Cost-effectiveness of Early Surgery versus Conservative Treatment with Optional Delayed Meniscectomy for Patients over 45 years with non-obstructive meniscal tears (ESCAPE study): protocol of a randomised controlled trial

INTRODUCTION

Recent studies show similar outcome between surgery and conservative treatment in patients with non-obstructive meniscal tears. However, surgery is still often preferred over conservative treatment. When conservative treatment is non-inferior to surgery, shifting the current standard treatment choice to conservative treatment alone could save over €30 millions of direct medical costs on an annual basis. Economic evaluation studies comparing surgery to conservative treatment are lacking.

METHODS AND ANALYSIS

A multicentre randomised controlled trial (RCT) with an economic evaluation alongside was performed to assess the (cost)-effectiveness of surgery and conservative treatment for meniscal tears. We will include 402 participants between 45 and 70 years with an MRI-confirmed symptomatic, non-obstructive meniscal tears to prove non-inferiority of conservative treatment. Block randomisation will be web-based. The primary outcome measure is a physical function, measured by the International Knee Documentation Committee 'Subjective Knee Form'. Furthermore, we will perform a cost-effectiveness and cost-utility analysis from societal perspective and a budget impact analysis from a societal, government and insurer perspective. Secondary outcomes include general health, quality of life, activity level, knee pain, physical examination, progression of osteoarthritis and the occurrence of adverse events.

ETHICS AND DISSEMINATION

This RCT will be performed in accordance with the Declaration of Helsinki and has been approved by the Ethics Committee (number NL44188.100.13). The results of this study will be reported in peer-reviewed journals and at international conferences. We further aim to disseminate our results to guideline committees.

TRIAL REGISTRATION NUMBER

NCT01850719.

Efficacy of Resorbable Plates for Reduction and Stabilization of Laryngeal Fractures

We evaluated the efficacy of resorbable reconstruction plates (polylactic acid copolymer) for the open reduction and stabilization of displaced laryngeal fractures. Both MacroPore and Leibinger reconstruction plates were used with equal ease of application in 3 adult male patients. We found the plating system to be especially effective for the reduction of comminuted cricoid fractures. Adequate skeletal stabilization allowed early resumption of phonatory and respiratory function without long-term intraluminal stenting for skeletal support. No complications of hematoma, seroma, or infection were experienced. Resorbable plates appear to be relatively safe and useful for internal fixation of both cartilaginous and ossified parts of the larynx, allowing rapid rehabilitation and return of function.

Osteochondral Fractures of the Knee in Skeletally Immature Patients: Short-Term Results of Operative Fixation using Omnitech Screws

PURPOSE OF THE STUDY

Retrospective case series looking at the use of Omnitech compression screws for the management of osteochondral fractures in skeletally immature patients.

MATERIAL AND METHODS

Nine patients with a mean age of 14 were included in the study with a mean follow up of 26 months.

RESULTS

The average KOOS, IKDC and Tegner Lysholm Scores were 86.7, 90.34 and 96.1 respectively.

CONCLUSION

The use of Omnitech screws in the acute setting for skeletally immature patients shows excellent short-term outcomes.

Fixation of chondral fracture of the weight-bearing area of the lateral femoral condyle in an adolescent

Purely chondral fractures of the distal femur associated with patellar dislocation are uncommon, and treatment varies from fixation to debridement and marrow stimulation techniques. The unusual case reported here involves an adolescent who underwent fixation of a purely chondral fracture involving a large weight-bearing portion of the lateral femoral condyle. Chondral fracture healing was confirmed on follow-up magnetic resonance imaging and arthroscopic examination. This case suggests that fixation of purely chondral fractures can be successful in weight-bearing areas of the knee. Level of evidence V.

Popliteomeniscal fascicle tears

Isolated popliteomeniscal fascicle tears are often unrecognized and misdiagnosed. Patients typically have vague symptoms and often-normal magnetic resonance imaging and physical examination findings. Isolated injuries are often misdiagnosed and mistreated, leading to delayed surgical treatment. Unrecognized tears can lead to continued disability, lateral meniscus tears, and chondral lesions. Appropriate diagnosis and treatment with inside-out lateral meniscus repair will allow the athlete to return to activity.

Arthroscopic biceps tenodesis compared with repair of isolated type II SLAP lesions in patients older than 35 years

This study compared arthroscopic biceps tenodesis with biceps repair for isolated type II superior labrum anterior and posterior (SLAP) lesions in patients older than 35 years. The authors identified isolated type II SLAP lesions that were surgically managed over a 5-year period. Minimum 2-year follow-up data were available for 22 patients who underwent biceps repair (repair group) and for 15 patients who underwent a primary biceps tenodesis (tenodesis group). Mean age at surgery was 45.2±5.5 years in the repair group and 52.0±8.0 years in the tenodesis group. In the repair group, functional outcome improved from baseline to final follow-up using the American Shoulder and Elbow Surgeons (ASES) (47.5 to 87.4, respectively; P<.0001) and University of California, Los Angeles (UCLA) scores (18.5 to 31.2, respectively; P<.0001). In the tenodesis group, similar findings were observed for the ASES (43.4 to 89.9, respectively; P<.0001) and UCLA scores (19.0 to 32.7, respectively; P<.0001). No difference was found in functional outcome between the groups. Full range of motion recovery was delayed by approximately 3 months in the repair group compared with the tenodesis group (P=.0631). Two patients in the repair group required a secondary capsular release. Seventy-seven percent of patients in the repair group and 100% of patients in the tenodesis group were satisfied and returned to normal activity (P=.0673). In the current study, individuals older than 35 years with an isolated type II SLAP lesion had a shorter postoperative recovery, a more predictable functional outcome, and a higher rate of satisfaction and return to activity with a biceps tenodesis compared with a biceps repair. Based on these observations, biceps tenodesis is preferable to biceps repair for isolated type II SLAP lesions in nonoverhead athletes older than 35 years.

3.0-Tesla MRI and arthroscopy for assessment of knee articular cartilage lesions

The purpose of this study was to evaluate the ability of 3.0-Tesla magnetic resonance imaging (MRI) to accurately assess knee articular cartilage lesions. Sixteen patients who had knee 3.0-T MRI and underwent knee arthroscopy for partial meniscectomy were included. Three fellowship-trained sports medicine orthopedic surgeons reviewed all images. Articular lesions on MRI were graded from I to IV and compared with arthroscopic grading using the Outerbridge and the International Cartilage Repair Society (ICRS) classifications. The articular surface was divided into 6 regions. Based on MRI findings, of the 288 articular surface evaluations, 113 (39%) surface evaluations were classified as disease-positive (grade 2 to 4). Kappa interrater reliability scores for MRI evaluation, Outerbridge classification, and ICRS classification were 0.13, 0.54, and 0.41, respectively. Using the Outerbridge classification as a reference standard, the sensitivity, specificity, and accuracy were 57%, 71%, and 63%, respectively. Using the ICRS classification, sensitivity, specificity, and accuracy were 59%, 71%, and 69%, respectively. When isolating the articular grading to the senior author on MRI evaluation vs Outerbridge classification, the sensitivity, specificity, and accuracy were 54%, 92%, and 75%, respectively. Based on the current findings, 3.0-T MRI is as an invaluable noninvasive tool with good diagnostic value for assessing articular cartilage lesions of the knee, although it may not be as sensitive and accurate as previously reported.

