PURPOSE. YouTube is a video sharing platform that is a common resource for patients seeking medical information. The objective of this study is to assess the educational quality of YouTube videos pertaining to total knee arthroplasty and knee arthritis. METHODS. A systematic search for the terms “knee replacement” and “knee arthritis” was performed using Youtube's search function. Data from the 60 most relevant videos were collected for each search term. Videos not in English or those without audio or captions were excluded. Quality assessment checklists with a scale of 0 to 10 points were developed to evaluate the video content. Videos were grouped into poor quality (grade 0–3), acceptable quality (grade 4–7) and excellent quality (grade 8– 10), respectively. Four independent reviewers assessed the videos using the same grading system and independently scored all videos. Discrepancies regarding the scoring were clarified by consensus discussion. RESULTS. Overall 106 videos were categorized. For videos regarding total knee replacements, the average number of views was 135,074 with an average duration of 14.53 minutes. Half of the videos were published by a physician or hospital sponsor and were for educational purposes. 64% of videos were of poor educational quality (32/50), 28% were of acceptable quality (14/50), and 8% were of good educational quality (4/50). Common missing information included discussion of surgical complications and implant duration. For videos regarding knee arthritis, the average number of views was 243,346 with an average duration of 4.97 minutes. 39% were published by a physician or hospital sponsor, with 64% of videos made for educational purposes. 66% of videos were of poor educational quality (37/56), 32% were of acceptable quality (18/56), and 2% were of good educational quality. The most common missing information were causes and risk factors for knee arthritis and long-term prognosis. CONCLUSIONS. The present study suggests that YouTube is a poor educational source for patients regarding knee arthroplasty and knee arthritis. Recognizing the limitations of YouTube as well as which topics are not commonly presented may guide clinicians to better educate their patients

Aims. An algorithm to determine the constitutional alignment of the lower limb once arthritic deformity has occurred would be of value when undertaking kinematically aligned total knee arthroplasty (TKA). The purpose of this study was to determine if the arithmetic hip-knee-ankle angle (aHKA) algorithm could estimate the constitutional alignment of the lower limb following development of significant arthritis. Methods. A matched-pairs radiological study was undertaken comparing the aHKA of an osteoarthritic knee (aHKA-OA) with the mechanical HKA of the contralateral normal knee (mHKA-N). Patients with Grade 3 or 4 Kellgren-Lawrence tibiofemoral osteoarthritis in an arthritic knee undergoing TKA and Grade 0 or 1 osteoarthritis in the contralateral normal knee were included. The aHKA algorithm subtracts the lateral distal femoral angle (LDFA) from the medial proximal tibial angle (MPTA) measured on standing long leg radiographs. The primary outcome was the mean of the paired differences in the aHKA-OA and mHKA-N. Secondary outcomes included comparison of sex-based differences and capacity of the aHKA to determine the constitutional alignment based on degree of deformity. Results. A total of 51 radiographs met the inclusion criteria. There was no significant difference between aHKA-OA and mHKA-N, with a mean angular difference of −0.4° (95% SE −0.8° to 0.1°; p = 0.16). There was no significant sex-based difference when comparing aHKA-OA and mHKA-N (mean difference 0.8°; p = 0.11). Knees with deformities of more than 8° had a greater mean difference between aHKA-OA and mHKA-N (1.3°) than those with lesser deformities (-0.1°; p = 0.009). Conclusion. This study supports the arithmetic HKA algorithm for prediction of the constitutional alignment once arthritis has developed. The algorithm has similar accuracy between sexes and greater accuracy with lesser degrees of deformity. Cite this article: Bone Joint Open 2020;1-7:339–345

