As the intervertebral disc is largely avascular, needle injection is the most practical method for delivery of therapeutic agents used in treatments for degenerative disc disease. Intradiscal pressure increases during injection, and insufficient recovery time prior to needle retraction may result in injectate leakage. In order to determine the maximum pressure and post-injection recovery time for a given injection volume and rate, an analytical model of intradiscal injection was developed and calibrated experimentally.

A governing equation was derived defining intradiscal pressure as a function of effective permeability, initial elastic stiffness, nonlinear stiffness term, and injection rate. The equation was solved using a fourth order Runge-Kutta routine with a 0.05s time step and a ramp-dwell injection.

The model was calibrated by performing controlled intradiscal injections on five bovine caudal intervertebral discs. Three had adjacent vertebrae intact, while two were separated from vertebrae and constrained between porous stainless steel platens. A syringe driven by a linear actuator was used to inject phosphate buffered saline through a 21g hypodermic needle inserted radially into the disc to a depth of one half of the disc diameter. Injection was performed at a rate of 75μL/s to a volume of 250μL followed by a 240s dwell. Fluid pressure was recorded during both the injection phase and subsequent recovery phase. For each experimental pressure vs time trace, model parameters were varied in order to obtain an optimal fit.

The model was run with the average parameter values across a grid of possible injection protocols, with injection volume ranging from 30 to 300μL and injection time ranging from 0.1 to 5s. For each case, peak pressure and time required to reach a 1kPa threshold were recorded.

Experimentally measured peak pressure ranged from 68 to 88kPa. Pressure at the end of the 240s dwell ranged from 49 to 69kPa. There was no apparent difference between discs with and without endplates. Leakage of fluid following needle retraction was observed in all specimens. Experimental data were well fit by the analytical model, which predicted higher peak pressure and longer recovery time with increasing volume, from approximately 1500s at 30μL to nearly 3000s at 300μL. The model was nearly insensitive to injection rate.

The experimental data confirm pressurization of the disc during injection and injectate leakage resulting from insufficient recovery time. The model predicts that the time required to recover to below threshold leakage pressure is impractically long for both laboratory and clinical injection protocols. Similar behavior with and without endplates confirms that fluid flow is limited by permeability of the tissue itself, not the boundary conditions. Slow recovery is likely attributable to the fact that peak injection pressures were lower than the hydraulic swelling pressure of the nucleus pulposus, which has been reported to be approximately 140kPa.

Due to the high swelling pressure of the nucleus pulposus, it is unlikely that intradiscal injection procedures can be performed without substantial injectate leakage following needle retraction.

Objectives

The objective of this study was to quantify the relative movement between the articular surfaces in the tibiotalar and subtalar joints during normal walking in asymptomatic individuals.

Background The minimum size required for a successful quadrupled hamstring autograft ACL reconstruction remains controversial. The risks of ACL re-tear in younger patients who tend to participate in a higher level of sports activity, and female athletes who have numerous predisposing factors, are poorly defined. Purpose To identify risk factors for graft re-tears within 2 years of ACL surgery. The hypotheses are that female sex, a smaller size graft, and younger patients will increase the odds of failure. Study Design Cohort Study. Level of evidence, 3.

A cohort of 503 athletes undergoing primary, autograft hamstring ACL reconstruction, performed by a single surgeon using the same surgical technique and rehabilitation protocol, between September-December 2012, was followed for a total duration of 2 years. Return to play was allowed between 6 and 12 months post-surgery upon completion of functional testing. Exclusion criteria included infections, revisions, double bundle techniques, multi-ligament injuries, non-compliance, BTB/allografts/hybrid grafts. Primary outcome consisted of binary data (ACL graft re-tear or no tear) as measured on physical exam (Lachman and pivot shift) and MRI. Multivariate logistic regression statistical analysis with model fitting was used to investigate the predictive value of sex, age, and graft size on ACL re-tear. Secondary sensitivity analyses were performed on the adolescent subgroup, age and graft size as categorical variables, and testing for interactions among variables. Sample size was calculated based on the rule of 10 events per independent variable for logistic regression.

