This randomized controlled study aimed to compare surgical duration, intra-operative blood loss, and fluoroscopy time between the suprapatellar and infrapatellar approaches for intramedullary interlocking nailing of tibia. We included 40 adult patients with tibial shaft fractures, excluding those with non-union, revision surgery, or polytrauma. Patients were divided equally into two groups using block randomization: Group A (20 patients) underwent the infrapatellar approach, and Group B (20 patients) underwent the suprapatellar approach. Blood loss was measured using gravimetric method and by changes in pre-operative and post operative haemoglobin levels. Surgical duration was estimated by calculating the time elapsed between the start and end of the procedure and fluoroscopy time was logged from the fluoroscopy machine. In group A, blood loss averaged 154±30.98ml, slightly more than in group B (150±32.92ml), though the difference was not statistically significant (p>0.05). Group A also showed a higher difference in haemoglobin levels (2.20±1.13 gm/dl) compared to group B (1.15±0.93 gm/dl), which was statistically significant (p=0.02). Fluoroscopy time and surgery duration were slightly longer in group A compared to group B but not statistically significant(p=0.693). The suprapatellar approach results in lesser blood loss, potentially promoting faster recovery, reduced need for blood transfusions and shorter hospital stays. It also entails shorter fluoroscopy time and surgical duration (though not statistically significant) which may reduce radiation exposure for the surgical team

Abstract. Background. With the increasingly accepted method of suprapatellar tibial nailing for tibial shaft fractures, we aimed to compare intraoperative and postoperative outcomes of infrapatellar (IP) vs suprapatellar (SP) tibial nails. Methods. A retrospective cohort analysis of 58 patients. 34 SP tibial nails over 3 years versus 24 IP tibial nails over a similar time frame. We compared; radiation exposure, patient positioning time (PPT), non-union rate and follow-up time. Knee pain in the SP group was evaluated, utilising the Hospital for Special Surgery (HSS) Knee injury and Osteoarthritis outcome score (KOOS). Results. 58 patients with a mean age of 43 years were included. Mean intraoperative radiation dose for SP nails was 61.78cGy (range 11.60 to 156.01cGy) vs 121.09cGy (range 58.01 to 18.03cGy) for IP nails (p < 0.05). Mean PPT for SP nails was 10 minutes vs 18 minutes for IP nails (p < 0.05). All fractures united in the SP group vs one non-union in the IP group. Mean follow-up was 5.5 months vs 11 months in the SP and IP group respectively. Mean KOOS was 7 (range 0 to 22) at 6 months for the SP group. Conclusion. The semi extended position (SP group) leads to reduced radiation exposure because of ease of imaging. All Patients in the SP group showed improved outcomes, with shorter follow-up and fracture union. The KOOS revealed SP nail patients had minimal pain and good knee function. This study establishes a management and PROMs baseline for ongoing evaluation of SP nails

The aim of our study was to compare the incidence of post-operative anterior knee discomfort after anterograde tibial nailing by suprapatellar and infrapatellar approaches. 95 subjects presenting with a tibial fracture requiring an intramedullary nail were randomised to treatment using a suprapatellar (SP) or infrapatellar (IP) approach. Anterior knee discomfort was assessed at 4 months, 6 months and 1 year post operatively using the Aberdeen Weightbearing Test-Knee (AWT-K), knee specific patient reported outcome measures and the VAS pain score. The AWT-K is an objective measure which uses weight transmitted through the knee when kneeling as a surrogate for anterior knee discomfort. 53 patients were randomised to an SP approach and 42 to an IP approach. AWT-K results showed a greater mean proportion of weight transmitted through the injured leg compared to the uninjured leg when kneeling in the SP group compared to the IP group at all time points at all follow-up visits. This reached significance at 4 months for all time points except 30 seconds. It also reached significance at 6 months at 0 seconds and 1 year at 60 seconds. We conclude that the SP approach for anterograde tibial nailing reduces anterior knee discomfort post operatively compared to the IP approach

