Adequate perpendicular access to the posterolateral talar dome for osteochondral defect repair is difficult to achieve and a number of different surgical approaches have been described. This cadaveric study examined the exposure available from various approaches to help guide pre-operative surgical planning. Four surgical approaches were performed in a step-wise manner on 9 Thiel-embalmed cadavers; anterolateral approach with arthrotomy, anterolateral approach with anterior talo-fibular ligament (ATFL) release, anterolateral approach with antero-lateral tibial osteotomy, and anterolateral approach with lateral malleolus osteotomy. The furthest distance posteriorly which allowed perpendicular access with a 2mm k-wire to the lateral surface of the talar dome was measured from the anterior aspect of the talar dome. The mean antero-posterior diameter of the lateral talar domes included in this study was 45.1mm. An anterolateral approach to the ankle with arthrotomy provided a mean exposure of the anterior 1/3rd of the lateral talar dome. ATFL release increased this to 43.2%. A lateral malleolus osteotomy provided superior exposure (81.5% vs 58.8%) compared to an anterolateral tibial osteotomy. Only the anterior half of the lateral border of the talar dome could be accessed with an anterolateral approach without osteotomy. A fibular osteotomy provided best exposure to the posterolateral aspect of the talar dome and is recommended for lesions affecting the posterior half of the lateral talar dome

Orthopedic surgery is one of the most blood-consuming surgeries. Currently there has been a radical change in transfusion policies, developing a series of therapeutic measures essentially created to minimize the use of allogeneic blood. On the one hand, the safety of our patients must be even more our main objective. On the other hand, our economic resources are more restricted and therefore we must evaluate our surgical techniques and proceedings in order to be safer and more cost-effective. The aim of this study is to report our results of the blood lost, the percentage of blood loss, the necessity of transfussions and how many blood pakages are needed. From a sample of 2400 total knee arthroplasties proceedings, we analyze some surgical proceedings such as lligament balance, patelar traking, artrotomy, ischemia, femoro-tibial axis and type of arthroplasty. We also examine the total blood lost and the percentage of total blood loss after 4 hours, after 24hours and after 48 hour of the total knee arthoplasty surgery. We made a statistical analysis with t-test or anova test when it was necesassary. The outcome of our investigation show that the blood loss when the ischemia is less than 50 minutes is 1470 cc and 1603 cc when is more than 50 minuntes (p<0.05). If we use the medial arthrotomy, the total bleeding is 1563cc, but with subvastus arthrotomy is 1294cc (p<0.05). If we use a primary rotational total knee arthroplasty the bleeding is 953cc, but if we use a PS or PCR the bleeding is 874cc (p<0.05). As a conclusion we should know that our patients have more blood loss when the ischemia is more than fifty minutes, the bleeding is higher when we make a medial arthrotomy and when we use a rotational knee primary arthroplasty

Historically avoidance of avascular necrosis (AVN) has been the primary objective in the management of an acute unstable slipped upper femoral epiphysis (SUFE). When achieved through pinning in situ it was invariably associated with significant malunion. With increasing appreciation of the consequences of femoroacetabular impingement, modern techniques aim to correct deformity and avoid AVN. Exactly what constitutes an acute unstable SUFE is a source of debate but should represent 5–10% of all cases. This audit reviewed cases over the past 25 years treated in one region. Of 89 patients with 113 slips, 21 hips were recorded as unstable. During this period the management has evolved from closed reduction and stabilization through pinning in situ, to open reduction. Radiographic outcomes following these three treatment methods were compared with record of any subsequent surgery in the form of osteotomy or total hip arthroplasty. Currently the lowest reported incidence of AVN in patients with an acute unstable slip is associated with the Parsch technique which combines open arthrotomy, digital reduction and screw fixation. Early outcomes with this technique are in accordance with those reported in the literature and represents a significant improvement in outcome when compared to earlier techniques used in the management of the severe unstable SUFE

