PURPOSE. YouTube is a video sharing platform that is a common resource for patients seeking medical information. The objective of this study is to assess the educational quality of YouTube videos pertaining to total knee arthroplasty and
Introduction and Objective. Malunion after trauma can lead to coronal plane malalignment in the lower limb. The mechanical hypothesis suggests that this alters the load distribution in the knee joint and that that this increased load may predispose to compartmental arthritis. This is generally accepted in the orthopaedic community and serves as the basis guiding deformity correction after malunion as well as congenital or insidious onset malalignment. Much of the literature surrounding the contribution of lower limb alignment to arthritis comes from cohort studies of incident osteoarthritis. There has been a causation dilemma perpetuated in a number of studies - suggesting malalignment does not contribute to, but is instead a consequence of, compartmental arthritis. In this investigation the relationship between compartmental (medial or lateral) arthritis and coronal plane malalignment (varus or valgus) in patients with post traumatic unilateral limb deformity was examined. This represents a specific niche cohort of patients in which worsened compartmental
Aims. An algorithm to determine the constitutional alignment of the lower limb once arthritic deformity has occurred would be of value when undertaking kinematically aligned total knee arthroplasty (TKA). The purpose of this study was to determine if the arithmetic hip-knee-ankle angle (aHKA) algorithm could estimate the constitutional alignment of the lower limb following development of significant arthritis. Methods. A matched-pairs radiological study was undertaken comparing the aHKA of an osteoarthritic knee (aHKA-OA) with the mechanical HKA of the contralateral normal knee (mHKA-N). Patients with Grade 3 or 4 Kellgren-Lawrence tibiofemoral osteoarthritis in an
The aim of the study was to investigate rotational behaviour of the
Aims. This study aims to determine the rate of and risk factors for total knee arthroplasty (TKA) after operative management of tibial plateau fractures (TPFs) in older adults. Methods. This is a retrospective cohort study of 182 displaced TPFs in 180 patients aged ≥ 60 years, over a 12-year period with a minimum follow-up of one year. The mean age was 70.7 years (SD 7.7; 60 to 89), and 139/180 patients (77.2%) were female. Radiological assessment consisted of fracture classification; pre-existing knee osteoarthritis (OA); reduction quality; loss of reduction; and post-traumatic OA. Fracture depression was measured on CT, and the volume of defect estimated as half an oblate spheroid. Operative management, complications, reoperations, and mortality were recorded. Results. Nearly half of the fractures were Schatzker II AO B3.1 fractures (n = 85; 47%). Radiological knee OA was present at fracture in 59/182 TPFs (32.6%). Primary management was fixation in 174 (95.6%) and acute TKA in eight (4.4%). A total of 13 patients underwent late TKA (7.5%), most often within two years. By five years, 21/182 12% (95% confidence interval (CI) 6.0 to 16.7) had required TKA. Larger volume defects of greater depth on CT (median 15.9 mm vs 9.4 mm; p < 0.001) were significantly associated with TKA requirement. CT-measured joint depression of > 12.8 mm was associated with TKA requirement (area under the curve (AUC) 0.766; p = 0.001). Severe joint depression of > 15.5 mm (hazard ratio (HR) 6.15 (95% CI 2.60 to 14.55); p < 0.001) and pre-existing knee OA (HR 2.70 (95% CI 1.14 to 6.37); p = 0.024) were independently associated with TKA requirement. Where patients with severe joint depression of > 15.5 mm were managed with fixation, 11/25 ultimately required TKA. Conclusion. Overall, 12% of patients aged ≥ 60 years underwent TKA within five years of TPF. Severe joint depression and pre-existing
The Authors performed a matched paired study between 2 groups UKR or CA-TKR implanted with a mini-incision (MICA group) in the treatment of isolated medial compartment
Introduction. Septic
Introduction: The
Aim. The aim of our study was to identify pathogens involved in septic
Background. Septic
In two years we treated four women with ununited stress fractures of their proximal tibial diaphyses. They all had arthritis and valgus deformity. The stress fractures had been treated elsewhere by non-operative means in three patients and by open reduction and internal fixation in one, but had failed to unite. After treatment with a modular total knee prosthesis with a long tibial stem extension, all the fractures united. A modular total knee prosthesis is suitable for the rare and difficult problem of ununited tibial stress fractures in patients with deformed
Aim: To evaluate results of fully congruent Mobile bearing knee arthroplasty for valgus
We hypothesize that tethering adhesions of the quadriceps muscle are the major pathological structures responsible for a limited range of motion in the stiff