Aims. The aticularis genu (AG) is the least substantial and deepest muscle of the anterior compartment of the thigh and of uncertain significance. The aim of the study was to describe the anatomy of AG in cadaveric specimens, to characterize the relevance of AG in pathological distal femur specimens, and to correlate the anatomy and pathology with preoperative magnetic resonance imaging (MRI) of AG. Methods. In 24 cadaveric specimens, AG was identified, photographed, measured, and dissected including neurovascular supply. In all, 35 resected distal femur specimens were examined. AG was photographed and measured and its utility as a surgical margin examined. Preoperative MRIs of these cases were retrospectively analyzed and assessed and its utility assessed as an anterior soft tissue margin in surgery. In all cadaveric specimens, AG was identified as a substantial structure, deep and separate to vastus itermedius (VI) and separated by a clear fascial plane with a discrete neurovascular supply. Mean length of AG was 16.1 cm ( ± 1.6 cm) origin anterior aspect distal third femur and insertion into suprapatellar bursa. In 32 of 35 pathological specimens, AG was identified (mean length 12.8 cm ( ± 0.6 cm)). Where AG was used as anterior cover in pathological specimens all surgical margins were clear of disease. Of these cases, preoperative MRI identified AG in 34 of 35 cases (mean length 8.8 cm ( ± 0.4 cm)). Results. AG was best visualized with T1-weighted axial images providing sufficient cover in 25 cases confirmed by pathological findings.These results demonstrate AG as a discrete and substantial muscle of the anterior compartment of the thigh, deep to VI and useful in providing anterior soft tissue margin in distal femoral resection in bone tumours. Conclusion. Preoperative assessment of cover by AG may be useful in predicting cases where AG can be dissected, sparing the remaining quadriceps muscle, and therefore function. Cite this article: Bone Joint Open 2020;1-9:585–593

Aim. Diagnosis and isolation of a causative organism is imperative for successful treatment of periprosthetic joint infections (PJI). While there are several diagnostic algorithms using microbiology, serum and synovial markers, the preoperative diagnosis of a low-grade infection remains a challenge, particularly in patients with unsuccessful aspiration. An incisional biopsy may be used in these cases as additional diagnostic tool. In this retrospective study we evaluated microbiological findings, sensitivity, and specificity of open synovial biopsies in cases of inconclusive preoperative diagnostics. Methods. In a retrospective databank analysis (2010–2018), we identified 80 TKAs that underwent an open biopsy because of inconclusive results after applying the CDC Criteria (2010) or the MSIS (2011–2018) for PJI. Infection makers in the serum (C-reactive protein [CRP], leucocytes count and interleukin-6 [IL-6]) and in the synovial aspirate (leucocyte count, percentage of neutrophiles) prior to the biopsy were analyzed. All biopsies were performed by suprapatellar mini-arthrotomy. If a subsequent revision surgery was performed, the isolated organisms in the open biopsy were compared to the results in the revision surgery and sensitivity and specificity were calculated. Serum markers were checked for correlation with a positive result in the open biopsy using Cramer-V and Chi. 2. -Test. Results. A positive result in the open biopsy occurred in 32 cases (40%) while 48 cases (60%) showed no growth of microorganisms. A preoperative elevated serum CRP (≥1mg/dl) showed a significant correlation for a positive biopsy (p=0.04). The odds ratio for a positive biopsy was 2.57 (95% CI 1.02–6.46) with elevated serum CRP. A revision surgery of the TKA with additional tissue sampling was performed in 27 (84%) cases with a positive biopsy and in 32 (67%) cases with a negative biopsy. The intraoperative tissue samples from the revision surgery showed microbial growth in only 52% of cases that were believed to be culture positive from the biopsy results, while positive cultures occurred in 41% of the cases with an initially negative biopsy. Patients with ≥ two cultures of the same microorganism in the biopsy presented a positive result in 73% of their revision surgeries. The open biopsy showed a sensitivity of 48% with a specificity of 62% in our collective if revision surgery was performed. Conclusion. Open biopsy may be considered with inconclusive preoperative serum and synovial fluid diagnostics for PJI, but sensitivity and specificity were rather low in this special collective. Further studies with bigger collectives should be performed to determine potential markers with a higher sensitivity