[Therapy of triangular fibrocartilage complex lesions]

The triangular fibrocartilage complex (TFCC) represents an important anatomical structure interposed between the ulnar carpus and the distal ulnar. Injuries and degenerative changes of the TFCC are of high clinical relevance and there are numerous treatment options available based on different concepts and which are being used to varying extents. The aim of this systematic review was to evaluate the effectiveness of different therapies for lesions of the TFCC. Studies on TFCC lesions were systematically reviewed, classified into evidence levels and selected according to predefined criteria. A total of 259 publications were identified as being potentially relevant and finally 35 studies could be included in the review. In addition, a survey was performed among German hand surgeons in order to identify commonly used procedures for TFCC lesions in Germany. The classification of Palmer is mostly used both in the literature and in Germany and therapeutic decisions are predominantly based on this classification. The systematic review revealed some common treatment strategies for traumatic and degenerative lesions. Generally, the level of evidence was poor for all identified publications. For this reason, evidence-based recommendations for the treatment of TFCC lesions could not be derived from the literature. There was broad consent between the results of the literature review and the survey.

Unusual orientation of talar osteochondral fragment: a case report

The identification of the correct orientation of an osteochondral fragment can be challenging. Orthopaedists have been able to take advantage of advanced imaging techniques to provide guidance to the appropriate surgical intervention. Many advancements have been made in imaging modalities specific to articular cartilage [Fischbach F, Bruhn H, Unterhauser F, Ricke J, Wieners G, Felix R, et al. Magnetic resonance imaging of hyaline cartilage defects at 1.5T and 3.0T: comparison of medium T2-weighted fast spin echo, T1-weighted two-dimensional and three-dimensional gradient echo pulse sequences. Acta Radiol 2005;46(1):67-73 [Erratum in: Acta Radiol 2005;46(April (2)):218]] Furthermore, with the increasing use of bioabsorbable fixation pins, it is imperative that careful attention is paid to the correct orientation of the fragment that is to be fixed. Without awareness of the orientation, it is possible that the 180° displaced fragment could potentially be fixed in this position. At the time of this report, the patient in this case was 6 weeks postoperative and reported 0/10 pain with full painless range of motion without instability. Our goal with this case report is to promote awareness among orthopaedists and radiologists alike regarding the importance of recognizing the orientation of an osteochondral fragment and/or defect of the talus. The patient was informed that data concerning the case would be submitted for publication, and he consented.

Micrometer-sized iron oxide particle labeling of mesenchymal stem cells for magnetic resonance imaging-based monitoring of cartilage tissue engineering

PURPOSE

To examine mesenchymal stem cell (MSC) labeling with micrometer-sized iron oxide particles (MPIOs) for magnetic resonance imaging (MRI)-based tracking and its application to monitoring articular cartilage regeneration.

METHODS

Rabbit MSCs were labeled using commercial MPIOs. In vitro MRI was performed with gradient echo (GRE) and spin echo (SE) sequences at 3T and quantitatively characterized using line profile and region of interest analysis. Ex vivo MRI of hydrogel-encapsulated labeled MSCs implanted within a bovine knee was performed with spoiled GRE (SPGR) and T(1ρ) sequences. Fluorescence microscopy, labeling efficiency, and chondrogenesis of MPIO-labeled cells were also examined.

RESULTS

MPIO labeling results in efficient contrast uptake and signal loss that can be visualized and quantitatively characterized via MRI. SPGR imaging of implanted cells results in ex vivo detection within native tissue, and T(1ρ) imaging is unaffected by the presence of labeled cells immediately following implantation. MPIO labeling does not affect quantitative glycosaminoglycan production during chondrogenesis, but iron aggregation hinders extracellular matrix visualization. This aggregation may result from excess unincorporated particles following labeling and is an issue that necessitates further investigation.

CONCLUSION

This study demonstrates the promise of MPIO labeling for monitoring cartilage regeneration and highlights its potential in the development of cell-based tissue engineering strategies.

Abdominal compartment syndrome after hip arthroscopy

As hip arthroscopy becomes a more common procedure, more complications may occur. We present a case of abdominal compartment syndrome resulting from fluid extravasation in a 42-year-old man who underwent routine hip arthroscopy for femoral acetabular impingement. He had not had previous surgeries to that hip, and arthroscopy was performed in the supine position. After adequate distraction, arthroscopy was performed with an automated pressure- and flow-controlled pump with the pressure maintained between 40 and 60 mm Hg. We performed debridement of a degenerative tear of the anterosuperior labrum, removal of a pincer lesion, and a psoas tenotomy through a capsular window. A distended abdomen was noted on drape removal, and the patient required decompressive laparotomy for abdominal compartment syndrome. Extravasation of arthroscopy fluid is a potentially devastating complication during hip arthroscopy, and there should be careful monitoring by the surgeons, anesthesiologists, and operating room staff.

Surgical management of articular cartilage defects in the knee

The treatment of isolated cartilage lesions of the knee is based on several underlying principles, including a predictable reduction in the patient's symptoms, improvements in function and joint congruence, and prevention of progressive damage. Surgical options for cartilage restoration are described as palliative treatments, such as débridement and lavage; reparative, such as marrow stimulation techniques; or restorative, such as osteochondral grafting and autologous chondrocyte implantation. The choice of an appropriate treatment should be made on an individual basis, with consideration for the patient's specific goals (such as pain reduction or functional improvement), physical demand level, prior treatment history, lesion size and location, and a systematic evaluation of the knee that considers comorbidities, including alignment, meniscal status, and ligament integrity. It is important for the physician to be familiar with the indications, surgical techniques, and clinical outcomes of the available treatment options for chondral defects of the knee.

[Laryngeal fractures due to blunt trauma]

INTRODUCTION

Laryngeal fractures due to blunt trauma are rare. Consensus on diagnosis and treatment is therefore needed.

MATERIALS AND METHODS

A retrospective search of patient records in the period 2000-2007. Data were obtained on sex, age, time from trauma to first medical visit, time from trauma to operation, result of laryngeal computertomography, pre- and postoperative videostroboscopy, pre- and postoperative evaluation of voice quality, method of operation and status at last follow-up.

