The posterior compartments of the knee are currently accessed arthroscopically through anterior, posteromedial or posterolateral portals. A direct posterior portal to access the posterior compartments has been overlooked due to a perceived high-risk of injury to the popliteal neurovascular structures. Therefore, this study aimed to investigate the safety and accessibility of a direct posterior portal into the knee. This cross-sectional study comprised a sample of 95 formalin-embalmed cadaveric knees and 9 fresh-frozen knees. Cannulas were inserted into the knees, 16mm from the vertical plane between the medial epicondyle of the femur and medial condyle of the tibia and 8 and 14mm (females and males respectively) from the vertical plane connecting the lateral femoral epicondyle and lateral tibial condyle. Landmarks were identified in full extension and cannula insertion was completed with the formalin-embalmed knees in full extension and the fresh-frozen in 90-degree flexion. Posterior aspects of the knees were dissected from superficial to deep, to assess potential damage caused by cannula insertion. Incidence of neurovascular damage was 9.6% (n=10); 0.96% medial cannula and 8.7% lateral cannula. The medial cannula damaged one small saphenous vein (SSV) in a male specimen. The lateral cannula damaged one SSV, 7 common fibular nerves (CFN) and both CFN and lateral cutaneous sural nerve in one specimen. All incidences of damage occurred in formalin-embalmed knees. The posterior horns of the menisci were accessible in all specimens. A medial-lying direct posterior portal into the knee is safe in 99% of occurrences. The lateral-lying direct posterior portal is of high risk to the CFN

Tibial cut is a crucial step in ensuring adequate and appropriate proximal tibial resection for mechanical orientation and axis in total knee replacement. We evolved the concept and technique of Condylar Differential for planned tibial cuts in conventional total knee replacement, which accounts for individual variations and reflects individual mechanical orientation and alignment. We used Condylar Differential in 37 consecutive total knee replacements including valgus knees and severe advanced osteoarthritis. First a vertical line is drawn on digital weight bearing anteroposterior radiograph for mechanical axis of tibia. Then a horizontal line is drawn across and perpendicular to the mechanical axis. The distances between the horizontal line and the lowest reproducible points of articular surfaces of medial and lateral tibial condyles respectively are measured. The difference between two measurements obviously represents Condylar Differential. Condylar Differential, adjusted to the nearest millimetre, is maintained in executing tibial cuts, successively if necessary. Condylar Differential measurement showed a very wide variation, ranging from 8–6 (2 mm) to 10-0 (10 mm). We found that prior measurement of Condylar Differential is a simple, consistent and effective estimate and individualises the tibial cut for optimal templating of tibia. We encountered no problems, adopting this technique, in our series. Condylar Differential contributes to optimal individualised tibial cut in conventional total knee replacement and is a useful alternative to computer navigated option with comparable accuracy in this respect. While we used the technique in digitised radiographs, this technique can also be applied to plain films, allowing for magnification

