Femoral neck shortening in adult patients under the age of 55 years is associated with worse functional outcomes: Analysis of the prospective multi-center study of hip fracture outcomes in China (SHOC)

IntroductionYoung femoral neck fracture patients require surgical fixation to preserve the native hip joint and accommodate increased functional demands. Recent reports have identified a high incidence of fracture shortening and this may have negative functional consequences. We sought to determine if fracture shortening is associated with poor functional outcome in young femoral neck fracture patients.Patients and methodsOne hundred and forty-two patients with femoral neck fractures age 18–55 were recruited in this prospective cohort study across three Level 1 trauma hospitals in Mainland China. Patient-reported and objective functional outcomes were measured with the Harris Hip Score (HHS), Timed Up and Go (TUG), and SF-36 Physical Component Summary (SF-36 PCS) at 12 months. Radiographic fracture shortening was measured along the long axis of the femoral neck and corrected for magnification. Severe shortening was defined as ≥10 mm. The primary analysis measured associations between severe radiographic shortening and HHS at one-year post-fixation.ResultsOne hundred and two patients had complete radiographic and functional outcomes available for analysis at one year. The mean age of participants was 43.7 ± 10.8 years and 53% were male. Fifty-five percent of fractures were displaced and 37% were vertically orientated (Pauwels Type 3). The mean functional outcome scores were: HHS 90.0 ± 10.8, TUG 12.0 ± 5.1 s, and PCS 48.5 ± 8.6. Severe shortening occurred in 13% of patients and was associated with worse functional outcome scores: HHS mean difference 9.9 (p = 0.025), TUG mean difference 3.2 s (p = 0.082), and PCS mean difference 5.4 (p = 0.055).ConclusionsSevere shortening is associated with clinically important decreases in functional outcome as measured by HHS following fixation of young femoral neck fractures, occurring in 13% of patients in this population. The principle of fracture site compression utilized by modern constructs may promote healing; however, excessive shortening is associated with worse patient-reported outcomes and objective functional measures.     

Individuals with high bone mass have an increased prevalence of radiographic knee osteoarthritis

We previously reported an association between high bone mass (HBM) and a bone-forming phenotype of radiographic hip osteoarthritis (OA). As knee and hip OA have distinct risk factors, in this study we aimed to determine (i) whether HBM is also associated with knee OA, and (ii) whether the HBM knee OA phenotype demonstrates a similar pattern of radiographic features to that observed at the hip.HBM cases (defined by DXA BMD Z-scores) from the UK-based HBM study were compared with unaffected family controls and general population controls from the Chingford and Hertfordshire cohort studies. A single blinded observer graded AP weight-bearing knee radiographs for features of OA (Kellgren–Lawrence score, osteophytes, joint space narrowing (JSN), sclerosis) using an atlas. Analyses used logistic regression, adjusting a priori for age and gender, and additionally for BMI as a potential mediator of the HBM–OA association, using Stata v12.609 HBM knees in 311 cases (mean age 60.8 years, 74% female) and 1937 control knees in 991 controls (63.4 years, 81% female) were analysed. The prevalence of radiographic knee OA, defined as Kellgren–Lawrence grade ≥ 2, was increased in cases (31.5% vs. 20.9%), with age and gender adjusted OR [95% CI] 2.38 [1.81, 3.14], p < 0.001. The association between HBM and osteophytosis was stronger than that for JSN, both before and after adjustment for BMI which attenuated the ORs for knee OA and osteophytes in cases vs. controls by approximately 50%.Our findings support a positive association between HBM and knee OA. This association was strongest for osteophytes, suggesting HBM confers a general predisposition to a subtype of OA characterised by increased bone formation.     

