Autologous matrix-induced chondrogenesis and bone marrow aspirate concentrate compared with microfracture for arthroscopic treatment of femoroacetabular impingement and chondral lesions of the hip: bridging the osteoarthritis gap and facilitating enhanced recovery.

In an attempt to bridge the osteoarthritis (OA) gap, this study compared biological reconstruction with traditional microfracture (MF) techniques in patients with femoroacetabular impingement and focal cartilage defects. Cohorts of two groups were investigated; age, gender and Tonnis grade matched comparison for outcomes between MF and newer biological reconstruction techniques hip arthroscopy surgery using autologous matrix-induced chondrogenesis and bone marrow aspirate combination. Outcomes investigated were pre-op and post-op mean iHOT-12 scores up to 18 months after surgery with a Kaplan-Meier survivorship analysis. Of 111 patients, 46 patients underwent MF and 65 biological reconstruction hip arthroscopy including cam/pincer osteoplasty and labral repair surgery. Age range was 20-69, mean age 45 years for both groups, Tonnis grading was as follows: Grade 0: 26% versus 30%, Grade 1: 52% versus 47% and Grade 2: 22% versus 23% in MF and biological reconstruction groups, respectively. The mean post-operative iHOT-12 score differences between MF and biological reconstruction were significant at 1-year minimum follow-up (P = 0.01, SD 2.8). Biological reconstruction allowed for an enhanced recovery protocol. The MF group had a 67.4% survivorship for conversion to hip replacement at 18 months (32.6% failure rate for any reason) and biological reconstruction had 100% survivorship at 18 months post-operatively with no failures for any reason. This study provides further support to the evidence base for biological reconstructive techniques as superior to MF in combination with joint preservation arthroscopic surgery, even in the face of focal cartilage defects and offers both surgeons and patients a potential bridging of the OA gap.

Early to mid-term outcome of Oxinium on Verilast highly cross-linked polyethylene bearing surface in uncemented total hip arthroplasty.

INTRODUCTION: We report 5- to 10-year clinical and radiological outcomes of a series of uncemented Oxinium on Verilast (highly cross-linked polyethylene liners) total hip replacements (THAs) using the Anthology stem and R3/Reflection cup system. METHODS: 116 THAs were performed by 2 senior authors in 104 patients from 2005 to 2009. The mean age at time of operation was 63.8 (45-80) years. The average length of follow-up was 8.8 years. At final data collection 12 patients had died (13 THAs) and 3 patients (3 THAs) were lost to follow-up. RESULTS: In the remaining 100 THAs, the preoperative Harris Hip Score of 39 improved to 91 and Oxford Hip Score improved from 16 to 44 (mean at 5 to 10 years). 100 THAs were available for radiographic analysis: all had stable bony ingrowth of both the stem and cup. Dorr's methods for wear in the 100 THAs showed an average wear <0.01 mm/year and no osteolysis; only 1 case showed 0.22 mm/year with some proximal femoral osteolysis but no cup lesions. There were no dislocations or revisions, survivorship in this series for both components for any cause as an endpoint was 100%. 1 intraoperative calcar fracture was sustained and treated with a cerclage wires, 2 peri-prosthetic fractures occurred and were treated with open reduction and fixation, both healed well with excellent outcomes. DISCUSSION: The study has shown good clinical and radiological outcomes at 5-10 years and supports existing data on the potential benefits of this bearing performance in literature.

Steroid-induced stress fracture of medial tibial condyle: a case report.

Corticosteroid-induced stress fractures have been described, but such a presentation is rare in tibial condyle where osteonecrosis secondary to steroid use is more common. In this report we describe a case of stress fracture of medial tibial condyle secondary to corticosteroid (glucocorticoid) intake in a 47-year-old man. We discuss in detail the pathogenesis of this condition, and highlight the importance of various diagnostic modalities to avoid misdiagnosis of the condition. We also reiterate the importance of early diagnosis and prompt immobilization to prevent long-term morbidity in such cases.

Mid-term results of third-generation alumina-on-alumina ceramic bearings in cementless total hip arthroplasty: a ten-year minimum follow-up.

