In arthritis of the varus knee, a high tibial osteotomy (HTO) redistributes load from the diseased medial compartment to the unaffected lateral compartment. We report the outcome of 36 patients (33 men and three women) with 42 varus, arthritic knees who underwent HTO and dynamic correction using a Garches external fixator until they felt that normal alignment had been restored. The mean age of the patients was 54.11 years (34 to 68). Normal alignment was achieved at a mean 5.5 weeks (3 to 10) post-operatively. Radiographs, gait analysis and visual analogue scores for pain were measured pre- and post-operatively, at one year and at medium-term follow-up (mean six years; 2 to 10). Failure was defined as conversion to knee arthroplasty. . Pre-operative gait analysis divided the 42 knees into two equal groups with high (17 patients) or low (19 patients) adductor moments. After correction, a statistically significant (p < 0.001, t-test,) change in adductor moment was achieved and maintained in both groups, with a rate of failure of three knees (7.1%), and 89% (95% confidence interval (CI) 84.9 to 94.7) survivorship at medium-term follow-up. At final follow-up, after a mean of 15.9 years (12 to 20), there was a survivorship of 59% (95% CI 59.6 to 68.9) irrespective of adductor moment group, with a mean time to conversion to knee arthroplasty of 9.5 years (3 to 18; 95% confidence interval ± 2.5). . HTO remains a useful option in the medium-term for the treatment of medial compartment osteoarthritis of the knee but does not last in the long-term. . Cite this article: Bone Joint J 2016;98-B:601–7

Aims. Arthrodesis is rarely used as a salvage procedure for patients with a chronically infected total knee arthroplasty (TKA), and little information is available about the outcome. The aim of this study was to assess the reliability, durability, and safety of this procedure as the definitive treatment for complex, chronically infected TKA, in a current series of patients. Methods. We retrospectively identified 41 patients (41 TKAs) with a complex infected TKA, who were treated between 2002 and 2016 using a deliberate, two-stage knee arthrodesis. Their mean age was 64 years (34 to 88) and their mean body mass index (BMI) was 39 kg/m. 2. (25 to 79). The mean follow-up was four years (2 to 9). The extensor mechanism (EM) was deficient in 27 patients (66%) and flap cover was required in 14 (34%). Most patients were host grade B (56%) or C (29%), and limb grade 3 (71%), according to the classification of McPherson et al. A total of 12 patients (29%) had polymicrobial infections and 20 (49%) had multi-drug resistant organisms; fixation involved an intramedullary nail in 25 (61%), an external fixator in ten (24%), and dual plates in six (15%). Results. Survivorship free from amputation, persistent infection, and reoperation, other than removal of an external fixator, at five years was 95% (95% confidence interval (CI) 89% to 100%), 85% (95% CI 75% to 95%), and 64% (95% CI 46% to 82%), respectively. Reoperation, other than removal of an external fixator, occurred in 13 patients (32%). After the initial treatment, radiological nonunion developed in ten knees (24%). Nonunion was significantly correlated with persistent infection (p = 0.006) and external fixation (p = 0.005). Of those patients who achieved limb salvage, 34 (87%) remained mobile and 31 (79%) had ‘absent’ or ‘minimal’ pain ratings. Conclusion. Knee arthrodesis using a two-stage protocol achieved a survivorship free from amputation for persistent infection of 95% at five years with 87% of patients were mobile at final follow-up. However, early reoperation was common (32%). This is not surprising as this series included worst-case infected TKAs in which two-thirds of the patients had a disrupted EM, one-third required flap cover, and most had polymicrobial or multi-drug resistant organisms. Cite this article: Bone Joint J 2020;102-B(6 Supple A):170–175