Background. Mechanics and kinematics of the knee following total knee replacement are related to the mechanics and kinematics of the normal knee. Restoration of neutral alignment is an important factor affecting the long-term results of total knee replacement. Tibial cut is a vital and crucial step in ensuring adequate and appropriate proximal tibial resection, which is essential for mechanical orientation and axis in total knee replacement. Tibial cut must be individually reliable, reproducible, consistent and an accurate predictor of individual anatomical measurements. Conventional tibial cuts of tibia with fixed measurements cannot account for individual variations. While computer navigated total knee replacement serves as a medium to achieve this objective, the technology is not universally applicable for differing reasons. Therefore we evolved the concept and technique of Condylar Differential for planned tibial cuts in conventional total knee replacement, which accounts for individual variations and reflects the individual mechanical orientation and alignment. Methods. We used the Condylar Differential in 37 consecutive total knee replacements. We also applied the technique in valgus knees and severe advanced osteoarthritis. First a vertical line is drawn on the digital weight bearing anteroposterior radiograph for mechanical axis of tibia. Then a horizontal line is drawn across and perpendicular to the mechanical axis of tibia. The distances between the horizontal line and the lowest reproducible points of the articular surfaces of the medial and lateral tibial condyles respectively are measured. The difference between the two measurements obviously represents the Condylar Differential. Condylar Differential, adjusted to the nearest millimeter, is maintained in executing the tibial cuts, if necessary successive cuts. Results. Condylar Differential measurement showed a very wide variation, ranging from 8–6 (2 mm) to 10-0 (10 mm). We found that prior measurement of Condylar Differential is a simple, consistent and effective estimate and individualizes the tibial cut for optimal templating of tibia in total knee replacement. We encountered no problems, adopting this technique, in our consecutive series of total knee replacements. Conclusions. Condylar Differential contributes to optimal individualized tibial cut in conventional total knee replacement and is a useful alternative to computer navigated option with comparable accuracy in this respect. While we used the technique of Condylar Differential in digitized radiographs, this technique can also be applied to plain films, allowing for the magnification

Introduction. We report a case which total knee arthroplasty (TKA) was able to be performed on schedule for the patient with occult fracture of proximal tibia which seemed to have occurred three months prior to the surgery, and has healed in short period of time by the use of Teriparatide. Case report. The patient is 84-year-old female, having right knee pain for past 7 years. Her knee pain increased by passive extension maneuver that was done by a bonesetter 3 months prior to the surgery. On her initial visit, the X-ray finding was severe medial osteoarthritis, and femorotibial angle (FTA) in the upright film was 197°, but there was no other disorder including fracture. Since the bone mineral density (BMD) of affected femoral neck was 62%YAM, and affected lateral femoral condyle as well as lateral tibial condyle seemed very porotic, we started using daily 20μg Teriparatide injection from 3 months prior to the surgery. Proximal tibial fracture was presented in the X-ray taken on the day before surgery, but since adequate bone union has already been formed, surgery was performed on schedule. Tibial implant with long stem was used for just to be certain. Thanks to the Teriparatide, the condition of cancellous bone in cut surface was excellent, and reaming of the tibia through fracture area felt very solid. Discussion. Proximal tibial fracture that occurred just before TKA is very rare. The fracture in this case was probably due to the maneuver done by the bonesetter. Teriparatide is indicated when osteoporosis is severe and the patient is at risk for fracture. We also indicate Teriparatide for the patients whose femoral neck BMD is very low and severe valgus knee or varus knee is present. Unloaded side of femoral or tibial condyle is usually very porotic in such a case. In our case, the fracture was so called fragility fracture which was found incidentally the day before surgery, but TKA could be done on schedule since adequate callus has been formed by the use of Teriparatide which started 3 months prior to the surgery

Aims: The relationship between the structural and histological changes of articular hyaline cartilage and the stiffness of this tissue was evaluated. Methods: Artscan 1000, an articular stiffness tester was used for in vivo measurements during arthroscopy indicated on orthopaedic or trauma disorders. 100 patients were involved in the study. Measurements were performed at eight standard sites: medial and lateral femoral condyles, medial and lateral tibial condyles, medial and lateral facet of the patellofemoral joint and medial and lateral facet of the patella. Standard 10N predefined loading force was applied during the measurements. The indenter force produced by the deformed cartilage tissue is used as the indicator of cartilage stiffness. Results: Clinical measurements revealed a topographical variation of the stiffness of normal cartilage. In general, the femoral cartilage is stiffer than tibial or patellar one. The stiffest cartilage was measured at the lateral femoral condyle. Conclusions: Changes of articular cartilage structure can be indirectly observed during arthroscopy as an alteration in cartilage stiffness

