Aims

In the UK, the agricultural, military, and construction sectors have stringent rules about the use of hearing protection due to the risk of noise-induced hearing loss. Orthopaedic staff may also be at risk due to the use of power tools. The UK Health and Safety Executive (HSE) have clear standards as to what are deemed acceptable occupational levels of noise on A-weighted and C-weighted scales. The aims of this review were to assess the current evidence on the testing of exposure to noise in orthopaedic operating theatres to see if it exceeds these regulations.

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.

Aims

The aim of this study was to examine the results of revision total knee arthroplasty (TKA) undertaken for stiffness in the absence of sepsis or loosening.

Patients with recurrent patella instability, who have an abnormal patellofemoral alignment (patella height or tibial tubercle-trochlear groove (TTTG) distance), benefit from tibial tubercle transfer along with medial patellofemoral ligament (MPFL) reconstruction. Between July 2008 and April 2013, 18 patients (21 knees) with recurrent patellar instability underwent combined MPFL reconstruction and tibial tubercle transfer. All patients had abnormal patellofemoral alignment in addition to MPFL insufficiency. 15 patients (16 knees) with a mean age of 24 years (16–41) had a mean follow up of 26 months (6–55). We assessed the outcome using KOOS, KUJALA, activity level and patient satisfaction scores. All patients had a stable patella. There was a significant improvement in outcome scores in 12 out of 15 patients. At final follow up KOOS score had improved from 68.25(44 to 93.9) to 77.05(48.8 to 96.4) and KUJALA score had improved from 63.3(41–88) to 78.06 (45 to 99). 9 patients showed excellent results and achieved at least a pre-injury level of activity. 4 of these had activity level better then preoperative level. 6 patients had a lower activity level than pre-injury (1 – ongoing physiotherapy, 1 – because of lack of confidence, and 4 – Life style modification). 14 patients were satisfied and happy to recommend this procedure. There were 3 postop complications, with 2 cases of stiffness and 1 case of non-union of the tibial tuberosity. Our prospective study has shown that restoration of tibial tubercle-trochlear groove index, Patella height and Medial Patellofemoral Ligament reconstruction yields good results in carefully selected patients

An increased tibial tubercle–trochlear groove (TT-TG) distance is related to patellar maltracking and instability. Tibial tubercle transfer is a common treatment option for these patients with good short-term results, although the results can deteriorate over time owing to the progression of osteoarthritis. We present a ten-year follow-up study of a self-centring tibial tubercle osteotomy in 60 knees, 30 with maltracking and 30 with patellar instability. Inclusion criteria were a TT-TG ≥ 15 mm and symptoms for > one year. One patient (one knee) was lost to follow-up and one required total knee arthroplasty because of progressive osteoarthritis. Further patellar dislocations occurred in three knees, all in the instability group, one of which required further surgery. The mean visual analogue scores for pain, and Lysholm and Kujala scores improved significantly and were maintained at the final follow-up (repeated measures, p = 0.000, intergroup differences p = 0.449). Signs of maltracking were found in only a minority of patients, with no difference between groups (p > 0.05). An increase in patellofemoral osteoarthritis was seen in 16 knees (31%) with a maximum of grade 2 on the Kellgren–Lawrence scale. The mean increase in grades was 0.31 (0 to 2) and 0.41 (0 to 2) in the maltracking and instability groups respectively (p = 0.2285)

This self-centring tibial tubercle osteotomy provides good results at ten years’ follow-up without inducing progressive osteoarthritis.

Cite this article: Bone Joint J 2015;97-B:329–36.

Purpose of Study:. Various techniques have been described and are still used for treating recurrent dislocation of the patella when conservative measures fail. Among them are distal, proximal and combined realignment techniques and lateral releases. Since being shown proof of the biomechanical importance of the medial patellofemoral ligament (MPFL) in patellofemoral instability, the reconstruction of the MPFL has gained in popularity. The objective of this paper is to present a case series with preliminary clinical results using the gracilis tendon to reconstruct the MPFL. Method:. Between 01/07 and 03/11 23 knees in 21 patients underwent reconstruction of the MPFL.4 of these patients had had previous surgery. Preoperatively the Caton Deschamps ratio using plain x-rays was worked out and the TT/TG distance was measured using CT scanning. Using these measurements as a guideline, 7 cases underwent a tibial tubercle transfer as an additional procedure. In 6 of the cases an additional cartilage procedure was required. The technique was simplified using intra-operative x-rays to achieve anatomical tunnel placement. Results:. The Tegner Activity Score was used to evaluate the patients preoperatively and at a minimum of 6 months postoperatively. The scores improved on average from 3,6 to 7,4. One patient had an extensor lag of 10 degrees at 3 months. This had normalised by 6 months. One patient had recurrence of her instability and required a revision MPFL reconstruction using an allograft. One patient had recurrent episodes of patella subluxation but no overt dislocation. Conclusion:. This case series gave good functional results using the Tegner Activity score. The procedure of MPFL reconstruction was effective in stabilising the patellae and in improving the symptoms of patellofemoral instability

