Objectives. Nylon sutures and skin staples are used commonly in total knee arthroplasty (TKA) surgical wound closure. However, there is no study that compares the wound healing efficacy and patient satisfaction scores of both techniques in the same knee. Methods. We randomised 70 patients who underwent primary TKA into two groups. In one group of 34 patients, the skin at the upper half of the wound was closed with skin staples and the lower half of the wound was closed with simple interrupted nylon sutures. In the other group of 36 patients, the skin at the upper half of the wound was closed with nylon stitches and the lower half of the wound was closed with skin staples. We recorded the wound closure time, pain score at the time of stitch removal, wound complication rate, patient satisfaction score, and the Hollander wound evaluation score at the post-operative periods of five days, 14 days, six weeks, three months, and six months. Each half wound was analysed separately. Results. The mean patient body mass index was 26.8 kg/m. 2. (standard deviation 6.3). A total of 70 nylon stitched wounds and 70 skin stapled wounds were analysed. There were no significant differences in wound complication rates, patient satisfaction score, and the Hollander wound evaluation score between both types of wounds (p > 0.05). The wound closure time for skin stapled wounds was significantly lower than the nylon stitched wounds (p < 0.001). However, the skin stapled wounds had a significantly higher pain score at the time of stitch removal (p < 0.001). Conclusion. Skin staples and nylon stitches had comparable results with respect to wound healing and patient satisfaction in TKA wound closure in non-obese patients. The benefit of skin staples over nylon stitches was a decrease in operative time, but was more painful upon removal. Cite this article: V. Yuenyongviwat. A randomised controlled trial comparing skin closure in total knee arthroplasty in the same knee: nylon sutures versus skin staples. Bone Joint Res 2016;5:185–190. DOI: 10.1302/2046-3758.55.2000629

In this report we present the results of the primary suture of the flexor tendons in zone II, in 198 patients who were operated in our department between 1998 and the first months of 2001. 142 were male from 16 to 65 years old and 56 were female between 14 to 60 years old. Children below 14 years old are not included in this report. The majority of patients in this review reported an accident during dancing and late night activities. Patients with complex injuries such as fractures of phalanges, phalangeal dislocations and extensive soft tissue laceration were excluded. The majority of the patients operated immediately within the first 48 hours and only 28 patients (14, 5%) were operated with a delay ranging between 1 – 5 weeks. The suturing technique was variable in all cases. A Bruner (zig-zag) incision was utilized to facilitate. The tendon was sutured using a standard Kleinert technique and 4.0 nylon sutures as supportive sutures, 5.0 nylon sutures were used to suture the epitendon in a continuous fashion. A dorsal splint holding the wrist in 40° of flexion and the MP joints in 70° of flexion and PIPs and DIPs in extension was used postoperatively. Early mobilization was initiated (shortly after surgery, 3 – 4 days) and lasted 4 weeks. After this period the patient underwent a program of full active motion for an additional 4 weeks. They finally allowed to perform freely after a 12-week postoperative period. We used the Kleinert score to evaluate the surgical results. According to this score results were found to be: Excellent in 80 patients (40%), good in 60 pts (30%), fair in 22 (12%) and poor in 16 pts (8%). Despite the satisfactory overall results we observed a high incidence of tendon ruptures (10%) in 20 patients and this may be related to poor follow up and rehabilitation conditions. No other complications (infection, hematoma formation, and skin slough) were observed in these patients

