Arthroscopic surgery is a common intervention for osteoarthritis of the knee. However, the benefits from such an intervention are not clear. The purpose of the study was to perform a questionnaire survey of orthopaedic surgeons of Wales to analyse the practice of arthroscopy for osteoarthritic knee.

Over a three-month period, a postal survey was conducted of all hospital orthopaedic consultants in Wales. Of a total of 62 questions sent we received a reply of 37. 31 surgeons perform arthroscopic lavage or debride-ment. 4 surgeons perform arthroscopic surgery for symptomatic meniscal tear only. There was no defined protocol regarding the management. Early OA was the commonest indication (18). Arthroscopic lavage (17) was equally popular to lavage and debridement (16). 6 respondents like to perform the surgery themselves while the majority would allow a middle grade surgeon to operate with or without supervision. 26 surgeons felt that the results of the procedure are unpredictable, but still continued to perform it. Only 6 surgeons felt a continued relevance of the procedure.

Arthroscopic surgery is a commonly performed symptomatic treatment for arthritic knee. It bears a significant financial commitment. 266 arthroscopic knee surgery were performed annually in a district general hospital, of whom 115 were arthroscopic washout. Average cost of each operation is £1000. The physiological basis for arthroscopic washout is not clear. A majority of the Welsh surgeons have reservations about this procedure. In spite of evidence of limited usefulness, it is still performed widely.

Introduction: Determination of the origin of chronic foot pain in osteoarthritis (OA) is challenging since clinical examination of the foot faces a complex anatomy with several joints, osseous, and non-osseous structures contributing to the symptoms. Non-invasive imaging methods (Rx, CT, MRI) show a poor correlation with pain degree. Studies using functional imaging based on the detection of activated osteoblasts with 99mTc-Dicarboxypropandiphosphate (DPD) to indicate painful facet joints show promising results, but so far no evaluation for chronic OA pain conditions in foot joints has been conducted and the diagnostic potential was limited due to poor spatial resolution of the scintigraphic assessment.

Single Photon Emission Computed Tomography – Computed Tomography (SPECT-CT) combines metabolic information with an exact anatomical localization. We hypothesised that diagnostic infiltration with a local anaesthetic of a painful hindfoot or midfoot joint showing 99mTc-DPD-uptake in SPECT-CT, leads to a positive OA pain response.

Methods: 26 patients with chronic OA pain and radiological signs of OA in a hindfoot or midfoot joint (27 feet) were included. Plain radiography was performed to detect degenerative changes and to rule out pathologies different from OA. Pain status was measured by Visual Analogue Scale (VAS). AOFAS hindfoot/midfoot score and SF-36–score were documented. All patients received a 99mTc-DPD SPECT-CT (Symbia T2, Siemens). The localisation of 99mTc-DPD-uptake and consequently the site of infiltration were defined. The infiltration was performed with a local anaesthetic (bupivacaine) and iodine solution under CT-guidance with exact documentation of the contrast media deposit by CT. Pain status was assessed directly post-infiltration. Pain relief in responders was defined as reduction of VAS-score > 50% immediately after infiltration, partial response as reduction of < 50%.

Results: Infiltration was performed in 26 hindfoot joints and 5 midfoot as indicated by 99mTc-DPD-uptake in SPECT-CT. Subsequent CT control scans showing contrast media depot confirmed exact successful infiltration in all indicated joints. In 22 patients an immediate significant (p< 0.01) postinterventional pain reduction of VAS more than 50% was observed. Mean VAS before infiltration was 5.77 (range 2–10; SD 2.22) and 0.82 (range 0–4; SD 1.26) immediately after infiltration. Two patients showed a partial response and one patient showed no pain resolution after infiltration.

Conclusion: The results show a significant correlation of uptake and pain resolution after infiltration allowing precise identification of OA hindfoot joints as pain inducing foci. SPECT-CT offers good prediction of outcome after infiltration improving the localisation of the pain inducing joint, thus aiding in pre-operative planning.