Introduction and Objective. Malunion after trauma can lead to coronal plane malalignment in the lower limb. The mechanical hypothesis suggests that this alters the load distribution in the knee joint and that that this increased load may predispose to compartmental arthritis. This is generally accepted in the orthopaedic community and serves as the basis guiding deformity correction after malunion as well as congenital or insidious onset malalignment. Much of the literature surrounding the contribution of lower limb alignment to arthritis comes from cohort studies of incident osteoarthritis. There has been a causation dilemma perpetuated in a number of studies - suggesting malalignment does not contribute to, but is instead a consequence of, compartmental arthritis. In this investigation the relationship between compartmental (medial or lateral) arthritis and coronal plane malalignment (varus or valgus) in patients with post traumatic unilateral limb deformity was examined. This represents a specific niche cohort of patients in which worsened compartmental knee arthritis after extra-articular injury must rationally be attributed to malalignment. Materials and Methods. The picture archiving system was searched to identify all 1160 long leg x ray films available at a major metropolitan trauma center over a 12-year period. Images were screened for inclusion and exclusion criteria, namely patients >10 years after traumatic long bone fracture without contralateral injury or arthroplasty to give 39 cases. Alignment was measured according to established surgical standards on long leg films by 3 independent reviewers, and arthritis scores Osteoarthritis Research Society International (OARSI) and Kellegren-Lawrence (KL) were recorded independently for each compartment of both knees. Malalignment was defined conservatively as mechanical axis deviation outside of 0–20 mm medial from centre of the knee, to give 27 patients. Comparison of mean compartmental arthritis score was performed for patients with varus and valgus malalignment, using Analysis of Variance and linear regression. Results. In knees with varus malalignment there was a greater mean arthritis score in the medial compartment compared to the contralateral knee, with OARSI scores 5.69 vs 3.86 (0.32, 3.35 95% CI; p<0.05) and KL 2.92 vs 1.92 (0.38, 1.62; p<0.005). There was a similar trend in valgus knees for the lateral compartment OARSI 2.98 vs 1.84 (CI −0.16, 2.42; p=0.1) and KL 1.76 vs 1.31 (CI −0.12, 1.01; p=0.17), but the evidence was not conclusive. OARSI arthritis score was significantly associated with absolute MAD (0.7/10mm MAD, p<0.0005) and Time (0.6/decade, p=0.01) in a linear regression model. Conclusions. Malalignment in the coronal plane is correlated with worsened arthritis scores in the medial compartment for varus deformity and may similarly result in worsened lateral compartment arthritis in valgus knees. These findings support the mechanical hypothesis that arthritis may be related to altered stress distribution at the knee, larger studies may provide further conclusive evidence

The aim of the study was to investigate rotational behaviour of the arthritic knee before (preimplant) and after (postimplant) total knee replacement (TKR) using (image-free navigation system as a measurement tool which recorded the axial plane alignment between femur and tibia, in addition to the coronal and sagittal alignment as the knee is flexed through the range of motion. The data on the rotation of the arthritic knee was collected after the knee exposure and registration of the lower limb (preimplant data). The position of rotation between the femur and tibia was recorded in 30° flexion, 45°, 60°, 90° and maximum degrees of flexion of the knee. The data was divided into subsets of varus and valgus knees and these were analysed pre and postimplant for their rotational position using SPSS for statistics. The system was used in 117 knees of which 91 had full data set available (43 male 48 female). These included 71 varus knees, 16 valgus knees and 4 neutral knees to start in extension. Preimplant data analysis revealed there is tendency for the arthritic knees to first go in internal rotation in the initial part of flexion to 30 degrees and then the rotation is reversed back. This happens irrespective of the initial starting rotational relationship between femur and tibia in full extension. This happens in both varus as well as valgus arthritic knees. This trend of internal rotation in this initial part of flexion is followed in TKR as well implanted with fixed bearing CR knees irrespective of the preoperative deformity. Also noteworthy was the difference in rotation at 30°, 60° and 90 degrees of flexion between preimplant and postimplant knees (irrespective of varus and valgus groups). When calculated at different points of flexion, there was statistically significant difference in the change of rotation at each point of flexion except 45 degree of flexion. The pre-operative values of change in rotation (internal being positive) at each step from the extended position being 5.4° (SD 4.5°) at 30 ° flexion, 4.7°(5.2°) at 45°, 3.6°(6.1°) at 60°, 3.5°(7.2°) at 90° and 4.2°(8.3°) at maximum flexion. Corresponding post-operative rotations were 2.2°(4.8°), 4.1°(6.4°), 6.6°(7.3°), 9.9°(8.8°) and 7.7°(8.9°). There was also an increase in the total range of rotation that the knee goes through after it has been implanted with prosthesis although it may not happen in every knee. This is statistically significant (p value <0.001) and seems more so in valgus group. The rotational movements and interrelationship of the femur and tibia is a complex issue, especially in the arthritic knees. Preimplant arthritic knee behaved generally similarly to normal knees according to the literature. Normal gait pattern demonstrates that the tibia moved through a 4° to 8° arc of internal rotation relative to the femur. The overall range (10.2° =/−4.2°) of knee rotation in this study greater than 8° might be explained by preimplant data acquired after the knee was approached and therefore releasing knee soft tissue envelop. This study confirmed that during the first 30° both varus and valgus knees moved internally. In our study there is increased range of total rotation postimplant (14° =/−6.8°) which may be explained by the fact that the anterior cruciate ligament is lost in all the TKRs and the posterior cruciate ligament may be dysfunctional as well. Thus the constraints on the knee rotation are decreased postimplant leading to increased rotation. We found some difference between varus and valgus post implant knees in that internal rotation seen in initial 30 degrees of flexion is much more pronounced in valgus knees as compared to varus knees (p value <0.001). This study confirmed knee internal rotation in initial stages of flexion, preimplant in arthritic knees during a passive knee flexion assessment. Varus and valgus knee seemed to behave similarly. This mimics the normal knee rotation. Postimplant knees in TKR behave differently

