Congruity Of Articular Surface Research Articles

Our Experience with Primary Trapeziometacarpal Implant Arthroplasty in Severely Comminuted Rolando Fractures

Abstract Background The concept of primary joint replacement in severely comminuted fractures in elderly patients has proven to be a suitable treatment option in the shoulder, elbow and knee joint. Comminuted intra-articular fractures of the first metacarpal base can pose significant technical challenges, and no established gold standard treatment currently exists. Conventional methods like open reduction and internal fixation or external fixation are commonly employed, emphasizing the importance of anatomical reduction for restoring the articular surface. However, achieving articular surface congruity is often unattainable in severely comminuted intra-articular fractures, leading to short-term joint stiffness and instability, as well as long-term complications like secondary osteoarthritis. Aims This case report aims to share our experience with the use of primary trapeziometacarpal implant arthroplasty in the treatment of two patients with severely comminuted Rolando fractures. Methods In two cases of comminuted Rolando fractures, a primary trapeziometacarpal prosthesis (MAÏA™) was implanted based on preoperative decision-making facilitated by 3D-CT analysis. Patient’s visual analogue score for pain, range of motion, pinch and grip strength compared to the contralateral side were asked and examined. Results Both patients exhibited successful adaptation to their daily routines within a three-month postoperative period. No complications, such as cup or stem loosening or dislocation, were identified. Both patients almost reached equal range of motion, pinch and grip strength compared to the contralateral side. Conclusion The use of primary trapeziometacarpal implant arthroplasty seems to be a viable alternative for managing severely comminuted Rolando fractures, particularly in elderly patients and those with pre-existing osteoarthritis. This approach offers promising outcomes. Studies with other implant arthroplasties have shown better outcomes in patients treated primarily, than after several failed surgeries. We suggest the same is true for the trapeziometacarpal joint. Further studies are necessary to validate the efficacy of this intervention in a larger cohort of patients.

Osteochondral Allograft Transplantation for the Unstable Capitellar Osteochondritis Dissecans Lesion: An Anconeus Preserving Approach

Background: Osteochondritis dissecans (OCD) of the capitellum can be a disabling condition that typically affects adolescent, overhead athletes. To date, a variety of different surgical treatment options have been described. Indications: Surgical indications for osteochondral allograft transplantation (OCA) for capitellar OCD lesions include failure of nonsurgical management or prior surgery and unstable, full-thickness lesions of almost any size affecting both bone and cartilage. The anconeus preserving approach specifically provides wide access to nearly the entire capitellum and can be used for lesions in almost any location. Technique Description: The anconeus preserving approach for OCA utilizes the interval between the anconeus and the ulna. With the patient positioned supine and the elbow flexed on an arm table, an incision is made approximately 1 cm lateral to the olecranon and is carried down to the fascia. Electric cautery is used to dissect the interval between the ulna and the anconeus. The anconeus is elevated off the ulna and retracted laterally to expose the underlying joint capsule. An L-shaped capsulotomy is performed over the center of the capitellum, just proximal to the annular ligament of the radial head. A pin is placed into the center of the lesion, perpendicular to the capitellum. A cannulated reamer 0.5 mm smaller than the lesion is used to ream the lesion to a depth of approximately 5 mm. Depth measurements are taken at all 4 poles of the defect. About 3 cc of bone marrow aspirate harvest is then obtained from the ulna using a cannulated needle. The oscillating saw is used to cut the graft to size using the prior measurements. The bone marrow aspirate is placed onto the osseous side of the graft before the osteochondral graft is impacted into the recipient site. The capsulotomy is then closed, and the anconeus is repaired back to the ulna. Postoperatively, patients begin range of motion as soon as tolerated, initiate strengthening at 6 weeks, and initiate return-to-sport programming at 3 months. Results: Lesions treated with OCA typically demonstrate improvement in all outcome measures, including functional scores, graft incorporation, articular surface congruity, and return-to-sport. Complications and graft failure is rare. Discussion/Conclusion: OCA using an anconeus preserving approach is a reliable option for surgical management of unstable OCD lesions. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Osteochondral techniques: where are we now?

