Aims

The Advance Medial-Pivot total knee arthroplasty (TKA) was designed to reflect contemporary data regarding the kinematics of the knee. We wished to examine the long-term results obtained with this prosthesis by extending a previous evaluation.

We report the outcome of 84 nonunions involving long bones which were treated with rhBMP-7, in 84 patients (60 men: 24 women) with a mean age 46 years (18 to 81) between 2003 and 2011. The patients had undergone a mean of three previous operations (one to 11) for nonunion which had been present for a mean of 17 months (4 months to 20 years). The nonunions involved the lower limb in 71 patients and the remainder involved the upper limb. A total of 30 nonunions were septic. Treatment was considered successful when the nonunion healed without additional procedures. The relationship between successful union and the time to union was investigated and various factors including age and gender, the nature of the nonunion (location, size, type, chronicity, previous procedures, infection, the condition of the soft tissues) and type of index procedure (revision of fixation, type of graft, amount of rhBMP-7) were analysed. The improvement of the patients’ quality of life was estimated using the Short Form (SF) 12 score.

A total of 68 nonunions (80.9%) healed with no need for further procedures at a mean of 5.4 months (3 to 10) post-operatively. Multivariate logistic regression analysis of the factors affecting union suggested that only infection significantly affected the rate of union (p = 0.004).Time to union was only affected by the number of previous failed procedures (p = 0.006). An improvement of 79% and 32.2% in SF-12 physical and mental score, respectively, was noted within the first post-operative year.

Rh-BMP-7 combined with bone grafts, enabled healing of the nonunion and improved quality of life in about 80% of patients. Aseptic nonunions were much more likely to unite than septic ones. The number of previous failed operations significantly delayed the time to union.

Cite this article: Bone Joint J 2015;97-B:997–1003.

The evaluation of the outcome of CCK prostheses in primary TKA

Between 2002 and 2008 we implanted 34 CCK knees in 31 patients. Mean age was 69 (58–79) 10 patients were operated because of valgus knee and lateral compartment arthritis, 8 because of post-traumatic ligamentous laxity and/or bone loss and the remaining patients presented with advanced OA and varus deformity exceeding 30 degrees. All patients were followed regularly with radiographs annually and there were assessed clinically with KSS and Womac score. The findings were compared with a group of patients with similar characteristics and a CR prosthesis.

Mean follow-up was 3 years (6–1) There was no revision in this group neither was any radiological abnormality. Clinical outcome in terms of KSS and WOMAC score was excellent and comparable to the CR group.

The main indication for a CCK prosthesis is the ligamentous insufficiency. There is enough evidence to support its superiority as a treatment option in valgus knees but long term performance is yet unclear.

CCK prostheses are a reliable solution for unstable or imbalanced knees their long term behaviour though, is yet unclear

Aim: To determine the quantity and the quality of the bone bridge between the bone tunnels, in both the femoral and tibial side, after double-bundle anterior cruciate ligament (ACL) reconstruction.

Material and methods: Twenty-seven patients undergoing primary double-bundle ACL reconstruction with hamstring tendon autograft were included in this prospective study. Computed tomography (CT) was performed in all patients at a mean of 13 months postoperatively. The amount of the bone bridge between the bone tunnels was measured, in both the femoral and tibial side, on an axial plane at three locations:

at the level of the joint line

In addition, the bone density of the bone bridge was measured in Hounsfield units (HU) in the same locations. Bone density of the anterior tibial cortex lateral femoral condyle, and adjacent cancellous area, and were measured for comparisons.

Results: CT confirmed that the bone bridge was triangular in shape in all cases in both the femoral and tibial side. On the femoral side, at the level of joint line (apex of the bone bridge) the mean thickness of the bone bridge was 1.7 mm, at the mid-portion the mean thickness of the bone bridge was 3.7 mm and at the base of the bone bridge the mean thickness was 7.1 mm. On the tibal side, at the level of joint line (apex of the bone bridge) the mean thickness of the bone bridge was 1.5 mm, at the mid-portion the mean thickness of the bone bridge was 3.2 mm and at the base of the bone bridge the mean thickness was 6.5 mm. Bone density at the mid-portion and at the base of the bone bridge was similar to the cancellous bone for both the femoral and tibial side. However, the bone density of the bone bridge, at the level of the joint line, for the femoral side was 860 HU and this was not statistically significant in comparison to the density of the lateral femoral cortex (960 HU). Similarly, the bone density of the bone bridge, at the level of the joint line, for the tibial side was 885 HU and this was not statistically significant in comparison to the density of the anterior tibial cortex (970 HU).