Threshold for lateral meniscal body extrusion on MRI in middle-aged and elderly patients with symptomatic knee osteoarthritis

PurposeTo determine the MRI-based threshold of lateral meniscal body extrusion (LMBE) that are associated with meniscal damage, cartilage damage and radiological knee osteoarthritis (OA).Materials and methodsA total of 142 patients (59 men and 83 women) with a mean age of 57.2 ± 7.9 (SD) years (range: 41–77 years) with symptomatic knee OA were included. Radiological assessment was performed using the Kellgren-Lawrence scoring system. Meniscus and cartilage damage were assessed using the whole-organ magnetic resonance imaging score. Meniscal extrusion was quantified on coronal sections of intermediate-weighted MRI sequences. Differences between medial and lateral compartments in meniscal extrusion and incidence of tibiofemoral OA-related structural changes were assessed using Wilcoxon signed rank test and Bowker test. Receiver operating characteristic curves and Youden index were used for determining thresholds for meniscal extrusion.ResultsA total of 142 knees were assessed. Meniscal body extrusion distances between medial and lateral compartments were significantly different in the entire sample, and in subjects with and without radiological knee OA (P < 0.05 for all). The incidence of structural changes between medial and lateral compartments were significantly different (P = 0.003 for meniscal damage; P = 0.001 for femoral cartilage damage). Three mm and 2 mm were determined to be the optimal thresholds for medial and lateral meniscal body extrusion, respectively.ConclusionMedial and lateral meniscal body extrusion were associated with the incidence of OA-related knee structural changes in symptomatic patients with knee OA. A threshold of 2 mm for LMBE with respect to meniscal damage, cartilage damage and radiological knee OA was determined.     

How are clinical outcomes related to the deviation severity of the tibiofemoral mechanical axis on coronal plane following knee arthroplasty?

ObjectiveTo analyze the effect of tibiofemoral mechanical axis (TFMA) deviation severity on clinical outcomes after total knee arthroplasty (TKA).MethodsWe retrospectively reviewed the patients who underwent primary TKA between January 2002 and December 2010. After applying inclusion/exclusion criteria, we evaluated 70 knees of 51 patients. The mean ± SD follow-up period was 7.08 ± 1.34 years. The knees were divided into 3 groups based on TFMAs. The first group, identified as “well aligned,” included the TFMAs that were neutral within 3° (0° ± 3°) of alignment. The second group, identified as “outliers 1,” included the slightly deviated TFMAs (−3° to −6° valgus and +3° to +6° varus). The third group, identified as “outliers 2,” included the severely deviated TFMAs of more than 6° from neutral alignment (<−6° valgus and > + 6° varus). The clinical outcomes of each group were compared by evaluating the Oxford Knee Score (OKS), visual analog scale (VAS), and Short Form-36 physical component summary (SF-36 PCS) and mental component summary (SF-36 MCS) scores.ResultsWe found that OKS, SF-36 PCS, and SF-36 MCS were nearly the same in the well-aligned and outliers 1 groups but worse in the outliers 2 group. VAS scores were nearly the same in all groups. (p > 0.05)ConclusionFunction scores were impaired when the TFMA deviated more than 6° from neutral. However, the differences in clinical outcomes between well-aligned knees and those of outliers were not found to be statistically significant in the medium term.     

The impact of residual angulation on patient reported functional outcome scores after non-operative treatment for humeral shaft fractures

PurposeTo determine if residual angular deformity following non-operative treatment of humeral diaphyseal fractures correlates with patient reported outcomes.MethodsSkeletally mature patients treated by one of three orthopaedic trauma surgeons at a level 1 trauma centre with humeral shaft fractures treated without surgery were retrospectively identified over a 7 year period. After inclusion and exclusion criteria, 42 patients were eligible for the study. Disabilities of the Arm, Shoulder, and Hand (DASH); Simple Shoulder Test (SST); General health questionnaire SF-12 physical component summary (SF-12 PCS) and mental component summary (SF-12 MCS) were obtained from study participants. Healed angular deformity was obtained from patient charts.ResultsThirty two subjects were successfully recruited (32/42 or 76%). Average age was 45 ± 22 with average study follow up being 47 ± 29 months. Average outcome scores were DASH 12 ± 16, SST 10 ± 2.7, SF-12 PCS 50 ± 7.9, and SF-12 MCS 54 ± 8.8. Healed sagittal plane deformity averaged 8 ± 5.7° [range 0−18], and 15 ± 7.9° [range 2−27] in the coronal plane. There was no correlation between residual sagittal or coronal plane deformity and outcome scores (DASH and SST for both p > 0.05). Patients with at least 20° (n = 7; 22%) of healed coronal deformity had similar outcomes to those with <20° ([DASH (13.2 ± 18.7 vs 11.7 ± 16.1; p = 0.83]; [SST (10.3 ± 2 vs 10.0 ± 2.9; p = 0.81]). Higher SF-12 PCS and MCS scores correlated with better DASH and SST scores (p < 0.05 for all).ConclusionResidual angular deformity ranging from 0 to 18° in the sagittal plane and from 2 to 27° in the coronal plane after non-operative treatment for humeral shaft fractures had no correlation with patient reported DASH scores, SST scores, or patient satisfaction. Instead, overall physical and mental health status as measured by the SF-12 significantly correlated with patient reported outcomes.     