Purpose: Osteoarthritis (OA) is a common disease with increasing prevalence and rising socioeconomic burden. Of all symptoms accompanying OA, pain is the most disabling and frequent and the major reason why patients affected seek medical help. The determination of the origin of chronic foot OA pain is challenging since clinical examination of the foot faces a complex anatomy with several joints, osseous, and non-osseous structures contributing to the symptoms. For OA non-invasive imaging methods like plain radiograph, CT or MRI underestimate the degree of degenerative changes and show a poor correlation with pain degree. Studies using functional imaging based on the detection of activated osteoblasts with 99mTc-Dicarboxypropandiphosphate (DPD) to indicate painful facet joints in the lower spine show promising results, but so far no evaluation for chronic OA pain conditions in foot joints has been conducted and the diagnostic potential was limited due to poor spatial resolution of the scintigraphic assessment. Single Photon Emission Computed Tomography – Computed Tomography (SPECT-CT) is a new hybrid technique combining metabolic information with an exact anatomical localization. We hypothesised that diagnostic infiltration with a local anaesthetic of a painful hindfoot or midfoot joint showing 99mTc-DPD-uptake in SPECT-CT, leads to a positive OA pain response.

Method: 26 patients with chronic OA pain and radiological signs of OA in a hindfoot or midfoot joint (27 feet) were included. Plain radiography was performed to detect degenerative changes and to rule out pathologies different from OA. Pain status was measured by Visual Analogue Scale (VAS). AOFAS hindfoot/midfoot score and SF-36-score were documented.. All patients received a 99mTc-DPD SPECT-CT (Symbia T2, Siemens). The localisation of 99mTc-DPD-uptake and consequently the site of infiltration were defined. The infiltration was performed with a local anaesthetic (bupivacaine) and iodine solution under CT-guidance with exact documentation of the contrast media deposit by CT. Pain status was assessed directly post-infiltration. Pain relief in responders was defined as reduction of VAS-score > 50% immediately after infiltration, partial response as reduction of < 50%.

Results: Infiltration was performed in 26 hindfoot joints and 5 midfoot as indicated by 99mTc-DPD-uptake in SPECT-CT. Subsequent CT control scans showing contrast media depot confirmed exact successful infiltration in all indicated joints. In 22 patients an immediate significant (p< 0.01) postinterventional pain reduction of VAS more than 50% was observed. Mean VAS before infiltration was 5.77 (range 2–10; SD 2.22) and 0.82 (range 0–4; SD 1.26) immediately after infiltration. Two patients showed a partial response and one patient showed no pain resolution after infiltration.

Conclusion: The results show a significant correlation of uptake and pain resolution after infiltration allowing precise identification of OA hindfoot joints as pain inducing foci. Non-invasive SPECT-CT offers good prediction of outcome after infiltration improving the localisation of the pain inducing pathology, thus aiding in pre-operative planning and avoiding unnecessary interventions, as diagnostic infiltrations, with its possible risks and side effects.

Aims. Hyaline cartilage has a low capacity for regeneration. Untreated osteochondral lesions of the femoral head can lead to progressive and symptomatic osteoarthritis of the hip. The purpose of this study is to analyze the clinical and radiological long-term outcome of patients treated with osteochondral autograft transfer. To our knowledge, this study represents a series of osteochondral autograft transfer of the hip with the longest follow-up. Methods. We retrospectively evaluated 11 hips in 11 patients who underwent osteochondral autograft transfer in our institution between 1996 and 2012. The mean age at the time of surgery was 28.6 years (8 to 45). Outcome measurement included standardized scores and conventional radiographs. Kaplan-Meier survival curve was used to determine the failure of the procedures, with conversion to total hip arthroplasty (THA) defined as the endpoint. Results. The mean follow-up of patients treated with osteochondral autograft transfer was 18.5 years (9.3 to 24.7). Six patients developed osteoarthritis and had a THA at a mean of 10.3 years (1.1 to 17.3). The cumulative survivorship of the native hips was 91% (95% confidence interval (CI) 74 to 100) at five years, 62% (95% CI 33 to 92) at ten years, and 37% (95% CI 6 to 70) at 20 years. Conclusion. This is the first study analyzing the long-term results of osteochondral autograft transfer of the femoral head. Although most patients underwent conversion to THA in the long term, over half of them survived more than ten years. Osteochondral autograft transfer could be a time-saving procedure for young patients with devastating hip conditions who have virtually no other surgical options. A larger series or a similar matched cohort would be necessary to confirm these results which, in view of the heterogeneity of our series, seems difficult to achieve. Cite this article: Bone Jt Open 2023;4(7):523–531

