Laser-assisted chondroplasty

Laser-assisted chondroplasty is a controversial issue in arthroscopy. Some preliminary research has demonstrated that laser energy can stimulate DNA synthesis and matrix production in articular cartilage. Other studies cite the dangers of thermal energy with laser use on articular cartilage. Commonly used lasers and their current research are discussed in this chapter. It is unclear whether or not the laser will remain in the arthroscopists' arsenal for chondroplasty, and further research is warranted.

Thermal energy in arthroscopic surgery of the wrist

Thermal energy in arthroscopic surgery needs further follow-up evaluation to clarify the potential benefits, specifically with respect to thermal shrinkage. Although the initial findings are promising, the long-term results need to be compared with other accepted standards of management. Preliminary findings seem to show that the addition of these surgical instruments and expanding operative techniques have definite roles in arthroscopic wrist surgery, as demonstrated through meticulous synovectomies and precise tissue debridement, along with the possible thermal shrinkage potential.

Histomorphometric analysis of a cell-based model of cartilage repair

This study examined the morphology of chondrocytes in an established model of articular cartilage repair. Articular cartilage was harvested from young sheep and seeded onto pieces of devitalized sheep cartilage. The seeded pieces were stacked in pairs and wrapped in fibrin glue, and then implanted subcutaneously in the dorsum of athymic mice. Samples were harvested after 6 weeks and examined by transmission electron microscopy (TEM) or by light microscopy. TEM revealed that the cells in direct apposition to the devitalized cartilage were elongated, with an enlarged cytoplasm, and a ruffled border. TEM of cells far from the interface with scaffold tissue revealed rounded cells with large nuclei that appeared similar to normal chondrocytes. Quantitative morphometry of histologic specimens revealed that cell area, relative amount of cytoplasm, cell aspect ratio, and relative nuclear displacement were all higher in cells near the interface with the scaffold tissue, and decreased with distance from the interface. These indices of cell morphology are all consistent with an active remodeling of the scaffold at the cell-scaffold interface.

Magnetic resonance imaging of pediatric musculoskeletal trauma

Musculoskeletal injury in children is common and can lead to lifelong disability. The unique ability of magnetic resonance imaging (MRI) to visualize the cartilaginous ends of growing bones, bone marrow, and supporting soft-tissue structures makes it ideally suited for evaluation of injury in these patients and the complicating growth disturbance. This article reviews the role of MRI in several common pediatric musculoskeletal injuries and their related growth disturbances. A review of normal musculoskeletal growth and enchondral ossification and the magnetic resonance signal characteristics of the growing skeleton is provided as necessary background. The discussion includes MRI features of physeal fractures and posttraumatic growth arrest, epiphyseal and osteochondral injuries, stress fractures, avulsion injuries, and musculoskeletal soft-tissue injuries.

Seat belt-related chondrosternal disruption with lung herniation

A case of blunt chest trauma resulting in anterior chondrosternal separation with right lung herniation and hemothorax is presented. The injury is related to the use of a seat belt restraint. The patient underwent surgical repair with polytetrafluoroethylene chest wall reconstruction. Postoperative recovery was complicated by respiratory insufficiency due to underlying pulmonary contusion and multiple rib fractures.

Management of avulsive injuries of the nasal bones: review of the literature and three case reports

Blunt contusions, lacerations, and avulsion-type trauma are the most often reported nasal injuries sustained in motor vehicle accidents. The nasal skeleton and soft tissues are frequently involved and may require surgical repair of the injuries. The primary reconstruction often requires the use of autogenous grafts, and secondary revision surgery may be necessary. The treatment may require a multidisciplinary surgical team or a single surgeon who knows how to manage the injury. Optimally, the reconstruction of nasal bone avulsions is performed primarily, using autogenous graft materials. This article presents reconstruction of the nasal deformities in 3 patients involved in motor vehicle accidents. The authors describe and evaluate the various graft materials and surgical techniques utilized. The advantages and disadvantages of autogenous and alloplastic materials are discussed. Studies with more patients and long-term follow-up are required for a definitive evaluation.

