly and gave a significant mean difference of 0.05 arbitrary units. Statistically significant differences in skin capacitance between CTS patients and controls have been demonstrated and quantified using a rapid and simple method. This can be used in clinic to reduce the reliance on Nerve Conduction Studies for diagnosing CTS.

Tourniquet use in upper limb surgery.

Tourniquets are compressive devices that occlude venous and arterial blood flow to limbs and are commonly used in upper limb surgery. With the potential risk of complications, there is some debate as to whether tourniquets should continue to be routinely used. In this review, we first look at the different designs, principles, and practical considerations associated with the use of tourniquets in the upper limb. The modern pneumatic tourniquet has many design features that enhance its safety profile. Current literature suggests that the risk of tourniquet-related complications can be significantly reduced by selecting cuff inflation pressures based on the limb occlusion pressure, and by a better understanding of the actual level of pressure within the soft tissue, and the effects of cuff width and contour. The evidence behind tourniquet time, placement, and limb exsanguination is also discussed as well as special considerations in patients with diabetes mellitus, hypertension, vascular calcification, sickle cell disease and obesity. We also provide an evidence-based review of the variety of local and systemic complications that may arise from the use of upper limb tourniquets including pain, leakage, and nerve, muscle, and skin injuries. The evidence in the literature suggests that upper limb tourniquets are beneficial in promoting optimum surgical conditions and modern tourniquet use is associated with a low rate of adverse events. With the improvement in knowledge and technology, the incidence of adverse events should continue to decrease. We recommend the use of tourniquets in upper limb surgery where no contraindications exist.