Hyaline articular cartilage is a unique, highly specialized tissue with a distinct architecture that lacks intrinsic means to heal effectively when injured in the adult. Symptomatic osteoarticular defects continue to be a formidable challenge for the clinical and scientific communities alike. Of the various surgical treatment options that have been proposed to this end, only osteochondral grafting techniques reliably restore appropriate hyaline tissue in acquired articular cartilage lesions, especially when these involve the subchondral bone. Both autologous and allogeneic graft sources are available to the surgeon, who must consider the unique qualities and characteristics of either approach in the treatment algorithm. Autografts and allografts alike adhere to a common methodology, relying on osseous healing of mature osteochondral constructs to transplant the adherent viable articular cartilage. The required surgical technique is straightforward and reproducible but requires precision to restore articular surface congruity, achieve reliable bony ingrowth, and, ultimately, clinical success. Scientific investigation to further validate empirical clinical practice and to improve implant quality and safety is ongoing and holds great promise for the future of osteochondral grafting in joint preservation.

A clinical study to determine the functional outcome of distal end radius fracture managed with volar locking plate and screws

Background and Objective: Fracture of the distal radius is one of the most common skeletal injuries treated by orthopaedic surgeons. For a favourable functional outcome, radial length, radial tilt angle, and articular surface congruity must all be restored. Recognition of fracture patterns and fixation of fracture to maintain reduction is the key for successful management of complex fractures of distal radius. Volar locking plates allow improved fracture fixation without leading to soft tissue and vascular complications. They have been shown to provide excellent stability for an unstable fracture with volar Metaphyseal comminution. The objective of the study was to evaluate the clinical and functional outcome of fracture of distal end of radius treated by ORIF by Volar locking plate and screws using Criteria of Gartland and Werley Point System. Methods: Thirty patients with fracture of distal end radius were treated by ORIF by Volar locking plate and screws in Karnataka institute of medical sciences, hubballi. Between from November 2020 to September 2022. Results: The study included 30 patients, 27 male and 3 females aged from 21 to 69 years with mean of 33.53 years. The average duration of follow-up was 12 months. Using the Demerit scoring system of Gartland and Werley score, we had 20% excellent results, 50% good results, 16.67% fair results and 13.3% poor result. As per our results, excellent to good results were found in 70% of patients. Interpretation & Conclusion: ORIF by Volar locking plate and screws can be an alternative to other procedures in treating the extra-articular fracture with volar displacement and volar Barton’s fracture radius. Excellent to good results are produced by using volar locking plate for fixation of distal radius fractures.

The Management of Posterior Malleolus Fractures in Unstable Ankle Injuries: Where Do We Stand Now?

The evaluation and treatment of the posterior malleolus fracture in unstable ankle injuries remain a topic of controversy. The main objective of this systematic review was to examine the available literature and identifythe variables that affect the management of posterior malleolar fractures and how these are related to the outcomes. To that end, a systematic review was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search of MEDLINE, Embase, and Cochrane Library was conducted. The search terms used were as follows: "posterior malleolar", "ankle fractures", "trimalleolar fractures", "ORIF", "surgery", "operative", and "conservative". The available studies were screened against the inclusion and exclusion criteria. Based on the review of the available literature, we have concluded that the size of the posterior malleolar fragment is not an accurate indicator, and clinicians should consider other factors such as fracture configuration and articular surface congruity. Also, the risk for the development of post-traumatic arthritis increases when the joint surface is not restored regardless of the surgical intervention and fragment size. The complications of posterior malleolus fractures necessitate evidence-based management. The assessment and the final treatment of these injuries in unstable ankle fractures should not be based on the traditional fragment-size parameters. Clinicians should assess the fracture configuration through imaging modalities and try to preserve the articular surface congruity so as to achieve optimal outcomes. Finally, more studies with high-level evidence are required in order to determine the most appropriate management pathway for these patients.

