Aims. Distal femoral osteotomies (DFOs) are commonly used for the correction of valgus deformities and lateral compartment osteoarthritis. However, the impact of a DFO on subsequent total knee arthroplasty (TKA) function remains a subject of debate. Therefore, the purpose of this study was to determine the effect of a unilateral DFO on subsequent TKA function in patients with bilateral TKAs, using the contralateral knee as a self-matched control group. Methods. The inclusion criteria consisted of patients who underwent simultaneous or staged bilateral TKA after prior unilateral DFO between 1972 and 2023. The type of osteotomy performed, osteotomy hardware fixation, implanted TKA components, and revision rates were recorded. Postoperative outcomes including the Forgotten Joint Score-12 (FJS-12), Tegner Activity Scale score, and subjective knee preference were also obtained at final follow-up. Results. A total of 21 patients underwent bilateral TKA following unilateral DFO and were followed for a mean of 31.5 years (SD 11.1; 20.2 to 74.2) after DFO. The mean time from DFO to TKA conversion was 13.1 years (SD 9.7) with 13 (61.9%) of DFO knees converting to TKA more than ten years after DFO. There was no difference in arthroplasty implant systems employed in both the DFO-TKA and TKA-only knees (p > 0.999). At final follow-up, the mean FJS-12 of the DFO-TKA knee was 62.7 (SD 36.6), while for the TKA-only knee it was 65.6 (SD 34.7) (p = 0.328). In all, 80% of patients had no subjective knee preference or preferred their DFO-TKA knee. Three DFO-TKA knees and two TKA-only knees underwent subsequent revision following index arthroplasty at a mean of 12.8 years (SD 6.9) and 8.5 years (SD 3.8), respectively (p > 0.999). Conclusion. In this self-matched study, DFOs did not affect subsequent TKA function as clinical outcomes, subjective knee preference, and revision rates were similar in both the DFO-TKA and TKA-only knees at mean 32-year follow-up. Cite this article: Bone Jt Open 2024;5(11):1013–1019

Aims. There is little literature about total knee arthroplasty (TKA) after distal femoral osteotomy (DFO). Consequently, the purpose of this study was to analyze the outcomes of TKA after DFO, with particular emphasis on: survivorship free from aseptic loosening, revision, or any re-operation; complications; radiological results; and clinical outcome. Patients and Methods. We retrospectively reviewed 29 patients (17 women, 12 men) from our total joint registry who had undergone 31 cemented TKAs after a DFO between 2000 and 2012. Their mean age at TKA was 51 years (22 to 76) and their mean body mass index 32 kg/m. 2. (20 to 45). The mean time between DFO and TKA was ten years (2 to 20). The mean follow-up from TKA was ten years (2 to 16). The prostheses were posterior-stabilized in 77%, varus-valgus constraint (VVC) in 13%, and cruciate-retaining in 10%. While no patient had metaphyseal fixation (e.g. cones or sleeves), 16% needed a femoral stem. Results. The ten-year survivorship was 95% with aseptic loosening as the endpoint, 88% with revision for any reason as the endpoint, and 81% with re-operation for any reason as the endpoint. Three TKAs were revised for instability (n = 2) and aseptic tibial loosening (n = 1). No femoral component was revised for aseptic loosening. Patients under the age of 50 years were at greater risk of revision for any reason (hazard ratio 7; p = 0.03). There were two additional re-operations (6%) and four complications (13%), including three manipulations under anaesthetic (MUA; 10%). The Knee Society scores improved from a mean of 50 preoperatively (32 to 68) to a mean of 93 postoperatively (76 to 100; p < 0.001). Conclusion. A cemented posterior-stabilized TKA has an 88% ten-year survivorship with revision for any reason as the endpoint. No femoral component was revised for aseptic loosening. Patients under the age of 50 years have a greater risk of revision. The clinical outcome was significantly improved but balancing the knee was challenging in 13% of TKAs requiring VVC. Overall, 10% of TKAs needed an MUA, and 6% of TKAs were revised for instability. Cite this article: Bone Joint J 2019;101-B:660–666

Aims

To assess the effect of high tibial and distal femoral osteotomies (HTO and DFO) on the pressure characteristics of the ankle joint.