RESULTS

Seven patients, six males aged 24-54 and one female aged 24. All had moderate to severe laryngeal trauma, and all except one needed surgical intervention. Three had the fracture stabilized with titanium net/miniplates. The postoperative voice was evaluated as good/acceptable in four patients, one had a recurrent nerve palsy and was lost to follow-up; one is still undergoing voice therapy.

CONCLUSION

Patients must be examined for hoarseness, laryngeal pain, aphonia, asymmetry, bleeding and subcutaneous emphysema located in or around the larynx. Based on a computertomography, dislocated fractures should be operated (preferably within 48 hours). It is necessary to obtain stable fractures. The use of titanium nets or miniplates is recommended.

Thyroid cartilage fracture: Treatment with biodegradable plates

A 29-year-old man fractured his thyroid cartilage while playing rugby. It was treated successfully with an Inion biodegradable plating system. Biodegradable plates are recommended for laryngeal reconstruction.

Laryngeal fractures: clinical findings and considerations on suboptimal outcome

CONCLUSION

We recommend early surgical exploration and fixation for patients with dislocated or comminuted laryngeal fractures to avoid long-term voice complications. One-third of 33 fracture patients rated their voice after the fracture had healed as fair but altered.

OBJECTIVES

To examine the indications for and the outcome of surgical management in patients with laryngeal fractures.

PATIENTS AND METHODS

The study was carried out in a tertiary care referral university hospital and was a retrospective study of case series. Thirty-three consecutive patients, aged 14-84 years, presented with various types of laryngeal fractures. Patients were staged according to the type of the fracture and surgical correction was performed when indicated. Voice outcome was documented and patients with subjectively suboptimal result were further evaluated by phoniatric specialist.

RESULTS

In all, 32 of 33 laryngeal fracture patients had blunt trauma and the main causative factors were sport injuries (39%) and physical assault (33%). All of the 33 laryngeal fracture patients had a good airway outcome. The subjective voice outcome was good for 20 (61%) and fair for 13 (39%) patients. The mean follow-up time was 39.5 months (range 2-114 months). In phoniatric evaluation most (six of eight) patients with fair voice outcome could not produce high pitched voices because of inability to stretch the vocal folds.

Collagen-based biomaterials and cartilage engineering. Application to osteochondral defects

Articular cartilage has a limited capacity for self-repair after trauma. Besides the conventional surgical techniques for repairing such defects, treatments involve implantation of autologous cells in suspension or within a variety of cell carrying scaffolds such as hyaluronic acid, alginate, agarose/alginate, fibrin or collagen. For the repair of full-thickness osteochondral defects, tissue engineers started to design single- or bi-phased scaffold constructs often containing hydroxyapatite-collagen composites, usually used as a bone substitute. The purpose of this study was to compare the behavior of bovine chondrocytes cultured in collagen-based scaffolds containing or not hydroxyapatite and cross-linked following two different methods. Calf chondrocytes seeded within Hemotèse and Collapat II sponges (SYMATESE biomaterials), chemically cross-linked with glutaraldehyde or EDC/NHS, were maintained up to one month in culture. The cells exhibited a similar behavior in the four scaffolds regarding proliferation level, deposition of glycosaminoglycans in the scaffolds and gene expression of types I, II and X collagens, aggrecan, MMP-1, -13 and the integrin subunits alpha10 and alpha11.

In-situ engineering of cartilage repair: a pre-clinical in-vivo exploration of a novel system

This investigation explores a new cartilage repair technique that uses a novel method to secure a non-woven multifilamentous scaffold in the defect site after microfracture. The hypothesis is that a scaffold provides a larger surface area for attachment and proliferation of the mesenchymal stem cells that migrate from the bone marrow. Two in-vivo studies were undertaken in an ovine model. The first study, which lasted for 8 weeks, aimed to compare the new technique with microfracture. Chondral defects, 7 mm in diameter, were created in both femoral medial condyles of five ewes. One defect was treated with the new technique while the contralateral knee was treated with microfracture alone. The results revealed that the quantity of repair tissue was significantly greater in the defects treated with the new system. The second study had two time points, 3 and 6 months, and used 13 ewes. In this study, both defects were treated with the new technique but one received additional subchondral drilling in order to stimulate extra tissue growth. The majority of the implants had good tissue induction, filling 50-100 per cent of the defect volume, while the compressive modulus of the repairs was in the range of 40-70 per cent of that for the surrounding cartilage. In addition, hyaline-like cartilage was seen in all the repairs which had the additional drilling of the subchondral bone.

[Use of bone marrow mesenchymal stem cells for ex vivo cartilage regeneration]

Articular cartilage disorders and injuries often result in lifelong chronic pain and compromised quality of life. When it comes to local articular cartilage defects, modern medicine is limited to short-term pain relief and inflammation control. In extreme cases the affected tissue is surgically removed and replaced by a synthetic prosthesis of limited durability. Cell-based therapies to regenerate articular cartilage have been in use since 1994. Such therapies provide a healthy population of cells to the injured site and require differentiated chondrocytes from the uninjured site as base material. Their usage often leads to donor site morbidity and they generate rigid fibrous cartilage where more flexible hyaline cartilage is required. The major restrictive factors for such methods are inadequate number and limited proliferation capacity of chondrocytes in vitro. Tissue engineering of adult marrow stromal cells/mesenchymal stem cells (MSCs) with their almost unlimited proliferation potential and proven capability to differentiate into chondrocytes for ex vivo generation of cartilage tissue still remains a vision. For optimal harnessing of MSCs as chondroprogenitor cells, basic background information regarding commitment to the lineage, cartilage differentiation and the regulatory factors and molecules involved is essential.

Distale osteochondrale Femurimpressionsfrakturen

BACKGROUND

Chondral or osteochondral avulsions of the lateral distal femur edge after luxation of the patella are well known. Less common are impression fractures of the retropatellar joint or the lateral trochlea. Furthermore, on standard knee X-rays these injuries may not be seen and thus not properly be treated. By presenting our cases we show clinical symptoms, diagnostic pathways and the therapeutic approach for osteochondral fractures of the distal femur.

MATERIALS AND METHODS

The first patient had a large osteochondral impression fracture of the lateral femur trochlea and retropatellar surface. The second patient had a chondral depression of the lateral trochlea femoris after kicking a football. The further examinations showed no other knee injuries in the first case, but a rupture of the outer meniscus plus ACL rupture and distortion of the medial collateral complex in the other one.

RESULTS

In both cases the whole degree of the injury was not seen on the standard X-rays, but only on MRI or CT scans. The clinical signs were also not so overwhelming, as both patients could walk with crutches, but suffered from haemarthrosis. Both patients were operated by arthroscopy first with surgery on the meniscus injury and ACL rupture. The impression was revised by an open procedure with elevation of the subchondral spongiosa. In the follow-up examination we saw no dissection of chondral flakes or local necrosis.