Femoral nerve block in a representative sample of elderly people with hip fracture: A randomised controlled trial

IntroductionThe number of elderly people with hip fracture and dementia is increasing, and many of these patients suffer from pain. Opioids are difficult to adjust and side effects are common, especially with increased age and among patients with dementia. Preoperative femoral nerve block is an alternative pain treatment.AimTo investigate whether preoperative femoral nerve block reduced acute pain and opioid use after hip fracture among elderly patients, including those with dementia.Patients and methodsIn this randomised controlled trial involving patients aged ≥70 years with hip fracture (trochanteric and cervical), including those with dementia, we compared femoral nerve block with conventional pain management, with opioid use if required. The primary outcome was preoperative pain, measured at five timepoints using a visual analogue scale (VAS). Preoperative opioid consumption was also registered.ResultsThe study sample comprised 266 patients admitted consecutively to the Orthopaedic Ward. The mean age was 84.1 (±6.9) years, 64% of participants were women, 44% lived in residential care facilities, and 120 (45.1%) had dementia diagnoses. Patients receiving femoral nerve block had significantly lower self-rated pain scores from baseline to 12 h after admission than did controls. Self-rated and proxy VAS pain scores decreased significantly in these patients from baseline to 12 h compared with controls (p < 0.001 and p = 0.003, respectively). Patients receiving femoral nerve block required less opioids than did controls, overall (2.3 ± 4.0 vs. 5.7 ± 5.2 mg, p < 0.001) and in the subgroup with dementia (2.1 ± 3.3 vs. 5.8 ± 5.0 mg, p < 0.001).ConclusionPatients with hip fracture, including those with dementia, who received femoral nerve block had lower pain scores and required less opioids before surgery compared with those receiving conventional pain management. Femoral nerve block seems to be a feasible pain treatment for elderly people, including those with dementia.     

Association of serum levels of aggrecan ARGS,NITEGE fragments and radiologic knee osteoarthritis in Tunisian patients

ObjectivesProteolytic degradation of aggrecan is a hallmark of the pathology of osteoarthritis. The aim of this study was to develop enzyme-linked immunosorbent assay (ELISA) to quantify the serum levels of specific aggrecan fragments generated by aggrecanases-mediated cleavage. We investigated the relationships between these two aggrecan degradations fragments and urinary CTX-II levels.MethodsThe competitive ELISAs employ a polyclonal antibody raised against the aggrecan fragments containing two neoepitopes NITEGE³⁷³ and ³⁷⁴ARGSVI. We measured serum levels of ARGSV and NITEGE in 125 women with knee osteoarthritis (mean ± SD age of 53.6 ± 7.6 years, mean ± SD disease duration of 3.6 ± 3.8 years), and 57 women age-matched controls.ResultsAggrecan neoepitopes assays showed an intra- and inter-assay imprecision (CV) lower than 20% for both tests and good linearity. Median serum ARGSVI (by 18%; P = 0.002), and NITEGE (36.4%; P < 0.001) levels were significantly decreased in patients with knee osteoarthritis compared with controls. Minimal joint space width was negatively correlated with ARGSVI (r = –0.368, P = 0.04) and NITEGE (r = –0.274, P = 0.038) in knee osteoarthritis patients. Median urinary CTX-II levels were significantly increased by 39.5% (P = 0.001) in knee OA patients compared with controls.ConclusionMarkers of degradation aggrecan were analyzed for the first time in an African osteoarthritis population. These markers can be used to monitor aggrecanase activity in human joint disease. Their combination with CTX-II can improve clinical investigation of patients with osteoarthritis patients.     

