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Background: The use of the vancomycin wrap to pretreat the hamstring graft in anterior cruciate ligament reconstruction (ACLR) has grown in popularity since it was first described in 2012 and has significantly reduced rates of postoperative infection. However, it remains unknown if this antibiotic treatment affects the molecular composition of the graft. Purpose: To establish whether treatment with vancomycin at 5 mg/mL, the most commonly used concentration, alters the molecular function of the hamstring graft in ACLR. Study Design: Controlled laboratory study. Methods: Surplus hamstring tendon collected after routine ACLR surgery was used for in vitro cell culture and ex vivo tissue experiments. Vancomycin was used at 5 mg/mL in RPMI or saline diluent to treat cells and tendon tissue, respectively, with diluent control conditions. Cell viability at 30, 60, and 120 minutes was assessed via colorimetric viability assay. Tendon cells treated with control and experimental conditions for 1 hour was evaluated using semiquantitative reverse transcription analysis, immunohistochemistry staining, and protein quantitation via enzyme-linked immunosorbent assay for changes in apoptotic, matrix, and inflammatory gene and protein expression. Results: Vancomycin treatment at 5 mg/mL significantly reduced tenocyte viability in vitro after 60 minutes of treatment ( P < .05); however, this was not sustained at 120 minutes. Vancomycin-treated tendon tissue showed no significant increase in apoptotic gene expression, or apoptotic protein levels in tissue or supernatant, ex vivo. Vancomycin was associated with a reduction in inflammatory proteins from treated tendon supernatants (IL-6; P < .05). Conclusion: Vancomycin did not significantly alter the molecular structure of the hamstring graft. Reductions in matrix protein and inflammatory cytokine release point to a potential beneficial effect of vancomycin in generating a homeostatic environment. Clinical Relevance: Vancomycin ACL wrap does not alter the molecular structure of the ACL hamstring graft and may improve graft integrity.

The practice of 'vancomycin wrapping' of harvested hamstring autografts during Anterior Cruciate Ligament Reconstruction (ACLR) surgery has gathered recent interest. This practice involves the wrapping of harvested grafts in a vancomycin-soaked swab during the preparatory phase. Different techniques are observed, and a small number of studies have shown that pre-soaking hamstring ACLR grafts in this manner dramatically reduces the post-surgical infection rate compared with standard intravenous antibiotic prophylaxis alone. However, the literature surrounding this practice is surprisingly limited and thus the basis and rationale of the 'vancomycin wrap' has established itself largely without question. The exact popularity of this practice is difficult to establish but there has been increasing disclosure of its efficacy in reducing post-operative infection in ACLR since 2012. We provide a synopsis of the current literature surrounding vancomycin and its use in 'wraps' in ACLR to help apprise the surgeon of the nature of infection in ACLR, the rationale for vancomycin, whilst considering evidence to support alternatives and discussing potential ramifications for future practice.

Objectives Tranexamic acid (TXA) is an anti-fibrinolytic medication commonly used to reduce perioperative bleeding. Increasingly, topical administration as an intra-articular injection or perioperative wash is being administered during surgery. Adult soft tissues have a poor regenerative capacity and therefore damage to these tissues can be harmful to the patient. This study investigated the effects of TXA on human periarticular tissues and primary cell cultures using clinically relevant concentrations. Methods Tendon, synovium, and cartilage obtained from routine orthopaedic surgeries were used for ex vivo and in vitro studies using various concentrations of TXA. The in vitro effect of TXA on primary cultured tenocytes, fibroblast-like synoviocytes, and chondrocytes was investigated using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) cell viability assays, fluorescent microscopy, and multi-protein apoptotic arrays for cell death. Results There was a significant (p < 0.01) increase in cell death within all tissue explants treated with 100 mg/ml TXA. MTT assays revealed a significant (p < 0.05) decrease in cell viability in all tissues following treatment with 50 mg/ml or 100 mg/ml of TXA within four hours. There was a significant (p < 0.05) increase in cell apoptosis after one hour of exposure to TXA (100 mg/ml) in all tissues. Conclusion The current study demonstrates that TXA caused significant periarticular tissue toxicity ex vivo and in vitro at commonly used clinical concentrations. Cite this article: M. McLean, K. McCall, I. D. M. Smith, M. Blyth, S. M. Kitson, L. A. N. Crowe, W. J. Leach, B. P. Rooney, S. J. Spencer, M. Mullen, J. L. Campton, I. B. McInnes, M. Akbar, N. L. Millar. Tranexamic acid toxicity in human periarticular tissues. Bone Joint Res 2019;8:11–18. DOI: 10.1302/2046-3758.81.BJR-2018-0181.R1.

