Study protocol for double-blind, randomised placebo-controlled trial evaluating semitendinosus function and morbidity following tendon harvesting for anterior cruciate ligament reconstruction augmented by platelet-rich plasma.

INTRODUCTION: Anterior cruciate ligament (ACL) rupture is debilitating, often requiring surgical reconstruction. An ACL reconstruction (ACLR) using a tendon autograft harvested from the semitendinosus results in substantial injury to the donor muscle. Following ACLR, patients rarely return to their preinjury level of physical activity, are at elevated risk of secondary lower limb injuries and early onset knee osteoarthritis. To date, no randomised controlled trial has evaluated the efficacy of platelet-rich plasma (PRP) in aiding knee function and semitendinosus morphology of following ALCR. METHODS AND ANALYSIS: This is a multicentre double-blind randomised placebo-controlled trial. Fifty-four ACLR patients aged 18-50 years will be randomised to receive either a single application of PRP (ACLR+) or placebo saline (ACLR) into the semitendinosus harvest zone at the time of surgery. All patients will undergo normal postoperative rehabilitation recommended by the attending orthopaedic surgeon or physiotherapist. The primary outcome measure is between-limb difference (ACLR compared with intact contralateral) in isometric knee flexor strength at 60o knee flexion, collected 10-12 months postsurgery. This primary outcome measure will be statistically compared between groups (ACLR+ and standard ACLR). Secondary outcome measures include bilateral assessments of hamstring muscle morphology via MRI, biomechanical and electromyographic parameters during an anticipated 45° running side-step cut and multidirectional hopping task and patient-reported outcomes questionaries. Additionally, patient-reported outcomes questionaries will be collected before (baseline) as well as immediately after surgery, and at 2-6 weeks, 3-4 months, 10-12 months and 22-24 months postsurgery 10-12 months following surgery. ETHICS AND DISSEMINATION: Ethics approval has been granted by Griffith University Human Research Ethics Committee, Greenslopes Research and Ethics Committee, and Royal Brisbane & Women's Hospital Human Research Ethics Committee. Results will be submitted for publication in a peer-reviewed medical journal. TRIAL REGISTRATION NUMBER: ACTRN12618000762257p.

Short-term Revision Risk of Patellofemoral Arthroplasty Is High: An Analysis from Eight Large Arthroplasty Registries.

BACKGROUND: Patellofemoral arthroplasty (PFA) is one option for the treatment of isolated patellofemoral osteoarthritis, but there are limited data regarding the procedure and results. Because isolated patellofemoral arthritis is relatively uncommon, available case series generally are small, and even within national registries, sample sizes are limited. Combining data from multiple registries may aid in assessing worldwide PFA usage and survivorship. QUESTIONS/PURPOSES: We combined and compared data from multiple large arthroplasty registries worldwide to ask: (1) What proportion of patients undergoing primary knee arthroplasty have PFA? (2) What are the patient and prosthesis characteristics associated with PFA in common practice, as reflected in registries? (3) What is the survivorship free from revision of PFA and what are the reasons for and types of revisions? METHODS: Data were provided by eight registries that are members of the International Society of Arthroplasty Registries (ISAR) who agreed to share aggregate data: Australia, New Zealand, Canada, Sweden, Finland, Norway, the Netherlands, and the United States. De-identified data were obtained for PFA performed from either the beginning of year 2000, or the earliest recorded implantation date after that in each individual registry when PFA data collection commenced, up to December 31, 2016. This included patient demographics, implant use, all-cause revision rate (determined by cumulative percent revision [CPR]), and reasons for and type of revision. RESULTS: During the data collection period, 6784 PFAs were performed in the eight countries. PFAs comprised less than 1% of primary knee replacements in all registries. Patient demographics were comparable in all countries. Patients were generally more likely to be women than men, and the mean age ranged from 50 years to 60 years. All registries showed a high rate of revision for PFA. The 5-year CPR for any reason ranged from 8.0% (95% CI 4.5 to 11.5) in Norway to 18.1% (95% CI 15.5 to 20.7) in the Netherlands. The most common reason for revision across all countries was disease progression (42%, 434 of 1034). Most PFAs (83%, 810 of 980) were revised to a TKA. CONCLUSIONS: The revision risk of PFA in all registries surveyed was more than three times higher than the reported revision risk of TKA at the same times. The survivorship of PFA is similar to that of the no-longer-used procedure of metal-on-metal conventional hip replacement. Although there may be potential functional benefits from PFA, these findings of consistent and alarmingly high rates of revision should create concern, particularly as this procedure is often used in younger patients. LEVEL OF EVIDENCE: Level III, therapeutic study.