Medial patellofemoral ligament (MPFL) reconstruction is used to treat patellar instability and recurrent patellar dislocation. Anatomical studies have found the MPFL to be a double-bundle structure. We carried out a meta-analysis of studies reporting outcomes of patellofemoral reconstruction using hamstring tendon autograft in a double-bundle configuration and patellar fixation via mediolateral patellar tunnels.

A literature search was undertaken with no language restriction in various databases from their year of inception to July 2012. The primary outcome examined was the post-operative Kujala score. We identified 320 MPFL reconstructions in nine relevant articles. The combined mean post-operative Kujala score was 92.02 (standard error (se) 1.4, p = 0.001) using a fixed effects model and 89.45 (se 37.9, p = 0.02) using random effect modelling. The reported rate of complications with MPFL reconstruction was 12.5% (40 of 320) with stiffness of the knee being the most common. High-quality evidence in assessing double-bundle MPFL reconstruction is lacking. The current literature consists of a mixture of prospective and retrospective case series. High-quality randomised trials evaluating this procedure are still awaited.

Cite this article: Bone Joint J 2013;95-B:900–5.

Seven stiff total knee arthroplasties are presented to illustrate the roles of: 1) manipulation under general anesthesia; 2) multiple concurrent diagnoses in addition to stiffness; 3) extra-articular pathology; 4) pain as part of the stiffness triad (pain and limits to flexion or extension); 5) component internal rotation; 6) multifactorial etiology; and 7) surgical exposure in this challenging clinical problem.

We present 10–15 year follow-up of 33 patients who underwent Elmslie-Trillat osteotomy for severe patellar subluxation or dislocation. In the literature it has been reported that tibial tubercle osteotomy predisposes to subsequent patella-femoral arthritis, however it has never been documented if pre-existent knee chondral damage has any role in this development. In our group all patients had pre-op knee arthroscopy performed and extant of chondral damage was documented. We preformed an evaluation by long-term follow-up to determine weather pre-op chondral damage was the cause of subsequent osteoarthritis of patella-femoral joint. All patients were invited to attend outpatient clinic for clinical examination and knee radiographs and assessed by an independent research surgeon. Mean age at follow-up was 43 years and average follow-up was 10.5 years (range 10–15 years). 90% follow-up was achieved. Knee function was assessed by clinical scores (Lysholm knee score, American Knee Score, Oxford Knee score, Tegner and Insall knee scores) and three radiographs (AP, Lateral and Merchant views). Four patients had developed significant arthritis and underwent joint arthroplasty. Majority of patients reported good results with no further dislocation. However we noticed that extant of pre-op chondral damage was a significant factor in subsequent development of patella-femoral arthritis. We will present our data which is unique as no previous such long-term results have been reported for tibial tubercle transfers followed-up for more than 10 years and have pre-op arthroscopic documented chondral damage

A consecutive series of patients with a hydroxyapatite-coated uncemented total knee replacement (TKR) performed by a single surgeon between 1992 and 1995 was analysed. All patients were invited for clinical review and radiological assessment. Revision for aseptic loosening was the primary outcome. Assessment was based on the Knee Society clinical score (KSS) and an independent radiological analysis. Of 471 TKRs performed in 356 patients, 432 TKRs in 325 patients were followed for a mean of 16.4 years (15 to 18). The 39 TKRs in 31 patients lost to follow-up had a mean KSS of 176 (148 to 198) at a mean of ten years. There were revisions in 26 TKRs (5.5%), of which 11 (2.3%) were for aseptic loosening. Other further surgery was carried out on 49 TKRs (10.4%) including patellar resurfacing in 20, arthrolysis in 19, manipulation under anaesthetic in nine and extensor mechanism reconstruction in one.

Survivorship at up to 18 years without aseptic loosening was 96% (95% confidence interval 91.9 to 98.1), at which point the mean KSS was 176 (134 to 200). Of 110 knees that underwent radiological evaluation, osteolysis was observed in five (4.5%), one of which was revised.

