Restoration of native Coronal Plane Alignment of the Knee (CPAK) phenotype is a strategy suggested to achieve better satisfaction. The aim of this study was to investigate the influence of changes in CPAK classification on patient-reported outcome measures (PROMs) and survivorship in a large cohort of manual mechanically aligned (MA) cemented TKAs. A retrospective analysis of 1062 consecutive cemented TKAs using MA philosophy at a single institution. Pre- and post-operative hip-knee-ankle radiographs were classified using the CPAK classification. Oxford Knee Score (OKS) and patient satisfaction (4-point-Likert scale) were collected prospectively. Implant survival data was obtained from our national arthroplasty database. We compared the outcomes of patients who maintained or changed their CPAK classification following TKA. Satisfaction was analysed using chi-square test, and OKS was analysed using Mann-Whitney test. Pre-operatively, most patients were CPAK type-I (38.8%). 85.5% of patients changed their CPAK type post-operatively, with CPAK type-V observed in 41.2% of these. Significantly better satisfaction (p=0.033) and OKS (p=0.021) were observed at one-year follow-up in patients who changed CPAK type, although the difference was below OKS minimally important clinical difference. There was no difference in satisfaction (p=0.73) and OKS (p=0.26) at one year between CPAK-V and non-V classifications. Post-operative CPAK type had no correlation with satisfaction and OKS. 12 TKAs (1.1%) were revised within 10 years (3 septic). In this large cohort of MA-TKA, excellent survivorship was observed at 10 years, with no demonstrable difference in outcome related to the final CPAK phenotype or change in phenotype

Aims. To investigate health-related quality of life (HRQoL) of older adults (aged ≥ 60 years) after tibial plateau fracture (TPF) compared to preinjury and population matched values, and what aspects of treatment were most important to patients. Methods. We undertook a retrospective, case-control study of 67 patients at mean 3.5 years (SD 1.3; 1.3 to 6.1) after TPF (47 patients underwent fixation, and 20 nonoperative management). Patients completed EuroQol five-dimension three-level (EQ-5D-3L) questionnaire, Lower Limb Function Scale (LEFS), and Oxford Knee Scores (OKS) for current and recalled prefracture status. Propensity score matching for age, sex, and deprivation in a 1:5 ratio was performed using patient level data from the Health Survey for England to obtain a control group for HRQoL comparison. The primary outcome was the difference in actual (TPF cohort) and expected (matched control) EQ-5D-3L score after TPF. Results. TPF patients had a significantly worse EQ-5D-3L utility (mean difference (MD) 0.09, 95% confidence interval (CI) 0.00 to 0.16; p < 0.001) following their injury compared to matched controls, and had a significant deterioration (MD 0.140, 95% CI 0 to 0.309; p < 0.001) relative to their preoperative status. TPF patients had significantly greater pre-fracture EQ-5D-3L scores compared to controls (p = 0.003), specifically in mobility and pain/discomfort domains. A decline in EQ-5D-3L greater than the minimal important change of 0.105 was present in 36/67 TPF patients (53.7%). Following TPF, OKS (MD -7; interquartile range (IQR) -1 to -15) and LEFS (MD -10; IQR -2 to -26) declined significantly (p < 0.001) from pre-fracture levels. Of the 12 elements of fracture care assessed, the most important to patients were getting back to their own home, having a stable knee, and returning to normal function. Conclusion. TPFs in older adults were associated with a clinically significant deterioration in HRQoL compared to preinjury level and age, sex, and deprivation matched controls for both undisplaced fractures managed nonoperatively and displaced or unstable fractures managed with internal fixation. Cite this article: Bone Jt Open 2023;4(4):273–282

