Patient specific instrumentation (PSI) for elective knee replacements in arthritic knees with severe deformities and in revision scenarios is becoming increasingly popular due to the advantage of restoring the limb axes, improved theatre efficiency and outcomes. Currently available systems use CT scan or MRI for pre-operative templating for design considerations with varied accuracy for sizing of implants.

We prospectively evaluated 200 knees in 188 patients with arthritic knees with deformities requiring serial clinical assessment, radiographs and CT scans for PSI templating for TruMatch knee system (DepuySynthes, Leeds, UK). The common indications included severe arthritic deformities, previous limb fractures and in obese limbs with difficult clinical assessment. Surgical procedure was performed on standard lines with the customised cutting blocks.

The ‘lead up’ time between the implant request and the operating date was 5 weeks on an average. We compared the pre op CT images and the best fit post-operative x- rays. The sizing accuracy for femur and tibia was 98.93 % and 95.75% respectively. All blocks fitted the femur and tibia. There were no bail outs, no cutting block breakage, 1 patient had residual deformity of 20 degrees, and 1 patient had late infection. The length of hospital stay, economic viability in terms of theatre turnover, less operating time, cost of sterilisation in comparison to conventional knee replacement surgery with other factors being unchanged was also assessed.

The projected savings was substantial along with improved geometrical restoration of the knee anatomy. We recommend the use of PSI based on CT scan templating in difficult arthritic knees.

Introduction

Computed tomography (CT) can be utilized to design patient specific instruments (PSI) for total knee arthroplasty (TKA). The PSI preoperative plans predict bone resection, anterior-posterior implant position, implant rotation and implant size. The purpose of this study was to compare preoperatively predicted implant sizes (tibia and femur) to the actual implanted sizes. Data were compiled from two surgeons, one in the United Kingdom (Surgeon 1, cruciate retaining) and one in the United States (Surgeon 2, posterior stabilizing). Both used the same primary TKA implant systems (Sigma® and Attune®; DePuySynthes®, Warsaw, Indiana). This is the largest comparison of CT-based PSI size accuracy between two implant systems.

Background: Tourniquet provides a blood less field for surgery, but it has few complications and contraindications. There are several studies identifying the tourniquet as a factor for increased risk of complications in knee arthroscopy, we reviewed 200 consecutive knee arthroscopies done in our hospital with out tourniquet to analyse the outcome.

Aim: To analyse the out come of 200 knee arthroscopies with out use of tourniquet; with respect to visualisation, time of surgery, bleeding, analgesia and post operative complications.

Materials and methods: We retrospectively analysed 200 consecutive knee arthroscopies with out tourniquet done in our institute. Average age of these patients was 39 (21–81). All patients underwent soft tissue procedures under general anaesthesia, supine, with sole support, no antibiotics and was done by same surgeon as day case. Same arthroscopic kit with pump was used for all patients, using 2 litre saline bag and pump set at 65 mm Hg pressure. First few cases had tourniquet applied but not inflated, but later even this was avoided. Procedures included were diagnostic arthroscopies, arthroscopic debridements, meniscal repairs and partial or complete meniscal resections. Procedures like arthroscopic ACL reconstruction and other bony procedures were excluded. We looked at any visualisation problems, time of surgery, bleeding, analgesia and post operative complications. We also looked weather any of these patients visited the consultant or GP for any wound related problem or pain before the usual review at 2 weeks.

Results: There was no problem with visualisation noted in any of the cases, or any incidence where arthroscopy was unduly prolonged. There was no incidence of bleeding, stiffness or increased need for analgesia in any of these patients. None of the patients had any wound problem or haemathrosis requiring intervention. There was no record of any patients reattending the clinic or their GP for pain or bleeding.

Conclusions: Many orthopaedic units continue to use a tourniquet routinely for soft tissue procedures in knee arthroscopy, probably in the belief that a clear operative view can only be achieved with one. However, the findings in our study indicate that knee arthroscopy for soft tissue procedures may be performed adequately without the use of a tourniquet provided a pump system is used and the pressure maintained above venous pressure. Therefore we recommend that its use for routine soft tissue arthroscopic procedures be discontinued.

Introduction: Clinical outcome studies have shown excellent results following unilateral total knee arthroplasty (TKA). A wide Pub Med search failed to find any literature on the outcome of results following bilateral staged TKA.

Aim: To determine the clinical outcomes of patients undergoing bilateral staged TKA.

Material & Methods: Patients who underwent bilateral staged TKA between 1994 – 2002 were assessed using the Knee Society Score (KSS) and Western Ontario and MacMaster Osteoarthritis Index (WOMAC) scoring systems. They were also asked regarding which TKA they considered ‘better’ and why.

Results: We clinically reviewed 110 patients who underwent bilateral staged TKA. The mean clinical follow-up time was 5.13 years. The mean pre-operative KSS was 95.8 for the right knee and 95.5 for the left knee. The mean post-operative KSS was 154.1 for the right knee and 155.9 for the left knee. Patients mean postoperative WOMAC scores for the right knee were; Pain – 1.67, Stiffness – 1.17 and Function – 10.78. Patients mean post-operative WOMAC scores for the left knee were, Pain – 1.77, Stiffness – 1.14 and Function – 10.69. Objectively there was no statistical significance between right and left KSS pre-operatively. There was no statistical significance between right and left KSS and WOMAC scores post-operatively. Subjectively, 44 patients reported their first TKA was ‘better’ than their second. 48 patients reported both TKA’s were as good as each other. 18 patients reported their second TKA was ‘better’ than their first. The 2 main reasons why one TKA was better than the other were pain and range of movement.

Conclusion: Objectively, staged bilateral TKA results in equally good outcome. Subjectively, the first TKA is ‘better’ or equal to the second TKA in 84% of cases. We feel that this information is important during counseling of patients undergoing bilateral staged TKA.

