Showing papers in "Archives of Orthopaedic and Trauma Surgery in 2007"

Thermal osteonecrosis and bone drilling parameters revisited

Abstract: During the drilling of the bone, the temperature could increase above 47°C and cause irreversible osteonecrosis. The result is weakened contact of implants with bone and possible loss of rigid fixation. The aim of this study was to find an optimal condition where the increase in bone temperature during bone drilling process would be minimal. Influence of different drill parameters was evaluated on the increase of bone temperature. Drill diameters were 2.5, 3.2 and 4.5 mm; drill speed 188, 462, 1,140 and 1,820 rpm; feed-rate 24, 56, 84 and 196 mm/min; drill point angle 80°, 100° and 120° and external irrigation with water of 26°C. Combinations of drill speed and drill diameter with the use of external irrigation produced temperatures far below critical. Without external irrigation, temperature values for the same combination of parameters ranged 31.4–55.5°C. Temperatures above critical were recorded using 4.5 mm drill with higher drill speeds (1,140 and 1,820 rpm). There was no statistical significance of different drill point angles on the increase or decrease of bone temperature. The higher the feed-rate the lower the increase of bone temperature. The external irrigation is the most important cooling factor. With all combinations of parameters used, external irrigation maintained the bone temperature below 47°C. The increase in drill diameter and drill speed caused increase in bone temperature. The changes in drill point angle did not show significant influence in the increase of the bone temperature. With the increase in feed-rate, increase in bone temperature is lower.

Modern concepts of primary aneurysmal bone cyst

Abstract: Despite the long experience of radiologists, pathologists and orthopaedists with aneurysmal bone cysts (ABC), there is limited knowledge regarding the cause of the lesion and the optimal treatment. The pathogenesis of ABC remains unclear with theories ranging from a post-traumatic, reactive vascular malformation to genetically predisposed bone tumours. Recent genetic and immunohistochemical studies proposed that primary ABC is a tumour and not a reactive tumour-simulating lesion. The chromosomal analyses and some reported familial cases of this osteolytic bone lesion propose a hereditary factor in a presumably multifactorial pathogenesis. The imaging studies, even CT scan and MRI sometimes do not provide clearly diagnostic criteria for the diagnosis of ABC. The radiographically differential diagnosis between ABC and unicameral bone cyst (UBC) is sometimes not clear. Double density fluid level, septation, low signal on T1 images and high intensity on T2 images strongly suggest the bone cyst is an ABC, rather than a UBC. Common methods of treatment vary considerably in the literature. The usual methods of treatment are curettage, resection, intracystic injections and embolization. Biopsy is imperative before any treatment. Ethibloc® treatment remains highly controversial. For some authors Ethibloc® injection can be recommended as the first-choice treatment excluding spinal lesions. A minimally invasive method by introduction of demineralized bone and autogenous bone marrow is able to promote the self-healing of a primary ABC.

Five-year follow-up examination after purely minimally invasive posterior stabilization of thoracolumbar fractures: a comparison of minimally invasive percutaneously and conventionally open treated patients

Abstract: Introduction It is well known that during posterior stabilization of the spinal column conventionally open methods are predominantly used. However, in this study a minimally invasive method was chosen to decrease the morbidity of the operative access and to protect the paravertebral musculature, which serves as an important spine-stabilizing factor during posterior stabilization. The aims of this retrospective non-randomized case-control study were to compare the clinical and radiological results of minimally invasive on the one hand and conventionally open posterior surgery on the other with each other and to measure the loss of correction after purely posterior stabilization.

Poor accuracy of freehand cup positioning during total hip arthroplasty.