Purpose of the study: There is no satisfactory surgical solution for symptomatic osteoarthritis of the elbow joint with preserved functional motion if arthroplasty is not indicated (age, functional demand). The same is true for resistant epicondylalgia. The joint denervation techniques applied for the wrist and proximal inter-phalangeal joints have demonstrated their efficacy. We conducted an anatomic study of elbow innervation as a preliminary step to the development of a standardized surgical procedure for complete denervation of the elbow compartment. Material and methods: The study was conducted on 15 right and left unprepared fresh cadaver specimens. A standardized dissection method was used. The terminal branches of the brachial plexus were dissected proximally to distally under magnification, from the root of the arm to the mid third of the forearm. Results: Innervation of the medial compartment arose: anteriorly, from one of the two capsuloperiosteal branches arising from the medial nerve; in the epitrochleo-olecraneal gutter, from capsular branches issuing from the trunk of the radial nerve at the root of the arm and running with the ulnar nerve. The innervation of the lateral compartment arose: anteriorly, from an inconstant capsular branch issuing from the musculo-cutaneous nerve arising 4 to 7 cm downstream from the joint space and running between the bones. In the other cases, this zone was innervated by a nerve branch coming from the dorsal cutaneous nerve of the forearm issuing from the radial nerve. This branch innervated the apex of the laeral epicondyle in all cases. The posterior part of the lateral compartment was constantly innervated by a branch arising from the radial nerve in the proximal part of the arm, running between the deep hed of the triceps and the vastus lateralis, giving rise of nerves innervating the joint and terminating in the body of the anconeus muscle. Discussion: Our study enabled the description of new sources of elbow innervation not reported by Wilhelm. Conclusion: This systematization study of elbow joint innervation is a preliminary step to the development of a complete procedure for unicompartmental lateral or medial denervation of the elbow joint. The fields of application are the treatment of symptomatic osteoarthritis of the elbow joint in patients with preserved joint motion and resistant epicondylalgia

Introduction. Simultaneous correction of knee varus malalignment with medial open wedge high tibial osteotomy (MOWHTO) combined with anterior cruciate ligament (ACL) surgery aims to address symptomatic unicompartmental osteoarthritis in addition to restore knee stability in order to improve outcomes. The aim of this study is to present at least 5 years results of 32 patients who underwent simultaneous knee realignment osteotomy with ACL surgery. Methods. Patients with symptomatic instability due to chronic ACL deficiency or failed previous ACL surgery together with a varus malalignment of ≥6°, previous medial meniscectomy and symptomatic medial compartment pain who were treated with MOWHTO combined with ACL surgery were enrolled. ACL surgery was performed with the anatomical single bundle all-inside technique using TightRope. ®. RT (Arthrex, Naples, FL, USA) and MOWHTO using TomoFix. ®. medial high tibia plate (DePuy Synthes, Raynham, MA, USA) in all cases. Patients were evaluated preoperatively and at 6 months, 12 months and annually postoperatively using the Knee Injury and Osteoarthritis Outcome Score (KOOS), Oxford Knee Score (OKS) and Euroqol's Visual Analogue Score (VAS) for pain. Results. 32 patients (22 men and 10 women) with a mean age of 41.2 years and mean BMI of 28.6 kg/m. 2. , underwent the combined procedures. Tibiofemoral neutral re-alignment was achieved in all patients with HTO. Complete subjective and objective scores have been obtained in 84.4% of patients with at least 5 years of follow-up (mean 8.7 years). An improvement in total KOOS of 27.1 points (p<0.003), OKS of 15.1 (p<0.003) and VAS for pain of 24.7 points (p<0.001) were detected. No ACL reconstruction failure was noted. Complications consisted of one superficial wound infection and one delayed union. Plate removal was needed in 20 (62.5%) patients due to pes anserinus pain. Conclusions. Simultaneous restoration of coronal knee axis by applying HTO and stability by ACL reconstruction/revision were reported to offer excellent improvement in early outcomes in patients with ACL rupture and symptomatic unicompartmental osteoarthritis. The combined procedure requires careful pre-operative planning and is therefore technically challenging. However, by restoring the neutral axis and providing stability, it represents a good joint preserving alternative to arthroplasty for active middle-aged patients