Introduction and Objective. Achilles tendon defect is difficult problem for orthopedic surgeon, and therefore the development of new treatments is desirable. Platelet-rich fibrin (PRF), dense fibrin scaffold composed of a fibrin matrix containing many growth factors, is recently used as regenerative medicine preparation. However, few data are available on the usefulness of PRF on Achilles tendon healing after injury. The objective of this study is to examine whether PRF promotes the healing of Achilles tendon defect in vivo and evaluated the effects of PRF on tenocytes in vitro. Materials and Methods. PRF were prepared from rats according to international guidelines on the literature. To create rat model for Achilles tendon defect, a 4-mm portion of the right Achilles tendon was completely resected, and PRF was placed into the gap in PRF group before sewing the gap with nylon sutures. To assess the histological healing of Achilles tendon defect, Bonar score was calculated using HE, Alcian-blue, and Picosirius-red staining section. Basso, Beattie, Bresnahan (BBB) score was used for the evaluation of motor functional recovery. Biomechanical properties including failure tensile load, ultimate tensile stress, breaking elongation, and elastic modulus were measured. We examined the effects of PRF on tenocytes isolated from rat Achilles tendon in vitro. The number of viable cells were measured by MTS assay, and immunostaining of ki-67 was used for detection of proliferative cells. Migration of tenocytes was evaluated by wound closure assay. Protein or gene expression level of extracellular matrix protein, such as collagen, were evaluated by immunoblotting, immunofluorescence, or PCR. Phosphorylation level of AKT, FGF receptor, or SMAD3 was determined by western blotting. Inhibitory experiments were performed using MK-2206 (AKT inhibitor), FIIN-2 (FGFR inhibitor), SB-431542 (TGF-B receptor inhibitor), or SIS3 (SMAD3 inhibitor). All p values presented are two-sided and p values < 0.05 were considered statistically significant. Results. In rat Achilles tendon defects, Bonar score was significantly improved in PRF group compared to control group. Collagen deposition at the site of Achilles tendon defect was observed earlier in PRF group. Consistent with the histological findings, BBB score was significantly improved in PRF group. PRF also significantly improved the biomechanical properties of injured Achilles tendon. Furthermore, proliferating tenocytes, labelled by ki-67 were significantly increased in PRF group. These data suggested PRF prompted the healing of Achilles tendon defect. Thus, we further examined the effects of PRF on tenocytes in vitro. PRF significantly increased the number of viable cells, the proliferative cells labelled by ki-67, and migratory ability. Furthermore, PRF significantly increased the protein expression levels of collagen-I, collagen-III, α-SMA, and tenascin-C in tenocytes. Next, we examined the signalling pathway associated with PRF-induced proliferation of tenocytes. PRF increased the phosphorylation level and induced nuclear translocation of AKT, known as key regulator of cell survival. PRF also induced the phosphorylation of FGF receptor. Inhibition of AKT or FGF-receptor completely suppressed the positive effects of PRF on tenocytes. Furthermore, we found that inhibition of FGF receptor partially suppressed the phosphorylation of AKT by PRF. Thus, PRF induced the proliferation of tenocytes via FGFR/AKT axis. We further evaluated the signalling pathway associated with PRF-induced expression of extracellular matrix. PRF increased the phosphorylation levels of SMAD3 and induced nuclear translocation of SMAD3. Furthermore, inhibition of TGF-B receptor or SMAD3 suppressed increased expression level of extracellular matrix by PRF. Thus, PRF increased expression level of extracellular matrix protein via TGF-BR/SMAD3 axis. Conclusions. PRF promotes tendon healing of the Achilles tendon defect and recovery of exercise performance and biomechanical properties. PRF increases the proliferation ability or protein expression level of extracellular matrix protein in tenocytes via FGFR/AKT or TGF-βR/SMAD3 axis, respectively

Aims. The aim of this study was to evaluate antegrade autologous bone grafting with the preservation of articular cartilage in the treatment of symptomatic osteochondral lesions of the talus with subchondral cysts. Patients and Methods. The study involved seven men and five women; their mean age was 35.9 years (14 to 70). All lesions included full-thickness articular cartilage extending through subchondral bone and were associated with subchondral cysts. Medial lesions were exposed through an oblique medial malleolar osteotomy, and one lateral lesion was exposed by expanding an anterolateral arthroscopic portal. After refreshing the subchondral cyst, it was grafted with autologous cancellous bone from the distal tibial metaphysis. The fragments of cartilage were fixed with 5-0 nylon sutures to the surrounding cartilage. Function was assessed at a mean follow-up of 25.3 months (15 to 50), using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot outcome score. The radiological outcome was assessed using MRI and CT scans. Results. The mean AOFAS score improved from 65.7 (47 to 81) preoperatively to 92 (90 to 100) at final follow-up, with 100% patient satisfaction. The radiolucent area of the cysts almost disappeared on plain radiographs in all patients immediately after surgery, and there were no recurrences at the most recent follow-up. The medial malleolar screws were removed in seven patients, although none had symptoms. At this time, further arthroscopy was undertaken, when it was found that the mean International Cartilage Repair Society (ICRS) arthroscopic score represented near-normal cartilage. Conclusion. Autologous bone grafting with fixation of chondral fragments preserves the original cartilage in the short term, and could be considered in the treatment for adult patients with symptomatic osteochondral defect and subchondral cysts. Cite this article: Bone Joint J 2018;100-B:590–5