Conclusions: Our study demonstrated one year after double-bundle ACL reconstruction the thickness of the triangular bone bridge between the bone tunnels is sufficient at the mid-portion and at the base of the triangle but is thin at the level of the joint line. However, the bone bridge at the apex of the triangle is very strong since its density is similar to that of cortical bone. We believe that the “corticalization” of the bone bridge at the level of the joint line on both the femoral and tibial side is important and contributes significantly to avoid communication of the bone tunnels.

INTRODUCTION: The process of ligamentization includes the histological and structural remodelling of the tendons graft to ligamentous tissue. There is little information documenting the mechanism of ligamentization process in molecular level. A number of essential genes are involved in this process and their expression can be regulated through complex biochemical pathways. Animal studies have shown that transcutaneous application of low intensity pulsed ultrasound (LiUS) accelerate the tendon and ligament healing process and recent reports have proven the efficacy of the transosseous application of LiUS for both enhancement and monitoring of the bone healing. The purpose of this study is to investigate the effect of transosseous low-intensity pulsed ultrasound (LiUS) during lingamentization process on the healing at tendon graft-bone interface in rabbits, by examining the expression levels of TGF-β1, biglycan and collagen I using semi-quantitive RT-PCR.

MATERIALS AND METHODS: Twenty-eight New Zealand rabbits were used in this study. The anterior cruciate ligament was excised and replaced with the long digital extensor. Custom-made ultrasound transducers were implanted onto the bone fragment and along the surface of the bone tunnel at the right knees of the rabbits (study group). The LiUS-treated animals received 200-μsec bursts of 1 MHz sine waves with pulse repetition rates of 1 KHz and average intensity of 30 mW/cm2, for 20 minutes daily, while the left knee received no LiUS (control group). Semi-quantitative RT-PCR was performed from RNA samples representing both study and control groups at 1, 2, 3, 5, 7, 8, 9, 12, 14 and 21 days, using specific primers.

RESULTS: Analysis of the RT-PCR products showed that there is significant up-regulation of biglycan and collagen-encoding genes in the study group compared to the control group. In addition, TGFb1-encoding gene exhibits a bimodal profile. In the study group, it represses its mRNA levels from day 1 until day 9 and then the initial expression levels are restored. The control group showed no essential alteration of expression levels for TGFb1.

DISCUSSION: Transosseous LiUS treatment affects the expression levels of significant genes like TGF-β1, big-lycan and collagen type I. All the above studied genes mediate important biochemical pathways in lingamentization process and possibly enhance the healing rate of the tendon graft-bone interface in a bone tunnel in rabbits. The present report is supportive of the hypothesis that transosseous application of LiUS enhances tendon graft healing to bone through effects on molecular level. These present findings suggest that indeed ultrasound treatment after joint ligament reconstruction may facilitate earlier rehabilitation.

Aim: We present the surgical technique and early functional and radiological results of cementless acetabular reconstruction with Monoblock Trabecular Metal (MTM) (Zimmer Warsaw, Indiana) cups in patients with Developmental Dysplasia of the Hip (DDH).

Materials and Methods: From 1997 to 2004, 70 hips (57 patients) with DDH were received an MTM acetabular component. There where 7 men and 49 women. Average age was 50 years (range 35 to 77). According to the classification of Hartofilakidis et al there where 14 hips with high dislocation, 15 with low type I, 16 with low type II, 8 with low type III dislocation and 17 with hip dysplasia. In all patients a MTM cup was implanted in the true acetabulum through a standard posterior approach. Morselized graft was used in 6 cases and a structural graft only in one. Diameter of the cup was ranging from 42 to 56 mm with 54 out of 70 cups being smaller than 50 mm. Screws where used in 12 out of 70 cases A femoral shortening osteotomy was utilized in only two high dislocation cases.

