Articular cartilage status 2 years after arthroscopic ACL reconstruction in patients with or without concomitant meniscal surgery: evaluation with 3.0T MR imaging.

PURPOSE: To assess articular cartilage changes in the knee joint as detected on 3.0T MR imaging after 2-year follow-up in patients who underwent arthroscopic anterior cruciate ligament reconstruction (ACLR) with or without concomitant meniscal surgery. METHODS: A total of twenty-nine patients (mean age 30.3 ± 10 years), who underwent arthroscopic ACLR, received clinical and imaging follow-up at an average of 27.8 ± 4.8 months after surgery. Our patients were divided into two subgroups: eighteen patients with additional meniscal injuries at the time of arthroscopic ACLR who underwent meniscal surgery and eleven patients with intact menisci. The cartilage status of all knees at the time of arthroscopic ACLR was recorded. All patients underwent an MRI scan preoperatively and at follow-up with the same imaging protocol. Cartilage status of all knee compartments was evaluated at the time of follow-up by MR imaging and the ICRS classification. RESULTS: Deterioration of the cartilage status was found at all knee compartments of our study group, with respect to the number of cartilage defects. The cartilage of the lateral femoral condyle (LFC) was most severely affected, followed by patellar and medial femoral condyle (MFC) cartilage. A statistically significant relation was found between surgery of the medial meniscus and the development of new cartilage defects in LFC (p = 0.01) and MFC (p = 0.03) after adjusting for the site of meniscal surgery. The cartilage of LFC and the status of the medial meniscus were also found to be significantly related (p = 0.04). Partial meniscectomy was found to be associated with an increased incidence of new cartilage defects when compared to either meniscal repair or absence of meniscal surgery, although it was not statistically significant. CONCLUSION: Development of new cartilage lesions was evident after 2-year follow-up in patients with arthroscopic ACLR as detected by MR imaging. There was a multicompartmental pattern of cartilage involvement, and the lateral compartment was most severely affected. Partial meniscectomy at the time of arthroscopic ACLR could be suggested as an additional risk factor for the progression of chondral lesions. LEVEL OF EVIDENCE: Prospective comparative study, Level II.

An 11- to 15-year clinical outcome study of the Advance Medial Pivot total knee arthroplasty: pivot knee arthroplasty.

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. PATIENTS AND METHODS: We retrospectively evaluated prospectively collected data from 225 consecutive patients (41 men and 184 women; mean age at surgery 71 years, 52 to 84) who underwent 284 TKAs with a mean follow-up of 13.4 years (11 to 15). Implant failure, complication rate, clinical (both subjective and objective) and radiological outcome were assessed. Pre- and post-operative clinical and radiographic data were available at regular intervals for all patients. A total of ten patients (4.4%; ten TKAs) were lost to follow-up. RESULTS: Survival analysis at 15 years showed a cumulative success rate of 97.3% (95% confidence interval (CI) 96.7 to 97.9) for revision for any reason, of 96.4% (95% CI 95.2 to 97.6) for all operations, and 98.8% (95% CI 98.2 to 99.4) for aseptic loosening as an end point. Three TKAs (1.06%) were revised due to aseptic loosening, two (0.7%) due to infection, one (0.35%) due to instability and one (0.35%) due to a traumatic dislocation. All patients showed a statistically significant improvement on the Knee Society Score (p = 0.001), Western Ontario and McMaster University Osteoarthritis Index (p = 0.001), Short Form-12 (p = 0.01), and Oxford Knee Score (p = 0.01). A total of 207 patients (92%) were able to perform age appropriate activities with a mean flexion of the knee of 117° (85° to 135°) at final follow-up. CONCLUSION: This study demonstrates satisfactory functional and radiographic long-term results for this implant. Cite this article: Bone Joint J 2016;98-B:1050-5.

RhBMP-7 for the treatment of nonunion of fractures of long bones.

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.

Digital coverage with flaps from the same or neighboring digits.

OBJECTIVE: Several flaps can be dissected from the same or neighboring digits for the reconstruction of relatively large soft tissue digital defects. MATERIAL AND METHODS: In a 6-year period, 106 large soft tissue digital defects were reconstructed with the use of flaps in 101 patients. For the reconstruction of 75 fingertip defects 73 neurovascular, island or advancement flaps (42 homodigital, 18 heterodigital, 13 advancement) and 2 thenar flaps were used. The 31 defects of the proximal and middle phalanges were reconstructed with 3 intermetacarpal and 28 cross-finger flaps (17 de-epithelialized and 11 classic for dorsal and palmar defects respectively). RESULTS: All flaps survived. Subjectively, the results were rated as good or excellent in 69 of 73 distal defects reconstructed with neurovascular island or advancement flaps and in 29 of 31 proximal defects treated with cross-finger and intermetacarpal flaps. The mean DASH score was 4.1 and 3.34 for the neurovascular island/advancement flaps and the cross-finger flaps respectively. CONCLUSIONS: This study elucidates the indications and presents the advantages and disadvantages of flaps used for reconstruction of proximal and distal digital defects. Good results can be obtained with appropriate flap selection and meticulous surgical technique.