Aim: There have been increasingly publications about the complicated disease of patello-femoral joints after total knee arthroplasty (TKA). We have treated soft tissue impingement under the patella after TKA by arthroscopic surgery and investigated the findings and efficacy of the treatment. Materials and Methods: 6 patients and 8 knees which showed soft tissue impingement of patello-femoral joints after TKA. Surgical arthroscopy was performed and impinging soft tissues were classified and the efficacy of arthroscopic treatment were evaluated. Results: We classified the patients with soft tissue impingement under the patella into three groups: (I) patellar clunk syndrome; the isolated fibrous nodule located suprapatellar lesion, without the other fibrous tissues causing the impingement, (II) impinging hypertrophic synovitis; generalized hypertrophic synovitis, no fibrous nodule, and (III) the combined type of (I)+(II), the suprapatellar fibrous nodule with generalized hypertrophic synovitis. Therapeutic efficacy was that in the category of type I two were good-excellent, in type II three were fair and one was poor, and in type III two were fair. Conclusions: Better results were obtained in type I (a patellar clunk syndrome) than type II (impingement synovitis)

Purpose: Patellar Clunk is associated with posterior stabilized (PS) femoral components in which a scarred synovial suprapatellar nodule catches on the femoral box with active extension of the flexed knee. We investigated whether a rotating platform tibial component increases the incidence of patellar clunk. Methods: From December 1998 to June 2006, a single surgeon performed 659 primary TKAs. 329 fixed-bearing tibial components and 330 rotating platforms were implanted. The same PS femoral component was used in all cases. All components were from the PFC Sigma Total Knee System (DePuy, Warsaw, IN, USA). The incidence of patellar clunk requiring reoperation was evaluated prospectively. Results: There were 17 arthroscopies performed on 16 knees in 15 patients. One patient required bilateral arthroscopies, and one a repeat arthroscopy. 6 (1.8%) arthroscopies were required in the fixed bearing group, and 10 (3%) in the rotating platform group (p< 0.10 NS). The repeat arthroscopy was in the rotating platform group. Time to arthroscopy from the index surgery was 13.6 months (Range 5–40) for the entire group, 15.2 months (Range 8–40) for the fixed-bearing group, and 12.6 months (Range 5–20) for the rotating platform group (p< 0.10 NS). Conclusions: The incidence of patellar clunk is not increased by the use of a rotating platform tibial component in TKA. While the mobile bearing may improve patellar tracking, causing the extensor mechanism to seat deeper in the trochlear groove, it does not seem to represent a risk factor for the development of the suprapatellar scarring that predisposes to patellar clunk

Introduction and aim. TKR remains one of the most successful surgeries in orthopedics. Still a sizeable number of patients remain dissatisfied reaching to a level of 30%. Our aim was to examine the excised synovium from the suprapatellar region in all osteoarthritic knees and evaluate the histopathological report to know if in a few cases the unrelenting pain and discomfort could be due to some undiagnosed pathology within the joint. Materials and Methods. We selected 40 consecutive knees at our institution operated from Oct 2014 to Jan 2015. Of the total knees 7 patients were operated as single stage bilateral TKR. Supra patellar synovium was thoroughly excised and sent for histopathology examination. Patients who were clinically, serologically and radiologically diagnosed as rheumatoid arthritis or sero negative arthritis were excluded. The implant used was Maxx Freedom knee (PS design). Results. We found abnormal reports in 8 of our 40 knees (20%). 6 of these were proven to be rheumatoid arthritis whilst 2 of the knees showed chronic villous synovitis. Conclusion. 20% of our patients exhibited result which were totally unexpected. This could be one of the many causes in persistently dissatisfied patient after a technically well done TKR. So as a routine we advocate all surgeons to send the excised synvoium for histopathology during a routine TKR. Also a large multi-centric study undertaken at various centers would definitely help to throw more light on this not so well understood topic and thus help reduce this lot of dissatisfied patients