Study of surgical and functional outcome in the management of proximal tibial fracture with circular wire-based external fixation

Background: The principle of treatment in proximal tibial fracture includes soft tissue care, restoring articular surface congruity and reduction of anatomical alignment enabling early joint mobility. Aim: Assessing surgical, and functional outcomes by evaluating pain, range of motion (ROM) and muscle power in circular wire-based external fixation procedure in proximal tibial fractures with complications. Objectives: Documenting clinical observations, preoperative, and postoperative symptoms in the study population with time for bony union and complications. Materials and Methods: Thirty patients aged 18–70 years with proximal tibial fractures excluding polytrauma and pathological fracture cases were included in the prospective observational study. Surgery and post-operative follow-up were done at 6, 12, 24 weeks and 6 months. Functional assessment is done by the knee society score system. Removal of fixator followed evidence of clinical and radiological union with advice for full weight bearing. Results: Road traffic accident was a major injury, right laterality more than left. The type of tibial fractures was 41A2, A3 and C3. Eighty per cent of patients had no persistent residual pain after fracture union; 80% showed normal relative to age walking capacity, and 95% showed normal to <10° lack of extension. Fourteen patients had ROM of 125° and 120° in ten. Twenty-six patients showed normal stability in extension and 20° flexion. Twenty-five patients showed excellent knee scores, 24 showed excellent functional scores; four showed good knee scores and five showed good functional scores. Post-operative complications included pin-tract infection in four patients followed by delayed and non-union in one patient each. Conclusion: Circular wire-based external fixation in the proximal tibial fracture is an effective method of treatment even with moderate soft-tissue injury showing excellent to good functional outcome.

Posterior Locking Plate Fixation of Bartoníček Type IV Posterior Malleolar Fracture: A Focus on Die-Punch Fragment Size

Die-punch fragments refer to articular cartilage and subchondral bone embedded in cancellous bone as part of an intra-articular fracture. Bartoníček type IV posterior malleolar fractures with associated die-punch fragments are rare, and the appropriate surgical approach remains unclear. We determined outcomes, and the effect of die-punch fragment size on outcomes, for 32 patients with Bartoníček type IV posterior malleolar fractures with die-punch fragments between January 2015 and December 2017. Mean follow-up for all patients was 23.8 (range 20.0-30.0) months. At the final follow-up visit, mean ankle dorsal extension was 24.6° and plantar flexion was 40.0°; American Orthopaedic Foot and Ankle Society ankle-hindfoot score was 88.6 ± 4.3; visual analog scale weightbearing pain score was 1.5 ± 0.6; and Bargon traumatic arthritis score was 0.8 ± 0.4. There were no severe complications. We divided patients into a small-fragment (≤3 mm) group (n=12) and large-fragment (>3 mm) group (n=20). The Bargon scores at final follow-up were 0.5 and 1, respectively (P=.02). There were no statistically significant differences between the 2 groups for the other outcome scores at various time intervals. The posterolateral approach with distal locking plate internal fixation for Bartoníček type IV posterior malleolar fractures with die-punch fragments can result in excellent anatomical reduction of the collapsed articular surface and the displaced fragment from the tibial plafond, recovery of articular surface congruity, and maintenance of joint stability. Die-punch fragment size may not impact clinical and functional outcomes but may contribute to post-traumatic arthritis.

Concurrent ipsilateral Tillaux fracture and medial malleolar fracture in adolescents: management and outcome

BackgroundThe concurrent ipsilateral Tillaux fracture with medial malleolar fracture in adolescents commonly suffer from high-energy injury, making treatment more difficult. The aim of this study was to discuss the mechanism on injury, diagnosis, and treatment of this complex fracture pattern.MethodsThe charts and radiographs of six patients were reviewed. The function was assessed by the American Orthopedic Foot and Ankle Society ankle-hindfoot scores.ResultsThe mean age at operation was 12.8 years. The mean interval from injury to operation was 7.7 days. Five Tillaux fractures and all medial malleolar fractures were shown on AP plain radiographs. One Tillaux fracture and two cases with avulsion of posterolateral tibial aspect were confirmed in axial computerized tomography. There was talar subluxation laterally with medial space widening in three and syndesmotic disruption in one. There were five patients sustaining ipsilateral distal fibular fractures. All fractures, except nonunion in two medial malleolar fractures and in one Tillaux fracture, healed within 6–8 weeks. There was one case of osteoarthritis of ankle joint. The average AOFAS score was 88.7.ConclusionsComputerized tomography is helpful in identifying the fracture pattern. Anatomic reduction and internal fixation of Tillaux and medial malleolar fracture was recommended to restore the articular surface congruity and ankle stability.