Introduction and Aims: Achieving bloodless surgical field is vital for any arthroscopy surgery. Olszewski et al showed that dilute adrenaline saline irrigation (1mg/l) improves the clarity of operative field by reducing the bleeding. Jensen et al also showed that dilute adrenaline saline irrigation (0.33mg/l) is beneficial in achieving bloodless field in shoulder arthroscopy.

Method: A prospective, randomised, double blind, control trial was carried out to determine the effect of adrenaline (epinephrine) in knee arthroscopy without tourniquet. Ethics Committee approval was obtained for this study. A Doctors/Dentists Exemption Certificate (DDX) was obtained from Medicines Control Agency (UK govt) for use of adrenaline (epinephrine) in this trial. All patients undergoing knee arthroscopy were randomised into two groups: 1) to have dilute adrenaline (1 mg of adrenaline into three-litre bags of normal saline (0.33mg/l) for irrigation); and 2) not to have dilute adrenaline in normal saline irrigation.

Results: A total of 40 patients (24 male and 16 female) were included in the trial. All operations were performed using pressure-controlled pump system (75 mm Hg). No tourniquets were used. A visual analogue score (VAS) of zero to 10 (worst to best) was used by the surgeon to determine the clarity of surgical field at the end of operation. Mean age was 46.5 years (IQR 27–63 years). Twenty patients had dilute adrenaline saline irrigation and 20 had normal saline irrigation. Mean VAS was 8.5 (IQR 6 – 10). Mean VAS for group 1 was 8.4 and for group 2 was 8.7 (p= 0.59). There were no intra-operative or immediate post-operative complications noted in either group.

Conclusion: The study failed to identify any benefit of using adrenaline (epinephrine) in normal saline irrigation fluid in terms of achieving bloodless surgical field in knee arthroscopy. The study also conclude that pressure controlled pump system provides excellent bloodless surgical field in knee arthroscopy without tourniquet.

Introduction: Clinical outcome studies have shown excellent results following unilateral total knee arthroplasty (TKA). We are unable to find in the medical literature the outcome of results following bilateral staged TKA.

Aim: To determine the clinical outcomes of patients undergoing bilateral staged TKA.

Material & Methods: Patients who underwent bilateral staged TKA between 1994 – 2002 were clinically assessed using the Knee Society Score (KSS) and Western Ontario and MacMaster Osteoarthritis Index (WOMAC) scoring systems. They were also asked regarding which TKA they considered ‘better’ and why.

Results: We clinically reviewed 110 patients who underwent bilateral staged TKA. The mean clinical follow-up time was 5.13 years. The mean pre-operative KSS was 95.8 for the right knee and 95.5 for the left knee. The mean post-operative KSS was 154.1 for the right knee and 155.9 for the left knee. Patients mean post-operative WOMAC scores for the right knee were; Pain – 1.67, Stiffness – 1.17 and Function – 10.78. Patients mean post-operative WOMAC scores for the left knee were, Pain – 1.77, Stiffness – 1.14 and Function – 10.69. Objectively there was no statistical significance between right and left KSS pre-operatively. There was no statistical significance between right and left KSS and WOMAC scores post-operatively. Subjectively, 44 patients reported their 1st TKA was ‘better’ than their 2nd. 48 patients reported both TKA’s were as good as each other. 18 patients reported their 2nd TKA was ‘better’ than their 1st. The 2 main reasons why one TKA was better than the other were pain and range of movement.

Conclusion: Objectively, staged bilateral TKA results in equal good outcome. Subjectively, the 1st TKA is ‘better’ or equal to the 2nd TKA in 84% of cases. We feel that this information is important during counseling of patients undergoing bilateral staged TKA.

We evaluated the clinical outcome of arthroscopic labroplasty in 56 patients treated for shoulder instability owing to ligamentous laxity.

In our technique, the antero-inferior labral capsular complex is detached and mobilised from the glenoid. It is advanced superiorly and plicated to create a new labrum, retensioning the capsule and decreasing the articular volume. Usually, a rotator interval plication is also added. Postoperatively, patients wear an adduction sling for three weeks, but movement is permitted within pain limits.

The mean time to follow-up, when patients were clinically reviewed and assessed on the Walch-Du Play score, was 26 months (12 to 74). No intra-operative complications or nerve injuries were encountered. There was a single failure with frank redislocation. The mean Walch-Du Play score was 88/100 (10 to 100).

Redundant capsule and a hypoplastic labrum are common in unstable shoulders owing to ligamentous laxity. The labroplasty creates a ‘bumper’ and addresses the excess of capsule. In our short-term experience, this arthroscopic technique is superior to the open capsular shift.

The supraspinatus tendon (SP) often ruptures. Gray established that the tendinous insertion always attaches to the highest facet of the greater tubercle of the humerus. Our osteological study of 124 shoulders in men and women between the ages of 35 and 94 years refocuses on the humeral insertion of the SP in relation to infraspinatus (IS) and teres minor (TM).

We found type-I SFs (cubic) in 53 shoulders (43%) and type-II SFs (rectangular or oblong) in 21 (17%). Type-III (ellipsoid) SFs were present in 20 shoulders (16%) and type-IV (angulated or sloping) in 11 (9%). SFs were type V (with tuberosity) in 12 shoulders (10%) and type VI (pitted) in three (2%). The facet area of the SP, IP and TM varied from 49 mm, 225 mm and 36mm2. Of the three muscles, the IS facet was consistently the largest (p < 0.05) and shaped rectangularly.

The SP inserted in a cubic or rectangular facet format in 75% of people. SP facet-size may relate to tendon strength, degeneration and rupture. This information may contribute to the understanding of tears of the rotator cuff.