The traumatic saddle nose deformity: etiology and treatment

The saddle nose resembles a saddle, i.e., with a concave, often flattened dorsum and an apparent cephalic rotation of the nasal tip. The concavity may be present in the osseous or cartilaginous dorsum, or both. The saddle nose deformity can be divided into congenital, postinfection, postsurgical, and traumatic types. Congenital saddle nose deformity is rare, often accompanying midfacial deficiency malformation syndromes. The advent of antimicrobial therapy has helped restrict the incidence of syphilitic or leprotic saddle nose to the nonindustrialized nations. Postsurgical saddle nose deformity occurs most often as a result of the overzealous septorhinoplasty. The most common type of saddle nose deformity may be traumatic. The authors use Kazanjian and Converse's characterization of the true saddle nose as one in which the bony and/or cartilaginous portions are depressed and the projection of the nose is generally preserved. This article describes the saddle nose deformity and its etiology and proposes a management technique with minimal complications.

Nasal fractures--the details

Due to the nose's prominent location and functional and cosmetic importance, nasal fractures present a challenge to the facial plastic surgeon to restore all things to normal. Although little groundbreaking news has been reported recently in the literature on nasal fractures, there is ample literature already in print on virtually every topic concerning nasal fractures. This article concentrates on the details of actually managing nasal fractures, with comments on present-day coding of posttraumatic septorhinoplasty.

[Bone marrow mesenchymal stem cells: progress in bone/cartilage defect repair]

Mesenchymal stem cells (MSC) are thought to be multi-potent cells that have the potential to differentiate into lineages of mesenchymal tissues, including bone, cartilage, tendon, fat, muscle, and marrow stroma during embryo morphogenesis. In recent years, cells that have the characteristics of mesenchymal stem cells were isolated from marrow aspirates of human and a few animals. It was found that these cells retain the characteristics of stem cells in vitro and could be induced to differentiate exclusively into the osteocytic, chondrocytic, myoblastic and adipocytic lineages. It was demonstrated that MSC could heal clinically significant bone and cartilage defects in animal models. The role of MSC in repairing tendon defect was also testified. In addition, for its multi-potential to differentiate into lineages of mesenchymal tissues, MSC could be used as gene vehicle for gene therapy of trauma care.

Differences in repair responses between immature and mature cartilage

Cartilage has a poor reparative capacity although it is unclear as to what extent this may be dependent on age or maturation. In the current study, the cellular responses of chondrocytes to experimental wounding in vitro using embryonic, immature, and mature cartilage have been compared. In all cases, the response was consistent (a combination of cell death that included apoptosis and proliferation). The speed of response varied in terms of cell death with embryonic cartilage showing the most rapid response and mature cartilage showing the slowest response. Intrinsic repair as assessed by the ability to heal the lesion was not detected in any of the culture systems used. It was concluded that the poor repair potential of cartilage is not maturation dependent in the systems studied.

Impact of mechanical trauma on matrix and cells

Posttraumatic arthritis is one of the most common causes of secondary osteoarthritis. The contribution of cell death to matrix degradation has not been characterized fully. The current study was designed to determine the effect of mechanical injury on chondrocyte viability and matrix degradation. Full-thickness bovine and human cartilage explants, 5 mm in diameter were subjected to mechanical loads representative of traumatic joint injury. Glycosaminoglycan release and percent apoptotic cells were measured. Unilateral patellas in eight anesthetized rabbits were subjected to an impact load. Rabbits were euthanized at 96 hours after injury and patellar cartilage was harvested for analysis. The effect of a pan-caspase inhibitor, z-VAD.fmk [benzyloxycarbonyl-Val-Ala-Asp (OMe) fluoromethylketone] in preventing chondrocyte apoptosis in human articular cartilage explants was determined. A significant increase in the number of apoptotic cells was observed in response to mechanical loading. The mean in vivo apoptotic rates were 1% in control rabbits and 15% in impacted patellas. Caspase inhibition reduced chondrocyte apoptosis from 34% to 25% after mechanical injury and was associated with reduction in glycosaminoglycan release. Mechanical injury induces chondrocyte apoptosis that is sensitive to pharmacologic inhibition. This identifies a new approach to limit traumatic cartilage injury and the subsequent development of secondary osteoarthritis.