BACKGROUND: Alumina ceramic-on-ceramic bearings have gained popularity in hip arthroplasty because of their properties of low wear and chemical inertness. In a previous study, we reported the excellent clinical results in a series of cementless ceramic-on-ceramic primary total hip arthroplasties at a minimum of five years of follow-up. The purpose of the present study was to determine the results in the same patient cohort at a minimum of ten years of follow-up. METHODS: A series of 301 consecutive primary cementless total hip arthroplasties was assessed clinically and radiographically. Clinical information was available for 244 hips in 227 surviving patients at a minimum of ten years of follow-up, and radiographic information was available for 184 hips in 172 patients. RESULTS: Twenty-six (9.2%) of the patients had died of an unrelated cause and eight (2.7%) had undergone revision arthroplasty by the time of the latest follow-up. The average Harris hip score was 94 points, with 95% (232) of the patients having an excellent or good result and <4% (nine) having moderate residual pain. All radiographic assessments showed evidence of stable osseous ingrowth. Nine revisions had been performed, including four femoral component revisions due to periprosthetic fracture, one femoral revision due to aseptic loosening, one femoral revision secondary to a femoral shortening osteotomy for nerve palsy, two acetabular cup revisions due to psoas tendinitis, and a repeat revision in one of the patients with psoas tendinitis due to acetabular osteolysis. The overall survival rate of the implants was 98% (95% confidence interval, 94.2% to 99.6%) at ten years with revision for any reason as the end point. CONCLUSIONS: The patients in our series had a good implant survival rate, good function, a low implant wear rate as reported in the previous study, and no further radiographic evidence of failure at ten years after cementless primary total hip arthroplasty with alumina ceramic-on-ceramic bearings.

Efficacy of immunohistological methods in detecting functionally viable mechanoreceptors in the remnant stumps of injured anterior cruciate ligaments and its clinical importance.

PURPOSE: Various histological and immunological methods have been used to detect the mechanoreceptors and nerve fibers on the intact ACLs as well as on the remnant stumps. However, some of these methods lack standardization, and the variable thickness of slices used often leads to misinterpretation. The study was based on the hypothesis that immunohistological methods are easier and more reliable means to demonstrate mechanoreceptors in the remnant ACL stumps as compared with the conventional methods. We also attempted to validate the methodology of immunohistology as a means of characterizing functional mechanoreceptors in the residual stump of an injured ACL. METHODS: The remnants of the ruptured ACL in 95 patients were harvested during arthroscopic ACL reconstruction and evaluated immunohistologically using hematoxylin and eosin (H&E), and monoclonal antibodies to S-100 and NFP. Multiple sections from each specimen were serially examined by two histologists. RESULTS: The positivity of monoclonal antibody against NFP showed a statistically significant relationship with the presence of morphologically normal mechanoreceptors, whereas the positivity of monoclonal antibody against S-100 showed a statistically significant relationship with the presence of free nerve ending in the residual stump of an injured ACL. CONCLUSIONS: Immunological methods are more reliable and easier to use as compared with the conventional methods of histological staining for identifying remnant stumps likely to be of some proprioceptive benefit after an ACL injury. Such an identification might help us preserve certain remnant stumps during ACL reconstruction which might in turn improve the postoperative functional outcomes.

The suitability of an uncemented hydroxyapatite coated (HAC) hip hemiarthroplasty stem for intra-capsular femoral neck fractures in osteoporotic elderly patients: the Metaphyseal-Diaphyseal Index, a solution to preventing intra-operative periprosthetic fracture.