Background. The optimal treatment of segmental tibial fractures (STF) is controversial. Intramedullary nailing (IMN) and external fixation (EF) have unique benefits and complications. Aim. To compare outcomes for AO/OTA 42C2 and 42C3 fractures treated using IMN with those treated using EF in a University Teaching Hospital. Methods. Retrospective case note and radiograph review of 31 segmental tibial fractures treated between 2010 and 2017. Results. There were 17 42C2 and 14 42C3 fractures. 17 patients underwent IMN and 14 EF, and were matched for age and gender. 9 fractures in each group were open. Median time to radiological union was 7 months for IMN and 8 months for EF. Revision surgery was needed for 4 IMN patients and 3 EF patients. The mean number of unplanned procedures was 1.46 for IMN and 1.1 for EF (p=0.69). Length of stay was 15.5 days for IMN and 16.2 days for EF (p=0.9). There was one compartment syndrome in each group and 2 cases of deep infection in the IMN group. There was no significant difference in coronal and sagittal plane alignment. Conclusions. Notwithstanding the small numbers and the retrospective design, the results show that the results of IMN may be equivalent to EF. Modern techniques using suprapatellar entry and blocking screws, combined with early plastic surgical coverage in open injuries are likely to have improved outcomes. Implications. Modern IM nailing techniques have produced similar clinical and radiological outcomes to that achieved by external fixation in this series

Achievement of adequate exposure in revision total knee arthroplasty is critical as it reduces the surgical time, enhances the ability for both component removal and reconstruction, and avoids devastating complications such as extensor mechanism disruption. However, this can be challenging as prior multiple surgeries and limited mobility contribute to a loss of tissue elasticity, thickened capsular envelope, and peri-articular soft tissue adhesions. A thorough pre-operative assessment of a patient's past surgical history, comorbidities, pre-operative radiographs (i.e. the presence of severe patella baja), and physical examination including range of motion, prior incisions, and soft tissue pliability are useful in determining the appropriate surgical techniques necessary for a successful revision. A systematic approach to the ankylosed knee is critical. Most techniques are geared towards mobilization of the extensor mechanism to safely displace the patella for component exposure. The initial exposure should consist of a long skin incision, a subperiosteal medial release, and debridement of suprapatellar, medial, and lateral adhesions to the femoral condyles. A lateral capsular release can prove helpful in further mobilization of the extensor mechanism. When performing a medial parapatellar arthrotomy it's important to keep in mind further extensile exposure techniques that may be required. For example, the arthrotomy should not extend proximally into the vastus intermedius or rectus femoris in the event that a quadriceps snip technique is to be used as this can compromise the ability to repair this exposure. Despite a large exposure and release of adhesions, sometimes the extensor mechanism remains at risk of rupture and adequate visualization cannot be obtained. In this event, extensile exposures such as a quadriceps snip, quadriceps turndown or tibial tubercle osteotomy are considered. The location of the patella often dictates the best exposure option as severe patella baja may not be overcome with a proximally based release. The quadriceps snip is most commonly used and provides improved exposure without the necessity of modifying the patient's post-operative rehabilitation. In addition, it can be extended to a quadriceps turndown which vastly improves visualization, but at the expense of needing to immobilise the knee post-operatively. A tibial tubercle osteotomy can also be used and provides excellent exposure especially in the case of severe patella baja or when removal of a cemented tibial stem is required. It preserves the extensor muscles, but risks include increased post-operative wound drainage due to limited soft tissue coverage, failure of fixation, or fracture of the tibial tubercle fragment or tibial shaft. Exposure in revision total knee arthroplasty is critical. Fortunately, this can be reliably achieved with a systematic approach to the knee and through the use of several extensile exposures at the surgeon's discretion