The mean age of the 503 athletes was 27.5 (SD 10.6; range = 12–61). There were 235 females (47%) and 268 males (53%) with a 6 % rate of re-tears (28 patients; 17 females). Mean graft size was 7.9 (SD 0.6; range = 6–10). Univariate analyses of graft size, sex, and age only in the model showed that younger age (odds ratio [OR] = 0.86; 95% confidence interval [CI] = 0.80–0.93; P = .001] and smaller graft size (OR = 0.36; 95% CI = 0.18–0.70; P = .003) were significantly predictive of re-tear. Female sex was correlated with re-tear but was not significant (OR = 1.8; 95% CI = 0.84–3.97; P = .13). Multivariate analysis with all 3 variables in the model showed similar significant results. Graft size < 8 mm (OR = 2.95; 95% CI = 1.33–6.53; P = .008) and age < 25 (OR = 7.01; 95% CI = 2.40–20.53; P = .001) were significantly predictive of re-tear. Entire model was statistically significant (Omnibus test P = .001; Hosmer-Lemeshow statistic P = .68; Receiver Operating Curve [ROC] = 0.8).

Surgeons should counsel their patients who are female, younger than 25 and with a graft size less than 8 mm accordingly and consider modifying their surgical or rehabilitation techniques to mitigate these re-tear risks.

Aim

Adverse tissue reactions have been a concern in relation to metal components, particularly in hip replacements. We look at a possible correlation between hip joint effusion and metal ion levels.

There has recently been an increase in the number of hip replacement procedures performed through an anterior approach. Every procedure has a risk profile, and in the case of a new procedure or technique it is important to investigate the incidence of complications. The aim of this study is to identify the complications encountered in the first 100 patients treated with the minimally invasive anterior approach.

This is a case series of the first 100 hips treated and were assessed for complications. These were classified according to the severity and outcome [1]. The 100 hip comprised of 98 patients; 46 males and 52 females with an average operation age on 70.1 (±9.38) years. There were 2 bilateral procedures. Specific patient selection criteria were used. All complications occurred within one month of surgery. Complications such as fracture, deep vein thrombosis (DVT), cup malposition, femoral stem malposition, retained screw, excessive acetabular reaming and skin numbness were noted. Complications associated with fracture were characterized as either periprosthetic or trochanteric. Clinical outcome scores of SF36v2, WOMAC, Harris Hip and Tegner activity score were analysed at pre-operative, 6 months, 12 months 24 months and 36 months intervals.

A total of 13 early complications occurred. Of these 13 complications the most common complications were trochanteric fracture, 3 instances (3.00%), periprosthetic fracture, 2 (2.00%), DVT, 2 (2.00%), numbness, 2 (2.00%) and loosening. Other complications recorded were cup malposition, 1 (1.00%), femoral stem malpositon, 1 (1.00%), retained screw, 1 (1.00%) and excessive acetabular reaming, 1 (1.00%). All fractures occurred in patients over the age of 60 years.

Significant differences (p<0.05) were observed between all clinical outcomes measures pre-operatively and postoperatively (6, 12, 24 and 36 months). The unfamiliarity of the approach, however, increased operating time, and exposure problems, lead to trochanteric fracture.

Introduction

Dissatisfaction with the posterior approach to total hip replacement has led to the anterior approach being adopted with enthusiasm in some areas.

Damage to metal-on-metal bearings (MOM) has been varyingly described as “edge wear,” third-body abrasive wear and “rim-damage” (1–4). However, no distinction has been made between any of these proposed wear mechanisms. The goal of this study was to discover what features might differentiate between surface damage created by either 2-body or 3-body wear mechanisms in MOM bearings. The hypotheses were that surface damage created by impingement of the cup rim (2-body wear) would be i) linear on the micro-scale, ii) reveal transverse striations (in direction of the sliding rim), iii) have either no raised lip or have a single lip along one side of the track, and iv) have an asymmetrical surface profile across the track width.

Five cases with 28 mm MOM, five of 34–38 mm MOM, and five of 50–56 mm diameter were studied (N = 15). The main wear zone (MWZ) was measured in each MOM head and the number of 2-body wear tracks recorded in the non-wear (NWZ) and main wear zone (MWZ). Bearing damage was examined using a white-light interferometer (Zygo Newview 600; 5x lens) and a scanning electron microscope (Zeiss MA15). The depths and slopes were assessed across the width of the damage tracks.

