Aims

The aim of this study was to determine whether closed suction drain (CSD) use influences recovery of quadriceps strength and to examine the effects of drain use on secondary outcomes: quadriceps activation, intra-articular effusion, bioelectrical measure of swelling, range of movement (ROM), pain, and wound healing complications.

Cryocompression therapy is a non-invasive and non-pharmacological modality used in managing acute post-operative inflammation and pain. A prospective, randomised controlled trial (RCT) was undertaken to evaluate the effectiveness of a post-operative cryocompression protocol using the Game Ready™ (GR) device versus usual care on recovery following total knee arthroplasty (TKA). A single centre RCT was conducted with 70 TKAs (68 patients) randomised to a 2-week intervention period consisting of treatment with GR cryocompression (n=33, 33.3% males) or a usual care protocol of ice with static compression using tubigrip (n=35, 54.3% males). Knee range of movement (ROM) (flexion and extension), a visual analogue pain score (VAS) and limb circumference were documented at day 1, 2 and 14, as well as 6 and 12 weeks post-surgery. ROM was also recorded at day 90, while medication use and length of hospital stay were documented. Patient reported outcome measures (PROMs) including the KOOS and patient satisfaction questionnaire were employed. The GR group demonstrated 2.3° more (p=0.05) knee extension ROM overall, as well as 2. 8° more at day 1 (p=0.048), 3.8° at day 14 (p=0.007) and 5.4° at 3 months (p=0.017). There were no group differences (p>0.05) observed in pain (VAS), flexion ROM, limb circumference, opioid use or other PROMs. Across the full cohort, higher pain levels resulted in increased opioid intake (p=0.002), older patients used significantly less opioids (p<0.001) and males reported significantly less pain (VAS) than females (p=0.048). Using GR following TKA is a safe, non-invasive tool that can be used to aid in the post-operative recovery period. Patients using the GR cryocompression device gained significantly more extension ROM compared to the conventional ice with compression group, despite no other group differences

Aims. The purpose is to determine the non-inferiority of a smartphone-based exercise educational care management system after primary knee arthroplasty compared with a traditional in-person physiotherapy rehabilitation model. Methods. A multicentre prospective randomized controlled trial was conducted evaluating the use of a smartphone-based care management system for primary total knee arthroplasty (TKA) and partial knee arthroplasty (PKA). Patients in the control group (n = 244) received the respective institution’s standard of care with formal physiotherapy. The treatment group (n = 208) were provided a smartwatch and smartphone application. Early outcomes assessed included 90-day knee range of movement, EuroQoL five-dimension five-level score, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) score, 30-day single leg stance (SLS) time, Time up and Go (TUG) time, and need for manipulation under anaesthesia (MUA). Results. Overall, 90-day mean flexion was not significantly different between the control (121° (SD 11.7°)) and treatment groups (121. o. ; p = 0.559); 90-day mean SLS was 22.7 seconds (SD 9.8) in controls and 24.3 seconds (SD 20.8) in treatment (p = 0.519); 90-day mean TUG times were 10.1 seconds (SD 4.8) in control and 9.3 seconds (SD 3.3) in treatment (p = 0.139). Mean KOOS JR scores were significantly different between control group (73.6 (SD 13.4)) and treatment group (70.4 (SD 12.6); p = 0.026). MUAs were performed in nine (3.7%) patients in the control group and four (1.9%) in the treatment group (p = 0.398). Physiotherapy was performed by 230 (94.4%) of control group and 123 (59.3%) of treatment group (p < 0.001). There were no significant differences between groups in postoperative urgent care visits, or readmissions within 90 days, with significantly fewer emergency department visits in the treatment group (16 (8.2%) vs five (2.5%), p = 0.014). Conclusion. The use of the smartwatch/smartphone care platform demonstrated non-inferiority of clinically significant outcomes to traditional care models, while requiring significantly less postoperative physiotherapy and fewer emergency department visits. This platform could aid in decreasing postoperative costs, while improving patient engagement and communication with the healthcare team. Cite this article: Bone Joint J 2021;103-B(6 Supple A):3–12