With the heightened popularity of childhood sporting activity, the number of paediatric anterior cruciate ligament (ACL) ruptures has increased. Management of these injuries presents a particular challenge due to the open femoral and tibial growth plates. Physeal damage has the potential to cause angular deformity or length discrepancy. This review was conducted to determine the best way to treat this injury. A primary search of Ovid MEDLINE (1 October 2017) used the terms: (ACL or anterior cruciate ligament) and (young or child or children or pediatric or immature or pre-pubescent). Titles/Abstracts of 369 articles were screened for relevance. A total of 217 were excluded, leaving 152 articles for full-paper retrieval. Of these, 9 articles remained with one further article identified during cross-referencing; 10 papers (1 level 2 and 9 level 3) were included for analysis. Comparative studies investigating surgical (140 knees) versus conservative (110 knees) treatment provide evidence in favour of the former, in reducing instability and meniscal tears and improving return to previous activity. Of the papers analysed (163 reconstructions), there was only one case of growth arrest (0.6%) and no cases of length discrepancy. In those studies investigating early (218 patients) versus delayed (140 patients) reconstruction, medial meniscal tears and chondral injuries occurred more frequently in the delayed group. To conclude, for children, there is level 2/3 evidence that early operative ACL reconstruction offers the best chance of a return to pre-injury sporting activity and minimises the risks of further structural damage. Iatrogenic growth disturbance remains a rare but worrying complication.

Background Incorrect femoral tunnel placement is the most common cause of graft failure during Anterior Cruciate Ligament (ACL) Reconstruction. A reliable landmark can minimize errors. Aim To identify whether the Lateral Intercondylar Ridge (LIR) is a consistent anatomical structure and define its relationship with the femoral ACL insertion. Materials and methods Phase 1: we studied 23 femoral dry bone specimens macroscopically. Using a digital microscribe, the medial surface of the lateral femoral condyle was reconstructed (3D) to evaluate whether there was an identifiable bony ridge. Phase 2: 7 cadaveric specimens with intact soft tissues were dissected to identify the femoral ACL insertion. A 3D reconstruction of the femoral ACL insertion and the surface allowed us to define the relationship between the LIR and the ACL insertion. Results All specimens had a defined LIR on the medial surface of the lateral femoral condyle. The ridge was consistently located just anterior to the femoral ACL insertion. The ACL footprint was present in the depression between the ridge and the Inferior Articular Cartilage Margin (IACM). The mean distance from the midpoint of the IACM to the LIR was 10.1 mm. Conclusions This is the first study to use the microscribe to digitally reconstruct the medial surface of the lateral femoral condyle. It shows that the LIR is a consistent anatomical structure that defines the anterior margin of the femoral ACL insertion, which guides femoral tunnel placement. Our findings support the ruler technique, which is a commonly used method for anatomic single bundle ACL reconstruction.

Alarmins S100A8 and S100A9 are endogenous molecules released in response to environmental triggers and cellular damage. They are constitutively expressed in immune cells such as monocytes and neutrophils and their expression is upregulated under inflammatory conditions. The molecular mechanisms that regulate inflammatory pathways in tendinopathy are largely unknown therefore identifying early immune effectors is essential to understanding the pathology. Based on our previous investigations highlighting tendinopathy as an alarmin mediated pathology we sought evidence of S100A8 & A9 expression in a human model of tendinopathy and thereafter, to explore mechanisms whereby S100 proteins may regulate release of inflammatory mediators and matrix synthesis in human tenocytes. Immunohistochemistry and quantitative RT-PCR showed S100A8 & A9 expression was significantly upregulated in tendinopathic tissue compared with control. Furthermore, treating primary human tenocytes with exogenous S100A8 & A9 significantly increased protein release of IL-6, IL-8, CCL2, CCL20 and CXCL10; however, no alterations in genes associated with matrix remodelling were observed at a transcript level. We propose S100A8 & A9 participate in early pathology by modulating the stromal microenvironment and influencing the inflammatory profile observed in tendinopathy. S100A8 and S100A9 may participate in a positive feedback mechanism involving enhanced leukocyte recruitment and release of pro-inflammatory cytokines from tenocytes that perpetuates the inflammatory response within the tendon in the early stages of disease.

With the heightened popularity of childhood sporting activity, the number of paediatric anterior cruciate ligament (ACL) ruptures has increased. Management of these injuries presents a particular challenge due to the open femoral and tibial growth plates. Physeal damage has the potential to cause angular deformity or length discrepancy. This review was conducted to determine the best way to treat this injury. A primary search of Ovid MEDLINE (1 October 2017) used the terms: (ACL or anterior cruciate ligament) and (young or child or children or pediatric or immature or pre-pubescent). Titles/Abstracts of 369 articles were screened for relevance. A total of 217 were excluded, leaving 152 articles for full-paper retrieval. Of these, 9 articles remained with one further article identified during cross-referencing; 10 papers (1 level 2 and 9 level 3) were included for analysis. Comparative studies investigating surgical (140 knees) versus conservative (110 knees) treatment provide evidence in favour of the former, in reducing instability and meniscal tears and improving return to previous activity. Of the papers analysed (163 reconstructions), there was only one case of growth arrest (0.6%) and no cases of length discrepancy. In those studies investigating early (218 patients) versus delayed (140 patients) reconstruction, medial meniscal tears and chondral injuries occurred more frequently in the delayed group. To conclude, for children, there is level 2/3 evidence that early operative ACL reconstruction offers the best chance of a return to pre-injury sporting activity and minimises the risks of further structural damage. Iatrogenic growth disturbance remains a rare but worrying complication.