Abstract: Several studies have demonstrated a correlation between the acetabular cup position and the risk of dislocation, wear and range of motion after total hip arthroplasty. The present study was designed to evaluate the accuracy of the surgeon’s estimated position of the cup after freehand placement in total hip replacement. Peroperative estimated abduction and anteversion of 200 acetabular components (placed by three orthopaedic surgeons and nine residents) were compared with measured outcomes (according to Pradhan) on postoperative radiographs. Cups were placed in 49.7° (SD 6.7) of abduction and 16.0° (SD 8.1) of anteversion. Estimation of placement was 46.3° (SD 4.3) of abduction and 14.6° (SD 5.9) of anteversion. Of more interest is the fact that for the orthopaedic surgeons the mean inaccuracy of estimation was 4.1° (SD 3.9) for abduction and 5.2° (SD 4.5) for anteversion and for their residents this was respectively, 6.3° (SD 4.6) and 5.7° (SD 5.0). Significant differences were found between orthopaedic surgeons and residents for inaccuracy of estimation for abduction, not for anteversion. Body mass index, sex, (un)cemented fixation and surgical approach (anterolateral or posterolateral) were not significant factors. Based upon the inaccuracy of estimation, the group’s chance on future cup placement within Lewinnek’s safe zone (5–25° anteversion and 30–50° abduction) is 82.7 and 85.2% for anteversion and abduction separately. When both parameters are combined, the chance of accurate placement is only 70.5%. The chance of placement of the acetabular component within 5° of an intended position, for both abduction and anteversion is 21.5% this percentage decreases to just 2.9% when the tolerated error is 1°. There is a tendency to underestimate both abduction and anteversion. Orthopaedic surgeons are superior to their residents in estimating abduction of the acetabular component. The results of this study indicate that freehand placement of the acetabular component is not a reliable method.

Correlation of intercondylar notch cross sections to the ACL size: a high resolution MR tomographic in vivo analysis.

Abstract: To correlate cross sections of the intercondylar notch to cross sections of the anterior cruciate ligament (ACL) and to analyze gender-related differences in notch and ACL morphometry with an attempt to explain the observation that a small intercondylar notch and the female gender predispose to a rupture of the ACL. High resolution MR imaging was performed on a 1.5 T magnet using a dedicated extremity-coil in ten left and ten right knee joints of 20 volunteers (10 male, 10 female, mean age 25 years) with no history of knee abnormalities. Continuous axial T2-weighted MR images perpendicular to the longitudinal axis of the ACL were acquired. Cross-sectional areas of the ACL midsubstance at the contact area to the posterior cruciate ligament were measured. For imaging and evaluation of the osseous limits of the intercondylar notch a 3D-dataset of the knee was acquired. Anterior, middle and posterior planes of the intercondylar notch were calculated and analyzed for measurement of the notch area AN and notch width index NWI. The ratio of the ACL cross-sectional area of the ACL and the cross-sectional area of the notch was defined as the ACL notch index (ANI) and used as a standardized tool for evaluation. For statistical evaluation, linear regression analysis was performed. Mean values between male and female were compared using a t test. In addition, five matched pairs of male and female volunteers of same height were analyzed. Mean cross-sectional size of the ACL at the crossing with the PCL was 54.4 ± 20.4 mm2. Regression analysis showed a significant correlation (P < 0.05) of the ACL cross-sectional area to the notch areas on all three planes and NWI, respectively. Comparison between the sexes revealed that female participants had significantly smaller cross-sectional areas of the ACL, the notch areas, the NWI and ANI. This difference was found for both the complete study group and the matched pairs of same height. The smaller the intercondylar notch the smaller the cross-sectional area of the ACL midsubstance. In addition to the impingement of the ACL at the anterior and posterior roof of the notch, a biomechanically weaker ACL may be the reason for disposition to an ACL rupture in patients with a small intercondylar notch. Women have a thinner ACL midsubstance than men of the same height which may be one of the critical etiologic factors that predispose women to an ACL rupture.

Rupture of the distal biceps brachii tendon: conservative treatment versus anatomic reinsertion--clinical and radiological evaluation after 2 years.