Percutaneous repair of the ruptured tendo Achillis has a low rate of failure and negligible complications with the wound, but the sural nerve may be damaged. We describe a new technique which minimises the risk of injury to this nerve. The repair is carried out using three midline stab incisions over the posterior aspect of the tendon. A No. 1 nylon suture on a 90 mm cutting needle approximates the tendon with two box stitches. The procedure can be carried out under local anaesthesia. We reviewed 27 patients who had a percutaneous repair at a median interval of 35 months after the injury. They returned to work at four weeks and to sport at 16. One developed a minor wound infection and another complex regional pain syndrome type II. There were no injuries to the sural nerve or late reruptures. This technique is simple to undertake and has a low rate of complications

In vivo loading data for the rotator cuff would be of value to scientists and clinicians interested in the shoulder in the testing of surgical repairs, design of rehabilitation programs and for finite element models. A technique for insertion and retrieval of the Arthroscopically Insertable Force Probe (AIFP - Microstrain Inc. Burlington, Vermont, USA) from the subscapularis is described was initially established in a cadaveric model. Ethical approval was obtained for AIFP insertion into the subscapularis tendon of volunteers during diagnostic shoulder arthroscopy. An in situ calibration was carried out using a modified arthroscopic grasper ( Smith and Nephew, Huntingdon, UK). After motor effects of interscalene block had worn off dynamic data relating to subscapularis tendon loading was collected. The AIFPs were removed through a port site by traction on an O (3.5 metric) nylon suture without complication. Maximum loading of the subscapularis tendon was measured during internal rotation from neutral with the arm fully adducted. Forces measured exceeded 200N. This paper describes a novel technique for the insertion, calibration and retrieval of AIFPs from the rotator cuff. In vivo tendon loading data was obtained. The techniques described may be applied to other structures of interest to orthopaedic surgeons

Amniotic band syndrome (ABS) is a congenital disorder characterized by limb constrictions. The disorder lacks precise definition, and its exact pathogenesis is unknown. Though theories have been advanced to explain the condition’s origin, none have been scientifically validated. The “exogenous” theory, popularized by Torpin, is the most widely accepted. It suggests that early amniotic rupture leads to formation of amniotic strands, which by means of progressive compression induce formation of extremity bands. In this disorder, histological examination of the excised bands demonstrates them to be composed of fibrous tissue. Multiple clinical and experimental data reveal this theory has only low plausibility. Our purpose is to assess whether annular external compression of a fetal rabbit limb will produce a band of subcutaneous fibrous tissue characteristic of amniotic band syndrome. We operated on one limb of 10 different rabbit fetuses, each at 21 days of gestation. The extremity was ligated with a nylon suture at the infracondylar level. At 30 days gestation, each fetus was delivered by caesarean section. Limbs were analyzed histologically using different techniques. Histological analysis did not show subcutaneous fibrous tissue in the mechanically constricted zone. The distal segment showed dilatation of lymphatic vessels and edema of soft tissue. Annular external compression of a fetal rabbit limb does not induce development of new fibrous tissue; therefore this experimental study does not support the theory of a mechanical exogenous pathogenesis in amniotic band syndrome