Differential articular calcified cartilage and subchondral bone in postmenopausal women with osteoarthritis and osteoporosis: Two-dimensional analysis

ObjectivesOsteoarthritis (OA) and osteoporosis (OP) are both common problems that affect life quality in aging society. It has been for decades of years to debate an inverse relationship between OA and OP. The objective of this paper was to compare structural properties of the articular calcified cartilage (ACC) and subchondral bone between postmenopausal women with OA and OP.MethodsEight femoral heads were taken from postmenopausal women during total hip replacement surgery due to primary OA. They were compared with nine femoral heads obtained from age-matched women with OP during hemi-hip arthroplasty surgery due to osteoporotic fracture of the proximal femur. Two-dimensional histomorphometric sections were prepared to measure the thickness of ACC and bone histomorphometric parameters. The ratio of ACC to the total articular cartilage (TAC) was also calculated in all bone specimens.ResultsOsteoarthritic donors had higher ACC and the ratio of ACC to TAC (ACC: 117.69 ± 28.16 μm vs. 97.88 ± 16.79 μm, P = 0.041; the ratio of ACC to TAC: 15.74% vs. 10.51%, P = 0.023). Lower bone volume fraction (BV/TV), trabecular thickness (Tb.Th), trabecular number (Tb.N) and the ratio of nodes to termini (Nd/Tm) were demonstrated in donors with OP (BV/TV: 21.55 ± 3.41% vs. 16.64 ± 2.26%, P = 0.003; Tb.Th: 121.33 ± 16.11 μm vs. 98.59 ± 18.56 μm, P = 0.017; Tb.N: 2.41 ± 0.73 mm^?1 vs. 1.37 ± 0.31 mm^?1, P = 0.001; Nd/Tm: 0.78 ± 0.22 vs. 0.50 ± 0.14, P = 0.007). However, trabecular space (Tb.Sp) increased in these osteoporotic patients (Tb.Sp: 345.49 ± 106.18 μm vs. 652.09 ± 159.71 μm, P = 0.0004).ConclusionsThe pathogenesis of OA and OP were influenced by differential properties of ACC and subchondral bone microstructure. Structural properties of the subchondral mineralized tissue supported that an inverse relationship existed between postmenopausal women with OA and OP.     

Impact of the ankylosing spondylitis on the professional activity

Purpose of the studyAnkylosing spondylitis (AS) is a chronic inflammatory disease affecting axial skeleton, occurring in young and active patients and often condition their professional prospects.ObjectivesTo describe the social and occupational characteristics of patients affected by AS, to estimate the impact of the disease on their professional activity and to determine factors exposing to elevated risk of premature withdrawal from the labor force.MethodsWe had performed a cross-sectional study of 103 patients with AS recruited during 2 years (2005–2007) at the Department of Rheumatology, fulfilling the modified criteria of New York. Demographic, social and professional characteristics were determinated and some disease-specific instruments: BASDAI, BASFI, BASMI, BASG-s, BASRI, as well as an indicator of quality of life: the Short Form Survey-36 (SF-36).ResultsIt is about 88 man and 15 women, the average age is 37.6 years ± 11.7 (18–59 years). Seventy percent of patients live in urban zone and 17% have an educational level superior to 13 years. The disease duration is on average of 11.2 ± 9.6 years. The mean score of BASFI is 45.5 ± 27.5 (7–100), the mean score of BASDAI is 45.9 ± 22.4 (9–100), the mean score of BASG-s is 53.8 ± 21.2, the mean score of BASMI is of 4.4 ± 2.2 (3–10), the mean score of BASRI is 8.4 ± 3.5 (2–16). Among these patients 95 (92%) are eligible to a professional activity (aged between 18 and 65 years and having ended their studies or vocational training). The global unemployment rate is 25.3%, that's attributed to the disease is 20.6%. Some factors are associated with high risk of work withdrawal: female gender (p = 0.0005), low educational level (p = 0.02), living in rural zone (p = 0.028), manual labor (p = 0.038), cold exposing in work place (p = 0.006), high work time a week (p = 0.02) and the absence of colleague help (p = 0.001). For the specific disease indexes, high risk of withdrawal is correlated with high scores of BASFI (p = 0.00002), BASDAI (p = 0.044), BAS-Gs (p = 0.0005) and BASMI (0.0000). Concerning the SF-36, only the item of physical activity is more significantly altered in patient's having stopped their work.ConclusionSeveral factors are identified to be associated to a high risk of premature working withdrawal in patients affected by AS. Prevention of this risk needs an early diagnosis and treatment of the disease, a vocational guidance, work preliminary training and eventually professional redeployment.     

