Cut-off values with highest sensitivity and specificity
for the synovial fluid white cell and differential count will facilitate
the accurate diagnosis of infection in total knee (TKR) and total
hip replacement (THR). All patients undergoing revision TKR or THR
for suspected prosthetic joint infection between 2009 and 2011 at
two hospitals were identified. A total of 75 patients were included
with a mean age of 70.3 years (38 to 89). Synovial fluid was aspirated
pre-operatively and peri-prosthetic tissue samples were taken intra-operatively
for histological and microbiological examination. Receiver operating characteristic (ROC) plots were constructed
for white cell and differential counts in aspirated fluid. The optimal
cut-off for TKR and THR was 1590 white cells/µl and 65% neutrophilia.
The white cell count cut-off value identified for THR was notably
lower than previously quoted in the literature. A cut-off value
for white cell count in synovial aspirate in suspected prosthetic
joint infection of between 1100 and 1700 white cells/µl is likely
to be applicable to both THR and TKR. Cite this article:
The belief that an intervertebral disc must degenerate
before it can herniate has clinical and medicolegal significance,
but lacks scientific validity. We hypothesised that tissue changes
in herniated discs differ from those in discs that degenerate without
herniation. Tissues were obtained at surgery from 21 herniated discs
and 11 non-herniated discs of similar degeneration as assessed by
the Pfirrmann grade. Thin sections were graded histologically, and
certain features were quantified using immunofluorescence combined
with confocal microscopy and image analysis. Herniated and degenerated
tissues were compared separately for each tissue type: nucleus, inner
annulus and outer annulus. Herniated tissues showed significantly greater proteoglycan loss
(outer annulus), neovascularisation (annulus), innervation (annulus),
cellularity/inflammation (annulus) and expression of matrix-degrading
enzymes (inner annulus) than degenerated discs. No significant differences
were seen in the nucleus tissue from herniated and degenerated discs.
Degenerative changes start in the nucleus, so it seems unlikely
that advanced degeneration caused herniation in 21 of these 32 discs.
On the contrary, specific changes in the annulus can be interpreted
as the consequences of herniation, when disruption allows local
swelling, proteoglycan loss, and the ingrowth of blood vessels,
nerves and inflammatory cells. In conclusion, it should not be assumed that degenerative changes
always precede disc herniation. Cite this article:
Our understanding of the origin of hip pain in
degenerative disorders of the hip, including primary osteoarthritis, avascular
necrosis and femoroacetabular impingement (FAI), is limited. We
undertook a histological investigation of the nociceptive innervation
of the acetabular labrum, ligamentum teres and capsule of the hip,
in order to prove pain- and proprioceptive-associated marker expression.
These structures were isolated from 57 patients who had undergone
elective hip surgery (44 labral samples, 33 ligamentum teres specimens,
34 capsular samples; in 19 patients all three structures were harvested).
A total of
15 000 histological sections were prepared that were investigated
immunohistochemically for the presence of protein S-100, 68 kDa
neurofilament, neuropeptide Y, nociceptin and substance P. The tissues
were evaluated in six representative areas. Within the labrum, pain-associated free nerve ending expression
was located predominantly at its base, decreasing in the periphery.
In contrast, the distribution within the ligamentum teres showed
a high local concentration in the centre. The hip capsule had an
almost homogeneous marker expression in all investigated areas. This study showed characteristic distribution profiles of nociceptive
and pain-related nerve fibres, which may help in understanding the
origin of hip pain. Cite this article:
The patellofemoral joint is an important source of symptoms in osteoarthritis of the knee. We have used a newly designed surgical model of patellar strengthening to induce osteoarthritis in BALB/c mice and to establish markers by investigating the relationship between osteoarthritis and synovial levels of matrix metalloproteinases (MMPs). Osteoarthritis was induced by using this microsurgical technique under direct vision without involving the cavity of the knee. Degeneration of cartilage was assessed by the Mankin score and synovial tissue was used to determine the mRNA expression levels of MMPs. Irrigation fluid from the knee was used to measure the concentrations of MMP-3 and MMP-9. Analysis of cartilage degeneration was correlated with the levels of expression of MMP. After operation the patellofemoral joint showed evidence of mild osteoarthritis at eight weeks and further degenerative changes by 12 weeks. The level of synovial MMP-9 mRNA correlated with the Mankin score at eight weeks, but not at 12 weeks. The levels of MMP-2, MMP-3 and MMP-14 mRNA correlated with the Mankin score at 12 weeks. An increase in MMP-3 was observed from four weeks up to 16 weeks. MMP-9 was notably increased at eight weeks, but the concentration at 16 weeks had decreased to the level observed at four weeks. Our observations suggest that MMP-2, MMP-3 and MMP-14 could be used as markers of the progression of osteoarthritic change.
Despite advances in contemporary hip and knee
arthroplasty, blood loss continues to be an issue. Though blood transfusion
has long been used to treat post-operative anemia, the associated
risks are well established. The objective of this article is to
present two practical and effective approaches to minimising blood
loss and transfusion rates in hip and knee arthroplasty: the use
of antifibrinolytic medications such as tranexamic acid and the
adoption of more conservative transfusion indications.