Abstract: Distal biceps tendon rupture is a relatively rare injury It commonly occurs in the dominant extremity of middle-aged men during an excessive eccentric tension as the arm is forced from a flexed position, while it is rarely observed during sport activities Many techniques, including non-operative and surgical option, have been described for the treatment of a ruptured distal biceps tendon, but there is still considerable controversy about the management of choice Nine patients affected with traumatic distal tendon ruptures of the biceps brachii were followed-up for a minimum of 24 months Five patients underwent surgery (two-incision technique) and four patients were treated conservatively Tendon readaptation to its origin was done by a suture metal anchor Outcome was evaluated based on the physical examination, radiographic analysis and the SECEC elbow score The SECEC elbow score results show that every single item result is in favour of surgical treatment On measurements of motion, we found a slight flexion–extension deficit in two patients, but reduced supination in six patients and reduced pronation in four Two patients had postoperative dysfunction of the deep branch of the radial nerve Radiographic examination showed heterotopic bone formation on the radial tuberosity around the presumed insertion of the reattached tendon in 2 of 5 patients and ectopic ossification more proximally in the area of the biceps muscle Our findings confirm the view that anatomic repair of distal biceps tendon rupture provides consistently good results and early anatomic reconstruction can restore strength and endurance for the elbow

Use of the AO hook-plate for treatment of unstable fractures of the distal clavicle

Abstract: Introduction We used a new internal fixative implant, the AO clavicle hook-plate, for treatment of unstable fractures of the distal clavicle. This study describes the operative procedure and the clinical results obtained, as well as discussion of the advantages and problems encountered.

Added value of SPECT/CT in patients suspected of having bone infection: preliminary results

Abstract: Aim We evaluated the contribution of SPECT/CT as an adjunct to combined three-phase bone scintigraphy (planar and SPECT) for diagnosing and localizing bone infection. Subsequently, the diagnostic performance of SPECT/CT was compared to visual fusion of SPECT with data of additional CT, X-ray, or MRI studies (SPECT + CT/X-ray/MRI).

Proximal humeral internal locking system (PHILOS) for the treatment of proximal humeral fractures

Abstract: The aim of this study was to describe early results of a new internal locking system, PHILOS, used for the treatment of proximal humeral fractures. A chart and radiographic review of 25 cases that had proximal humeral internal locking system (PHILOS) plate for the treatment of proximal humeral fractures was performed. Of the 25 cases, 20 went to union with a mean neck/shaft angle of 127.2°. Five cases required or were considered for revision surgery for non-union or implant failure. Of the 25 implants, 4 had screw protrusion into the gleno-humeral joint, 4 had screw loosening and backing out, and 1 plate broke without further trauma. Our results suggest that PHILOS is an effective system for providing fracture stabilisation to bony union but awareness of potential hardware complications is essential.

Long-term outcome after high tibial osteotomy.

Abstract: The frequency of tibial osteotomy in the treatment of osteoarthritis of the knee has decreased due to the demanding surgical procedure and the rising number of total knee replacements (TKR). Only few data exist concerning survival rates after high tibial osteotomy (HTO) with a follow-up exceeding 10 years. We want to present long-term results with a follow-up of more than 18 years after operation. Survival rates and the influence of age, gender and the mechanical axis were investigated in 134 lateral closing-wedge osteotomies in 111 patients. The survival rate was 94% after 5 years, 79.9% after10 years, 65.5% after 15 years, and 54.1% after 18 years. Age had a significant influence on the survival and gender and the mechanical axis had no significant influence. We conclude, that with a 54.1% survival after 18 years HTO is a useful facility to protract the implantation of a total knee prosthesis.

Effect of tourniquet application on deep vein thrombosis after total knee arthroplasty

Abstract: Introduction There is a great deal of controversy about the effect of tourniquets on development of deep vein thrombosis (DVT) after total knee arthroplasty (TKA).

