Lachlan Batty

Autologous chondrocyte implantation: an overview of technique and outcomes

Articular cartilage is susceptible to damage; however, it has limited capacity for repair. Damage can lead to persistent symptoms including pain, swelling, and loss of function and may ultimately progress to symptomatic degeneration of the joint. To restore function and minimize symptoms, many advocate surgical intervention in selected candidates, which can range from arthroscopic debridement to restorative procedures depending on patient and lesion characteristics. Autologous Chondrocyte Implantation (ACI) is a two‐stage, typically second‐line intervention where cultured autologous chondrocytes are used with the aim of resurfacing symptomatic chondral defects with hyaline or hyaline‐like cartilage. Careful patient selection is important. We present an overview of this procedure including indications and contraindications, surgical technique, and post‐operative management. A review of published ACI outcomes is then presented.

Synthetic Devices for Reconstructive Surgery of the Cruciate Ligaments: A Systematic Review

PURPOSE The role of synthetic devices in the management of the cruciate ligament-injured knee remains controversial. The aim of this systematic review was to assess the safety and efficacy of synthetic devices in cruciate ligament surgery. METHODS A systematic review of the electronic databases Medline, Embase, and The Cochrane Library (issue 1, 2014) on January 13, 2014, was performed to identify controlled and uncontrolled trials. Trials that assessed the safety and efficacy of synthetic devices for cruciate ligament surgery were included. The main variables assessed included rates of failure, revision, and noninfective effusion and synovitis. Patient-reported outcome assessments and complications were also assessed where reported. RESULTS From 511 records screened, we included 85 articles published between 1985 and 2013 reporting on 6 synthetic devices (ligament augmentation and reconstruction system [Ligament Augmentation and Reconstruction System (LARS; Surgical Implants and Devices, Arc-sur-Tille, France)]; Leeds-Keio [Xiros (formerly Neoligaments), Leeds, England]; Kennedy ligament augmentation device [3M, St Paul, MN]; Dacron [Stryker, Kalamazoo, MI]; Gore-Tex [W.L. Gore and Associates, Flagstaff, AZ]; and Trevira [Telos (limited liability company), Marburg, Germany]). The heterogeneity of the included studies precluded meta-analysis. The results were analyzed by device and then type of reconstruction (anterior cruciate ligament [ACL]/posterior cruciate ligament [PCL]/combined ACL and PCL). The lowest cumulative rates of failure were seen with the LARS device (2.6% for ACL and 1% for PCL surgery). The highest failure rate was seen in the Dacron ACL group (cumulative rate, 33.6%). Rates of noninfective synovitis and effusion ranged from 0.2% in the LARS ACL group to 27.6% in the Gore-Tex ACL group. Revision rates ranged from 2.6% (LARS) to 11.8% (Trevira-Hochfest; Telos). Recent designs, specifically the LARS, showed good improvement in the outcome scores. The mean preoperative and postoperative Lysholm knee scores were 54 and 88, respectively; the mean preoperative and postoperative Tegner activity scale scores were 3.3 and 6, respectively. CONCLUSIONS Preliminary results for newer-generation devices, specifically the LARS, show lower reported rates of failure, revision, and sterile effusion/synovitis when compared with older devices. LEVEL OF EVIDENCE Level IV, systematic review of Level II through IV studies.

Undergraduate perspectives on the teaching and learning of anatomy.

The volume of time dedicated to anatomy teaching has steadily decreased in the context of increasingly dense undergraduate curricula. We examine the complex topic of anatomical education from the undergraduate perspective, with a focus on student perceptions, their origins and their potential solutions. A limited dataset suggests students perceive their tuition in anatomy may be suboptimal. Multiple factors (including the intensity of pre‐clinical studies, academic criticism of modern courses, surgical culture and misinformation) may account for the unrest. It is difficult to objectively measure the impact of modified anatomy curriculum on clinical performance and patient safety. While there is a case (on the basis of student perception at least) for reinvigorating elements of undergraduate anatomy education, the modern medical educational framework is here to stay, and students and clinicians must learn to adapt. Anatomy must be linked with contemporary approaches to medical education and it should be integrated, continuous and guided. It is critical that clinicians engage in the teaching of anatomy in the clinical environment and they must be adequately resourced to do so. Graduates must emerge with a core understanding of anatomy, but not an encyclopaedic knowledge of the human form. Undergraduate programme should simply strive to equip their graduates with a foundation for lifelong learning and a platform for safe practice as interns.