Introduction. While knee arthrodesis is a salvage option for recalcitrant total knee arthroplasty (TKA) periprosthetic joint infection (PJI) it is used relatively uncommonly and contemporary data are limited. We sought to determine the reliability, durability and safety of knee arthrodesis as the definitive treatment for complex, persistently infected TKA in a modern series of patients. Methods. We retrospectively identified 41 knees treated from 2002–2016 with a deliberate, two-stage knee arthrodesis protocol (TKA resection, high-dose antibiotic spacer, targeted IV antibiotics and followed by subsequent knee arthrodesis) in patients with complex TKA PJI. Mean age was 64 years & mean BMI was 39 kg/m. 2. Mean follow-up was 4 years. The extensor mechanism was deficient in 66% of knees, and flap coverage was required in 34% of knees. The majority of patients were host grade B (56%) or C (29%), and extremity grade of 3 (71%). Twenty-nine percent had poly-microbial infections, and 49% had multi-drug resistant organisms. Fixation included intramedullary nail (61%), external fixator (24%), and dual plating (15%). Results. Two patients (5%) required amputation for persistently infected non-unions; therefore, limb salvage was accomplished in 95% of patients. After initial treatment, there were non-unions in 24% and persistent infection in 17%. Non-union was significantly correlated with persistent infection, with 50% of non-unions having persistent infection compared with just 6% of united knees (p=0.006). External fixation was a significant risk factor for non-union (70%) compared to intramedullary fixation (8%; p=0.005). Overall, twenty-seven complications occurred in 20 patients and 31% required reoperation other than external fixator removal. Intramedullary fixation led to a 90% rate of both infection control and radiographic union. Conclusion. Two-stage knee arthrodesis using a deliberate protocol (resection, high-dose abx spacer, targeted IV abx, and subsequent arthrodesis) ultimately achieved successful limb salvage in 95% of patients with complex infected TKA. One or more complications occurred in nearly half the patients and reoperation was required for 1-in-3. That substantial risk of complications is not surprising as this large contemporary series included complex, worst-case infected TKA in which: 2/3 had disrupted extensor mechanism, 1/3 required flap coverage, and the majority had poly-microbial or multi-drug resistant organisms. Summary. For contemporary patients with very complex, infected TKA a two-stage knee arthrodesis was reliable in achieving limb salvage (95%) at the cost of a high initial complication and reoperation rate. For figures, tables, or references, please contact authors directly

This animal study compares different methods of performing an osteotomy, including using an Erbium-doped Yttrium Aluminum Garnet laser, histologically, radiologically and biomechanically. A total of 24 New Zealand rabbits were divided into four groups (Group I: multihole-drilling; Group II: Gigli saw; Group III: electrical saw blade and Group IV: laser). A proximal transverse diaphyseal osteotomy was performed on the right tibias of the rabbits after the application of a circular external fixator. The rabbits were killed six weeks after the procedure, the operated tibias were resected and radiographs taken. . The specimens were tested biomechanically using three-point bending forces, and four tibias from each group were examined histologically. Outcome parameters were the biomechanical stability of the tibias as assessed by the failure to load and radiographic and histological examination of the osteotomy site. . The osteotomies healed in all specimens both radiographically and histologically. The differences in the mean radiographic (p = 0.568) and histological (p = 0.71) scores, and in the mean failure loads (p = 0.180) were not statistically significant between the groups. . Different methods of performing an osteotomy give similar quality of union. The laser osteotomy, which is not widely used in orthopaedics is an alternative to the current methods. Cite this article: Bone Joint J 2015;97-B:1628–33

We report the outcome of 32 patients (37 knees) who underwent hemicallostasis with a dynamic external fixator for osteoarthritis of the medial compartment of the knee. There were 16 men (19 knees) and 16 women (18 knees) with a mean age at operation of 54.6 years (27 to 72). The aim was to achieve a valgus overcorrection of 2° to 8° or mechanical axis at 62.5% (± 12.5%). At a mean follow-up of 62.8 months (51 to 81) there was no change in the mean range of movement, and no statistically significant difference in the Insall-Salvati index or tibial slope (p = 0.11 and p = 0.15, respectively). The mean hip-knee-ankle angle changed from 190.6 (183° to 197°) to 176.0° (171° to 181°), with a mean final position of the mechanical axis of 58.5% (35.1% to 71.2%). The desired alignment was attained in 31 of 37 (84%) knees. There were 21 excellent, 13 good, two fair and one poor result according to the Oxford knee score with no correlation between age and final score. This score was at its best at one year with a statistically significant deterioration at two years (p = 0.001) followed by a small but not statistically significant deterioration until the final follow-up (p = 0.17). All the knees with Ahlback grade 1 osteoarthritis had excellent or good results. Complications included pin tract infections involving 16.4% of all pins used, delayed union in two, knee stiffness in four, fracture of the lateral cortex in one and ring sequestrum in one. In conclusion, hemicallostasis provides precision in attaining the desired alignment without interfering with tibial slope or patellar height, and is relatively free of serious complications

