The goal of this study was to identify the effect of mismatches in the subchondral bone surface at the native:graft interface on cartilage tissue deformation in human patellar osteochondral allografts (OCA). Hypothesis: large mismatches in the subchondral bone surface will result in higher stresses in the overlying and surrounding cartilage, potentially increasing the risk of graft failure. Nano-CT scans of ten 16mm diameter cadaveric patellar OCA transplants were used to develop simplified and 3D finite element (FE) models to quantify the effect of mismatches in the subchondral bone surface. The simplified model consisted of a cylindrical plug with a 16 mm diameter (graft) and a washer with a 16 mm inner diameter and 36 mm outer diameter (surrounding native cartilage). The thickness of the graft cartilage was varied from 0.33x the thickness of native cartilage (proud graft subchondral bone) to 3x the thickness of native cartilage (sunken graft subchondral bone; Fig. 1). The thickness of the native cartilage was set to 2 mm. The surface of the cartilage in the graft was matched to the surrounding native cartilage. A 1 MPa pressure was applied to the fixed patellar cartilage surface. Scans were segmented using Dragonfly and meshed using HyperMesh. FE simulations were conducted in Abaqus 2019. The simplified model demonstrated that a high stress region occurred in the cartilage at the sharp bony edge between the graft and native subchondral bone, localized to the region with thinner cartilage. A 20% increase in applied pressure occurs up to 50μm away from the graft edge (primarily in the graft cartilage) for grafts with proud subchondral bone but varies little based on the graft cartilage thickness. For grafts with sunken subchondral bone, the size of the high stress region decreases as the difference between graft cartilage and native cartilage thickness decreases (Fig. 2-4), with a 200 μm high stress region occurring when graft cartilage was 3x thicker than native cartilage (i.e., greater graft cartilage thickness produces larger areas of stress in the surrounding native cartilage). The 3D models reproduced the key features demonstrated in the simplified model. Larger differences between native and graft cartilage thickness cause larger high stress regions. Differences between the 3D and simplified models are caused by heterogeneous cartilage surface curvature and thickness. Simplified and 3D FE analysis confirmed our hypothesis that greater cartilage thickness mismatches resulted in higher cartilage stresses for sunken subchondral bone. Unexpectedly, cartilage stresses were independent of the cartilage thickness mismatch for proud subchondral bone. These FE findings did not account for tissue remodeling, patient variability in tissue mechanical properties, or complex tissue loading. In vivo experiments with full-thickness strain measurements should be conducted to confirm these findings. Mismatches in the subchondral bone can therefore produce stress increases large enough to cause local chondrocyte death near the subchondral surface. These stress increases can be reduced by (a) reducing the difference in thickness between graft and native cartilage or (b) using a graft with cartilage that is thinner than the native cartilage. For any figures or tables, please contact the authors directly

