Though knee osteoarthritis (OA) is diagnosed and monitored radiographically, full thickness cartilage loss (FTCL) has rarely been correlated with radiographic classification. This study aims to analyse which classification system correlates best with FTCL and assessing their reliability. Prospective study of 300 consecutive patients undergoing total knee arthroplasty (TKA) for OA. Two blinded examiners independently graded preoperative radiographs using 5 systems: Kellgren-Lawrence (KL); International Knee Documentation Committee (IKDC); Fairbank; Brandt; and Ahlback. Interobserver agreement was assessed using the intraclass correlation coefficient. Intraoperatively, anterior cruciate ligament (ACL) status and FTCL in 16 regions of interest were recorded. Radiographic classification and FTCL were correlated using the Spearman correlation coefficient. On average, each knee had 6.8±3.1 regions of FTCL, most common medially. The commonest patterns of FTCL were medial with patellofemoral (48%) and tricompartmental (30%). ACL status was associated with pattern of FTCL (p=0.02). All classification systems demonstrated moderate ICC, but this was highest for IKDC: whole knee 0.68 (95%CI 0.60–0.74); medial compartment 0.84 (0.80–0.87); and lateral compartment 0.79 (0.73–0.83). Correlation with FTCL was strongest for Ahlback (Spearman rho 0.27–0.39) and KL (0.30–0.33), though all systems demonstrated medium correlation. The Ahlback was the most discriminating in severe OA. Osteophyte presence in the medial compartment had high positive predictive value for FTCL, but not in the lateral compartment. The Ahlback and KL systems had the highest correlation with confirmed cartilage loss. However, the IKDC system displayed best interobserver reliability, with favourable correlation with FTCL in medial and lateral compartments, though less discriminating in severe disease

INTRODUCTION. This study aimed to intra-operatively quantify the improvements in knee stability given both by anatomic double-bundle (ADB) and single-bundle with additional lateral plasty (SBLP) ACL reconstruction using a navigation system. MATERIALS AND METHODS. We prospectively included 35 consecutive patients, with an isolated anterior cruciate ligament injury, that underwent both ADB and SBLP ACL reconstruction (15 ADB, 20 SBLP). The testing protocol included anterior/posterior displacement at 30° and 90° of flexion (AP30–AP90), internal/external rotation at 30° and 90° of flexion (IE 30–IE90) and varus/valgus test at 0° and 30° of flexion (VV0–VV30); pivot-shift (PS) test was used to determine dynamic laxity. The tests were manually performed before and after the ACL reconstruction and the data were acquired by means a surgical navigation system (BLU-IGS, Orthokey, USA). Comparisons of pre- and post-reconstruction laxities were made using paired Student t-test (P=0.05) within the same group; comparison between ADB and SBLP groups was indeed performed using independent Student t-test (P=0.05), analysing both starting pre-operative condition and post-operative one. RESULTS. Statistically significant reduction of the global amount of laxity and global displacement was observed for both reconstructions (p<0.05) in all the performed clinical tests. Statistical differences was found between the two reconstruction considering the recovery (pre-post laxities) due to the each reconstruction, in VV0 (SBLP: 3.7±0.2° and ADB: 2.3±0.5°, p<0.0001) and in IE90 (SBLP: 9.2±3.1° and ADB: 5.0±2.8°, p=0.0022). Statistical differences were also found between the two reconstruction considering the recovery of global displacement, in particular for the lateral compartment during AP90 SBLP: 8.8±1.0 mm, ADB: 6.4±0.4 mm, p<0.0001), for the maximal lateral joint opening during VV0 (SBLP: 4.5±1.2 mm, ADB: 1.2±1.1 mm, p<0.0001) and VV30 (SBLP 3.5±1.3 mm, ADB 1.8±0.1 mm, p=0.0013) and both for the medial and lateral AP displacement during IE90 (in in medial compartment SBLP:5.6±0.6 mm, ADB: 2.7±0.7 mm, p<0.0001, in lateral compartment SBLP:8.2±1.0 mm, ADB: 3.9±0.8 mm, p<0.0001). During PS test ADB patients revealed less “hysteresis” after reconstruction (p=0.0005). Moreover SBLP patients presented more acceleration after the reconstruction compared to ADB and more evident displacement (p=0.0009). DISCUSSION. Both the reconstructions worked similarly for what concerns knee static laxity. The considered extra-articular procedure plays an important role in better controlling lateral tibial compartment displacement in drawer test and in controlling maximal lateral joint opening both at 0° and 30° of flexion. On the other hand the ADB reconstruction better restores the dynamic behaviour of the joint under PS test

