Aims

This prospective study reports longitudinal, within-patient, patient-reported outcome measures (PROMs) over a 15-year period following cemented single radius total knee arthroplasty (TKA). Secondary aims included reporting PROMs trajectory, 15-year implant survival, and patient attrition from follow-up.

Aims

Tibial tubercle osteotomy (TTO) facilitates surgical exposure and protects the extensor mechanism during revision total knee arthroplasty (rTKA). The purpose of this study was to determine the rates of bony union, complications, and reoperations following TTO during rTKA, to assess the functional outcomes of rTKA with TTO at two years’ minimum follow-up, and to identify the risk factors of failure.

Aims

Open reduction and plate fixation (ORPF) for displaced proximal humerus fractures can achieve reliably good long-term outcomes. However, a minority of patients have persistent pain and stiffness after surgery and may benefit from open arthrolysis, subacromial decompression, and removal of metalwork (ADROM). The long-term results of ADROM remain unknown; we aimed to assess outcomes of patients undergoing this procedure for stiffness following ORPF, and assess predictors of poor outcome.

Post-traumatic elbow stiffness is a disabling condition that remains challenging for upper limb surgeons. Open elbow arthrolysis is commonly used for the treatment of stiff elbow when conservative therapy has failed. Multiple questions commonly arise from surgeons who deal with this disease. These include whether the patient has post-traumatic stiff elbow, how to evaluate the problem, when surgery is appropriate, how to perform an excellent arthrolysis, what the optimal postoperative rehabilitation is, and how to prevent or reduce the incidence of complications. Following these questions, this review provides an update and overview of post-traumatic elbow stiffness with respect to the diagnosis, preoperative evaluation, arthrolysis strategies, postoperative rehabilitation, and prevention of complications, aiming to provide a complete diagnosis and treatment path.

Cite this article: Bone Joint Open 2020;1-9:576–584.

Aims

The aim of this study was to report a single surgeon series of consecutive patients with moderate hallux valgus managed with a percutaneous extra-articular reverse-L chevron (PERC) osteotomy.

Although patients with a history of venous thromboembolism (VTE) who undergo lower limb joint replacement are thought to be at high risk of further VTE, the actual rate of recurrence has not been reported.

The purpose of this study was to identify the recurrence rate of VTE in patients who had undergone lower limb joint replacement, and to compare it with that of patients who had undergone a joint replacement without a history of VTE.

From a pool of 6646 arthroplasty procedures (3344 TKR, 2907 THR, 243 revision THR, 152 revision TKR) in 5967 patients (68% female, mean age 67.7; 21 to 96) carried out between 2009 and 2011, we retrospectively identified 118 consecutive treatment episodes in 106 patients (65% female, mean age 70; 51 to 88,) who had suffered a previous VTE. Despite mechanical prophylaxis and anticoagulation with warfarin, we had four recurrences by three months (3.4% of 118) and six by one year (5.1% of 118). In comparison, in all our other joint replacements the rate of VTE was 0.54% (35/6528).

The relative risk of a VTE by 90 days in patients who had undergone a joint replacement with a history of VTE compared with those with a joint replacement and no history of VTE was 6.3 (95% confidence interval, 2.3 to 17.5). There were five complications in the previous VTE group related to bleeding or over-anticoagulation.

Cite this article: Bone Joint J 2014;96-B:1515–19.

Coronal plane fractures of the posterior femoral condyle, also known as Hoffa fractures, are rare. Lateral fractures are three times more common than medial fractures, although the reason for this is not clear. The exact mechanism of injury is likely to be a vertical shear force on the posterior femoral condyle with varying degrees of knee flexion. These fractures are commonly associated with high-energy trauma and are a diagnostic and surgical challenge. Hoffa fractures are often associated with inter- or supracondylar distal femoral fractures and CT scans are useful in delineating the coronal shear component, which can easily be missed. There are few recommendations in the literature regarding the surgical approach and methods of fixation that may be used for this injury. Non-operative treatment has been associated with poor outcomes. The goals of treatment are anatomical reduction of the articular surface with rigid, stable fixation to allow early mobilisation in order to restore function. A surgical approach that allows access to the posterior aspect of the femoral condyle is described and the use of postero-anterior lag screws with or without an additional buttress plate for fixation of these difficult fractures.

Cite this article: Bone Joint J 2013;95-B:1165–71.