One-Year MRI Outcomes of Osteochondral Allograft Transplantation of the Knee for Large Chondral Defects: Comparison of Elliptical, Stacked, and Single Allografts

Objectives:Osteochondral allograft transplantation (OCA) is a proven cartilage restoration procedure for patients with large chondral defects. However, elongated condylar lesions pose a challenge for dowel OCA in restoring articular surface congruity. Recently, instrumentation to harvest a single, elliptical allograft has been developed for treating ovoid lesions without requiring an adjacent-plug (stacked or snowman) technique. The purpose of this study was to compare 1-year MRI outcomes of patients treated with elliptical, stacked, or single OCA using the Osteochondral Allograft MRI Scoring System (OCAMRISS) and percent osseous integration.Methods:A retrospective review on patients treated from 2000 to 2018 with OCA for condylar defects of the knee was conducted. Inclusion criteria included those followed prospectively with a MRI at ˜1 year after surgery. OCAMRISS and osseous integration scores (0-25%; 26-50%; 51-75%; 76%-100%) were graded by a musculoskeletal radiologist blinded to the outcomes. Comparisons of demographics and MRI scores were performed with the ANOVA.Results:A total of 57 knees (mean age, 35.8 years; 70% male) met the inclusion criteria and were treated with either elliptical (n=19), stacked (n=19), or single (n=19) OCA. Mean time to post-operative MRI was 10.7, 11.1, and 12.4 months, respectively (p=0.17). There were no significant differences in demographics or number of prior ipsilateral knee surgeries among groups. Defect characteristics were significantly different between groups, where single plugs treated a higher percentage of LFC defects (58%) compared to elliptical and stacked (26%, each) (p=0.02). Total chondral defect area was greatest in the stacked group (5.4 ± 1.3) compared to elliptical (4.6 ± 1.2) and single (4.6 ± 1.4) (p=0.12). Bone, cartilage, ancillary, and total OCAMRISS scores were not significantly different between groups. A trend towards a higher percentage of osseous integration (single>stacked>elliptical) was noted which correlated with less transplanted allograft bone, however, these differences were not significant (p=0.15).Conclusion:One-year OCAMRISS and osseous integration scores did not differ among patients treated with elliptical, stacked, or single OCA. Further investigation is needed to explore potential differences in clinical outcomes and long-term osseous integration between elliptical and stacked OCA for the treatment of elongated condylar defects of the knee.Table 1.Patient Demographics, Intraoperative Data, and OCAMRISS Scores at 1-year Postoperative MRI Elliptical (n = 19) Stacked (n = 19) Single (n = 19) P Value Patient CharacteristicsAge, y37.0 ± 13.937.5 ± 11.133.1 ± 11.80.48Sex (male/female), n14/513/613/60.92Body mass index, kg/m2 25.7 ± 2.826.5 ± 5.025.9 ± 3.20.78No. of prior ipsilateral knee surgeries1.1 ± 1.41.9 ± 2.41.4 ± 0.80.29MRI follow-up, mo10.7 ± 3.911.1 ± 1.912.4 ± 2.20.17Lesion CharacteristicsOCA location, n (%)0.02Medial femoral condyle14 (74)14 (74)8 (42)Lateral femoral condyle5 (26)5 (26)11 (58)Total chondral defect area, cm2 4.6 ± 1.25.4 ± 1.34.6 ± 1.40.12OCAMRISS ScoreCartilage features3.5 ± 1.52.9 ± 1.53.4 ± 2.10.48Bone features3.0 ± 0.72.7 ± 0.72.8 ± 0.60.30Ancillary features3.0 ± 1.12.9 ± 1.02.6 ± 1.10.46Total9.5 ± 2.18.4 ± 2.58.8 ± 3.10.45Osseous Integration Score2.1 ± 1.11.7 ± 0.901.5 ± 0.600.15

Medial Femoral Trochlea Osteochondral Graft: A Quantitative Anatomic Comparison to the Proximal Pole of the Scaphoid.