The lifetime prevalence of symptomatic osteoarthritis at the knee is 50% osteoarthritis of the ankle occurs in only 1% of the population. This variation in prevalence has been hypothesised to result from the differential responsiveness of the joint cartilages to catabolic stimuli. Human cartilage explants were taken from the talar domes (n=12) and the femoral condyles (n=7) following surgical amputation. Explants were cultured in the presence of either a combination of high concentration cytokines (TNFα, OSM, IL-1α) to resemble a post traumatic environment or low concentration cytokines to resemble a chronic osteoarthritic joint. Cartilage breakdown was measured by the percentage loss of Sulphated glycosaminoglycan (sGAG) from the explant to the media during culture. Expression levels of the pro-inflammatory molecules nitric oxide and prostaglandin E. 2. were also measured. Significantly more sGAG was lost from knee cartilage exposed to TNFα (22.2% vs 13.2%, P=0.01) and TNFα in combination with IL-1α (27.5% vs 16.0%, P=0.02) compared to the ankle; low cytokine concentrations did not affect sGAG release. Significantly more PGE. 2. was produced by knee cartilage compared to ankle cartilage however no significant difference in nitrite production was noted. Cartilage from the knee and ankle has a divergent response to stimulation by pro-inflammatory cytokines, with high concentrations of TNFα alone, or in combination with IL-1α amplifying cartilage degeneration. This differential response may account for the high prevalence of
We have reviewed 183 patients (215 knees) assessing results and indications of High Tibial Osteotomies in medial gonarthrosis. Material: 128 females and 55 males. Follow up is 11.5 years, 120 cases with average varus angle 13° had opening ; 95 cases with average varus angle 10° had closing wedges. Ahlback classification showed stages I: 54, II: 71, III: 66 and IV: 24. H.S.S. scoring was 61 for opening and 68 for closing wedge. Results: 27 re-operations and 13 other complications. Healing delay was 55 days for closing and 70 for opening. R.O.M. was 125°. 25 knees are painful. 1/After opening, scoring is 77 and valgus angle is 3°. 2/After closing, scoring is 80 and valgus angle is 5°. 3/Global results: very good: 26%, good: 33%, medium: 28% and poor: 13%. Discussion: H.T.O. decreases stresses on medial compartment and widens joint space. No significant aggravation is observed at follow up. Clinical results are satisfying in early surgery. Reaxation is good for delaying or managing arthritis. The average of 5° mechanical valgus at osteotomy seems to be effective. Conclusions: -Opening wedge for medium severity and wide varus angle, till the age of 70. -Closing wedge for medium varus in younger patients. H.T.O. allows quite pain-free knees, restores axes and avoids or delays T.K.R. H.T.O. gives satisfactory results and should be then considered the best choice for early prevention and treatment of varus
High tibial osteotomy for knee realignment is effective at relieving symptoms of knee osteoarthritis but the operation is surgically challenging. A new personalised treatment with simpler surgery using pre-operatively planned measurements from computed tomography (CT) imaging and 3D-printed implants and instrumentation has been designed and is undergoing clinical trial. The aim of this study was to evaluate the early clinical results of a preliminary pilot study evaluating the safety of this new personalised treatment. The single-centre prospective clinical trial is ongoing (IRCCS Istituto Ortopedico Rizzoli; IRB-0013355; ClinicalTrials.gov NCT04574570), with recruitment completed and all patients having received the novel custom surgical treatment. To preserve the completeness of the trial reporting, only surgical aspects were evaluated in the present study. Specifically, the length of the implanted osteosynthesis screws was considered, being determined pre-operatively eliminating intraoperative measurements, and examined post-operatively (n=7) using CT image processing (ScanIP, Synopsys) and surface distance mapping. The surgical time, patient discharge date and ease of wound closure were recorded for all patients (n=25).Abstract
Objectives
Methods
Traditionally, serum white blood count (WBC), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) have been utilized as markers to evaluate septic arthritis (SA). Recently, neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been identified as prognostic factors for treatment failure, mortality and morbidity in various clinical settings. To date, these markers have not been utilized for evaluating outcomes after hip and knee SA. Thus, the purpose of this study was to determine the ability of admission NLR and PLR to predict treatment failure and postoperative 90-day mortality in hip and knee SA. A retrospective study was performed using our institutional research patient database to identify 235 patients with native hip and knee septic arthritis from 2000–2018. Patient demographics, comorbidities and social factors (alcohol intake, smoking and intravenous drug use) were obtained, and NLR and PLR were calculated based on complete blood count values (absolute neutrophil, lymphocyte and platelet count) on admission. Treatment failure was defined as any reoperation or readmission within 90 days after surgery. Receiver operating curves were analyzed, and optimal thresholds for NLR and PLR were determined using Youden's test. Univariate and multivariate analyses were performed to determine if these ratios were independent predictors of treatment failure and 90-day mortality after surgery. These ratios were compared to serum WBC, CRP, and ESR.Aim
Method
A multi-centre clinical trial of ICLH (Freeman-Swanson) arthroplasty has been in progress since 1971. In this paper the results up to two years after operation are reported in seventy-one knees displaying at least 30 degrees of fixed flexion, 25 degrees of valgus or 20 degrees of varus, before operation. It has been found that knees displaying 70 degrees of fixed flexion, 70 degrees of valgus, 30 degrees of varus or 50 degrees of valgus/varus instability can be satisfactorily aligned and stabilised with acceptable function. Three knees required revision. The other complications are listed and were unremarkable in nature. These results depend upon the prosthesis and upon the operative technique. The latter avoids damage to healthy bone but does involve the replacement of the tissues in the midline of the knee.