The use of passive stretching of the elbow after arthrolysis is controversial. We report the results of open arthrolysis in 81 patients. Prospectively collected outcome data with a minimum follow-up of one year were analysed. All patients had sustained an intra-articular fracture initially and all procedures were performed by the same surgeon under continuous brachial plexus block anaesthesia and with continuous passive movement (CPM) used post-operatively for two to three days. CPM was used to maintain the movement achieved during surgery and passive stretching was not used at any time. A senior physiotherapist assessed all the patients at regular intervals. The mean range of movement (ROM) improved from 69° to 109° and the function and pain of the upper limb improved from 32 to 16 and from 20 to 10, as assessed by the Disabilities of the Arm Shoulder and Hand score and a visual analogue scale, respectively. The greatest improvement was obtained in the stiffest elbows: nine patients with a pre-operative ROM < 30° achieved a mean post-operative ROM of 92° (55° to 125°). This study demonstrates that in patients with a stiff elbow after injury, good results may be obtained after open elbow arthrolysis without using passive stretching during rehabilitation.

Aim

Over the last 15 years there has been a series of publications reporting the beneficial effects of elbow arthrolysis, with considerable variation in operative technique and post-operative management. Many advocate the use of passive stretching techniques in the early post-operative period if range of motion fails to improve satisfactorily. The purpose of this study was to assess our results of open elbow arthrolysis in patients who did not receive any passive stretching after discharge from hospital.

Aim: To assess the functional and occupational outcome of open elbow arthrolysis for post-traumatic contractures.

Materials and Methods: Prospective evaluation of 60 consecutive cases (86% male,14%female) of post-traumatic extrinsic elbow stiffness. Average age was 37 years (24–48). Moderate to high physical demand at work in 96% of cases. 56% of cases involved the right side.

Open arthrolysis (column procedure) trough a lateral (72%) or posterior (28%) approach followed a minimum rehabilitation period of 6 months post original injury. In 8 cases, an anterior transposition of the ulnar nerve was required. Patients received postoperative analgesia with Bupivacaine 0,0125% trough an indwelling catheter. No chemical or radiotherapy ectopic calcification prophylaxis was used. Postoperative complications, range of motion, X-ray evaluation, time to return to work, activity level and workers’ compensation were evaluated at the end of follow-up (24 months, range 12–36).

Results: Complications occurred in 14% of cases. Two patients required revision surgery for ectopic calcifications restricting prono-supination. The flexo-extension (FE) arc of motion improved from 49 ° to 115 ° and that of prono-supination (PS) from 100 ° to 158 ° The results were found to be statistically significant for FE (p= 0.054) and PS (p> 0,00001).

In 20% of cases, patients returned to their previous job with some restrictions (33% disability) and 12% changed to a less physically demanding occupation.

Conclusions: Open arthrolysis is an effective surgical procedure to improve mobility in post-traumatic stiff elbows. It is indicated when the joint interline is preserved. Good functional and occupational outcome in a high percentage of case in the working population was observed.

Restricted motion in flexion is a frequent TKA complication (0.1–5.3%). The aetiology has to be searched because adhesive knee arthritis is a rare pathology. Neglecting an implant malposition, an infection or a RSDS can lead to early recurrence of stiffness. After 8 weeks, it is very dangerous to try a knee manipulation under anaesthesia. Thus, we have the choose between two difficult arthrolysis: the open and the arthroscopic. We have developed the Less Invasive Arthrolysis (LIA) as a less aggressive technique to treat knee flexion stiffness. This subcutaneous procedure (performed by one or two arthroscopic portals) was already described on a short number of patients or as a part of the arthroscopic arthrolysis. In our institution, we have performed 3738 TKA, 144 knee manipulations (3.8%) and 67LIA after TKA (21% from other surgeons) between 1997 and 2009. We have reviewed retrospectively these 67 cases (Group A) and reviewed clinically 41 of these patients in a study consultation (Group B). Subjective results: from 41 patients (B), 66% have more flexion, 32% feel less pain (VAS: 6), 49% feel better than before LIA. 58% would undergo a new LIA if they had to do it again. Objective ROM (A):preoperative ROM: 88°, in the early postoperative period, we noted a 31° flexion improvement. At the last evaluation (6–120m after LIA), the flexion improvement was 17°(−15/+80) and the final ROM was 105°. The flexion falls of 45% in the first 6 months and became stable at the 7th month (until120m). We have isolated two particular subgroups: the first including the carriers of femoral implants positioned in internal rotation (< 5°) (6% of A), in which the flexion was only improved by 6°; the second including those who underwent a stiffness recurrence (9% of A) after knee manipulation, for which we obtained a stabilization of their flexion at 105° 1 year after LIA. Relative patellar mobility(B): 66% kept a free and painless patella. Mean clinical scores (B): the long term OXF-12 score (best=12) is 33 (−18%), the HSS (best=104) is 74 (+12%). Considering the delay between TKA and LIA (67 patients, mean 28m (2–120)), the best results were obtained when we performed 6 to 24m after TKA (flexion +19° in the 7–12m, +17° in the 13–24m, versus 14° in the > 25m group). No infection occurred (0/67). We never did twice the LIA in the same knee. The published series on open arthrolysis performed 17m after TKA show an improvement of flexion by 25°, 8° for extension. An arthroscopic arthrolysis performed 12m after TKA can lead to 20° of improvement in flexion (17–42) and 3° in extension. The gold operative indication is a flexion reduced to less than 90°, 6 months after TKA, with anterior knee pain. This study presents a reliable less invasive technique studied on a bigger group with a longer follow-up and approachable by the majority of surgeons