Introduction. In the setting of periprosthetic joint infection, the complete removal of implants and cement can be challenging with well-fixed, cemented implants about the knee. This can get especially complex in the setting of long cemented femoral stems. Osteotomies are well described in the proximal femur and tibia for removal of implants and cement. There is little information available on distal femoral osteotomies to facilitate knee implant and retained cement removal. Methods. We describe a novel anterolateral oblique distal femoral osteotomy for the removal of well-fixed, cemented components during resection knee arthroplasty that preserves vascularity to the osteotomized segment. Cadaveric anatomic vascular injection studies were performed to document vascularity of the osteotomized segment. Clinical examples, and results will be presented. Results. Anatomic vascular studies documented preserved vascularity to the osteotomized segment. In two patients intramedullary infected implant and cement was completely removed. At reimplantation and final followup the osteotomy was radiographically healed, implants well fixed, and no recurrent infections were noted. Conclusions. This osteotomy appears to be useful when removing well fixed, cemented femoral components during periprosthetic infection. Vascularity and union was preserved and obtained in all patients. For figures, tables, or references, please contact authors directly

Abstract. Introduction. Knee osteotomy, both high tibial and distal femoral osteotomy, is a well-recognised treatment for young, active patients with unicompartmental knee osteoarthritis. Osteotomy around the knee is usually performed as an inpatient procedure. The aim of this study was to assess the effectiveness and patient satisfaction of our day-case protocol for knee osteotomy. Methodology. All patients who underwent day-case knee osteotomy at the study unit, over a three-year period, were reviewed to assess the success of ambulatory care for knee osteotomy. Patients were sent questionnaires to assess functional outcome and patient satisfaction with our day-case process. Results. Thirty-three knee osteotomies were performed as a day-case protocol, of which same day discharge was achieved in 24 patients (73%) and discharge within 24 hours achieved in 32 patients (97%). The mean post-operative Knee Osteoarthritis Outcome Score (KOOS) was 67.1 and 79% of patients rated their care as good or excellent. Return to sporting activities was achieved in 75% of patients, and 88% of patients reported they would be happy to undergo day-case knee osteotomy again. Conclusion. Knee osteotomy, both high tibial and distal femoral osteotomy, can be successfully performed as a day-case procedure with similar improvements in functional outcomes and no increased complication rate, compared to in-patient osteotomy

Abstract. Introduction. Osteotomy is recognised treatment for osteoarthritis of the knee. Evidence suggests favourable outcomes when compared to arthroplasty, for younger and more active individuals[1]. Double level osteotomy (DLO) is considered when a single level is insufficient to restore both joint line obliquity and adequate realignment[2]. This paper aims to establish the functional outcomes up to two years post operatively for patients undergoing DLO, using patient reported outcome measures (PROMs). Methodology. All patients who underwent a DLO at either Lister Hospital, Stevenage, or One Hatfield Hospital, Hertfordshire, between 1st January 2018 and 1st October 2020 were identified. DLO were performed by two specialist consultants, independently or in combination. PROMs including pain scores, health score, Oxford knee score (OKS) and knee injury and osteoarthritis outcome score (KOOS) were recorded pre-operatively and at six month, one and two year post operative intervals. Results. 24 patients underwent DLO; a medial opening wedge high tibial osteotomy and lateral closing wedge distal femoral osteotomy. The cohort comprised 21 males, 3 females with an average age of 54.09 (38–77) years. Preoperative pain scores graded from 0–10 improved from 6.86 to 2.0 at 2 years. OKS improved from 23.94 to 47.88, as did KOOS 43.55 to 87.51, over the same duration. Conclusion. DLO was associated with improvements in pain and functional outcomes, compared to pre-operative levels. In patients for whom arthroplasty may be unfavourable, this provides an alternative to non-operative management, the options for which are frequently exhausted early in the disease process

Aims

This study aimed to identify the tibial component and femoral component coronal angles (TCCAs and FCCAs), which concomitantly are associated with the best outcomes and survivorship in a cohort of fixed-bearing, cemented, medial unicompartmental knee arthroplasties (UKAs). We also investigated the potential two-way interactions between the TCCA and FCCA.

Aims

The aim of this study was to report the outcome of femoral condylar fresh osteochondral allografts (FOCA) with concomitant realignment osteotomy with a focus on graft survivorship, complications, reoperation, and function.

Aims

Anterior cruciate ligament (ACL) and multiligament knee (MLK) injuries increase the risk of development of knee osteoarthritis and eventual need for total knee arthroplasty (TKA). There are limited data regarding implant use and outcomes in these patients. The aim of this study was to compare the use of constrained implants and outcomes among patients undergoing TKA with a history of prior knee ligament reconstruction (PKLR) versus a matched cohort of patients undergoing TKA with no history of PKLR.

Aims

Meniscal allograft transplantation is undertaken to improve pain and function in patients with a symptomatic meniscal deficient knee compartment. While case series have shown improvements in patient reported outcome measures (PROMs), its efficacy has not been rigorously evaluated. This study aimed to compare PROMs in patients having meniscal transplantation with those having personalized physiotherapy at 12 months.