Background Treatment of scaphoid proximal pole (SPP) nonunion with a vascularized osteochondral graft from the medial femoral trochlea (MFT) has been described, with positive outcomes thus far. However, our understanding of the congruency between the articular surfaces of these structures is incomplete. Objective Our purpose was to evaluate the congruency of the MFT and SPP using a quantitative anatomical approach. Methods The distal femur and ipsilateral scaphoid were dissected from 12 cadavers and scanned with computerized tomography. Three-dimensional models were created and articular surfaces were digitally "dissected." The radius of curvature (RoC) of the radioulnar (RU) and proximodistal (PD) axes of the SPP and MFT, respectively, as well as the orthogonal axes (SPP, anteroposterior [AP]; MFT, mediolateral [ML]) were calculated. The RoC values were compared using the Wilcoxon signed-rank test. Results The RoC values for the SPP and MFT were not significantly different in the RU-PD plane ( p = 0.064). However, RoC values for the SPP and MFT were significantly different in the AP-ML plane ( p = 0.001). Conclusions For most individuals, the RU curvature of the SPP was similar to the PD curvature of the MFT. For nearly all individuals, the AP curvature of the SPP and the ML curvature of the MFT shared less congruence. Clinical Relevance Articular surface congruity may not be a critical factor associated with improvements in wrist function following this procedure.

Retrograde Drilling for Osteochondral Lesion of the Talus in Juvenile Patients.

Background:Retrograde drilling (RD) is generally used for treating osteochondral lesion of the talus (OLT) with a stable osteochondral fragment and nearly normal articular cartilage surface. Previous studies that included participants of various ages have reported good clinical results. This study aimed to clarify the clinical outcomes of RD for OLT in juvenile patients whose bone-forming ability and physical activity might affect the healing process.Methods:This retrospective study included 8 juvenile patients who underwent RD for OLT (5 boys and 3 girls, mean age 14.9 years, mean follow-up 2 years, 7 medial and 1 central lesion). American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score and ankle activity score were evaluated, and arthroscopic findings were graded according to the International Cartilage Research Society (ICRS) classification system. The condition of the underlying bone was assessed on preoperative computed tomographic images. The stability, incorporation, and subsidence of the osteochondral fragment, articular surface congruity, and the area of the bone marrow lesion (BML) were evaluated using magnetic resonance imaging (MRI).Results:AOFAS ankle-hindfoot score and ankle activity score significantly improved postoperatively. Arthroscopically, the lesions were classified as ICRS grade 0 or 1. Bone sclerosis or multiple small cysts of the underlying bone were observed in all patients. MRI demonstrated no signs of osteochondral fragment instability or subsidence, good or fair fragment incorporation, good articular surface congruity, or slight irregularity. The postoperative BML was reduced; however, these BMLs were still detectable at 1 year after surgery.Conclusion:Our data suggested that RD is an option for treating juvenile patients with OLT refractory to nonoperative treatment at short-term follow-up. Although bone sclerosis or multiple small cysts were identified in the underlying bone preoperatively and the BML under the osteochondral fragment remained postoperatively, clinical status such as pain and physical activity level were improved by RD.Level of Evidence:Level IV, retrospective case series.

Allografts in Foot and Ankle Surgery: A Critical Analysis Review.

Allografts are commonly used during reconstructive procedures around the foot and ankle1. Compared with autograft tissue, allografts offer the advantage of unlimited tissue sources, decreased operative time, and lack of potential donor-site morbidity1. Allografts can be classified into three broad categories: (1) osteochondral grafts, (2) osseous/structural grafts (which can be subclassified as either bulk grafts or cortical/cancellous chips), and (3) allograft tendons. The use of these grafts has increased dramatically in the past decade, but there is concern that enthusiasm surrounding their use has outpaced the published evidence supporting their efficacy and safety. This article will critically review the available evidence regarding outcomes related to the use of allografts in foot and ankle surgery. Symptomatic osteochondral defects at any anatomic site present a substantial treatment challenge. The goals of operative treatment include the resolution of pain and/or mechanical symptoms, the restoration of articular surface congruity, the prevention of articular surface collapse, and, ultimately, the prevention of degenerative arthritis of the apposing joint surfaces2. In foot and ankle surgery, osteochondral allografts are most commonly …

Articular Congruity Is Associated with Short-Term Clinical Outcomes of Operatively Treated SER IV Ankle Fractures