These data indicate that uncemented hydroxyapatite-coated TKR can achieve favourable long-term survivorship, at least as good as that of cemented designs.

We present 10–15 year follow-up of 33 patients who underwent Elmslie-Trillat osteotomy for severe patellar subluxation or dislocation. In the literature it has been reported that tibial tubercle osteotomy predisposes to subsequent patella-femoral arthritis, however it has never been documented if pre existent knee chondral damage has any role in this development. In our group all patients had pre-op knee arthroscopy performed and extant of chondral damage was documented. We pre-formed an evaluation by long-term follow-up to determined weather pre-op chondral damage was the cause of subsequent osteoarthritis of patella-femoral joint. All patients were invited to attend outpatient clinic for clinical examination and knee radiographs and assessed by an independent research surgeon. Mean age at follow-up was 43 years and average follow-up was 10.5 years (range 10–15 years). 90% follow-up was achieved. Knee function was assessed by clinical scores (Lysholm knee score, American Knee Score, Oxford Knee score, Tegner and Insall knee scores) and three radiographs (AP, Lateral and Merchant views) were performed. Four patients had developed significant arthritis and underwent joint arthroplasty. Majority of patients reported good results with no further dislocation. However we noticed that extant of pre-op chondral damage was a significant factor in subsequent development of patella-femoral arthritis. We will present our data which is unique as no previous such long-term results have been reported for tibial tubercle transfers followed-up for more than 10 years and have pre-op arthroscopic documented chondral damage

To share our results following Medial Patellofemoral ligament (MPFL) reconstruction for patellar instability problems using ipsilateral semitendinosus graft anchored to the patella and the medial femoral condyle using biotenodesis screws. Study design and methods: 35 patients were assessed with a mean follow up of 18 months. All patients had preoperative true lateral knee x-ray, MRI or CT scan to look at trochlear dysplasia and the sulcus tuberosity distance. They all under went MPFL reconstruction using ipsilateral semitendinosus tendon. Two patients had sulcus tuberosity distance greater than 20 mm and they under went a tibial tubercle transfer in addition. Two patients had trochlear dysplasia and hence a trochlearplasty was also done. In skeletally mature patients the hamstrings tendon were anchored to the medial side of the patella in a 5×15mm blind tunnel using biotenodesis screw. This significantly reduces the risk of having patella fracture. All patients were treated by the same surgeon and assessments were performed by a different surgeon based on kujala scores and tegner scores. Results: Symptom relief was noted in all patients with in 3 months. No patient had patella dislocation or fracture after this procedure. They all had full range of movements and their kujala scores and tegner scores were good to excellent. Conclusion: MPFL reconstruction using hamstrings tendon anchored to the medial side of the patella and femur using biotenodesis screw gave a good result clinically and is associated with fewer complications including patellar fractures

Recurrent patellar instability and anterior knee pain is a common problem after patellar dislocation. The medial patellofemoral ligament (MPFL) which contributes 40–80% of the total restraining forces is either attenuated or ruptured in these patients. Various techniques have been described in reconstructing this MPFL using hamstrings tendons. We wish to share our experience in treating these patients using ipsilateral semitendinosus tendon anchored to the medial femoral condyle and medial side of the patella using biotenodesis screws. Study design and methods: 15 patients were assessed with a mean follow up of 12 months. All patients had pre-operative true lateral knee x-ray, MRI or CT scan to look at trochlear dysplasia and the sulcus tuberosity distance. They all under went MPFL reconstruction using ipsilateral semitendinosus tendon. Two patients had sulcus tuberosity distance greater than 20 mm and they under went a tibial tubercle transfer in addition. Two patients had trochlear dysplasia and hence a trochleaplasty was also done. In skeletally mature patients the hamstrings tendon was anchored to the medial side of the patella in a 5x15mm blind tunnel using biotenodesis screw. This significantly reduces the risk of having patella fracture. In. children the graft was sutures to the soft tissues along the medial side of the patella and the medial femoral condyle. All patients were treated by the same surgeon and assessments were performed by a different surgeon based . on Kujala scores and Tegner scores. Results: Symptom relief was noted in all patients with in 3 months. No patient had patella dislocation or fracture after this procedure. They all had full range of movements and their Kujala scores and Tegner scores were good to excellent. Conclusion: MPFL reconstruction using hamstrings tendon anchored to the medial side of the patella and femur using biotenodesis screw gave a good result clinically and is associated with fewer complications including patellar fractures

