The objectives of the study were to investigate demographic, injury and surgery/treatment-associated factors that could influence clinical outcome, following Autologous Chondrocyte Implantation (ACI) in a large, “real-world”, 20 year longitudinally collected clinical data set. Multilevel modelling was conducted using R and 363 ACI procedures were suitable for model inclusion. All longitudinal post-operative Lysholm scores collected after ACI treatment and before a second procedure (such as knee arthroplasty but excluding minor procedures such as arthroscopy) were included. Any patients requiring a bone graft at the time of ACI were excluded. Potential predictors of ACI outcome explored were age at the time of ACI, gender, smoker status, pre-operative Lysholm score, time from surgery, defect location, number of defects, patch type, previous operations, undergoing parallel procedure(s) at the time of ACI, cell count prior to implantation and cell passage number. The best fit model demonstrated that for every yearly increase in age at the time of surgery, Lysholm scores decreased by 0.2 at 1-year post-surgery. Additionally, for every point increase in pre-operative Lysholm score, post-operative Lysholm score at 1 year increased by 0.5. The number of cells implanted also impacted on Lysholm score at 1-year post-op with every point increase in log cell number resulting in a 5.3 lower score. In addition, those patients with a defect on the lateral femoral condyle (LFC), had on average Lysholm scores that were 6.3 points higher one year after surgery compared to medial femoral condyle (MFC) defects. Defect grade and location was shown to affect long term Lysholm scores, those with grade 3 and patella defects having on average higher scores compared to patients with grade 4 or trochlea defects. Some of the predictors identified agree with previous reports, particularly that increased age, poorer pre-operative function and worse defect grades predicted poorer outcomes. Other findings were more novel, such as that a lower cell number implanted and that LFC defects were predicted to have higher Lysholm scores at 1 year and that patella lesions are associated with improved long-term outcomes cf. trochlea lesions.
Stratification is required to ensure that only patients likely to benefit, receive Autologous Chondrocyte Implantation (ACI). At Stage I (SI), healthy cartilage is harvested from the joint and chondrocytes culture expanded before being implanted into a chondral/osteochondral defect at Stage II (SII). In ACI non-responders, there is a marked shift in the profile and abundance of proteins detectable in the synovial fluid (SF) at SII, many being associated with an acute phase response (APR). However, clinical biomarkers are easier to measure in blood than SF, so we have now performed this investigation in plasma. Isobaric tag for relative and absolute quantitation mass-spectrometry was used to assess the proteome in plasma pooled from ACI responders (mean Lysholm improvement of 33, n=10) or non-responders (mean: −13 points, n=10), collected at SI or SII surgeries. Interactome networks were generated using STRING. Plasma proteome data were compared to matched SF data, previously analysed, to identify any proteins that changed across the fluids. Clusterin concentration was quantitated (ELISA; Biotechne).Abstract
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Methods
In the human knee, the cells of the articular cartilage (AC) and subchondral bone (SB) communicate via the secretion of biochemical factors. Chondrocyte-based AC repair strategies, such as articular chondrocyte implantation, are widely used but there has been little investigation into the communication between the native SB cells and the transplanted chondrocytes. We hypothesise that this communication depends on the health state of the SB and could influence the composition and quality of the repair cartilage. An indirect co-culture model was developed using transwell inserts, representing a chondrocyte/scaffold-construct for repair of AC defects adjoining SB with varying degrees of degeneration. Donor-matched populations of human bone-marrow derived mesenchymal stromal cells (BM-MSCs) were isolated from the macroscopically and histologically best and worst osteochondral tissue, representing “healthy” and “unhealthy” SB. The BM-MSCs were co-cultured with normal chondrocytes suspended in agarose, with the two cell types separated by a porous membrane. After 0, 7, 14 and 21 days, chondrocyte-agarose scaffolds were assessed by gene expression and biochemical analyses.Abstract
