Tim Briggs

The role of autologous chondrocyte implantation in the treatment of symptomatic chondromalacia patellae.

PurposeChondromalacia patella is a distinct clinical entity of abnormal softening of the articular cartilage of the patella, which results in chronic retropatellar pain. Its aetiology is still unclear but the process is thought to be a due to trauma to superficial chondrocytes resulting in a proteolytic enzymic breakdown of the matrix. Our aim was to assess the effectiveness of autologous chondrocyte implantation on patients with a proven symptomatic retropatellar lesion who had at least one failed conventional marrow-stimulating therapy.MethodsWe performed chondrocyte implantation on 48 patients: 25 received autologous chondrocyte implantation with a type I/III membrane (ACI-C) method (Geistlich Biomaterials, Wolhusen, Switzerland), and 23 received the Matrix-assisted Chondrocyte Implantation (MACI) technique (Genzyme, Kastrup, Denmark).ResultsOver a mean follow-up period of 40.3xa0months, there was a statistically significant improvement in subjective pain scoring using the visual analogue scale (VAS) and objective functional scores using the Modified Cincinnati Rating System (MCS) in both groups.ConclusionsChondromalacia patellae lesions responded well to chondrocyte implantation. Better results occurred with MACI than with ACI-C. Excellent and good results were achieved in 40% of ACI-C patients and 57% of MACI patients, but success of chondrocyte implantation was greater with medial/odd-facet lesions. Given that the MACI procedure is technically easier and less time consuming, we consider it to be useful for treating patients with symptomatic chondral defects secondary to chondromalacia patellae.

Autologous Chondrocyte Implantation in the Adolescent Knee

Background Autologous chondrocyte implantation (ACI) has been shown to have favorable results in the treatment of symptomatic chondral and osteochondral lesions. However, there are few reports on the outcomes of this technique in adolescents. Purpose The aim of this study was to assess pain relief and functional outcome in adolescents undergoing ACI. Study Design Case series; Level of evidence, 4. Methods Thirty-five adolescent patients undergoing ACI or matrix-assisted chondrocyte implantation (MACI) were identified from a larger cohort. Four patients were lost to follow-up, leaving 31 patients (24 ACI, 7 MACI). The mean age was 16.3 years (range, 14-18 years) with a mean follow-up of 66.3 months (range, 12-126 months). There were 22 male and 9 female patients. All patients were symptomatic; 30 had isolated lesions and 1 had multiple lesions. Patients were assessed preoperatively and post-operatively using the visual analog scale (VAS) score for pain, the Bentley Functional Rating Score, and the Modified Cincinnati Rating System. At 1 year postoperatively, patients were recalled for a diagnostic biopsy, which was successfully attained in 21 patients. Results The mean pain scores improved from 5 preoperatively to 1 postoperatively. The Bentley Functional Rating Score improved from 3 to 0, while the Modified Cincinnati Rating System improved from 48 preoperatively to 92 postoperatively with 84% of patients achieving excellent or good results. All postoperative scores exhibited significant improvement from preoperative scores. One patient underwent graft hypertrophy and 1 patients graft failed and was revised. Biopsy results revealed hyaline cartilage in 24% of cases, mixed fibro/hyaline cartilage in 19%, and fibrocartilage in 57%. Conclusion Results show that, in this particular group who received ACI, patients experienced a reduction in pain and significant improvement in postoperative function after ACI or MACI. The authors believe that ACI is appropriate in the management of carefully selected adolescents with symptomatic chondral and osteochondral defects.