Meniscal allograft transplantation: undersizing grafts can lead to increased rates of clinical and mechanical failure.

PURPOSE: To assess mid-term survivorship of meniscal allograft transplantation (MAT) and determine the effect that pre-operative meniscal sizing has upon functional outcome and mechanical survivorship. METHODS: A prospectively collected database of patients receiving MAT from 2001 to 2017 was analysed. Data include demographics; sizing measurements, complications, further surgery, and patient-reported outcome measures (PROMs). Allografts were fresh frozen, non-irradiated, and sized using the Pollard technique. RESULTS: Seventy-three MATs were performed in 67 patients; mean age at MAT was 34 years (range 14-52 years). 56% were male and 62% were medial. The mean follow-up was 75 months (6.25 years). Mechanical survival at 5 and 10 years was 96% and 89.4%, respectively. There were statistically significant improvements in all PROMs; mean Lysholm score improved by 17.5 points [95% confidence interval (CI) 22.2-12.9, p < 0.001]; mean IKDC score improved significantly by 13.3 points (CI 19.3-7.4, p < 0.001); mean OKS improved by 5.6 points (CI 9.2-2.2, p < 0.002); and the median Tegner improved by 1 point. Forty-one MATs (56%) were undersized for width (range 1-11 mm). Seven MATs (10%) were undersized for length (range 1-4 mm). There was no statistically significant difference in mechanical survivorship or clinical outcomes between undersized, matched, or oversized grafts overall; however, sub-group analysis demonstrated increased failure when allografts were undersized by more than 5 mm in width. CONCLUSIONS: MAT is an effective treatment to improve function and alleviate pain with excellent survivorship in this series. Accepting an allograft that is more than 5 mm smaller in width than pre-operative templating increases the likelihood of clinical and mechanical failure. We, therefore, urge surgeons to be familiar with the measuring process used by their individual tissue bank provider to avoid graft-host mismatch that could affect outcome.

Meniscal transplantation: procedures, outcomes, and rehabilitation.

Meniscal allograft transplantation (MAT) is a possible treatment option for patients with joint pain after meniscectomy. It is necessary that the joint be aligned and stable. Current evidence shows that MAT improves pain and mechanical function in the mid to long term with patients reporting significantly improved outcomes at up to 15 years following surgery. Studies on survivorship showed up to 76% graft survival at 10 years. Recent studies have suggested a chondroprotective effect, but there is, at present, no evidence to support MAT in the prevention of osteoarthritis. This review article reported the current evidence for MAT showing support for fresh frozen, nonirradiated allografts. However, further research is required to determine the ideal indications for MAT, the optimal graft fixation method, and the safest rehabilitation protocol.

Current Controversies of Alignment in Total Knee Replacements.

Total knee replacement is an increasingly popular operation for end stage knee arthritis. In the majority it alleviates pain and improves function. However up to 20% of patients remain dissatisfied, even with well-aligned and secure implants. Restoration of a neutral mechanical axis has traditionally been strived for, to improve both function and implant survival and there is historical data to support this. More recently this view has been questioned and some surgeons are trying to improve the function and outcomes by moving away from standard alignment principles in an attempt to reproduce the kinematics of the pre-arthritic knee of that individual. Others are using computers, robots and patient specific guides to improve accuracy. This article aims to review the traditional alignment concept and the newer techniques, along with the evidence behind it.

Long-Term Comparison of Porous Versus Hydroxyapatite Coated Sleeve of a Modular Cementless Femoral Stem (SROM) in Primary Total Hip Arthroplasty.

UNLABELLED: Hydroxyapatite (HA) is commonly used on femoral stems to assist in osseous integration but there is limited evidence of the benefit it provides. We report a prospective comparison of 117 and 102 patients receiving either porous or HA coated sleeves respectively. Patients were evaluated at mean of 12.5 years in the porous and 13.7 years in the HA groups. The mean Harris Hip Score was 94.7 and 94.5 in the porous and HA groups respectively. One porous and 2 HA stems required revision. This study demonstrates that there is no long-term advantage to using an HA coating on the sleeve of this modular stem and confirms excellent long-term results for the SROM stem in a primary arthroplasty setting. LEVEL OF EVIDENCE: II (prospective cohort study).

Meniscal allograft transplantation: how should we be doing it? A systematic review.

