Functional restoration of patella kinematics is an essential component of TKA, whether the patella is replaced or not. This goal is accomplished by a multifactorial approach: establish proper component position and alignment, especially rotation; avoid IR of the femoral and ER of the tibial components; maintain correct joint line position; achieve symmetrical soft tissue balance.

Most modern TKA designs have an anatomic trochlear groove shape to enable midline tracking. Patella implants are better designed as well with three equilateral lugs for fixation and either dome or anatomic shape. The apex of the patella component should be aligned with the apex of the patella raphe which is more medial than lateral. This method leaves an island of exposed lateral patella facet which is managed with the “lateral slat technique” to be described. It is essentially an intraosseous lateral release. The early mobilization of modern TKA patients demands watertight closure to prevent soft tissue attenuation and late tracking issues.

When confronted with a patient with a laterally dislocated patella, implementation of the “lateral slat technique” should be done at the approach to obtain midline tracking. Such patients require a median parapatellar (MPP) approach and may need distal-lateral vastus medialis advancement (Insall Procedure).

Adherence to the principles iterated herein will produce a happy patient with good patello-femoral kinematics and function.

The major benefit of TKA with tourniquet is operating in a bloodless field. A possible secondary benefit is a better cement bone interface for fixation.

The disadvantages of tourniquet use for TKA include multiple risk factors both local and systemic - Nerve damage; Altered hemodynamics with limb exsanguinations (15‐20% increase in circulatory volume) and reactive hyperemia with tourniquet release (10% increase in limb size increasing soft tissue tension and secondary pain); Delay in recovery of muscle function; Increased risk of DVT with direct trauma to vessel walls and increased levels of thrombin-antithrombin complexes; A 5.3x greater risk for large venous emboli propagation and transesophageal echogenic particles; Vascular injury with higher risk in atherosclerotic, calcified arteries; Increase in wound healing disturbances.

Our initial experience with TKA without tourniquet was in high risk patients with previous DVT or PE, multiple scarring, or compromised cardiovascular status. We have used this method on all patients for the last eight years. The protocol includes regional anesthesia, incision and approach made with 90-degree knee flexion, meticulous hemostasis, jet lavage and filtered carbon dioxide delivered to dry and prepare bone beds for cementation, application of topical tranexamic acid and routine closure. We have encountered no differences in blood loss or transfusion rates, less postoperative pain, faster straight leg raise and knee flexion gains, and fewer wound healing disturbances. We recommend TKA sans tourniquet. Let it bleed!

Purpose and Background

Back pain impinges upon all aspects of life, has a reported UK lifetime prevalence as high as 84% and considering approximately a third of our lives are spent asleep the paucity of research into the effect a mattress has on back pain and sleep is surprising. Mood changes, effecting an increase in pain perception, due to sleep loss may also lead to a downward spiral of increasing back pain and greater sleep loss. A controllable factor in this spiral, affecting both aspects, is the mattress but to the authors' knowledge none currently available on the market have any robust, published research to objectively support any claims made and at best being ‘endorsed’ by experts. This may lead to possible misinterpretation of efficacy and leave professionals at a loss with what to advise when questioned.

Stoppa approach has recently been adapted for pelvic surgery as it allows direct intra-pelvic reduction and fixation of the quadrilateral plate and anterior column. We report our early experience, indications and complications with this exposure introduced in 2010 in our tertiary unit.

A Retrospective review of all Stoppa approaches in pelvic-acetabular fixations was performed from a prospectively maintained database.

Of the 25 patients, mean age 40 years (range 15–76), who underwent pelvic-acetabular fixation using Stoppa approach, 21 patients had mean follow up of 7.3 months (1–48 months). All except 24% of patients had one or more additional systemic injury some requiring additional surgery. There were 6 acetabular fractures, 13 pelvic ring injuries and 6 combined fractures. Mean injury-surgery interval was 9 days (range 3–20). 8 patients had an isolated Stoppa approach whilst the remaining others also had an additional approach. Mean surgical time was 239 minutes. Anatomical reduction was achieved in 96% (24/25) cases. There was 1 minor intra-operative vascular injury, repaired immediately successfully, and no late wound infections, or other visceral complications. One patient reported new onset sensory numbness which resolved after the first review. Two patients reported erectile dysfunction thought to be caused by the initial injury. One patient had asymptomatic plate loosening. None required revision surgery.