Trochanteric fractures in the elderly: the influence of primary hip arthroplasty on 1-year mortality

Abstract: Introduction The aim of the study was to compare the mortality risk and complication rate after operative treatment of pertrochanteric fractures with primary arthroplasty, dynamic hip screw (DHS) or proximal femoral nail (PFN). Patients and methods Clinical records including X-rays of all patients with trochanteric femoral fractures, except pathologic fractures and a minimum age of 60 years, which were treated between 1992 and 2005 were entered in this retrospective study. Of these 283 patients, 132 were treated by primary arthroplasty, 109 with a DHS and 42 with a PFN. Survival after 1 year and complications, which had to be treated within this period were our main outcome measurement. InXuencing cofactors such as age, gender and comorbidities were reduced by multivariate logistic regression analysis. Results Mortality was signiWcantly inXuenced by age, gender and amount of comorbidities but not by fracture classiWcation. Primary hip arthroplasty did not bear a higher 1-year mortality risk than osteosynthesis in a multiple regression analysis. The main complication with DHS and PFN were cutting out of the hip screw and non-union with a revision rate of 12.8%. With the introduction of hemiarthroplasty, the postoperative dislocation rate decreased from 12 to 0%. Conclusion For stable fractures a dynamic hip screw (DHS) and for unstable fractures a short proximal femoral nail (PFN) can be recommended. The mortality risk of primary cemented arthroplasty did not diVer signiWcantly from the other treatment groups and because of its low complication rate it is a viable treatment option for trochanteric fractures if osteoporosis prevents from full weight bearing or if osteoarthritis makes further operations likely. Primary total hip replacement should be handled with care due to its signiWcantly higher dislocation rate compared with hemiarthroplasty especially in unstable fractures.

Anatomical reconstruction for Reverse Hill-Sachs lesions after posterior locked shoulder dislocation fracture: a case series of six patients

Abstract: Posterior locked shoulder dislocation fracture is a rare injury. Impression fractures of the humeral articular surface are common with this injury. Different methods exist to restore impression fractures. We present a case series and the results of six patients that had an anatomical repair with spongiotic autograft/allograft for humeral head impression fractures after locked posterior shoulder dislocation. Six patients with an average age of 52.5 years at time of surgery were included. All patients had an anteromedial impression fracture, one patient had an additional two part fracture. The injury was caused by epileptic seizures in five and by direct trauma in one patient. The diagnosis was made on the day of the injury for two patients (33%). For the other patients the time span between the injury and the diagnosis ranged between 5 and 180 days. The impressed cartilage of the defect was first elevated in one piece, the defect filled with the graft and the cartilage fixed on top of the graft by Mitek ancres introduced under the affected area. One patient had an additional two-part fracture that was fixed separately. At a mean time follow-up of 62.7 (18–95) months the result was found to be excellent for two patients and good for four patients with a mean Constant Score of 88.2 points (range 83–98). One patient had a redislocation after three months that was fixed by the same method. At the last follow-up no redislocation or graft collapse was seen. The proposed method of anatomical head reconstruction by spongiotic auto/allograft proved to be a valid and good method to restore shoulder function and stability.

The role of sacroiliac joint dysfunction in the genesis of low back pain: the obvious is not always right.

Abstract: It is a common practice to the link low back pain with protruding disc even when neurological signs are absent Because pain caused by sacroiliac joint dysfunction can mimic discogenic or radicular low back pain, we assumed that the diagnosis of sacroiliac joint dysfunction is frequently overlooked To assess the incidence of sacroiliac joint dysfunction in patients with low back pain and positive disc findings on CT scan or MRI, but without claudication or objective neurological deficits Fifty patients with low back pain and disc herniation, without claudication or neurological abnormalities such as decreased motor strength, sensory alterations or sphincter incontinence and with positive pain provocation tests for sacroiliac joint dysfunction were submitted to fluoroscopic diagnostic sacroiliac joint infiltration The mean baseline VAS pain score was 78 ± 177 (range 5–10) Thirty minutes after infiltration, the mean VAS score was 13 ± 176 (median 0000E+00 with an average deviation from median = 130) (P = 00002) Forty-six patients had a VAS score ranging from 0 to 3, 8 weeks after the fluoroscopic guided infiltration There were no serious complications after treatment An unanticipated motor block that required hospitalization was seen in four patients, lasting from 12 to 36 h Sacroiliac joint dysfunction should be considered strongly in the differential diagnosis of low back pain in this group of patients