The process by which pathologic scar tissue forms after TKA and restricts functional range of motion is relatively poorly understood. Arthrofibrosis may develop in patients who have normal intra-operative range of motion (ROM). However, passive flexion, extension, or both can become restricted and painful, sometimes several weeks after surgery following an early post-operative period of normal motion. The response to both nonsurgical and surgical treatment is often unsatisfactory. Arthrofibrotic scar contains dense fibrous tissue with abundant fibroblasts. Heterotopic bone is frequently found in patients with arthrofibrosis. Stiffness may result from inadequate postsurgical pain management or rehabilitation or from a biologic process that causes rapid proliferation of scar tissue. Genetic factors also may play a role, although it is difficult to predict which patients are at increased risk for arthrofibrosis after TKA. Surgical technique also can contribute; oversizing the femoral component, overstuffing the patella, or rotational malalignment can play a role. Manipulation can be helpful, particularly during the first three months after surgery. However, maintaining motion long term also requires an effective pain management and physical therapy program after manipulation. Arthroscopy may also have a role to remove scar tissue in the suprapatellar pouch and medial and lateral gutters usually between six months and one year after TKA. After one year following TKA, open surgical release or revision surgery is the most effective method to increase motion. However, only modest gains are likely to be achieved and pain may not be improved

Aims

Metal particles detached from metal-on-metal hip prostheses (MoM-THA) have been shown to cause inflammation and destruction of tissues. To further explore this, we investigated the histopathology (aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL) score) and metal concentrations of the periprosthetic tissues obtained from patients who underwent revision knee arthroplasty. We also aimed to investigate whether accumulated metal debris was associated with ALVAL-type reactions in the synovium.

Aims

Treatment of high-grade limb bone sarcoma that invades a joint requires en bloc extra-articular excision. MRI can demonstrate joint invasion but is frequently inconclusive, and its predictive value is unknown. We evaluated the diagnostic accuracy of direct and indirect radiological signs of intra-articular tumour extension and the performance characteristics of MRI findings of intra-articular tumour extension.

Introduction: This is a report of a new anatomical feature in the knee. This finding to our knowledge has never been described before. The feature consists of a shallow oval impression in the synovium on the femoral surface of the floor of the suprapatellar pouch over the lateral side just before the trochlear entry to the lateral femoral condyle. Clinical correlation was considered to be a separate study and not part of this anatomic description. Methods: During arthroscopy of the knee the presence or absence of the “entry feature” was noted, entered on a database consecutively and prospectively. All arthroscopies were carried out by the senior author. 21 cadaveric knees (formalin preserved) were dissected. Results: Out of 457 consecutive knee arthroscopies carried out by the senior author the “entry feature” was present in 294 and not noticed in 163. Histology of the synovium in this region was normal. 21 formalin preserved cadaveric knees demonstrated the “entry feature” in 17 and absent in 4. Conclusion: We propose the “entry feature” as a new anatomical landmark for the arthroscopic knee surgeon. It gives an initial impression of the patellar position on the synovial floor just before commencing its excursion towards the trochlear

Purpose: The Subacromial bursa is the largest bursa in the body. In 1934 Codman described the presence of Subacromial plicae, similar to the suprapatellar plicae found in the knee. This anatomical finding was again described by Strizak et al. in 1982. It is recognised that plicae in the knee can cause anterior knee pain with impingement against the patella in young people. We investigate the possibility that a similar situation exists with plicae of the Subacromial bursa. The aims of this study were to document the incidence of bursal plicae seen at bursoscopy during arthroscopic Subacromial decompressions of the shoulder, and to assess whether there is any pattern to the occurrence of these plicae, and the relation to impingement lesions seen at bursoscopy. Methods: A review of all patients undergoing Arthroscopic Subacromial Decompression (ASD) of the shoulder between January 1996 and July 2001. Results: A total of 2043 ASD procedures were performed in the study period. Of these, the number of plicae found was 130, with an incidence of 6.4%. There was a strong age predilection, with a significantly higher incidence in younger age groups. There was no difference between males and females. Where a plica was present the impingement lesion seen on the cuff side was significantly greater than the lesion seen on the acromial side (p< 0.0001). This suggests that the impingement might be due to the plica itself. Conclusions: This study is the first to describe the presence of Subacromial plicae in living subjects and correlates with previous anatomical studies. The younger age predominance correlates with the findings of plicae in the knee. Our findings suggest that Subacromial plica may be a cause of impingement in young patients

