Background and objectives: Total knee replacement (TKR) produces severe postoperative pain. Peripheral nerve blocks can be used as analgesic adjuncts for TKR, but the efficacy of a sciatic nerve block as an adjunct to a femoral nerve block is controversial. The aim of this study was to compare femoral with femoral and sciatic nerve blocks in postoperative pain management of patients undergoing total knee arthroplasty (TKA).

Methods: 42 patients were involved in the study. 20 patients received only a femoral nerve block, consisting of 20ml of 0.5% Chirocaine and 22 patients received femoral and sciatic nerve blocks, consisting of 20ml of 0.375% Chirocaine for the femoral nerve and 10ml of 0.5% Chirocaine for the sciatic nerve. The primary outcome measures used were visual analogue scale (VAS) scores for pain at 24 hours, 48 hours and 72 hours after the surgery, opiates consumption post-operatively and PCA use. The secondary outcomes were post-operative nausea and vomiting, sensory deficit, quadriceps contraction, straight leg raise, knee flexion, independent mobility and discharge from the hospital.

Results: The results showed no difference in opiate consumption, PCA use, independent mobility and time of discharge from the hospital between the two groups.

Conclusion: The study shows that the addition of a sciatic nerve block to the femoral nerve block does not provide additional benefits.

Introduction: As the age for performing a primary knee replacement is gradually falling there is increase need and demand for revision total knee replacement and subsequent revisions thereafter. There are very few published studies showing the outcome of re revision knee replacement surgery.

Aim: We aim to show functional outcome of 21 patients at 3 to 5 years after undergoing Re revision knee arthroplasty.

Methods: We defined re revision as a procedure where there was exchange of either one or both Tibial and Femoral components using a modular revision system. We included all patients undergoing re revision knee replacement and had complete records & X rays . We excluded patients with incomplete records, those who could not be assessed due to medical infirmity or other reasons. We also excluded patients with 2 stage revision knee replacement for infection. This left us with 21 patients in our cohort operated between 1996–2002.

The patients were scored pre operatively using Knee society score ( KSS) and Western Ontario and McMasters Osteoarthritis Index (WOMAC). Patients were assessed with same scoring system post operatively at 3 months, 1 year and annually there after. Post op x rays were reviewed by Knee society Radiological Evaluation.

Results: 18 modular revision prosthesis ( Co ordinate ultra, DePuy) and 3 rotating hinge (S Rom) prosthesis were used. The mean follow up was 3.5 years range from 11 months to 5.7 years. The mean post operative KSS score improved to 83 from pre op 41. Final post operative WOMAC scores for pain 12.3, Stiffness 5.6, Function are 47.1. We had few minor complication not requiring further surgery. Overall in 15 patients (71.43%) had a statistically significant improvement at latest follow up. 4 patients (19%) had moderate improvement and 2 patients ( 8%) had no improvement in scores.

Conclusion: We conclude that re revision knee arthroplasty provides satisfactory pain relief and knee stability. As 71% of our cohort improved significantly we continue to support the clinical use of this procedure.

Purpose of study: The purpose of the study was to determine the influence of patient’s pre-operative mental state on post-operative physical outcomes in primary and revision total knee arthroplasty (TKA).

Methods: 100 Primary and 60 Revision TKA patients were prospectively assessed using SF-12 and WOMAC outcome measures. They were assessed pre-operatively and at six and twelve months post-operatively.

All surgery was performed by a single surgeon, using one prosthesis design in each group.

The data were assessed for any correlation between the pre-operative MCS and post-operative PCS, Pain, Stiffness and Function scores using Spearman’s Rank Correlation.

Results: There was a significant positive correlation between pre-operative MCS and post-operative PCS scores at six and twelve months (P=0.01 and P=0.031 respectively) in the primary TKA patients. There was no correlation in the revision patients.

There was a statistically significant negative correlation between pre-operative MCS and six month WOMAC Pain, Stiffness and Function scores (P=0.025, P=0.019 and P=0.011 respectively) in the primary patients. There was no significant correlation with twelve months WOMAC scores.

There was no significant correlation in terms of pre-operative MCS and six months WOMAC scores in the revision patients, but there was a statistically significant negative correlation between pre-operative MCS and the twelve months pain score (P=0.039).

Conclusion: The results support the concept that high generic mental health scores in patients prior to primary TKA are associated with good physical outcomes in terms of both generic health outcome measures and disease-specific outcome measures.

Twenty four operations were reviewed in 23 patients to show a modified Roux-Goldthwait operation would improve the symptoms of chronic patella instability. This retrospective study used a questionnaire to record symptoms before and after surgery. The examination assessed joint hypermobility, patella tracking and stability, the Q and valgus angles of the knee. Apprehension test and assessment of patella tilt was also assessed. All patients underwent radiographic assessment. Twenty of 23 patients were improved by this procedure. Patella subluxation was reduced by 22%. Patella dislocation was reduced by 86%. The 3 unsuccessful cases had generalised joint laxity and may have been improved by the addition of a medial reefing procedure. There were no cases of tibial tuberosity numbness post operatively, patella tilt or failure of the transposed tendon. We showed that this procedure is effective, regardless of x-ray signs. We did observe a subjective increase in patellofemoral pain post operatively.