All patients where followed up prospectively and evaluated clinically and radiologicaly at three, six months at one year and yearly thereafter. The clinical outcome was assessed with the Harris Hip score (HHS) and Oxford Score (OS).

Results: Average follow up was 50 months (range 103 to 24). There were no revisions for aseptic loosening, radiologic loosening or cup migration during last evaluation. Two patients developed non-progressive radiolucencies in zone one.

There were four dislocations in this group. One required open reduction and head replacement while another one needed cup revision due to mal orientation. There were five femoral fractures treated intraoperatively with wires, two patients developed transient sciatic nerve palsy and two non fatal PE.

Harris Hip Score was 91 (range 69 to 97) compared with 48 (range 24 to 58) before surgery. The outcome was excellent in 59 hips, very good in 8, good in two and fair in one. Leg length discrepancy more than 2 cm was evident in five unilateral cases (range 2 to 4.5). Trendelebourgh sign was evident in four patients.

Conclusion: MTM acetabular component achieved adequate initial stability in this demanding group of patients and they have excellent radiological and clinical results. Posterior approach without femoral osteotomy provided adequate exposure in almost all cases.

Purpose: To evaluate the differencies in graft orientation between transtibial and anteromedial portal technique using magnetic resonance imaging (MRI) in anterior cruciate ligament (ACL) reconstruction.

Materials and Methods: Fifty one patients who undergoing arthroscopically ACL reconstruction underwent MRI of their reconstructed knee. Thirty patients had ACL reconstruction using the transtibial technique (group A) while in the rest 21 the anteromedial technique (group B) was used. In the femoral part graft orientation was evaluated using the femoral graft angle (FGA). The FGA was depicted at the coronal views by two axes: the anatomical axis of the femur and the axis of the femoral tunnel. In the tibial part graft orientation was evaluated using the tibial graft angle (TGA). The TGA was specified as the angle between the axis of the graft and a line parallel to the tibial plateau at the sagittal view.

Results: The mean FGA for group A was 12.52° while for the group B was 27.06°. This difference was statistically significant (p< 0.001 paired t-test). The mean TGA for group A was 64.24° while for the group B was 63.11° but this was not statistically significant.

Conclusions: Using the anteromedial portal technique the ACL graft is placed in a more oblique direction in comparison with the transtibial technique in the femoral part. This may have an impact in rotatory knee stability. However, there are no differencies between the two techniques in graft orientation in the tibial part.

Background: Clinical tests used for the detection of knee meniscal tears do not present acceptable diagnostic sensitivity and specificity values. Diagnostic accuracy is improved by arthroscopic evaluation or performing magnetic resonance imaging (MRI) tests. The objective of this study was to evaluate the diagnostic accuracy of a new dynamic clinical examination test for the detection of meniscal tears.

Methods: Two hundred and thirteen symptomatic patients with recent knee injuries who all were clinically examined, had MRI tests and underwent arthroscopic surgery and 197 asymptomatic volunteers who all were clinically examined and had MRI tests of their normal knees were included in this study. For clinical examination the medial and lateral joint line tenderness test, McMurray test, Apley compression and distraction test, Thessaly test at 5° and Thessaly test at 20° of flexion were used. For al clinical tests sensitivity, specificity, negative predictive value and diagnostic accuracy rates were calculated against arthroscopic and magnetic resonance imaging data.

Results: Thessaly test at 20° of flexion showed a high diagnostic accuracy rate at the level of 94% and a low number of false negative recordings in detecting tears of both the medial and lateral meniscus. Other traditional clinical examination tests, with the exception of joint line tenderness which presented a diagnostic accuracy rate of 88% in detecting lateral meniscal tears, showed inferior rates.

Conclusions: Thessaly test at 20° of flexion can be safely used as a first line screening clinical test for the detection of meniscal tears reducing the need and the cost of modern magnetic resonance imaging methods.