Aims

To evaluate whether low-intensity pulsed ultrasound (LIPUS) accelerates bone healing at osteotomy sites and promotes functional recovery after open-wedge high tibial osteotomy (OWHTO).

We studied the complications after open-wedge osteotomy by hemicallotasis in 308 consecutive patients, most of whom had osteoarthritis of the knee. The participating surgeons, who worked at 17 hospitals, used their discretion in selecting patients, operating techniques and external fixators. The general complications included 11 cases of deep-vein thrombosis (4%), six of nonunion (2%) and one of septic arthritis of the knee. There were technical complications in 13 patients (4%). In 157 patients (51%) pin-site infections were recorded; of these, 96% were minor and responded to wound toilet and antibiotic treatment. A total of 18 revision procedures was carried out

Purpose. To study the initial presentation and subsequent investigation and management of acute knee dislocations at a regional trauma centre. Introduction. Knee dislocation requires high energy trauma, and often affects young working adults. The high incidence of associated arterial, neurological, ligamentous, and other soft tissue injuries, can produce potentially devastating outcomes. Rapid mobilisation of traditionally distinct surgical teams, with urgent vascular imaging and emergency surgery are often necessary. The extent and severity of ligamentous damage may require multiple operations to repair. Methods. A retrospective nine-year study of knee dislocations managed in the Trauma and Orthopaedic Department of the Royal Hospitals, Belfast was performed using a Fractures Outcomes Research Database (FORD), a chart review, and a review of relevant radiology. Demographic data, mechanisms of injury, associated neurovascular injuries, ligamentous damage, and operative intervention were recorded. Results. 15 patients were identified over 9 years (2000-2008 inclusive). Mean age at injury was 38 years, median 37. 14 (93%) of patients were male, 1 (7%) was female. 6 injuries (40%) were sport-related, 3 (20%) occurred as a result of road traffic collisions, 5 (33%) were accidents in the workplace, and 1 (7%) was a result of a fall while intoxicated with alcohol. 5 (33%) patients experienced a common peroneal nerve palsy. 10 (67%) received vascular imaging, and 2 (13%) underwent vascular surgery as part of the initial theatre episode. All 15 dislocations led to some degree of structural soft tissue knee injuries. These included 12 (80%) anterior cruciate ligaments, 8 (53%) posterior cruciate ligaments, 7 (47%) lateral collateral ligaments, and 5 (33%) medial collateral ligaments. 3 posterolateral corner injuries required repair. Of the 15 patients, 2 (13%) underwent no operative procedures following closed reduction, and the remaining 13 patients had 21 distinct theatre episodes recorded between them. 2 fasciotomies for compartment syndrome, and 2 common peroneal nerve decompression/explorations were performed in the initial theatre episode. 3 patients (20%) were managed with an external fixator initially. 1 patient (7%) developed complications and required trans-femoral amputation. Conclusions. Knee dislocation remains uncommon, and even major centres may receive only a few injuries per year. Orthopaedic, Vascular and Plastic surgeons, as well as Emergency Physicians and Radiologists must remain vigilant to the challenge which this injury can present, and the opportunity for excellent outcomes through a coordinated approach with close communication, awareness of injury patterns, and availability of theatre and imaging resources

Aims

To present our experience of using a combination of intra-articular osteotomy and external fixation to treat different deformities of the knee.

