Introduction

Osteonecrosis of the knee encompasses three conditions; spontaneous osteonecrosis of the knee, secondary osteonecrosis (ON) and post-arthroscopic ON. Early stage lesions can be managed by non-operative measures that include protected weight-bearing and analgesia. The aim of this study was to report the experience of the authors in managing early stages of knee ON by analysing the functional outcome and need for surgical intervention.

Introduction: The purpose of this study was to assess the effect of lateral release surgery in our middle aged to elderly population with advanced isolated patellofemoral osteoarthritis while the weight bearing part of the joint is well preserved. We hypothesized that lateral release is a helpful procedure in improving function and relieving pain and hence deferring the need for arthroplasty.

Material and Methods: This is a prospective study performed in patients with patellofemoral pain recalcitrant to conservative management. 57 Knees (11 Bilateral) had arthroscopic lateral retinacular release from October 1999 to Jan 2007. All patients had pain secondary to Patellofemoral osteoarthritis or ELPS (Excessive Lateral Pressure Syndrome) and had through arthroscopic evaluation of the knee prior to the lateral retinacular release. Decision was made after assessing the patella tracking from the superolateral portal using a 70 degree arthroscope. There were forty two females and 15 males with a mean age of 63 years (41 – 84 years). Thirty five procedures were done on the left knee and 22 on the right. The average body weight was 12.9 stone (9.7 – 16.5). The mean follow-up was 72 months (36 – 130). Clinical assessment tools used were the IKDC, Tegner, WOMAC and Knee Society Scores. Visual analogue pain scale and the need for reoperation were also recorded. All but one patient, who died of other medical reason, were asked to fill out questionnaires based on the above outcome measures.

Results: One patient developed swelling in the calf postoperatively. Doppler study ruled out deep vein thrombosis. No other complication (hemarthrosis or infection) was noted.

Mean pre and post operative functional score were compared. Tegner Activity scale was unchanged. Lysholm score was improved from 48(13 – 80) to 87(60–100) (p < 0.004). Post op IKDC Subjective knee score was 60(32–82). Post op WOMAC score was 42 (26–77), while The Knee Society and Functional scores were 86(63–100) and 86(45–100) respectively. Finally Visual analogue pain scale was 6(4–10) pre-op which improved to 2(0–6). At the final follow-up (mean 72 weeks), only seven patients (12%) require arthroplasty. Four patients require Total knee replacement while three patients required patellofemoral replacement at an average of 21 months (8–32) post op.

Conclusion: This procedure appears to improve function and provide significant relief of pain. The need for arthroplasty can be deferred in successful cases. Only 12 percent of our patients required arthroplasty at an average of seventy two months follow up.

Thus this confirms our hypothesis. With a low failure rate and morbidity, we do recommend this procedure in middle aged to elderly patients who has patellofemoral osteoarthritis.

Introduction: We present preliminary short term results of medial opening wedge high tibial osteotomy with hemicallotasis using a monolateral external fixator, combined with microfracturing, in younger active patients with established Grade IV medial compartment osteoarthritis.

Methods: Prospectively collected data was analysed for 28 consecutive knees in 27 patients undergoing this procedure. Mean age was 47 years (range 28 to 64), follow up was 23 months (range 7 to 61).

Results: Mean Lysholm scores improved from 63.6 before surgery (range 42 to 85) to 81.6 at latest follow-up (range 46.5–100) (p< 0.001). Similarly, the mean Tegner activity scale improved from 1.7 (range 1 – 4) to 3.3 (range 1 – 6) (p< 0.001). Average IKDC score at last follow-up was 68 (range 35.6 – 100). Mean pain score (visual analogue scale 0 to 10) improved from 5.5 pre-operatively (range 1 – 9), to 3.5 at latest follow-up (range 0 – 8) (p< 0.001). All but 4 patients reported improved pain scores.

Superficial pin site infection occurred in 6 patients (21.4%) and settled with oral antiobiotics in all cases. One patient had persistent patellofemoral (PF) pain.

Discussion: The use of hemicallotasis for high tibial osteotomy (HTO) in association with extensive microfracturing of the medial compartment provides a viable, minimally invasive method for management of the young active patient with medial compartment osteoarthritis, without the risk of serious complications. In the short term even with advanced full thickness cartilage damage, this provides effective pain relief, helps put off more major arthroplasty alternatives and improves activity levels.

Introduction: We present preliminary short term results of medial opening wedge high tibial osteotomy with hemicallotasis using a monolateral external fixator, combined with microfracturing, in younger active patients with established Grade IV medial compartment osteoarthritis.

Methods: Prospectively collected data was analysed for 28 consecutive knees in 27 patients undergoing this procedure. Mean age was 47 years (range 28 to 64); follow up was 23 months (range 7 to 61).

Results: Mean Lysholm scores improved from 63.6 before surgery (range 42 to 85) to 81.6 at latest follow-up (range 46.5–100) (p< 0.001). Similarly, the mean Tegner activity scale improved from 1.7 (range 1–4) to 3.3 (range 1–6) (p< 0.001). Average IKDC score at last follow-up was 68 (range 35.6–100). Mean pain score (visual analogue scale 0 to 10) improved from 5.5 pre-operatively (range 1–9), to 3.5 at latest follow-up (range 0–8) (p< 0.001). All but 4 patients reported improved pain scores, one of whom had patellofemoral pain. Superficial pin site infection occurred in 6 patients (21.4%) and settled with oral antibiotics in all cases.

Discussion: The use of hemicallotasis for high tibial osteotomy in association with extensive microfracturing of medial compartment provides a viable, minimally invasive method for management of the young active patient with medial compartment osteoarthritis, without the risk of serious complications. In the short term even with advanced full thickness damage, this provides effective pain relief, helps put off more major arthroplasty alternatives and allows patients an improved activity level. The external fixator provides a very stable functional stabilization, superior to other available methods of internal fixation.

To review the results of the treatment of pilon fracture with percutaneous internal fixation and extrarticular ring fixation in neutralization, twenty-two fractures in twenty-one patients were included in the study. The mean follow-up time was 5.3 years. Five fractures were classified Ruedi-Algower type I, six were Ruedi-Algower type II and eleven Ruedi-Algower type III. Six were open fractures (3 Gustilo type III) and there were 19 associated fibular fractures (five were internally fIxed). Thirteen fractures (60%) were associated with metaphysealdiaphyseal dissociation (MDD). The majority of fractures were high energy (18 out of 22). General health outcome was assessed with the use of the SF-36 and functional outcome was evaluated with AOFAS score and Bone’s criteria.

The average AOFAS score for the study population was 79.4. The AOFAS scores decreased as the severity of the fracture increases and these differences were statistically significant between the Ruedi-Algower types I and III. The pilon fractures population scored lower in all SF-36 categories but mental health and energy and vitality when compared to an age matched population but statistically significant differences were only found in the categories of physical function and limitation due to health problems. 65% achieved excellent or good results according to Bone’s criteria. No significant differences were found in the union times in the MDD group (253 days) when compared to the fractures with no MDD (224 days), but this can be due to the high incidence of autograft in the MDD group (7 out of 13). All patients achieved full weight bearing at 6 weeks. Fourteen patients had superficial pin site infections (one needed screw removal) that settled with oral antibiotics. There was one case of non-union and two varus heels.

Conclusion: Good results are achieved treating pilon fractures with minimal internal fixation and the Sheffield ring fixator in neutralization but quality of life and functional scores significantly worsen in the most severe Ruedi-Algower type III fractures.