Aims. The aims of this study were to investigate the ability to kneel after total knee arthroplasty (TKA) without patellar resurfacing, and its effect on patient-reported outcome measures (PROMs). Secondary aims included identifying which kneeling positions were most important to patients, and the influence of radiological parameters on the ability to kneel before and after TKA. Methods. This prospective longitudinal study involved 209 patients who underwent single radius cruciate-retaining TKA without patellar resurfacing. Preoperative EuroQol five-dimension questionnaire (EQ-5D), Oxford Knee Score (OKS), and the ability to achieve four kneeling positions were assessed including a single leg kneel, a double leg kneel, a high-flexion kneel, and a praying position. The severity of radiological osteoarthritis (OA) was graded and the pattern of OA was recorded intraoperatively. The flexion of the femoral component, posterior condylar offset, and anterior femoral offset were measured radiologically. At two to four years postoperatively, 151 patients with a mean age of 70.0 years (SD 9.44) were included. Their mean BMI was 30.4 kg/m. 2. (SD 5.36) and 60 were male (40%). They completed EQ-5D, OKS, and Kujala scores, assessments of the ability to kneel, and a visual analogue scale for anterior knee pain and satisfaction. Results. The ability to kneel in the four positions improved in between 29 (19%) and 53 patients (35%) after TKA, but declined in between 35 (23%) and 46 patients (30%). Single-leg kneeling was most important to patients. After TKA, 62 patients (41%) were unable to achieve a single-leg kneel, 76 (50%) were unable to achieve a double-leg kneel, 102 (68%) were unable to achieve a high-flexion kneel and 61 (40%) were unable to achieve a praying position. Posterolateral cartilage loss significantly affected preoperative deep flexion kneeling (p = 0.019). A postoperative inability to kneel was significantly associated with worse OKS, Kujala scores, and satisfaction (p < 0.05). Multivariable regression analysis identified significant independent associations with the ability to kneel after TKA (p < 0.05): better preoperative EQ-5D and flexion of the femoral component for single-leg kneeling; the ability to achieve it preoperatively and flexion of the femoral component for double-leg kneeling; male sex for high-flexion kneeling; and the ability to achieve it preoperatively, anterior femoral offset, and patellar cartilage loss for the praying position. Conclusion. The ability to kneel was important to patients and significantly influenced knee-specific PROMs, but was poorly restored by TKA with equal chances of improvement or decline. Cite this article: Bone Joint J 2021;103-B(9):1514–1525

Introduction. The degree of cartilage degeneration assessed intraoperatively may not be sufficient as a criterion for patellar resurfacing in total knee arthroplasty (TKA). However, single-photon emission tomography/computed tomography (SPECT/CT) is useful for detecting osteoarthritic involvement deeper in the subchondral bone. The purpose of the study was to determine whether SPECT/CT reflected the cartilage lesion underneath the patella in patients with end-stage osteoarthritis (OA) and whether clinical outcomes after TKA without patellar resurfacing differed according to the severity of patellofemoral (PF) OA determined by visual assessment and SPECT/CT findings. Methods. This study included 206 knees which underwent TKA. The degree of cartilage degeneration was graded intraoperatively according to the International Cartilage Repair Society grading system. Subjects were classified into four groups according to the degree of bone tracer uptake (BTU) on SPECT/CT in the PF joint. The Feller's patella score and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were assessed preoperatively and postoperative 1 and 2 years. Results. The increased BTU in the PF joint was associated with more severe degenerative cartilage changes underneath the patella (P < 0.001). The risk for the presence of denudated cartilage was greater in the high uptake group (odds ratio = 5.89). There was no association between clinical outcomes and visual grading of patellar cartilage degeneration or the degree of BTU on SPECT/CT. Discussion and Conclusions. The visual assessment of the degree of cartilage degeneration underneath the patella and preoperative SPECT/CT evaluation of the PF joint were not predictive of clinical outcome after TKA with unresurfaced patella

Osteoarthritis (OA) is a disease that affects both bone and cartilage. Typically, this disease leads to cartilage degradation and subchondral bone sclerosis but the link between the two is unknown. Also, while OA was traditionally thought of as non-inflammatory condition, it now seems that low levels of inflammation may be involved in the link between these responses. This is particularly relevant in the case of Post-Traumatic OA (PTOA), where an initial phase of synovial inflammation occurs after injury. The inflammatory mediator interleukin 1 beta (IL-1B) is central to this response and contributes to cartilage degradation. However, whether there is a secondary effect of this mediator on subchondral bone, via bone-cartilage crosstalk, is not known. To address this question, we developed a novel patellar explant model, to study bone cartilage crosstalk which may be more suitable than commonly used femoral head explants. The specific aim of this study was to validate this novel patellar explant model by using IL-1B to stimulate the inflammatory response after joint injury and the subsequent development of PTOA. Female Sprague Dawley rats (n=48) were used to obtain patellar explants, under an institutional ethical approval license. Patellae were maintained in high glucose media, under sterile culture conditions, with or without IL-1B (10ng/ml), for 7 days. Contralateral patellae served as controls. One group (n= 12) of patellae were assessed for active metabolism, using two both Live and Dead (L/D) staining and an Alamar Blue assay (AB). A second group (n=12) was used for tissue specific biochemical assays for both bone (Alkaline Phosphatase) and cartilage (sulfated proteoglycan and glycosaminoglycan (sGaG)). Finally, a third group (n=28) of explants were used for histologically analysis. Samples were decalcified, embedded in paraffin and sectioned to 7µm thickness, and then stained using H&E; and Safranin O with fast green. Additionally, toluidine blue and alkaline phosphatase staining were also performed. Our results demonstrate that our system can maintain good explant viability for at least 7 days, but that IL-1B reduces cell viability in patellar cartilage, as measured by both L/D and AB assays after 0, 2, 4 and 7 days in culture. In contrast, sGaG content in cartilage were increased by this treatment. Additionally, ALP, a marker of osteoblastic activity, was increased in IL-1B treated group 4 and 7 days, but was also showed some increase in control groups. Histological analyses showed that IL-1B treatment resulted in reduced proteoglycan staining, demonstrating the powerful effect of this factor in injury response over time. Thus, we conclude that IL-1B affects both bone and cartilage tissues independently in this system, which may have relevance in understanding bone-cartilage crosstalk after injury and how this is involved in PTOA development