Most problems encountered in complex revision total knee arthroplasty can be managed with the wide range of implant systems currently available. Modular metaphyseal sleeves, metallic augments and cones provide stability even with significant bone loss. Hinged designs substitute for significant ligamentous deficiencies. Catastrophic failure that precludes successful reconstruction can be encountered. The alternatives to arthroplasty in such drastic situations include knee arthrodesis, resection arthroplasty and amputation. The relative indications for the selection of these alternatives are recurrent deep infection, immunocompromised host, and extensive non-reconstructible bone or soft-tissue defects.

Aims

Knee joint distraction (KJD) is a relatively new, knee-joint preserving procedure with the goal of delaying total knee arthroplasty (TKA) in young and middle-aged patients. We present a randomised controlled trial comparing the two.

We report the long-term outcome of 33 patients (37 knees) who underwent proximal tibial open-wedge osteotomy with hemicallotasis (HCO) for medial osteoarthritis of the knee between 1995 and 2000. Among these, 29 patients with unilateral HCO were enrolled and 19 were available for review at a mean of 14.2 years (10 to 15.7) post-operatively. For these 19 patients, the mean Hospital for Special Surgery knee score was 60 (57 to 62) pre-operatively and 85 (82 to 87) at final follow-up (p < 0.001; paired t-test). The femorotibial angle and tibial inclination angle (IA) were measured at short-term follow-up, one to four years post-operatively, and showed no significant subsequent changes. The clinical scores and radiological measurements showed little change over time. One patient required conversion to total knee replacement during this time. These results suggest that the coronal angle achieved at operation is maintained at long-term follow up after HCO without alteration of the IA, providing a good long-term clinical outcome.

Cite this article: Bone Joint J 2014;96-B:467–72.

Objectives

The purpose of this study was to clarify the appearance of the reparative tissue on the articular surface and to analyse the properties of the reparative tissue after hemicallotasis osteotomy (HCO) using MRI T1ρ and T2 mapping.

We compared the results ten years after an inverted V-shaped high tibial osteotomy with those of a historical series of conventional closing-wedge osteotomies. The closing-wedge series consisted of 56 knees in 51 patients with a mean follow-up of 11 years (10 to 15). The inverted V-shaped osteotomy was evaluated in 48 knees in 43 patients at a mean follow-up of 14 years (10 to 19). All the patients were scored using the Japanese Orthopaedic Association rating scale for osteoarthritis of the knee and radiological assessment.

The pre-operative grade of osteoarthritis was similar in both groups. Post-operatively, the knee function score was graded as satisfactory in 63% (35) of the closing-wedge group but in 89% (43) of the inverted V-shaped osteotomy group. Post-operative radiological examination showed that delayed union and loss of correction occurred more often after a closing-wedge osteotomy than after an inverted V-shaped procedure.

Our study suggests that the inverted V-shaped osteotomy may offer more dependable long-term results than traditional closing-wedge osteotomy.

This review considers the surgical treatment of displaced fractures involving the knee in elderly, osteoporotic patients. The goals of treatment include pain control, early mobilisation, avoidance of complications and minimising the need for further surgery. Open reduction and internal fixation (ORIF) frequently results in loss of reduction, which can result in post-traumatic arthritis and the occasional conversion to total knee replacement (TKR). TKR after failed internal fixation is challenging, with modest functional outcomes and high complication rates. TKR undertaken as treatment of the initial fracture has better results to late TKR, but does not match the outcome of primary TKR without complications. Given the relatively infrequent need for late TKR following failed fixation, ORIF is the preferred management for most cases. Early TKR can be considered for those patients with pre-existing arthritis, bicondylar femoral fractures, those who would be unable to comply with weight-bearing restrictions, or where a single definitive procedure is required.