Introduction. The purpose of this study was to evaluate the mid-term clinical and radiological results in patients who were managed by double metal augmentations in proximal tibial uncontained bony defects undergoing primary or revision total knee arthroplasty. Materials and Methods. We performed double metal augmentations in proximal tibial uncontained bony defects undergoing total knee arthroplasty. Out of total 14 patients, 8 patients (4 priamry arthroplasty, 4 revision arthroplasty), mean 61.3 (50–80) years, were available for review at least 5 years follow up. The average follow up period was 86.3(60–99) months. Range of motion, American Knee Society Score were evaluated pre- and postoperatively as a clinical values. Another clinical assessments undertaken at the final reviews, Western Ontario and McMaster Universities osteoarthritis index (WOMAC), Oxford knee score (OKS), Short Form-36 (SF-36), Lower extremity functional scale (LEFS), and Lower extremity activity scale (LEAS) were checked. Radiological results, involving presence of radiolucent lines (RLLs) > 1mm in width, and osteolysis at the block-cement-bone interface were taken under fluoroscopic images at postoperatively and annually thereafter. Results. At the final follow-up, range of motion was increased from 97.5° to 121.3° and American Knee society score was significantly improved from 30.4 to 92.6 (p=0.03) and functional score from 43.1 to 86.9 (p=0.03). At the final follow-up, average WOMAC score was 10(2–20), OKS was 40.5(33–47), LEFS was 55.8(34–75), and LEAS was 10.9(7–15). There was no broken or deterioration sign at between first and second metal block at radiographically. RLLs at the block-cement-bone interfaces under fluoroscopic images were examined in 3 knees, but didn't cause any failure sign such as osteolysis, or collapse, or instability at final reviews. Conclusions. The clinical and radiological evaluations showed that the double metal augmentations is a favorable and useful way to manage severe uncontained proximal tibial bony defects at least 5 years mid-term follow up period. Preoperative standing anteroposterior (AP) radiograph (Fig 1) shows severe uncontained proximal tibial bone defects, approximately 23 mm compared with unaffected lateral tibial condyle. AP view of fluoroscopy with medial double metal blocks (10 mm block + down sized 10 mm block) combined intramedullary stem at 60-month follow-up after primary total knee arthroplasty, demonstrating radiolucent line (white arrow) of 2.5 mm width bottom the block (Fig 2). AP view at 92-month follow-up indicating non-progressive stable radiolucent lines (white arrow) at same area without any radiographic failure signs and broken sign between first and second metal block (Fig 3)

Introduction. To achieve well aligned and balanced knee is essential for the post-operative outcome in total knee arthroplasty (TKA). Gap balancing technique can adjust the bone cut depending on the soft tissue balance in addition to soft tissue releases. Therefore, gap balancing technique would be more advantageous in soft tissue balance comparing to measured resection technique (MRT) in which soft tissue balancing relayed on soft tissue releases alone. Nevertheless, the influence of surgical technique on the post-operative knee stability has not been fully investigated. Objective. We introduced a new surgical technique (medial gap technique: MGT) according to modified gap technique regarding medial knee stability as important. The intra-operative soft tissue balance and post-operative knee stability were compared between MGT and MRT in posterior-stabilized (PS) TKA for varus type osteoarthritic knees. Materials & Methods. Sixty varus type osteoarthritis knees were involved in this study. PS type TKAs (NexGen LPS flexR) were performed using MGT in 30 knees (MGT group) and MRT in 30 knees (MRT group). The extension gap was made in the same manners in both groups. Both femoral and tibial bone cuts were perpendicular to the mechanical axis. Medial soft tissue releases were limited until the spacer block with the thickness corresponding to the resected lateral tibial condyle could be inserted. After extension gap was prepared, OFR-tensorR was used to assess soft tissue balance (center gap, varus angle) at extension and flexion prior to posterior femoral condyle bone resection. Both differences of the center gap and varus angle between at extension and flexion were calculated and used for size selection and external rotation angle of femoral component in MGT. The final joint component gaps were evaluated using OFR-tensorR with both femoral trial in place and patello-femoral joint reduced at 0, 10, 30, 45, 60, 90, 120 and 135 degrees of flexion. Quantitative stress radiographies were performed at 1 month, 6 months and 1 year post-operatively to assess joint stability. Joint opening distance (mm) at both medial and lateral joint compartment were measured with knee extension and flexion. Each parameter was compared between MGT and MRT group using unpaired t-test (p<0.05). Results. Pre-operative factors showed no significant differences between 2 groups. The joint component gaps were significantly larger in MRT group from 45 to 135 degrees of flexion (Fig.1). The joint opening at the lateral compartment was significantly larger than medial at both knee extension and flexion in both groups. The joint openings were significantly larger bilaterally in MRT group comparing to MGT group at both extension and flexion (Fig.2, 3). Discussions. Medial instability has been reported as a possible reason for the persistent knee pain after TKA in the varus knees. We proposed a new surgical technique (MGT) not to deteriorate medial stability and allow lateral looseness in TKA. Post-operative knee stability was superior in MGT group comparing to MRT group from one month to one year after surgery. The difference of the intra-operative soft tissue balance might play an important role on the post-operative knee stability