Review of 133 cases of Anterior Cruciate Ligament (ACL) reconstruction, showed 91 cases had been arthroscoped twice. The incidence of meniscus pathology, at first arthroscopy was 71% and this fell to 63% at the second arthroscopy and reconstruction. 21% of recurrent tears were in previously undamaged menisci. The medial meniscus, was the most commonly damaged meniscus, at the time of the first arthroscopy. The incidence of lateral and bilateral meniscus pathology increased in the time period awaiting ACL reconstruction. The mean time between the two arthroscopies were 27 months. Damaged menisci continued to tear over the time period between first and second arthroscopies or new pathology occurred. The paper concludes that if ACL reconstruction is performed by a mini open technique then it should be re-arthroscoped immediately before the ACL reconstruction. This is essential to avoid missing meniscus pathology, even in previously arthroscoped knees.

There has been speculation as to whether the outcome of revision total knee arthroplasty (TKA) is as successful as primary TKA, this study was designed to compare the outcomes of primary and revision TKA in order to address this question.

The study collected data prospectively from patients operated upon by one surgeon using one prosthesis design in each group. All patients undergoing revision TKA between 1997 and 2000 were included in the study. 100 consecutive patients undergoing primary TKA between 1997 and 1999 were included in the study. All surgery was performed by the senior author.

Patients completed SF-12 and WOMAC questionnaires pre-operatively and at six and twelve months post-operatively. Mean scores were calculated for the different areas within both outcome measures (WOMAC pain, stiffness and function; SF-12 – physical constant score [PCS] and mental constant score [MCS])

The results were entered into a database and analysed using a combination of two way and simple repeated measures analysis of variance (ANOVA) and t-tests. Only if the result of the ANOVA was significant were post-hoc adjusted t-tests performed on the data values.

WOMAC scores did not differ between the two groups pre-operatively. Both patient groups showed a significant improvement in WOMAC scores at six months (P< 0.0005). In the primary group the pain and function scores improved significantly between six and twelve months (P=0.0258 and P=0.0019 respectively). This was not the case in revision patients.

SF-12 PCS scores were significantly better in the primary patients pre-operatively (P< 0.0005). Both groups showed a significant improvement at six months assessment (P< 0.0005). Neither group demonstrated an improvement between six and twelve months. SF-12 MCS scores did not show any difference between the two groups pre-operatively. No significant change in MCS score occurred during the study in either the primary or revision patients.

The SF-12 and WOMAC health questionnaires are valid, reliable and responsive outcome measures. The study has collected data prospectively from patients operated upon by one surgeon using one prosthesis design in each group. These findings support the concept that revision TKA leads to a comparable improvement in patient perceived outcomes of physical parameters as does primary TKA in both generic health outcome measures and disease specific outcome measures.

Aim: The aim of this study was to evaluate the results of the Co-ordinate revision knee prosthesis (Depuy Ltd, Johnson and Johnson, Warsaw, In) between 1995–2001.

Methods: One hundred and thirty-three knees (126 patients) undergoing revision total knee replacement between 1995–2001 were followed up prospectively. Surgery was performed by one surgeon (senior author). The patients were scored pre-operatively and postoperatively with SF-12 and WOMAC score. Surgery was performed for aseptic loosening (92%) and infection (8%). The changes in SF-12 physical score and the WOMAC score between pre and post operation were significant (SF-12 p < 0.0018, WOMAC pain p< 0.0001, WOMAC stiffness p< 0.0001, WOMAC Function p< 0.0001)). The prosthesis produced reliable relief of pain and improved range of movement with minimal complications.

Conclusion: This modular knee revision system produced satisfactory results in dealing with bone loss and instability in the medium term.

We report the role of our advanced nurse practitioner (ANP) with particular relevance to cost effectiveness, patient satisfaction and data collection.

Our nurse practitioner has been involved in arthroplasty care since 1996. Her duties include preoperative assessment, health advice, informed consent, clinical follow up and maintenance of a database for research/audit. Follow up radiographs are reviewed regularly by the entire medical team in a teaching environment. Relative costs of this service were calculated using outpatient charging data. 100 postal questionnaires were used to assess patient satisfaction. Patients answered 13 questions relating to the service they received.

Knee arthroplasty follow up through the nurse led clinic was half the cost of follow up through the consultant led clinic. 80 patients returned the postal questionnaire. Responses were very supportive of the nurse practitioner service. 76 (95%) of patients were happy to be assessed by the ANP and felt that their problems were dealt with appropriately. 17 (21%) of patients felt they should be seen by a surgeon at some stage during their routine follow up. Overall, 75 (94%) of patients were very satisfied or satisfied with the service, 1 (1%) was dissatisfied and 4 (5%) did not answer this question.

Increasing patient numbers and demand for high quality care combined with a decrease in doctors hours worked has lead to a shortage of time for discussion of ‘prehabilitation’ and postoperative care. Long term clinical and radiological follow up leading to adequate research and audit must not be compromised. A trained nurse practitioner working in conjunction with the surgical team is a cost effective way of improving total patient care, audit and research within a department. We have found a high degree of patient satisfaction with this approach.