Range of motion after total knee replacement is an important outcome variable. Motion impacts the patient’s ability to perform a variety of activities of daily living. In addition, a stiff knee is also a painful knee secondary to continuous soft tissue irritation. Appropriate knowledge in terms of variables that effect range of motion as well as evaluation of the stiff knee are therefore important in the practice of total knee arthroplasty. The most important and consistent factor in determining postoperative flexion is preoperative flexion. Other factors that have been invariably associated with flexion after knee replacement include weight of the patient, age, preoperative diagnosis, and implant design. In terms of implant design, cruciate substituting designs have been reported in several studies to have better motion than cruciate retaining designs. Recent data also suggests that patients with a high visual analogue scale for pain also had poor range of motion following total knee replacement. In analysing a patient with a stiff knee it is thus first important to try and determine what the patients preoperative range of motion was. This helps in determining what the biologic capacity for range of motion after knee replacement. Evaluation of the preoperative x-ray is important in determining factors such as elevation of the joint line and matching the tibial slope especially in cruciate retaining implants. Failure to appropriately match the patient’s tibial slope leads to a tight flexion gap and a decrease in flexion. Malrotation of the components and stuffing the patello-femoral compartment with a thick patellar reconstruction can also decrease postoperative flexion. Balancing of the posterior cruciate ligament in cruciate retaining designs is obviously critical. It is difficult to tell based on physical examination whether the cruciate ligament is in fact tight as secondary contractures develop. If preoperative evaluation determines that the implants are well-positioned manipulation under anaesthesia is a viable option. In both cruciate retaining and posterior cruciate substituting designs this can be safely done up to three months after surgery. For patients who present late after total knee replacement with significant complaints of stiffness, an arthrotomy with debridement of the of the suprapatellar pouch, recreation of the medial and lateral gutters and resection of the posterior cruciate ligament can be successful. Finally implant revision is sometimes required

Introduction In the past years a lot of interest has been raised on the mini-invasive surgical techniques in many fields of orthopaedic surgery.However,true innovative techniques have been rarely proposed,other then reducing the length of the incision with the aid of specially designed tools,particularly in the hip surgery.In the knee also, shorter scars should not be considered as the main purpose of the so called MIS(minimally invasive surgery)but as the side beneficial effect and the natural consequence of a more conservative technique,sparing soft tissues such as the quadriceps tendon,the extensor mechanism and the suprapatellar pouch,as well as nervous tissue and vascular supply.Considering this,the Mis-Quad Sparing technique is a really new technique,that has in view the object to preserve anatomic structures,and in particularly the extensor apparatus. Patients and methods From june 2003 to june 2004 we’ve studied two homogeneous cohorts of patients uniform for age,gender,BMI and local and radiographic objectivity(Baseline characteristics have been compared between groups by means of Student T test or Fisher exact test)operated with the same implant(Zimmer, NexGen CR),one with QS technique(30 patients)and one with the standard approach(26 patients). For the post-operative evaluation and for the critical comparison of the two groups we’ve considered the following parameters:length of operation,blood loss,ROM(at discharge,at 1 month,at 3 months,at 6 months),functional scores(using the Knee Society Assessment& Function Score),implants position and postoperative pain.In order to evaluate the differences among the two groups over time,we adopted a general linear model for repeated measures with calculation of Huber White robust standard errors to account for intra-patients correlation over time: a 2 sided p-value< 0.0125 was considered significant and Bonferroni correction was applied for post-hoc test. Results and discussion The study has demonstrated that the Mis-QS technique allows less blood loss(p< 0.001 at all times considered),less pain (mean 10 points less with VAS),more rapid and better functional restoration (significant differences,p< 0.001,observed between groups and over time),with the same length of operation(at mean QS required only 10′ more than standard)and the same implant’s precision(p> 0.30 for all implant’s angles considered).Therefore,the supposed advantages of the QS technique can be considered real,based on our statistical comparison