We compared the intracompartmental pressures
(ICPs) of open and closed tibial fractures with the same injury pattern
in a rabbit model. In all, 20 six-month-old New Zealand White male
rabbits were used. They were randomised into two equal groups of
ten rabbits; an open fracture group (group 1) and a closed fracture
group (group 2). Each anaesthetised rabbit was subjected to a standardised
fracture of the proximal half of the right tibia using a custom-made
device. In order to create a grade II open fracture in group 1,
a 10 mm segment of fascia and periosteum was excised. The ICP in
the anterior compartment was monitored at six-hourly intervals for
48 hours. Although there was a statistically significant difference
in ICP values within each group (both p <
0.001), there was no
significant difference between the groups for all measurements (all
p ≥ 0.089). In addition, in both groups there was a statistically
significant increase in ICP within the first 24 hours, whereas there
was a statistically significant decrease within the second 24 hours
(p <
0.001 for both groups). We conclude that open tibial fractures
should be monitored for the development of acute compartment syndrome
to the same extent as closed fractures. Cite this paper:
In a randomised controlled pragmatic trial we
investigated whether local infiltration analgesia would result in earlier
readiness for discharge from hospital after total knee replacement
(TKR) than patient-controlled epidural analgesia (PCEA) plus femoral
nerve block. A total of 45 patients with a mean age of 65 years
(49 to 81) received a local infiltration with a peri-articular injection
of bupivacaine, morphine and methylprednisolone, as well as adjuvant
analgesics. In 45 PCEA+femoral nerve blockade patients with a mean
age of 67 years (50 to 84), analgesia included a bupivacaine nerve
block, bupivacaine/hydromorphone PCEA, and adjuvant analgesics.
The mean time until ready for discharge was 3.2 days (1 to 14) in
the local infiltration group and 3.2 days (1.8 to 7.0) in the PCEA+femoral
nerve blockade group. The mean pain scores for patients receiving
local infiltration were higher when walking (p = 0.0084), but there
were no statistically significant differences at rest. The mean
opioid consumption was higher in those receiving local infiltration. The choice between these two analgesic pathways should not be
made on the basis of time to discharge after surgery. Most secondary
outcomes were similar, but PCEA+femoral nerve blockade patients
had lower pain scores when walking and during continuous passive
movement. If PCEA+femoral nerve blockade is not readily available, local
infiltration provides similar length of stay and similar pain scores
at rest following TKR. Cite this article:
Intra-operative, peri-articular injection of
local anaesthesia is an increasingly popular way of controlling
pain following total knee replacement. The evidence from this study suggests that it is safe to use
peri-articular injection in combination with auto-transfusion of
blood from peri-articular drains during knee replacement surgery.
This study prospectively evaluated the outcome of manipulation under anaesthesia and hydrodilatation as treatments for adhesive capsulitis. A total of 36 patients (38 shoulders) were randomised to receive either method, with all patients being treated in stage II of the disease process. The mean age of the patients was 55.2 years (44 to 70) and the mean duration of symptoms was 33.7 weeks (12 to 76). Eighteen shoulders (17 patients) underwent manipulation under anaesthesia and 20 (19 patients) had hydrodilatation. There were three insulin-dependent diabetics in each group. The mean visual analogue score in the manipulation under anaesthesia group was 5.7 (3 to 8.5; n = 18) before treatment, 4.7 (0 to 8.5; n = 16) at two months (paired The mean Constant score in those manipulated was 36 (26 to 66) before treatment, 58.5 (24 to 90) at two months (paired The range of movement improved in all patients over the six months, but was not significantly different between the groups. At the final follow-up, 94% of patients (17 of 18) were satisfied or very satisfied after hydrodilatation compared with 81% (13 of 16) of those receiving a manipulation. Most of our patients were treated successfully, but those undergoing hydrodilatation did better than those who were manipulated.
We evaluated the possible induction of a systemic immune response to increase anti-tumour activity by the re-implantation of destructive tumour tissue treated by liquid nitrogen in a murine osteosarcoma (LM8) model. The tumours were randomised to treatment by excision alone or by cryotreatment after excision. Tissue from the tumour was frozen in liquid nitrogen, thawed in distilled water and then re-implanted in the same animal. In addition, some mice received an immunological response modifier of OK-432 after treatment. We measured the levels of interferon-gamma and interleukin-12 cytokines and the cytotoxicity activity of splenocytes against murine LM8 osteosarcoma cells. The number of lung and the size of abdominal metastases were also measured. Re-implantation of tumour tissue after cryotreatment activated immune responses and inhibited metastatic tumour growth. OK-432 synergistically enhanced the anti-tumour effect. Our results suggest that the treatment of malignant bone tumours by reconstruction using autografts containing tumours which have been treated by liquid nitrogen may be of clinical value.
Curettage and packing with polymethylmethacrylate cement is a routine treatment for giant-cell tumour (GCT) of bone. We performed an We found that the cytotoxic effect of eluted drugs depended on their concentration and the time interval, with even the lowest dose of each drug demonstrating an acceptable rate of cytotoxicity. Even in low doses, cytotoxic drugs mixed with polymethylmethacrylate cement could therefore be considered as effective local adjuvant treatment for GCTs.