Abstract

Background

Recurrent patellar dislocation in combination with cartilage injures are difficult injuries to treat with confounding pathways of treatment. The aim of this study is to compare the clinical and functional outcomes of patients operated for patellofemoral instability with and without cartilage defects.

There is a lack of evidence surrounding selective patella resurfacing, but patella cartilage loss at time of total knee arthroplasty (TKA) is often used as an indication in those who perform it. This study compares the outcomes of TKA without patella resurfacing in patients with and without patella cartilage loss (PFOA).

Prospective case control study of 209 consecutive patients undergoing cruciate retaining single radius TKA without patella resurfacing for KL≥3 osteoarthritis. The presence and location of full thickness patella cartilage loss was documented intra-operatively at TKA, identifying n=108 cases with PFOA (mean age 70±9.7, mean BMI 31±6.2, 72 (67%) female) Vs n=101 controls without PFOA (age 68±9.2, BMI31±5.6, 52 (51%) female). Primary outcome measure was improvement in the Oxford Knee Score (OKS) at one year.

There were more females in the PFOA group (67% Vs 51%, p=0.037), but no other preoperative differences. There was no difference in preoperative OKS between patients with patella cartilage loss (20.6±7.9) and those without (21.0±7.2, p=0.720). There was no difference in OKS improvement following TKA without patella resurfacing between those with full thickness patella cartilage loss (14.2±9.8) and those without (15.4±9.5, p=0.365). Facet involvement (number and location) did not affect OKSs. No differences were found in the individual OKS questions between groups (p>0.05).

There was no difference in one-year OKS or improvements therein between patients with and without full thickness patella cartilage loss treated with single radius cruciate retaining TKA without patella resurfacing, questioning its use an indication for selective patella resurfacing.

Aims

The aim of this study was to evaluate cartilaginous patellotrochlear congruence and patellofemoral alignment parameters after deepening trochleoplasty in severe trochlear dysplasia.