Non-surgical osteoarthritis management includes analgesia escalation to oral opiates; however, tolerance can occur. This study aims to assess analgesic effects of opiate use pre-operatively and whether this influences outcome 1-year post-operatively in patients undergoing total hip/knee arthroplasty (THA/TKA). This prospective study assessed 1487 patients undergoing primary THA (n=729) or TKA (n=758) for osteoarthritis, with 95 respectively reporting pre-operative opiate use >1 month. THA opiate users had significantly higher BMI (p=0.007) and more likely to suffer associated comorbidities. TKA opiate users were significantly younger (p<0.001), with higher BMI (p=0.019) and more likely to suffer associated comorbidities. Pre-operative quality of life (QoL) and joint specific function were significantly worse (Hip EQ-5D 0.17 vs 0.41, p<0.001, OHS 14.6 vs 21.2, p<0.001; Knee EQ-5D 0.27 vs 0.44, p<0.001, OKS 16.4 vs 21.4, p<0.001). Pre-operative pain was significantly worse in those taking opioids (Hip Pain VAS 42.73 vs 50.70, p<0.001; Knee Pain VAS 50.93 vs 53.36, p=0.30). Post-operatively the THA opiate group had significant improvement in EQ-5D (0.175, p<0.001) and OHS (6.5, p<0.001) but were significantly less improved than opiate naïve patients after adjusting for confounding (EQ-5D 0.10, p<0.001; OHS 3.2, p<0.001). TKA opiate group also had significant improvement in EQ-5D (p<0.001) and OKS (p<0.001) but were significantly less (EQ-5D 0.089, p<0.001; OKS 3.9, p<0.001) than opioid naïve patients. Pre-operative opiate use was associated with significantly worse pre-operative QoL, joint specific function and worse subjective pain. Post-operatively, the opiate group had significantly lower improvement in their QoL and joint specific function

There is a lack of evidence surrounding selective patella resurfacing, but patella cartilage loss at time of total knee arthroplasty (TKA) is often used as an indication in those who perform it. This study compares the outcomes of TKA without patella resurfacing in patients with and without patella cartilage loss (PFOA). Prospective case control study of 209 consecutive patients undergoing cruciate retaining single radius TKA without patella resurfacing for KL≥3 osteoarthritis. The presence and location of full thickness patella cartilage loss was documented intra-operatively at TKA, identifying n=108 cases with PFOA (mean age 70±9.7, mean BMI 31±6.2, 72 (67%) female) Vs n=101 controls without PFOA (age 68±9.2, BMI31±5.6, 52 (51%) female). Primary outcome measure was improvement in the Oxford Knee Score (OKS) at one year. There were more females in the PFOA group (67% Vs 51%, p=0.037), but no other preoperative differences. There was no difference in preoperative OKS between patients with patella cartilage loss (20.6±7.9) and those without (21.0±7.2, p=0.720). There was no difference in OKS improvement following TKA without patella resurfacing between those with full thickness patella cartilage loss (14.2±9.8) and those without (15.4±9.5, p=0.365). Facet involvement (number and location) did not affect OKSs. No differences were found in the individual OKS questions between groups (p>0.05). There was no difference in one-year OKS or improvements therein between patients with and without full thickness patella cartilage loss treated with single radius cruciate retaining TKA without patella resurfacing, questioning its use an indication for selective patella resurfacing

One potential approach to addressing the current hip and knee arthroplasty backlog is via adoption of surgical prioritisation methods, such as use of pre-operative health related quality of life (HRQOL) assessment. We set out to determine whether dichotomization using a previously identified bimodal EuroQol Five-Dimension (EQ-5D) distribution could be used to triage waiting lists. 516 patients had data collected regarding demographics, perioperative variables and patient reported outcome measures (pre-operative & 1-year post-operative EQ-5D-3L and Oxford Hip and Knee Scores (OHS/OKS). Patients were split into two equal groups based on pre-operative EQ-5D Time Trade-Off (TTO) scores and compared (Group1 [worse HRQOL] = −0.239 to 0.487; Group2 [better HRQOL] = 0.516 to 1 (best)). The EQ5D TTO is a widely used and validated HRQOL measure that generates single values for different combinations of health-states based upon how individuals compare x years of healthy living to x years of illness. We identified that those in Group1 had significantly greater improvement in post-operative EQ-5D TTO scores compared to Group2 (Median 0.67vs.0.19; p<0.0001 respectively), as well as greater improvement in OHS/OKS (Mean 22.4vs16.4; p<0.0001 respectively). Those in Group2 were significantly less likely to achieve EQ-5D MCID attainment (OR 0.13, 95%CI 0.07–0.23; p<0.0001) with a trend towards lower OHS/OKS MCID attainment (OR 0.66, 95%CI 0.37–1.19; p=0.168). There was no statistically significant difference in adverse events. These finding suggest that a pre-operative EQ-5D cut-off of ≤0.487 for hip and knee arthroplasty prioritisation may help to maximise clinical utility and cost-effectiveness in a limited resource setting post COVID-19

