Anatomic studies have demonstrated that bipolar glenoid and humeral bone loss have a cumulative impact on shoulder instability, and that these defects may engage in functional positions depending on their size, location, and orientation, potentially resulting in failure of stabilisation procedures. Determining which lesions pose a risk for engagement remains a challenge, with Itoi's 3DCT based glenoid track method and arthroscopic assessment being the accepted approaches at this time. The purpose of this study was to investigate the interaction of humeral and glenoid bone defects on shoulder engagement in a cadaveric model. Two alternative approaches to predicting engagement were evaluated; 1) CT scanning the shoulder in abduction and external rotation 2) measurement of Bankart lesion width and a novel parameter, the intact anterior articular angle (IAAA), on conventional 2D multi-plane reformats.

Hill-Sachs and Bony Bankart defects of varying size were created in 12 cadaveric upper limbs, producing 45 bipolar defect combinations. The shoulders were assessed for engagement using cone beam CT in various positions of function, from 30 to 90 degrees of both abduction and external rotation. The humeral and glenoid defects were characterised by measurement of their size, location, and orientation. The abduction external rotation scan and 2D IAAA approaches were compared to the glenoid track method for predicting engagement.

Engagement was predicted by Itoi's glenoid track method in 24 of 45 specimens (53%). The abduction external rotation CT scan performed at 60 degrees of glenohumeral abduction (corresponding to 90 degrees of abduction relative to the trunk) and 90 degrees of external rotation predicted engagement accurately in 43 of 45 specimens (96%), with sensitivity and specificity of 92% and 100% respectively. A logistic model based on Bankart width and IAAA provided a prediction accuracy of 89% with sensitivity and specificity of 91% and 87%. Inter-rater agreement was excellent (Kappa = 1) for classification of engagement on the abduction external rotation CT, and good (intraclass correlation = 0.73) for measurement of IAAA.

Bipolar lesions at risk for engagement can be identified using an abduction external rotation CT scan at 60 degrees of glenohumeral abduction and 90 degrees of external rotation, or by performing 2D measurements of Bankart width and IAAA on conventional CT multi-plane reformats. This information will be useful for peri-operative decision making around surgical techniques for shoulder stabilisation in the setting of bipolar bone defects.

The purpose of this study was to validate a dry model for the assessment of performance of arthroscopic rotator cuff repair (RCR) and labral repair (LR). We hypothesised that the combination of a checklist and a previously validated global rating scale (GRS) would be a valid and reliable means of assessing RCR and LR when performed by residents in a dry model.

An arthroscopic RCR and LR was performed on a dry model by residents, fellows, and sports medicine staff. Any prior RCR and LR exposure was noted. Participants were given a detailed surgical manuscript and technique video before the study began. Evaluation of residents was performed by staff surgeons with task-specific checklists created using a modified Delphi procedure, and the Arthroscopic Surgical Skill Evaluation Tool (ASSET). The hand movements and arthroscopic view of the procedures were recorded. Both videos were scored by a fellow blinded to the year of training of each participant.

A total of 35 residents, six fellows and five staff surgeons performed both arthroscopic RCR and LR on a dry model model (48 total). The internal reliability (Cronbach's Alpha) of the test using the total ASSET score was high (>0.8)). One-way analysis of variance for the total ASSET score and the total checklist score demonstrated a difference between participants based upon year of training (p<0.05). Post hoc analysis also demonstrated a significant difference in global ratings and checklist scores between junior residents (PGY1–3) and senior residents (PGY4&5), senior residents and fellows, and fellows and staff. A good correlation was seen between the total ASSET score and prior exposure to RCR and LR. The inter-rater reliability (ICC) between the examiner ratings and the blinded assessor ratings for the total ASSET score was good (0.8).

The results of this study provide evidence that the performance of a RCR and LR in a dry model is a valid and reliable method of assessing a resident's ability to perform these procedures, prior to performance in the operating room.

Osteoarthritis (OA) is a debilitating disease characterised by degradation of articular cartilage and subchondral bone remodeling. Current therapies for early or midstage disease do not regenerate articular cartilage, or fail to integrate the repair tissue with host tissue, and therefore there is great interest in developing biological approaches to cartilage repair. We have shown previously that platelet-rich plasma (PRP) can enhance cartilage tissue formation. PRP is obtained from a patient's own blood, and is an autologous source of many growth factors and other molecules which may aid in healing. This raised the question as to whether PRP could enhance cartilage integration. We hypothesise that PRP will enhance integration of bioengineered cartilage with native cartilage.