Arthrolysis and dynamic splinting have been used in the treatment of elbow contractures, but there is no standardised protocol for treatment of severe contractures with an arc of flexion < 30°. We present our results of radical arthrolysis with twin incisions with the use of a monolateral hinged fixator to treat very severe extra-articular contracture of the elbow. This retrospective study included 26 patients (15 males and 11 females) with a mean age of 30 years (12 to 60). The mean duration of stiffness was 9.1 months (5.4 to 18) with mean follow-up of 5.2 years (3.5 to 9.4). The mean pre-operative arc of movement was 15.6° (0° to 30°), with mean pre-operative flexion of 64.1° (30° to 120°) and mean pre-operative extension of 52.1° (10° to 90°). Post-operatively the mean arc improved to 102.4° (60° to 135°), the mean flexion improved to 119.1° (90° to 140°) and mean extension improved to 16.8° (0° to 30°) (p < 0.001). The Mayo elbow score improved from a mean of 45 (30 to 65) to 89 (75 to 100) points, and 13 had excellent, nine had good, three had fair and one had a poor result. We had one case of severe instability and one wound dehiscence which responded well to treatment. One case had deep infection with poor results which responded well to treatment. Our findings indicate that this method is very effective in the treatment of severe elbow contracture; however, a randomised controlled study is necessary for further evaluation

Objective: This study compares the results obtained from arthrolysis of the elbow performed arthroscopically with those done open.

Material and Methods: 139 patients from 3 hospitals, who had undergone an arthrolysis of their elbow, were studied retrospectively. 58 had an arthroscopic arthrolysis and 81 were open. The patients included were aged between 18 and 65, had a loss of passive range of motion, due to either osteoarthritis or post trauma. Patients with previous extra articular osteotomy, septic or inflammatory synovitis were excluded. The clinical evaluation comprised measuring their: range of motion, pain, level of activities, presence of effusion or locking. The images obtained were standard radiographs, CT scan and bone scans to allow us to accurately determine the presence of loose bodies, fibrous tissue in the fossae, the presence of osteophytes or arthritis. All data was recorded in preoperative, postoperative and final assessment.

This study also discusses various issues regarding operative techniques (surgical approaches, debridement of joint and capsular releases).

Results: The two groups were similar on all points with the exception of their aetiologies. There was no clinical difference preoperatively. The arthroscopy was performed through 4 portals in 94% of cases; in the open cases the most common approach was lateral (53%). Intra operatively the significant differences were the removal of posterior osteophytes and capsular releases (p< 0.001) were performed more frequently in the open procedure. At the end of the procedure, the flexion and the gain in flexion-extension range was greater in the arthrotomy group; however the arthroscopic group lost less motion from end of procedure to the final result (8 versus 17 degrees). At the last review, the gain in range of motion remained greater in the group with the open arthrotomy. The number of complications in the 2 groups was identical, though the location of any nerve injury was different. The method of rehabilitation was the same; however this was continued for longer in the arthroscopic group. Final radiographic assessment showed that a less extensive debridement of bone was achieved arthroscopically.