The Use of Massive Endoprostheses for the Treatment of Bone Metastases

Purpose. We report a series of 58 patients with metastatic bone disease treated with resection and endoprosthetic reconstruction over a five-year period at our institution. Introduction. The recent advances in adjuvant and neoadjuvant therapy in cancer treatment have resulted in improved prognosis of patients with bone metastases. Most patients who have either an actual or impending pathological fracture should have operative stabilisation or reconstruction. Endoprosthetic reconstructions are indicated in patients with extensive bone loss, failed conventional reconstructions, and selected isolated metastases. Methods and Results. We identified all patients who were diagnosed with metastatic disease to bone between 1999 and 2003. One hundred and seventy-one patients were diagnosed with bone metastases. Metastatic breast and renal cancer accounted for 84 lesions (49%). Fifty-eight patients with isolated bone metastasis to the appendicular skeleton had an endoprosthetic reconstruction. There were 28 males and 30 females. Twelve patients had an endoprosthesis in the upper extremity and 46 patients had an endoprosthesis in the lower extremity. The mean age at presentation was 62 years (24 to 88). At the time of writing, 19 patients are still alive, 34 patients have died, and 5 have been lost to follow up. Patients were followed up and evaluated using the musculoskeletal society tumour score (MSTS) and the Toronto extremity salvage score (TESS). The mean MSTS was 73% (57% to 90%) and TESS was 71% (46% to 95%). Mean follow-up was 48.2 months (range 27 to 82 months) and patients died of disease at a mean of 22 months (2 to 51 months) from surgery. Complications included 5 superficial wound infections, 1 aseptic loosening, 4 dislocations, 1 subluxation, and 1 case, where the tibial component of a prosthesis rotated requiring open repositioning. Conclusions. We conclude that endoprosthetic replacement for the treatment of isolated bone metastases is a reliable method of limb reconstruction in selected cases. It is associated with low complication and failure rates in our series, and achieves the aims of restoring function, allowing early weight bearing and alleviating pain.

Diffuse pigmented villonodular synovitis of the foot and ankle treated with surgery and radiotherapy

We followed up seven patients with histologically confirmed diffuse pigmented villonodular synovitis in a prospective study between 1992 and 2001. The mean age at diagnosis was 30.7 years. The patients underwent synovectomy, followed by radiotherapy with a total dose of 35xa0Gy in 20 fractions. In all cases, the excision was considered incomplete when examined histologically. At an average follow up of 24 (18–36) months, six patients reported better function and reduced levels of pain. One patient remained symptomatic but did not have a recurrence. We conclude that a combined approach to a primary pigmented villonodular synovitis of the foot and ankle may reduce the risk of recurrence without functional impairment.RésuméNous avons suivi sept malades avec une synovite villonodulaire pigmentée diffuse confirmé histologiquement dans une étude prospective entre 1992 et 2001. Lâge moyen au diagnostic était de 30,7 ans. Les malades ont subi une synovectomie suivie dune radiothérapie avec une dose totale de 35xa0Gy en 20 fractions. Dans tous les cas, la résection a été considérée incomplète à lexamen histologique. À une moyenne de suivi de 24 (18–36) mois, six malades ont une meilleure fonction et un niveau réduit de douleur. Un malade est resté symptomatique, mais sans récidive. Nous concluons quun traitement combiné dune synovite villonodulaire pigmenté du pied et de la cheville peut réduire le risque de récidive sans dégradation fonctionnelle.

Custom-made hinged spacers in revision knee surgery for patients with infection, bone loss and instability

Polymethyl methacrylate spacers are commonly used during staged revision knee arthroplasty for infection. In cases with extensive bone loss and ligament instability, such spacers may not preserve limb length, joint stability and motion. We report a retrospective case series of 19 consecutive patients using a custom-made cobalt chrome hinged spacer with antibiotic-loaded cement. The SMILES spacer was used at first-stage revision knee arthroplasty for chronic infection associated with a significant bone loss due to failed revision total knee replacement in 11 patients (58%), tumour endoprosthesis in four patients (21%), primary knee replacement in two patients (11%) and infected metalwork following fracture or osteotomy in a further two patients (11%). Mean follow-up was 38 months (range 24-70). In 12 (63%) patients, infection was eradicated, three patients (16%) had persistent infection and four (21%) developed further infection after initially successful second-stage surgery. Above knee amputation for persistent infection was performed in two patients. In this particularly difficult to treat population, the SMILES spacer two-stage technique has demonstrated encouraging results and presents an attractive alternative to arthrodesis or amputation.