Background. The optimal treatment for symptomatic elbow osteoarthritis remains debatable especially in patients still involved in heavy manual work. The Outerbridge-Kashiwagi (OK) procedure has been used when simple measures fail. The aim of this study is to analyse the results of the OK procedure in patients with symptomatic osteoarthritis. Methods. Twenty-two patients were included in the study. The male:female ratio was 18:4. The mean age was 60 years with mean follow-up of 38 months (24–60 months). 17 were manual workers, 3 involved in sports activities and 2 non-manual workers. All patients were assessed using Mayo Elbow Performance Index Score system. Preoperative radiological assessment showed osteophytes around olecranon and coronoid process and joint space narrowing in radio-humeral articulationin all cases. Results. There was a significant improvement (p<0.05) in movement in the flexion-extension axis from 78.2° to 107.3°. There was a significant reduction in pain post-operatively (p<0.001). Mean MEPI score improved from 50 to 87.4 post surgery which was significant (p<0.05). One patient had ulnar nerve palsy which resolved in six months with conservative management. The results were excellent in six patients (27%), good in fifteen (68%), fair in one (5%) and one (5%) had poor result. Discussion and conclusion. The present study indicates that the OK procedure provides significant pain relief and a functionally useful range of movement of more than 100°. The procedure can be used in high demand patients, wherein total elbow replacement is not indicated. It significantly reduces the disability in patients with significant elbow arthritis

The treatment of medial knee osteoarthritis (OA) in conjunction with anterior knee laxity is an issue of debate. Current treatment options include knee joint distraction, unicompartmental knee replacement (UKR) or high tibial osteotomy with anterior cruciate ligament (ACL) reconstruction or total knee replacement. Bone-conserving options are preferred for younger and active patients with intact lateral and patello-femoral compartment. However, still limited experience exists in the field of combining medial UKR and ACL reconstruction. The aim of this study is to retrospectively evaluate the results of combined fixed-bearing UKR and ACL reconstruction, specifically with regard to patient satisfaction, activity level, and postoperative functional outcomes. The hypothesis was that this represents a safe and viable procedure leading to improved stability and functional outcome in patients affected by isolated unicompartmental OA and concomitant ACL deficiency. Fourteen patients with ACL deficiency and concomitant medial compartment symptomatic osteoarthritis were treated from 2006 to 2010. Twelve of them were followed up for an average time of 7.8 year (range 6–10 years). Assessment included Knee Osteoarthritis Outcome Score (KOOS), Oxford Knee score (OKS), American Knee Society scores (AKSS), WOMAC index of osteoarthritis, Tegner activity level, objective examination including instrumented laxity test with KT-1000 arthrometer and standard X-rays. Wilcoxon test was utilized to compare the pre-operative and follow-up status. Differences with a p value <0.05 were considered statistically significant. KOOS score, OKS, WOMAC index and the AKSS improved significantly at follow-up (p < 0.05). There was no clinical evidence of instability in any of the knees as evaluated with clinical an instrumented laxity testing (p < 0.05). No pathologic radiolucent lines were observed around the components. In one patient a total knee prosthesis was implanted due to the progression of signs of osteoarthritis in the lateral compartment 3 years after primary surgery. UKR combined with ACL reconstruction is a valid therapeutic option for young and active patients with a primary ACL injury who develop secondary OA and confirms subjective and objective clinical improvement up to 8 years after surgery

Introduction: The majority of patients with osteoarthritis of the knee suffer from femorotibial pain with a smaller proportion suffering predominantly patellofemoral symptoms. No clear consensus exists as to the need for patellar resurfacing when performing total knee replacement for patients with symptomatic femorotibial osteoarthritis but without prominent patellofemoral symptomatic and radiographic disease. Aims: To identify the advantages and disadvantages of both resurfacing and non-resurfacing of the patella during cemented total knee replacement performed for osteoarthritis predominantly of the femorotibial joint. To objectively clarify the rationale for the use of either procedure in clinical practice. Methods: Prospective randomised double blinded clinical trial. Patients with osteoarthritis of the knee and principally femorotibial symptoms were included. Patients with rheumatoid arthritis, gross deformity of the knee and gross radiological or clinical patellofemoral arthritis were excluded. The implant used was a cemented posterior stabilised AMK (DePuy, Leeds UK) prosthesis. Preoperative American Knee Society Score, SF-36 questionnaire and WOMAC scores were calculated for each patient. These instruments were repeated and combined with clinical and radiological follow up at 3 months, 6 months and 1 year. Results: 58 patients were recruited into the study, 53 of whom completed follow up and were in included in the analysis. Baseline characteristics were similar in each group. Operating room time was less in the non-resurfaced group (p< 0.05). At 2 years, 3 patients in the non resurfaced group had undergone a revision procedure. There was no difference between the resurfaced and non-resurfaced groups in terms of global functional outcome as measured by SF36 and WOMAC scores at 1 and 2 years post-operatively. The American Knee Society score showed no difference between the two groups (p=0.86) at 1 year post surgery. Conclusion: There is no significant difference in clinical outcome at 1 and 2 years following surgery vis-à-vis those who did and did not have patellar resurfacing performed during knee replacement for predominantly femorotibial symptomatic osteoarthritis. There was a higher revision rate in the non-resurfaced group. In TKR using a PS AMK prosthesis routine resurfacing of the patella should be performed