Pulmonary embolism and the use of vena cava filters after major trauma

Major trauma patients are at significant risk of developing pulmonary embolism (PE). We aimed to (i) analyse the current incidence and timing of PE after injury; (ii) identify risk factors that predispose major trauma patients to the occurrence of PE; and (iii) describe the use of vena cava filters (VCFs) following major trauma.

Anteromedial Tibial Tubercle Osteotomy (Fulkerson Osteotomy)

Multiple case series have reported outcomes of the AMZ procedures. Despite the heterogeneity in outcome measurements, results demonstrate high percentages of excellent and good results and improvements in objective, subjective and functional measures. Attention to details related to surgical planning and properly managing patient expectations is most likely to lead to good or excellent results. Newer techniques (i.e., the T3 system) allow the surgeon to objectively determine the inclination of the osteotomy to properly restore patellofemoral mechanics based upon the preoperative planning.

A spontaneous cholecystocutaneous fistula

Described in 1670, spontaneous cholecystocutaneous fistulae are now a rare occurrence. A 1996 review found 15 reported cases in the preceding 50 years. We therefore, present a case of a spontaneous cholecystocutaneous fistula. An 89-year-old man under care from the general medical team for treatment of pneumonia was incidentally noted to have a sinus in the right upper quadrant. The sinus was inferior to the right costal margin at the mid-clavicular line (Fig. 1). Collateral history from the patient’s general practitioner revealed the sinus manifested spontaneously six months earlier following the development of an erythematous area and pustule. There was no history of any previous gallbladder pathology including episodes of biliary colic, gallbladder surgery or percutaneous intervention. Laboratory investigations revealed a haemoglobin of 99 g/dL, leukocytosis of 11.4 ¥ 10/L and C-reactive protein of 199 mg/L. Liver function tests revealed a gamma-glutamyl transferase of 120 U/L and an alkaline phosphatase of 134 U/L. Bilirubin was normal. A CT scan demonstrated cholelithiasis, subcutaneous soft tissue thickening and a central focus of gas in the right upper quadrant, corresponding with the sinus location. There was teathering of the gall bladder to the peritoneum and abdominal wall musculature. A communicating tract to the external sinus was demonstrated confirming the diagnosis of a cholecystocutaneous fistula. Spontaneous cholecystocutaneous fistulae are believed to be the consequence of chronic, untreated cholelithiasis. Obstruction of the cystic duct with an increase in cholecystic pressures is thought to lead to impaired vascular supply to the gall bladder wall. Areas of necrosis and gall bladder perforation can then occur resulting in a peri-cholecystic collection. This may track to form an internal or external fistula. Although rare, cholecystocutaneous fistulae should be considered in the differential diagnosis for any patient with a sinus or abscess in the right upper quadrant or chest wall.

A spontaneous cholecystocutaneous fistula: Letters to the editor

Described in 1670, spontaneous cholecystocutaneous fistulae are now a rare occurrence. A 1996 review found 15 reported cases in the preceding 50 years. We therefore, present a case of a spontaneous cholecystocutaneous fistula. An 89-year-old man under care from the general medical team for treatment of pneumonia was incidentally noted to have a sinus in the right upper quadrant. The sinus was inferior to the right costal margin at the mid-clavicular line (Fig. 1). Collateral history from the patient’s general practitioner revealed the sinus manifested spontaneously six months earlier following the development of an erythematous area and pustule. There was no history of any previous gallbladder pathology including episodes of biliary colic, gallbladder surgery or percutaneous intervention. Laboratory investigations revealed a haemoglobin of 99 g/dL, leukocytosis of 11.4 ¥ 10/L and C-reactive protein of 199 mg/L. Liver function tests revealed a gamma-glutamyl transferase of 120 U/L and an alkaline phosphatase of 134 U/L. Bilirubin was normal. A CT scan demonstrated cholelithiasis, subcutaneous soft tissue thickening and a central focus of gas in the right upper quadrant, corresponding with the sinus location. There was teathering of the gall bladder to the peritoneum and abdominal wall musculature. A communicating tract to the external sinus was demonstrated confirming the diagnosis of a cholecystocutaneous fistula. Spontaneous cholecystocutaneous fistulae are believed to be the consequence of chronic, untreated cholelithiasis. Obstruction of the cystic duct with an increase in cholecystic pressures is thought to lead to impaired vascular supply to the gall bladder wall. Areas of necrosis and gall bladder perforation can then occur resulting in a peri-cholecystic collection. This may track to form an internal or external fistula. Although rare, cholecystocutaneous fistulae should be considered in the differential diagnosis for any patient with a sinus or abscess in the right upper quadrant or chest wall.