Conclusion: A more extensive release and an easier intra operative evaluation resulting in a better improvement in range of motion at the end of procedure are achieved with arthrotomy. The subsequent loss of motion is more significant in this group however the final outcome showed the gain in range of motion remained greater. It was noted however, that even with less improvement in mobility, with either technique, the patients were equally satisfied.

Over the last 15 years there have been a series of publications reporting the beneficial effects of elbow arthrolysis, with considerable variation in operative technique and post-operative management.

Aim. To assess the results of open elbow arthrolysis in patients who did not receive any physiotherapy after discharge from hospital, although this is routinely prescribed by many surgeons.

Patients and Methods. Prospectively collected data of 34 patients with a minimum follow-up of 1 year after arthrolysis was analysed. All the procedures were performed by the same surgeon, achieving as much improvement in elbow motion as possible at operation. All the patients had continuous brachial plexus blocks and continual passive motion for 2–3 days postoperatively but none received any physiotherapy after discharge. At review, a senior physiotherapist formally assessed all the patients, including measuring elbow motion with a goniometer.

Results. All patients’ arc of movement improved from, with mean elbow flexion increasing by 16 degrees and extension 20 degress at the last follow-up. Upper limb function, assessed with a Disabilities of the Arm, Shoulder and Hand score (DASH), had improved 30%. Pain had decreased from 4.8 to 3.1 using the Visual Analogue Score. The greatest improvement in motion was obtained in the stiffest elbows – 5 patients with an arc of 30 degrees or less pre-operatively achieved an arc of 96 degrees by the time of the last review. Only early complications occurred – ulnar neuritis and significant pain – but these symptoms had largely settled by the time of the last review.

Conclusions. Good results of open arthrolysis for post-traumatic elbow stiffness can be achieved with continuous brachial plexus blocks and continual passive motion for 2–3 days post-operatively. There appears to be little evidence to support formal treatment with physiotherapy after discharge from hospital, as our results are similar to other reported series.

Previous studies have demonstrated the benefits of arthroscopic arthrolysis in relieving pain and improving motion in arthritic elbows, but none have reported the specific functional recovery. This study aims to review the functional outcome and patient satisfaction in a series of patients who underwent arthroscopic elbow arthrolysis for intrinsic stiffness, pain and arthritis not suitable for arthroplasty. Twenty six patients who underwent arthroscopic arthrolysis over a three year period were included. All patients were manual workers or strength athletes. All had pain and stiffness secondary to primary or secondary arthritis, with or without loose bodies. Pre- and post-operative evaluation included the Elbow Functional Assessment score, patient satisfaction and return to work and sports. The mean follow up period was 22 months. Function improved significantly in 87% with overall improvement in the Elbow Functional Assessment score from a preoperative score of 48 to a postoperative score of 84 (p< 0.05). All except three patients returned to their desired level of activity by 3 months postoperatively. Pain improved in 91%, mechanical symptoms in 80%, stiffness in all except one. The arc of elbow movement improved from 106° to 124° with a mean gain in elbow extension of 13°. Mayo elbow performance index also significantly improved postoperatively. Overall, 87% patients were very satisfied with the outcome. We conclude that the arthroscopic arthrolysis improves elbow function and returns patients to their desired level of activity, as well as improving range of motion and pain in patients with intrinsic elbow stiffness and pain.

The purpose of this study was to demonstrate the beneficial effects of elbow arthrolysis.

This was a prospective study on 88 patients with post-traumatic elbow stiffness with a mean follow-up of 51 months (1 year - 11 years), who had failed to improve their range of movement at a mimimum period of 6 months after their injury. All patients had an open arthrolysis. Post-operatively patients received continuous passive movement (CPM) for 48 to 72 hours. This was facilitated by good analgesia afforded by a continuous brachial plexus block. All patients received no physiotherapy thereafter and were advised to actively mobilise their elbow. ROM was assessed using a goniometer and function assessed using the Mayo elbow performance index.

The ROM improved from a mean of 56 degrees pre-operatively to 106 degrees post-operatively. This improvement in ROM was reflected in the improvement of pre-operative flexion from 107 to 138 degrees and improvement of extension from 60 to 31 degrees. Function improved from a mean of 65 to 85 on the Mayo elbow performance score. 95% of the patients were satisfied with the outcome. Complications included ulnar nerve paraesthesia in 3 patients, 1 triceps avulsion and 1 superficial infection. 3 patients required a manipulation of the elbow in the postoperative period. This was performed within 2 weeks of the operation. There were no cases of elbow instability or heterotopic ossification in this series.