Introduction: The majority of patients with osteoarthritis of the knee suffer from femorotibial pain with a smaller proportion suffering predominantly patello-femoral symptoms. No clear consensus exists as to the need for patellar resurfacing when performing total knee replacement for patients with symptomatic femorotibial osteoarthritis but without prominent patello-femoral symptomatic and radiographic disease. Aims: To identify the advantages and disadvantages of both resurfacing and non-resurfacing of the patella during cemented total knee replacement performed for osteoarthritis predominantly of the femorotibial joint. To objectively clarify the rationale for the use of either procedure in clinical practice. Methods: Prospective randomized double blinded clinical trail. Patients with osteoarthritis of the knee and principally femorotibial symptoms were included. Patients with rheumatoid arthritis, gross deformity of the knee and gross radiological or clinical patello-femoral arthritis were excluded. The implant used was a cemented posterior stabilized AMK (Depuy, Leeds UK) prosthesis. Pre-operative American Knee Society Score, SF-36 questionnaire and WOMAC scores were calculated for each patient. These instruments were repeated and combined with clinical and radiological follow up at 3 months, 6 months and one year. Results: 58 patients were recruited into the study, 53 of whom completed follow-up and were included in the analysis. Baseline characteristics were similar in each group. Operating room time was less in the non-resurfaced group (p< 0.05). At one year, no patient in either group had needed to undergo a revision procedure. There was no difference between the resurfaced and non-resurfaced groups in terms of global functional outcome as measured by SF36 and WOMAC scores at one-year post operatively. The American Knee Society score showed no difference between the two groups (p=0.86) at one-year post surgery. Conclusion: There is no significant difference in clinical outcome at one year following surgery vis-à-vis those who did and did not have patellar resurfacing performed during knee replacement for predominantly femorotibial symptomatic osteoarthritis. Patellar resurfacing as a procedure is not without complications. In patients with osteoarthritis of the knee and predominantly femorotibial disease based on clinical and radiographic findings, we do not advocate the routine use of patellar resurfacing

The lifetime prevalence of symptomatic osteoarthritis at the knee is 50% osteoarthritis of the ankle occurs in only 1% of the population. This variation in prevalence has been hypothesised to result from the differential responsiveness of the joint cartilages to catabolic stimuli. Human cartilage explants were taken from the talar domes (n=12) and the femoral condyles (n=7) following surgical amputation. Explants were cultured in the presence of either a combination of high concentration cytokines (TNFα, OSM, IL-1α) to resemble a post traumatic environment or low concentration cytokines to resemble a chronic osteoarthritic joint. Cartilage breakdown was measured by the percentage loss of Sulphated glycosaminoglycan (sGAG) from the explant to the media during culture. Expression levels of the pro-inflammatory molecules nitric oxide and prostaglandin E. 2. were also measured. Significantly more sGAG was lost from knee cartilage exposed to TNFα (22.2% vs 13.2%, P=0.01) and TNFα in combination with IL-1α (27.5% vs 16.0%, P=0.02) compared to the ankle; low cytokine concentrations did not affect sGAG release. Significantly more PGE. 2. was produced by knee cartilage compared to ankle cartilage however no significant difference in nitrite production was noted. Cartilage from the knee and ankle has a divergent response to stimulation by pro-inflammatory cytokines, with high concentrations of TNFα alone, or in combination with IL-1α amplifying cartilage degeneration. This differential response may account for the high prevalence of knee arthritis compared to ankle OA and provide a future pharmacological target to treat post traumatic arthritis of the knee

