The effects of TNF-alpha inhibition on cartilage: a systematic review of preclinical studies.

OBJECTIVE: To report the most up-to-date evidence on the effects of tumour necrosis factor (TNF)-alpha inhibition on cartilage with a focus on its clinical relevance. DESIGN: A systematic review was performed by searching PubMed, Embase and Cochrane Library databases. Inclusion criteria were studies of any level of evidence published in peer-reviewed journals reporting clinical or preclinical results written in English. Relative data were extracted and critically analysed. PRISMA guidelines were applied, and risk of bias was assessed as well as the methodological quality of the included studies. RESULTS: 13 studies were included after applying the inclusion and exclusion criteria. Three were in vitro human studies from osteoarthritis (OA) patients. Ten were animal modal studies including two in vitro studies, and eight in vivo studies. TNF-alpha inhibition in in vitro studies was generally reported beneficial due to the improved osteochondral viability, proliferation and chondrogenesis. In addition, TNF-alpha inhibition was noted to be beneficial in promoting the natural repair of osteochondral lesions and has a chondroprotective effect in in vivo studies. CONCLUSION: Based on current evidence, TNF might have the potential to interfere with the healing process of chondral and osteochondral defects occurring naturally or in low inflammatory environment after a cartilage repair procedure. Therefore, the use of biological agents to inhibit its action in cartilage repair surgery could be beneficial, and this could translate into a promising therapy that improves the outcome of currently available cartilage procedures.

Plaster of Paris-Short History of Casting and Injured Limb Immobilzation.

Various materials have been used since ancient times to help immobilise fractures. In this review, we discuss the history and developments of these materials as well as plaster of Paris. There has been a recent trend away from non-operative management of fractures, and skills in the use of plaster of Paris are declining. For the successful treatment of patients, it is important to appreciate how plaster works, how it should be used, and what can go wrong. In this review, we also discuss principles of applications and complications of plaster of Paris.

Serial Femoral Fractures in An Amputation Stump: A Case Report.

We report a case of an above-knee amputee who underwent dynamic hip screw fixation for a proximal femoral fracture and then open reduction and internal fixation a few years later for a further femoral fracture in the same stump. The patient had a good outcome. We aim to discuss the challenges in decision making, surgical technique and potential complications for the patient.

Biomaterials and Fabrication to Optimise Scaffold Properties for Musculoskeletal Tissue Engineering.

Tissue engineering has emerged as a promising scientific field potentially yielding in vitro developed tissue to replace degenerative or injured tissues in vivo, thus avoiding the donor site morbidity associated with reconstructive surgery. Integral to the process is the role of scaffolds and the biomaterials used to form them. This review explores the concept of scaffold based tissue engineering and design considerations. The scaffold needs to have certain mechanical and architectural properties, it needs to be biocompatible and biodegradable, and allow combination with bioactive molecules. We also discuss scaffolding techniques, different biomaterial options and fabrication technologies, and future areas of development.

Outcome of surgery for chronic patellar tendinopathy: A systematic review.

There is no consensus on how to best surgically treat chronic patellar tendinopathy. This systematic review investigates the surgical treatment for chronic patellar tendinopathy, and the outcomes. A database search was performed to identify all relevant articles, to which exclusion criteria were then applied. Data was extracted from 24 studies, and the outcomes were then systematically reviewed. The results showed that the success rate of surgery for patellar tendinopathy is generally over 77%. Return to sports rates are better for proximal tendon patients who undergo bony procedures. Patients return to sports faster if they undergo arthroscopic procedures, and fewer complications are described. Studies that did not involve any procedure on the proximal tendon did not produce a different result to studies where the tendon was operated on. We found no effect of post-operative immobilisation on outcome. Based on the included studies, surgery gives satisfactory results in the treatment of patellar tendinopathy. There is a lack of high-quality evidence on the effects of surgery and post-operative rehabilitation regime on chronic patellar tendinopathy, as well as lack of objective outcome measures.

First Metatarsalphalangeal Joint Arthrodesis: A Retrospective Comparison of Two Methods of Fixation.