High tibial osteotomy (HTO) is a common procedure for treating medial compartment knee arthritis. The main goal is to reduce knee pain by transferring weight-bearing loads to the relatively unaffected lateral compartment and thus delaying the need of total knee replacement (TKR) by slowing or stopping destruction of medial compartment. Between 2002 and 2010, 34 HTO's were carried out in 32 patients (Mean age 44.2). Results were reviewed in 23 patients with an average follow-up of 10.2 years (range 6–14 years). Oxford knee score (OKS) assessment was carried out on those patients. Of the remaining 11 patients, one was excluded, 2 were lost to follow-up, and 2 had died. Five cases had TKR at an average 8.8 years since having HTO. OKS results revealed nine cases (39.1percnt;) scored (40–48) which indicate satisfactory joint function and don't require treatment. Three cases (13percnt;) scored (30–39) indicating mild to moderate arthritis. Six cases (26.1percnt;), scored (20–29) indicating moderate to severe arthritis. Five cases (21.8percnt;) scored (0–19) indicating severe arthritis. Only five patients (14.7percnt;) had TKR (6–14) years after there HTO. The majority of cases had an OKS suggesting satisfactory joint function. Even those with scores suggesting moderate to severe arthritis were able to function normally for more than 6 years. The successful outcome of HTO can be maintained for more than 6–16 years. We conclude that HTO should be recommended for the treatment of medial compartment arthritis of the knee in young and active patients for symptomatic improvement and maintenance of activity levels

To our knowledge in medial unicompartmental knee arthroplasty (UKA) no study has specifically assessed the difference in outcome between matched gender groups. Previous unmatched gender studies have indicated more favourable results for women. Method. 2 groups of 40 of either sex was determined sufficient power for significant difference. These consecutively were matched with both the pre-operative clinical and radiological findings. Minimum follow up of 2 years, mean follow-up 5.9 years. Mean age at operation was 71 years. Results. In both groups, the mean IKS knee and function scores improved significantly (p< 0.001) post operatively. There were no significant differences were between the 2 groups. In both groups mean preoperative flexion was 130 degrees and remained unchanged at final follow-up. No significant differences in preoperative and postoperative axial alignment and in the number of radiolucent lines, between groups. With component size used there was a significant difference (p < 0.001) between the 2 groups. However the size of the femoral or tibial implant used was significantly related (p< 0.001) to patient height for both sexes. Radiolucent lines were more frequent on the tibial component, but were considered stable with none progressing. No revisions for component failure. 1 patient in each group developed lateral compartment degenerative change. Male group; one conversion to TKA for undiagnosed pain, three patients underwent reoperation without changing the implant. Female group; no implants were revised, and two patients required a reoperation. Kaplan-Meier 5-year survival rate of 93.46% (84.8; 100) for men and100% for women. The survival rate difference is not significant (p=0.28). Conclusion. These results suggest that there is no difference in outcome between sexes and that gender should not enter into the selection criteria for UKA. It also suggests that height and not gender is important to predict the appropriate UKA components

Background. The reported outcomes of unicompartmental knee replacement (UKR) for spontaneous osteonecrosis of the knee (SPONK) often derive from small series with an average followup of 5 years, enabling to generate meaningful conclusions. Therefore, we determined the long-term functional results and the 10-years survivorship of the implant in all patients with advanced SPONK of the medial tibio-femoral compartment treated with a unicompartmental knee arthroplasty at our institute. Methods. We retrospectively evaluated 84 consecutive patients with late stage SPONK. All patients received a pre-operative MRI to confirm the diagnosis, to exclude any metaphyseal involvement and to assess the absence of significative degenerative changes in the lateral and PF compartment. Mean age at surgery was 66 years and mean body mass index (BMI) was 28.9. In all cases, SPONK involved the medial compartment; in 77 cases the medial femoral condyle (MFC) was involved, while in 7 cases the pathology site was the medial tibial plateau (MTP). Radiological evaluation was conducted by 3 different radiologists and clinical evaluation according to KSS and WOMAC score was performed by 3 fellows from outside institutions, with no previous clinical contact with the patients, at a mean followup of 98 months. Results. We found a significant improvement in VAS score for residual pain self-assessment and maximum knee flexion (p<0.0001). The 10-year Kaplan-Meier survivorship with revision for any reason as endpoint was 89%. Mean results at final observation point for global KSS and WOMAC score were 87.1 (range 45–100; standard deviation 13.8) and 12 (range 0–44; standard deviation 10.3), respectively. No patient had significant radiographic signs of osteoarthritis progression in the lateral compartment or in the patello-femoral compartment at final evaluation. Conclusions. Our findings suggest that medial UKR performed for late stage SPONK of the medial tibio-femoral compartment in selected patients provides satisfactory long term clinical and radiographical results, with a 10-years Kaplan-Meier survivorship of the implant of 89%