Since 2005, the author has performed nearly 1000 Oxford medial unicompartmental arthroplasties (UKA) using a mobile bearing. The indications are 1) Isolated medial compartment osteoarthritis with ‘bone-on-bone’ contact, which has failed prior conservative treatment, 2) Medial femoral condyle avascular necrosis or spontaneous osteonecrosis, which has failed prior conservative treatment. Patients are recommended for UKA only if the following anatomic requirements are met: 1) Intact ACL, 2) Full thickness articular cartilage wear limited to the anterior half of the medial tibial plateau, 3) Unaffected lateral compartment cartilage, 4) Unaffected patellar cartilage on the lateral facet, 5) Less than 10 degrees of flexion deformity, 6) Over 100 degrees of knee flexion, and 7) Varus deformity not exceeding 15 degrees. Exclusion criteria for surgery are BMI of more than 30, prior high tibial osteotomy, and inflammatory arthritis. All cases were performed with a tourniquet inflated using a minimally-invasive incision with a quadriceps-sparing approach. Both femoral and tibial components were cemented. Most patients were discharged home the next morning; bilaterals usually stayed a day longer. We have previously described our results and the factors determining alignment. In a more recent study, we have compared the coronal post-operative limb alignment and knee joint line obliquity after medial UKA with a clinically and radiologically (less than Grade 2 medial OA) normal contralateral lower limb. In our series, we have had 1 revision for aseptic loosening of both components, conversion to TKRs in a patient with bilateral UKAs who developed rheumatoid arthritis 3 years later, and 9 meniscal dislocations. There have been no cases of wound infections and thromboembolism. We have reviewed our patients with a minimum 10-year follow-up which will be presented. The vast majority of our patients have been generally very satisfied with the results. Our study shows that most patients (who have no disease in the contralateral knee) regain their ‘natural’ alignment and joint line obliquity comparable to their contralateral limb. Over the past few years our percentage of UKAs has been steadily rising to about a third of our knee cases. UKA serves as a definitive procedure in the elderly. We see it as a suitable procedure in middle-aged patients who want an operation that provides a quick recovery, full function and range of motion, and near-normal kinematics, with the understanding that they have a small chance of conversion to a total knee arthroplasty in the future

Patellar instability most frequently presents during adolescence. Congenital and infantile dislocation of the patella is a distinct entity from adolescent instability and measurable abnormalities may be present at birth. In the normal patellofemoral joint an increase in quadriceps angle and patellar height are matched by an increase in trochlear depth as the joint matures. Adolescent instability may herald a lifelong condition leading to chronic disability and arthritis.

Restoring normal anatomy by trochleoplasty, tibial tubercle transfer or medial patellofemoral ligament (MPFL) reconstruction in the young adult prevents further instability. Although these techniques are proven in the young adult, they may cause growth arrest and deformity where the physis is open. A vigorous non-operative strategy may permit delay of surgery until growth is complete. Where non-operative treatment has failed a modified MPFL reconstruction may be performed to maintain stability until physeal closure permits anatomical reconstruction. If significant growth remains an extraosseous reconstruction of the MPFL may impart the lowest risk to the physis. If minor growth remains image intensifier guided placement of femoral intraosseous fixation may impart a small, but acceptable, risk to the physis.

This paper presents and discusses the literature relating to adolescent instability and provides a framework for management of these patients.

Cite this article: Bone Joint J 2017;99-B:159–70.

Whether or not to resurface the patella in total knee arthroplasty (TKA) remains controversial. Several methods of dealing with the patella exist: ALWAYS resurface; NEVER resurface; SOMETIMES resurface. There is good reason to consider selective patellar resurfacing. First, in an age of partial knee arthroplasty we have become more tuned in to analyzing patterns of arthritis. In TKA there is a high percentage of patients who do not have significant patellar cartilage wear or anterolateral knee pain. These patients may be candidates for leaving the patella unresurfaced in TKA. Arno et al found that 42% of patients had no significant patellar arthritis at the time of TKA. Roberts et al found that only 15% of patients should undergo patella resurfacing based on the presence of exposed bone on the patella; the other 85% could be considered suitable for leaving the patella unresurfaced. Second, despite a cumulative incidence of less than 5–10%, problems related to patellar resurfacing account for perhaps the most catastrophic complications encountered, with treatments that have limited success. These complications include fracture, avascular necrosis, extensor mechanism disruption, and anterior knee pain. Third, it is a fallacy to think that anterior knee pain (AKP) does not exist despite primary patellar resurfacing in TKA. Meftah (Ranawat) et al found that AKP persists in 30% of patients and new AKP develops in 10% of patients after TKA with patellar resurfacing. Barrack et al found that with patellar resurfacing the incidence of AKP is 28% in patients without preop AKP and 9% in those with preop AKP. They also found that without patellar resurfacing the incidence of new AKP was 14% and persistent AKP was 23%. Fourth, only roughly 44–64% of patients who undergo secondary patellar resurfacing for AKP after TKA with an unresurfaced patella actually get relief of their pain, suggesting that there is some other etiology of anterior knee pain. Residual component malalignment, boxy femoral components, PF overstuffing, referred pain or asymmetric resurfacing may explain ongoing pain. Finally, the data in well-designed studies show that selective patellar resurfacing can produce similar outcomes with and without resurfacing, particularly in those without significant patellar arthritis. In multiple studies, higher rates of secondary surgery occur when the patella is left unresurfaced in primary TKA, but this is for “pain” without clear etiology. On the other hand secondary surgery is rarely performed in TKA with patellar resurfacing for “pain” only, despite its high incidence. The quality of patellar cartilage at the time of primary TKA should be considered, as that may be the best indicator of whether a knee will do well without patellar resurfacing (that is, selective patellar resurfacing may be a better idea than never resurfacing the patella). While patellar resurfacing remains controversial in modern TKA, excellent outcomes are achievable with, and without, primary patellar resurfacing. Selectively leaving the patella unresurfaced when there is limited patellar arthritis may not only be highly effective, but it may also limit the incidence of secondary resurfacing that may occur with more substantial patellar arthritis while also minimizing the risk of some of the devastating complications that can occur due to patellar resurfacing in TKA