With regard to supination-external rotation type-IV (SER IV) ankle fractures, there is no consensus regarding which patient, injury, and treatment variables most strongly influence clinical outcome. The purpose of this investigation was to examine the impact of articular surface congruity on the functional outcomes of operatively treatment of SER IV ankle fractures. A prospectively generated database consisting of operatively treated SER IV ankle fractures was reviewed. Postoperative computed tomography (CT) scans were used to assess ankle joint congruity. Ankles were considered incongruent in the presence of &gt;2 mm of articular step-off, intra-articular loose bodies, or an articular surface gap of &gt;2 mm (despite an otherwise anatomic reduction) due to joint impaction and comminution. Patients with at least one year of clinical follow-up were eligible for analysis. The primary and secondary outcome measures were the Foot and Ankle Outcome Score (FAOS) and ankle motion. One hundred and eight SER IV fractures met our inclusion criteria. The average duration of follow-up was twenty-one months. Seventy-two patients (67%) had a congruent ankle joint, and thirty-six (33%) had elements of articular surface incongruity on postoperative CT scanning. These two groups were similar with regard to comorbidities and injury and treatment variables. At the time of the final follow-up, the group with articular incongruity had a significantly worse FAOS with regard to symptoms (p = 0.012), pain (p = 0.004), and activities of daily living (p = 0.038). Those with articular incongruity had worse average scores in the FAOS sport domain as well. No significant differences in ankle motion were found between the two groups. In this population of patients with an operatively treated SER IV ankle fracture, the presence of postoperative articular incongruity correlated with inferior early clinical outcomes. Orthopaedic surgeons should scrutinize ankle fracture reductions and strive for perfection to allow for the best possible clinical outcome. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The use of locking plates in complex midfoot fractures.

INTRODUCTIONComplex fracture dislocations of the midfoot are uncommon. Improved outcomes have been demonstrated where it has been possible to restore and maintain the length and alignment of the medial column as well as the congruity of the articular surfaces. We present our experience with the use of angle-stable locking plates in the stabilisation of complex midfoot fracture dislocations.METHODSTwelve patients were identified on a prospective trauma database between 2003 and 2009. All fractures involved the medial column with four associated fracture subluxations of the lateral column also. Patients underwent open reduction internal fixation (ORIF) with restoration of the medial column axis, reduction of the articular surface congruity and stabilisation with angle-stable locking plates.RESULTSThere were no post-operative infections or neurological injuries. Ten of the twelve patients required metalwork removal. There were no implant failures prior to removal of the metalwork. At a mean follow-up of 12.4 months (range: 4–32 months), 11 patients had minimal symptoms of swelling, discomfort or stiffness in the midfoot. This did not restrict their daily activities. One patient developed post-traumatic arthritis and collapse of the medial longitudinal arch. Two patients declined removal of the metalwork.CONCLUSIONSAngle-stable locking plates provide satisfactory stabilisation following ORIF of complex midfoot fracture dislocations. Most patients will require removal of the metalwork. Following removal of metalwork, the majority of patients will maintain the length, alignment and stability of the midfoot.

HS10P DYNAMIC EXTERNAL FIXATION FOR COMMINUTED INTRA‐ARTICULAR METACARPAL HEAD FRACTURE OF THE THUMB

Principles of osteosynthesis for intra‐articular fractures dictate anatomic reduction of the fracture fragments to restore articular surface congruity and to allow early active joint motion. Open reduction and internal fixation of small comminuted intraarticular fragments may not be possible and risk devitalizing blood supply to the small fragments. Suzuki et al. described the Pins and Rubber band Traction System (PRTS) for proximal interphalyngeal joint pilon fractures. This method relies on capsuloligamentotaxis to reduce the fracture. We describe the successful use of this device for a severely comminuted fracture of the thumb metacarpal head.A 52 year old right hand dominant office manager sustained a mechanical fall with an axial compression force onto the right thumb and sustained a closed comminuted intraarticular fracture of the metacarpal head. Given the degree of comminution seen on CT, we elected to treat this with the PRTS although it is for a different indication than that described by Suzuki. We modified the post‐operative rehabilitation regime.The QuickDASH score was 20/100. The patient had achieved full range of motion (equal to the uninjured side) and full return of function by the 6 week follow up. Six month follow‐up revealed an excellent outcome and repeat radiograph showed preservation of joint space and remodelling of the metacarpal head. This paper discussed the operative and rehabilitation details of this case. We feel that in such cases minimally invasive treatment with dynamic external fixation allows early joint motion and excellent outcomes without inherent risks of open reduction and internal fixation of the small comminuted fragments.