CECS is an exercised induced condition that causes pain, typically in the lower limbs, and is relieved by rest. It is often seen in military personnel significantly restricting their duties. Conservative treatment is rarely successful and patients often require surgical decompression by fasciotomy or fasciectomy. All IMP (intramuscular pressure) tests (n=286) carried out between December 2007 and October 2010 on patients with suspected CECS in the anterior compartment of the lower leg were reviewed. The treatment and outcomes of those referred for surgery were analysed. Pre- and post-surgery military medical grading for leg function was extracted from the medical records system. Independent t-tests compared differences between patients that had surgery or did not. The Wilcoxon signed-rank test compared grades before and after surgery. According to the diagnostic criterion, 80% of patients undergoing IMP testing had CECS. Of these, 179 (68%) patients underwent surgery, 17 (9%) of these were for recurrent symptoms. Almost all decompressions were bilateral (95%). The majority of operations (121) were fasciectomies of the anterior compartment only and were performed by 2 surgeons. The remaining operations (58) were performed by 6 surgeons and were fasciotomies of both anterior and lateral compartments. The mean time from testing to surgery was 24 (median 11) weeks. There were 23 (13%) complications other than recurrence including 16 wound infections, 6 seromas and 1 haematoma. Pre- and post-surgery grading was available for 67% of patients. These patients had significantly better leg function after surgery (Z=−3.67, p<0.001). Of these, 47% improved, 38% showed no improvement and 15% had a poorer outcome had. Those who had a fasciectomy were significantly more likely to improve than those who had a fasciotomy (p=0.023, rho=−1.96). Our results demonstrate that patients generally improve lower limb function following surgical decompression. However, 53% showed no improvement or deteriorated in their medical grading. In addition, there is a high diagnosis rate for CECS following IMP measurement. This may reflect the poor validity of the diagnostic criterion or this could be due to good clinical selection for testing. Furthermore, fasciectomy shows a greater correlation with improved outcome than fasciotomy. There is a need to develop more accurate diagnostic criteria and to evaluate the benefits of standardising surgical technique

Introduction. Unicompartmental arthroplasty is still a controversial issue in knee replacement, mainly due to a marked variation in published survival rates of the implants. The aim of this study was to analyse possible risk factors for revision following Oxford unicompartmental knee arthroplasties (OUKA). Material and methods. Since 1997 data for all patients with primary and revision knee arthroplasties performed in our department have been stored in a database. Selected for the present study was all primary OUKA performed in the period 1997–2006 as well as any revision following these operations until the end of 2008. We got information from The National Health Register and the CPR register about any revision performed at other institutions and date in case of death. Primary OUKA were grouped in three categories according to the experience of the surgeon: 1 for operation done by a surgeon who had performed less than 20 OUKA, 2 for operation by a surgeon who had performed 20–40, and 3 for operation by a surgeon who had performed more than 40. Risk of revision was analysed by Cox regression. Revisions due to pain as the only reason were excluded from the analyses. Age and gender of the patients, previous surgical intervention, operation time, and the experience of the surgeon were included as possible risk factors in the analysis. Results. 445 primary Oxford knee arthroplasties were included. These were followed by 46 revisions. The indications for the revisions were: aseptic loosening 16 knees, progression of the osteoarthritis to the lateral compartment 7 knees, dislocation of the polyethylene meniscus 5 knees, varus-valgus instability 3 knees, fracture of the medial tibia condyle 3 knees, collision of the polyethylene meniscus and the femur condyle 1 knee, and pain as the only reason 11 knees. Age and gender of the patients as well as previous surgical intervention in the knee in question were not correlated to the risk of revision. Operation time was correlated to risk of revision with decreasing risk with increasing operation time (p=0,001). The experience of the surgeon was also correlated to risk of revision with decreasing risk with increasing experience (p=0,02). The 6 years survival rate for an experienced surgeon using an operation time at 90 min. or more was 97,5 % compared to a survival rate at 78,7 % for an inexperienced surgeon with an operation time less than 90 min. Conclusion. OUKA performed by an inexperienced surgeon and OUKA performed with short operation time had marked reduced survival rates. This seems to be an essential information to institutions performing OUKA