The Authors performed a matched paired study between 2 groups UKR or CA-TKR implanted with a mini-incision (MICA group) in the treatment of isolated medial compartment knee arthritis. The Authors hypothesized that UKR offers a real less invasive surgery with lower economical costs despite a worse limb/implant alignment. Furthermore at a minimum 40 months follow-up they hypothesized that this small implant guarantees still both better clinical score and patient satisfaction than in the MICA group. Thirty two patients with isolated medial compartment knee arthritis who underwent to a medial UKR from February 2001 to September 2002 were included in the study (UKR group). In all 32 knees the arthritic change was graded according to the classification of Älback . 1. Arthritic change did not exceed grade IV in the medial compartment and grade II in the patello-femoral compartment. All patients had an asymptomatic patello-femoral joint. All patients had a varus deformity lower than 8° and a body mass index lower than 30. No patient had any clinical evidence of ACL laxity or flexion deformity and all had a preoperative range of motion of a least 110°. At a minimum follow-up of 48 months, every single patients in group A was matched with a patient who had undergone a computer assisted TKR performed with a less invasive approach (shorter than 12 cm) for an isolated medial compartment knee arthritis between August 1999 and September 2002 (MICA group) in our hospital. At latest follow-up the clinical outcome was evaluated using both the Knee Society Score and a dedicated UKR score developed by the Italian Orthopaedic UKR Users Group (GIUM). The HKA angle and the Frontal Tibial Component angle (FTC) were measured at latest follow up on long leg standing anterior-posterior radiographs and the mean values between the 2 surgeons assessments were used as final values. Furthermore during the hospital staying we registered in both the groups when each patient was standing comfortably in full weight-bearing according to a self- answered questionnaire and the data were compared. Statistical analysis of the results was performed using parametric test (Student’s t-test). A statistical comparison of the percentage of results for the GIUM score was performed using the Chi-square test. A statistically significant result was given a p≤ 0.05. Both hospital stay and operative time were statistically longer obviously in MICA group. In the UKR group the mean surgical time was 51.5 minutes (range: 36–75) (p< 0.001) while in the MICA group was 108.8 minutes (range: 80–132) (p< 0.001). In the UKR group the patients remained in the hospital for a mean of 5.1 days (range: 3–7) and in the MICA group 8.2 days (range: 4–16). At the latest follow-up the mean Knee Society Score was 80.5 (range: 70–100) and 78.4 (range: 70–87) for group A and B respectively. No statistically significant difference was seen for the Knee Society score between the 2 groups (p=0.08). The mean Functional score was 83.5 (range: 73–100) for group A and 78.8 (range: 59–90) for group B. A statistically significant difference was seen for the Functional score with superior results for group A (p=0.02). A statistically significant difference was seen for the GIUM score with better results for group A (p=0.01). The mean GIUM score was 76 (range: 67–90) and 73.02 (mean: 65–85) for group A and B respectively. At latest follow up the mean HKA angle was 176.8° for group A (range: 174°–182°) and 179.3° for group B (range 177–182) (p< 0.001). The mean FTC angle was 86.9° (range: 84°–90°) and 89.4° (range: 87°–92°) for group A and B respectively (p< 0.001). All TKR implants were positioned within 4 degrees of a HKA angle of 180° and FTC angle of 90°. At the latest follow-up (minimum 48 months) no statistically significant difference was seen in the postoperative Knee Society score for either group. However, significant differences were seen between the 2 groups in the functional results and in the GIUM score with better results in the UKR group. All the patients achieved a range of motion greater than 120° and could walk for longer distances. During the hospital staying in this group the patients reported a statistically significant earlier full weight-bearing. This was despite a significant less accurate limb alignment. In addition to inferior results for the computer assisted mini-invasive TKR group the costs of the procedure were obviously greater because of the expensive implants and technology along with statistically significant longer surgical times and hospital stay