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The Oswestry-Bristol Classification (OBC) is an MRI-specific assessment tool to grade trochlear dysplasia. The aim of this study is to validate clinically the OBC by demonstrating its use in selecting treatments that are safe and effective. The OBC and the patellotrochlear index were used as part of the Oswestry Patellotrochlear Algorithm (OPTA) to guide the surgical treatment of patients with patellar instability. Patients were assigned to one of four treatment groups: medial patellofemoral ligament reconstruction (MPFLr); MPFLr + tibial tubercle distalization (TTD); trochleoplasty; or trochleoplasty + TTD. A prospective analysis of a longitudinal patellofemoral database was performed. Between 2012 and 2018, 202 patients (233 knees) with a mean age of 24.2 years (SD 8.1), with recurrent patellar instability were treated by two fellowship-trained consultant sports/knee surgeons at The Robert Jones and Agnes Hunt Orthopaedic Hospital. Clinical efficacy of each treatment group was assessed by Kujala, International Knee Documentation Committee (IKDC), and EuroQol five-dimension questionnaire (EQ-5D) scores at baseline, and up to 60 months postoperatively. Their safety was assessed by complication rate and requirement for further surgery. The pattern of clinical outcome over time was analyzed using mixed regression modelling.Aims
Methods
Meniscus allograft and synthetic meniscus scaffold (Actifit®) transplantation have shown promising outcomes for symptoms relief in patients with meniscus deficient knees. Untreated chondral defects can place excessive load onto meniscus transplants and cause early graft failure. We hypothesised that combined ACI and allograft or synthetic meniscus replacement might provide a solution for meniscus deficient individuals with co-existing lesions in cartilage and meniscus. We retrospectively collected data from 17 patients (16M, 1F, aged 40±9.26) who had ACI and meniscus allograft transplant (MAT), 8 patients (7M, 1F, aged 42±11) who underwent ACI and Actifit® meniscus scaffold replacement. Other baseline data included BMI, pre-operative procedures and cellular transplant data. Patients were assessed by pre-operative, one-year and last follow-up Lysholm score, one-year repair site biopsy, MRI evaluations.Abstract
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The ability to predict which patients will improve following routine surgeries aimed at preventing the progression of osteoarthritis is needed to aid patients being stratified to receive the most appropriate treatment. This study aimed to investigate the potential of a panel of biomarkers for predicting (prior to treatment) the clinical outcome following treatment with microfracture or osteotomy. Proteins known to relate to OA severity, with predictive value in autologous cell implantation treatment or that had been identified in proteomic analyses (aggrecanase-1/ ADAMTS-4, cartilage oligomeric matrix protein (COMP), hyaluronic acid (HA), Lymphatic Vessel Endothelial Hyaluronan Receptor-1, matrix metalloproteinases-1 and −3, soluble CD14, S100 calcium binding protein A13 and 14-3-3 protein theta) were assessed in the synovial fluid (SF) of 19 and 13 patients prior to microfracture or osteotomy, respectively, using commercial immunoassays. Levels of COMP and HA were measured in the plasma of these patients. To find predictors of postoperative function, multiple linear regression analyses were performed.Abstract
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“Simulation”, “deliberate practice”, “rehearsal” have been used to describe safe acquisition and practice of skills before patient contact. Simulation resources are being introduced as a General Medical Council mandate. Individual simulators have shown multi-level evidence but there is no guidance to form a simulation curriculum. We devised a pilot arthroscopy course based on a 4-stage model. Stage 1: session covering anatomy, equipment, and skills required; Stage 2: practice on low fidelity simulators (Arthroscopic Skills Acquisition Tools (ASATs), ArthroBox, Synthetic Knee); Stage 3: practice on high fidelity simulators (Cadaveric Knee, Virtual Reality); Stage 4: assessment on performance intra-operatively. This study sought feedback on Stages 1–3 with the aim that the feedback will help identify how trainees wish to use simulators. Five arthroscopic simulators were used in this one-day pilot course. Prior to commencing, participants were asked which simulator they felt would help them the most. Feedback on each stage, and individual simulator (Likert scale), and how trainees would like to be trained was prospectively collected. Seven orthopaedic juniors took part. All felt the high-fidelity simulators will be the most useful. All stages were ranked with equal importance, whilst cadaveric, plastic, VR, Arthrobox and lastly ASATs ranked in order of realism respectively. For cadaveric arthroscopy trainees wished the trainers to be there all the time (6/7), whilst for VR all trainees wanted their trainers part of the time. We have shown that junior trainees value a structured method of skills acquisition and have identified that high fidelity simulation requires trainers to be present to provide relevant feedback. Such feedback mechanisms need to be incorporated in any curriculum so that simulation tools are not seen as a standalone training method.