Anterolateral rotational knee instability: role of posterolateral structures

Abstract: Introduction The aim of this study was to determine the anterolateral rotational instability (ALRI) of the human knee after rupture of the anterior cruciate ligament (ACL) and after additional injury of the different components of the posterolateral structures (PLS). It was hypothesized that a transsection of the ACL will significantly increase the ALRI of the knee and furthermore that sectioning the PLS [lateral collateral ligament (LCL), popliteus complex (PC)] will additionally significantly increase the ALRI.

Proximal humerus fractures: a comparative biomechanical analysis of intra and extramedullary implants

Abstract: Introduction The biomechanical stability of a newly developed humerus nail (Sirus™) for the treatment of fractures of the proximal humerus was analyzed in comparison to established systems. In total, three randomized groups were formed (n = 4 pairs) from 12 matched pairs of human cadaver humeri.

Treatment of type IIIA open fractures of tibial shaft with Ilizarov external fixator versus unreamed tibial nailing.

Abstract: Introduction The aim of this study was to compare the radiographic results and clinical outcome of unreamed tibial nailing (UTN) and Ilizarov external fixation (IEF) for the treatment of type IIIA open fractures of the tibia.

Minimally invasive plating for complex humeral shaft fractures.

Abstract: The treatment for humeral shaft fracture is still controversial, especially for complex fractures. The purpose of this study was to evaluate the clinical and radiographic outcomes of treating complex humeral shaft fractures by using locking compression plate with minimally invasive technique. A total of 21 patients with 21 acute complex humeral shaft fractures (AO type C) were included in this study. All were treated with locking compression plate in a minimally invasive way. The average age of the patients was 42.9 years and there were 14 males and 7 females. Plain radiographs of humerus were used to assess bony union. Functional recovery of the shoulder joint was assessed using the Constant and HSS scoring systems. The patients were followed for a mean of 28.7 months (range 19–37). With one operation, nineteen fractures (90.4%) achieved a solid union in an average of 14.3 weeks. At final follow-up, 20 patients (95.2%) had satisfactory alignment, except for one associated with olecranon fracture, all patients had a good to excellent elbow function with a mean HSS score of 91.7 points. Eighteen patients (85.7%) achieved satisfactory shoulder function with a mean Constant score of 83.1 points. One superficial infection (4.8%) and two non-unions (9.6%) were found postoperatively. It was concluded that use of a minimally invasive plate osteosynthesis with locking compression plate is a safe alternative way to classic surgical methods in the treatment of complex humeral shaft fractures, which had a high union rate with less risk of complications.

Tissue engineering of the anterior cruciate ligament: a new method using acellularized tendon allografts and autologous fibroblasts.