We retrospectively evaluated eight patients who underwent arthrodesis of the knee using cannulated screws. There were six women and two men, with a mean age of 53 years. The indications for arthrodesis were failed total knee arthroplasty, septic arthritis, tuberculosis, and recurrent persistent infection. Solid union was achieved in all patients at a mean of 6.1 months. One patient required autogenous bone graft for delayed union. One suffered skin necrosis which was treated with skin grafting. The mean limb-length discrepancy was 3.1 cm. On a visual analogue scale, the mean pain score improved from 7.9 to 3.3. According to the Knee Injury and Osteoarthritis Outcome score quality of life items, the mean score improved from 38.3 pre-operatively to 76.6 at follow-up. Cannulated screws provide a high rate of union in arthrodesis of the knee with minimal complications, patient convenience, and a simple surgical technique.

Valgus high tibial osteotomy for osteoarthritis of the medial compartment of the knee can be performed using medial opening- and lateral closing-wedge techniques. The latter have been thought to offer greater initial stability.

We measured and compared the stability of opening- and closing-wedge osteotomies fixed by TomoFix plates using radiostereometry in a series of 42 patients in a prospective, randomised clinical trial.

There were no differences between the opening- and closing-wedge groups in the time to regain knee function and full weight-bearing. Pain and knee function were significantly improved in both groups without any differences between them. All the osteotomies united within one year. Radiostereometry showed no clinically relevant movement of bone or differences between either group.

Medial opening-wedge high tibial osteotomy secured by a TomoFix plate offers equal stability to a lateral closing-wedge technique. Both give excellent initial stability and provide significantly improved knee function and reduction in pain, although the opening-wedge technique was more likely to produce the intended correction.

A prospective, randomised, controlled trial compared two different techniques of high tibial osteotomy with a lateral closing wedge or a medial opening wedge, stabilised by a Puddu plate. The clinical outcome and radiological results were examined at one year.

The primary outcome measure was the achievement of an overcorrection of valgus of 4°. Secondary outcome measures were the severity of pain (visual analogue scale), knee function (Hospital for Special Surgery score), and walking distance.

Between January 2001 and April 2004, 92 patients were randomised to one or other of the techniques. At follow-up at one year the post-operative hip-knee-ankle angle was 3.4° (± 3.6° sd) valgus after a closing wedge and 1.3° (± 4.7° sd) of valgus after an opening wedge. The adjusted mean difference of 2.1° was significant (p = 0.02). The deviation from 4° of valgus alignment was 2.7° (± 2.4° sd) in the closing wedge and 4.0° (± 3.6° sd) in the opening-wedge groups. The adjusted mean difference of 1.67° was also significant (p = 0.01).

The severity of pain, knee score and walking ability improved in both groups, but the difference was not significant.

Because of pain, the staples required removal in 11 (23%) patients in the closing-wedge group and a Puddu plate was removed in 27 (60%) patients in the opening-wedge group. This difference was significant (p < 0.001).

We conclude that closing-wedge osteotomy achieves a more accurate correction with less morbidity, although both techniques had improved the function of the knee at one year after the procedure.

Our aim was to compare the degree of patellar descent and alteration in angle of the inclination of the tibial plateau in lateral closing-wedge and medial opening-wedge high tibial osteotomy (HTO) in 51 consecutive patients with osteoarthritis of the medial compartment and varus malalignment. Patellar height was measured by the Insall-Salvati (IS) and the Blackburne-Peel (BP) ratios. The tibial inclination was determined by the Moore-Harvey (MH) method. Multivariate linear regression analysis was used to determine the influence of the type of HTO (closing vs opening wedge) on the post-operative patellar height or tibial inclination. The intra- and interobserver variability of these methods was determined before operation and at follow-up at one year.

After an opening-wedge HTO the patellar height was significantly more decreased (mean post-operative difference: IS = 0.15; 95% confidence interval (CI) 0.06 to 0.23; BP = 0.11; 95% CI 0.05 to 0.18) compared with a closing-wedge HTO.

The angle of tibial inclination differed significantly (mean post-operative difference MH = −6.40°; 95% CI −8.74 to −4.02) between the two HTO techniques, increasing after opening-wedge HTO and decreasing after closing-wedge HTO.

There was no clinically-relevant difference in the intra- and interobserver variability of measurements of patellar height either before or after HTO.