70 patients who underwent dynamic MRI scanning for chronic anterior knee pain were retrospectively evaluated. All patients had been symptomatic for over a year. 43 patients had been treated conservatively and 27 had undergone surgical procedures (arthroscopy -13, lateral release- 9, tibial tubercle transfer 5). The extent of subluxation, tilt and cartilage abnormalities on MRI scans, during resisted extension were assessed. Functional scoring (Oxford, Lysholm and Tegner scores) was done through questionnaires and correlated with the radiological findings. 54 (77%) patients were found to have some patellofemoral abnormality on the scans. Subluxation was the most common finding with mild subluxation in 30, moderate in 18 and severe in 17 knees. Mild tilt was seen in 26 knees and moderate to severe tilt in 14 knees. Tilt was found in association with subluxation except in 8 cases. Grade 1 and 2 cartilage wear were seen in 13 knees and Grade 3 and 4 in 21 knees. The “Tibial Tubercle to Trochlear Groove distance” (TTD) was measured in all knees and correlated with subluxation. The average distance was 13.5mm, 13.6mm and 18.8mm for mild, moderate and severe subluxation respectively. All patients with a TTD _ 20mm had moderate or severe subluxation. The specificity of a TTD _ 20mm for severe maltracking was 100% but the sensitivity was only 42%. The TTD appears to be the single most significant parameter determining patella tracking. We have proposed an algorithm for the surgical and non-surgical treatment of chronic anterior knee pain. We recommend lateral release for those with moderate and severe subluxation and a tibial tubercle transfer as well in those with a TTD _ 20mm. The functional scores did not zshow a significant correlation with the grading of subluxation

Chronic patellofemoral instability can be a disabling condition. Management of patients with this condition has improved owing to our increased knowledge of the functional anatomy of the patellofemoral joint. Accurate assessment of the underlying pathology in the unstable joint enables the formulation of appropriate treatment. The surgical technique employed in patients for whom non-operative management has failed should address the diagnosed abnormality. We have reviewed the literature on the stabilising features of the patellofemoral joint, the recommended investigations and the appropriate forms of treatment.

An abnormal lateral position of the tibial tuberosity causes distal malalignment of the extensor mechanism of the knee and can lead to lateral tracking of the patella causing anterior knee pain or objective patellar instability, characterised by recurrent dislocation. Computer tomography is used for a precise pre-operative assessment of the tibial tubercle-trochlear groove distance. A distance of more than 15 mm is considered to be pathological and an indication for surgery in symptomatic patients.

In a prospective study we performed a subtle transfer of the tibial tuberosity according to the information gained from the pre-operative CT scan. This method was applied to two groups of patients, those with painful lateral tracking of the patella, and those with objective patellar instability. We evaluated the clinical results in 30 patients in each group. The outcome was documented at 3, 12 and 24 months using the Lysholm scale, the Kujala score, and a visual analogue pain score.

Post-operatively, all but one patient in the instability group who had a patellar dislocation requiring further surgery reported good improvement with no further subluxation or dislocation. All patients in both groups had a marked improvement in pain and functional score. Two patients sustained a tibial fracture six and seven weeks after surgery. One patient suffered a per-operative fracture of the tibial tubercle which later required further fixation.

If carefully performed, this type of transfer of the tibial tubercle appears to be a satisfactory technique for the treatment of patients with an increased tibial tubercle-trochlear groove distance and who present with symptoms related to lateral maltracking of the patella.

Background: Symptomatic patellofemoral osteoarthritis is a challenge to the orthopaedic surgeon. In comparison to Total Knee Arthroplasty (TKA), little has been written about unicompartmental patellofemoral arthroplasty. Although, recent reports have shown more promise, the procedure has not gained wide acceptance. Materials and Methods: We present the outcome of 23 unicompartmental patellofemoral arthroplasties on 19 patients performed in a district general hospital in the UK. The procedures were performed by a single surgeon (RSG), with a special interest in knee surgery. All the patients had failed a trial of non-operative treatment which included non-steroidal anti-inflammatory analgesia and physiotherapy. Some knees had undergone previous surgical procedures including arthroscopy (12), carbon fibre patch implantation (5), tibial tubercle transfer (1), lateral release (1), medial release (1) and excision of patellar bursa (1). Multiple arthroscopies had been performed on 4 knees. The arthroplasty was performed via an anterior midline incision and medial parapatellar approach. All patients received Leicester Patellofemoral Prosthesis (Corin). One patient had a revision procedure following a failed PFJR performed elsewhere. The age of the patient at the time of operation ranged from 31–68 years (Mean age 50.3 years). The duration of follow-up was 6 months to 88 months (Mean 36 months). The results were evaluated using the Oxford Knee Score. Results: One patellofemoral arthroplasty was converted to TKA after 41 months. There was no infection or loosening of the components in any patient. All patients reported relief of post-operative discomfort by 6 months except for one patient who developed hypersensitive skin lateral to the scar at 6 months. All patients said that their knees were significantly better after the procedure. Oxford Knee Scores ranged from 17 to 54 (Median 29). All except one patient reported that they would to undergo the procedure on their other knee (unilateral cases) and would recommend the procedure to friends/family. Conclusion: The early and medium term results of uni-compartmental patellofemoral arthroplasty in our study are encouraging with patients reporting significant improvement in knee symptoms. We feel that careful patient selection and meticulous attention to surgical detail contribute to better outcomes