Abstract: The availability of autogenous tendons (middle part of patellar tendon, semitendinosus/gracilis, or quadriceps tendon) for cruciate ligament reconstructions is restricted and related to withdrawal morbidity. Allografts and synthetic ligament materials often show problems regarding long-term stability and immunological reactions. Therefore, the aim of this study was to develop and characterize a new scaffold based on acellular allografts seeded with autologous cells for tissue engineering of the anterior cruciate ligament (ACL). Semitendinosus tendons of New Zealand White (NZW) rabbits were harvested and acellularized using the detergent sodium dodecyle sulfate (SDS) as the main ingredient. After that, cultured (37°C, 5% CO2, medium) dermal fibroblasts were injected into the tendons. These constructs were further cultivated for 4, 7, or 14 days under the same culture conditions. Native, acellular, and seeded tendons underwent biomechanical testing (ultimate load to failure [N], stiffness [N/mm], and elongation [%], each n = 9] and histological hematoxylin-eosin (H.E.) staining. Detailed immunohistochemical (collagen I, III, IV, VI, pro-collagen I, versican, and vimentin) analyses were conducted to detect changes in the composition and structure of the extracellular matrix (ECM) after acellularization. Histologically, a cell-free, crimped slack tendon structure after acellularization and a good integration of the cells after injection (4, 7, and 14 days) were seen. Metabolic activity of the seeded cells was demonstrated by positive immunohistochemical staining for pro-collagen I, which was negative in nonseeded constructs. Major differences in staining patterns of the various other ECM components were not observed. Biomechanically, the maximum load to failure of these tendons was comparable to native tendons (P = 0.429; native 134.5 ± 12.9 N; acellular 118.5 ± 7.3 N; seeded 132.3 ± 5.6 N). Stiffness and elongation were comparable between native and acellular tendons, but differed significantly after seeding (P < 0.001). The described method is suitable to make tendons completely cell free without changing their major biomechanical properties. Preservation of the ECM and of the collagen fiber structure by this method should give an ideal environment for autologous cell integration and metabolic activity in contrast to other approaches for tissue acellularization. The cell disruption and extraction of cell detritus should minimize adverse immunogenic reactions.

Antegrade intramedullary splinting or percutaneous retrograde crossed pinning for displaced neck fractures of the fifth metacarpal

Abstract: Introduction It is generally accepted that severely displaced or malrotated neck fractures of the fifth metacarpal should be treated by closed reduction and pinning. As antegrade intramedullary splinting avoids adhesions of the extensor hood and provides intramedullary stability this technique seems to be advantageous in comparison with traditional retrograde percutaneous crossed pinning. We raised the question whether the antegrade technique would give clinical and radiological results superior to the retrograde technique and investigated this within a comparative clinical study.

The non-steroidal anti-inflammatory drug diclofenac reduces appearance of osteoblasts in bone defect healing in rats

Abstract: Introduction Non-steroidal anti-inflammatory drug (NSAID) is well known to significantly delay fracture healing. Results from in vitro studies implicate an impairment of osteoblast proliferation due to NSAIDs during the initial stages of healing. We studied whether diclofenac, a non-selective NSAID, also impairs appearance of osteoblasts in vivo during the early phase of healing (at 10 days).

Comparison of delayed and primary wound closure in the treatment of open tibial fractures

Abstract: Introduction Primary wound closure in the management of open tibial fractures has generally been discouraged. Several prior studies suggest that infections are not caused by the initial contamination, but are instead the result of organisms acquired in the hospital. Primary wound closure after adequate wound care and fracture stabilisation could therefore be considered a reasonable option.

Use of antibiotic cement rod to treat intramedullary infection after nailing: preliminary study in 19 patients

Abstract: The treatment of intramedullary infections after nailing usually includes removal of the nail, debridement, and, in some cases, insertion of antibiotic-impregnated cement beads. We use this self-made antibiotic cement rod to treat intramedullary infections. Compared with the beads, it provides some limited mechanical support and can be preserved in the canal for a long time. We reviewed 19 infected patients who underwent removal of the nails, excision of sinus tracks, debridement of the canal and insertion of the rods. No recurrent infection occurred in 18 cases and 11 cases achieved bone healing, 6 cases achieved partial union. One patient had nonunion and one patient underwent amputation because of severe primary trauma and long-term infection. The rod was removed between 35 and 123 days after implantation. We conclude that the antibiotic cement rods could be a relatively effective, simple and inexpensive method of treating intramedullary infections after nailing.

Angular and sliding stable antegrade nailing (Targon PH) for the treatment of proximal humeral fractures.