Osteotomies are performed in patients with lower limb malalignment, usually associated with osteoarthritis of the knee or instability. The surgery realigns the mechanical axis of the leg by either an opening or closing wedge procedure with the goal of decreasing symptoms, improving function, and delaying the progression of osteoarthritis. The 103 patients that had undergone osteotomy surgery were studied prospectively, and data was analysed one year post surgery. We examined subjective outcomes, patient history and surgical variables using backwards stepwise multiple regression models to determine whether there were any associations between these. Subjective outcomes from a total of 103 osteotomy patients at one year post surgery were compared to patient history and surgical variables. All categories of KOOS and WOMAC scores were improved after surgery. The multivariate models showed that variables significantly influencing the outcomes were pre-operative flexion, pre-operative weight, the size of the HTO plate used and tourniquet time. Greater pre-operative flexion; lower weight; larger plate used, indicating larger corrections; and lower tourniquet times were shown to result in improved scores. Not all variables influenced all categories of the scores. While flexion and pre-operative weight influenced across the categories of both scores, plate size influenced KOOS pain and symptoms and tourniquet time influenced KOOS sport and quality of life. Knee flexion and body weight were the most influential variables when considering KOOS and WOMAC outcome scores as a measure of success. The size of the correction may have influenced the pain and symptom scores because patients with greater malalignment may have initially had worse symptoms and their perception of their current function and pain is affected by their previous levels of pain and function. Osteotomy results in improved function and pain scores and our results indicate that there are several variables which significantly influence patient outcomes and may be of greater importance than other variables.
Soft tissue balancing in fixed genu valgum can be challenging and may lead to instability in flexion. Current techniques involve release of the tight secondary structures initially, with the fascia lata and the lateral capsule usually addressed first, and then the posterior capsule if necessary. If ligament testing does not permit neutral alignment in extension, release of the lateral collateral ligament becomes necessary. The most common way of achieving neutral alignment is by lengthening the lateral structures through elevation of the proximal insertion of the lateral collateral ligament (LCL). This technique has two drawbacks: the lengthening affects both extension and flexion gaps and may give rise to excessive external rotation of the femoral implant, with too much offset of the rotational centre. Particularly when non-constrained prostheses are used, the resulting lateral instability in flexion can be a problem. An alternative is to perform a release at the level of the distal insertion of the LCL, as advocated by Keblish and Buechel. However, this still induces undue external rotation of the femoral implant. We think that if the situation in flexion before any release is satisfactory in terms of the patella, it should not be changed. This means that in order to maintain optimal patellofemoral function, the flexion gap should be addressed before any release. The task is then to achieve a good extension gap with a well-aligned knee. In fixed valgus deformities, this means distal translocation of the femoral insertion of the LCL by distal sliding lateral condylar osteotomy. This procedure aims to preserve the flexion condition and to allow distal slide of the lateral condylar osteotomised fragment. In doing the osteotomy, it is important to make the lateral fragment sufficiently large to allow relocation of the osteotomised fragment inside the prosthesis. This provides the immediate stability necessary for good healing. We have been using two simple cortical screws to ensure stability of the fragment. This paper reports our experience in 100 cases.