Introduction. Septic knee arthritis with severe osteoarthritis (OA) presents challenging clinical situations because of unexpected and long time for treatment and less satisfactory clinical outcomes. Septic arthritis with damage to articular cartilage developed osteomyelitis (OM) frequently. Although arthroscopic debridement was the common treatment of septic arthritis, there was some limitation on the management of infected bone structures and then open arthrotomy should be reserved. In the patients of OM located only periarticular areas, the author used the PROSTALAC system for infected total knee arthroplasty (TKA) and achieved good results. Objectives. In periarticular OM with septic knee arthritis in patients with severe OA, we report the rate of control of infection using the PROSTALAC articulating spacer and to assess the clinical outcome after staged TKA. Methods. This study was conducted on a total of 11 patients (11 knees) treated for septic knee arthritis in patients with Kellgren-Lawrence classification grade 3–4 OA between April, 2014 and April, 2015. Of these, we retrospectively reviewed 6 knees of 6 patients (54.5%) who underwent staged TKA using the PROSTALAC articulating spacer. The inclusion criteria were periarticular OM confirmed by magnetic resonance imaging (MRI) and whole body bone scan (WBBS), affected bone could be resected and covered by the PROSTALAC system. There were 2 males and 4 females with a mean age of 64 years (range, 61 to 68 years). Prior to the initial surgery, the average erythrocyte sedimentation rate (ESR) 87mm/h, and C-reactive protein (CRP) 8.8 mg/dl. The mean follow-up period was 14 months (range, 12 to 24 months). For clinical assessment, WOMAC, UCLA, Patient Satisfaction scores and postoperative complications were evaluated. For radiological assessment, weight-bearing radiographs of the knee were obtained to evaluate bone change, component loosening, and recurrence of infection. Results. The mean interval between initial operation using the PROSTALAC system and staged TKA was 8.2 weeks (range, 8–10 weeks). The species could be identified in the culture of aspiration of joint fluid prior to the initial operation. The most frequently found etiologic agent was gram-positive cocci (66.6%), followed by MRSA (16.7%) and yeast like fungi (16.7%). At last review, ESR and CRP returned to normal and follow-up cultures were negative in all patients. We observed improvements in mean WOMAC, UCLA, and Patient Satisfaction scores at last review. Radiographs at final follow-up showed well-fixed implants with no radiographic evidence of loosening or infection. Conclusions. In this study, we observed a 100% microbiologic cure and 89% clinical cure in patients who underwent a staged TKA using the PROSTALAC system with a 14-months follow-up. This method appears to have several important advantages (1) there is less possibility of additional bone resection due to uncontrolled infection of adjacent bone; (2) there are possibly expected interval between two stages and more good patient satisfaction. The staged TKA using the PROSTALAC spacer would have a predictable, favorable effect on the control of infection and improvements in the functional outcomes for the treatment periarticular OM with septic knee arthritis in patients with severe arthritis