Since 2005, the author has performed 422 Oxford medial unicompartmental arthroplasties (UKA) using a mobile bearing. There were 263 females and 119 males, (40 patients had bilateral UKAs) with a mean age of 62 years. The indications were: Isolated medial compartment osteoarthritis with ‘bone-on-bone’ contact, which had failed prior conservative treatment; Medial femoral condyle avascular necrosis or spontaneous osteonecrosis, which had failed prior conservative treatment. Patients were recommended UKA only if the following anatomic requirements were met: Intact ACL, Full thickness articular cartilage wear limited to the anterior half of the medial tibial plateau, Unaffected lateral compartment cartilage, Unaffected patellar cartilage on the lateral facet, Less than 10 degrees of flexion deformity, Over 100 degrees of knee flexion, Varus deformity not exceeding 15 degrees. Exclusion criteria for surgery were BMI of more than 30, prior high tibial osteotomy, and inflammatory arthritis. All cases were performed with a tourniquet inflated using a minimally-invasive incision with a quadriceps-sparing approach. Both femoral and tibial components were cemented. Rehabilitation consisted of teaching the patients 6 exercises to regain strength and range of motion, and weight-bearing as tolerated with a cane began from the evening of surgery. Most patients were discharged home the next morning; bilaterals usually stayed a day longer. We have previously described our results and the factors determining alignment. In a more recent study we have compared the coronal postoperative limb alignment and knee joint line obliquity after medial UKA with a clinically and radiologically (less than Grade 2 medial OA) normal contralateral lower limb. In our series of 423 cases, we have had 1 revision for aseptic loosening of both components, and 4 meniscal dislocations. There have been no cases of wound infections and thromboembolism. We are currently undertaking a review of the 2–10 year follow-up of our cases. The vast majority of our patients have been generally very satisfied with the results. Our study shows that most patients (who have no disease in the contralateral knee) regain their ‘natural’ alignment and joint line obliquity comparable to their contralateral limb. Over the past few years our percentage of UKAs has been steadily rising. UKA serves as a definitive procedure in the elderly. We see it as a suitable procedure in middle-aged patients who want an operation that provides a quick recovery, full function and range of motion, and near-normal kinematics, with the understanding that they have a small chance of conversion to a total knee arthroplasty in the future

Aims

Medial unicompartmental knee arthroplasty (UKA) is associated with successful outcomes in carefully selected patient cohorts. We hypothesised that severity and location of patellofemoral cartilage lesions significantly influences functional outcome after Oxford medial compartmental knee arthroplasty.