Aims. Once
The October 2023 Trauma Roundup. 360. looks at: Intramedullary nailing versus sliding hip screw in trochanteric fracture management: the INSITE randomized clinical trial; Five-year outcomes for patients with a displaced fracture of the distal tibia; Direct anterior versus anterolateral approach in hip joint hemiarthroplasty; Proximal humerus fractures: treat them all nonoperatively?; Tranexamic acid administration by prehospital personnel; Locked plating versus nailing for proximal tibia fractures: a multicentre randomized controlled trial; A retrospective review of the rate of septic
Valgus knee deformity can present a number of
unique surgical challenges for the total knee arthroplasty (TKA)
surgeon. Understanding the typical patterns of bone and soft-tissue pathology
in the valgus
The October 2015 Knee Roundup360 looks at: Allergy and outcome in arthroplasty; Physiotherapy and drains not such a bad combination?; Another nail in the coffin for arthroscopists?; Graft precondition hocus pocus; Extended dose steroids in
Proximal femoral focal deficiency is a congenital disorder of malformation of the proximal femur and/or the acetabulum. Patients present with limb length discrepancy and clinical features along a spectrum of severity. As these patients progress through to skeletal maturity and on to adulthood, altered biomechanical demands lead to progression of arthropathy in any joint within the lower limb. Abnormal anatomy presents a challenge to surgeons and conventional approaches and implants may not necessarily be applicable. We present a case of a 62-year-old lady with unilateral proximal femoral focal deficiency (suspected Aitken Class A) who ambulated with an equinus prosthesis for her entire life. She presented with ipsilateral knee pain and instability due to
Arthritis is a common and debilitating disease and is associated with an increased fall risk. The purpose of this study was to examine the effect of impacted joint and limb on fall risk as measured by the margin of stability (MOS). There were 110 participants, including healthy controls (HC; n=30), ankle arthritis (AA; n=30),
Abstract. Background. Distal femoral osteotomy is an established successful procedure which can delay the progression of arthritis and the need for knee arthroplasty. The surgery, however, is complex and lengthy and consequently it is generally the preserve of highly experienced specialists and thus not widely offered. Patient specific instrumentation is known to reduce procedural complexity, time, and surgeons’ anxiety levels. 1. in proximal tibial osteotomy procedures. This study evaluated a novel patient specific distal femoral osteotomy procedure (Orthoscape, Bath, UK) which aimed to use custom-made implants and instrumentation to provide a precision correction while also simplifying the procedure so that more surgeons would be comfortable offering the procedure. Presenting problem. Three patients (n=3) with early-stage
Introduction. Transtibial osseointegration (TFOI) for amputees has limited but clear literature identifying superior quality of life and mobility versus a socketed prosthesis. Some amputees have
Aims. A comprehensive classification for coronal lower limb alignment with predictive capabilities for knee balance would be beneficial in total knee arthroplasty (TKA). This paper describes the Coronal Plane Alignment of the Knee (CPAK) classification and examines its utility in preoperative soft tissue balance prediction, comparing kinematic alignment (KA) to mechanical alignment (MA). Methods. A radiological analysis of 500 healthy and 500 osteoarthritic (OA) knees was used to assess the applicability of the CPAK classification. CPAK comprises nine phenotypes based on the arithmetic HKA (aHKA) that estimates constitutional limb alignment and joint line obliquity (JLO). Intraoperative balance was compared within each phenotype in a cohort of 138 computer-assisted TKAs randomized to KA or MA. Primary outcomes included descriptive analyses of healthy and OA groups per CPAK type, and comparison of balance at 10° of flexion within each type. Secondary outcomes assessed balance at 45° and 90° and bone recuts required to achieve final knee balance within each CPAK type. Results. There was similar frequency distribution between healthy and arthritic groups across all CPAK types. The most common categories were Type II (39.2% healthy vs 32.2% OA), Type I (26.4% healthy vs 19.4% OA) and Type V (15.4% healthy vs 14.6% OA). CPAK Types VII, VIII, and IX were rare in both populations. Across all CPAK types, a greater proportion of KA TKAs achieved optimal balance compared to MA. This effect was largest, and statistically significant, in CPAK Types I (100% KA vs 15% MA; p < 0.001), Type II (78% KA vs 46% MA; p = 0.018). and Type IV (89% KA vs 0% MA; p < 0.001). Conclusion. CPAK is a pragmatic, comprehensive classification for coronal knee alignment, based on constitutional alignment and JLO, that can be used in healthy and
There are many reasons that the surgically inclined orthopaedic surgeon should be responsible for the medical management of osteoarthritis of the knee. These include: 1) The non-operative treatment of OA is often highly effective for all stages of the disease; 2) A non-operative treatment program is the best preparation for a successful surgical outcome; and 3) Patients appreciate a surgeon's interest in their overall care and are likely to return if surgery is needed; 4) Medicare and many insurance companies are refusing to pay for a TJA until many months of conservative management has been administered. There are many potential causes of pain in an
There are many reasons that the surgically inclined orthopaedic surgeon should be responsible for the medical management of osteoarthritis of the knee. These include: 1) The nonoperative treatment of OA is often highly effective for all stages of the disease; 2) A nonoperative treatment program is the best preparation for a successful surgical outcome; and 3) Patients appreciate a surgeon's interest in their overall care and are likely to return if surgery is needed; 4) Medicare and many insurance companies are refusing to pay for a TJA until many months of conservative management has been administered. There are many potential causes of pain in an
Patient specific instrumentation (PSI) for elective knee replacements in
Introduction.