CONCLUSION

Osteochondral lesions of the distal femur can be neglected, as it is an uncommon diagnosis and the radiological signs may not be impressing. The more important is a subtle anamnesis and further diagnostic regime via CT or MRI as it is a prearthrotic injury. Intraoperatively the impression must be elevated or in the case of a dislocation refixed. Further knee injuries have to be detected. In the follow-up one should check for signs of flake dissection or necrosis.

The fate of implanted autologous chondrocytes in regenerated articular cartilage

Autologous chondrocyte implantation (ACI) is used to treat some articular cartilage defects. However, the fate of the cultured chondrocytes after in-vivo transplantation and their role in cartilage regeneration remains unclear. To monitor the survival and fate of such cells in vivo, the chondrocytes were labelled with a lipophilic dye and the resultant regenerated tissue in dogs examined. It was found that, 4 weeks after implantation, the osteochondral defects were filled with regenerative tissue that resembled hyaline cartilage. Fluorescence microscopy of frozen sections of the regenerated tissue revealed that the majority of cells were derived from the DiI-labelled implanted chondrocytes. From these results, it was concluded that a large population of implanted autologous chondrocytes can survive at least 4 weeks after implantation and play a direct role in cartilage regeneration. However, it remains unknown whether other cells, such as periosteal cells or bone marrow stromal stem cells, are involved in the regeneration of cartilage after ACI.

Light and low-frequency pulsatile hydrostatic pressure enhances extracellular matrix formation by bone marrow mesenchymal cells: An in-vitro study with special reference to cartilage repair

Ovine bone marrow mesenchymal cells (BMMCs) were seeded on to non-woven filamentous plasma-treated polyester scaffolds and cultured in a chondrogenic medium for 4 weeks. Thereafter a pulsatile hydrostatic pressure (PHP) was applied to these cell-scaffolds constructs at an amplitude of 0.1 MPa and frequency of 0.25 Hz, for 30 min a day, over a period of 10 days. Samples ( n=6) were removed 24 h after PHP stimulation at days 1, 4, 7, and 10 for biochemical analysis. Similar analyses were conducted, at the same time points, on control samples that were not subjected to a PHP. The results showed that the glycosaminoglycan (GAG) content did not significantly increase until after the application of a PHP for 7 days. The GAG content was 1.5 and 2.7 times higher in the PHP group than in the control group at days 7 and 10 respectively ( p < 0.01). The deoxyribonucleic acid (DNA) content was 1.5 times greater in the PHP group than in the control group at day 10 ( p < 0.01). GAG synthesis amounts, expressed as the total GAG contents per microgram of DNA, were 1.6 and 1.8 times higher in the PHP group than in the control group at days 7 and 10 respectively ( p < 0.01). The total collagen content in the medium did not change until after PHP application for 10 days, when it was 1.9 times higher than the control ( p < 0.05). The results suggest that a light PHP applied at a low frequency has a cumulative stimulatory effect on the BMMCs' metabolic activities including cell proliferation and synthesis of the extracellular matrix.

Poly-L-D-Lactic Acid Scaffold in the Repair of Porcine Knee Cartilage Lesions

Articular cartilage injuries cause a major clinical problem because of the negligible repair capacity of cartilage. Autologous chondrocyte transplantation is a surgical method developed to repair cartilage lesions. In the operation, cartilage defect is covered with a periosteal patch and the suspension of cultured autologous chondrocytes is injected into the lesion site. The method can form good repair tissue, but new techniques are needed to make the operation easier and to increase the postoperative biomechanical properties of the repair tissue. In this study, we investigated poly-L,D-lactic acid (PLDLA) scaffolds alone or seeded with autologous chondrocytes in the repair of circular 6-mm cartilage lesions in immature porcine knee joints. Spontaneous repair was used as a reference. Histologic evaluation of the repair tissue showed that spontaneous repair exhibited higher scores than either PLDLA scaffold group (with or without seeded chondrocytes). The scaffold material was most often seen embedded in the subchondral bone underneath the defect area, probably because of the hardness of the PLDLA material. However, some of the cell-seeded and nonseeded scaffolds contained cartilaginous tissue, suggesting that invasion of mesenchymal cells inside nonseeded scaffolds had occurred. Hyaluronan deposited in the scaffold had possibly acted as a chemoattractant for the cell recruitment. In conclusion, the PLDLA scaffold material used in this study was obviously mechanically too hard to be used for cartilage repair in immature animals.

Die Behandlung femoropatellarer Knorpelschäden mit einem dreidimensionalen Kollagengel: Klinische Ergebnisse im Zwei-Jahres-Verlauf

AIM

Here we present first clinical results of the treatment of patellofemoral cartilage lesions with a 3D collagen gel (CaReS).

METHODS

Isolated patellofemoral cartilage lesions in 14 patients (13 patellar, 1 trochlear) were treated by matrix-based ACT using a collagen gel seeded with autologous chondrocytes. In this study, only those patients were taken into account who complied with the inclusion criteria of the German working group "tissue regeneration and tissue substitutes". Data were analysed in accordance with the ICRS criteria and the Brittberg score. We present the 2-year postoperative clinical follow-up.

RESULTS

After 2 years the ICRS-IKDC and Brittberg scores revealed a statistically significant improvement. The preoperative rating of the objectiveIKDC and functional ICRS score improved from 0/14 and 2/14 (14.3%) to 11/14 (78.6%) in the categories A/B and I/II, respectively. 11 Patients(78.6%) judged the clinical outcome as excellent or good. The subjective IKDC score improved from 32.4 +/- 8.4 prior to operation to 67.8 +/- 27.4 at the 2-years follow-up.

CONCLUSION

The use of 3D matrix systems could represent a promising improvement of conventional ACT in the treatment of patellofemoral cartilage lesions, but the results have to be verified by long-term investigations.