An inability to extend the hallux following trauma is most often observed after direct laceration to the Extensor Hallucis Longus [EHL]. Primary repair, subsequent splinting and appropriate rehabilitation best deal with this type of injury. Damage to either the EHL muscle belly or the motor nerve to EHL are uncommon causes of the dropped hallux and present difficult reconstructive problems. Damage to the motor nerve branch to EHL in isolation is an uncommon problem and as far as we are aware surgery to address this pathology has not previously been described in the literature. This problem can occur after a penetrating injury, high tibial osteotomy or intramedullary nailing of a fractured tibia. We describe the operative procedure, technique and outcome in two cases of extensor hallucis longus to extensor digitorum communis (EDC) transfer to overcome this problem. A longitudinal skin incision is made just lateral to the tibia in the distal anterior part of the leg. The extensor retinaculum is divided and the EHL tendon identified and divided just distal to the EHL musculotendinous junction. The extensor digitorum communis (EDC) is then identified and the proximal stump of EHL woven into the EDC. A Pulvertaft weave technique is used and secured with 3/0 Ethibond suture. The appropriate amount of tension is placed on the repair by simulating weight bearing on the foot, ensuring the great toe remains in the neutral position. The extensor retinaculum is then repaired with 2/0 Vicryl and the skin closed with interrupted nylon sutures. The wound is infiltrated with 0.5% Marcaine to aid postoperative pain relief. A protected active motion rehabilitation program follows the surgery. We have used this technique in two cases, both have regained active extension of the hallux

Introduction: Closure with interrupted mattress sutures is useful where careful skin apposition is required following hindfoot surgery. However, suture removal around the hindfoot can be awkward and painful. Modification with an additional loop creates a “traction loop suture”. We hypothesise this technique makes removal easier and reduced tension placed on sutures during their removal reduces pain. Materials: 17 patients undergoing elective hindfoot surgery were included. Nylon suture was used for all wound closures. Suturing and removal techniques were standardised. Ethical approval and patient consent was obtained. Methods: Half of each wound length was sutured normally and the other with traction loop sutures (both interrupted mattress type). Follow-up was at 2 and 6 weeks. Comparison of time taken for suture removal and associated wound complications were noted for both. Pain scores during suture removal were recorded using a screen to “blind” the patient and a visual analogue pain score (VAPS) was obtained. Statistical analysis calculated p-values at the 5% significance level and 95% confidence intervals (CI). Results: Traction loop sutures were 20% faster to remove than normal interrupted sutures (mean difference 19.3 seconds, CI 5.39 to 33.1 seconds, p-value 0.004). Traction loop sutures were also 20% less painful during removal (mean difference 1.05 on VAPS, CI 0.021 to 2.085, p-value 0.027. At 2 weeks, 1 normally sutured wound suffered complications. At 6 weeks, no complications were noted in either group. Discussion: Traction loop sutures provide a statistically significant method of reducing pain and time during suture removal. The study method could be applied to comparisons of other skin closures where removal is required. The technique is novel and requires minimal change in suturing. Conclusion: Pain levels and time taken for removal of interrupted mattress sutures are significantly reduced using the traction loop suture technique in hindfoot surgery. The study is continuing

Introduction. The interstitial fluid of bone fluid flow is supplied by flowing blood. Blood flow is determined by three kinds of muscles: cardiac, smooth, and skeletal. Cardiac muscle establishes baseline blood pressure. Smooth muscle controls vessel diameter and skeletal muscle creates intermittent intravascular pressure pulses. For the tibia the relevant skeletal muscle is the gastrocnemius which functions as a muscle pump. This study tested the hypotheses: 1) skeletal muscle-caused pressure pulses increase cortical blood flow, 2) extravasation of vascular fluid and, consequently, interstitial bone fluid flow are enhanced by resultant increased microvascular pressure and 3) bone healing is enhanced by increased bone fluid flow. Methods. Eighteen skeletally mature female New Zealand white rabbits were implanted with bone chamber windows (BCIs) as described previously. The windows were exposed at three weeks and observed weekly until Week 10 using intravital microscopy. During observation, the subject was suspended in prone position in a mesh fabric torso sling jacket so as to eliminate gravity-based reaction forces. Electrodes of a transcutaneous electrical nerve stimulator (TENS) were gel-glued at each rabbits gastroc-soleus position; but activated only in the 11 experimentals. A 4Hz 2.8 ± 1.3V impulse was delivered for 60 minutes. Still and video images were obtained at 0, 2, and 60 minutes following injection of 1μm fluorescent microspheres. Each such injection was followed by injection of 70 kD FITC- or RITC-dextran to define vascularity and capillary filtration. Additional still images were obtained at 5, 30, and 55 minutes. Muscle contraction forces during TENS were obtained acutely following the Week 10 observation with a Futek force transducer cell through an attached nylon suture. Bone mineral density was obtained at Week 3 and Week 10 with a Stratec pQCT and associated software. Data were analyzed statistically using a Wilcoxon signed rank test. Results. All three hypotheses were supported statistically by the data. The average force produced by TENS stimulated gastrocnemius contraction was 18.98 ± 9.42 N/kg muscle. This produced a microstrain of 192μe in bone around the BCI. Bloodflow results are shown in the figure. On average, flow decreased in controls by 12.6% and increased in experimentals by about 2%. Capillary filtration in experimentals was about 34.6% higher than controls after 60 minutes of TENS. Bone formation rate was 62.5% higher with TENS. Conclusion. In order to understand the role of fluid flows in bone physiology, we need to know the how and where of movement. These results suggest the part played by skeletal muscle in bone fluid movement cannot be ignored. As with many evolutionary adaptations, the muscle pump's hydrodynamic contribution to bone may be redundant and merely serve as a backup to percolation from poroelastic deformation. On the other hand, it may be crucial in disuse osteoporosis instigating conditions such as microgravity. The measured increases in capillary filtration and blood flow suggest that intravascular pressure which drives the former and resultant percolation has been increased by the muscle pump. It follows that fluid shear on cortical bone cells also increased. The challenge now is to obtain local flow measurements that would tell us how much