This study aimed to determine the long-term functional, clinical and radiological outcomes in patients with Schatzker IV to VI fractures of the tibial plateau treated with an Ilizarov frame. Clinical, functional and radiological assessment was carried out at a minimum of one year post-operatively. A cohort of 105 patients (62 men, 43 women) with a mean age of 49 years (15 to 87) and a mean follow-up of 7.8 years (1 to 19) were reviewed. There were 18 type IV, 10 type V and 77 type VI fractures. All fractures united with a mean time to union of 20.1 weeks (10.6 to 42.3). No patient developed a deep infection. The median range of movement (ROM) of the knee was 110^o and the median Iowa score was 85.

Our study demonstrates good long-term functional outcome with no deep infection; spanning the knee had no detrimental effect on the ROM or functional outcome.

High-energy fractures of the tibial plateau may be treated effectively with a fine wire Ilizarov fixator.

Cite this article: Bone Joint J 2015;97-B:1693–7.

Radiological evidence of post-traumatic osteoarthritis (PTOA) after fracture of the tibial plateau is common but end-stage arthritis which requires total knee arthroplasty is much rarer.

The aim of this study was to examine the indications for, and outcomes of, total knee arthroplasty after fracture of the tibial plateau and to compare this with an age and gender-matched cohort of TKAs carried out for primary osteoarthritis.

Between 1997 and 2011, 31 consecutive patients (23 women, eight men) with a mean age of 65 years (40 to 89) underwent TKA at a mean of 24 months (2 to 124) after a fracture of the tibial plateau. Of these, 24 had undergone ORIF and seven had been treated non-operatively. Patients were assessed pre-operatively and at 6, 12 and > 60 months using the Short Form-12, Oxford Knee Score and a patient satisfaction score.

Patients with instability or nonunion needed total knee arthroplasty earlier (14 and 13.3 months post-injury) than those with intra-articular malunion (50 months, p < 0.001). Primary cruciate-retaining implants were used in 27 (87%) patients. Complication rates were higher in the PTOA cohort and included wound complications (13% vs 1% p = 0.014) and persistent stiffness (10% vs 0%, p = 0.014). Two (6%) PTOA patients required revision total knee arthroplasty at 57 and 114 months. The mean Oxford knee score was worse pre-operatively in the cohort with primary osteoarthritis (18 vs 30, p < 0.001) but there were no significant differences in post-operative Oxford knee score or patient satisfaction (primary osteoarthritis 86%, PTOA 78%, p = 0.437).

Total knee arthroplasty undertaken after fracture of the tibial plateau has a higher rate of complications than that undertaken for primary osteoarthritis, but patient-reported outcomes and satisfaction are comparable.

Cite this article: Bone Joint J 2015;97-B:532–8.

Nonunion of the tibia associated with bone loss, previous infection, obliteration of the intramedullary canal or located in the distal metaphysis poses a challenge to the surgeon and significant morbidity to patients. We retrospectively reviewed the records of 24 patients who were treated by central bone grafting and compared them to those of 20 who were treated with a traditional posterolateral graft. Central bone grafting entails a lateral approach, anterior to the fibula and interosseous membrane which is used to create a central space filled with cancellous iliac crest autograft. Upon consolidation, a tibiofibular synostosis is formed that is strong enough for weight-bearing. This procedure has advantages over other methods of treatment for selected nonunions.

Of the 24 patients with central bone grafting, 23 went on to radiographic and clinical union without further intervention. All healed within a mean of 20 weeks (10 to 48). No further bone grafts were required, and few complications were encountered. These results were comparable to those of the 20 patients who underwent posterolateral bone grafting who united at a mean of 31.3 weeks (16 to 60) but one of whom required below-knee amputation for intractable sepsis.

Central bone grafting is a safe and effective treatment for difficult nonunions of the tibia.