Aims. Tibial plateau fractures are serious injuries about the knee that have the potential to affect patients’ long-term function. To our knowledge, this is the first study to use patient-reported outcomes (PROs) with a musculoskeletal focus to assess the long-term outcome, as compared to a short-term outcome baseline, of tibial plateau fractures treated using modern techniques. Methods. In total, 102 patients who sustained a displaced tibial plateau fracture and underwent operative repair by one of three orthopaedic traumatologists at a large, academic medical centre and had a minimum of five-year follow-up were identified. Breakdown of patients by Schatzker classification is as follows: two (1.9%) Schatzker I, 54 (50.9%) Schatzker II, two (1.9%) Schatzker III, 13 (12.3%) Schatzker IV, nine (8.5%) Schatzker V, and 26 (24.5%) Schatzker VI. Follow-up data obtained included: Visual Analogue Scale (VAS) or Numeric Rating Scale (NRS) pain scores, Short Musculoskeletal Functional Assessment (SMFA), and knee range of movement (ROM). Data at latest follow-up were then compared to 12-month data using a paired t-test. Results. Patient-reported functional outcomes as assessed by overall SMFA were statistically significantly improved at five years (p < 0.001) compared with one-year data from the same patients. Patients additionally reported an improvement in the Standardized Mobility Index (p < 0.001), Standardized Emotional Index (p < 0.001), as well as improvement in Standardized Bothersome Index (p = 0.003) between the first year and latest follow-up. Patient-reported pain and knee ROM were similar at five years to their one-year follow-up. In total, 15 of the patients had undergone subsequent orthopaedic surgery for their knees at the time of most recent follow-up. Of note, only one patient had undergone knee arthroplasty following plateau fixation related to post-traumatic osteoarthritis (OA). Conclusion. Knee pain following tibial plateau fracture stabilizes at one year. However, PROs continue to improve beyond one year following tibial plateau fracture, at least in a statistical sense, if not also clinically. Patients displayed statistical improvement across nearly all SMFA index scores at their minimum five-year follow-up compared with their one-year follow-up. Cite this article: Bone Joint J 2020;102-B(5):632–637

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. Patients and Methods. Patients with a history of ACL or MLK reconstruction who underwent TKA between 2007 and 2017 were identified in a single-institution registry. There were 223 patients who met inclusion criteria (188 ACL reconstruction patients, 35 MLK reconstruction patients). A matched cohort, also of 223 patients, was identified based on patient age, body mass index (BMI), sex, and year of surgery. There were 144 male patients and 79 female patients in both cohorts. Mean age at the time of TKA was 57.2 years (31 to 88). Mean BMI was 29.7 kg/m. 2. (19.5 to 55.7). Results. There was a significantly higher use of constrained implants among patients with PKLR (76 of 223, 34.1%) compared with the control group (40 of 223, 17.9%; p < 0.001). Subgroup analysis showed a higher use of constrained implants among patients with prior MLK reconstruction (21 of 35, 60.0%) compared with ACL reconstruction (55 of 188, 29.3%; p < 0.001). Removal of hardware was performed in 69.5% of patients with PKLR. Mean operative time (p < 0.001) and tourniquet time (p < 0.001) were longer in patients with PKLR compared with controls. There were no significant differences in rates of deep vein thrombosis, pulmonary embolism, infection, transfusion, postoperative knee range of movement (ROM), or need for revision surgery. There was no significant difference in preoperative or postoperative Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) scores between groups. Conclusion. Results of this study suggest a history of PKLR results in increased use of constrained implants but no difference in postoperative knee ROM, patient-reported outcomes, or incidence of revision surgery. Cite this article: Bone Joint J 2019;101-B(7 Supple C):77–83