Risk of revision following total knee replacement is relatively high in patients under 55 years of age, but little is reported regarding non-revision outcomes. This study aims to identify predictors of dissatisfaction following TKR in patients younger than 55 years of age. We assessed 177 TKRs (157 consecutive patients) from 2008 to 2013. Data was collected on age, sex, implant, indication, BMI, social deprivation, range of motion, and prior knee surgery in addition to Oxford Knee Score (OKS) and SF-12 score. Postoperative data included knee range of motion, complications, and OKS, SF-12 score and satisfaction measures at one year. Overall, 24.9% of patients (44/177) were unsure or dissatisfied with their TKR. Significant predictors of dissatisfaction on univariable analysis (p<0.05) included: Kellgren-Lawrence grade 1/2 osteoarthritis; indication; poor preoperative OKS; postoperative complications; and poor improvements in OKS and pain component score (PCS) of the SF-12. Odds ratios for dissatisfaction by indication compared to primary OA: OA with previous meniscectomy 2.86; OA in multiply operated knee 2.94; OA with other knee surgery 1.7; OA with BMI>40kgm-2 2; OA post-fracture 3.3; and inflammatory arthropathy 0.23. Multivariable analysis showed poor preoperative OKS, poor improvement in OKS and postoperative stiffness, particularly flexion of <90°, independently predicted dissatisfaction (p<0.005). Patients coming to TKR when under 55 years of age differ from the ‘average’ arthroplasty population, often having complex knee histories and indications for surgery, and an elevated risk of dissatisfaction

Introduction. The options for the treatment of the young active patient with unicompartmental symptomatic osteoarthritis and pre-existing Anterior Cruciate Ligament (ACL) deficiency are limited. Patients with ACL deficiency and end-stage medial compartment osteoarthritis are usually young and active. The Oxford Unicompartmental Knee Replacement (UKA) is a well established treatment option in the management of symptomatic end-stage medial compartmental osteoarthritis, but a functionally intact ACL is a pre-requisite for its satisfactory outcome. If absent, high failure rates have been reported, primarily due to tibial loosening. Previously, we have reported results on a consecutive series of 15 such patients in whom the ACL was reconstructed and patients underwent a staged or simultaneous UKA. The aim of the current study is to provide an update on the clinical and radiological outcomes of a large, consecutive cohort of patients with ACL reconstruction and UKA for the treatment of end-stage medial compartment osteoarthritis and to evaluate, particularly, the outcome of those patients under 50. Methods. This study presents a consecutive series of 52 patients with ACL reconstruction and Oxford UKA performed over the past 10 years (mean follow-up 3.4 years). The mean age was 51 years (range: 36–67). Procedures were either carried out as Simultaneous (n=34) or Staged (n=18). Changes in clinical outcomes were measured using the Oxford Knee Score (OKS), the change in OKS (OKS=Post-op − Pre-op) and the American Knee Society Score (AKSS). Fluoroscopy assisted radiographs were taken at each review to assess for evidence of loosening, radiolucency progression, (if present), and component subsidence. Results. Five year survival was 90%. At last follow-up, the mean outcome scores for the group were: OKS 40 (SD: 8.3), objective AKSS 77 (SD: 16.1), functional AKSS 93 (SD: 13.7) and OKS of 11. Complications were recorded in three patients, (one early infection requiring a two-stage revision, a bearing dislocation and progression of OA in the lateral compartment). 25 patients, whose procedure occurred under the age of 50, had mean outcome scores of: OKS 38 (SD: 7.7), objective AKSS 73 (SD: 20.2), functional AKSS 93 (SD: 11.9) and OKS 12. No patients had radiological evidence of component loosening. Discussion and Conclusion. This study has demonstrated that combined ACL reconstruction and Oxford UKA provide good medium-term clinical and radiological results. The mobile bearing used in the Oxford knee minimises wear and our radiographic study has seen no suggestions of loosening

To validate the Modified Forgotten Joint Score (MFJS) as a new patient-reported outcome measure (PROM) in hip and knee arthroplasty (THR/TKR) against the UK's gold standard Oxford Hip and Knee Scores (OHS/OKS). The MFJS is a new assessment tool devised to provide a greater discriminatory power, particularly in well performing patients. It measures an appealing concept; the ability of a patient to forget about their artificial joint in everyday life. Postal questionnaires were sent out to 400 THR and TKR patients who were 1–2 years post-op. The data collected from the 212 returned questionnaires was analysed in relation to construct and content validity. 77 patients took part in a test-retest repeatability assessment. The MFJS proved to have an increased discriminatory power in high-performing patients in comparison to the OHS and OKS, highlighted by its more normal frequency of distribution and reduced ceiling effects. 30.8% of patients (n=131) achieved excellent OHS/OKS scores of 42–48 this compared to just 7.69% of patients who achieved a proportionately equivalent MFJS score of 87.5–100. The MFJS proved to have an increased test-retest repeatability based upon its intra-class correlation coefficient of 0.97 compared to the Oxford's 0.85. The MFJS provides a more sensitive tool in the assessment of well performing hip and knee arthroplasties in comparison to the OHS/OKS. The MFJS tests the concept of awareness of a prosthetic joint, rather than pain and function and therefore should be used as adjunct to the OKS/OHS