Despite the obvious learning curve, we found this approach safe and it did not compromise accuracy of reduction in well selected patients, but early surgery within 10–14 days is recommended to aid optimal reduction.

Introduction:

The Best Practice Tariff (BPT) for hip fractures was introduced in April 2010 to promote a number of quality markers, including surgery within 36 hours. We conducted an audit to see whether the introduction of the BPT has had an inadvertent adverse effect on delay to fixation of unstable ankle fractures.

Introduction:

In 2009 the Smart Toe implant was introduced as an option for lesser toe fusion in our department. The Smart Toe is an intramedullary device made from Nitinol, an alloy that can change shape with a change of temperature, expanding within the intramedullary canals of the proximal and middle phalanx to achieve fixation. The advantages of the Smart Toe are that patients are spared 6 weeks with K-wires protruding from their toes and there is no need for wire removal. We conducted a retrospective review of radiographic and clinical outcomes to assess the performance of this implant.

Aims

Femoroacetabular Junction Impingement (FAI) describes abnormalities in the shape of the femoral head–neck junction, or abnormalities in the orientation of the acetabulum. In the short term, FAI can give rise to pain and disability, and in the long-term it significantly increases the risk of developing osteoarthritis. The Femoroacetabular Impingement Trial (FAIT) aims to determine whether operative or non-operative intervention is more effective at improving symptoms and preventing the development and progression of osteoarthritis.

The K2M MESA Rail is a new implant with a unique beam-like design which provides increased rigidity compared with a standard circular rod of equivalent diameter potentially allowing greater control and maintenance of correction. The aim of this study was to review our early experience of this implant.

We retrospectively reviewed the case notes and radiographs of all consecutive cases of spinal deformity correction in which at least one rail was used. All radiological measurements were made according to the Scoliosis Research Society definitions.

Since June 2012 thirty-three cases of spinal deformity correction were performed using the K2M Rail system. One case was excluded as there were no pre-operative radiographs. Median age was 15 years; there were 23 females. There were 26 scoliosis cases of which two had associated Chiari malformation, three were neuromuscular, and the remainder were adolescent idiopathic cases. Six patients had kyphotic deformity secondary to Scheuermann's disease. Mean length of follow-up was 16 months. In the scoliosis cases the mean pre-operative Cobb angle of the major curve was 58.6° with a mean correction of 35.6°. The mean post-operative thoracic kyphosis was 21.1°. The median number of levels included in the correction was 13. Bilateral rails were used in four cases, the remainder had one rail on the concave side and a contralateral rod. No patients required an anterior release or staged surgery. All kyphosis cases had posterior apical corrective osteotomies. The mean pre-operative thoracic kyphosis was 75.5° with a mean correction of 31°. The median number of levels included in the correction was 11. Four patients had bilateral rails. No patients required anterior release. Complications: two patients had prominent hardware. One patient had a malpositioned screw causing nerve root irritation, which was removed. There were three superficial infections, which settled with antibiotics. There were no cases of implant breakage, screw pull-out, or loss of correction.

The K2M MESA Rail is a powerful new implant design which helps to achieve and maintain satisfactory correction of complex spinal deformity, and is particularly strong at correcting kyphotic deformity. It also enables restoration of normal thoracic kyphosis, particularly in idiopathic thoracic curves, which tend to be lordosing. This may prevent thoracic flat back and potential long-term sequelae. Early results show that the system is as safe and effective as other posterior deformity correction implants on the market, however, it requires further prospective follow-up to ascertain its outcomes in the long-term.

Unicompartmental knee arthroplasty (UKA) has been gaining popularity in recent years due to its perceived benefits over total knee arthroplasty (TKA), such as greater bone preservation, reduced operating-room time, better post-operative range of motion and improved gait. However there have been failures associated with UKA caused by misalignment of the implants that have lead to revisions. To improve the implant alignment a robotic guidance system called the RIO Robotic Arm has been developed by MAKO Surgical Corp (Ft. Lauderdale, FL), which is designed to give improved accuracy compared to traditional UKA using cutting jigs and other manual instrumentation.