Aims. The use of vitamin E-infused highly crosslinked polyethylene (HXLPE) in total knee prostheses is controversial. In this paper we have compared the clinical and radiological results between conventional polyethylene and vitamin E-infused HXLPE inserts in total knee arthroplasty (TKA). Patients and Methods. The study included 200 knees (175 patients) that underwent TKA using the same total knee prostheses. In all, 100 knees (77 patients) had a vitamin E-infused HXLPE insert (study group) and 100 knees (98 patients) had a conventional polyethylene insert (control group). There were no significant differences in age, sex, diagnosis, preoperative knee range of movement (ROM), and preoperative Knee Society Score (KSS) between the two groups. Clinical and radiological results were evaluated at two years postoperatively. Results. Differences in postoperative ROM and KSS were not statistically significant between the study and control groups. No knee exhibited osteolysis, aseptic loosening, or polyethylene failure. Additionally, there was no significant difference in the incidence of a radiolucent line between the two groups. One patient from the study group required irrigation and debridement, due to deep infection, at six months postoperatively. Conclusion. Clinical results were comparable between vitamin E-infused HXLPE inserts and conventional polyethylene inserts at two years after TKA, without any significant clinical failure. Cite this article: Bone Joint J 2019;101-B:559–564

Aims. There are comparatively few randomized studies evaluating knee arthroplasty prostheses, and fewer still that report longer-term functional outcomes. The aim of this study was to evaluate mid-term outcomes of an existing implant trial cohort to document changing patient function over time following total knee arthroplasty using longitudinal analytical techniques and to determine whether implant design chosen at time of surgery influenced these outcomes. Methods. A mid-term follow-up of the remaining 125 patients from a randomized cohort of total knee arthroplasty patients (initially comprising 212 recruited patients), comparing modern (Triathlon) and traditional (Kinemax) prostheses was undertaken. Functional outcomes were assessed with the Oxford Knee Score (OKS), knee range of movement, pain numerical rating scales, lower limb power output, timed functional assessment battery, and satisfaction survey. Data were linked to earlier assessment timepoints, and analyzed by repeated measures analysis of variance (ANOVA) mixed models, incorporating longitudinal change over all assessment timepoints. Results. The mean follow-up of the 125 patients was 8.12 years (7.3 to 9.4). There was a reduction in all assessment parameters relative to earlier assessments. Longitudinal models highlight changes over time in all parameters and demonstrate large effect sizes. Significant between-group differences were seen in measures of knee flexion (medium-effect size), lower limb power output (large-effect size), and report of worst daily pain experienced (large-effect size) favouring the Triathlon group. No longitudinal between-group differences were observed in mean OKS, average daily pain report, or timed performance test. Satisfaction with outcome in surviving patients at eight years was 90.5% (57/63) in the Triathlon group and 82.8% (48/58) in the Kinemax group, with no statistical difference between groups (p = 0.321). Conclusion. At a mean 8.12 years, this mid-term follow-up of a randomized controlled trial cohort highlights a general reduction in measures of patient function with patient age and follow-up duration, and a comparative preservation of function based on implant received at time of surgery. Cite this article: Bone Joint J 2020;102-B(4):434–441