Introduction: The knee arthritis is a very common seen chronic disease in an orthopaedic practice. It is mostly seen in patients after 6 decade of life and connected with a severe knee pain. In most of the cases the surgical intervention is indicated because of unicondylar arthritis changes. Because of the costs of the hemiarthroplasty we choose a high tibial osteotomy for tibial axis correction to prevent further gonarthrosis. The aim of this study was to evaluate the late results after high tibial osteotomy in patients with unicondylar gonarthrosis. Material and Methods: In our Institution during last 20 years 94 high tibial osteotomy were performed because of unicondylar, medial gonarthrosis. The mean age of the patient at the time of surgery was 56 years (from 19 to 72 years). The mean follow-up was 16 years. Only patients with arthritic changes on the medial compartment of the knee with a “good” lateral part of the knee were scheduled for this type of surgery. In every case the dome type of osteotomy was performed followed by 1cm resection of fibula. After surgery the limb was stabilized with plate in 16 cases, K-wires in 4 cases, Ilizarov frame in 43 cases, orthofix device in 8 cases and other type of external fixator in remaining 23 cases. In patients where external fixator was used the full weight bearing was recommended as soon as patient tolerated the pain. The external fixator was removed after an average period of 6 weeks when bone callus was diagnosed. To assess of the clinical results based on HSS score and radiological results were evaluated using the modified Dihlmann classification. Results: In 88,8% of all cases the final result was graded as excellent and good, in 1,9% the final results was satisfactory and in 7.8% the final results was poor. From analyzed patients 46% was scheduled for TKR at an average time of 12 years after initial surgical procedure. In 28% after average 16 years after high tibial osteotomy the good shape of the knee joint was observed with good clinical function and radiographic appearance. Pain was reduced in 82% of all cases, increased range of the knee motion was observed in 65% and improved walking ability in 64% of all cases. The poor results were connected with not adequate patients selection for this type of surgery (patients after 7 decade of life) and with advanced arthritic knee changes before the surgery. Conclusions : The high tibial osteotomy is a good method for preventing gonarthrosis. When early performed gives good long-lasting result. In our opinion is recommended for unicondylar gonarthrosis as an alternative to the knee hemiarthroplasty

Background. Septic knee arthritis is one of the most serious complications after total knee arthroplasty (TKA), and the effectiveness of its treatment affects the patient's quality of life. In our super-aging society, the frequency of TKA in the elderly, often combined with various comorbidities, is increasing. Careful management should be considerd during the management of septic arthritis after TKA in these patients. Purpose. To analyze the clinical features and outcomes of septic arthritis after TKA in our institution. Materials and Methods. Between April 1999 and March 2014, 534 TKAs (osteoarthritis [OA]; 381, rheumatoid arthritis [RA]; 154) were performed. Of these patients, 8 with post-operative infected TKA were retrospectively surveyed. Results. The TKA-associated infection rates were 0.83% (0.35%, OA; 1.7%, RA) during the study period. Five male and 3 female patients were included, with a mean age of 68 years (range, 39–88 years) and primary diagnoses of OA (5) and RA (3). Malignant rheumatoid arthritis (MRA) was present in 1 patient. The infection was affected by a comorbidity in 2 (diabetes mellitus and mixed connective tissue disease). Microorganisms were detectable in 7 patients (methicillin-resistant Staphylococcus aureus [MRSA], 1; methicillin-sensitive Staphylococcus aureus, 2; Streptococcus pyogens, 1; Streptococcus oralis, 1; Escherichia coli, 1; Staphylococcus epidermidis, 1; and unknown, 1) (Fig. 1). The use of the Segawa/Leone classification resulted in 5 patients with type III (acute hematogenous) and 3 with type IV (late) infections. Four patients with type III (80%) infection underwent open debridement, continuous irrigation, and successful implant retention (Fig. 2). The MRA patient had type III infection and an MRSA infection that was treated with two-stage revision, but the infection recurred. We could not perform a re-implantation, and resection arthroplasty was needed. Arthroscopic irrigation in 1 patient with type III infection ended in failure, and open debridement was required. We attempted to retain the implant in 1 patient with type IV infection, but implant removal was required. Three patients with type IV infection underwent two-stage revision successfully. Discussion. The post-TKA infection rate was 0.83% in our institution. Of the implants, 50% (type III, 80%; type IV, 0%) were successfully retained. Early open debridement and irrigation are important for implant retention in patients with infected TKAs, while arthroscopic debridement does not appear to be effective for infected TKA. Implant retention was difficult in the presence of resistant microorganisms. Two-stage revision was required in patients with type IV infection, with a success rate of 75%