Human Amniotic Membrane as a Delivery Matrix for Articular Cartilage Repair

The purpose of this study is to evaluate the feasibility of human amniotic membrane (HAM) as a chondrocyte carrier by assessing cell proliferation and maintenance of phenotype in vitro and cartilage regeneration in vivo. Intact HAM was treated with 0.1% trypsin-ethylenediaminetetraacetic acid (EDTA) for 15 min and the epithelial cells removed to make a denuded HAM. Rabbit articular chondrocytes were then seeded on three different HAM substrates: the epithelial side of intact HAM (IHE), basement side of denuded HAM (DHB), and stromal side of denuded HAM (DHS). These cell-substrate specimens were cultured for up to 4 weeks, and cell proliferation rate and phenotypic stability were examined at weeks 1 and 4. While chondrocytes grew in monolayer fashion on the surface of IHE and DHB substrates, the cells seeded in DHS penetrated and spread into the whole thickness of the stromal layer. The proliferating activity of chondrocytes in DHB was continuously up-regulated. A similar proliferating activity was observed in DHS in the first week, which remained stable for up to 4 weeks. The expression of type II collagen gradually increased with time in the DHS group, while it gradually decreased in the DHB group or was not detected at all in the IHE group. These results suggested that denuded HAM was able to support chondrocyte proliferation and maintenance of phenotype in vitro, seemingly more favorable when DHS was used. Based on this data, the DHS with chondrocytes was used to cover rabbit osteochondral defect with the stromal side facing in. The defect area was successfully regenerated with hyaline cartilage in the Safranin-O stain and International Cartilage Repair Society (ICRS) scoring after 8 weeks of implantation. In conclusion, our findings suggest that denuded HAM could be one of the ideal cell carrier matrices for cartilage regeneration.

Matrix-Induced Autologous Chondrocyte Implantation (MACI®): Biological and Histological Assessment

Matrix-induced autologous chondrocyte implantation (MACI) has been a treatment of cartilage injury since 2000, but little is known of the histological paradigm of tissue regeneration after implantation. MACI is a stable cell-based delivery system that enables the regeneration of hyaline-like cartilage. From a cohort of 56 MACI patients, we examined the phenotype of chondrocytes seeded on type I/III collagen scaffold, and conducted progressive histologic assessment over a period of 6 months. Chondrocyte-seeded collagen scaffolds from patient implants were analyzed by electron microscopy, immunohistochemistry (type II collagen and S-100), and reverse transcription polymerase chain reaction (RT-PCR) (aggrecan and type II collagen). Coincidental cartilage biopsies were obtained at 48 hours, 21 days, 6 months, 8 months, 12 months, 18 months, and 24 months. Our data showed that chondrocytes on the collagen scaffold appeared spherical, well integrated into the matrix, and maintained the chondrocyte phenotype as evidenced by aggrecan, type II collagen, and S-100 expression. Progressive histologic evaluation of the biopsies showed the formation of cartilage-like tissue as early as 21 days, and 75% hyaline-like cartilage regeneration after 6 months. This preliminary study has suggested that MACI may offer an improved alternative to traditional treatments for cartilage injury by regenerating hyaline-like cartilage as early as 6 months after surgery.

Tissue-Engineering zur Knorpelreparatur verbessert durch Gentransfer

Cartilage tissue engineering is the creation of functional substitutes of native articular cartilage in bioreactors by attaching chondrogenic cells to polymer scaffolds. One limitation of tissue engineering is the delivery of regulatory signals to cells according to specific temporal and spatial patterns. Using gene transfer techniques, polypeptide growth factor genes such as the human insulin-like growth factor I (IGF-I) gene can be transferred into chondrocytes. When these modified cells are used for cartilage tissue engineering, the resulting cartilaginous constructs have improved structural and functional characteristics compared to constructs based on nonmodified cells. The combination of cartilage tissue engineering with overexpression of potential therapeutic genes using gene transfer technologies provides a basis for the development of novel molecular therapies for the repair of cartilage defects.

Repair of nasal complex fractures and the need for secondary septo-rhinoplasty

PURPOSE

This study was undertaken to evaluate the efficacy of closed reduction of nasal fractures and determine the incidence of the need for post-traumatic septo-rhinoplasty in the management of residual nasal deformities.

PATIENTS AND METHODS

Medical records of all patients with nasal fractures evaluated and treated by the Division of Oral and Maxillofacial Surgery at the University of Florida Health Science Center, Jacksonville, FL between January 2001 and October 2004 were retrospectively evaluated. Out of a total of 344 patients, 50 patients met the inclusion criteria. Forty-four patients (group A) underwent closed reduction of nasal bones and septum along with a septoplasty if needed within 2 weeks of initial injury. Six patients (group B) could not tolerate any surgical intervention because of multisystem injury or comorbidities. All 50 patients were then followed up in the Division of Oral and Maxillofacial Surgery to determine overall efficacy of the initial treatment modality, as well as the need for secondary post-traumatic septo-rhinoplasty. Group A was then further subdivided into groups A1 and A2. Group A1 consisted of patients who underwent a closed reduction of their nasal complex fracture without a residual deformity or the need for a secondary post-traumatic septo-rhinoplasty. Group A2 consisted of patients who underwent a closed reduction of their nasal complex fracture and developed a secondary nasal deformity significant enough to require a septo-rhinoplasty.

RESULTS

The follow-up period ranged from 1 week to 12 months. Nine patients in group A were lost to follow-up. Patients in group A1 (31 patients) were pleased with their results and did not require a secondary surgery. Four patients developed a post-traumatic nasal deformity requiring a post-traumatic septo-rhinoplasty (group A2). All patients in group B required post-traumatic septo-rhinoplasty.

CONCLUSION

Closed reduction of nasal fractures appears to be an effective method of treatment as long as careful attention is paid to the key regions in the nasal complex, including the septum at the initial time of treatment. Ideal results are obtained when surgery is performed within 2 weeks of initial injury. Factors such as timing of surgery, the status of the nasal septum, delay in treatment, and other associated injuries may influence the overall result.

Postoperative Evaluation of the Knee after Autologous Chondrocyte Implantation: What Radiologists Need to Know

Articular cartilage lesions occur commonly. Cartilage is relatively avascular and is unable to self-repair. A chondral lesion may become symptomatic. It may lead to osteoarthritis and increased morbidity. The aim of cartilage repair is to restore hyaline cartilage. There are many types of cartilage repair surgery, most of which result in fibrocartilage repair tissue that is suboptimal. Autologous chondrocyte implantation has been shown to produce hyaline-type repair tissue. Magnetic resonance (MR) imaging is performed preoperatively to define the ulcer and postoperatively to evaluate the technical success of implantation and the state of cartilage healing and to identify potential complications. Features of the autologous chondrocyte implantation graft that are assessed include the degree of filling by repair tissue, its integration with native cartilage and subchondral bone, the character of the graft substance and surface, and the underlying bone. MR arthrography is superior to unenhanced MR imaging because intraarticular contrast material allows the recipient site to be physically separated from adjacent structures so that it can be characterized more accurately. MR imaging and arthroscopy are complementary investigations in the follow-up of an autologous chondrocyte implantation in the knee. The appearance of the knee after autologous chondrocyte implantation varies among individuals and according to the time-course of healing. Familiarity with the surgical procedure and imaging appearance is essential for an accurate postsurgical assessment.

[Articular cartilage lesions in unstable knees]

OBJECTIVES

The purpose of this retrospective analysis was to evaluate the management of chondral defects in knees with anterior cruciate ligament (ACL) disruption.