Aims. The Precice intramedullary limb-lengthening system has demonstrated significant benefits over external fixation lengthening methods, leading to a paradigm shift in limb lengthening. This study compares outcomes following antegrade and retrograde femoral lengthening in both adolescent and adult patients. Patients and Methods. A retrospective review of prospectively collected data was undertaken of a consecutive series of 107 femoral lengthening operations in 92 patients. In total, 73 antegrade nails and 34 retrograde nails were inserted. Outcome was assessed by the regenerate healing index (HI), hip and knee range of movement (ROM), and the presence of any complications. Results. The mean lengthening was 4.65 cm (1.5 to 8) in the antegrade group and 4.64 cm (1.6 to 8) in the retrograde group. Of the 107 lengthenings, 100 had sufficient datapoints to calculate the mean HI. This was 31.6 days/cm (15 to 108). There was a trend toward a lower (better) HI with an antegrade nail and better outcomes in adolescent patients, but these were not statistically significant. Hip and knee ROM was maintained and/or improved following commencement of femoral lengthening in 44 patients (60%) of antegrade nails and 13 patients (38%) of retrograde nails. In female patients, loss of movement occurred both earlier and following less total length achieved. Minor implant complications included locking bolt migration and in one patient deformity of the nail, but no implant failed to lengthen and there were no deep infections. Three patients had delayed union, five patients required surgical intervention for joint contracture. Conclusion. This study confirms excellent results in femoral lengthening with antegrade and retrograde Precice nails. There is a trend for better healing and less restriction in hip and knee movement following antegrade nails. There are clinical scenarios, that mandate the use of a retrograde nail. However, when these are not present, we recommend the use of antegrade nailing. Cite this article: Bone Joint J 2019;101-B:1168–1176

Computer navigation systems enable precise measurement and intra- operative knee range of movement analysis. We present a series of five knees that demonstrated unusual kinematics. Five of 80 computer navigated knee replacements that were part of a prospective randomised trial were found to have unusual joint lines. Range of motion assessment was performed with computer assisted navigation after exposure and registration of bony landmarks and before bony resection was commenced. This revealed valgus alignment in extension that drifted into varus with knee flexion. We referred to these unusual patterns as ‘oblique joint lines’. The data from the navigation log files of these five knees was analysed in detail. Average age of patients in this series was 68years and all were female. The average pre- operative angle between femoral axis and distal femoral articular surface was 101 degrees. All five knees had a tibial varus with average angle between the tibial axis and articular surface being 85 degrees. In two knees, more bone was resected from the medial posterior femoral condyle using 4 degrees external rotation. These two knees showed improved kinematics and horizontal joint line post- operatively. Computer assisted navigation provides a precise understanding of the pre- operative knee kinematics. Bony cuts can be tailored to suit the pre- operative deformity. Increased external rotation of the femur with adequate medial soft tissue release is an alternate approach for difficult knees with ‘oblique joint lines’

Objective. To determine differences in fracture stability and functional outcome between synthetic bone graft and allograft/autograft with internal fixation of tibia plateau metaphyseal defects. Patient & Methods. Between 2007- 2008, 84 consecutive cases of internal fixation of tibia plateaux were identified from our theater logbook. 29 patients required additional autologous, allogenic bone graft, or synthetic bone graft substitute to ensure fracture stability. 5 patients were excluded due to lost to follow up leaving a cohort of 24 patients. Hydroxyapatite calcium carbonate synthetic bone graft was utilised in 14 patients (6 male and 8 female). Allograft/autograft were utilised in the remaining 10 patients (6 male and 4 female). All 24 patients had closed fractures, classified using the AO and Schatzker classification. Roentograms at presentation, post-operatively and regular follow-up till 12 months were analysed for maintenance of reduction, early and late subsidence of the articular surface. Functional outcomes such as knee range of movement and WOMAC Knee scores were compared between groups. Results. There was no significant statistical difference between groups for post-operative joint reduction, long term subsidence, and WOMAC scores. The degree of subsidence was not related to age or fracture severity. Maintenance of knee flexion was found to be better in the allograft/autograft group (p=0.015) when compared between groups. Multivariate analysis compared graft type, fracture severity, postoperative reduction, subsidence rate, range of movement and WOMAC score. The only finding was a statistical significant (p=0.025) association with the graft type and range of movement. Conclusion. Allograft/autograft may allow better recovery of long-term flexion, possibly due to reduced inflammatory response compared with synthetic bone graft. However, all other parameters such as maintenance of joint reduction and subjective outcome measures were comparable with the use of hydroxyapatite calcium carbonate bone graft. This study shows that synthetic bone graft is a suitable option in fixation of unstable tibia plateau fractures, avoiding risk of viral disease transmission with allograft and donor site morbidity associated with autograft