Objective. The aim of this study was to evaluate the shape of patella relative to the femoral epicondylar axis and to find sex differences. Materials and methods. Computed tomography (CT) images of 100 knees with tibiofemoral osteoarthritis in 100 patients were prospectively collected. All patients were diagnosed as varus-type osteoarthritis with no destructive patellar deformity. Fifty patients were male and 50 female. The average male age was 70.8±14.6 (mean ± SD) years and the average female age was 73.3±6.7 years. Forty nine knees were right and 51 knees were left. The average height of males was 162.6±7.4 cm and that of females 149.6±5.7 cm. Males were significantly taller than females. The CT scan was performed with 2mm-interval slices in the vertical plane to the long axis of femoral shaft. Every CT image was examined to determine the maximum distance between the medial and lateral femoral epicondyle (inter-epicondylar distance, IED) along the epicondylar axis. The maximum patellar width and thickness were also measured at the image which had these maximum distances, while patellar cartilage thickness in anteroposterior diameter was not measured in this study. For evaluating the patellar size, each measured value was divided by IED and calculated each ratio. The ratio of patellar width to patellar thickness was also calculated. All parameters were compared between males and females. Statistical software Statview ver.5.0 (SAS Institute Inc.) was used for all analyses with significance being set at the 5% level. Results. Measured values are presented on Table 1. The average IED, patellar width and patellar thickness of males were all significantly larger than those of females. As shown in Table 2, by contrast, each ratio to IED was almost the same between the sexes and there were no significant differences. The ratio of patellar width to patellar thickness was 46.7±2.6% in males and 46.6±2.9% in females. Discussion. Although some studies have assessed the actual measurement values of patella, no prior study, to our knowledge, has morphologically evaluated the patella relative to the femur. This is the first study to investigate the configuration and location of patella relative to femoral epicondylar axis. Our results showed the configuration of patella relative to the femoral epicondylar axis was the same between sexes. The patellar width is approximately 56% and TGD is approximately 39% of IED. The most common complications after the surgery are related to patellofemoral problems. The ideal thickness of the resurfaced patella has not been clearly investigated. Patellar disabilities are associated with both decreased and increased patellar thickness— a thin patella could lead to anteroposterior patellar instability and a thick patella could increase the risk of stiffness of the knee and patellar subluxation. Therefore, it is desirable to restore the original patellar thickness during surgery. The results of current study showed that the ratio of patellar width to the patellar thickness was about 47%, which is useful to determine the thickness of patella during surgeries for severely damaged knees or revision surgeries

Objectives

During open orthopaedic surgery, joints may be exposed to air, potentially leading to cartilage drying and chondrocyte death, however, the long-term effects of joint drying in vivo are poorly understood. We used an animal model to investigate the subsequent effects of joint drying on cartilage and chondrocytes.

Summary. Nasal Chondrocytes are safe and feasible for tissue engineering approaches in articular cartilage repair. Introduction. As compared to articular chondrocytes (AC), nasal septum chondrocytes (NC) proliferate faster and have a higher and more reproducible capacity to generate hyaline-like cartilaginous tissues. Moreover, the use of NC would allow reducing the morbidity associated with the harvesting of cartilage biopsy from the patient. The objective of the present study was to demonstrate safety and feasibility in the use of tissue engineered cartilage graft based on autologous nasal chondrocytes for the repair of articular defect in goats. Methods. Isolated autologous NC and AC from 6 goats were expanded and GFP-labelled before seeding 4×10. 4. cells/cm. 2. on a type I/III collagen membrane (Chondro-Gide®, Geistlich). After 2 weeks of chondrogenic differentiation 2 NC- and 2 AC-based grafts were implanted into chondral defects (6mm diameter) of the same posterior stifle joint. Repair tissue was harvested after 3 or 6 months and the decalcified samples evaluated according to O'Driscoll. Furthermore, samples from the surrounding fat pad, ligament, synovium, tendon and patellar cartilage were harvested and isolated cells tested for GFP-positivity after expansion using FACS. Results. No surgical complication or signs of inflammation occurred in any of the animals. GFP-positive cells were detectable in the repair tissue, indicating the contribution of the implanted cells to the newly formed cartilage. The O'Driscoll score of the repair tissue increased from 8.6 and 7.6 after 3 months to 14.1 and 12.4 after 6 months for nasal and articular grafts, respectively. Surrounding tissues showed no or very low (fat pad 0–0.36%) migration of the grafted cells. Conclusion. Our results demonstrate the use of NC as safe and feasible for tissue engineering approaches in articular cartilage repair. The repair tissue-quality generated by NC-grafts was demonstrated to be at least comparable to that of AC-grafts, thus opening the way for clinical test of a novel therapeutic strategy