Aim. The aim of our study was to identify pathogens involved in septic knee arthritis after ACLR and to describe clinical features, treatment and outcome of infected patients. Methods. We conducted a retrospective observational study including all patients with ACLR infection in 3 orthopedic centers sharing the same infectious disease specialists. Results. During a seven-year period (2011–2017) we identified 74 infected patients among 9858 patients who had ACLR (incidence rate = 0.0075). Fourteen patients had polymicrobial infection. We identified 89 pathogens. Twenty four patients (34.4 %) were infected with S. aureus (27% of all isolates)(only one oxacillin-resistant strain). C. acnes was the second most frequent pathogen, identified in 14 patients (18.9%) (15.7% of all isolates). S. lugdunensis was identified in 9 patients (12.2%) (10.1% of all isolates). S. caprae was as frequent as S. epidermidis identified in 8 patients each (10.8%) (9 % of all isolates for each). No strain of S. lugdunensis and S. caprae was resistant to oxacillin, levofloxacin or rifampicin. Ten patients infected by C. acnes, 8 infected by S. lugdunensis, and 7 infected by S. caprae had an early acute infection. In all cases but one an arthroscopic lavage was performed, in 14 cases two lavages were required and in 4, 3 lavages. All patients infected by a strain susceptible to levofloxacin and rifampicin, including those with C. acnes, S. caprae and S. lugdunensis infection, were treated with an oral combination of levofloxacin and rifampicin, after a couple of days of IV empirical treatment with vancomycin and a broad spectrum beta-lactam. The median duration of treatment was 6 weeks. Seventy one patients were considered cured. Conclusions. To our knowledge this is the largest reported series of infection after ACLR. S. aureus is the main pathogen (27% of all strains). C. acnes, S. lugdunensis and S. caprae accounted for almost 35% of pathogens and 38% of infections. A conservative strategy consisting in arthroscopic lavage(s) and a 6-week treatment with levofloxacin and rifampicin was effective

Aim: To evaluate results of fully congruent Mobile bearing knee arthroplasty for valgus arthritic knees using lateral capsular approach and realignment of vastus lateralis. Material and Method: We reviewed results of 50 mobile bearing total knee arthroplasties performed consecutively between 2001 and 2006 for Valgus arthritic knees, using lateral capsular approach and realignment of vastus lateralis. Patients were evaluated using oxford and International knee society Score. Radiographs were examined for alignment of the component, evidence of loosening and scanograms assessed to evaluate the restoration of mechanical axis. Results: The study group consisted of 47 patients, 20 men and 27 women who received fifty knees. The mean age at the primary operation was 71.57 years (range 47–82 years; SD, 9.5). The mean follow up was 4.2 years (range 1–6 years; SD, 1.35). The mean Valgus deformity was 15.92° (rang from 15–20 SD 1.89). Fixed flexion deformity was seen in 15 knees. The mean Oxford Knee Society ratings was 52 (range 47–55; SD, 3.18) preoperatively, and 19 (range 14–24; SD, 3.72) at final follow up. The pre op mean range motion was 84.28° (range 45°–120°; SD 21.73). At final follow up the average range of motion was 107.5° (range 95°–120°; SD 8.93). According to the system of the Knee Society, the average knee score was 94 points and the average functional score was 89 points at final follow up. There were no clinical failures or cases of postoperative instability and no cases of radiographic loosening or wear. Radiological evaluation: None of these knees had radiographic evidence of loosening or osteolysis. Mechanical axis was restored in all the patients. Conclusion: This study demonstrates satisfactory results of Mobile bearing knee arthroplasty using lateral parapatellar with proximal realignment of vastus lateralis for Valgus arthritic knees

We hypothesize that tethering adhesions of the quadriceps muscle are the major pathological structures responsible for a limited range of motion in the stiff arthritic knee. Forty-two modified quadriceps muscle releases were performed on 24 patients with advanced osteoarthritis scheduled for total knee arthroplasty. The ranges of motion were documented intraoperatively both before and immediately after the release. Passive flexion improved significantly in all patients (mean, 32.4 degrees of improvement, P < .001) following a modified quadriceps release, despite any presence of osteophytes or severe deformities. These results strongly implicate adhesions of the quadriceps muscle to the underlying femur, which prevent the distal excursion of the quadriceps tendon, as the restrictive pathology preventing deep flexion in patients with osteoarthritis