The lateral compartment is predominantly affected in approximately 10% of patients with osteoarthritis of the knee. The anatomy, kinematics and loading during movement differ considerably between medial and lateral compartments of the knee. This in the main explains the relative protection of the lateral compartment compared with the medial compartment in the development of osteoarthritis. The aetiology of lateral compartment osteoarthritis can be idiopathic, usually affecting the femur, or secondary to trauma commonly affecting the tibia. Surgical management of lateral compartment osteoarthritis can include osteotomy, unicompartmental knee replacement and total knee replacement. This review discusses the biomechanics, pathogenesis and development of lateral compartment osteoarthritis and its management.

Cite this article: Bone Joint J 2013;95-B:436–44.

Objectives

Subtotal or total meniscectomy in the medial or lateral compartment of the knee results in a high risk of future osteoarthritis. Meniscal allograft transplantation has been performed for over thirty years with the scientifically plausible hypothesis that it functions in a similar way to a native meniscus. It is thought that a meniscal allograft transplant has a chondroprotective effect, reducing symptoms and the long-term risk of osteoarthritis. However, this hypothesis has never been tested in a high-quality study on human participants. This study aims to address this shortfall by performing a pilot randomised controlled trial within the context of a comprehensive cohort study design.

Previous studies from single centres or single-surgeon series report good early and mid-term results for high tibial osteotomy (HTO) in the treatment of osteoarthritis of the knee. However, the survivorship of HTO at a national level is unknown. This registry-based study included 3195 high HTOs performed between 1987 and 2008. Kaplan-Meier analysis revealed an overall survivorship of 89% (95% confidence interval (CI) 88 to 90) at five years and 73% (95% CI 72 to 75) at ten years, when conversion to total knee replacement was taken as the endpoint. Females and patients aged > 50 years had worse survivorship than males or patients aged ≤ 50 years (hazard ratio (HR) 1.26 (95% CI 1.11 to 1.43) and HR 1.41 (95% CI 1.23 to 1.64), respectively). The survivorship of HTOs performed between 1998 to 2008 was worse than for those performed between 1987 and 1997.

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.

We have studied the concept of posterior condylar offset and the importance of its restoration on the maximum range of knee flexion after posterior-cruciate-ligament-retaining total knee replacement (TKR). We measured the difference in the posterior condylar offset before and one year after operation in 69 patients who had undergone a primary cruciate-sacrificing mobile bearing TKR by one surgeon using the same implant and a standardised operating technique. In all the patients true pre- and post-operative lateral radiographs had been taken.

The mean pre- and post-operative posterior condylar offset was 25.9 mm (21 to 35) and 26.9 mm (21 to 34), respectively. The mean difference in posterior condylar offset was + 1 mm (−6 to +5). The mean pre-operative knee flexion was 111° (62° to 146°) and at one year postoperatively, it was 107° (51° to 137°).

There was no statistical correlation between the change in knee flexion and the difference in the posterior condylar offset after TKR (Pearson correlation coefficient r = −0.06, p = 0.69).

We have developed a new tensor for total knee replacements which is designed to assist with soft-tissue balancing throughout the full range of movement with a reduced patellofemoral joint. Using this tensor in 40 patients with osteoarthritis we compared the intra-operative joint gap in cruciate-retaining and posterior-stabilised total knee replacements at 0°, 10°, 45°, 90° and 135° of flexion, with the patella both everted and reduced.

While the measurement of the joint gap with a reduced patella in posterior-stabilised knees increased from extension to flexion, it remained constant for cruciate-retaining joints throughout a full range of movement. The joint gaps at deep knee flexion were significantly smaller for both types of prosthetic knee when the patellofemoral joint was reduced (p < 0.05).

We carried out a prospective study of 118 hydroxyapatite-coated, cementless total knee replacements in patients who were ≤ 55 years of age and who had primary (92; 78%) or post-traumatic (26; 22%) osteoarthritis. The mean period of follow-up was 7.9 years (5 to 12.5). The Knee Society clinical scores improved from a pre-operative mean of 98 (0 to 137) to a mean of 185 (135 to 200) at five years, and 173 (137 to 200) at ten years. There were two revisions of the tibial component because of aseptic loosening, and one case of polyethylene wear requiring further surgery. There was no osteolysis or progressive radiological loosening of any other component. At 12 years, the overall rate of implant survival was 97.5% (excluding exchange of spacer) and 92.1% (including exchange of spacer).

Cementless total knee replacement can achieve excellent long-term results in young, active patients with osteoarthritis. In contrast to total hip replacement, polyethylene wear, osteolysis and loosening of the prosthesis were not major problems for these patients, although it is possible that this observation could change with longer periods of follow-up.