Conclusion: Open elbow arthrolysis combined with continuous brachial plexus block and CPM in the postoperative period is a safe, reliable and durable procedure for improving ROM and function in patients with post-traumatic elbow stiffness.

We carried out a prospective study of 118 hydroxyapatite-coated, cementless total knee replacements in patients who were ≤ 55 years of age and who had primary (92; 78%) or post-traumatic (26; 22%) osteoarthritis. The mean period of follow-up was 7.9 years (5 to 12.5). The Knee Society clinical scores improved from a pre-operative mean of 98 (0 to 137) to a mean of 185 (135 to 200) at five years, and 173 (137 to 200) at ten years. There were two revisions of the tibial component because of aseptic loosening, and one case of polyethylene wear requiring further surgery. There was no osteolysis or progressive radiological loosening of any other component. At 12 years, the overall rate of implant survival was 97.5% (excluding exchange of spacer) and 92.1% (including exchange of spacer).

Cementless total knee replacement can achieve excellent long-term results in young, active patients with osteoarthritis. In contrast to total hip replacement, polyethylene wear, osteolysis and loosening of the prosthesis were not major problems for these patients, although it is possible that this observation could change with longer periods of follow-up.

Introduction and purpose: When treating for loss of mobility in the elbow, after at least six months of conservative treatment following an injury we should consider surgery. The purpose of this study is to evaluate the improvement in range of motion after surgery.

Materials and methods: We reviewed the cases of elbow arthrolysis carried out in our hospital from 1999 to 2004, analysing the following variables: personal data (sex, age, type of work) and information on the injury (type, location, associated lesions and degree of stiffness). The main variables were degree of mobility in flexion/extension (F-E) and pronation/supination (P-S) before and after surgery, in addition to functional and occupational results.

Statistical analysis: Percentage estimate and by 95% confidence intervals, and analysis of increased mobility after surgery in F-E and P-S using Student’s t-test of repeated measures.

Results: 52 patients who underwent arthrolysis (86% males, mean age 37.2 years) whose jobs required average exercise and with grade II stiffness in 46.2% of the cases. The average preoperative ranges of motion for F-E and P-S were 74.52 (SD 32.3) and 120.10 (SD 66.6) degrees, respectively. The postoperative estimates for both parameters were 96.5 (SD 29.5) for F-E and 158.9 (SD 39.8) for P-S. The increases were statistically significant (p< 0.00001). The increased motion in P-S was slightly better than for F-E (p=0.054).

Conclusions: After our study, we can confirm that arthrolysis is an effective surgical procedure to improve mobility in stiff elbows. It is indicated when the joint interline is preserved. The lateral approach is the most common because it enables access to the anterior and posterior aspects of the capsule. Good functional and occupational outcome in a high percentage of cases.

Introduction: Stiffness following Total Knee Arthroplasty is a serious and debilitating complication. There are many different patient and surgical factors implicated in it cause. Previous studies have suggested that it will occur in approximately 1% of TKR patients. Arthrofibrosis is an uncommon but potentially debilitating cause in an otherwise well positioned implant. The cause of this abnormal scar formation is as yet unknown. The treatment of this condition remains difficult and controversial. Revision of the TKR has been suggested as the gold standard treatment as other operative strategies have had limited success. Our approach to this problem has been to conserve the prosthesis and try to release the scar tissue. Aim: The aim of this study is to assess the results of open arthrolysis in the treatment of established arthrofibrosis. Method: 1522 patients undergoing primary uncemented TKR have been prospectively followed up (2022 TKR’s) using the International Knee Society Scores. 13 patients underwent open Arthrolysis for stiffness post-op (Incidence 0.64%). The average age was 65 (range 50–78). 6 cases were simultaneous bilateral procedures (Incidence 1.2% of simultaneous bilateral procedures). The average time between TKR and arthrolysis was 14 months. Our average follow-op was 7.2 years (range 2 – 10 years). Results: The average ROM just prior to Arthrolysis was 58°. The average ROM six months after surgery had improved to 91° (p< 0.05). The average ROM at last follow-up was 95° (p< 0.05) with an average Knee Society score of 155 (pain 83, function 72). No patients have required revision of their components. Conclusions: We have found open arthrolysis a successful approach to post-op arthrofibrosis. Although a large procedure it has been well tolerated by our patients. They have had an improvement in range of movement by six months which has been maintained up to 10 years