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

We have reviewed 183 patients (215 knees) assessing results and indications of High Tibial Osteotomies in medial gonarthrosis. Material: 128 females and 55 males. Follow up is 11.5 years, 120 cases with average varus angle 13° had opening ; 95 cases with average varus angle 10° had closing wedges. Ahlback classification showed stages I: 54, II: 71, III: 66 and IV: 24. H.S.S. scoring was 61 for opening and 68 for closing wedge. Results: 27 re-operations and 13 other complications. Healing delay was 55 days for closing and 70 for opening. R.O.M. was 125°. 25 knees are painful. 1/After opening, scoring is 77 and valgus angle is 3°. 2/After closing, scoring is 80 and valgus angle is 5°. 3/Global results: very good: 26%, good: 33%, medium: 28% and poor: 13%. Discussion: H.T.O. decreases stresses on medial compartment and widens joint space. No significant aggravation is observed at follow up. Clinical results are satisfying in early surgery. Reaxation is good for delaying or managing arthritis. The average of 5° mechanical valgus at osteotomy seems to be effective. Conclusions: -Opening wedge for medium severity and wide varus angle, till the age of 70. -Closing wedge for medium varus in younger patients. H.T.O. allows quite pain-free knees, restores axes and avoids or delays T.K.R. H.T.O. gives satisfactory results and should be then considered the best choice for early prevention and treatment of varus knee arthritis

Abstract

Aims

The Coronal Plane Alignment of the Knee (CPAK) classification is a simple and comprehensive system for predicting pre-arthritic knee alignment. However, when the CPAK classification is applied in the Asian population, which is characterized by more varus and wider distribution in lower limb alignment, modifications in the boundaries of arithmetic hip-knee-ankle angle (aHKA) and joint line obliquity (JLO) should be considered. The purposes of this study were as follows: first, to propose a modified CPAK classification based on the actual joint line obliquity (aJLO) and wider range of aHKA in the Asian population; second, to test this classification in a cohort of Asians with healthy knees; third, to propose individualized alignment targets for different CPAK types in kinematically aligned (KA) total knee arthroplasty (TKA).

Aim

Traditionally, serum white blood count (WBC), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) have been utilized as markers to evaluate septic arthritis (SA). Recently, neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been identified as prognostic factors for treatment failure, mortality and morbidity in various clinical settings. To date, these markers have not been utilized for evaluating outcomes after hip and knee SA.

Thus, the purpose of this study was to determine the ability of admission NLR and PLR to predict treatment failure and postoperative 90-day mortality in hip and knee SA.

Introduction: Patients with advanced osteoarthritis tend to have limited range of motion; the purpose of this in vivo anatomical study is to identify the anatomical structures responsible for limited knee movement in patient with osteoarthritis.

Materials and Methods: 42 quadriceps releases were performed in patients who had TKA. The releases were carried out utilizing subvastus approach and just before proceeding with the knee replacement surgery. The ranges of motion were documented before and after the release using digital photography and lateral portable x-ray. No bony resection was done, and no ligament release was performed. Quadriceps excursion was also studied under fluoroscopy in six volunteers throughout the range of movement

Results: The quadriceps release improved the range of motion in all patients; at least 135 degrees of flexion were obtained. The average of improvement in knee flexion after the release was 36 degrees. The presence of osteophytes or gross deformity did not influence the degree of improvement. The fluoroscopy study has shown that the average excursion of quadriceps muscle from 0 to 145 degrees is 7 cm. The excursion per degree varies throughout the range of motion; it is more per degree near full flexion and extension than around 90 degree of flexion

Conclusion: The limited excursion of the quadriceps muscle is the main limiting factor to knee flexion. Other pathological changes such as osteophytes, surface pathology, posterior capsule and the cruciate ligaments play very limited roles.

Osteotomies are performed in patients with lower limb malalignment, usually associated with osteoarthritis of the knee or instability. The surgery realigns the mechanical axis of the leg by either an opening or closing wedge procedure with the goal of decreasing symptoms, improving function, and delaying the progression of osteoarthritis.