The superficial anterior vasculature of the knee is variably described; most of our information comes from anatomical literature. Descriptions commonly emphasise medial-dominant genicular branches of the popliteal artery. Describing the relative contribution of medial and lateral vessels to the anastomotic network of the anterior knee may help provide grounds for selecting one of a number of popular incisions for arthrotomy. The aim of this study is to describe the relative contribution of vessels to anastomoses supplying the anterior knee. Cadaveric knees (n = 16) were used in two cohorts. The first cohort (n = 8) were injected at the popliteal artery with a single colour of latex, and then processed through a modified diaphanisation technique (chemical tissue clearance) before final dissection and analysis. This was repeated for the second cohort, but with initial dissection to identify potential source vessels at their origin. Each source vessel was injected with a different colour of latex. The dominant sources were determined in each specimen. The majority of the specimens (n = 13; 81%) demonstrated that an intramuscular branch though the vastus medialis muscle was the dominant vessel. Anastomoses were most common over the medial side of the knee, both superiorly and inferiorly (3-5 anastomoses in all cases). Anastomosis over the lateral knee was infrequent (1 anastomosis in 1 specimen). The results suggest that anterior vasculature of the knee is predominately medial in origin, but not from the genicular branches as previously described. This network of vessels found in the anterior knee is thought to be the main supply to the patella, extensor apparatus, anterior joint capsule and skin. Optimum placement of incision for arthrotomy is a subject of debate. Considering the main blood supply to the anterior knee may help in choosing a particular approach

Perivascular stem cells (PSCs) from lipoaspirate demonstrate increased purity and immaturity with greater engraftment potential than standard mesenchymal stem cells (MSCs). MSCs from the infra-patellar fat pad (IFP) have previously demonstrated increased chondrogenic potential. This study investigated the availability and potential of PSCs harvested from the infra-patellar fat pad of the human knee for musculoskeletal regeneration. Tissue sections of IFP were stained with markers for PSCs, MSCs and endothelial cells to confirm their presence and location. Samples were obtained from patients undergoing TKR (n=13) or ACL reconstructions (n=10). Pericytes and adventitial cells made up 3.8% and 21.2% respectively of the stromal vascular fraction. The total number of pericytes and adventitial cells were 4.6±2.2×104 and 16.2±3.2×104 respectively. Cells were cultured both separately and combined. Cell identity was ascertained using fluorescence-activated cell sorting, immunocytochemistry and PCR. Cultured PSCs were differentiated using chondrogneic, osteogenic, adipogenic and myogenic medias. Differentiation was determined using Alcian Blue, Alizarin red, Oil Red O and myosin staining. This study demonstrates that the IPFP is a viable source of PSCs that can be harvested either arthroscopically or through an arthrotomy by orthopaedic surgeons for cell-based musculoskeletal regeneration. Their potential now needs to be compared to conventional MSCs

Perivascular stem cells (PSCs) from lipoaspirate demonstrate increased purity and immaturity with greater engraftment potential than standard mesenchymal stem cells (MSCs). MSCs from the infra-patellar fat pad (IFP) have previously demonstrated increased chondrogenic potential. This study investigated the availability and potential of PSCs harvested from the infra-patellar fat pad of the human knee for musculoskeletal regeneration. Sections of IFP were stained with markers for PSCs, MSCs and endothelial cells to confirm their presence and location. Samples were obtained from patients undergoing TKR (n=13) or ACL reconstructions (n=10). Pericytes and adventitial cells made up 3.8% and 21.2% respectively of the stromal vascular fraction. The total number of pericytes and adventitial cells were 4.6±2.2×10. 4. and 16.2±3.2×10. 4. respectively. Cells were cultured both separately and combined. Cell identity was ascertained using fluorescence-activated cell sorting and immunocytochemistry. Cultured PSCs were differentiated using chondrogneic, osteogenic, adipogenic and myogenic medias. Differentiation was determined using Alcian Blue, Alizarin red, Oil Red O and mysosin staining. This study demonstrates that the IFP is a viable source of PSCs that can be harvested either arthroscopically or through an arthrotomy by orthopaedic surgeons for cell-based musculoskeletal regeneration. Their potential now needs to be compared to conventional MSCs

Aims

The modified Radiological Union Scale for Tibia (mRUST) fractures score was developed in order to assess progress to union and define a numerical assessment of fracture healing of metadiaphyseal fractures. This score has been shown to be valuable in predicting radiological union; however, there is no information on the sensitivity, specificity, and accuracy of this index for various cut-off scores. The aim of this study is to evaluate sensitivity, specificity, accuracy, and cut-off points of the mRUST score for the diagnosis of metadiaphyseal fractures healing.