PURPOSE: We undertook a systematic review to assess a number of the technical aspects of meniscal allograft transplantation (MAT) that have not been covered in other reviews. Specific variables studied included the indications for MAT, graft fixation method, rehabilitation protocols, outcome scores, and definition of failure. METHODS: We performed a systematic literature review of the PubMed, EMBASE, and Cochrane databases to determine the outcomes of meniscal transplantation at greater than 2 years postoperatively. PRISMA (Preferred Reporting for Systematic Reviews and Meta-Analyses) guidelines were followed with a PRISMA checklist. The search was completed on January 5, 2014. RESULTS: These queries returned 629 results from which 41 articles were identified as meeting the inclusion criteria. No studies in this review were randomized or controlled. CONCLUSIONS: MAT is a worthwhile procedure, with evidence that it provides pain relief and improved function, and good results reported in mid- to long-term studies. The procedure should be considered only in a patient with localized pain and a stable (or stabilized) and well-aligned (or realigned) knee. The controversial areas studied in this review include the following: there is no evidence to support fixation with either bone plugs or soft tissue; there is no standardized rehabilitation program, but it appears that full weight bearing by 6 weeks is not detrimental; and a clear and uniform definition of failure and use of consistent outcome scores would aid future reporting and analysis of the results of meniscal transplantation. LEVEL OF EVIDENCE: Level IV, systematic review of Level II to IV studies.

Surveillance after treatment of children with developmental dysplasia of the hip: current UK practice and the proposed Stanmore protocol.

Monitoring of a patient with developmental dysplasia of the hip (DDH) is required after initial treatment to ensure early detection and correction of complications or poor progression. We established the current practice of surveillance in DDH in the UK. A protocol has been designed at this unit with the aim of identifying the stages in the progression of DDH when imaging of the hip is necessary to detect failure or possible complications of treatment. The outcomes and secondary procedure rates under the surveillance protocol used at this unit, for a UK population, have been reviewed with a minimum of 5 years of follow-up. Frequency of follow-up has been reported as yearly or more frequently until skeletal maturity by 70% of respondents. Ninety patients presenting with DDH were managed under the protocol developed at this unit, with equivalent outcomes as those in patients who reported yearly follow-up. Following our proposed protocol we believe it is possible to limit disruption to the patient's life, reduce costs and maintain compliance and ensure timely detection of any complications, without significant increase in secondary procedure rates.

Unicompartment compartment syndrome following laparascopic colonic resection.

We report the case of a 43-year-old man who developed anterior compartment syndrome following laparoscopic colorectal surgery in the lithotomy position. This was initially masked by postoperative epidural usage and ultimately diagnosed 2 days postoperatively. The patient underwent decompression by four compartment fasciotomy and two follow-up re-explorations of the affected lower limb. This case is unique for two reasons: only the anterior compartment of the lower limb was affected--which is rare in itself--and there was a delay in presentation secondary to postoperative epidural usage.

Resurfacing hip arthroplasty in neuromuscular hip disorders - A retrospective case series.

BACKGROUND: Management of the degenerate hip in patients with neuromuscular conditions should be aimed at improving quality of life and ease of nursing care. Arthroplasty poses a significant challenge with predisposition to dislocation and loosening due to anatomical abnormalities, soft tissue contractures and impaired muscle tone. METHODS: We present a series of 11 hips (9 patients) following total hip resurfacing arthroplasty for painful osteoarthritis in patients with differing neuromuscular conditions. Patients were assessed clinically and radiographically and also for satisfaction of their carers due to improved ability to provide nursing care. Mean patient age was 33.1 years (range 13-49 years) with mean follow up at publication 63.7 months (41-89 months). All patients were operated by a single surgeon (AHN) and received the required post operative care and physiotherapy. Soft tissue releases were performed when necessary. All hips were assessed clinically and radiographically at 6 weeks and 6 months and 1 year post-operatively. Six month follow-up also included a questionnaire with scoring of care-provider satisfaction. RESULTS: Ten hips had good clinical results with improvement in pain and function and radiologically showed no signs of loosening. One hip required revision to proximal femoral excision due to dislocation and loose acetabular component with severe pain. None of the other hips dislocated. Analysis of care provider satisfaction assessing ability to provide personal care, positioning and transferring, comfort, interaction and communication scored excellent to good in 10 patients and satisfactory in one. CONCLUSION: We believe hip resurfacing arthroplasty to be a viable option in the treatment of the complex problem of osteoarthritis in the hips of patients with neuromuscular disease. The improved biomechanics confer greater stability when compared to conventional total hip arthroplasty. Although technically demanding, a successful result has been shown to improve patient pain, function and ease of nursing care. LEVEL OF EVIDENCE: Level IV.

Scapular fracture following electronic muscle stimulation.

We present the case of a transverse fracture of the scapula resulting from the use of electronic muscle stimulation (EMS): highlighting the dangers of these devices that are commonly used for massage and body-building purposes.