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

MOXIMED KineSpring® Knee Implant System is an Orthopaedic device designed for younger or highly active patients with osteoarthritis. The device is placed under the skin, is attached to the tibia and femur, and contains springs which help limit some of the forces that are transmitted through the knee during activities such as walking or running and thereby relieve pain that may be experienced by patients with early arthritis of the knee. The aim of this study is to determine the long term safety and efficacy of the KineSpring knee implant system. This is a prospective case series involving two centres in Glasgow. 29 patients (mean age of 45.1 years and range 18-65 years) were recruited into the study between 2011 and 2016. The Primary outcome measure was Oxford knee score (OKS) at 2, 5 and 10 years post-operatively. Secondary outcome measures include device related complications and survival, patient reported functional outcome measures, patient satisfaction, pain levels and change in radiographic classification of osteoarthritis. At 2-year follow-up, 7 implants were removed (74.1% survival). Complications include deep infection, requiring removal in 1 patient, 2 implant failures requiring removal and one spring breakage. In comparison to pre-operative measures there was an improvement in the pain (3.58 vs. 5.20, p=0.02), stiffness (4.16 vs. 4.47, p=0.6) and OKS (32.4 vs. 36.9, p=0.03). The KineSpring improves overall pain, stiffness and functional outcome at 2 years following surgery, however there was a high rate of removal and further long-term follow up analysis is required regarding its effectiveness

We report on the 5 year results of a randomized study comparing TKR performed using conventional instrumentation versus electromagnetic computer-assisted surgery. This study analysed patient reported outcome measures (PROMs) at 5 years utilising the American Knee Society Score (AKSS), Oxford Knee Score (OKS), the Short Form 36 score and range of motion (ROM). Of the 200 patients enrolled 125 completed 5 year follow up, 62 in the navigated group and 63 in the conventional group. There were 28 deceased patients, 29 withdrawals and 16 lost to follow-up. There was improvement in clinical function in most PROMs from 1-5 year follow up across both groups. OKS improved from a mean of 26.6 (12–55) to 35.1 (5–48). AKSS increased from 75.3 (0–100) to 78.4 (−10–100), SF36 from 58.9 (2.5–100) to 53.2 (0–100). ROM improved by an average 7 degrees from 110 degrees to 117 degrees (80–135). There was no statistically significant difference in PROMs between the groups at 5 years. Patients undergoing revision surgery were identified from the dataset and global PACS. There were no revisions within 5 years in the navigated group and 3 revisions in the conventional group, two for infection and one for mid-flexion instability, giving an all cause revision rate of 3.06% at 5 years for this group. There appears to be no significant advantage in clinical function for patients undergoing TKR for OA of the knee with electromagnetic navigation when compared to conventional techniques. There may be an advantage in reducing early revision rates using this technology

This study assessed whether patient satisfaction with their hospital stay influences the early outcome of total knee replacement (TKR). During a five year period patients undergoing primary TKR at the study centre had prospectively outcome data recorded (n=2264). Patients with depression (p=0.04) and worse mental wellbeing (p<0.001), according to the short form (SF)-12, were more likely to be dissatisfied with their hospital stay. Decreasing level of satisfaction with their hospital stay was associated with a significantly worse post-operative OKS (p<0.001) and SF-12 score (p<0.001). Multivariable regression analysis confirmed that the patients perceived level of satisfaction with their hospital stay was an independent predictor of change in the OKS (p<0.001) and SF-12 score (p<0.001) after adjusting for confounding variables. Patient satisfaction with their TKR was significantly influenced by their hospital experience, decreasing from 96% in those with an excellent experience to 42% in those with a poor experience. Food, staff/care, and the hospital environment were the most frequent reasons of why patients rated their hospital experience as fair or poor. A patient's perception of their inpatient hospital experience after surgery is an important modifiable predictor of early functional outcome and satisfaction with TKR