METHODS

Twenty-seven patients (mean age 35 years; range, 20 to 48 years) were randomized to osteochondral autologous transplantation (OAT, n=14) or a microfracture (MF, n=13) procedure together with ACL reconstruction in the same session for symptomatic lesions of the articular cartilage in ACL-deficient knees. The mean follow-up period was 34 months (range 24 to 53 months) in the OAT group, and 49 months (range 24 to 97 months) in the MF group. Patients were evaluated using the Lysholm and IKDC 2000 (International Knee Documentation Committee) scores.

RESULTS

Patients undergoing OAT had a mean IKDC 2000 score of 49.2 (range 30.1 to 64.7), and Lysholm score of 43.4 (range 33.2 to 58.9) preoperatively. At the end of follow-up, these scores increased to 93.3 (range 73 to 98) and 97.5 (range 38.7 to 100), respectively. In the MF group, the mean IKDC 2000 score increased from 53.6 (range 47.1 to 64.7) to 72.3 (range 62.8 to 94), and the mean Lysholm score increased from 48 (range 38.2 to 58.9) to 81.3 (range 72.7 to 100).

CONCLUSION

Treatment of chondral lesions should be added to ACL reconstruction in unstable knees secondary to ACL deficiency.

[Use of intranasal splints in acute septoplasty in the treatment of composite nasoseptal fractures]

Etiology and pathogenesis of nasoseptal fractures are reviewed. The results of examination and treatment of 103 patients with acute nasal traumas are analysed. Efficacy of intranasal splints in acute septoplasty for creation of nasal septum base in the treatment of composite nasoseptal fractures compared to conventional methods are shown.

Intra-articular fibrous tissue formation following ankle fracture: the significance of arthroscopic debridement of fibrous tissue

PURPOSE

The purposes of this study were to understand the clinical consequences of arthrofibrosis following surgical reduction of ankle fractures and to examine the effectiveness of arthroscopic debridement.

METHODS

Subjects included 33 patients (26 males, 7 females) aged 14 to 78 years (mean, 40.2 years) who had undergone open reduction and internal fixation of ankle fractures between May 2000 and May 2003. Arthroscopic examination was performed at the time of implant removal after an average of 12.4 months (range, 6 to 43 months), and abnormal fibrous tissue, when present, was removed through arthroscopy. The mean follow-up period after arthroscopy was 43.7 months (range, 22 to 68 months). Clinical outcomes before and after arthroscopy were evaluated with the American Orthopaedic Foot and Ankle Society scale and our own functional evaluation method. Arthroscopic findings, including the degree of articular cartilage damage and the quantity of fibrous tissue, were scored on a 3-point scale.

RESULTS

Functional deterioration of the ankle joint was observed in 27% of subjects. Arthroscopy showed articular cartilage damage in 33% of patients and arthrofibrosis in 73%. In patients with functional deterioration, the rate of articular cartilage damage was 78%, and arthrofibrosis was present in all cases. Furthermore, when extensive fibrosis and impingement on the articular surface were present, 88% of patients showed impaired articular function. Arthroscopic debridement of fibrous tissue resulted in improved articular function in 89% of patients with functional deterioration of the ankle joint before arthroscopy.

CONCLUSIONS

Arthrofibrosis following ankle fracture causes an unfavorable surgical outcome, and arthroscopic debridement of fibrous tissue is an effective means of improving articular function.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

[Cartilage repair in the knee joint]

Full thickness defects of the articular cartilage in the knee joint have lower regenerative properties compared to chondral lesions of the ankle. In order to avoid early osteoarthritis, symptomatic articular cartilage defects in younger patients should undergo biological reconstruction as early as possible. There are different surgical procedures available to achieve a biological resurfacing of the articular joint line. Numerous animal experiments and clinical studies have shown that early biological reconstruction of circumscribed cartilage defects in the knee is superior to a conservative or delayed operative treatment. This effect refers not only to the defect healing but also to the elimination of changes following secondary osteoarthritis. The different surgical procedures can be differentiated concerning the various indications and the final outcome. Additional malalignment, meniscus tears, and/or ligament instabilities should be treated simultaneously together with the cartilage resurfacing. The mid- and long-term results of the different current techniques are promising, but further modifications and improvements are needed.

[First clinical experiences with a novel 3D-collagen gel (CaReS) for the treatment of focal cartilage defects in the knee]

AIM

In this prospective study we present a novel technique of matrix-based chondrocyte transplantation for the treatment of focal cartilage defects.

METHOD

22 patients with chondral or osteochondral femoral defects were treated with 3D-collagen type-I gel seeded with autologous chondrocytes (CaReS). Overall handling of this novel method is described, and results after 2 years follow-up with regard to the ICRS-score are presented.

RESULTS

14 patients were treated because of a focal chondral lesion, in 8 cases subchondral bone had to be reestablished. The average defect size was 6 cm(2). In all cases cell-seeded matrix samples could be fixed with fibrin glue without any problems. The average surgery time was 69 min, length of the surgical approach was 8.2 cm. No surgery-specific problems had to be observed. A significant improvement in IKDC-score, functional score and overall rating after 3 or 6 months up to 2 years follow-up was detected. After 2 years post-OP 13 Patients were evaluated and matrix-based defect treatment by CaReS was rated good to excellent by 84.6 % of the patients.

CONCLUSION

Defect treatment with cell-seeded 3D-collagen gel is easy to handle with a good clinical outcome after 2 years follow-up. Further investigations with higher patient number, longer follow-up time and histological and biomechanical sample analysis are needed in order to establish this method as an improvement of conventional ACT.

Labral tears, extra-articular injuries, and hip arthroscopy in the athlete

Labral tears in athletes can lead to disabling hip pain and affect their athletic performance. Other intra-articular lesions, including chondral injuries, capsular abnormalities, and ligamentum teres tears, commonly coexist with acetabular labral tears. Isolated athletic injury or repetitive traumatic activity can lead to labral tears; however, underlying structural (femoroacetabular impingement) and developmental abnormalities predisposing athletes to labral pathology must be addressed. Recent studies have demonstrated lesions associated with acetabular labral tears, and that labral tears rarely occur as isolated injuries. Return to sport is favorable in athletes who have labral tears if they are properly treated with arthroscopic intervention.

[Results of SaluCartilage implantation for stage IV chondral defects in the knee joint area]

AIM OF STUDY

This prospective report presents SaluCartilage hydrogel implants, an alternative therapy option in the treatment of chondral defects.

METHODS

For the prospective study between October 2002 and July 2003, 18 patients suffering from stage IV chondral defects received 49 hydrogel implants and were subsequently examined by means of clinical, radiological, and magnetic resonance imaging assessment. The knee function was classified using the McDermott score.

