Pain is the main indication for performing total knee replacement (TKR). In most patients after TKR there is an improvement, but a few continue to have pain. Generally, the cause of the pain can be addressed when it is identified. However, unexplained pain can be more difficult to manage because revision surgery is likely to be unrewarding in this group. In our study of 622 cemented TKRs in 512 patients with a mean age of 69 years (23 to 90) treated between January 1995 and August 1998, we identified 24 patients (knees) with unexplained pain at six months. This group was followed for five years (data was unavailable for 18 knees) and ten patients (55.5%) went on to show an improvement without intervention.

In the case of unexplained pain, management decisions must be carefully considered, but reassurance can be offered to patients that the pain will improve in more than half with time.

Abstract. Introduction. Active, middle-aged patients with symptomatic cartilage or osteochondral defects can find themselves in a treatment gap when they have failed conservative measures but are not yet eligible for conventional arthroplasty. Data from various cohort studies suggests that focal knee resurfacing implants such as HemiCAP, UniCAP, Episealer or BioBoly are cost-effective solutions to alleviate pain, improve function and delay or eliminate the need for conventional replacement. A systematic review and meta-analysis were conducted in order to(i) evaluate revision rates and implant survival of focal resurfacing; (ii) explore surgical complications; and (iii) evaluate various patient reported clinical outcome measures. Methodology. PubMED, Cochrane Library and Medline databases were searched in February 2022 for prospective and retrospective cohort studies evaluating any of the available implant types. Data on incidence of revision, complications and various patient reported outcome measures was sourced. Results. A total of 24 unique studies were identified with a total of 1465 enrolled patients. A revision rate of 12.97% over a 5.9 year weighted mean follow-up period was observed across all implant types. However, in one series a Kaplan-Meir survival as high as 92.6% at a 10-year follow-up period was noted. A statistically significant improvement was documented across multiple subjective clinical outcomes scores. There was a low reported incidence of post-operative complications such as aseptic loosening or deep wound infection. Conclusions. Focal femoral resurfacing appears to be a viable treatment option for focal symptomatic chondral lesions in patients beyond biological reconstruction, with low revision rates and high patient satisfaction

Abstract. Introduction. Secondary osteonecrosis of the knee affects young population and causes bilateral extensive lesions. Arthroplasty is the last resort in younger population and joint preserving options questionable in pathological bone. Conservative measures have shown failure in multiple studies and hence no gold standard treatment advocated. We aimed at identifying and analysing various treatment options for secondary osteonecrosis with respect to the outcomes and studying features of symptomatic secondary osteonecrosis with regards to demographic pattern, radiological features and causative factors. Methods. A systematic review of literature was performed in accordance with the Cochrane handbook for systematic reviews and reported according to the PRISMA guidelines. Results. Six studies which included a total of 192 patients with data on 240 knee joints were included in the final review. Follow up period ranged from 1 year to 16 years. The mean age of the patients was 34.7. 3 studies were on arthroplasty and 3 on joint preserving interventions. Majority of patients were in Stage 2 or Stage 4 of osteonecrosis. Steroid induced osteonecrosis was the majority followed by SLE and sickle cell disease. The pooled analysis showed an improvement of pre-operative knee score from 50.47 to 89.21 post-operatively. The pooled effect size for failure rate was 8.7% in joint preserving interventions and 9.2% in joint replacement group. Conclusion. Joint preserving techniques with bone marrow aspirate infiltration showed promising functional outcome and to a certain extent reversal of the pathological process. For advanced stages with subchondral collapse cemented arthroplasty showed satisfactory functional outcomes

Abstract. Introduction. MCL injuries often occur concurrently with ACL rupture – most noncontact ACL injuries occur in valgus and external rotation (ER) - and conservative MCL treatment leads to increased rate of ACL reconstruction failure. There has been little work developing effective MCL reconstructions. Methods. Cadaveric work measured MCL attachments by digitisation and radiographically, relating them to anatomical landmarks. The isometry of the superficial and deep MCL (sMCL and dMCL) and posterior oblique ligament (POL) was measured using fine sutures led to displacement transducers. Contributions to stability (restraint) were measured in a robotic testing system. Two MCL reconstructions were designed and tested: 3-strand reconstruction (sMCL+dMCL+POL), and 2-strand method (sMCL+dMCL) addressing anteromedial rotatory instability (AMRI). The resulting stability was measured in a kinematics test rig, and compared to the ‘anatomic’ sMCL+POL reconstruction of LaPrade. Results. The sMCL was isometric, centred on the medial epicondyle, and the primary restraint of valgus. The dMCL elongated rapidly in ER, and was the primary restraint of ER near knee extension. The POL slackened rapidly with flexion and only stabilised the knee near extension. With sMCL+dMCL+POL deficiency (‘grade 3’), the 2-strand AM reconstruction restored all stability measures to native, apart from internal rotation. The 3-strand reconstruction restored all stability measures to native. The LaPrade reconstruction did not control ER, lacking a dMCL graft, or valgus in flexion, being anisometric. Conclusions. This work has revealed the importance of the dMCL in stabilising AMRI as part of anatomical MCL reconstruction, with the sMCL restraining valgus