Purpose: To determine the relationship between the in vivo indentation stiffness and indices of histopathological degeneration of human knee articular cartilage. Materials and Methods: Cartilage compressive stiffness was measured in 98 patients during in vivo knee arthroscopies. The age of the patients ranged from 21 to 63 years (mean age 29 years). Male to female ratio of the patients was 37:61. The measurements were performed at eight standard sites. No chondropathic or grade I. chondropathic surfaces were measured. An indentation instrument, Artscan 1000, was used for in vivo measurements. Four plugs were harvested from each knee for histological analysis. The stage of cartilage degeneration was assessed according to Mankin histolopathology score. 16 measurements were performed after ACI. Results: Lateral femoral condyle stiffness (mean + SD; 5.12 ±1.02N) was greater than all other sites and was significantly greater than mean values obtained for medial femoral condyle (4.8 ± 1.22N); medial and lateral trochlea (4.2 + 0.92, 4.6 + 1.27N), medial (3.1 ± 0.66N) and lateral patella (3.3 ± 1.01N); and medial and lateral tibial condyle for all subjects (2.4 ± 1.17N and 3.2 ± 1.16N). The dynamic modulus of the normal or mildly degenerated cartilage correlated negatively with the Mankin score: r (Spearman) = −0.823, n = 348. Stiffness at the repaired site was similar to normal cartilage at adjacent sites in the knee. Conclusion: The high negative correlation between stiffness and the Mankin score suggests that the stage of cartilage degeneration can be quantitatively and indirectly assessed with a hand-held instrument during arthroscopy

Purpose: To determine the relationship between the in vivo indentation stiffness and indices of histopathological degeneration of human knee articular cartilage. Materials and Methods: Cartilage compressive stiffness was measured in 98 patients during in vivo knee arthroscopies. The age of the patients ranged from 21 to 63 years (mean age 29 years). Male to female ratio of the patients was 37:61. The measurements were performed at eight standard sites. No chondropathic or grade I. chondropathic surfaces were measured. An indentation instrument, Artscan 1000, was used for in vivo measurements. Four plugs were harvested from each knee for histological analysis. The stage of cartilage degeneration was assessed according to Mankin histolopathology score. 16 measurements were performed after ACI. Results: Lateral femoral condyle stiffness (mean + SD; 5.12 ±1.02N) was greater than all other sites and was significantly greater than mean values obtained for medial femoral condyle (4.8 ± 1.22N); medial and lateral trochlea (4.2 + 0.92, 4.6 + 1.27N), medial (3.1 ± 0.66N) and lateral patella (3.3 ± 1.01N); and medial and lateral tibial condyle for all subjects (2.4 ± 1.17N and 3.2 ± 1.16N). The dynamic modulus of the normal or mildly degenerated cartilage correlated negatively with the Mankin score: r (Spearman) = −0.823, n =. 348. All visually degenerated samples were softer (dynamic modulus < 2.9 Mpa) than the visually and histologically normal samples (dynamic modulus = 14.7 + 2.9 MPa). Stiffness at the repaired site was similar to normal cartilage at adjacent sites in the knee. Conclusion: The high negative correlation between stiffness and the Mankin score suggests that the stage of cartilage degeneration can be quantitatively and indirectly assessed with a hand-held instrument during arthroscopy