Ulnar shortening after failed arthroscopic treatment of triangular fibrocartilage complex tears

Ulnar shortening osteotomy was performed in 11 wrists with ulnar abutment syndrome, after failed arthroscopic surgery on the TFCC (ten debridements, one repair). A delayed union was present in three, a non-union occurred in two, of whom one needed a revision and grafting procedure. According to the Mayo wrist score, only four had an acceptable outcome. Patient's satisfaction was higher: seven were satisfied, four were not. The postoperative wrist pain score was good in ten patients. Overall outcome was not very successful. Problems related to the procedure could be avoided by adapting the technique (oblique osteotomy, palmar placement of the plate, and compression devices). The key statement remains however to us; ulnar sided wrist pain thought to be caused by an ulnar abutment is not necessarily resolved by decompressing the ulnocarpal joint.

Cytokines in cartilage injury and repair

Joint injury results in cartilage lesions that are characterized by a poor repair response, and such lesions often progress to osteoarthritis. Acute joint injury or chronic exposure of cartilage to an abnormal biochemical or biomechanical environment results in the activation of chondrocytes. This chondrocyte response is manifested by enhanced cell proliferation and death, matrix degradation, and new matrix synthesis. Cytokines are important stimuli of this chondrocyte activation response and trigger joint inflammation that can accompany cartilage injury. The presence of cytokines in cartilage is associated with abnormal extracellular matrix remodeling and loss, therefore defining them as a class of targets for therapeutic interventions. Insight into intracellular signaling mechanisms that are activated by cytokines may provide the basis for pharmacologic interventions that promote cartilage repair.

MR assessment of meniscal movement during knee flexion: correlation with the severity of cartilage abnormality in the femorotibial joint

PURPOSE

The purpose of this study was to assess the degree of meniscal movement during knee flexion on MR images and to correlate it with the severity of cartilage damage in the femorotibial joint.

METHOD

Sagittal MR images were obtained at extension and 45 degrees of flexion in 35 knees. A shortening ratio in the distance between the anterior and posterior horns at 0-45 degrees of knee flexion was calculated in each meniscus and was correlated with the degree of cartilage abnormality in the femorotibial joint.

RESULTS

The shortening ratio of the meniscus was reduced in knees with cartilage abnormality in the femorotibial joint. The shortening ratio of the medial meniscus was inversely correlated with the degree of cartilage abnormality in the medial femoral condyle and with that in the medial tibial plateau.

CONCLUSION

Restricted shortening ratio of the meniscus may be related to cartilage damage in the femorotibial joint.

Cartilaginous abrasion and debridement: correlation between type of cartilaginous injury and results in patients with a 4 to 9-year follow-up

It is the purpose of this study to verify whether or not there is a correlation between some parameters for cartilaginous injury (width, depth, and type of injury), analyzed separately, and the medium to long-term prognosis of the same. Thus, the parameters were analyzed, correlating them individually with the results obtained when a self-evaluation form was used, and the Lysholm-Gillquist score system. The small number of patients (because of the strict criteria for inclusion) does not allow for a statistically valid analysis of the results obtained. At any rate, the following considerations may be made: the depth parameter for the injury may be a valid element alone in determining a medium- to long-term prognosis; this agrees with what is reported in the literature. The parameter for width of the injury, based on our results, does not appear to be a sufficient element to determine a correlation with future prognosis. As for the type of lesion parameter, this could be correlated with the prognosis. Studies conducted in this sense with higher numbers of patients could determine the type of injury with the worst prognosis.