A randomised clinical trial was undertaken to find out if treatment time and failure rate in children treated by the Ponseti method differed between below-knee vs above-knee cast groups. Eligible children with idiopathic clubfoot, treated using the Ponseti method, were randomised to either below knee or above knee plaster of Paris casting. Outcome measures were total treatment time and the occurrence of failure, defined as two slippages or a treatment time above eight weeks. Twenty-six children (33 feet) were entered into the trial, with a mean age of 17 days (range 1–40) in the above knee and 11 days (range 5–20) in the below knee group. Because of six failures in the below knee group (38%), the trial was stopped early for ethical reasons. Failure rate was significantly higher in the below-knee group (P 0.039). The median treatment times of six weeks in the below knee and four weeks in the above knee group differed significantly (P 0.01).Statement of purpose:
Methods and Results:
A description of a procedure to stabilize symptomatic complete discoid menisci with medium term results. Children with mechanical symptoms of lateral meniscal instability were assessed by MRI scan. In those with a lateral discoid meniscus an arthroscopic examination was performed to identify the presence of tears and confirm the radiological diagnosis. No incomplete or Wrisberg variant types were encountered. An antero-lateral arthrotomy was performed. The anterior horn of the meniscus was mobilized and traction sutures inserted. Flexion and extension of the knee whilst traction was applied led to delivery of the anterior horn into the wound. After confirmation of position with image intensifier a groove was fashioned in the anterior aspect of the cartilaginous portion of the proximal tibial epiphysis. Typically three titanium bone anchors with non absorbable sutures were placed in the base of the groove. The anterior horn of the meniscus was drawn into the groove and anchored with sutures. Active range of motion exercises were encouraged but a canvas knee immobilizer was employed whilst walking for the first six weeks. Four boys and three girls underwent meniscopexy performed at a mean age of 9.4 years (range 5.7 to 12.4 years). Follow up was at a mean of 4.9 years. At last follow up no patient reported symptoms of locking or pain. No patient has required revision surgery but one girl had a subsequent meniscopexy procedure on the opposite knee. Five of the children have had Lysholm scores performed at last follow up averaging 93.5 (80 to 100 points).Purpose of Study
Methods and Results
Salvage procedures on the 1st MTPJ following failed arthroplasty, arthrodesis or hallux valgus surgery are difficult and complicated by bone loss. This results in shortened first ray and transfer metatarsalgia. We present our experience of using tri-cortical interposition grafts to manage this challenging problem. Between 2002 and 2009 our department performed 21, 1st MTPJ arthrodeses using a tri-cortical iliac crest interposition graft. Surgical fixation was achieved with a compact foot plate. We performed a retrospective review from the medical notes and radiographs along with American Foot and Ankle scores which were collected prospectively. We analysed the following parameters: time to radiological, requirement for further surgery, lengthening of 1st ray and any post operative complications.Background
Methods
The mechanical disadvantage and detrimental effect to articular cartilage following meniscectomy has been well documented in the literature. Meniscal repair in the avascular (white on white zone) is controversial and would be deemed inappropriate by many. Prospective data collection on all meniscal repairs between 1999 and 2008. 423 patients underwent meniscal repair at our unit during this time. We identified 88 patients who underwent a meniscal repair of a non peripheral tear (white on white zone) where there was no co-existent ACL injury or instability. There were 74 males and 14 females with a mean age of 26 years (13-54). There were 50 medial meniscal tears and 38 lateral tears, all in the non peripheral area of the meniscus. The criterion for failure was any reoperation on the same meniscus requiring excision or re fixation.Background
Methods
Avascular meniscal tears can be repaired with good clinical outcomes. The mechanical disadvantage and detrimental effect to articular cartilage following meniscectomy has been well documented in the literature. Meniscal repair in the avascular (white on white zone) is controversial and would be deemed inappropriate by many.Hypothesis
Background