Introduction. The prevalence of symptomatic osteoarthritis (OA) in the knee is 11–11% compared to 3.4–4.4% in the ankle. In addition to this, 70% of ankle arthritis is post-traumatic while the vast majority of knee arthritis is primary OA. Several reports have previously implicated biochemical differences in extracellular matrix composition between these joint cartilages; however, it is unknown whether there is an inherent difference in their transcriptome and how this might affect their respective functionality under load, inflammatory environment etc. Therefore, we have analysed the transcriptome of ankle and knee cartilage chondrocytes to determine whether this could account for the lower prevalence and altered aetiology of ankle OA. Methods. Human full-depth articular cartilage was taken from the talar domes (n=5) and the femoral condyles (n=5) following surgical amputation. RNA was extracted and next generation sequencing (NGS) performed using the NextSeq®500 system. Statistical analysis was performed to identify differentially regulated genes (p adj < 0.05). Data was analysed using Integrated Pathway Analysis software and genes of interest validated by quantitative PCR. Results. 809 genes were differentially expressed in this NGS study: 781 genes were significantly up-regulated and 27 significantly down-regulated in ankle cartilage with respect to knee. Preliminary analysis has identified several pathways which are differentially regulated including ‘inflammation mediated by cytokines’, ‘glutamate receptor pathway, ‘heterotrimeric-G-protein signalling pathways’, ‘WNT signalling’ and ‘integrin signalling’. Discussion. This is the first report identifying genes that are differentially expressed in ankle cartilage compared to the knee. Validation is currently being performed to ascertain the importance of these gene changes and correlation with their protein expression in the different joints. An understanding of the inherent biological differences in the cartilage between these two joints will provide invaluable insight into why the ankle is relatively spared from primary OA and the majority of ankle arthritis occurs following trauma

Background. High tibial osteotomy is a common procedure to treat symptomatic osteoarthritis of the medial compartment of the knee with varus alignment. This is achieved by overcorrecting the varus alignment to 2–6° of valgus. Various high tibial osteotomy techniques are currently used to this end. Common procedures are medial opening wedge and lateral closing wedge tibial osteotomies. The lateral closing wedge technique is a primary stable correction with a high rate of consolidation, but has the disadvantage of bone loss and change in tibial condylar offset. The medial opening wedge technique does not result in any bone loss but needs to be fixated with a plate and may cause tibial slope and medial collateral ligament tightening. Purpose. The purpose of this article is to examine correlation between femoral rotational angle and subjective satisfaction of high tibial osteotomy outcome of the range of motion of knee joint. Materials and methods. The subjects were 15 patients (6 males, 9 females) with primary osteoarthritis undergoing high tibial osteotomy from June of 2004 to August of 2008. They were CT tested on the knee joint before and after high tibial osteotomy. TEA and Akagi's line are analysed as percentages. The Kendall's and Spearman's nonparametric correlation coefficient were used for the statistical tests with 0.5 level of significance. Results. We observed a negative linear relationship (p = 0.0001) between the femoral component external rotation (measured by TEA) and active and passive ROM. Pearson Coefficient was −0.80, −0.57, respectively. We can find a negative linear relationship (p=0.001) between Akagi's line and passive ROM, and Pearson coefficient was −0.863. Preoperative flexion contracture, age, tibiofibula angle, pain, and other factors do not influence the ROM of the patient. Follow up duration do not influence the ROM of the patient. Conclusion. The result reveals that femoral rotational angle correlates with not the range of motion of knee joint but subjective satisfaction of the patients. In HTO, beside deformity correction in coronal plane, rotation of the femur contributes postoperative pain relief

Patients with symptomatic osteoarthritis of the knee are typically obese and relatively less active and may be associated with cardiovascular deconditioning and increased risk of heart disease. Purpose of this study was to evaluate the impact of the total knee arthroplasty upon cardiovascular status of the patient, as indicated by assessment of the endothelial function and correlation of the same with the functional outcome. Endothelial function has been found to correlate with the cardiovascular health of an individual closely and therefore was chosen as a noninvasive means to study the same. This study was conducted prospectively in 34 patients of advanced Osteoarthritis of knee joint (11 males, 23 females) who underwent unilateral (25) or bilateral (9) total knee arthroplasty at a mean age of 59.2 + 9.7 years (range 40–77 years). All the patients underwent preoperative assessment of endothelial function by the method of flow mediated dilatation (FMD). We report the results at 2 to 3.5 years (mean, 3.0) follow-up. The reassessment of the endothelial function and functional outcome in terms of Knee society score were performed at follow up. We noted excellent improvement in Knee society score (mean 102.3 + 22.9 at 6 months, 152.5 + 19.8 at 18 months and 174.4 + 17.3 at 42 months compared to 65.4 + 30.3 preoperatively). There was good improvement in endothelial function at 6 months (29.98 + 19.28%) and excellent improvement (69.87 + 35.57%) at 18 months and (85.65 + 26.14%) at 42 months respectively. Significant improvement in endothelial function can result following total knee arthroplasty