Aims

Cartilage injuries rarely heal spontaneously and often require surgical intervention, leading to the formation of biomechanically inferior fibrous tissue. This study aimed to evaluate the possible effect of amelogenin on the healing process of a large osteochondral injury (OCI) in a rat model.

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The aims of this study were to develop an in vivo model of periprosthetic joint infection (PJI) in cemented hip hemiarthroplasty, and to monitor infection and biofilm formation in real-time.

Upper limb amputations, ranging from transhumeral to partial hand, can be devastating for patients, their families, and society. Modern paradigm shifts have focused on reconstructive options after upper extremity limb loss, rather than considering the amputation an ablative procedure. Surgical advancements such as targeted muscle reinnervation and regenerative peripheral nerve interface, in combination with technological development of modern prosthetics, have expanded options for patients after amputation. In the near future, advances such as osseointegration, implantable myoelectric sensors, and implantable nerve cuffs may become more widely used and may expand the options for prosthetic integration, myoelectric signal detection, and restoration of sensation. This review summarizes the current advancements in surgical techniques and prosthetics for upper limb amputees.

Cite this article: Bone Joint J 2021;103-B(3):430–439.

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Dystrophic calcification (DC) is the abnormal appearance of calcified deposits in degenerating tissue, often associated with injury. Extensive DC can lead to heterotopic ossification (HO), a pathological condition of ectopic bone formation. The highest rate of HO was found in combat-related blast injuries, a polytrauma condition with severe muscle injury. It has been noted that the incidence of HO significantly increased in the residual limbs of combat-injured patients if the final amputation was performed within the zone of injury compared to that which was proximal to the zone of injury. While aggressive limb salvage strategies may maximize the function of the residual limb, they may increase the possibility of retaining non-viable muscle tissue inside the body. In this study, we hypothesized that residual dead muscle tissue at the zone of injury could promote HO formation.

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Poly (ADP-ribose) polymerase (PARP) inhibitor has been reported to attenuate inflammatory response in rat models of inflammation. This study was designed to investigate the effect of PARP signalling in osteoarthritis (OA) cartilage inflammatory response in an OA rat model.

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To compare results of institutional preferences with regard to treatment of soft tissues in the setting of open tibial shaft fractures.

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The aim was to compare long-term patient-reported outcome measures (PROMs) after operative and nonoperative treatment of acute Achilles tendon rupture in the context of a randomized controlled trial.

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Biofilm formation is intrinsic to prosthetic joint infection (PJI). In the current study, we evaluated the effects of silver-containing hydroxyapatite (Ag-HA) coating and vancomycin (VCM) on methicillin-resistant Staphylococcus aureus (MRSA) biofilm formation.

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Graft infection following anterior cruciate ligament reconstruction (ACLR) may lead to septic arthritis requiring multiple irrigation and debridement procedures, staged revision operations, and prolonged courses of antibiotics. To our knowledge, there are no previous studies reporting on how gentamicin pre-soaking of hamstring grafts influences infection rates following ACLR. We set out to examine this in our study accordingly.