Methods and materials: Between August 2000 and August 2002, 28 patients, average age of 78 years (range 62 to 94 years), with distal femoral fractures (33A1 – 17, 33A2 – 1, 33C1 – 6, 33C2 – 4) were treated with DFN. All the patients had sustained the injury following a simple fall. Periprosthetic fractures were excluded from this study. Two fractures required additional procedures in the form of circleage wires. Nailing was performed through a midline mini arthrotomy. Post operative protocol was to mobilise the patient weight bearing as tolerated. Results: All fractures healed without the need for secondary procedures. Average period of follow up was 8.5 months. Average hospital stay was 18 days (range 10 to 34). Post operative mobility returned to pre operative state in 15 patients. Three patients died within 3 months due to unrelated medical causes. There was no incidence of extension lag or malunion. Knee range of movement was on average 95°. Patients with pre existing knee arthritis had slight worsening of the pain. Hospital for Special Surgery knee scores were on average 78.3. 23 patients were rated as excellent, 4 good and 1 poor. In one patient the distal screws broke without significant functional impairment. Conclusion: We recommend the use of DFN in supracondylar femoral fractures in the elderly as it produced satisfactory results with low operative and post operative morbidity. It can be performed with minimal soft tissue damage with good purchase in the osteoporotic bone which allows early mobilisation

When managing malignant bone tumours in the distal femur with limb salvage, resection and reconstruction with a distal femoral replacement (DFR) conventionally entails prosthetic replacement of the knee joint. In younger patients it is desirable to try to preserve the knee joint. We now use a new Joint-Sparing distal femoral prosthesis in those cases where it is possible to resect the tumour and preserve the femoral condyles. Purpose of study: To look at our early results with knee joint preserving DFR’s. Methods: Between June 2001 and March 2004 the prosthesis was implanted in 8 patients (5 males and 3 females) aged between 8 and 24 years at the time of surgery. The diagnosis was osteosarcoma in 6 cases and chondrosarcoma in 2 cases. All patients were followed regularly and knee range of movement was recorded as well as any complications that occurred. Patients were functionally evaluated using the MSTS Scoring System. Results: Six of the patients had a mean follow-up of 20 months (range 8–33) and in this group 4 had good knee flexion with a mean flexion of 122° (110–130), 1 patient had fair flexion of 60° and 1 patient had poor flexion of 20°. The mean fixed flexion deformity in the 3 patients who had such a deformity was 10° (5–15). There were no intraoperative complications but the patient with poor flexion required an arthrolysis and because of the poor result is under consideration for conversion to a conventional DFR. Two patients had follow-up periods of 3 months or less and are still in their early rehabilitation period. One patient in this group developed sepsis that resolved after an open washout. Conclusions: Our early results with this prosthesis, in the patients with adequate follow-up, have been good in the majority but the two cases of fair and poor knee flexion are disappointing. This particular problem may relate to design and technical factors, which will be discussed in detail