Is there any place for the variable angle proximal femoral plate? A case matched cohort study against the Dynamic Hip Screw system

IntroductionThe Variable angle Martin Plate (MP) is designed to offer patient-specific adaption for the treatment of intertrochanteric hip fractures. Its proposed benefits include optimization of lag screw placement, plate shaft congruence and reduced risk of failure. Often its use has been criticized as representing a poor reduction of the fracture. The purpose of this study was to assess for a poorer quality of reduction, and compare functional outcomes and mortality, using a MP to that of a fixed angle Dynamic Hip Screw (DHS) in a matched cohort of patients.MethodsA retrospective review of a prospective fracture database system was undertaken between 1st January 2004 to 31st December 2013. MP patients were matched to a cohort of DHS patients. Outcomes measure were a quality of procedure score(QPS), 1-year mortality rates, reoperation rates, and Barthel Index functional outcome. Minimum follow up was 12 months.ResultsA total of 77 Martin Plate patients were identified and case matched. The mean pre- and post-op Neck Shaft Angle (NSA) in the MPs was significantly different (132.97 ± 7.78 Vs 126 ± 8.62; p < 0.0001). Conversely, the mean pre op DHS NSA and the mean post op NSA was not (p = 0.397). Mean Tip-Apex Distance (TAD) was significantly different between groups; MP mean 26.51 ± 9.09 mm vs DHS 23.50 ± 8.14 mm (p = 0.023). The QPS consisted of 4 variables. A significant inverse relationship between QPS and the incidence of construct related complications exists. TAD > 25 mm, and a change in AP NSA of >5°conveyed the greatest risk of complications. No difference occurred in complications, nor 12-month mortality.ConclusionsNo statistical difference was found in the quality of reduction between MP and DHS in this group of matched patients. QPS demonstrated a significant inverse correlation with implant-related complications. No significant difference was noted in the incidence of complications, Barthel Index functional scores, or 12-month mortality between implants.A rationale exists regarding the use of MPs, particularly in patients with varus NSA. However, planning and adequate reduction are essential regardless of implant choice.     

Does restoration of leg length and femoral offset play a role in functional outcome one year after hip hemiarthroplasty?

BackgroundThe objective of this study was to evaluate the correlation between specific joint biomechanical parameters and 1 year functional outcome scores in elderly patients receiving hemiarthroplasty in the setting of intracapsular hip fractures.MethodsThis is a retrospective, institutional registry based study. 168 hip hemarthroplasties were captured from October 2013 to June 2015. Patients were excluded based on contralateral hip surgery, perioperative complications or inadequate radiographs. 84 patients were alive at one year follow up. We compared mobility and pain scores to radiographically determined variations of leg lengths and femoral offset. We also compared the performance of fellowship trained arthroplasty surgeons to their non-fellowship trained counterparts.ResultsThe operated leg was a mean of 1.12 ± 6.8 mm longer than the contralateral. leg length discrepancy (LLD) was less than 10 mm in 72 patients. Mean difference in offset between limbs was 0.25 ± 3.3 mm. The difference was within 5 mm in 79 patients (94%). We found no statistically significant correlation between mobility or pain scores and variations in leg length or offset. We found significantly better performance of the arthroplasty surgeons in restoring leg length but no difference in offset reconstruction or functional benefit for the patient.ConclusionsOur study was unable to demonstrate a significant relationship between leg length or femoral offset restoration and the patient’s ultimate functional recovery. Arthroplasty surgeons performed better in restoring leg length, but no associated functional advantage was seen.     

Patient satisfaction after open reduction and internal fixation through lateral extensile approach in displaced intraarticular calcaneal fractures (Sander's type II and III)

AimTo determine patient satisfaction in the patients of displaced intraarticular calcaneal fractures treated with standard lateral approach.MethodThe patients of displaced calcaneal fractures (Sander's type II and III) treated between March 2009 and March 2012 were included in the retrospective review and functional outcome was evaluated using American Orthopaedic Foot and Ankle Society (AOFAS) hind foot score, Creighton Nebraska Health Foundation Assessment (CNHFA) scale and foot function index (FFI).ResultThe cohort included 26 patients (19 males: seven were females) with a mean age of 38.16 ± 13.53 years (range 18–64 years). The mean period of follow-up was 24.42 ± 6.68 months. The patients achieved good functional scores after anatomical reduction of the fracture. The complication rate was low following strict inclusion criteria.ConclusionCareful patient selection in displaced intraarticular calcaneal fractures treated through lateral extensile approach achieves good patient satisfaction.     