This study will seek to identify a measurable radiographic index, the Metaphyseal-Diaphyseal Index (MDI) score to determine whether intra-operative fracture in osteoporotic bone can be predicted.A 5 year prospective cohort of 560 consecutive patients, undergoing hemiarthroplasty (cemented or uncemented), was evaluated. A nested case-control study to determine risk factors affecting intra-operative fracture was carried out. The Vancouver Classification was used to classify periprosthetic fracture. The MDI score was calculated using radiographs from the uncemented group. As a control (gold standard), Yeung et al's Canal Bone Ratio (CBR) score was also calculated. From this, a receiver operating characteristic (ROC) curve was formulated for both scores and area under the curve (AUC) compared. Intra and inter-observer correlations were determined. Cost analysis was also worked out for adverse outcomes. Four hundred and seven uncemented and one hundred and fifty-three cemented stems were implanted. The use of uncemented implants was the main risk factor for intra-operative periprosthetic fracture. Sixty-two periprosthetic fractures occurred in the uncemented group (15.2%), nine occurred in the cemented group (5.9%), P < 0.001. The revision rate for sustaining a periprosthetic fracture (uncemented group) was 17.7%, P < 0.001 and 90 day mortality 19.7%, P < 0.03. MDI's AUC was 0.985 compared to CBR's 0.948, P < 0.001. The MDI score cut-off to predict fracture was 21, sensitivity 98.3%, specificity 99.8%, positive predictive value 90.5% and negative predictive value 98%. Multivariate regression analysis ruled out any other confounding factors as being significant. The intra and inter-observer Pearson correlation scores were r = 0.99, P < 0.001. JRI uncemented hemiarthroplasty has a significantly higher intra-operative fracture rate. We recommend cemented arthroplasty for hip fractures. We propose a radiographic system that may allow surgeons to select patients who are good candidates for uncemented arthroplasty, but it needs prospective validation.

Long-term survival of high tibial osteotomy for medial compartment osteoarthritis of the knee.

BACKGROUND: The management of degenerative arthritis of the knee in the younger, active patient presents a challenge to the orthopaedic surgeon. Surgical treatment options include high tibial osteotomy (HTO), unicompartmental knee arthroplasty, and total knee arthroplasty. PURPOSE: To examine the long-term survival of closing wedge HTO in a large series of patients up to 19 years after surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Four hundred fifty-five consecutive patients underwent lateral closing wedge HTO for medial compartment osteoarthritis between 1990 and 2001. Between 2008 and 2009, patients were contacted via telephone, and assessment included incidence of further surgery, current body mass index (BMI), Oxford Knee Score, and British Orthopaedic Association Patient Satisfaction Scale. Failure was defined as the need for revision HTO or conversion to unicompartmental knee arthroplasty or total knee arthroplasty. Survival analysis was completed using the Kaplan-Meier method. RESULTS: High tibial osteotomy survival was determined in 413 patients (91%). Of the 397 remaining living patients at the time of final review, 394 (99%) were contacted for follow-up via telephone interview. The probability of survival for HTO at 5, 10, and 15 years was 95%, 79%, and 56%, respectively. Multivariate regression analysis showed that age under 50 years (P = .001), BMI less than 25 (P = .006), and ACL deficiency (P = .03) were associated with better odds of survival. Mean Oxford Knee Score was 40 of 48 (range, 17-48). Overall, 85% of patients were enthusiastic or satisfied, and 84% would undergo HTO again at a mean 12 years of follow-up. CONCLUSION: High tibial osteotomy can be effective for periods longer than 15 years; however, results do deteriorate over time. Age less than 50 years, normal BMI, and ACL deficiency were independent factors associated with improved long-term survival of HTO.

Five- to 8-year results of the uncemented Duracon total knee arthroplasty system.

We report prospective clinical and radiographic outcomes of a series of 219 hydroxyapatite-coated Duracon (Stryker Howmedica Osteonics Corporation, Kalamazoo, Mich) total knee arthroplasties with a follow-up of 5 to 8 years. Knee Society Score, Western Ontario and McMaster Universities Osteoarthritis index (WOMAC), and SF-12 Health Status Questionnaire were used. Analysis of fluoroscopic radiographs was performed with the American Knee Society Score. All living patients (186 knees) were followed up. Twenty-eight patients (30 knees) had died. The preoperative Knee Society Score of 43.8 increased to 77.1 and the preoperative Function score of 20.3 increased to 63.4. WOMAC scores showed marked improvement (pain, 250 preoperatively to 157; stiffness, 115 preoperatively to 56; and function, 910 preoperatively to 588). There was no radiographic evidence of loosening or migration. Gaps visible at the bone-implant interface healed over the first year. Three prostheses were revised, 2 for deep infection and 1 for tibial tray subsidence. A survivorship of 98.6% has been achieved at 8 years. This intermediate-term study with 100% follow-up at 8 years demonstrates excellent clinical and radiographic outcomes. It is our opinion that these are comparable to the gold standard cemented total knee arthroplasties and may have advantages over other uncoated cementless designs.