Achieving deep flexion of knee after total knee arthroplasty (TKA) is particularly desirable in some Asian and Middle Eastern who have daily or religious customs typically use full knee flexion. After TKA, some patients complained about anterior knee pain during deep knee flexion. We evaluated the efficacy of arthroscopic fat pad resection in a series of patients suffering from anterior knee pain associated with high flexion achievement after TKA. The efficacy of fat pad resection via arthroscopy for treating anterior knee pain associated with high flexion angle (average = 133.1°) was evaluated in eight knees of eight patients among 207 knees performed between 1996 and 1999. The mean age of patients was 71.1 years when the primary TKA was performed. All implatants were posterior stabilized type (IB-II, Nexgen PS and LPS). The symptom of anterior knee pain during deep knee flexion developed within one year after TKA in all cases. In addition to pain in eight knees, two patients have crepitation as the knee was flexed and extended and three patients had hydrarthrosis. Impingement and fibrosis of fat pad were confirmed, and fibrous structures were removed by arthroscopy. Before arthroscopy, the symptom obviously subsided after injection of local anesthesia into infrapatellar fat pad. Patellar clunk syndrome is also soft tissue impingement and suprapatellar fibrous nodule becomes entrapped intercondylar notch on the femoral component during knee flexion. On this point, these cases does not cause by patellar clunk syndrome. After fat pad resection, the symptom disappeared, and keeps symptom-free after a mean follow-up of six years five months in all cases. Any complications following fat pad resection, such as patella baja and necrosis, were not experienced. Those cases achieving higher flexion angle tended to experience severe pain and shorter time interval between TKA and arthroscopic surgery, suggesting impingement of the infrapatellar fat pad is closely related to deep flexion after TKA. These results demonstrate that the anterior knee pain due to repetitive infrapatellar fat pad impingement is one of the complications during deep knee flexion after TKA, and the arthroscopic fat pad resection is useful to relief the anterior knee pain. Because of our experience with patients encountering anterior knee pain, we have begun to remove 70 to 80% of the fat pad during the primary TKA procedure since 1999, and until today, none developed anterior knee pain thought to be associated with fat pad impingement, patellar baja nor patellar necrosis. We suggest that fat pad resection is necessary to prevent the anterior knee pain due to fat pad impingement during deep flexion in TKA