Clinical outcomes comparing arthroscopic vs open ankle arthrodesis

BackgroundOver the last twenty years, minimally invasive ankle arthrodesis has evolved into a well-tolerated and safe procedure. It has grown in favor to open ankle arthrodesis due to shorter length of stay and fewer complications recorded. This paper aims to compare the clinical outcomes of arthroscopic vs open ankle arthrodesis at 24-months followup.MethodsFrom 2004 to 2015, we reviewed a prospectively collected database in a tertiary hospital foot and ankle registry. 28 feet that underwent arthroscopic ankle arthrodesis were matched to 56 feet that underwent open ankle arthrodesis for age, sex and body mass index (BMI). Visual analogue scale (VAS) scores, American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-hindfoot Scores and Short Form Health Survey (SF-36) were obtained to assess clinical outcomes. These parameters were collected before surgery, at 6 months and 24 months after surgery.ResultsThe arthroscopic group demonstrated significant less pain in the perioperative period (arthroscopic: 1.9 ± 1.2, open: 3.8 ± 1.1, p < 0.001) and shorter length of hospitalization stay (arthroscopic: 2.1 ± 0.7 open: 3.5 ± 1.7, p < 0.001). Patients who underwent arthroscopic ankle arthrodesis also reported a higher SF-36 score on physical functioning at 6 months (arthroscopic: 58.4 ± 27.1, open: 47.1 ± 24.0, p < 0.05) and higher AOFAS Ankle-hindfoot Scale score at 24-months (arthroscopic: 78.9 ± 18.9, open: 68.9 ± 24.7, p < 0.05). There were no postoperative complications in the arthroscopic group but 11 in the open group, including 9 which required followup operations. There was no significant difference in length of operative procedure between both groups.ConclusionsWe conclude that the arthroscopic group displayed better clinical outcomes compared to the open group at the 24 months followup. The advantages of arthroscopic ankle arthrodesis include significantly less perioperative pain, higher AOFAS Ankle-hindfoot scores at 24 months, shorter length of stay, fewer postoperative complications and followup operations.Level of evidenceLevel III, retrospective comparative series.     

Bone mass and anthropometry in patients with osteoarthritis of the foot and ankle

BackgroundPatients with hip and knee osteoarthritis (OA) have high bone mineral density (BMD) and high BMI. If the same accounts for patients with foot or ankle OA is unknown.MethodsWe measured BMD and femoral neck (FN) width by dual-energy X-ray absorptiometry in 42 women and 19 men with idiopathic OA in the foot or ankle, and in 99 women and 82 men as controls.ResultsWomen with OA had significant higher BMI than controls. Women with OA had higher BMI-adjusted BMD (p < 0.01) and smaller BMI-adjusted FN width (p < 0.01) than controls. Men with OA had higher BMI adjusted-BMD (p < 0.05) and smaller BMI-adjusted FN width (p < 0.01) than controls.ConclusionPatients with OA in the foot or ankle have higher BMD and smaller bone size than being expected by their BMI. This phenotype may provide unfavourable forces across the joint and is hypothetically important for development of OA.     

Long-term follow-up evaluation of autologous chondrocyte implantation for symptomatic cartilage lesions of the knee: A single-centre prospective study