Aims. Recent studies have suggested that corticosteroid injections into the knee may harm the joint resulting in cartilage loss and possibly accelerating the progression of osteoarthritis (OA). The aim of this study was to assess whether patients with, or at risk of developing, symptomatic osteoarthritis of the knee who receive intra-articular corticosteroid injections have an increased risk of requiring arthroplasty. Methods. We used data from the Osteoarthritis Initiative (OAI), a multicentre observational cohort study that followed 4,796 patients with, or at risk of developing, osteoarthritis of the knee on an annual basis with follow-up available up to nine years. Increased risk for symptomatic OA was defined as frequent knee symptoms (pain, aching, or stiffness) without radiological evidence of OA and two or more risk factors, while OA was defined by the presence of both femoral osteophytes and frequent symptoms in one or both knees. Missing data were imputed with multiple imputations using chained equations. Time-dependent propensity score matching was performed to match patients at the time of receving their first injection with controls. The effect of corticosteroid injections on the rate of subsequent (total and partial) knee arthroplasty was estimated using Cox proportional-hazards survival analyses. Results. After removing patients lost to follow-up, 3,822 patients remained in the study. A total of 249 (31.3%) of the 796 patients who received corticosteroid injections, and 152 (5.0%) of the 3,026 who did not, had knee arthroplasty. In the matched cohort, Cox proportional-hazards regression resulted in a hazard ratio of 1.57 (95% confidence interval (CI) 1.37 to 1.81; p < 0.001) and each injection increased the absolute risk of arthroplasty by 9.4% at nine years’ follow-up compared with those who did not receive injections. Conclusion. Corticosteroid injections seem to be associated with an increased risk of knee arthroplasty in patients with, or at risk of developing, symptomatic OA of the knee. These findings suggest that a conservative approach regarding the treatment of these patients with corticosteroid injections should be recommended. Cite this article: Bone Joint J 2020;102-B(5):586–592

Background. Secondary osteonecrosis of the knee (SOK) generally occurs in relatively young patients in their working years; at advanced stages of SOK, the only viable surgical option is total knee arthroplasty (TKA). We conducted a retrospective study to investigate implant survivorship, clinical and radiographic outcomes, and complications of cemented TKA with/without patellar resurfacing for SOK. Methods. Thirty-eight cemented TKAs in 27 patients with non-traumatic SOK with a mean age 43 years (range 17–65) were retrospectively reviewed. Twenty-one patients (78%) were female. Mean body mass index was 31 kg/m. 2. (range 20–48); 11 patients (41%) received bilateral TKAs. Twenty patients (74%) had a history of corticosteroid use and 18% had a history of alcohol abuse. Patellar osteonecrosis was coincidentally found in six knees (16%), all of which had no anterior knee pain and had no patellofemoral joint collapse. The mean follow-up was 7 years (range 2–12). Knee Society Score (KSS) and radiographic outcomes were evaluated at 6 weeks, 1 year, then every 2–3 years thereafter. Results. Ninety-two percent had implant survivorship free from revision with significant improvement in KSS. Causes of revision included aseptic tibial loosening (one), deep infection (one), and instability with patellofemoral issues (one). Four of six cases also with patellar osteonecrosis received resurfacing, including one with a periprosthetic patellar fracture after minor trauma, with satisfactory clinical results after conservative treatment. None of the unrevised knees had progressive radiolucent lines or evidence of loosening. Non-resurfacing of the patella, use of a stem extension or a varus-valgus constrained prosthesis constituted 18%, 8% and 3% of knees, respectively. Conclusion. Cemented TKAs with selective stem extension in patients with SOK had satisfactory implant survivorship and reliable outcomes at a mean of 7 years. Patellar resurfacing is unnecessary in younger patients with no symptoms of anterior knee pain and no patellar collapse radiographically. For any figures or tables, please contact the authors directly

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A fracture of the medial tibial plateau is a serious complication of Oxford mobile-bearing unicompartmental knee arthroplasty (OUKA). The risk of these fractures is reportedly lower when using components with a longer keel-cortex distance (KCDs). The aim of this study was to examine how slight varus placement of the tibial component might affect the KCDs, and the rate of tibial plateau fracture, in a clinical setting.