Childhood discitis is rare, can be difficult to diagnose and it is unclear whether it is an infective or simply an inflammatory process. A departmental database search of 46 434 patients identified 12 cases from 1990-2008. The mean time to diagnosis from onset was 22 days. The children usually present with altered gait, a normal infection screen (temperature, white cell count, C-reactive protein, blood cultures) and radiographic loss of intervertebral disc height. Antibiotics were given in 11 cases and but no immobilization was used. Symptoms resolved by a mean of 6.5 weeks with no recurrence. This study highlights the unusual features of this rare condition which should be confirmed with MRI scanning.

The Rotaglide knee arthroplasty has a highly congruent mobile meniscal bearing allowing both rotation and antero-posterior translation. We reviewed 137 consecutive primary arthroplasties in 120 patients at mean 11.1 years (10-12.9) following surgery. No cases were lost to follow-up. Hospital for Special Surgery (HSS) and American Knee Society (AKSS) scores were recorded at a review clinic. Radiographs were assessed using the Knee Society's roentgenographic evaluation system. Forty-two patients had died, leaving 78 patients (87 knees) available for review. Sixty-four patients (70 knees) were assessed at a clinic and in 14 (17 knees) clinical outcomes were obtained via telephone and their most recent radiographs were assessed. There were three cases of aseptic loosening and one deep infection requiring revision surgery. Two meniscal bearings were replaced with thicker inserts, one following bearing fracture and one following bearing dislocation. Survival at 11 years for aseptic loosening was 97.6% (95% CI 94.3 to 1.0) and survival using re-operation for any cause was 95.3% (95% CI 90.8 to 99.8). The Rotaglide mobile-bearing total knee replacement demonstrates good survivorship and outcome scores at 11 years following surgery.

The objective of this study was to determine the effectiveness of screening and successful treatment of methicillin-resistant Staphylococcus aureus (MRSA) colonisation in elective orthopaedic patients on the subsequent risk of developing a surgical site infection (SSI) with MRSA. We screened 5933 elective orthopaedic in-patients for MRSA at pre-operative assessment. Of these, 108 (1.8%) were colonised with MRSA and 90 subsequently underwent surgery. Despite effective eradication therapy, six of these (6.7%) had an SSI within one year of surgery. Among these infections, deep sepsis occurred in four cases (4.4%) and superficial infection in two (2.2%). The responsible organism in four of the six cases was MRSA. Further analysis showed that patients undergoing surgery for joint replacement of the lower limb were at significantly increased risk of an SSI if previously colonised with MRSA. We conclude that previously MRSA-colonised patients undergoing elective surgery are at an increased risk of an SSI compared with other elective patients, and that this risk is significant for those undergoing joint replacement of the lower limb. Furthermore, when an infection occurs, it is likely to be due to MRSA.

The Rotaglide knee arthroplasty has a highly congruent mobile meniscal bearing allowing both rotation and antero-posterior translation. We reviewed 137 consecutive primary arthroplasties in 120 patients at mean 11.1 years (10-12.9) following surgery. No cases were lost to follow-up. Hospital for Special Surgery (HSS) and American Knee Society (AKSS) scores were recorded at a review clinic. Radiographs were assessed using the Knee Society's roentgenographic evaluation system. Forty-two patients had died, leaving 78 patients (87 knees) available for review. Sixty-four patients (70 knees) were assessed at a clinic and in 14 (17 knees) clinical outcomes were obtained via telephone and their most recent radiographs were assessed. There were three cases of aseptic loosening and one deep infection requiring revision surgery. Two meniscal bearings were replaced with thicker inserts, one following bearing fracture and one following bearing dislocation. Survival at 11 years for aseptic loosening was 97.6% (95% CI 94.3 to 1.0) and survival using re-operation for any cause was 95.3% (95% CI 90.8 to 99.8). The Rotaglide mobile-bearing total knee replacement demonstrates good survivorship and outcome scores at 11 years following surgery.

Anterior knee pain following primary total knee arthroplasty is common and can be difficult to treat satisfactorily. We reviewed 28 consecutive patients (29 knees) who underwent secondary resurfacing of the patella for persistent anterior knee pain and report on the results. Mean follow-up was 28 months (range12-61) with no cases lost to follow-up. Oxford knee scores, range of motion, the patient's assessment of outcome and overall satisfaction were recorded. Seventeen out of 19 (59%) felt their knee was better following patellar resurfacing, 10 out of 29 (34%) felt it was the same and two out of 29 (7%) felt it was worse. There was a significant improvement in Oxford knee scores (p < 0.001) and significant increase in patient satisfaction (p < 0.001) following secondary resurfacing. While secondary resurfacing of the patella does not provide the solution for every case of anterior knee pain following total knee joint replacement, in greater than 50% of cases it can be effective at relieving symptoms and in this series carries a low risk of worsening symptoms or complications.