First metatarsalphalangeal joint arthrodesis is a well established and successful treatment; however there still remains controversy over the best choice of construct. We performed a retrospective study of patients undergoing first metatarsalphalangeal fusion over eighteen months (n=52) using either dorsal non-locking plate with additional compression lag screw fixation or dorsal non-locking plate alone. We found when assessing clinical criteria, patients with dorsal non-locking plates and additional compression lag screw fixation had a significantly higher rate of fusion (100% vs 77.8%), significantly higher rate of fusion within the first two months (55.6% vs 83.3%), significantly earlier time to fusion (52.2 days vs 75.6 days), and significantly lower rate of non-union (0% vs 22.2%). When blindly assessing radiographic criteria, the patients treated with the plate and compression screw had a significantly higher rate of fusion and lower rate of non-union (0% vs 33%). There was no statistically significant difference between the frequencies of complications in the groups. We believe that the interfragmentary compression is a crucial factor in achieving good union rates and recommend the use of non-locking pre-contoured plating with additional interfragmentary compression screw as the fixation method of choice for these procedures.

A Literature Review of Total Hip Arthroplasty in Patients with Ankylosing Spondylitis: Perioperative Considerations and Outcome.

Ankylosing spondylitis is a spondyloarthropathy affecting the sacro-iliac joints with subsequent progression to the spine and the hip joints. The hip joints are affected by synovitis, enthesial inflammation, involvement of medullary bone, progressive degeneration and secondary osteoarthritis. Clinical presentation is usually in the form of pain and stiffness progressing to disabling fixed flexion contractures and in some instances, complete ankylosis. Hip arthroplasty should be considered for hip pain, postural and functional disability, or pain in adjacent joints due to hip stiffness. We conducted a literature review to determine peri-operative considerations and outcome in ankylosing spondylitis patients undergoing hip arthroplasty. In this review, we have discussed pre-operative surgical planning, thromboprophylaxis, anaesthetic considerations and heterotopic ossification. Outcomes of arthroplasty include range of movement, pain relief, survivorship and complications.

Current Evidence for the Use of Laminar Flow in Reducing Infection Rates in Total Joint Arthroplasty.

Since the introduction of laminar air flow in orthopaedic theatres by Sir John Charnley, it has widely become accepted as the standard during orthopaedic procedures such as joint arthroplasty. We present a review of available current literature for the use of laminar flow operating theatre ventilation during total joint arthroplasty and examines the effectiveness of laminar flow ventilated operating theatres in preventing post-operative wound infection. Results of our findings suggest that while bacterial and air particulate is reduced by laminar air flow systems, there is no conclusive effect on the reduction of post-operative wound infections following total joint arthroplasty. We conclude that a combination of strict aseptic technique, prophylactic antibiotics and good anaesthetic control during surgery remains crucial to reduce post-operative surgical infections.

Single Stage Knee Arthroplasty Revision Surgery: A Systematic Review of the Literature.

Total Knee Arthroplasty is an increasingly common procedure and revision surgery, particularly for infection, is associated with significant morbidity and healthcare costs. The current gold standard is a two stage revision procedure but single stage revision is increasingly being used in some departments to improve patient outcomes. We conducted a systematic review of the literature to determine the up-to-date evidence underlying the use of a single stage knee approach in revision surgery. A total of 12 studies were included in this review amounting to 433 revision surgeries. This is the largest review of single stage knee revision surgery. The procedures described were heterogenous and included the 'two-in-one' technique as well as other single stage revision procedures. There were also differences in implants and antibiotic regimens. The mean re-infection rates described in 10 studies was 9.4% (range 0-19.2%) after a mean follow-up of 40.3 months (range 7-180 months). The re-infection rates in the studies published over the last 30 years are falling, and this is not accounted for by any significant change in duration of follow-up during this period. The outcome scores varied, but patients generally showed an improvement. The Knee Society Score and the Oxford Knee Score were the most commonly used in five and three studies respectively. We conclude that the current evidence for single stage revision is variable and there is a lack of good quality evidence to address whether single stage revisions is thorough enough to eradicate deep infection and is able to restore adequate function. There is a need for larger prospective studies with standardised procedures and protocol, and with adequate follow-up. Till then, patients considered for a single stage approach should be thoroughly assessed and the surgery should be performed by a senior surgeon with experience in single stage knee revisions.