Pseudomyogenic (epithelioid sarcoma-like) hemangioendothelioma: characterization of five cases

ObjectiveTo describe the imaging and histopathology of pseudomyogenic hemangioendothelioma.Materials and methodsFive cases of pseudomyogenic hemangioendothelioma, which presented over the last 5xa0years, were retrieved from the files of the Royal National Orthopaedic Hospital. The imaging and histopathology were reviewed in all cases. Magnetic resonance imaging, which was available from all cases, was assessed for the following features: the number of lesions, location in soft tissue (superficial and or deep/subfascial) and bone, and the signal characteristics and morphology of individual lesions. Immunohistochemistry was performed in all cases to characterize the lesions.ResultsFour of the five patients had multiple lesions involving a single limb. Bone was involved in 3 of the 5 individuals. All tumors diffusely expressed ERG and cytokeratins AE1/3, but not MNF116. CD31 was weakly positive in 4 cases. INI-1 expression was retained in all cases. Imaging features included ill-defined, infiltrative lesions in subcutaneous fat with extension to the adjacent skin, poor- to well-defined intramuscular nodules and predominantly intracortical focal bone lesions with rare medullary involvement.ConclusionPseudomyogenic hemangioendothelioma represents a distinct recently characterized tumor type presenting in young adults, with a tendency towards multicentric bone and soft tissue involvement.

Soft tissue tumours of the extremities

Require a high index of suspicion to enable early referral

Sequential outcome following autologous chondrocyte implantation of the knee: A six-year follow-up

This prospective six-year longitudinal study reviews the clinical outcome of patients undergoing autologous chondrocyte implantation (ACI) and a porcine type I/III collagen membrane cover for deep chondral defects of the knee. We present 57 patients (31 male, 26 female) with a mean age of 31.6xa0years (range 15–51xa0years) that have undergone ACI since July 1998. The mean size of the defect was 3.14xa0cm2 (range 1.0–7.0xa0cm2). All patients were assessed annually using seven independent validated clinical rating scores with the data analysed using ANOVA. ACI using a porcine type I/III collagen membrane cover produced statistically significant improvements (pu2009<u20090.001), maintained for up to six years, in knee symptoms compared to pre-operative levels. This study provides evidence of the medium-term benefit achieved by transplanting autologous chondrocytes to osteochondral defects.

Myopericytoma in Kager's fat pad.

Myopericytoma is a recently described, rare, soft-tissue tumour with perivascular differentiation of myoid cells. We present a case of myopericytoma occurring around the ankle in a 68-year old man. The patient presented with a history of a lump around the ankle of 4 years’ duration. Clinical presentation, radiological features and histopathologic findings of this case are reported, and the relevant literature is reviewed.

Treating articular cartilage injuries of the knee in young people

#### Summary pointsnnArticular chondral and osteochondral injuries of the knee are common in people aged under 35 years, and symptomatic lesions left untreated may lead to chronic pain and disability. Patients with articular chondral injuries often have a poorer function score than those awaiting surgery for other knee disorders, such as osteoarthritis or a ruptured anterior cruciate ligament.1 Patients with articular cartilage injuries may go on to develop early onset osteoarthritis with long term morbidity and consequent high use of health service resources; successful early treatment of these lesions would probably be cost effective.nnChondral and osteochondral lesions may not be diagnosed or may present late because patients will often give a history of an apparent insignificant trauma and doctors may fail to understand the importance of an effusion in the knee joint, which always indicates joint disease.2 Radiographs of the knee may be poorly interpreted. This review discusses the diagnosis and management (conservative and surgical) of injuries to the articular cartilage of the knee and draws on published research articles and the authors’ own experience.nnWe searched the Cochrane database, PubMed, and Google Scholar up to December 2009. We analysed randomised controlled trials and comparison trials, as well as articles on operative technique and case series. nnLong bone articular surfaces are covered with hyaline cartilage. Damage to this hyaline cartilage is known as a chondral injury or, if the underlying bone is also fractured, an osteochondral injury.nnArticular cartilage is avascular and aneural, so pain would not be expected. Yet some patients with chondral lesions do present with …