The University of Strathclyde in association with Glasgow Royal Infirmary has undertaken the first independent RCT trial of the MAKO system against the Oxford unicompartmental knee arthroplasty – a conventional UKA used in the UK. Motion analysis was used in order to obtain a quantitative assessment of their movement. The results from a total of 51 patients (23 MAKO, 28 Oxford) that underwent a one year post-operative biomechanical assessment were investigated.

Motion analysis showed that during level walking the MAKO group achieved a higher knee excursion during the highest flexion portion of the weight bearing stage of the gait cycle (foot-strike to mid-stance) compared to the Oxford group (18.6° and 15.8° respectively). This difference was statistically significant (p-value = 0.03). Other knee excursion values that were compared were from mid-stance to terminal stance, and overall knee flexion. No statistically significant differences were seen in either of these measurements. A subsequent comparison of both MAKO and Oxford groups with a matched normal cohort (50 patients), demonstrated that there wasn't a statistically significant difference between the MAKO group and the normal knees during mean knee excursion from foot-strike to mid-stance (18.6° and 19.5° respectively, p-value 0.36). However the Oxford group, with a lower knee excursion was found to be significantly different to our normal control group (15.8° and 19.5° respectively, p-value < 0.001).

This suggests that the robotic-assisted knees behaved more similarly to normal gait during this phase of the gait cycle than those of the conventional group. While significant differences in gait were found between the Oxford and MAKO groups, further work is required to determine if this results in improved knee function that is perceptible to the patient.

Summary

This study shows a significant reduction in knee adduction moment in patients with medial compartment osteoarthritis, in both the symptomatic and asymptomatic knees. Long-term follow-up studies are required to confirm the effect of treating the asymptomatic side on disease progression.

Summary Statement

This study provides preliminary evidence that people with knee osteoarthritis have greater asymmetry in joint loading than healthy controls. Altered loading of the contralateral limb may signify increased risk of injury to other lower limb joints in knee osteoarthritis.

Summary

The dGEMRIC index correlates more strongly with the pattern of radiographic joint space narrowing in hip osteoarthritis at five year follow-up than morphological measurements of the proximal femur. It therefore offers potential to refine predictive models of hip osteoarthritis progression.

Summary

162 patient cohort with serial Metal Artefact Reduction Sequence MRI scans. Patients with normal initial scans can be followed up at 1 year. Those with abnormal scans should be followed up at a shorter interval of 6 months.

The major benefit of TKA with tourniquet is operating in a bloodless field. A possible secondary benefit is a better cement bone interface for fixation.

The disadvantages of tourniquet use for TKA include multiple risk factors both local and systemic.

Nerve damage

Our initial experience with TKA without tourniquet was in high risk patients with previous DVT or PE, multiple scarring, or compromised cardiovascular status. We have used this method on all patients for the last eight years. The protocol includes regional anesthesia, incision and approach made with 90-degree knee flexion, meticulous hemostasis, jet lavage and filtered carbon dioxide delivered to dry and prepare bone beds for cementation, application of topical tranexamic acid and routine closure. We have encountered no differences in blood loss or transfusion rates, less post-op pain, faster straight leg raise and knee flexion gains, and fewer wound healing disturbances. We recommend TKA sans tourniquet. Let it bleed!

Infection after total knee arthroplasty poses formidable challenges to the surgeon. Once an infection is diagnosed, the identification of the organism and its sensitivity to antibiotics is essential. The host's healing capacity is vital. Optimisation of modifiable comorbidities, supplemental nutrition and cessation of smoking can improve wound healing. Surgical goals include debridement of necrotic tissue and elimination of the dead space. Intravenous antibiotics and a two-stage protocol are the standard of care. At our institution, the first stage is performed with an implant and antibiotic-cement composite. This articulating spacer maintains limb length and tissue compliance. The patient can maintain a functional status between stages. Definitive reconstruction is more readily accomplished with this method in contrast to the static spacer approach. The clinical efficacy of this protocol has been well documented in the literature.

Summary Statement

We have shown that integrin mRNA expression is regulated by the application of mechanical load. This indicates that mechanical loading may modify cell sensitivity to perceive further load through increased interaction with the ECM.