Purpose: Since the pathomechanism of patellofemoral malalignment is complex, multifactorial and varies individually, the ideal treatment has been a matter of controversy. The purpose of this study was to demonstrate the clinical outcome and radiographic changes of knees with patellofemoral malalignment treated with Fulkerson osteotomy after a minimum follow-up of 24 months. Materials and Methods: Sixty knees in 40 patients (32 female and 8 male) were examined with a mean of 55 20 (25 97) months after having undergone medialization of the tibial tubercle using Fulkerson osteotomy for patel-lofemoral malalignment. Mean age at surgery was 20 7 (12 42) years. Prior surgery of medial retinacular plication in 4 knees and lateral retinacular release in 1 knee had been performed. During surgery, amount of tibial tubercle transfer was determined by examining the patellar tracking over full range of knee motion. After Fulkerson osteotomy, proximal realignment procedures were added depending on arthroscopic appearance of the patellofemoral adaptation. The clinical outcome was evaluated using Fulkersons knee instability scale. The radiographic parameters including congruence angle, lateral patellofemoral angle, tilting angle and lateral shift ratio were measured in Merchant view. Results: Mean distance of medial transfer of tibial tubercle was 12.8 3.1 (8 22) mm. Lateral retinacular release in 54 knees and adductor magnus tenodesis (Avikainen procedure) in 2 knees were simultaneously performed combined with Fulkerson osteotomy. All radiographic parameters at the final follow-up were significantly improved compared to the preoperative values (p < 0.05 in a paired t-test), that is, from 23.0 14.6 to 0.4 13.7 degrees in congruence angle, from −6.3 9.0 to 0.4 6.9 degrees in lateral patellofemoral angle, from 25.1 11.5 to 16.3 5.6 degrees in tilting angle and from 35 24 to 17 9% in lateral shift ratio. Mean score in Fulkersons knee instability scale was 96 5 points at the final follow-up. All knees except 3 were ranked as excellent, very good or good. Two knees with moderate osteoarthritis of the patellofemoral joint were ranked as fair. One knee that had postoperative recurrence of patellar subluxation underwent a revision surgery with Avikainen procedure. Discussion: In the clinical study with a minimum 2-year follow-up, Fulkerson tibial tubercle osteotomy provided excellent or good overall outcome in 93% of patients in combination with proximal realignment surgeries. Although all radiographic parameters were significantly improved, it was found that the lateral shift of the patella was more effectively corrected compared to the lateral tilt. It was suggested that reconstruction of the medial patellofemoral structures might be more suitable than Fulkerson osteotomy for some knees characterized by significant lateral tilt

Purpose of the study: To develop a new treatment algorithm for patients with chronic anterior knee pain based on kinematic patella tracking MR imaging. Methods and Results: Patients with anterior knee pain of more than one year duration and not responding to non-operative treatment, underwent kinematic MRI study. The provocative test was performed with the conventional MRI scanner and the patient extending the knee against resistance, the resistance provided by inflated beach ball. A retrospective analysis was done of first seventy patients, who had undergone this scanning technique. On the imaging films, four measurements were made. They were patella subluxation, tilt, cartilage thickness and the Tibial Tubercle Trochlear distance (TTD). Patellar subluxation was classified as mild, moderate and severe. We found that a Tibial Tubercle Trochlea distance of 18mm had a specifity of 100% and a sensitivity of 89% for severe maltracking. Conclusion: Kinematic MR Imaging is a useful investigation before considering operative treatment for patients with chronic anterior knee pain. Based on our study, we conclude that those patients with moderate lateral maltracking with a TTD< 18 mm should be offered lateral release and those with severe maltracking and TTD> 18mm should have a tibial tubercle transfer, in addition to lateral release