Severe patellar loss, which precludes adequate fixation of another patellar implant, may be treated by patellectomy, retention of the remaining patellar bony shell (resection arthroplasty), gull wing osteotomy, or patellar bone grafting. In contrast to other treatment alternatives, patellar bone grafting uniquely imparts the potential for restoration of patellar bone. Technique: It is helpful to retain the pseudomeniscus of scar tissue and most of the peripatellar fibrosis tissue to facilitate suture fixation of the tissue flap to the patellar rim. The patellar shell is prepared by removing all fibrous membrane in the crevices of the remaining patellar bone. The tissue flap is created from one of several sources including large flaps of peripatellar fibrotic tissue or a free tissue flap obtained from either the suprapatellar pouch or the fascia lata obtained in the lateral gutter of the knee joint. The tissue flap is sewn to the peripheral patellar rim and peripatellar fibrosis tissue with multiple, nonabsorbable size zero sutures to provide a watertight closure. A small purse string opening is left in one portion of the tissue flap repair to facilitate delivery of bone graft into the patellar defect. Cancellous autograft is harvested from the metaphyseal portion of the central femur during preparation of the femur for the revision implant. In the absence of locally available cancellous autograft, cancellous allograft bone can be used. The bone graft is prepared by morsellising the bone into small fragments of approximately 5 to 8 mm in height and width to facilitate tight impaction of the bone graft into the patellar shell-tissue flap construct. The bone graft is tightly impacted through the opening of the fascial flap into the patellar bone defect with enough volume so that the height of the final patellar construct has a final height measuring more than 20 mm. The tissue flap is then completely closed to contain the bone graft within the patellar shell. The peripatellar arthrotomy is provisionally repaired with several sutures or towel clips to mould the patellar construct in the femoral trochlea as the knee is placed through the full range of motion. Postoperative rehabilitation is not altered from the usual revision knee arthroplasty protocol. In contrast with the treatment alternatives of patellectomy or retention of the bony shell, this new surgical procedure uniquely imparts the potential for restoration of patellar bone stock and may improve the functional outcome in these patients by facilitating patellar tracking and improving quadriceps leverage. The procedure is simple to perform and does not require sophisticated instrumentation or a long learning curve. Based on the current satisfactory short-term to mid-term clinical results, this surgical procedure provides an important addition to the armamentarium of the revision knee arthroplasty surgeon

Introduction. Synovectomy in children with juvenile rheumatoid arthritis (JRA) and psoriatic arthritis (PSA) is still subject of controversial discussion. Our results of arthroscopic synovectomy of the knee in children with chronic inflammatory joint disease are presented. Material. From 1989–1997 27 synovectomies were performed in 27 children with inflammatory arthritis (15 JRA, 12 PSA). Average age at surgery was 12. 5 y (2. 9–17. 8 y). Mean follow-up was 4. 9 years. Methods. Onset of disease and conservative therapy was documented. Each patient was physically and radiologically examined preoperatively and 24 children postoperatively (mean follow-up 4. 9 years). For arthroscopic shaver-assisted synovectomy of the knee we used minimum 4 portals and normally 6 portals (2 anterior, 2 suprapatellar and 2 posterior portals). In addition to the physical examination we used a special clinical score (Laurin 1974). We compared the pre- and postoperative limits of active and passive knee movement. We performed sonographs and radiographs of the infected joint. Radiography was classified following the Larsen-Scale. Patient and parents gave their opinion whether the operation was successful. Before surgery all children had intensive drug and physical therapy for 8–62 months (42 month). In the course of conservative treatment, knees had local joint treatment with triamcinolonhex-acetomid (THA), normally for three times before surgery. Preoperative X-rays showed Larsen stage I in 3 knee joints and Larsen stage 0 in the other knees. Results. In 85% of the children, we found good or excellent surgical outcome. 2 joints achieved fair and 2 joints poor outcome. Concerning subjective outcome 22 (82%) children had been very satisfied (56%) or satisfied (26%). 25 of the children’s parents would agree in the same surgical procedure again. In 6 knee joints we found recurrent synovitis. 2 of these knee joints were reoperated (30 and 22 month postoperatively with satisfying result), the other 4 joints were treated with THA i. a.. The 2 reoperations were regarded as poor result. We had no postoperative complications and the normal hospitalisation was 15 days. Prior to surgery, 12 knee joints had an average deficit of active knee extension of 10° (5–20°). Postoperatively, no extension deficit was found anymore in 25 of the knees. Compared to the contralateral knees, a flexion deficit of 10° (5–15°) was obtained postoperatively. At sonography, no joint effusion could be revealed. Postoperative X-rays showed no progression in Larsen stage. Outcome in children with oligoarthritis was better than in those with polyarthritic disease. Discussion. Early arthroscopic synovectomy of the knee in children with chronic inflammatory joint disease is, in case of failure of conservative treatment, a useful method of treatment. We propose early synovectomy of the knee joint as an essential part of the treatment scheme for children with inflammatory joint disease