IntroductionAutologous Chondrocyte Implantation (ACI) has been the first technique in reconstruction of a valid articular surface. The aim of this study was to evaluate clinical results of this technique at an average follow up of 162 ± 27 months (range 88–208) in a group of patients who underwent ACI.Materials and methods32 patients were operated between 1997 and 2007 for chondral lesions or osteochondritis dissecans of the knee. Mean size of the defect was 5.48 cm² ± 1.53 (range 2–9). Nine patients were treated with I generation technique and 23 with II generation. All patients were evaluated with Subjective IKDC and Tegner Activity Scales for clinical outcomes and with EQ-VAS for a quantitative measure of health after intervention, starting from pre-operative period and at regular follow up (minimum 88 months-maximum 208 months).ResultsA significant increment of all scores was noticed comparing preoperative and postoperative results. In particular medium IKDC score increased from 40.3 ± 9.6 in preoperative evaluation to 74.2 ± 11.6 at one year (p < 0.00001) and to 83.9 ± 10.4 at 5 years follow up (p < 0.001). Mean IKDC values at the last follow-up were 80.3 ± 14.2, showing no statistical differences with those obtained at five-year follow-up. Tegner Activity Scale values increased from 2.8 ± 1.1 preoperatively to 4.1 ± 1.1 (p < 0.0001) after one year and to 6 ± 1.1 at five years (p < 0.0001). Mean Tegner Activity Scale values decreased to 4.8 ± 1.4 at the last follow-up. EQ-VAS evaluation showed superposable results comparing the 5 years evaluation with the ones at a medium follow up of 162 ± 27 months.DiscussionThe most important finding is the reliability at long-term of ACI technique, which in our series gave excellent clinical results. No statistical differences were observed between first- and second-generation. Clinical outcomes were significantly better for defects in the femoral condyles, influenced by age (worse results over 30 years old).ConclusionsACI represents a valid technique for chondral and osteochondral lesions of the knee in a population heterogeneous for age, sex and activity level with good results even at a long term follow up.     

Synergism of a natural plant product,oleanolic acid with calcineurin inhibitor in prolonging islet allograft survival

BackgroundOleanolic acid (OA) is a natural plant-derived triterpenoid with potent anti-inflammatory properties. Since inflammatory cytokines released following islet transplantation hinders engraftment and long-term function, we determined the synergistic ability of OA to with Cyclosporine-A (CSA), a calcineurin inhibitor in improving islet allograft's function and survival.MethodsC57BL/6 mice were rendered diabetic using streptozotocin (200 mg/kg). BALB/c islets were transplanted under the kidney capsule alone (control) or along with administration of OA alone, CSA alone or a combination of both OA and CSA (OA + CSA). T-cell infiltration was analyzed by immunohistochemistry; cytokine concentration was analyzed by Luminex; T-cell cytokine phenotype was analyzed by ELISpot; and alloimmune response was analyzed by flow cytometry.ResultsOA + CSA markedly prolonged islet allograft survival compared to controls (37 ± 5 days vs. 8 ± 3 days). A significant decrease of CD4 + (34 ± 9 vs. 154 ± 42 cells/hpf) and CD8 + T-cellular (46 ± 22 vs. 224 ± 51 cells/hpf, p < 0.0001) infiltration into the graft in OA + CSA treated mice compared to controls. A significant decrease in T cell infiltration was demonstrated in the OA + CSA cohort over either compound application individually. An increase in anti-inflammatory molecules, IL-10 (2.4-fold) and vascular endothelial growth factor (1.6-fold), along with decreased pro-inflammatory cytokines IFN-γ, IL-1β (1.3–2.4-fold) and IL-17 (3.2-fold) was demonstrated. OA + CSA also significantly decreased the frequency of allo-specific T-cell responses. Development of antibodies against donor antigens was also delayed (39 vs 22 days; p < 0.05) in the OA + CSA cohort over administration of either agent individually.ConclusionsOA and CSA exert synergistic effect towards enhancing islet allograft survival and function. This synergistic effect resulted in markedly reduced graft infiltrating cells with attenuation of inflammatory cytokine milieu leading to impairment of both cellular and humoral alloimmune responses. Therefore, novel therapeutic approaches involving combination of OA with calcineurin-inhibitor based immunosuppressant CSA will produce potential beneficial outcomes in clinical islet transplantation.     

Minimally invasive distal metaphyseal metatarsal osteotomy (DMMO) for symptomatic forefoot pathology – Short to medium term outcomes from a retrospective case series