We aimed to investigate the effect of Seprafilm®, a synthetic biomembran, on the intra-articular adhesion formation in an experimental arthrofibrosis model. Twenty male white rabbits were randomly allocated into two groups of 10 animals in each. A standard surgical procedure aiming at the development of arthrofibrosis and including medial parapatellar arthrotomy, lateral eversion of the patella, partial synovectomy and debridement of anterior of supracondylar area and patella joint surface by scalpel was performed on all rabbits' right knees. Group 1 rabbits served as controls, and in Group 2 rabbits a Seprafilm®, barrier placed into the described area. In both groups, after surgery, knee joint was immobilized by a no.5 wire suture passing from the ankle and groin and keeping the joint in 140° of flexion. At 6th week, all animals were sacrificed and adhesion formation was evaluated both macroscopically and histo-pathologically. All data were semi-quantified and analyzed statistically by Fisher's exact test. While all rabbits in control group displayed different rates of adhesion macroscopically (62.5% severe, 25% moderate, 12.5% mild), none in the study group had it. The average macroscopic adhesion score was 2.5 ± 0.75 in control group, and 0 in Seprafilm® group. Histopathologic evaluation also revealed microscopic adhesion in all rabbits in control group, but none in Seprafilm® group. Fibroblast proliferation in Seprafilm® group (100% mild) was significantly lower than in control group (62.5% severe, 37.5% moderate) (p<0.05). In conclusion, use of Seprafilm® as a mechanical barrier may be of value against the formation of arthrofibrosis in risky knees such as septic and traumatic ones

The Bernese Periacetabular Osteotomy (PAO) has become the established method for treating developmental dysplasia of the hip. In the 1990s, the surgical technique was modified to avoid postoperative cam impingement due to uncorrected head neck offset or pincer impingement due to acetabular retroversion after reorientation. The goal of the study was to compare the survivorship of two series of PAOs with and without the modifications of the surgical technique and to calculate predictive factors for a poor outcome. A retrospective, comparative study of two consecutive series of PAOs with a minimum follow-up of 10 years was carried out. Series A included 75 PAOs performed between 1984 and 1987 and represent the first cases of PAO. Series B included 90 hips that underwent PAO between 1997 and 2000. In this series, emphasis was put on an optimal acetabular version next to the correction of the lateral coverage. Additionally, a concomitant arthrotomy was performed in every hip to check impingement-free range of motion after reorientation and in 50 hips (56%) an additional offset correction was performed. Survivorship analyses according to Kaplan and Meier were carried out and the endpoint was defined as conversion to a total hip arthroplasty, progression of osteoarthritis, or a Merle d'Aubign score 14. Predictive factors for poor outcome were calculated using the Cox-regression analysis. The cumulative 10-year survivorship of Series A was significantly decreased (77%; 95%-confidence interval [CI] 72–82%) compared to Series B (86%; 95%-CI 82–89%, p=0.005). Hips with an aspherical head showed a significantly increased survivorship if a concomitant offset correction was performed intraoperatively (90% [95%-CI 86–94%] versus 77% [95%-CI 71–82%], p=0.003). Preoperative factors predicting poor outcome included a high age at surgery, a Merle d'Aubign score 14, a positive impingement test, a positive Trendelenburg sign, limp, an increased grade of osteoarthritis according to Tönnis, and (sub-) luxation of the femoral head (Severin > 3). In addition, predictive factors related to the three dimensional orientation of the acetabular fragment were identified. These included total, anterior, and posterior acetabular over-coverage or under-coverage, acetabular retroversion or excessive anteversion, a lateral center edge angle < 22 °, an acetabular index > 14 °, and no offset correction in aspherical femoral heads. A good long term result after PAO mainly depends on optimal three-dimensional orientation of the acetabulum and impingement-free range of motion with correction of an aspherical head neck junction if necessary