Unicompartmental knee replacement (UKR) is technically challenging, but has the advantage over total knee replacement (TKR) of conserving bone and ligaments, preserving knee range of movement and stability. Computer navigation allows for accurate placement of the components, important for preventing failures secondary to mal-alignment. Evidence suggests an increase in failure rates beyond 3 degrees of coronal mal-alignment. Our previous work has shown superior functional scores in those patients having undergone UKR, when compared with those having had TKR. However, to a certain extent, this is likely to be due to differences in the two cohorts. Those selected for UKRs are likely to be younger, with less advanced and less widespread degenerative disease. It is almost inevitable, therefore, that functional outcomes will be superior. We aimed to compare the functional and radiological outcomes of UKR vs TKR in a more matched population. Ninety-two patients having had one hundred consecutive computer navigated UKRs were reviewed both clinically and radiographically. The Smith & Nephew Accuris fixed-bearing modular prosthesis was used in all cases, with the ‘Brainlab’ navigation system. For our comparative group we identified patients who had actually undergone navigated TKR several years ago, but who, in retrospect, would have now been offered a UKR in line with our current practice. These patients were identified following review of pre-operative radiographs and operation notes, confirming degenerative disease confined mainly to one compartment of the knee, in the absence of any concern as to the integrity of the anterior cruciate ligament. This sub-group of patients were also assessed clinically and radiographically. Mean follow-up for the UKR group was 25 months, (range 8–45.) For our TKR sub-group, nineteen patients were identified. Average length of stay for the UKR group was 3.7 days, (range 2 to 7,) and for the TKR group this was 5.2 days, (range 3 to 10.). Functional scores (Oxford Knee Score) were good to excellent for the majority of patients in both groups, although they were significantly better in the UKR group. Mean Oxford Knee Score in the UKR group was 7.5, (0–48, with 0 being best.) Mean score in the TKR sub-group was 12.1. (p = 0.02). Reliably comparing TKR with UKR is difficult, due to the fundamental differences in the two groups. We have endeavoured to match these two cohorts as best possible, in order to compare the outcomes of both. Our use of computer navigation in both groups allows for accurate prosthesis placement. When measuring component position, there were no ‘outliers,’ outside of the widely accepted three degrees of deviation. We propose that, with the correct patient selection, UKR gives a better functional outcome than TKR. Longer-term follow-up of our UKR group is required to monitor the onset of progressive arthrosis in other joint compartments, although our early results are very encouraging. Furthermore, we advocate the use of computer navigation to firstly allow for more accurate component positioning, and secondly to make challenging UKR surgery less technically demanding

Introduction: The emergence of Independent Sector Treatment Centres (ISTCs) in the UK for the provision of elective orthopaedic services began in 2002–3. Within our trust the bulk of elective orthopaedic surgery is performed in an ISTC however there is a small but significant cohort of patients who are deemed not suitable for treatment at the ISTC. Patients with a BMI (body mass index) ≥40 or an ASA (American society of anaesthesiologists) grade of 3 or more are automatically rejected. With increasing levels of obesity and an aging population the size of the reject cohort is going to rise. These patients are then returned to the NHS to be placed on a new (complex elective) waiting list for their surgery. The aim of this study was to assess the early outcomes and complications following primary knee arthroplasty on our high risk patients. Methods: A retrospective review of a consecutive series of 214 primary knee arthroplasties in patients rejected from the ISTC was performed. Data (demographics, ASA grade, BMI, length of stay, complications, range of knee movement and requirement for HDU/ICU) were collected from preoperative assessments, inpatient notes, anaesthetic charts, discharge summaries and follow up clinic letters. All patients were followed up for a minimum of 6 months. Results: 155 (72%) patients were female. 140 (65%) had ASA of 3 or more. 88 (41%) had a BMI of 40 or more. Median length of stay was 8 days (6 to 11 IQR) and did not vary with increasing BMI but increased to 10 days in the ASA 3 and 12 days in the ASA 4 group. There were a total 90 complications in 71 patients. The most common complications were 22 superficial wound infections (10.3%), 11 Pneumonias (5.1%), and 9 symptomatic DVTs (4.2%). There were 16 severe complications (2 Deep infections, 4 PEs, 2 CVAs, 4 acute renal failures and 4 dislocations) in 15 patients. Patients with a BMI < 40 had a total complication rate of 38% (7.9% severe) compared with 26% (5.7% severe) in BMI ≥40 group. Patients with an ASA < 3 had a complication rate of 31% (4.1% severe) vs. 34% (8.6% severe) in patients with an ASA ≥ 3. HDU/ICU beds were required postoperatively for 20 patients (9 planned and 11 unplanned). At six months 72% achieved a knee range of movement ≥ 0 to 90 degrees. Surgeons who performed high volumes of surgery in this difficult group had lower complications then lower volume surgeons. Conclusion: This is one of the largest consecutive groups of high risk patients undergoing primary total knee arthroplasty. Our results show that elevated BMI does not appear to adversely affect complication rates in knee arthroplasty in our series although ASA grades of 3 and 4 are associated with increased length of stay and complication rates. It is also clear that small groups of surgeons operating on these difficult patients may reduce complications