The 103 patients that had undergone osteotomy surgery were studied prospectively, and data was analysed one year post surgery. We examined subjective outcomes, patient history and surgical variables using backwards stepwise multiple regression models to determine whether there were any associations between these.

Subjective outcomes from a total of 103 osteotomy patients at one year post surgery were compared to patient history and surgical variables. All categories of KOOS and WOMAC scores were improved after surgery.

The multivariate models showed that variables significantly influencing the outcomes were pre-operative flexion, pre-operative weight, the size of the HTO plate used and tourniquet time.

Greater pre-operative flexion; lower weight; larger plate used, indicating larger corrections; and lower tourniquet times were shown to result in improved scores. Not all variables influenced all categories of the scores. While flexion and pre-operative weight influenced across the categories of both scores, plate size influenced KOOS pain and symptoms and tourniquet time influenced KOOS sport and quality of life.

Knee flexion and body weight were the most influential variables when considering KOOS and WOMAC outcome scores as a measure of success. The size of the correction may have influenced the pain and symptom scores because patients with greater malalignment may have initially had worse symptoms and their perception of their current function and pain is affected by their previous levels of pain and function. Osteotomy results in improved function and pain scores and our results indicate that there are several variables which significantly influence patient outcomes and may be of greater importance than other variables.

Purpose: The purpose of the study is to compare the disease severity at the time of surgical intervention between patients undergoing primary joint replacement under the National Health Service and Private Health-care Systems.

Materials: 166 patients were included in the study – 101 NHS and 65 Private. Inclusion criteria were: 1) hip or knee osteoarthritis, 2) primary joint replacement, and 3) informed consent of the patient. Patients with arthropathy of inflammatory, infectious or neoplastic aetiology were excluded. Physician evaluation included medical history, calculation of Charleson Comorbidity Scores, and Knee Society rating. Patients were given self-assessment health questionnaires including WOMAC, SF-36, and Nottingham Health Profile.

Results: Mean age was 69.4 years and did not vary significantly between NHS and Private groups. Charleson Comorbidity Scores were significantly worse in the NHS group than in the private. Health assessment questionnaire scores were all adjusted for age, sex, and comorbidity. In NHS patients undergoing TKR, we demonstrate significantly worse pre-operative comorbidity than in private group for indices of function and pain. Patients undergoing THR showed little difference in pre-operative comorbidity.

Conclusion: NHS patients undergoing primary TKR have significantly more advanced disease than their counterparts who are privately insured. Access to TKR surgery is determined by the healthcare delivery system rather then a threshold level of disease severity. Further follow-up of the outcomes of TKR in these two groups needs to be carried out to determine the long-term effects of accessing surgical care at a more advanced stage of disease.

Soft tissue balancing in fixed genu valgum can be challenging and may lead to instability in flexion. Current techniques involve release of the tight secondary structures initially, with the fascia lata and the lateral capsule usually addressed first, and then the posterior capsule if necessary. If ligament testing does not permit neutral alignment in extension, release of the lateral collateral ligament becomes necessary.

The most common way of achieving neutral alignment is by lengthening the lateral structures through elevation of the proximal insertion of the lateral collateral ligament (LCL). This technique has two drawbacks: the lengthening affects both extension and flexion gaps and may give rise to excessive external rotation of the femoral implant, with too much offset of the rotational centre. Particularly when non-constrained prostheses are used, the resulting lateral instability in flexion can be a problem.

An alternative is to perform a release at the level of the distal insertion of the LCL, as advocated by Keblish and Buechel. However, this still induces undue external rotation of the femoral implant.

We think that if the situation in flexion before any release is satisfactory in terms of the patella, it should not be changed. This means that in order to maintain optimal patellofemoral function, the flexion gap should be addressed before any release. The task is then to achieve a good extension gap with a well-aligned knee. In fixed valgus deformities, this means distal translocation of the femoral insertion of the LCL by distal sliding lateral condylar osteotomy. This procedure aims to preserve the flexion condition and to allow distal slide of the lateral condylar osteotomised fragment. In doing the osteotomy, it is important to make the lateral fragment sufficiently large to allow relocation of the osteotomised fragment inside the prosthesis. This provides the immediate stability necessary for good healing. We have been using two simple cortical screws to ensure stability of the fragment.

This paper reports our experience in 100 cases.