Complete Exposure of the Articular Surface for Fixation of Patellar Fractures

Anterior tension band fixation constructs are among the mainstay of treatment of patella fractures and lead to reliable results with simple transverse fracture patterns. However, comminuted fractures of the patella require much more extensive articular reconstruction than interdigitating two large fragments to achieve a good result. In this report, we describe a technique for exposure, reduction, and stabilization of patella fractures that allows for direct visual reduction of the articular surface. Subsequent devices are applied directly to the bony surfaces of the patella without soft-tissue interposition, which distinguishes it from traditional approaches. This technique may be used to ensure articular surface congruity in simple transverse fractures and may be particularly useful in comminuted fractures when patellar excision would otherwise be considered.

The Effect of Graft Height Mismatch on Contact Pressure following Osteochondral Grafting

Hypothesis Incongruity of the articular cartilage following osteochondral transplantation affects surface contact pressure. Study Design An 80 N load was applied for 120 seconds to the femoral condyles of 10 swine knees. Contact pressures were measured using Fuji prescale film. Seven conditions were tested: (1) intact articular surface; (2) 4.5-mm diameter defect; (3) grafted with 4.5-mm diameter plug elevated 1 mm above adjacent cartilage; (4) plug elevated 0.5 mm; (5) plug flush; (6) plug sunk 0.5 mm below surface; and (7) sunk 1.0 mm. Conclusions Peak contact pressures were significantly (P< .001) elevated by ~20% after defect creation and were reduced to normal when plugs were flush. There were large and significant (P< .001) increases in pressure with plugs elevated 1 and 0.5 mm. Contact pressures with plugs sunk 0.5 and 1 mm were significantly (P< .01) higher than intact cartilage but were significantly (P < .01) lower than an empty defect. Clinical Relevance Normal contact pressures and patterns can be duplicated with flush articular surface grafts. However, small incongruities, particularly when the plug is elevated, can lead to significantly increased pressure. This reinforces the importance of articular surface congruity in the initial biomechanical state following osteochondral implantation.

Osteochondritis dissecans of the knee: A radiology case report

Objective: To discuss the case of a patient with osteochondritis dissecans, a common disorder primarily affecting children and adolescent patients that involves the medial femoral condyle, and to examine its radiologic appearance. Clinical Features: A 25-year-old man with knee pain sought treatment at a chiropractic clinic. The patient had a 2-year history of left knee pain that was exacerbated by activity and relieved with rest. Plain film radiography of the knee revealed findings consistent with osteochondritis dessicans. Intervention and Outcome: The patient was promptly referred for a concurrent orthopedic consultation with subsequent management. A trial basis of conservative care was initiated with the possibility of future surgical intervention if necessary. Conclusions: Osteochondritis dissecans is a common disorder of unknown and perhaps controversial cause. The disease is characterized by a fragment of articular cartilage and subchondral bone (osteochondral fragment) that becomes separated from the underlying bone. Treatment is aimed primarily at the preservation of articular surface congruity. (J Manipulative Physiol Ther 2000;23:347–51)

Osteochondritis dissecans of the knee: A radiology case report

Objective: To discuss the case of a patient with osteochondritis dissecans, a common disorder primarily affecting children and adolescent patients that involves the medial femoral condyle, and to examine its radiologic appearance.Clinical Features: A 25-year-old man with knee pain sought treatment at a chiropractic clinic. The patient had a 2-year history of left knee pain that was exacerbated by activity and relieved with rest. Plain film radiography of the knee revealed findings consistent with osteochondritis dessicans.Intervention and Outcome: The patient was promptly referred for a concurrent orthopedic consultation with subsequent management. A trial basis of conservative care was initiated with the possibility of future surgical intervention if necessary.Conclusions: Osteochondritis dissecans is a common disorder of unknown and perhaps controversial cause. The disease is characterized by a fragment of articular cartilage and subchondral bone (osteochondral fragment) that becomes separated from the underlying bone. Treatment is aimed primarily at the preservation of articular surface congruity.