Impact of Weekend Physiotherapy Service on the Cost Effectiveness of Elective Orthopaedic Hip and Knee Arthroplasty.

We performed a prospective correlational study to evaluate the efficiency and cost effectiveness of weekend physiotherapy in accelerating rehabilitation, reducing hospital stay as well as hospital costs for joint arthroplasty patients in a busy Scottish district general hospital. Patients that underwent elective hip (470) and knee (321) arthroplasty were analysed over a 12 month period. A four month period with weekend physiotherapy provision was arranged to ascertain its effectiveness on the length of stay and the achievement of set physiotherapy milestones. Data collected included length of stay and progression in a defined set of physiotherapy milestones. The relationship between time to discharge, mobilisation with sticks, straight leg raise, 90º knee flexion and cost effectiveness of service were used to determine the correlation, and analysis of the interactions of these factors separately. Our Outcome data demonstrate a statistical significance for the time to mobilisation with two sticks for hip (p=0.0030) and knee (p= 0.0037) arthroplasty patients. There was a trend towards earlier discharge times for all patients receiving weekend physiotherapy, but this was not statistically significant. We conclude that the provision of a continuous programme of weekend physiotherapy for all arthroplasty patients has the potential benefit of a quicker rehabilitation that would results in a cost saving.

Surgical management of the forefoot in patients with rheumatoid arthritis - a review article.

Foot and ankle pathologies cause a significant disease burden on rheumatoid patients. Forefoot pathologies causes pain, callosities and possibly ulceration, and can cause problems with footwear. Forefoot correction in rheumatoid patients has historically comprised of excision of diseased joints. While satisfaction was high with this procedure, complications, changing expectations and improvement in medical therapy have raised expectation of patients, physicians and surgeons alike. This review assesses the role of joint preserving osteotomies and arthrodesis, as well as associated complications. It also describes the role of the multidisciplinary team in the management of these patients.

Perioperative management of cardiac disease.

Pre-existing cardiac disease contributes significantly to morbidity and mortality amongst patients undergoing non cardiac surgery. Patients with pre-existing cardiac disease or with risk factors for it, have as much as a 3.9% risk of suffering a major perioperative cardiac event (Lee et al 1999, Devereaux 2005). Furthermore, the incidence of perioperative myocardial infarction (MI) is increased 10 to 50 fold in patients with previous coronary events (Jassal 2008).

Carpal tunnel syndrome: a review of the recent literature.

Carpal Tunnel Syndrome (CTS) remains a puzzling and disabling condition present in 3.8% of the general population. CTS is the most well-known and frequent form of median nerve entrapment, and accounts for 90% of all entrapment neuropathies. This review aims to provide an overview of this common condition, with an emphasis on the pathophysiology involved in CTS. The clinical presentation and risk factors associated with CTS are discussed in this paper. Also, the various methods of diagnosis are explored; including nerve conduction studies, ultrasound, and magnetic resonance imaging.

Optimising human mesenchymal stem cell numbers for clinical application: a literature review.

Adult mesenchymal stem cells (MSCs) are being investigated further for their use in stem cell therapies. However, as they are found in very low numbers in adult tissue, expansion in vitro is required to produce desired MSC numbers for clinical application. The need for effective cell-based therapies is increasing due to a rise in the ageing population, increasing the prevalence of musculoskeletal disorders. This review investigates how factors, age and gender of donor, as well as seeding density can affect MSC expansion. Age and gender of donor have received mixed results from studies, whereas seeding density studies have produced consistent results for numerous MSC sources, favouring lower seeding densities. Further research is required to reduce the risk of infection, loss of cell characterisation in cell culture, and making cell-based therapies more cost effective through creating rapid expansion of MSCs regardless of patient factors.