Abstract: The optimal surgical treatment for displaced proximal humeral fractures continues to be controversial. Different treatment modalities are available. Mechanical implant-related problems, however, and the preservation of the biological integrity of the humeral head remain unsolved. New implants providing angular stability are expected to maintain the intraoperative result of reduction until definitive healing. The purpose of this study was to evaluate the functional outcome and the complication rate of an angular and sliding stable antegrade interlocking nail for the treatment of displaced proximal humeral fractures. In a prospective study, 112 consecutive patients with displaced proximal humeral fractures were treated. Complete 12 months postoperative follow-up was available for 74 patients. Fracture types were classified according to the Neer-classification. Clinical, functional and radiographic follow-up evaluations were performed 3, 6 and 12 months after surgery. The Constant Score (CS) was used to assess shoulder function. All fractures were united. The CS (MV ± SD) of the injured side 3, 6 and 12 months after surgery were 42.1 ± 15.1, 56.1 ± 20.1 and 70.9 ± 19.3, respectively. Patients sustaining Neer III and VI/3 fractures revealed better shoulder function (68.8 ± 14.7, 74.9 ± 17.6) 12 months postoperatively than those with Neer IV/4 fractures (60.7 ± 23.2), where most complications occurred. Complications requiring surgical therapy were seen in a total of 24 patients (30%) and included backing out of screws in nails without peak inlay (20%; 2000–2003), protrusion of screws into the gleno-humeral joint (5%), loss of reduction with malunion (9%) and major tubercle displacement (7%). The treatment of displaced proximal humeral fractures with an angular and sliding stable antegrade nail (Targon-PH) led to good functional results, especially in 2- and 3-part fractures. There exists a substantial risk for postoperative complications and bad motor function in Neer IV/4 fractures. Lateral backing out of screws was abolished by implant modifications (PEEK-inlay) from 2003 onwards. Additional tension wire banding of the major tubercle may further reduce the risk of secondary displacement.

Tissue engineering of tendons and ligaments by human bone marrow stromal cells in a liquid fibrin matrix in immunodeficient rats: results of a histologic study

Abstract: The original complex structure and mechanical properties are not fully restored after ligament and tendon injuries. Due to their high proliferation rate and differentiation potential, Bone Marrow Stromal Cells (BMSC) are considered to be an ideal cell source for tissue engineering to optimize the healing process. Ideal matrices for tissue engineering of ligaments and tendons should allow for homogenous cell seeding and offer sufficient stability. A mixture of human BMSC and liquid fibrin glue was injected into a standardized full-thickness window defect of the patellar tendon of immunodeficient rats (BMSC group). The histology of the tissue was analysed 10 and 20 days postoperatively and compared to four control groups. These groups consisted of a cohort with a mixture of human fibroblasts and fibrin glue, fibrin glue without cells, a defect group without treatment, and a group with uninjured patellar tendon tissue. Tendon defects in the BMSC group revealed dense collagen fibres and spindle-shaped cells, which were mainly orientated along the loading axis. Histologic sections of the control groups, especially of untreated defects and of defects filled with fibrin glue only, showed irregular patterns of cell distribution, irregular formed cell nucleoli and less tissue maturation. Compared to healthy tendon tissue, higher numbers of cells and less intense matrix staining was observed in the BMSC group. No ectopic bone or cartilage formation was observed in any specimen. Injection of human BMSC in a fibrin glue matrix appears to lead to more mature tissue formation with more regular patterns of cell distribution. Advantages of this “in-vivo” tissue engineering approach are a homogenous cell-matrix mixture in a well-known and approved biological matrix, and simple, minimally-invasive application by injection.