Arthroscopic intervention for early symptoms of arthrosis of the knee was a well-established procedure until Moseley cited his study showing no difference in outcomes when compared to “sham” surgery. Now there is no opportunity for reimbursement with arthroscopic debridement unless mechanical internal derangement can be documented. There are, however, several specific lesions of arthrosis which respond well to arthroscopic intervention and are reimbursed by third party payers.

Arthroscopic three compartment microfracture with non-weight bearing and passive motion for eight weeks post- op has significantly relieved symptoms. Second look biopsies have confirmed type II hyaline cartilage and increased joint interval. Proper patient selection is paramount and guidelines will be discussed.

Isolated severe patellofemoral arthrosis with patella subluxation responds to arthroscopic patella lateral facetectomy. Jones has reported significant pain relief up to two years with this excellent option for a difficult patient problem. The technique and results will be presented in detail.

Loss of terminal extension in the arthritic knee can accelerate deterioration and force earlier decision for TKA. Parson's third tubercle is an osteophyte that forms just anterior to the ACL insertion on the tibia and is the frequent cause of extension loss. Arthroscopic resection of the tubercle results in increased extension and diminishes the stress concentration assuring better longevity for the native knee. The diagnostic characteristics, resection techniques and results of the Dallas series will be presented.

Functional restoration of patella kinematics is an essential component of TKA, whether the patella is replaced or not. This goal is accomplished by a multifactorial approach: establish proper component position and alignment, especially rotation, avoid IR of the femoral and ER of the tibial components, maintain correct joint line position, and achieve symmetrical soft tissue balance

Most modern TKA designs have an anatomic trochlear groove shape to enable midline tracking. Patella implants are better designed as well with three equilateral lugs for fixation and either dome or anatomic shape. The apex of the patella component should be aligned with the apex of the patella raphe which is more medial than lateral. This method leaves an island of exposed lateral patella facet which is managed with the “lateral slat technique” to be described. It is essentially an intraosseous lateral release. The early mobilisation of modern TKA patients demands watertight closure to prevent soft tissue attenuation and late tracking issues.

When confronted with a patient with a laterally dislocated patella, implementation of the “lateral slat technique” should be done at the approach to obtain midline tracking. Such patients require a median parapatellar (MPP) approach and may need distal-lateral vastus medialis advancement (Insall Procedure).

Adherence to the principles iterated herein will produce a happy patient with good patello-femoral kinematics and function.

The number of primary Total Knee Arthroplasty (TKA) and primary Total Hip Arthroplasty (THA) procedures carried out in England and Wales is increasing annually. The British Orthopaedic Association guidelines for follow up currently differ for patients with TKA and THA. In THA the BOA recommends that Orthopaedic Data Evaluation Panel (ODEP) 10A rated implants should be followed up in the first year, once at seven years and three yearly thereafter. The BOA guidelines for TKA minimum requirement is radiographs at 5 years and each five years thereafter. Few studies have investigated if early follow up affects patient management following total hip and knee arthroplasty

We carried out a retrospective review of all revision procedures carried out in our institution between April 2010 to April 2013. The medical notes and radiographs for each patient were examined to determine the operative indications and patients symptoms. 92 knee revisions and 143 hip revisions were identified. Additionally we retrospectively reviewed the outcome of 300 one year routine arthroplasty follow up appointments.

The mean time of hip revision was 8.5years (range 0 to 27years) and 5.6years (range 0 to 20years) for knee revisions. The commonest cause for revision was aseptic loosening associated with pain in 49 (53%) of knee revision patients and 89 (63%) of hip revisions. Infection accounted for 26 (28%) knee revisions and 16 (12%) hip revisions. Only 1% of hip and knee revisions was carried out in asymptomatic patients with aseptic loosening.

We did not identify any cases were a patients management was altered at the routine arthroplasty review clinic and none were referred on for further surgical treatment. The findings of our study suggest there is no evidence for a routine one year arthroplasty review and revisions were carried out in asymptomatic patients in 1% of patients.

Aim:

To determine the efficacy and safety of the Magec system in early onset scoliosis (EOS).