Introduction To assess five-year survivorship and clinical outcome following unicompartmental knee replacement (UKR) and total knee replacement (TKR) in pre-operatively matched patient groups. Methods From a prospective database of over 600 patients undergoing knee replacement for osteoarthritis, 70 primary Oxford UKRs (62 patients) were matched pre-operatively with 70 primary PFC TKRs (68 patients) for age, sex, body mass index, knee range of movement and Knee Society Score (KSS). The two groups were assessed at six, eighteen, thirty-six and sixty months following knee replacement and compared for survivorship of the prosthesis (with failure defined as revision for any reason or ‘worst-case’ assuming all patients lost to follow up are revised), post-operative ROM achieved and clinical outcome based on the KSS (reported as separate knee and function score). Results Three (5 percent) patients in the UKR group and two (3 percent) in the TKR group were unavailable for follow-up at five years. Five-year survivorship based on revision for any reason was 90 percent (95 percent Confidence Interval (CI): 82 to 98) for UKR and 100 percent (95 percent CI: 100 to 100) for TKR (log rank test: p=0.009). The ‘worst-case’ five-year survivorship (assuming all patients lost to follow up are revised) was 85 percent (95 percent CI: 76 to 94) for UKR and 97 percent (95 percent CI: 93 to 100) for TKR (log rank test: p=0.02). The mean post-operative ROM achieved was 105.3 degrees following UKR and 98.3 degrees following TKR (difference 7.0 (95 percent CI 3.3 to 10.6), p< 0.001). There was no difference in the KSS between the two groups for the knee score (difference 0.1 (95 percent CI: −4.3 to 4.5), p=0.9) and function score (difference 2.6 (95 percent CI: −1.7 to 6.9), p=0.2). Conclusion In comparable patients with osteoarthritis of the knee, survivorship remains superior for TKR at five years. The ROM achieved is greater for UKR but there is no difference in the overall clinical outcome following UKR or TKR. We believe that UKR should only be performed in carefully selected cases because mid-term clinical outcome is similar following UKR or TKR and the complication rate may be higher for UKR

Total knee arthroplasty (TKA) is an established and successful procedure. However, the design of prostheses continues to be modified in an attempt to optimise the functional outcome of the patient. . The aim of this study was to determine if patient outcome after TKA was influenced by the design of the prosthesis used. A total of 212 patients (mean age 69; 43 to 92; 131 female (62%), 81 male (32%)) were enrolled in a single centre double-blind trial and randomised to receive either a Kinemax (group 1) or a Triathlon (group 2) TKA. . Patients were assessed pre-operatively, at six weeks, six months, one year and three years after surgery. The outcome assessments used were the Oxford Knee Score; range of movement; pain numerical rating scales; lower limb power output; timed functional assessment battery and a satisfaction survey. Data were assessed incorporating change over all assessment time points, using repeated measures analysis of variance longitudinal mixed models. Implant group 2 showed a significantly greater range of movement (p = 0.009), greater lower limb power output (p = 0.026) and reduced report of ‘worst daily pain’ (p = 0.003) over the three years of follow-up. Differences in Oxford Knee Score (p = 0.09), report of ‘average daily pain’ (p = 0.57) and timed functional performance tasks (p = 0.23) did not reach statistical significance. Satisfaction with outcome was significantly better in group 2 (p = 0.001). These results suggest that patient outcome after TKA can be influenced by the prosthesis used. Cite this article: Bone Joint J 2015;97-B:64–70