The use of the s-quattro dynamic external fixator for the treatment of intra-articular phalangeal fractures: a review of the literature.

Intra-articular phalangeal fractures are a common injury. If left untreated, these injuries can lead to poor functional outcome with severe dehabilitating consequences, especially in younger patients.The S-Quattro external fixator device (Surgicraft®, UK) can be used to treat such injuries. Its use has been widely documented and has shown many advantages in comparison to other conventional treatments. Advantages include reduced operative time, rigid fixation and early range of motion.We present a review of the current literature and use of the S-Quattro serpentine system in the management of intraarticular phalangeal fractures.

Fat pad-derived mesenchymal stem cells as a potential source for cell-based adipose tissue repair strategies.

BACKGROUND: Mesenchymal stem cells are able to undergo adipogenic differentiation and present a possible alternative cell source for regeneration and replacement of adipose tissue. The human infrapatellar fat pad is a promising source of mesenchymal stem cells with many source advantages over from bone marrow. It is important to determine whether a potential mesenchymal stem-cell exhibits tri-lineage differentiation potential and is able to maintain its proliferation potential and cell-surface characterization on expansion in tissue culture. We have previously shown that mesenchymal stem cells derived from the fat pad can undergo chondrogenic and osteogenic differentiation, and we characterized these cells at early passage. In the study described here, proliferation potential and characterization of fat pad-derived mesenchymal stem cells were assessed at higher passages, and cells were allowed to undergo adipogenic differentiation. MATERIALS AND METHODS: Infrapatellar fat pad tissue was obtained from six patients undergoing total knee replacement. Cells isolated were expanded to passage 18 and proliferation rates were measured. Passage 10 and 18 cells were characterized for cell-surface epitopes using a range of markers. Passage 2 cells were allowed to undergo differentiation in adipogenic medium. RESULTS: The cells maintained their population doubling rates up to passage 18. Cells at passage 10 and passage 18 had cell-surface epitope expression similar to other mesenchymal stem cells previously described. By staining it was revealed that they highly expressed CD13, CD29, CD44, CD90 and CD105, and did not express CD34 or CD56, they were also negative for LNGFR and STRO1. 3G5 positive cells were noted in cells from both passages. These fat pad-derived cells had adipogenic differentiation when assessed using gene expression for peroxisome proliferator-activated receptor γ2 and lipoprotein lipase, and oil red O staining. DISCUSSION: These results indicate that the cells maintained their proliferation rate, and continued expressing mesenchymal stem-cell markers and pericyte marker 3G5 at late passages. These results also show that the cells were capable of adipogenic differentiation and thus could be a promising source for regeneration and replacement of adipose tissue in reconstructive surgery.

Ligament tissue engineering and its potential role in anterior cruciate ligament reconstruction.

Tissue engineering is an emerging discipline that combines the principle of science and engineering. It offers an unlimited source of natural tissue substitutes and by using appropriate cells, biomimetic scaffolds, and advanced bioreactors, it is possible that tissue engineering could be implemented in the repair and regeneration of tissue such as bone, cartilage, tendon, and ligament. Whilst repair and regeneration of ligament tissue has been demonstrated in animal studies, further research is needed to improve the biomechanical properties of the engineered ligament if it is to play an important part in the future of human ligament reconstruction surgery. We evaluate the current literature on ligament tissue engineering and its role in anterior cruciate ligament reconstruction.

The potential of stem cells in the treatment of skeletal muscle injury and disease.

Tissue engineering is a pioneering field with huge advances in recent times. These advances are not only in the understanding of how cells can be manipulated but also in potential clinical applications. Thus, tissue engineering, when applied to skeletal muscle cells, is an area of huge prospective benefit to patients with muscle disease/damage. This could include damage to muscle from trauma and include genetic abnormalities, for example, muscular dystrophies. Much of this research thus far has been focused on satellite cells, however, mesenchymal stem cells have more recently come to the fore. In particular, results of trials and further research into their use in heart failure, stress incontinence, and muscular dystrophies are eagerly awaited. Although no doubt, stem cells will have much to offer in the future, the results of further research still limit their use.