Aim: To assess and establish the reason for repeating knee arthroscopies. A retrospective study at Torbay General Hospital. Methods and results: The sample period was from January-2004 to July 2007 during which 695 knee arthroscopies were done, of which 71 patients (10 %) were coded as having same knee scoped again. A total of 58 out of 71 patients notes were available for review of which 12 were excluded due to coding-error and septic-arthritis. Among the 45 patients included, 67% were males and mean age was 44 years (range 17 to 70 years). The average time from listing the patient to actual scope was 20 weeks (range 0 to 54). At their first scope 24 patients required partial meniscectomies, of which 11 (45%) and 6 (25%) patients had posterior-horn and body of medial meniscal tears respectively, and 7 (29%) had tears in posterior-horn of lateral meniscus. Among the 23 who had chondral defects, 73% had changes on medial femoral condyle, 70% on patella, 52% on medial tibial condyle, 47% over lateral femoral condyle, 43% on trochlear grove, and 39% on lateral tibial condyle. Thirty-three-percent patients had anterior cruciate ligament (ACL) tears and 6% require loose bodies removal. Average time between re-scopes was 16 months (range 0 to 3.5 years). The numbers of patients requiring repeat knee arthroscopy for similar clinical problems were 16 out of 695 patients (2.3%). During repeat arthroscopies, 10/16 (62%) required procedures on meniscus, 4/16 (25%) for osteochondral lesions 2 patients had same diagnosis as ACL tears. 90% of partial meniscectomies were repeated on the posterior horn of both medial and lateral meniscus, and 20% required trimming of body of the meniscus. Conclusion: Contrary to general opinion being too many patients knees are been re-scoped, only 16/695 patients (2.3%) had their knees re-scoped for similar problem as found at first arthroscopy. 62% of these patients required partial meniscectomy mainly on the posterior-horns and 25% had chondral defects. We concluded that MR-arthrogram should be considered due to its specificity and sensitivity as detailed in literature, before performing repeated knee arthroscopy

The aim of this paper is to present our experience from the surgical treatment of lower limb fractures in the developing skeleton with the use of bio-absorbable PLLA implants as a means of internal fixation. From 1997 until 2002, twenty-three patients (15 boys and 8 girls, ages ranging from 7 to 15 years old, mean of 12 years) who had suffered from 30 lower limb fractures were operated on in our department, with the use of PLLA screws as a means of internal fixation that followed the standard open reduction procedure. We surgically treated 20 tibial fractures (distal metaphysis:1,medial malleolar:6,distal epiphysis lesions:9,tibial spine:2, lateral tibial condyle:1, tibial shaft:1), 8 fibular fractures (distal metaphysis:2, distal epiphysis lesions:5, fibular shaft:1), one transtrochanteric fracture and 1 patellar fracture. All patients were operated on under constant radiographic control. A cast was applied, post-operatively, to all patients, for a period of 3–4 weeks. Gradual and assisted weight-bearing and ambulation, was commencing immediately after the cast removal. All patient’s (with the exception of 1 case of delayed callus formation) post-operative period was completely normal. However, follow-up revealed the development of osteolytic lesions (bone absorption cysts) in 3 of our patients. All lesions were located in the border between epiphysis and metaphysis, at the exact position were the PLLA screws had been placed. The use of PLLA implants in the treatment of fractures renders unnecessary a second operation for the removal of the osteosynthesis’ material. Nevertheless, we should be quite reluctant when deciding to use the PLLA screws in the treatment of these fractures in the developing skeleton, especially of the lower limbs, were the applied weight bearing forces are quite powerful