Early and accurate prediction of hospital length-of-stay (LOS) in patients undergoing knee replacement is important for economic and operational reasons. Few studies have systematically developed a multivariable model to predict LOS. We performed a retrospective cohort study of 1609 patients aged ≥ 50 years who underwent elective, primary total or unicompartmental knee replacements. Pre-operative candidate predictors included patient demographics, knee function, self-reported measures, surgical factors and discharge plans. In order to develop the model, multivariable regression with bootstrap internal validation was used. The median LOS for the sample was four days (interquartile range 4 to 5). Statistically significant predictors of longer stay included older age, greater number of comorbidities, less knee flexion range of movement, frequent feelings of being down and depressed, greater walking aid support required, total (versus unicompartmental) knee replacement, bilateral surgery, low-volume surgeon, absence of carer at home, and expectation to receive step-down care. For ease of use, these ten variables were used to construct a nomogram-based prediction model which showed adequate predictive accuracy (optimism-corrected R. 2. = 0.32) and calibration. If externally validated, a prediction model using easily and routinely obtained pre-operative measures may be used to predict absolute LOS in patients following knee replacement and help to better manage these patients. . Cite this article: Bone Joint J 2013;95-B:1490–6

We report the results of revision total knee replacement (TKR) in 26 patients with major metaphyseal osteolytic defects using 29 trabecular metal cones in conjunction with a rotating hinged total knee prosthesis. The osteolytic defects were types II and III (A or B) according to the Anderson Orthopaedic Research Institute (AORI) classification. The mean age of the patients was 72 years (62 to 84) and there were 15 men and 11 women. In this series patients had undergone a mean of 2.34 previous total knee arthroplasties. The main objective was to restore anatomy along with stability and function of the knee joint to allow immediate full weight-bearing and active knee movement. Outcomes were measured using Knee Society scores, Oxford knee scores, range of movement of the knee and serial radiographs. Patients were followed for a mean of 36 months (24 to 49). The mean Oxford knee clinical scores improved from 12.83 (10 to 15) to 35.20 (32 to 38) (p < 0.001) and mean American Knee Society scores improved from 33.24 (13 to 36) to 81.12 (78 to 86) (p < 0.001). No radiolucent lines suggestive of loosening were seen around the trabecular metal cones, and by one year all the radiographs showed good osteo-integration. There was no evidence of any collapse or implant migration. Our early results confirm the findings of others that trabecular metal cones offer a useful way of managing severe bone loss in revision TKR. Cite this article: Bone Joint J 2013;95-B:1069–74

We have sought to clarify whether the traditional Arabic lifestyle prevents restriction of movement in patients with degenerative arthritis of the knee. The range of movement of 68 osteoarthritic knees of Arabic patients was compared with that of 51 healthy knees of Muslim patients and 83 osteoarthritic knees in non-Arabic patients. The range of flexion of the osteoarthritic knees in the Arabic patients matched that of the healthy control knees, but was significantly better than that of the osteoarthritic knees in the non-Arabic patients. There was also a statistically significant difference between the mean extension deficit of the two groups with osteoarthritis. Exercises may help to prevent restriction of movement in osteoarthritis of the knee

We have investigated the ability to kneel after total knee replacement. We asked 75 patients (100 knees) at least six months after routine uncemented primary total knee replacement, to comment on and to demonstrate their ability to kneel. Differences between the perceived and actual ability to kneel were noted. In 32 knees patients stated that they could kneel without significant discomfort. In 54 knees patients avoided kneeling because of uncertainties or recommendations from third parties (doctors, nursing staff, friends, etc). A total of 64 patients was actually able to kneel without discomfort or with mild discomfort only and 12 of the remainder were unable to kneel because of problems which were not related to the knee. Twenty-four patients therefore were unable to kneel because of discomfort in the knee. There was no difference between the ‘kneelers’ and ‘non-kneelers’ with regard to overall knee score, range of movement and the presence of patellar resurfacing