Treatment of intra-articular fractures of the distal radius: fluoroscopic or arthroscopic reduction?

In a randomised prospective study, 20 patients with intra-articular fractures of the distal radius underwent arthroscopically- and fluoroscopically-assisted reduction and external fixation plus percutaneous pinning. Another group of 20 patients with the same fracture characteristics underwent fluoroscopically-assisted reduction alone and external fixation plus percutaneous pinning. The patients were evaluated clinically and radiologically at follow-up of 24 months. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and modified Mayo wrist score were used at 3, 9, 12 and 24 months postoperatively. In the arthroscopically- and fluoroscopically-assisted group, triangular fibrocartilage complex tears were found in 12 patients (60%), complete or incomplete scapholunate ligament tears in nine (45%), and lunotriquetral ligament tears in four (20%). They were treated either arthroscopically or by open operation. Patients who underwent arthroscopically- and fluoroscopically-assisted treatment had significantly better supination, extension and flexion at all time points than those who had fluoroscopically-assisted surgery. The mean DASH scores were similar for both groups at 24 months, whereas the difference in the mean modified Mayo wrist scores remained statistically significant. Although the groups are small, it is clear that the addition of arthroscopy to the fluoroscopically-assisted treatment of intra-articular distal radius fractures improves the outcome. Better treatment of associated intra-articular injuries might also have been a reason for the improved outcome.

Purulent flexor tenosynovitis: factors influencing the functional outcome.

This retrospective study aimed to evaluate the factors that influence the final outcome of treatment of purulent flexor tenosynovitis, viz. delay in treatment, severity of the condition, the infecting pathogen and the method of treatment. Of 41 patients with this condition treated by drainage and irrigation through two small incisions (16) and wide incision (25), 16 were treated after a delay. Continuous postoperative irrigation was applied in 26 patients. Re-operation was necessary in 11 patients. In most cases, Staphylococcus aureus was detected. The results were excellent in 32 cases and the mean Disabilities of the Arm, Shoulder and Hand score was 8.1. Irrigation through small incisions and continuous postoperative irrigation decreased the probability of an unfavourable outcome. Delayed treatment and infections with specific pathogens led to a worse outcome. Early diagnosis of purulent flexor tenosynovitis followed by drainage through small incisions and continuous postoperative irrigation appear, from this retrospective review, to lead to the best functional outcome.

Restoration of function and sensitivity utilizing a homodigital neurovascular island flap after amputation injuries of the fingertip.

Sixty-three fingertip amputations in 50 patients were reconstructed using a homodigital neurovascular island flap technique based on a single neurovascular pedicle without further shortening of the distal phalanx. The procedure was carried out under regional anaesthesia, using a tourniquet and magnifying loupes. All of the flaps survived and achieved normal or adequate two-point discrimination without any painful scar or cold hypersensitivity. Fifteen patients had some loss of distal interphalangeal joint extension. The technique is simple and presents an excellent method for fingertip reconstruction in Allen type II, III and IV injuries.

Three-dimensional computerized selection of hip prostheses in patients with congenital dislocated hips.

This study assessed the effectiveness of the combined use of computed tomography (CT) and computer-aided design (CAD) in the preoperative evaluation and implant selection in 20 patients (20 hips) with congenital dislocation of the hip who were scheduled to undergo total hip arthroplasty. Computerized selection of the femoral implant with optimum fit and fill was made after a three-dimensional reconstruction of the femoral canal using CT data and CAD. Implantation of all sizes of 5 noncemented and 2 cemented femoral implants was simulated using CATIA software (IBM, Kingstone, NY). When patients underwent surgery, 18 of 20 preselected prostheses agreed by type and size with the prostheses implanted. The remaining 2 preselected implants agreed by type only. In patients with dislocated and dysplastic hips, combined use of CT and CAD allows effective preoperative planning by providing the surgeon with vital information about the proximal femoral canal geometry and the possible femoral implant with optimum fit and fill to be used.

Complications in limb-lengthening procedures: a review of 49 cases.

The purpose of this study was to examine the nature and number of complications relative to magnitude of limb lengthening. Results and complications of 50 limb-lengthening procedures were analyzed. There were 49 patients. Mean age was 21 years (range, 7-48 years). Lengthening was performed in 24 femora, 18 tibiae, 4 humerii, 3 radii, and 1 ulna. Average length gained was 5 cm (range, 3-15 cm) at average follow-up of 48 months (range, 12-76 months). Desired length was accomplished in all but 1 patient. The 69 complications varied in severity, but only 5 of these significantly impaired end results. The most serious complications occurred in patients with >30% bone lengthening. Patients with <15% lengthening had a significantly decreased complication rate. The healing index was lower in children. We conclude that incidence and severity of complications after limb-lengthening procedures are significantly influenced by relative lengthening of bone.