RESULTS

The average McDermott score was improved to 75 points (p<0.05) after 3 months postoperatively and to 80 points (p<0.05) 6 months postoperatively, but after 12 months it decreased to 69 points. After 3 and 6 months, the MRI showed in all patients that there was fluid around the hydrogel implants without dislocation. After 12 months postoperatively the hydrogel implants had been destroyed in two patients.

CONCLUSION

The short-term results showed subjective and objective improvement of the medical conditions probably because of the placeholder function. This alternative should be critically discussed because of the inadequate connection to the bone with risk of dislocation.

Cricotracheal separation: a review and a case with bilateral recovery of recurrent laryngeal nerve function

Cricotracheal separation (CTS) is an uncommon injury, with a high index of suspicion required to establish the diagnosis. Computerized tomography (CT) plays a role in diagnosis but cannot necessarily be relied upon. Bilateral recurrent laryngeal nerve (RLN) palsies are usually associated with this type of injury. We recently treated a patient with CTS in whom one RLN was intact from the time of the injury and the other nerve recovered within three months. Computed tomography was inconclusive.

Early open repair of the injury and frequent follow-up examinations led to successful decannulation after six weeks and excellent short-term voice and airway outcomes.

A detailed discussion of this unusual case is followed by a review of the current literature on CTS, with particular emphasis on significant management dilemmas and controversies.

Clinical suspicion remains more sensitive than investigations in diagnosing CTS. Permanent bilateral RLN palsies are not inevitable following these injuries.

Midterm results of meniscal repair using the BioStinger meniscal repair device

PURPOSE

The purpose of this study was to evaluate the midterm healing rate and any adverse events from meniscus repair using the BioStinger meniscus repair device (Linvatec, Largo, FL).

METHODS

A retrospective review of a consecutive series of meniscal repairs performed by a single surgeon using the BioStinger was conducted. The BioStinger is cannulated, made of molded poly L-lactic acid, and inserted over a needle into the meniscus tissue. Clinical results and adverse events were noted, and Lysholm, Tegner, Cincinnati, and International Knee Documentation Committee (IKDC) activity scores were obtained on all patients.

RESULTS

Forty-one patients underwent 41 meniscal repairs with an average follow-up of 38.6 months (range, 24 to 69 months); 35 meniscus repairs were performed in conjunction with anterior cruciate ligament reconstruction and 6 in stable knees. Tears repaired were peripheral, posterior horn tears with an average length of 2 cm. Clinical evidence of meniscal healing was observed in 95% at the time of last follow-up. Six second-look arthroscopies were performed and 2 failures were found. All other patients were symptom free. At follow-up, the mean Tegner score was 6.1 (2.8 preoperative), IKDC activity score was 3.3 (2.1 preoperative), Lysholm score was 90.6 (48.7 preoperative), and the mean Cincinnati score was 86.7 (41.3 preoperative). Four patients had peripheral migration of the device without skin tenting or perforation; 3 underwent removal of the BioStinger from the soft tissues and the other resolved after 12 months.

CONCLUSIONS

The midterm clinical success rate was 95% using the BioStinger device. Adverse events were observed in few cases.

LEVEL OF EVIDENCE

Level IV, cases series.

Meniscal debridement with an arthroscopic radiofrequency wand versus an arthroscopic shaver: comparative effects on menisci and underlying articular cartilage

PURPOSE

Meniscal debridement with an arthroscopic radiofrequency (RF) wand versus an arthroscopic shaver and their comparative effects on menisci and underlying articular cartilage were studied.

METHODS

When repair is not feasible, degenerative or post-traumatic meniscal tears often need debridement. Six fresh bovine knees were harvested, the tibial plateau was dissected free from the femoral articulation and placed in a saline bath at 28 degrees C, with 10% to 15% of the posterior horn of menisci debrided arthroscopically, and the surfaces debrided using a basket punch plus shaver, punch plus RF wand, RF wand alone, and untreated control. Treatment time of each case was 24 seconds at wand power 7. We characterized an injury zone, as well as viability and metabolic activity of meniscal cells and tibial articular cartilage chondrocytes.

RESULTS

Chondrocyte viability of the tibial articular surface was 96% to 98%. We saw no differences in viability or injury zone (0 to 150 microm) among debrided groups or versus the control for any experimental surface, with no significant difference in metabolic activity in menisci debrided surfaces versus control. Meniscal viability was variable with analyses showing substantial levels (150 to 500 microm) of cell death in debrided and control groups. Metabolic activity in treated meniscus was lower than in cartilage specimens. No significant differences were observed among treatment groups versus control.

CONCLUSIONS

Focal areas of chondrocyte cell death were not seen. Meniscal samples showed cell death (150 to 500 mum) throughout the tissue.

CLINICAL RELEVANCE

Debridement of menisci with a bipolar RF wand produces levels of cell injury and death similar to those of debridement with a basket punch mechanical shaver. The RF wand did not harm underlying articular surfaces and produced a precise cut to the meniscal surface.

Effect of lesion location on fixation strength of the meniscal viper repair system: an in vitro study using porcine menisci

PURPOSE

The Meniscal Viper Repair System (Arthrex, Naples, FL) is a novel suture-based all-inside meniscal repair system. This study was performed to test whether the Meniscal Viper Repair System would provide superior fixation characteristics for vertical longitudinal meniscal lesions located closer to the periphery compared with those located further away from the periphery.

METHODS

Vertical longitudinal lesions were created either 1 to 2 mm or 3 to 4 mm away from the periphery of porcine menisci. After repair with the Meniscal Viper Repair System, fixation characteristics were studied during cyclic (500 cycles, 5 to 50 N) and load to failure testing (5 mm/min) in a servo hydraulic device.

RESULTS

Meniscal lesion repair location did not show significant differences in displacement or stiffness during cyclic testing. During load to failure testing, meniscal lesion repairs located 1 to 2 mm from the periphery showed superior load at failure (188.8 +/- 45.4 N) compared with repairs located 3 to 4 mm from the periphery (114.4 +/- 35.0 N) (P = .01). Stiffness and displacement during load to failure testing did not show statistically significant differences.

CONCLUSIONS

The Meniscal Viper Repair System provides stronger meniscal repair strength when lesions are located within 1 to 2 mm of the periphery.

CLINICAL RELEVANCE

The Meniscal Viper Repair System is better suited for repair of peripheral meniscal lesions located within 1 to 2 mm of the periphery. For lesions located in zone 2 (within the central 50%), careful assessment of their distance from the periphery is recommended. For lesions located more than 3 to 4 mm away from the periphery, alternative repair systems or augmentation with other devices may be prudent.