The options for treatment of the young active patient with isolated symptomatic osteoarthritis of the medial compartment and pre-existing deficiency of the anterior cruciate ligament are limited. The indications for the unicompartimental knee prosthesis are selective. Misalignment femoral-tibia, varo-valgus angle more than 7°, over-weight, and knee instability were considered to be a contraindication. The potential longevity of the implant and levels of activity of the patient may preclude total knee replacement, and tibial osteotomy and unicompartmental knee arthroplasty are unreliable because of the ligamentous instability. Therefore, we combined reconstruction of the anterior cruciate ligament first and unicompartmental arthroplasty of the knee. We included in this study six patients, three males and three female, mean age 53.6 years, that presented only osteoarthritis of medial femoral condyle and ACL deficiency. In the first group included 2 patients, we performed arthroscopy ACL reconstruction with hamstring and unicompartimental knee prosthesis one-step, and in the second group included 4 patients, we performed the same surgical procedure in two-step. The clinical and radiological data at a minimum of 1.5 years at follow-up. We evaluated all patients with KOOS score, and IKDC score. At the last follow-up, no patient had radiological evidence of component loosening, no infection, no knee remainder instability. The subjective and objective outcome assessed with the scale documented satisfactory average results, both in patients of first group and in those of second group. ACL deficiency induced knee osteoarthritis for incorrect knee biomechanics, and all patients could be submit a total knee replacement. What method for preventing it? This combined surgical treatment seems to be a viable treatment option for young active patients with symptomatic arthritis of the medial compartment, in whom the anterior cruciate ligament has been ruptured. Future developments and more data are necessary for standardised surgical approach

Introduction and Method: For 16 years, now, we have been using custom made femoral stems (titanium stem, HA coated) based on preoperative patient CT scans in young patients presenting with symptomatic osteoarthritis of the hip. The aim was to provide optimum initial fit-and-fill of the stem in the femoral medullary canal, conferring the best chance of secondary osteoin-tegration. This, with a goal of long term survivorship. The custom stem also enables dialling-in correction of the (often abnormal) femoral neck version (in young patients presenting with arthritis) to a more normalised 15 degrees of anteversion. Results: We present the long term results (5–16 year, mean of 10 years), clinical, survivorship and radiological, of 312 primary total hip arthroplasties in 280 patients, all of whom were under the age of 50 years of age (mean age 40). At 10 years we have a survivorship, if femoral aseptic loosening is used as an end point, of 97.6%. There was a deep infection rate of 1.2%, and a dislocation rate of 1.9%. There were no cases of thigh pain, and no intra-operative femoral neck/shaft fractures. Discussion: The under 50’s with hip arthritis requiring total hip arthroplasty are a highly challenging group, they are young, active and tend to have distorted anatomy. Our results are superior to those previously published using either cemented or standard uncemented stems. Thus, justifying the increased initial financial outlay on the custom-made stem

Despite widespread use, the benefit of knee arthroscopy for symptomatic osteoarthritis (OA) remains controversial. The theoretical benefit of removal of particulate debris and washout of inflammatory cytokines has not been supported by strong evidence. Arguments exist for its short term benefit in well selected patients. We sought to determine if arthroscopy provided any short term symptomatic relief in patients with a clinical diagnosis of OA in our unit. A total of 20 patients were listed for routine arthroscopy over a one year period for OA. Mean age was 60 (range 48–74) years and 3 in 5 patients were female. 9 patients were listed by registrars, 6 by locum consultants and 5 by substantive consultants. One procedure was cancelled on the day of surgery due to lack of indication, with 19 knees proceeding to surgery. There was evidence of significant arthritis in 17 knees, 6 of which had associated degenerate meniscus tears. Two knees had meniscus tears without significant arthritis. All patients had washout and debridement and in addition, 8 partial menisectomies were carried out together with 3 loose body removals. Patients were followed up after an average of 12 weeks. The 2 patients (both male, mean age 52) with meniscus tears in the absence of significant arthritis fully recovered. Both had symptoms of true locking. 2 patients with loose bodies also fully recovered. With the exception of 2 patients with partial relief, the remainder had no symptomatic relief. One reported a worsening of symptoms and progressed to total knee arthroplasty. These results suggest that arthroscopic debridement and washout plays a limited role in the short term symptomatic relief of OA. Surgeons should limit its use to younger patients with mild radiographic disease and true mechanical symptoms who are otherwise unsuitable for arthroplasty and not keen on undergoing joint conserving surgery