The effect of locally applied vascular endothelial growth factor on meniscus healing: gross and histological findings

Abstract: Introduction: Tears in the peripheral part of the menisci have a better healing potential than tears in the central part, because the central two-thirds of the menisci are avascular. We hypothesized that healing of meniscus tears in the avascular zone can be promoted by the local application of the angiogenic factor vascular endothelial growth factor (VEGF). Materials and methods: A tear was created in the avascular zone of the medial meniscus in 18 merino sheep. The tear was then repaired with an uncoated suture (group 1), a suture coated with PDLLA (group 2), and by a suture coated with PDLLA/VEGF (group 3). Results: After 6 weeks, we observed increased immunostaining for factor VIII in the VEGF-treated group 3. However, in this treatment group no meniscus healed completely. In the uncoated suture group and in the PDLLA-coated-suture group, partial healing was observed in three animals and complete healing in three animals, respectively. Conclusion: In this experiment the local application of VEGF via PDLLA-coated sutures did not promote meniscus healing. Growth factors might not always be a promising tool for tissue repair.

Radial head fractures: effectiveness of conservative treatment versus surgical intervention. A systematic review.

Abstract: Introduction Radial head fractures are common elbow fractures. The Mason classification is used to describe the fracture. As of yet, there is no consensus on optimal treatment strategy for Mason II–IV fractures. The aim of this study was to compare the results of conservative treatment with different surgical strategies for radial head fractures.

“Silent” bone stress injuries in the feet of diabetic patients with polyneuropathy: a report on 12 cases

Abstract: Bone stress injuries are rarely being diagnosed in patients with sensory neuropathy, most likely because they may be silent in terms of pain. Load-related pain is considered a key feature of any bone stress injury, a symptom, which may be partially or completely absent in subjects with sensory neuropathy (loss of protective sensation). We evaluated the clinical course of bone stress injuries in insensitive feet in diabetic patients with polyneuropathy. We investigated 12 consecutive diabetic patients with bone stress injuries of the foot (bone marrow edema, bone bruise and microtrabecular fractures, on magnetic resonance imaging MRI), which were undetectable on plain X-ray. All patients suffered from diabetic polyneuropathy, none of them had an active foot ulcer. The patients presented with a swollen foot, which was only mildly painful and did not prevent them from walking. Complaints were related to the swelling, which increased during load-bearing. In seven cases, a traumatic event preceding the onset of symptoms could be ascertained. MRI disclosed stress injuries in 2.5 (1–8) [median (range)] bones per foot. In 11 patients, treatment was started immediately by off-loading with total contact cast for 17 (8–52) weeks, followed by gradual increase in weight bearing. One patient unfortunately received off-loading treatment only after deforming fractures had developed. All bone injuries healed uneventuelly in eight patients, and with residual mild osteoarthrosis in three patients without gross deformities. However, the untreated patient developed severe Charcot foot deformity. In diabetic patients with polyneuropathy, symptoms of bone stress injuries of the foot are atypical, in that there is load-related swelling rather than load-related pain. Immediate diagnosis, and treatment with off-loading, leads to a restitutio ad integrum like in non-neuropathic patients. Delayed cessation of overuse, however, may cause irreversible joint and bone damage (Charcot foot).

Displaced paediatric fractures of the distal radius.

Abstract: Introduction The purpose of this study was to review, over a fixed period of time and in a geographically defined area, all paediatric fractures of the distal radius that were initially reduced. We wished to assess the fracture pattern at different ages, the seasonal variation, the severity of the initial angulation, and the radiological outcome in terms of reangulation, remodelling, refracture, growth disturbance, and functional outcome.

Methicillin resistant Staphylococcus aureus versus methicillin sensitive Staphylococcus aureus adult haematogenous septic arthritis.

Abstract: Introduction Septic arthritis is an orthopaedic emergency and Staphylococcus aureus (SA) is the number one cause. Methicillin resistant Staphylococcus aureus (MRSA) is increasing in incidence but how it differs from methicillin sensitive Staphylococcus aureus (MSSA) septic arthritis is unclear. Our aim was to delineate the differences in clinical features and outcomes between patients with MRSA and MSSA septic arthritis.