BackgroundMinimally invasive distal metaphyseal metatarsal osteotomy (DMMO) may be used to treat metatarsalgia and forefoot pathology. Few large series report its results or examine the degree of metatarsal shortening with this technique. The clinical and radiographic results of a cohort of patients treated with DMMOs at our unit are reported.MethodsThis was a single-centre retrospective study looking at the outcome of consecutive patients undergoing DMMOs. Demographics, radiological and clinical outcomes, complications and patient reported outcome measures (PROMs) were analysed.ResultsDMMOs on 106 toes in 43 feet were included. Mean age was 60.2 ± 10.2 years and median follow-up was 38 months. Concurrent procedures were performed in 26 cases (60%). DMMO was performed on multiple toes in 42 cases (97%). Mean shortening achieved was 3.6 ± 2.2 mm, 4.1 ± 1.6 mm, and 3.6 ± 1.6 mm for the second, third and fourth metatarsals respectively. Mean time to fusion was 11.4 ± 7.8 weeks and union occurred in 105 toes (99%). The single non-union was asymptomatic at 12 months. Two patients required a subsequent additional DMMO for transfer metatarsalgia. Minor complications were seen in 11 patients (26%). At final follow-up PROMs data was available for 42 cases: mean MOxFQ was 28.8 ± 27.6, mean EQ-5D was 0.789 ± 0.225, mean EQ-VAS was 68.5 ± 20.3, mean VAS-Pain score was 3.1 ± 2.8, and patients were satisfied overall in 40 cases (95%).ConclusionsThe authors demonstrate excellent radiological and clinical outcomes in the short to medium term with DMMOs and present data on metatarsal shortening achieved with this technique.     

The treatment strategies of intertrochanteric fractures nonunion: An experience of 23 nonunion patients

BackgroundIntertrochanteric femoral fractures are common, but the nonunion of intertrochanteric fractures is not. The purpose of this study was to divide intertrochanteric fracture nonunion into different types and give corresponding treatment strategies.MethodsWe retrospectively evaluated 23 patients with intertrochanteric fracture nonunion. The patients were divided into five groups and each group was treated with a different strategy. All patients had staged clinical and radiographic follow-ups and the mean follow-up was 16.0 ± 4.6 months.ResultsExcept for the patients treated with total hip arthroplasty, all patients achieved fracture union. The mean union time was 4.7 ± 1.2 months. The Harris hip function score differed significantly from preoperative (28.9 ± 6.8) to postoperative (83.8 ± 6.3; p < 0.05). For the three patients who were classified as type III, the femoral neck shaft angle was corrected to a significant degree, from 97.3 ± 6.4 to 127.3 ± 2.5 (p < 0.05). For the four patients who were classified as type V, the mean time from debridement to re-internal fixation was 3.7 ± 1.5 months.ConclusionsThere are several factors associated with the failure of intertrochanteric fracture treatments. We need to analyze the causes of fracture treatment failure carefully. Based on our five classifications and corresponding treatment strategies, the radiographic and functional treatment outcomes were satisfactory. Future larger comparative studies are needed to confirm our results.     

The frailty tipping point: Determining which patients are targets for intervention in a burn population

ObjectiveElderly burn patients vary in physiologic age and frailty. While previous evidence suggests that frailty on admission is associated with poor outcomes, changes in frailty during hospitalization for a burn injury have not been reported.MethodsWe performed a two-year retrospective review of all elderly (≥65 years) burn-patients admitted to our burn center. Patients who died during admission were excluded. Data collected include: demographics, injury characteristics, outcomes, and discharge disposition. Canadian Study on Health and Aging Clinical Frailty Scores (CFS) were calculated on admission and at discharge. Change in frailty was calculated for each patient. Mean values are represented as mean ± standard deviation, median values are represented as median (IQR).ResultsSeventy-nine patients, mean age of 75 ± 8 years, with a mean admission CFS was 4.3 ± 1.2 and discharge CFS was 5.1 ± 1.2 were included in the study. The mean change in CFS was −0.55 ± 0.93. Forty-six patients (59%) had no change or an improvement in frailty during hospitalization while 32 (41%) had worsened CFS at discharge. Patients whose CFS was worse at discharge had larger burns (12.8 ± 10.7% vs. 6.28 ± 5.7%), lower admission CFS (3.88 ± 1.5 vs. 4.93 ± 1.0), and longer ICU stays (15.6 ± 18.9 vs. 7.64 ±  10.6 days) than patients without change in CFS. On multivariate regression analysis TBSA (OR 1.2 (1.07–1.3)) and admission CFS of 1–4 (OR 7.9 (2.2–28)) were significant predictors of worsened CFS at discharge.ConclusionsIn our study population, patients with low admission frailty scores are at greatest risk for worsened frailty at discharge and should be targeted for the development of future frailty prevention programs.