Purpose: We reviewed retrospectively 27 ankle arthrodesis procedures performed from 1990 to 2001 to assess the mid-term outcome. These patients had had on average 1.5 ankle interventions before the arthrodesis. Mean follow-up was seven years. Material and methods: The arthrodeses were performed for posttraumatic degeneration (n=21), sequelae of septic arthritis (n=3), poliomyelitis (n=2), and rheumatoid arthritis (n=1). Forty-four percent of the patients had osteoarthritis of the subtalar joint. The transfibular approach was used for 21 patients and an external fixation for five. One woman was treated with a 90 LC-DCP 4.5 plate. Results: Union was achieved in 13 weeks. There were three cases of wound necrosis (11%), two cases of superficial infection 7%) and one case each of axonotomesis of the posterior tibial nerve (3%) and malunion (3%) which required revision for insertion of a transplantar screw. Using the AOFAS system, the mean function score at last follow-up 88.4/92 compared with 42/92. Eighty-eight percent of the patients were satisfied. At last follow-up, 75% of patients had signs of active subtalar osteoarthritis. Three patients were symptomatic. Conclusion: Ankle arthrodesis is a good indication for symptomatic osteoarthritis of the ankle joint despite that it in the long-term it accelerates the development of degenerative disease in the subjacent articulations

Aims of the study: The purpose of this paper was to evaluate the long term results of the open Bankart procedure for an anterior shoulder instability in heterogenic non selected patients. Material and Methods: Hundred and seventy seven patients were operated on at our instutution using open Bankart technique without using suture anchors, between 1993 and 2002. Hundred and sixty nine patients were evaluated. Average follow up was nine years and seven months (4–13 years). Average age at the time of operation was 27 (15 – 67). 89 % of shoulders had more than 3 dislocations, 60 % had more than 10 and 37 % more than 20 dislocations. American Shoulder and Elbow Society Scoring System and Constant Scoring System were used for assessment. Results: 155 patients (92 %) had Bankart lesion and 150 patients (89%) had Hill-Sachs lesion. Five patients (2.9%) had redislocation of the operated shoulder caused by new trauma, two of them underwent reoperation. 164 patients were satisfied and very satisfied with the results. None of patients needed a shoulder arthroplasty because of symptomatic osteoarthritis. Average Constant score was 92 and American Shoulder and Elbow Society Scoring System was 90. Average loss of external rotation in adduction was 6 degrees and loss of external rotation in 90 degrees abduction was 3 degrees comparing to contra lateral shoulder. Discussion/Conclusion: The Bankart procedure for anterior shoulder instability gives reliable long-term results

Introduction: Diabetes mellitus type 2 (DM II) affects 18.2 million Americans and can cause several chronic and morbid complications. Furthermore, 90% of Americans have radiographic evidence of osteoarthritis by age 40. Diabetes may be an important risk factor for symptomatic osteoarthritis later in life. The aim of our study is to determine if diabetic patients are predisposed to osteoarthritis. Methods: We conducted a review of the all total knee arthroplasty (TKA) cases performed at our institute during the past two years for end stage osteoarthritis. We excluded TKAs performed for post-traumatic arthritis and patients with inflammatory diseases. Comorbidities and demographical information including age, gender, BMI, and family history were collected from our database. A cross sectional study was performed to analyze the prevalence of DM II in our population. This prevalence was compared to that of diabetics in the general population available from various sources including the National Center for Health Statistics. Results: Our cohort included a total of 3421 patients (1972 females, 1449 males) who had undergone TKA for end stage osteoarthritis. The average age and BMI were 66 years (range: 39–92) and 32 (range: 21–65) respectively. The prevalence of diabetes mellitus type 2 in our cohort was 12%, while the prevalence of DM II in the general US population currently ranges from 6%–7%. Discussion: Chronic diabetes causes multiorgan failure via microvascular and macrovascular damage and may possibly lead to degeneration of articular cartilage and eventual arthritis. Based on this study, diabetes appears to be a strong predisposing factor for arthritis. Our laboratory has launched an extensive series of experiments delinating the potential cellular mechanism for such association