The primary aim of this study was to compare the knee specific functional outcome of partial compared with total knee replacement (TKR) for the management of patellofemoral osteoarthritis. Fifty-four consecutive Avon patellofemoral replacements were identified and propensity score matched to a group of 54 patients undergoing a TKR with patella resurfacing for patellofemoral osteoarthritis. The Oxford knee score (OKS), the Short Form (SF-) 12 and patient satisfaction were collected (mean follow up 9.2 years). Survival was defined by revision or intention to revise. There was no significant difference in the OKS (p>0.60) or SF-12 (p>0.28) between the groups. The TKR group was significantly less likely to be satisfied with their knee (95.1% versus 78.3%, OR 0.18, p=0.03). Length of stay was significantly (p=0.008) shorter for the Avon group (difference 1.8 days, 95% CI 0.4 to 3.2). The 10 year survival for the Avon group was 92.3% (95% CI 87.1 to 97.5) and for the TKR group was 100% (95% CI 93.8 to 100). There was no statistical difference in the survival rate (Log Rank p=0.10). The Avon patellofemoral replacement have a shorter length of stay with a functional outcome and satisfaction rate that is equal to that of TKR. The benefits of the Avon need to be balanced against the increased rate of revision when compared with TKR

Anterior knee pain post Total knee Replacement (TKR) has been reported to be as high as 49%. The source is poorly understood; both the peripatellar soft tissues and the infrapatellar fat pad have been implicated. Immunohistochemical studies demonstrate hyperinnervation of the peripatellar soft tissues. In theory circumferential electrocautery denervates the patella. However there is little evidence that this practice translates into improved clinical outcomes. This study aimed to find the effect on clinical outcome, of intraoperative circumpatellar electrocautery in patients undergoing TKR. 200 patients undergoing primary TKR were randomised to circumferential circumpatellar electrocautery or nothing. Patients were assessed for Visual (VAS) for anterior knee pain and Oxford Knee Score (OKS) preoperatively, 3 months, 6 months and 1 year post-procedure. Patients and assessors were blinded to treatment allocation until the end of the study. There were 91 patients in the electrocautery group and 94 controls. The mean VAS improvement from pre-op to one year was 3.8 in both groups. The mean improvement in OKS was 16.6 points in the control and 17.7 in the electrocautery group (p= 0.40). There were no significant differences between the two groups in terms of VAS or OKS at any other time. Although previous studies have conflicting outcomes, to our knowledge this is the first prospective randomised controlled blinded trial of significant power, to evaluate the effect of peripatellar diathermy in TKR. We conclude that denervation electrocautery of the patella makes no difference to the clinical outcomes of TKR

Electromagnetic navigation versus conventional Total Knee Arthroplasty: Clinical improvements Optical and electromagnetic (EM) tracking systems are widely used commercially. However in orthopaedic applications optical systems dominate the market. Optical systems suffer from deficiencies due to line of sight. EM trackers are smaller but are affected by metal. The accuracy of the two tracker systems has been seen to be comparable1. Recent advancements in optical navigated TKA have shown improved overall limb alignment, implant placement and reduce outliers when compared to conventional TKA2-4. This study is the first RCT to compare EM and conventional TKA. Two groups of 100 patients underwent TKA using either the EM navigation system or the conventional method. Frontal, sagittal and rotational alignment was analysed from a CT scan. Clinical scores including Oxford Knee Score (OKS) and Knee/Function American Knee Society Score (AKSS) were recorded pre-op, and at 3 and 12 months post-op. 3 month data presented includes 180 patients (n = 90). The 12 months data presented includes 140 (n = 70). The two groups had similar mean mechanical axis alignments (EM 0.31o valgus, conventional 0.15o valgus). The mechanical axis alignment was improved in the EM group with 92% within +/-3o of neutral compared to 84% of the conventional group (p = 0.90). The alignment of the EM group was improved in terms of frontal femoral, frontal tibial, sagittal femoral, sagittal tibial and tibial rotation alignment. However, only the sagittal femoral alignment was significantly improved in the EM group (p = 0.04). Clinically, both TKA groups showed significant improvements in OKS and AKSS scores between both pre-op to 3 month post-op and 3 months to 12 months post-op (p<0.001). The OKS and the AKSS knee score for the EM group was significantly better at 3 months post-op (OXS p = 0.02, AKSS knee p = 0.04). However there was no difference between the groups at 12 months. The mean pre-op range of motion (ROM) for both groups was 105o. This decreased to 102o in the EM group and 99o in the conventional group at 3 months. There was a significant improvement at 12 months post-op, EM = 113o (p = 0.012) and conventional = 112o (p = 0.026). There was no significant difference in ROM between the two groups at 3 or 12 months post-op. Therefore the alignment outcome of the EM TKA group was improved compared to the conventional group. The EM group also showed clinical improvements at 3 months post-op however these were not seen again at 12 months post-op. ROM was seen to decrease at 3 months post-op but then significantly improve by 12 month post-op