The purpose of this study was to measure the radiological parameters of femoral component alignment of the Oxford Phase 3 unicompartmental knee replacement (UKR), and evaluate their effect on clinical outcome. Multiple regression analysis was used to examine the relative contributions of the radiological assessment of femoral component alignment in 189 consecutive UKRs performed by a single surgeon. The American Knee Society scores were compared between groups, defined as being within or outside recommended tolerances of the position of the femoral component. For the flexion/extension position 21 UKRs (11.1%) lay outside the recommended limits, and for posterior overhang of the femoral component nine (4.8%) lay outside the range. The pre-operative hip/knee/ankle (HKA) angle, narrowest canal distance from the distal femoral entry point of the alignment jig and coronal entry-point position had significant effects on the flexion/extension position. Pre-operative HKA angle had a significant influence on posterior overhang of the femoral component. However, there was no significant difference in American Knee Society scores relative to the position of the femoral component.

Patella subluxation assessed on dynamic MRI has previously been shown to be associated with anterior knee pain. In this MRI study of 60 patients we investigated the relationship between subluxation and multiple bony, cartilaginous and soft-tissue factors that might predispose to subluxation using discriminant function analysis.

Patella engagement (% of patella cartilage overlapping with trochlea cartilage) had the strongest relationship with subluxation. Patellae with > 30% engagement tended not to sublux; those with < 30% tended to sublux. Other factors that were associated with subluxation included the tibial tubercle-trochlea notch distance, vastus medialis obliquus distance from patella, patella alta, and the bony and cartilaginous sulcus angles in the superior part of the trochlea. No relationship was found between subluxation and sulcus angles for cartilage and bone in the middle and lower part of the trochlea, cartilage thicknesses and Wiberg classification of the patella.

This study indicates that patella engagement is a key factor associated with patellar subluxation. This suggests that in patients with anterior knee pain with subluxation, resistant to conservative management, surgery directed towards improving patella engagement should be considered. A clinical trial is necessary to test this hypothesis.

The efficacy of circumpatellar electrocautery in reducing the incidence of post-operative anterior knee pain is unknown. We conducted a single-centre, outcome-assessor and patient-blinded, parallel-group, randomised, controlled trial to compare circumpatellar electrocautery with no electrocautery in total knee replacement in the absence of patellar resurfacing. Patients requiring knee replacement for primary osteoarthritis were randomly assigned circumpatellar electrocautery (intervention group) or no electrocautery (control group). The primary outcome measure was the incidence of anterior knee pain. A secondary measure was the standardised clinical and patient-reported outcomes determined by the American Knee Society scores and the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index. A total of 131 knees received circumpatellar electrocautery and 131 had no electrocautery.

The overall incidence of anterior knee pain at follow-up at one year was 26% (20% to 31%), with 19% (12% to 26%) in the intervention group and 32% (24% to 40%) in the control group (p = 0.02). The relative risk reduction from electrocautery was 40% (9% to 61%) and the number needed to treat was 7.7 (4.3 to 41.4). The intervention group had a better mean total WOMAC score at follow-up at one year compared with the control group (16.3 (0 to 77.7) versus 21.6 (0 to 76.7), p = 0.04). The mean post-operative American Knee Society knee scores and function scores were similar in the intervention and control groups (knee score: 92.4 (55 to 100) versus 90.4 (51 to 100), respectively (p = 0.14); function score: 86.5 (15 to 100) versus 84.5 (30 to 100), respectively (p = 0.49)).

Our study suggests that in the absence of patellar resurfacing electrocautery around the margin of the patella improves the outcome of total knee replacement.