Objectives. The aim of this study was to determine the polyethylene wear rate of Phase 3 Oxford Unicompartmental Knee Replacement bearings and to investigate the effects of resin type and manufacturing process. Methods. A total of 63 patients with at least ten years’ follow-up with three bearing types (1900 resin machined, 1050 resin machined, and 1050 resin moulded) were recruited. Patients underwent full weight-bearing model-based radiostereometric analysis to determine the bearing thickness. The linear wear rate was estimated from the change in thickness divided by the duration of implantation. Results. The wear rate for 1900 resin machined (n = 19), 1050 machined (n = 21), and 1050 moulded bearings (n = 23) were 60 µm/year (. sd. 42), 76 µm/year (. sd. 32), and 57 µm/year (. sd. 30), respectively. There was no significant difference between 1900 machined and 1050 machined (p = 0.20), but 1050 moulded had significantly less wear than the 1050 machined (p = 0.05). Increasing femoral (p < 0.001) and tibial (p < 0.001) component size were associated with increasing wear. Conclusion. Wear rate is similar with 1050 and 1900 resin, but lower with moulded bearings than machined bearings. The currently used Phase 3 bearings wear rate is low (1050 moulded, 57 µm/year), but higher than the previously reported Phase 2 bearings (1900 moulded, 20 µm/year). This is unlikely to be due to the change in polyethylene but may relate to the minimally invasive approach used with the Phase 3. This approach, as well as improving function and thus increasing activity levels, may increase the risk of surgical errors, such as impingement or bearing overhang, which can increase wear. Surgeons should aim to use 4 mm thick bearings rather than 3 mm thick bearings in young patients, unless they are small and need conservative bone resections. Cite this article: Bone Joint Res 2019;8:535–543

Aims. Patients with osteoarthritis of the knee commonly have degenerative meniscal tears. Arthroscopic meniscectomy is frequently performed, although the benefits are debatable. Recent studies have concluded that there is no role for arthroscopic washout in osteoarthritis of the knee. Our aim was to perform a systematic review to assess the evidence for the efficacy of arthroscopic meniscectomy in patients with meniscal tears and degenerative changes in the knee. Patients and Methods. A literature search was performed, using the PubMed/MEDLINE database, for relevant articles published between 1975 and 2015. A total of six studies, including five randomised controlled trials and one cross-sectional study of a prospective cohort, met the inclusion criteria. Relevant information including study design, operations, the characteristics of the patients, outcomes, adverse events and further operations were extracted. Results. The degree of osteoarthritis in the patients who were included and the rate of cross over from one form of treatment to another varied in the studies. Two randomised controlled trials showed a benefit of arthroscopic surgery in patients with limited degenerative joint disease, compared with conservative treatment. One cross-sectional study showed that patients with less severe degenerative changes had better outcomes. Conclusion. Patients with symptomatic meniscal tears and degenerative changes in the knee can benefit from arthroscopic meniscectomy, particularly if the osteoarthritis is mild. A trial of conservative management may be effective and should be considered, especially in patients with moderate osteoarthritis. Cite this article: Bone Joint J 2016;98-B:934–8

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The aim of this study was to evaluate the cost-effectiveness of arthroscopic partial meniscectomy versus physical therapy plus optional delayed arthroscopic partial meniscectomy in young patients aged under 45 years with traumatic meniscal tears.

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Medial unicompartmental knee arthroplasty (mUKA) is an advised treatment for anteromedial knee osteoarthritis. While long-term survival after mUKA is well described, reported incidences of short-term surgical complications vary and the effect of surgical usage on complications is less established. We aimed to describe the overall occurrence and treatment of surgical complications within 90 days of mUKA, as well as occurrence in high-usage centres compared to low-usage centres.

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Blood transfusion and postoperative anaemia are complications of total knee arthroplasty (TKA) that are associated with substantial healthcare costs, morbidity, and mortality. There are few data from large datasets on the risk factors for these complications.

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Robotic arm-assisted surgery offers accurate and reproducible guidance in component positioning and assessment of soft-tissue tensioning during knee arthroplasty, but the feasibility and early outcomes when using this technology for revision surgery remain unknown. The objective of this study was to compare the outcomes of robotic arm-assisted revision of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA) versus primary robotic arm-assisted TKA at short-term follow-up.

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This study investigated the effects of transcatheter arterial embolization (TAE) on pain, function, and quality of life in people with early-stage symptomatic knee osteoarthritis (OA) compared to a sham procedure.

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Periprosthetic fractures (PPFs) around the knee are challenging injuries. This study aims to describe the characteristics of knee PPFs and the impact of patient demographics, fracture types, and management modalities on in-hospital mortality.

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To explore the efficacy of extracorporeal shockwave therapy (ESWT) in the treatment of osteochondral defect (OCD), and its effects on the levels of transforming growth factor (TGF)-β, bone morphogenetic protein (BMP)-2, -3, -4, -5, and -7 in terms of cartilage and bone regeneration.

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The aim of this study was to compare the preinjury functional scores with the postinjury preoperative score and postoperative outcome scores following anterior cruciate ligament (ACL) reconstruction surgery (ACLR).

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This study aims to identify the top unanswered research priorities in the field of knee surgery using consensus-based methodology.

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A novel enhanced cement fixation (EF) tibial implant with deeper cement pockets and a more roughened bonding surface was released to market for an existing total knee arthroplasty (TKA) system.This randomized controlled trial assessed fixation of the both the EF (ATTUNE S+) and standard (Std; ATTUNE S) using radiostereometric analysis.

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The aim of this study was to determine the risk of tibial eminence avulsion intraoperatively for bi-unicondylar knee arthroplasty (Bi-UKA), with consideration of the effect of implant positioning, overstuffing, and sex, compared to the risk for isolated medial unicondylar knee arthroplasty (UKA-M) and bicruciate-retaining total knee arthroplasty (BCR-TKA).