By the end of training, every registrar is expected to demonstrate proficiency in total knee replacement (TKR). It is unclear whether functional outcomes for knee arthroplasty performed by training grade doctors under supervision of a consultant have equivalent functional outcomes to those performed by consultants. This study investigated the functional outcomes following TKR in patients operated on by a supervised orthopaedic trainee compared to a consultant orthopaedic surgeon. Patients undergoing surgery by a consultant (n=491) or by a trainee under supervision (n=145) between 2003 and 2006 were included. There was a single implant, approach and postoperative rehabilitation regime. Patients were reviewed eighteen months, three years and five years postoperatively. There were no significant differences in preoperative patient characteristics between the groups. There was no difference in length of stay or transfusion or tourniquet time. Both consultant (p<0.001) and trainee (p<0.001) groups showed significant improvement in AKSK and AKSF scores between preoperative and 18 month review and there was no difference in the magnitude of observed improvement between groups (AKSK p=0.853; AKSF p=0.970). There were no significant differences in either score between the groups preoperatively or at any review point postoperatively. At five years postoperative, both groups had a median OKS of 34 (p=0.921). This is the largest reported series of outcomes following primary TKR examining functional outcome linked with grade of surgeon. It shows that a supervised trainee will achieve comparable functional outcomes at up to 5 years post operatively

There is conflicting data from small retrospective studies as to whether pre-operative mental health influences the outcome of total knee replacement (TKR). We assessed the effect of mental disability upon the outcome of TKR and whether mental health improves post-operatively. During a three year period patients undergoing TKR for primary osteoarthritis at the study centre had prospectively outcome data recorded (n=962). Pre-operative and one year short-form (SF) 12 scores and Oxford knee scores (OKS) were obtained. The mental component of the SF-12 was stratified into four groups according to level of mental disability (none ≥50, mild 40to49, moderate 30to39, severe <30). Ethical approval was obtained (11/AL/0079). Patients with any degree of mental disability had a significantly greater subjective physical disability according to the SF-12 (p=0.06) and OKS (p<0.001). Although the improvement in the disease specific score (OKS) was not affected by a patients mental health (p=0.33). In contrast the improvement of the global physical health (SF-12) for patients with a mental disability did not improve to the same magnitude (p<0.001). However, patients with mental disability, of any degree, had a significant improvement in their mental health post-operatively (p<0.0001). Despite the similar improvement in the disease specific scores and improvement in their mental health, patients with mental disability were significantly more likely to be dissatisfied with their TKR at one year (p=0.001). TKR for patients with poor mental health benefit from improvement in their mental health and in their knee function, but do have a higher rate of dissatisfaction

Unicompartmental knee replacements (UKRs) have inconsistent and variable survivorships reported in the literature. It has been suggested that many are revised for ongoing pain with no other mode of failure identified. Using a medial UKR with an all-polyethylene non-congruent tibial component from 2004–7, we noted a revision rate of 9/98 cases (9.2%) at a mean of 39 months. Subchondral sclerosis was noted under the tibial component in 3/9 revisions with well fixed implants, and the aim of this study was to investigate this as a mode of failure. 89 UKRs in 77 patients were investigated radiographically (at mean 50 months) and with SF-12 and Oxford Knee scores at mean follow up 55 months. Subjectively 23/89 cases (25%) had sclerosis under the tibial component. We describe a method of quantifying this sclerosis as a greyscale ratio (GSR), which was significantly correlated with presence/absence of sclerosis (p<0.001). Significant predictors of elevated GSR (increasing sclerosis) were female sex (p<0.001) and elevated BMI (P=0.010) on both univariate and multivariate analysis. In turn, elevated GSR was significantly associated with poorer improvement in OKS (p<0.05) at the time of final follow up. We hypothesise that this sclerosis results from repetitive microfracture and adaptive remodelling in the proximal tibia due to increased strain. Finite element analysis is required to investigate this further, but we suggest caution should be employed when considering all polyethylene UKR implants in older women and in those with BMI >35

Aims

The aim of this study was to assess the feasibility of conducting a full-scale, appropriately powered, randomized controlled trial (RCT) comparing internal fracture fixation and distal femoral replacement (DFR) for distal femoral fractures in older patients.

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.