Coronal plane fractures of the posterior femoral condyle, also known as Hoffa fractures, are rare. Lateral fractures are three times more common than medial fractures, although the reason for this is not clear. The exact mechanism of injury is likely to be a vertical shear force on the posterior femoral condyle with varying degrees of knee flexion. These fractures are commonly associated with high-energy trauma and are a diagnostic and surgical challenge. Hoffa fractures are often associated with inter- or supracondylar distal femoral fractures and CT scans are useful in delineating the coronal shear component, which can easily be missed. There are few recommendations in the literature regarding the surgical approach and methods of fixation that may be used for this injury. Non-operative treatment has been associated with poor outcomes. The goals of treatment are anatomical reduction of the articular surface with rigid, stable fixation to allow early mobilisation in order to restore function. A surgical approach that allows access to the posterior aspect of the femoral condyle is described and the use of postero-anterior lag screws with or without an additional buttress plate for fixation of these difficult fractures.

Cite this article: Bone Joint J 2013;95-B:1165–71.

Objectives

Osteochondral injuries, if not treated adequately, often lead to severe osteoarthritis. Possible treatment options include refixation of the fragment or replacement therapies such as Pridie drilling, microfracture or osteochondral grafts, all of which have certain disadvantages. Only refixation of the fragment can produce a smooth and resilient joint surface. The aim of this study was the evaluation of an ultrasound-activated bioresorbable pin for the refixation of osteochondral fragments under physiological conditions.

In order to achieve satisfactory reduction of complex distal humeral fractures, adequate exposure of the fracture fragments and the joint surface is required. Several surgical exposures have been described for distal humeral fractures. We report our experience using the anconeus pedicle olecranon flip osteotomy approach. This involves detachment of the triceps along with a sliver of olecranon, which retains the anconeus pedicle. We report the use of this approach in ten patients (six male, four female) with a mean age of 38.4 years (28 to 51). The mean follow-up was 15 months (12 to 18) with no loss to follow-up. Elbow function was graded using the Mayo Score. The results were excellent in four patients, good in five and fair in one patient. The mean time to both fracture and osteotomy union was 10.6 weeks (8 to 12) and 7.1 weeks (6 to 8), respectively. We found this approach gave reliably good exposure for these difficult fractures enabling anatomical reduction and bicondylar plating without complications.

Cite this article: Bone Joint J 2014;96-B:1252–7.

A total of 179 adult patients with displaced intra-articular fractures of the distal radius was randomised to receive indirect percutaneous reduction and external fixation (n = 88) or open reduction and internal fixation (n = 91). Patients were followed up for two years. During the first year the upper limb musculoskeletal function assessment score, the SF-36 bodily pain sub-scale score, the overall Jebsen score, pinch strength and grip strength improved significantly in all patients. There was no statistically significant difference in the radiological restoration of anatomical features or the range of movement between the groups.

During the period of two years, patients who underwent indirect reduction and percutaneous fixation had a more rapid return of function and a better functional outcome than those who underwent open reduction and internal fixation, provided that the intra-articular step and gap deformity were minimised.

We treated 47 patients with a mean age of 57 years (22 to 88) who had a proximal humeral fracture in which there was a severe varus deformity, using a standard operative protocol of anatomical reduction, fixation with a locking plate and supplementation by structural allografts in unstable fractures. The functional and radiological outcomes were reviewed.

At two years after operation the median Constant score was 86 points and the median Disabilities of the Arm, Shoulder and Hand score 17 points. Seven of the patients underwent further surgery, two for failure of fixation, three for dysfunction of the rotator cuff, and two for shoulder stiffness. The two cases of failure of fixation were attributable to violation of the operative protocol. In the 46 patients who retained their humeral head, all the fractures healed within the first year, with no sign of collapse or narrowing of the joint space. Longer follow-up will be required to confirm whether these initially satisfactory results are maintained.