Reconstruction of the anterior cruciate ligament with the iliotibial band autograft in patients with chronic knee instability

We performed combined internal and external anterior cruciate ligament (ACL) reconstruction with the iliotibial band autograft in 169 consecutive patients with chronic ACL insufficiency who were followed up for 24-61 months. Of these, 155 (91%) agreed to an additional independent observer follow-up after 24-92 months. Eight patients (5%) had sustained a rerupture/elongation of the graft and were operated on again; nine (6%) had sustained a tear of the contralateral ACL. Knee function and activity increased after the reconstruction. Lysholm scores improved from median 81 preoperatively to 99 at follow-up and Tegner scores from median 4 to 7. At follow-up 97 (71%) were active at the same level as prior to injury. In 17 of the 40 patients (12%) dropping to a lower activity level this was due to knee problems. The side-to-side difference in anterior-posterior knee laxity was more than 3 mm in 18 knees (13%) and more than 5 mm in 3 knees (2%). Including eight reruptures, this results in a "stability" failure rate of 8.8%. The overall IKCD rating showed normal knee function in 88 (73%) and nearly normal knee function in 30 (25%). Anterior knee pain was present in 14 (10%) of the patients at follow-up. Patients with isolated ACL injury had higher Lysholm scores and Tegner scores than patients with associated injuries. No clinical signs of varus knee development were seen. Of the 155 patients 94% would have the procedure repeated if necessary with the knowledge that they have today. The combined internal and external iliotibial band procedure can restore knee stability and function in the majority of chronic ACL-insufficient knees.

Arthroscopic repair of triangular fibrocartilage complex injuries

The triangular fibrocartilage complex is a functionally and anatomically intricate group of structures located at the ulnar aspect of the wrist. Injury to this structure affects the biomechanics of the wrist and makes functional restoration difficult. This article reviews the anatomy, biomechanics, diagnosis, and arthroscopic treatment of triangular fibrocartilage complex injuries.

Repair of cartilage defect in the rabbit with cultured mesenchymal stem cells from bone marrow

In 16 mature New Zealand white rabbits mesenchymal stem cells were aspirated from the bone marrow, cultured in monolayer and implanted on to a full-thickness osteochondral defect artificially made on the patellar groove of the same rabbit. A further 13 rabbits served as a control group. The rabbits were killed after 14 weeks. Healing of the defect was investigated histologically using haematoxylin and eosin and Safranin-O staining and with immunohistochemical staining for type-II collagen. We also used a reverse transcription-polymerase chain reaction (RT-PCR) to detect mRNA of type-I and type-II collagen. The semiquantitative histological scores were significantly higher in the experimental group than in the control group (p < 0.05). In the experimental group immunohistochemical staining on newly formed cartilage was more intense for type-II collagen in the matrix and RT-PCR from regenerated cartilage detected mRNA for type-II collagen in mature chondrocytes. These findings suggest that repair of cartilage defects can be enhanced by the implantation of cultured mesenchymal stem cells.

Flap transfers for the treatment of perichondrial ring injuries with soft tissue defects

Seven cases (six fresh) of perichondrial ring injury with skin defects were treated using flap transfers. The study included four boys and three girls ranging in age from 2 to 9 years (average 6). They were followed up for an average of 8 years and 10 months. The period from injury to flap coverage was 8-12 days, with an average of 10 days in the fresh cases. Fracture was noted in four cases, with one an epiphyseal fracture. Peroneal flaps were transferred in four cases, latissimus dorsi myocutaneous flaps in two, and gastrocnemius muscle flap in one. Six flaps survived perfectly, and one failed due to venous thrombosis. This latter case was treated with a cross leg flap. Postoperative radiographic assessments confirmed partial growth plate arrest in the chronic case, but all the fresh cases had no postoperative growth disturbance. Flap coverage, for perichondrial ring injuries with wide skin defects, is a useful method not only for skin coverage, but for the prevention of growth disturbances as well.

Costal cartilage fractures as revealed on CT and sonography

OBJECTIVE

We describe the CT and sonographic appearance of 15 costal cartilage fractures observed in eight patients.

CONCLUSION

On CT, fracture was seen as a low-density area through the costal cartilage, with surrounding calcifications present near old fractures, and gas density within the cleft in some cases. On sonography, cartilage fracture appeared as an interruption of the smooth anterior aspect of the cartilage.