Purpose: Arthroscopy offers a view of intra-articular pathology, but its use in the treatment of intra-articular distal radius fractures remains controversial. This study compares functional and radiologic outcomes of arthroscopically assisted (AA) versus fluoroscopically assisted (FA) reduction and external fixation (EF) of distal radius fractures.

Type of study: double randomised prospective, comparison of 2 different procedures.

Methods: Between January 2000 and December 2003, 20 patients with comminuted intra-articular distal radius fractures underwent AA EF and percutaneous pinning and 20 patients underwent and FA EF reduction and pinning.

Results: Follow-up period was 9–27 months. Evaluation was clinical (grip strength, range of motion) and radiographic (palmar tilt, radial shortening, stepoff). The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the MAYO wrist score were used 3-9-12 months postoperatively. In 9/20 patients of AA group the subchodral pins were changed after artrhroscopic view because of stepoff. The following tears were found: TFCC (12 of 20 patients), SL (9/20), LT (4/20). Patients who underwent AA surgery had significantly better supination; wrist extension; and flexion compared with the FA surgery group (86 vs 75; 76 vs 65; and 76 vs 63 degrees respectively). Radial shortening and DASH scores were better for the AA group compared to the FA group (AA:12, FA:25) the 3rd and 6th postoperative month but the difference decreased after the 12th month.

Conclusions: A reduction and fixation of intra-articular distal radius fractures provides improved inspection of the ulnarsided components of the injury. Long term evaluation revealed that patients with AA procedures returned in decreased periods to their previous activities (based on DASH score) and had better of supination, flexion, and extension than patients with FA surgery.

Purpose: The aim of this study was to document donor site problems one year after anterior cruciate ligament (ACL) reconstruction and to compare the differencies between hamstring and patellar tendon autografts.

Materilas and Methods: Sixty-four patients undergoing primary arthroscopically ACL reconstruction were randomized to have a central third bone patellar tendon bone (PT) autograft (30 patients) or a doubled semiten-dinosus/doubled gracilis (HS) autograft (34 patients). The postoperative rehabilitation regimen was identical for both groups. All patients were examined one year postoperatively. Objective parameters evaluated included pre and postoperative IKDC and Lysholm score, side-to-side KT-1000 maximum-manual arthrometer differences. The Shelbourne score was used to evaluate anterior knee symptoms. Loss of sensitivity in the anterior knee region postoperatively as well as scar sensitivity were also recorded.

Results: Three patients (10%) in the PT group had anterior knee symptoms while only one (3%) in the HS group. The mean Shelbourne score was 98 for the HS group and 93 for the PT group but this was not statistically significant. However, 8 pateints (23%) had disturbed sensitivity in the anterior knee region in the HS group, but none in the PT group and this was statistically significant (p< 0.005). Scar sensitivity was present in 3 patients (10%) in the PT group and in one (3%) in the HS group. No differencies were found postoperatively between the groups regarding IKDC, Lysholm score and side-to-side KT-1000 measurements.

Conclusions: Although,notstatisticallysignificantpatients in the PT group had more anterior knee symptoms and scar sensitivity, one year postoperatively. In contrast, harvesting of hamstring tendons produces significantly more sensory nerve complications in the anterior knee region than harvesting the middle third of patellar tendon. Both grafts seem to improve equally patients’ performance.

Introduction: Suppurative conditions in closed cavities/tunnels require surgical drainage and irrigation for elimination of infection. The purpose of this study is to evaluate the pattern of extension of infections in hand compartments and the necessity for intraoperative and continuous postoperative catheter irrigation.

Material and Methods: Compartmental infections of the hand and wrist (CIHW) were diagnosed in 42 consecutive patients involving the flexor tendon sheaths (pyogenic flexor tenosynovitis) (28); the tip (3); the carpal tunnel (2); or extended to multiple compartments including the above mentioned and the thenar, midpalmar, web and Parona’s (9). Three patients had diabetes mellitus, 2 suffered from bites, 15 had penetrating injuries and 7 were working with animals or meat products. Fifteen were previously treated in other centers. After meticulous clinical evaluation to define all the involved compartments, all patients were treated with drainage of the respective compartments, sheath irrigation and appropriate antibiotics, whereas continuous postoperative catheter irrigation was used in 24. Hand therapy started the third postoperative day.