Chondrocytes were isolated from bovine metacarpal-phalangeal joints, seeded on a porous bone substitute (calcium polyphosphate) and grown in the presence of FBS to form an in vitro model of osteochondral-like tissue. After 7 days, the biphasic constructs were soaked in PRP for 30 minutes prior to implantation into the core of a ring-shaped biphasic explant of native bovine cartilage and bone. Controls were not soaked in PRP. The resulting implant-explant construct was cultured in a stirring bioreactor in serum free conditions for 2 weeks. The integration zone was visualised histologically. A push-out test was performed to assess the strength of integration. Matrix accumulation at the zone of integration was assessed biochemically and the gene expression of the cells in this region was assessed by RT-PCR. Significance (p<0.05) was assessed by a student's t-test or one-way ANOVA with tukey's post hoc.

PRP soaked bioengineered implants, integrated with the host tissue in 73% of samples, whereas control bioengineered implants only integrated in 19% of samples based on macroscopic evaluation (p<0.05). The integration strength, as determined by the normalised maximum force to failure, was significantly increased in the PRP soaked implant group compared to controls (219 +/− 35.4 kPa and 72.0 +/− 28.5 kPa, respectively, p<0.05). This correlated with an increase in glycosaminoglycan and collagen accumulation in the region of integration in the PRP treated implant group, compared to untreated controls after 2 weeks (p<0.05). Immunohistochemical studies revealed that the integration zone was rich in collagen type II and aggrecan. The cells at the zone of integration in the PRP soaked group had a 2.5 fold increase in aggrecan gene expression (p=0.05) and a 3.5 fold increase in matrix metalloproteinase 13 expression (p<0.05) compared to controls.

PRP soaked bio-engineered cartilage implants showed improved integration with native cartilage compared to non-treated implants, perhaps due to the increased matrix accumulation and remodeling at the interface. Further evaluation is required to determine if PRP improves integration in vivo.

Pigmented villonodular synovitis (PVNS) is a rare proliferative process of the synovium which most commonly affects the knee and occurs in either a localised (LPVNS) or a diffuse form (DPVNS). The effect of different methods of surgical synovectomy and adjuvant radiotherapy on the rate of recurrence is unclear. We conducted a systematic review and identified 35 observational studies in English which reported the use of surgical synovectomy to treat PVNS of the knee.

A meta-analysis included 630 patients, 137 (21.8%) of whom had a recurrence after synovectomy. For patients with DPVNS, low-quality evidence found that the rate of recurrence was reduced by both open synovectomy (odds ration (OR) = 0.47; 95% CI 0.25 to 0.90; p = 0.024) and combined open and arthroscopic synovectomy (OR = 0.19, 95% CI = 0.06 to 0.58; p = 0.003) compared with arthroscopic surgery. Very low-quality evidence found that the rate of recurrence of DPVNS was reduced by peri-operative radiotherapy (OR = 0.31, 95% CI 0.14 to 0.70; p = 0.01). Very low-quality evidence suggested that the rate of recurrence of LPVNS was not related to the surgical approach.

This meta-analysis suggests that open synovectomy or synovectomy combined with peri-operative radiotherapy for DPVNS is associated with a reduced rate of recurrence. Large long-term prospective multicentre observational studies, with a focus on both rate of recurrence and function, are required to confirm these findings.

Cite this article: Bone Joint J 2015;97-B:550–7.

Purpose: In evaluating injury severity of acute medial collateral ligament (MCL) injuries, the current standard is to perform a history and physical examination and static MRI of the injured joint. With recent advances in dynamic MR imaging technology, we hypothesized that concurrent physical examination and dynamic MRI of the knee joint in patients with acute MCL injuries is feasible and would provide new insight into the injured joint kinematics while correlating to clinical and diagnostic imaging criteria for injury severity.

Method: 10 patients (5 male, 5 female) with isolated, unilateral, acute MCL injuries were prospectively enrolled in the study. An orthopedic surgeon performed initial physical examination and clinical grading. Dynamic MRI with concurrent physical examination was performed in a 1.5T wide-bore magnet and compared to the uninjured knee as a control. The dynamic MR imaging data was compared with morphologic MCL changes on static MRI, with dynamic examination of the contralateral knee and with the clinical grading of MCL injury. The width of the medial joint space and the opening angle between the femur and tibia were measured.

Results: Clinically, one patient had grade 1 and nine had grade 2 injuries. Using morphologic MRI criteria there were nine grade 2 and one grade 3 injuries. Mean and median medial opening angles of all affected knees was 2.8/2.5 mm and 2.8/2.6°, respectively, as compared to 1.8/1.8 mm and 2.2/2.1° in the normal side. Measurements of medial joint-space opening showed little quantitative difference between grade 1, 2 and 3 injuries. Interobserver agreement (intraclass correlation coefficients) varied from 0.9 to 0.93.

Conclusion: Dynamic MR imaging with concurrent physical examination is feasible and correlates to clinical and morphologic grading of severity. Our study suggests that traditional clinical grading systems of MCL injuries overestimate medial joint space opening.