Thirteen of the 15 MOM bearings showed wear tracks that exhibited all four of the hypothesized 2-body wear characteristics. These wear tracks will be referred to as “micro-segments”. While micro-segments visually appeared linear, microscopically they revealed a semi-lunar edge coupled with transverse striations leading to a linear edge. This indicated that during impingement episodes, the cup rim ploughed material from the CoCr surface at the semi-lunar edge (Fig. 1), thereby creating the abruptly raised lip on the linear edge of the track. This “snow plough effect” and its distinct edge effect can account for the asymmetrical surface profile. A different type of 2-body wear was identified and referred to as “furrows”. Furrows also visually appeared linear visually, but microscopically revealed longitudinal striations and a symmetrical surface profile (Fig. 2). Furrows had lips raised on both sides of the track, but not circumscribing the terminal ends of the track. Instead, the ends of the furrows are tapered smooth transitions to the articular surface.

Thus, 2-body tracks were found to be distinguishable from 3-body tracks (micro-grooves) and were classified as either micro-segments or furrows. Micro-segements supported hypotheses 1–3 and provided a clearer definition for hypothesis-4, while furrows only supported hypothesis 1. The divergence in features between micro-segments and furrows allude to different interactions between the bearing and cup rim that led to each type of track. While these data represent a small set of cases (n = 15) this evidence shows for the first time what was previously only suspected (2), that the CoCr rim can routinely create 2-body wear damage mechanisms in MOM femoral heads.

There is a consensus that impingement, subluxation, and dislocation are major risks that can lead to failure in total hip arthroplasty (1). As well as producing edge-wear, such clinical events also may create additional loads of particulate debris (2). It has been suggested that the release of metal debris with collateral damage on metal-on-metal (MOM) bearings creates a particularly severe abrasive wear, hitherto not understood, and recently termed ‘micro-grooving’ (3,4). Perhaps related to this micro-grooving, large surface depressions have also been observed. These we labeled ‘Dongas’, from the South African term for a steep-sided gully created by erosion. The goal of this study was to examine Dongas found on retrieved MOM bearings and to correlate factors such as cause of revision, MOM diameter and Donga locations with respect to regions of normal and stripe wear. Our hypotheses were: (1) Dongas will be most visible in non-wear zones (NWZ) adjacent to the main-wear zone boundary (MWZ), (2) the 28 mm MOM, being inherently less stable compared to large-diameter MOM, will show a higher Donga frequency and (3) patients with subluxation or dislocation complaints will reveal a higher Donga frequency.

Five cases with 28 mm MOM, five of 34–38 mm, and five of 50–56 mm diameter were studied (N = 15). The MWZ was measured in each MOM head and the number of NWZ and MWZ Dongas recorded. Bearing damage was examined using a white-light interferometer (Zygo; 5x lens).

Dongas were mainly elliptical in shape, but sometimes highly irregular. They were commonly circumscribed by raised lips (Fig. 1). Donga “trails” were also found, appearing as a linear series of similar-sized Dongas (Fig. 2). Donga trails exhibited some variability with raised lips either lining only the opposite sides or circumscribing most of the perimeter. The Dongas were commonly found in NWZ, with less than 20% found in MWZ. For this set of 15 MOM bearings, large-diameter bearings showed the largest number of Dongas and the greatest frequency of Dongas resulted from either loose or migrating cups.

The high occurrence of dongas in the non-wear zone (supporting hypothesis-1) may be a result of particles swept into the bearing interface (2,5). The size of the Dongas and their frequent association to local micro-grooves indicated that these were the impact sites of circulating particles. Such large surface depressions (40–200 μm) have not been described previously and may be unique to MOM bearings (3,4). The observation that Dongas were most prevalent in cases with loose or migrating cups left hypothesis-2 unsatisfied. The much higher incidence of Dongas in the large-diameter MOM was surprising and negated hypothesis-3. Overall these new data relating Dongas and micro-grooves gives new credence to a hitherto unsuspected 3^rd-body abrasive wear mechanism due to repetitive subluxation or impingement.