Results: Mean follow-up time was 20 months. The most common pathogen was S. aureus (14 patients) whereas cultures were negative in 15. Three patients received additional fungal treatment. Results were excellent or very good in 25 hands and good in 12 regaining full or near full ROM. Recurrence of infection in 4 (that were initially treated inadequately in other centers or had intraoperative sheath irrigation without postoperative continuous irrigation) necessitated a revision of the procedure with extensive debridement and continuous postoperative irrigation. Finally, 1 patient developed complex regional pain syndrome.

Conclusions: A high index of suspicion and profound knowledge of the anatomy is essential for early diagnosis and prompt surgical treatment of CIHW. Initially «benign» infections often extend in multiple compartments of the hand as a result of inadequate initial treatment. Intraoperative irrigation is not always adequate for the resolution of infection, especially in neglected cases or cases with underlying conditions. Early surgical debridement of all the involved compartments in combination to continuous postoperative irrigation, administration of appropriate antibiotics and precocious onset of hand therapy is the treatment of choice for these potentially debilitating, infectious conditions of the hand.

Purpose:In this study we investigated the MRI þndings of healing process after arthroscopic meniscal repair. Methods and Materials: 15 patients with buckethandle medial meniscal tears were operated arthroscopically within 3 weeks after injury. All had accurately diagnosed meniscal tear with preoperative MRI. Six patients had an additional anterior cruciate ligament tear, also primarily reconstructed with the meniscal repair. The MR examination was perfrormed with a 1 T scanner, applying the following pulse sequences: T1-w Spin Echo (SE), PD-w Turbo Spin Echo (TSE) with fat suppression, T2-w TSE and T1-w SE in coronal and axial plane after iv administration of paramagnetic contrast agent. The postoperative MRI examinations were performed in 3 weeks intervals starting at the 6th postop and till the 18th , and 6 weeks thereafter. All patients were asymptomatic postoperatively. Results:Grade III and IV signal alterations were present on all MRI scans. Contrast enhanced images showed in addition: a) signal alterations extending through the path of suture out of the meniscus, b) enhancement of the medial collateral ligament simulating injury and c) synovitis in all patients. In one patient examined sequentially, the contrast-enhanced images demonstrated that a and b decreased after 3 months and synovitis was no more evident. Conclusion:Contrast enhanced MRI is the method of choice for demonstrating the normal healing process of the arthroscopic meniscal repair in bucket-handle tears. A gradually disappearing of the abnormal enhancement is related to scar tissue rather than to meniscal retear.

Objective: The aim of this study was to present a review of intraarticular ganglia of the knee. Materials: Cases of intraarticular ganglia of the knee were isolated from a group of 1405 consecutive patients referred for MR imaging examinations of the knee. Diagnoses were conþrmed by means of a histological study after arthroscopic or surgical excision. Results: 14 pts (10 men and four women) had intraarticular ganglia of the knee. 3 ganglia were found in Hoffañs fat pad, 5 were associated with the anterior cruciate ligament, 5 were associated with the posterior cruciate ligament, and one was associated with the ligament of Humphrey. Pain was the most common complaint. Symptoms grew worse with activity in 9 pts. There was associated limited knee extension in 4 cases and limited knee ßexion in 3 cases. One of the three pts with ganglia in Hoffañs fat pad had a palpable mass on physical examination. The cysts were ßuidþlled, with low T1-w and high T2-w signal intensity. 10 cases demonstrated peripheral thin rim enhancement on fat-suppressed contrast-enhanced T1-w SE images. Grad echo sequences were useful in excluding areas of hemosiderin. Conclusion: Intraarticular ganglia of the knee have been found to occur commonly, with a prevalence of 1.% in the present series. The clinical presentation of intra-articular ganglion cyst is varied according to its intra-articular location. Radiologists should be aware of this entity and its defferential diagnoses. The contrast-enhanced sequences allow intraarticular ganglia to be distinguished from PVNS, synovial hemangioma and synovial sarcoma.