A generic measure of health related quality of life was used to evaluate outcome following ACL reconstruction. This study quantifies the domains of poorer health-related quality of life and provides pre- and postoperative SF-36 scores for patients with ACL deficient knees. Pre-operative Sf-36 scores in ACL deficient knees were significantly lower than age matched normals in the physical domains of physical functioning, role-physical and bodily pain (p< 0.001). Post-operatively, SF-36 scores were significantly improved (p< 0.001) in all domains except general health and social functioning.

Evaluation of the ACL injured knee and the success of reconstructive surgery has traditionally focused on an assessment of knee function. These have proven to be poor indicators of general functional outcome and health related quality of life. The purpose of this study was to use the SF-36 survey to determine whether health related quality of life in patients with ACL deficient knees differed from that of healthy individuals and whether SF-36 scores improved after undergoing ACL reconstruction.

Sixty patients with ACL deficient knees underwent ACL reconstruction using arthroscopically assisted patellar tendon insertion. Prior to surgery and a minimum of two- years post-operatively, patients completed the SF-36 general Health Survey questionnaire. Pre- and post-operative SF-36 scores were compared to each other and to standard scores obtained from a healthy population of a similar age.

Pre-operative Sf-36 scores in ACL deficient knees were significantly lower than age matched normals in the physical domains of physical functioning, role-physical and bodily pain (p< 0.001). Post-operatively, SF-36 scores were significantly improved (p< 0.001) in all domains except general health and social functioning. Comparison between age matched normals were significantly higher in the domains of role-emotional, vitality, mental health and general health

A generic measure of health related quality of life was used to evaluate outcome following ACL reconstruction. This study quantifies the domains of poorer health-related quality of life and provides pre- and post-operative SF-36 scores for patients with ACL deficient knees.

Our finding indicates that ACL reconstruction using patellar tendon autograft with arthroscopically assisted technique improved ling term health related quality of life.

A tantalum AVN implant was used in sixteen patients with advanced AVN (Grade 3/4). No reports have been published of use of this implant in advanced disease. Outcomes included radiological, SF36, Harris hip score and secondary surgeries. HHS improved from fifty-two to seventy. SF36 scores approached controls. At over one year average follow-up five patients are revised to THA, however, all hips except one have at least minor pain. Revisions occurred in older patients or those with 100% head involvement. In younger patients, with up to 50% head involvement, this technique seems to be a viable option for advanced AVN. Evaluation of tantalum AVN implants in patients with advanced AVN. In younger patients, with up to 50% hip head involvement, this technique seems to be a viable option for advanced AVN. Revisions in general are in older patients or those with 100% head involvement.

Most treatment options have had poor outcomes with advanced AVN. Surgeons generally perform THA or core decompression in these cases. Market pressure for a non-vascularized option to fill the channel after decompression has resulted in new implants. A tantalum device has been designed to fill the post-core decompression channel to allow subchondral support. This is a minimally invasive procedure with theoretically low morbidity. The average orthopedic surgeon would have no difficulty in the use of this implant.

HHS improved from fifty-two to seventy. SF36 scores were below age-matched controls. At over one-year average follow-up five patients are revised to THA, however, all hips except one have at least minor pain. Revisions in general are in older patients or those with 100% involvement. In younger patients, with up to 50% head involvement, this technique seems to be a viable option.

This device was used in a prospective cohort of sixteen patients with advanced AVN (Grade 3/4) with femoral head fracture/collapse. Operative technique including reduction of the fracture allows for improved results. Outcomes included radiological parameters (advancing disease, placement, ingrowth), SF36, Harris hip score and secondary surgeries.

Avascular necrosis is poorly understood. The etiological factors have not been fully delineated. This disease process had a huge cost impact on the health system due to surgical treatment. Patients with avascular necrosis seen at a single institution underwent DNA extraction and analysis, coagulation-related analysis and buccal smears with DNA analysis. In this patient group 60% tested positive for at least one thrombophilic or hypofibrinolysis factor. We make recommendations depending on the defect in the cascade, allowing for potential non-surgical management of osteonecrosis in patients undergoing therapy with known antagonistic medications (i.e. corticosteroids).

The etiology and pathogenesis of nontraumatic AVN need to be better elucidated.

Our study identifies the potential association of thrombophilic and hypofibrinolytic factors and osteonecrosis of the hip, particularly genetic markers as identified through DNA markers

The significance of this study:

Osteonecrosis is a devastating musculoskeletal condition;

60% of patients had at least one tested thrombophilic or hypofibrinolysis factor positive. Most patients never had a thrombotic event.

Genetic screening, multiple hematological paramteres were tested on patients with avascular necrosis.

hypercoagulability plays a role in the development of AVN of the hip, mainly at the microvascular level;