Introduction

Injectable collagenase clostridium histolyticum (CCH) is a minimally invasive non-surgical therapy with efficacy in correcting Dupuytren's contracture (DC). In the concurrently run JOINT I and JOINT II studies, designed to follow clinical practice, we evaluated the efficacy of ?5 CCH injections in patients with DC.

Purpose: Glenoid replacement remains challenging due to the difficult visualization of anatomical reference landmarks and highly variable version angles. Improper positioning of the glenoid component leads to loosening, early wear, and instability. The objective of this study was to develop and evaluate a tracking system for glenoid implantation. We hypothesized that Computer Assisted Glenoid Implantation (CAGI) would achieve a more accurate and reliable placement of the glenoid component compared to traditional methods.

Methods: 3D CT models of sixteen paired cadaveric shoulder specimens were reconstructed and angles were measured using 3D modeling softwares. Jigs were developed to track instruments and to correct for scapular motion. A standardized protocol for determining in real-time via electromagnetic tracking the glenoid centre, version, inclination and ultimate component placement was previously developed and validated in our laboratory. Specimens were randomized to either traditional or CAGI performed by one of two blinded fellowship trained shoulder surgeons. The mean age was 67 years (range 61–88). Native version and inclination were similar in both groups. All phases of glenoid implantation were navigated.

Results: CAGI was more accurate in achieving the correct version during all phases of glenoid implantation (p < 0.05; paired t-test). CAGI CONTROL Initial pin * 6.3 ± 2.9° Reaming *7.0 ± 3.9° Post drilling * 0.6 ± 0.4° 8.3 ± 4.6°|Post cement * 2.3 ± 2.0° 7.9 ± 3.6°|Post implant CT * 1.8 ± 0.9° 7.7 ± 4.0°. Table 1. Absolute values of the mean error ± SD of version angles obtained with either CAGI or the traditional method (goal = 0° version; * p < 0.05). The largest errors with traditional were observed during drilling and reaming where visualization was especially obscured by the reamer heads. The trend was to retrovert the glenoid. There was no difference with respect to inclination angles (p > 0.05).

Conclusions: Preoperative planning using CT imaging with 3D modeling and intra-operative tracking were combined to produce improved accuracy and reliability of glenoid implantation.

Funding : Other Education Grant

Funding Parties : National Sciences & Engineering Research Council research grant

The purpose of this study was to determine if arthroscopic release is safe and effective in the management of elbow contracture. Twenty patients (mean age of forty-two), undergoing arthroscopic contracture release were retrospectively reviewed at a minimum follow-up of one year (mean twenty-five months). Most patients had combined extrinsic & intrinsic causes for contractures. Mean flexion improved from 122 to 137°. Mean extension improved from 38° to 18°. The mean arc improvement was 35° (p < 0.001). None of the patients had instability and there were no major neuro-vascular complications. All patients had decreased pain and improved elbow function.

To determine if arthroscopic release is safe and effective in the management of elbow contracture.

Twenty patients (mean age of forty-two), undergoing arthroscopic contracture release were retrospectively reviewed at a minimum follow-up of one year (mean twenty-five months). Most patients had combined extrinsic & intrinsic causes for contractures. Motion and strength were measured with standard goniometry and the LIDO isokinetic system by independent evaluators.

Mean flexion improved from 122 ± 16° to 137 ± 12°. Mean extension improved from 38 ± 18° to 18 ± 14°. The mean arc improvement was 35 ± 21° (p < 0.001). Arthroscopic release did not affect forearm rotation or strength. One patient developed a permanent medial antebrachial cutaneous neuroma. One patient required a repeat surgery to remove a loose body. There were no instability and no major neurovascular complications. All patients had improved elbow function with a mean ASES score of thirty-one out of thirty-six. Most patients were satisfied with their surgery, had minimal pain, considered themselves in good physical health on the SF-36, and had minimal impairment on the DASH.

Arthroscopic release is safe and effective in experienced hands.

Results are comparable to traditional open techniques. The theoretical advantages of arthroscopy include improved joint visualization, decreased morbidity and earlier rehabilitation.

Disadvantages include the potential for serious neurovascular complications, and the inability to deal with ulnar nerve pathology or heterotopic ossification. Indications for conversion to open release include excessive swelling, and failure to maintain adequate view.