We undertook a retrospective case-control study
to assess the clinical variables associated with infections in open fractures.
A total of 1492 open fractures were retrieved; these were Gustilo
and Anderson grade I in 663 (44.4%), grade II in 370 (24.8%), grade
III in 310 (20.8%) and unclassifiable in 149 (10.0%). The median
duration of prophylaxis was three days (interquartile range (IQR)
1 to 3), and the median number of surgical interventions was two
(1 to 9). We identified 54 infections (3.6%) occurring at a median
of ten days (IQR 5 to 20) after trauma. Pathogens intrinsically
resistant to the empirical antibiotic regimen used (enterococci, Infection in open fractures is related to the extent of tissue
damage but not to the duration of prophylactic antibiotic therapy.
Even for grade III fractures, a one-day course of prophylactic antibiotics
might be as effective as prolonged prophylaxis. Cite this article:
We evaluated the efficacy of Cite this article:
The use of ultrasound in the diagnosis and management of disorders of the tendo Achillis is discussed. Some of the pathological processes which occur in Achilles tendinopathy can be identified by ultrasound, which may also be used to direct local treatment.
The October 2012 Hip &
Pelvis Roundup360 looks at: diagnosing the infected hip replacement; whether tranexamic acid has a low complication rate; the relationship between poor cementing technique and early failure of resurfacing; debridement and retention for the infected replacement; triple-tapered stems and bone mineral density; how early discharge can be bad for your sleep; an updated QFracture algorithm to predict the risk of an osteoporotic fracture; and local infiltration analgesia and total hip replacement.
Lower limb muscle power is thought to influence outcome following
total knee replacement (TKR). Post-operative deficits in muscle
strength are commonly reported, although not explained. We hypothesised
that post-operative recovery of lower limb muscle power would be
influenced by the number of satellite cells in the quadriceps muscle at
time of surgery. Biopsies were obtained from 29 patients undergoing TKR. Power
output was assessed pre-operatively and at six and 26 weeks post-operatively
with a Leg Extensor Power Rig and data were scaled for body weight.
Satellite cell content was assessed in two separate analyses, the
first cohort (n = 18) using immunohistochemistry and the second
(n = 11) by a new quantitative polymerase chain reaction (q-PCR)
protocol for Pax-7 (generic satellite cell marker) and Neural Cell
Adhesion Molecule (NCAM; marker of activated cells).Objectives
Methods
We produced large full-thickness articular cartilage defects in 33 rabbits in order to evaluate the effect of joint distraction and autologous culture-expanded bone-marrow-derived mesenchymal cell transplantation (ACBMT) at 12 weeks. After fixing the knee on a hinged external fixator, we resected the entire surface of the tibial plateau. We studied three groups: 1) with and without joint distraction; 2) with joint distraction and collagen gel, and 3) with joint distraction and ACBMT and collagen gel. The histological scores were significantly higher in the groups with ACBMT collagen gel (p <
0.05). The area of regenerated soft tissue was smaller in the group allowed to bear weight (p <
0.05). These findings suggest that the repair of large defects of cartilage can be enhanced by joint distraction, collagen gel and ACBMT.
In this paper, we consider wound healing after
total knee arthroplasty.
We describe a new surgical technique for the
treatment of lacerations of the extensor tendon in zone I, which involves
a tenodesis using a length of palmaris longus tendon one-quarter
of its width. After exposing the dorsal aspect of the distal interphalangeal
joint and harvesting the tendon, a 1.5 mm drill bit is passed through
the insertion of the extensor tendon into the distal phalanx where
it penetrates through the skin of the pulp of the digit. The palmaris
longus tendon is threaded through the drill hole from dorsal to
ventral and the ventral end is tied in a simple knot and trimmed.
The palmaris longus tendon is then sutured to the extensor tendon
close to its insertion, and also at the middle of the middle phalanx. The operation was undertaken on 67 patients: 27 with an acute
injury and 40 patients with a chronic mallet deformity. One finger
(or the thumb) was involved in each patient. At a mean follow-up
of 12 months (6 to 18), 66 patients (98.5%) received excellent or
good results according to both the American Society for Surgery
of the Hand (ASSH) classification and Miller’s classification. Tenodesis using palmaris longus tendon after complete division
of an extensor tendon in zone 1 is a reliable form of treatment
for isolated acute or chronic ruptures.
We used a goat model of a contaminated musculoskeletal defect to determine the effectiveness of rapidly-resorbing calcium-sulphate pellets containing amikacin to reduce the local bacterial count. Our findings showed that this treatment eradicated the bacteria quickly, performed as well as standard polymethylmethacrylate mixed with an antibiotic and had many advantages over the latter. The pellets were prepared before surgery and absorbed completely. They released all of the antibiotic and did not require a subsequent operation for their removal. Our study indicated that locally administered antibiotics reduced bacteria within the wound rapidly. This method of treatment may have an important role in decreasing the rate of infection in contaminated wounds.