A biomechanical comparison of the FasT-Fix meniscal repair suture system and the RapidLoc device in cadaver meniscus

PURPOSE

This biomechanical study compared the fixation characteristics of horizontally or vertically implanted FasT-Fix devices (Smith & Nephew, Endoscopy Division, Andover, MA) consisting of two 5-mm PLLA suture T-bar anchors with a pretied self-sliding knot (No. 0 nonabsorbable, USP, braided polyester suture material) and the RapidLoc device (Mitek Surgical Products, Westwood, MA) consisting of a PLLA T-bar anchor or "backstop," a connecting suture (No. 2 nonbiodegradable Ethibond; Ethicon, Somerville, NJ), and a PLLA grommet, for repairing posterior third lesions in human menisci.

TYPE OF STUDY

Controlled laboratory biomechanical study.

METHODS

After repair of a vertical longitudinal meniscus lesion with either vertically or horizontally implanted FasT-Fix devices or RapidLoc devices, 3 groups of 6 specimens underwent cyclic loading (5 mm/minute, cycling between 5 and 50 N at 1 Hz for 500 cycles) before load to failure testing on a servo hydraulic device. One-way analysis of variance and Tukey HSD post hoc tests were used to evaluate group differences (P < .05).

RESULTS

The vertical FasT-Fix device group (3.2 +/- 0.49 mm) had less displacement after cyclic testing than either the horizontal FasT-Fix (4.4 +/- 0.73 mm, P = .003) or the RapidLoc (4.6 +/- 0.22 mm, P = .002) device groups. The vertical FasT-Fix device group had greater stiffness during cyclic testing (14.4 +/- 2.1 N/mm) than the horizontal FasT-Fix (10.4 +/- 1.6 N/mm, P = .0001) or the RapidLoc (9.7 +/- 0.44 N/mm, P = .0001) device groups. During load to failure testing, the vertical FasT-Fix group (125.3 +/- 39 N) had 28% greater strength than the horizontal FasT-Fix device group (89.7 +/- 14 N, P = .02) and 30% greater strength than the RapidLoc device group (87.1 +/- 13 N, P = .028), whereas displacement and stiffness did not show statistically significant group differences.

CONCLUSIONS

The vertical FasT-Fix group had superior biomechanical characteristics for meniscal fixation during cyclic and load to failure testing compared with horizontal FasT-Fix or RapidLoc devices.

CLINICAL RELEVANCE

Although the RapidLoc devices provided fixation characteristics comparable to horizontally implanted FasT-Fix devices, vertically implanted FasT-Fix devices may provide superior all-inside fixation.

Rehabilitation Following Hip Arthroscopy

The management of hip injuries has evolved significantly in recent years with the advancement of arthroscopic techniques. These recent surgical advances require establishment of rehabilitation protocols that follow several basic principles including (1) consideration of soft-tissue healing constraints, (2) control of swelling and pain to limit muscular inhibition and atrophy, (3) early range of motion, (4) limitations of weight bearing, (5) early initiation of muscle activity and neuromuscular control, (6) progressive lower extremity strengthening and proprioceptive retraining, (7) cardiovascular training, and (8) sport-specific training. The following protocols should not be considered a cookbook approach to rehabilitation, rather guidelines that are used to achieve consistent outcomes. These guidelines will continue to evolve as we learn more about the hip joint and surrounding musculature.

[Bilateral post-traumatic acetabular dysplasia]

Traumatic disruption of the acetabular triradiate cartilage is an infrequent injury. When it occurs in early childhood, it may lead to growth changes in acetabular morphology. The morphology of this kind of acetabular dysplasia is uniform and differs significantly from that seen in classic developmental dysplasia of the hip. We present a case of bilateral post-traumatic acetabular dysplasia, which to our knowledge has not been reported. The morphology and the symptoms of impingement and periacetabular osteotomy of the hip joint are discussed.

Unicortical transverse osteochondral fracture of the patella: a case report

Chondral lesions are relatively common and they usually occur as a result of high energy trauma. Chondral fractures of the patella ordinarily occur during an acute dislocation of the patella. Patellar chondral fractures without either a dislocation or a patella fracture are extremely rare. We have treated a 25-year-old male who had a unicortical transverse osteochondral fracture of the patella without a dislocation which was produced by high energy trauma. Chondral fractures of the patella are often overlooked because they are difficult to detect on plain radiographs. A persistent cartilaginous irregularity from either a chondral or osteochondral fracture may lead to the development of secondary osteoarthrosis. In this case, restoration of the articular surface was achieved by elevation of the compressed osteochondral fragment. This case demonstrates that understanding the mechanism of injury can be helpful in the treatment of osteochondral lesions.

Labrum acetabulare

The acetabular labrum makes a vital contribution to the stability of the hip joint. Hip arthroscopy has revolutionized the diagnosis and treatment of labral pathology. Lesions that would otherwise have gone unrecognised are now amenable to resection and in some cases repair. Symptomatic relief is generally good after treatment of traumatic tears but patients with co-existing articular cartilage degeneration do less well. The long-term results of arthroscopic surgery for the acetabular labrum are awaited.

Internal fixation of comminuted cartilaginous fracture of the larynx with mini-plates

Acute laryngeal trauma is an uncommon injury. Such trauma is not generally encountered by oral and maxillofacial surgeons. We illustrate a patient who sustained a severe penetrating laryngeal injury. His subsequent management was optimised by the joint intra-operative surgical collaboration between otorhinolaryngology and maxillofacial disciplines.

[Axial load in case of press-fit fixation of the ACL graft--a fundamental study]

AIM

The aim of this study was the determination of the axial fixation load resting on smooth press-fit dowels needed for fixation of the patellar tendon graft (BTB) in order to reach the same fixation properties compared to the interference screw on anterior cruciate ligament (ACL) plasty.

METHOD

Bovine test specimens with 27 BTB grafts fixed in tibial drill holes were used and divided in 3 groups: interference screw, and press-fit cylinder (Ø 7 mm) with 150 N and 100 N axial loads. Prior to fixation, impactation of the transplant into bone was carried out. Failure testing was done in a tensiometer at a cross-head speed of 50 mm/min. Determinations of peak load and stiffness were also made.

RESULTS

Similar peak loads and stiffness were reached on introducing a press-fit dowel (slashed circle 7 mm) with 100 N and 150 N axial load compared to interference screw fixation of the BTB graft. Peak load: 988.1 N +/- 365.1 (screw) versus 1 210.4 N +/- 292.4 (dowel 150 N) and 1 109.8 N +/- 505.4 (dowel 100 N). Stiffness: 86.4 N/mm +/- 20.5 (screw) versus 102.4 N/mm +/- 15.2 (dowel 150 N) and 77.1 N/mm +/- 11.0 (dowel 100 N). There was no significant difference.

CONCLUSION

When introducing a press-fit dowel (slashed circle 7 mm) with 100 N axial load into a preformed bone bed, the same fixation properties are reached as in the case of an interference screw on BTB-ACL plasty.