Introduction: The usual surgical treatment of valgus knee in Ellis van Creveld Syndrom (EVC), is high tibial osteotomy. However, this approach failed to achieve the expected goal of lasting correction. Based on Dr. Paley’s observations, and our previous unsuccessful treatment of valgus knee in EVC syndrome, we changed the surgical approach. The aim of the surgical treatment is to eradicate all the elements causing sever valgus knee: 1) dysplasic lateral tibial condyle, 2) progressive depression of the lateral tibial plateau, 3) short fibula, 4) short and contracted fascia lata, 5) short lateral collateral ligament and biceps femoris, 6) short lateral head of gastrocnemius, and 7) contracted lateral knee capsule and lateral retinaculum. In many aspects the pathology of Blount’s disease grade 5 or 6 is similar, but located at the medial tibia causing genu vara. Materials and Methods: Three valgus knees of EVC syndrome and two varus knees of Blount’s disease grade 5 & 6 underwent surgical treatment by a unique surgical approach to address all pathologies which contribute to the deformity. In the cases of EVC syndrome the first stage operation included: 1) peroneal nerve release and soft tissue release including T.F.L., B.F., L.C.L., capsule and gastrocnemius, 2) arthrogram, 3) fibulectomy, 4) elevation of lateral tibial plateau with bone graft, 5) reconstruction of L.C.L. and B.F., 6) lateral release of retinacula and rerouting of patella, and 7)cast application. In the second stage operation of these cases a corrective high tibial osteotomy was performed. In the Blount’s disease knees the operative treatment was performed in one stage and included: 1) arthrogram, 2) elevation of the medial tibial plateau, 3) fibulotomy, 4) closing wedge tibial osteotomy based laterally, 5) transfer of the bony wedge under the elevated plateau and fixation. Results: All deformities were corrected with no recurrence, and stability of the knees persisted. We had one common peroneal nerve neuropraxia that recovered and one wound dehiscence. Conclusions: In both conditions, EVC syndrome and Blount’s disease, corrective high tibial osteotomy does not address the pathology, and recurrence is to be expected. The described surgical technique fulfills that target – eradication of the pathologic elements that lead to valgus or varus

Aims

This study investigated the effects of transcatheter arterial embolization (TAE) on pain, function, and quality of life in people with early-stage symptomatic knee osteoarthritis (OA) compared to a sham procedure.

Aims

Mobile-bearing unicompartmental knee arthroplasty (UKA) with a flat tibial plateau has not performed well in the lateral compartment, leading to a high rate of dislocation. For this reason, the Domed Lateral UKA with a biconcave bearing was developed. However, medial and lateral tibial plateaus have asymmetric anatomical geometries, with a slightly dished medial and a convex lateral plateau. Therefore, the aim of this study was to evaluate the extent at which the normal knee kinematics were restored with different tibial insert designs using computational simulation.

Objectives

Little biomechanical information is available about kinematically aligned (KA) total knee arthroplasty (TKA). The purpose of this study was to simulate the kinematics and kinetics after KA TKA and mechanically aligned (MA) TKA with four different limb alignments.

Objectives

The purpose of this study was to clarify the appearance of the reparative tissue on the articular surface and to analyse the properties of the reparative tissue after hemicallotasis osteotomy (HCO) using MRI T1ρ and T2 mapping.

Objectives

There remains a lack of data on the reliability of methods to estimate tibial coverage achieved during total knee replacement. In order to address this gap, the intra- and interobserver reliability of a three-dimensional (3D) digital templating method was assessed with one symmetric and one asymmetric prosthesis design.