Aims. The lack of disease-modifying treatments for osteoarthritis (OA) is linked to a shortage of suitable biomarkers. This study combines multi-molecule synovial fluid analysis with machine learning to produce an accurate diagnostic biomarker model for end-stage knee OA (esOA). Methods. Synovial fluid (SF) from patients with esOA, non-OA knee injury, and inflammatory
Background. Artificial total knee designs have revolutionized over time, yet 20% of the population still report dissatisfaction. The standard implants fail to replicate native knee kinematic functionality due to mismatch of condylar surfaces and non-anatomically placed implantation. (Daggett et al 2016; Saigo et al 2017). It is essential that the implant surface matches the native knee to prevent Instability and soft tissue impingement. Our goal is to use computational modeling to determine the ideal shapes and orientations of anatomically-shaped components and test the accuracy of fit of component surfaces. Methods. One hundred MRI scans of knees with early osteoarthritis were obtained from the NIH Osteoarthritis Initiative, converted into 3D meshes, and aligned via an anatomic coordinate system algorithm. Geomagic Design X software was used to determine the average anterior-posterior (AP) length. Each knee was then scaled in three dimensions to match the average AP length. Geomagic's least-squares algorithm was used to create an average surface model. This method was validated by generating a statistical shaped model using principal component analysis (PCA) to compare to the least square's method. The averaged knee surface was used to design component system sizing schemes of 1, 3, 5, and 7 (fig 1). A further fifty
Introduction. Bilateral TKA is proven to be safe in a select group of patients. Patients with symptomatic bilateral
Objectives. Opening wedge high tibial osteotomy (HTO) is an established surgical procedure for the treatment of early-stage
Total knee arthroplasty becomes more challenging when
Genu recurvatum deformity is uncommon in
Numerous studies have demonstrated that concomitant lower back pain (LBP) results in worse functional outcomes in patients undergoing surgical treatment for the management of end stage hip and
The patient with a painful
While no one would argue the necessary role for the medical management of patients with early
Aims. The morphometry of the distal femur was largely studied to improve
bone-implant fit in total knee arthroplasty (TKA), but little is
known about the asymmetry of the posterior condyles. This study
aimed to investigate the dimensions of the posterior condyles and
the influence of externally rotating the femoral component on potential prosthetic
overhang or under-coverage. Patients and Methods. We analysed the shape of 110
In this paper, we will consider the current role
of simultaneous-bilateral TKA. Based on available evidence, it is
our opinion that bilateral one stage TKR is a safe and efficacious treatment
for patients with severe bilateral
While no one would argue the necessary role for the medical management of patients with early
Background. The JOURNEY™ II Cruciate-Retaining Total Knee System (JIICR) and the JOURNEY™ II Bi-Cruciate Stabilized Total Knee System (JIIBCS) (both, Smith & Nephew, Memphis, TN, USA) are used for the treatment of end-stage degenerative
We performed a systematic literature review to define features of patients, treatment, and biological behaviour of multicentric giant cell tumour (GCT) of bone. The search terms used in combination were “multicentric”, “giant cell tumour”, and “bone”. Exclusion criteria were: reports lacking data, with only an abstract; papers not reporting data on multicentric GCT; and papers on multicentric GCT associated with other diseases. Additionally, we report three patients treated under our care.Aims
Methods