The purpose of our study was to assess the reproducibility and reliability of traditional radiographic methods of diagnosing trochlear dysplasia compared with the gold standard of MRI. Plain radiographs and MRI scans of 36 knees in 28 patients with proven trochlear dysplasia were compared with 18 controls in a single surgeon's practice. The sulcus angle on MRI and axial radiographs was measured. The lateral radiograph was assessed for adequacy, the crossing sign and the trochlear bump sign. The mean axial (radiograph) and MRI sulcus angles in the dysplastic group were 145° and 158° respectively (p=0.0001) compared to 135° and 138° in the control group (p=0.09). The crossing sign was present in 34 out of 36 lateral radiographs in the dysplastic group and 8 out of 18 in the control group equating to a sensitivity of 94% and specificity of 56%. The quality of the lateral radiograph did not significantly alter the sensitivity or specificity of the crossing sign (p=0.01). The bump sign was present in 22 out of 36 lateral radiographs in the dysplastic group and 1 out of 18 in the control group equating to a sensitivity of 61% and specificity of 94%. Our study shows that an increased radiographic sulcus angle is reliable in diagnosing trochlear dysplasia but underestimates it. The bump sign is a reliable predictor of trochlear dysplasia. The crossing sign is sensitive but not specific in diagnosing dysplasia

Abstract. Introduction. High posterior tibial slope (PTS) has been recognised as a risk factor for anterior cruciate ligament rupture and graft failure. This prospective randomised study looked at intra-operative findings of concomitant intra-articular meniscal and chondral injuries during a planned ACL reconstruction. Material and Methods. Prospective data was collected as part of a randomised trial for ACL reconstruction techniques. Intra-operative data was collected and these findings were compared with the PTS measured on plain radiograph by a single person twice through a standardised technique and intra-observer analysis was performed. Results. 49 confirmed ACL rupture patients were in the trial. The average age was 34 (23–66) years and 12 patients were female. 17 patients (34%) had PTS of 12 degrees or more. The intra-observer analysis for PTS measurements in a 2-sided paired T test, showed a mean difference of 0.03 degrees with a P value = 0.83. 23 patients had medial meniscal pathology identified, 15 (65%) had a PTS <12 degrees. 16 patients had lateral meniscus pathology and 9 (56%) had a PTS <12 degrees. Chondral damage did not appear significantly different in the two groups (<12 degrees 15% vs >12 degrees 23%). Conclusion. In this sample, a PTS >12 degrees was not associated with a higher incidence of meniscal or chondral damage after a confirmed ACL rupture

Aims. The mean age of patients undergoing total knee arthroplasty (TKA) has reduced with time. Younger patients have increased expectations following TKA. Aseptic loosening of the tibial component is the most common cause of failure of TKA in the UK. Interest in cementless TKA has re-emerged due to its encouraging results in the younger patient population. We review a large series of tantalum trabecular metal cementless implants in patients who are at the highest risk of revision surgery. Methods. A total of 454 consecutive patients who underwent cementless TKA between August 2004 and December 2021 were reviewed. The mean follow-up was ten years. Plain radiographs were analyzed for radiolucent lines. Patients who underwent revision TKA were recorded, and the cause for revision was determined. Data from the National Joint Registry for England, Wales, Northern Island, the Isle of Man and the States of Guernsey (NJR) were compared with our series. Results. No patients in our series had evidence of radiolucent lines on their latest radiological assessment. Only eight patients out of 454 required revision arthroplasty, and none of these revisions were indicated for aseptic loosening of the tibial baseplate. When compared to data from the NJR annual report, Kaplan-Meier estimates from our series (2.94 (95% confidence interval (CI) 1.24 to 5.87)) show a significant reduction in cumulative estimates of revision compared to all cemented (4.82 (95% CI 4.69 to 4.96)) or cementless TKA (5.65 (95% CI 5.23 to 6.10)). Our data (2.94 (95% CI 1.24 to 5.87)) also show lower cumulative revision rates compared to the most popular implant (PFC Sigma Cemented Knee implant fixation, 4.03 (95% CI 3.75 to 4.33)). The prosthesis time revision rate (PTIR) estimates for our series (2.07 (95% CI 0.95 to 3.83)) were lower than those of cemented cases (4.53 (95% CI 4.49 to 4.57)) from NJR. Conclusion. The NexGen trabecular (tantalum) cementless implant has lower revision rates in our series compared to all cemented implants and other types of cementless implants, and its use in younger patients should be encouraged. Cite this article: Bone Jt Open 2024;5(4):277–285

Aims. The primary aim of this study was to compare the postoperative systemic inflammatory response in conventional jig-based total knee arthroplasty (conventional TKA) versus robotic-arm assisted total knee arthroplasty (robotic TKA). Secondary aims were to compare the macroscopic soft tissue injury, femoral and tibial bone trauma, localized thermal response, and the accuracy of component positioning between the two treatment groups. Methods. This prospective randomized controlled trial included 30 patients with osteoarthritis of the knee undergoing conventional TKA versus robotic TKA. Predefined serum markers of inflammation and localized knee temperature were collected preoperatively and postoperatively at six hours, day 1, day 2, day 7, and day 28 following TKA. Blinded observers used the Macroscopic Soft Tissue Injury (MASTI) classification system to grade intraoperative periarticular soft tissue injury and bone trauma. Plain radiographs were used to assess the accuracy of achieving the planned postioning of the components in both groups. Results. Patients undergoing conventional TKA and robotic TKA had comparable changes in the postoperative systemic inflammatory and localized thermal response at six hours, day 1, day 2, and day 28 after surgery. Robotic TKA had significantly reduced levels of interleukin-6 (p < 0.001), tumour necrosis factor-α (p = 0.021), ESR (p = 0.001), CRP (p = 0.004), lactate dehydrogenase (p = 0.007), and creatine kinase (p = 0.004) at day 7 after surgery compared with conventional TKA. Robotic TKA was associated with significantly improved preservation of the periarticular soft tissue envelope (p < 0.001), and reduced femoral (p = 0.012) and tibial (p = 0.023) bone trauma compared with conventional TKA. Robotic TKA significantly improved the accuracy of achieving the planned limb alignment (p < 0.001), femoral component positioning (p < 0.001), and tibial component positioning (p < 0.001) compared with conventional TKA. Conclusion. Robotic TKA was associated with a transient reduction in the early (day 7) postoperative inflammatory response but there was no difference in the immediate (< 48 hours) or late (day 28) postoperative systemic inflammatory response compared with conventional TKA. Robotic TKA was associated with decreased iatrogenic periarticular soft tissue injury, reduced femoral and tibial bone trauma, and improved accuracy of component positioning compared with conventional TKA. Cite this article: Bone Joint J 2021;103-B(1):113–122

Introduction. The objectives of this study were to compare the systemic inflammatory reaction, localised thermal response and macroscopic soft tissue injury outcomes in conventional jig-based total knee arthroplasty (conventional TKA) versus robotic total knee arthroplasty (robotic TKA). Methods. This prospective randomised controlled trial included 30 patients with symptomatic knee osteoarthritis undergoing conventional TKA versus robotic TKA. Predefined serum markers of inflammation and localised knee temperature were collected preoperatively and postoperatively at 6 hours, day 1, day 2, day 7, and day 28 following TKA. Blinded observers used the Macroscopic Soft Tissue Injury (MASTI) classification system to grade intraoperative periarticular soft tissue injury and bone trauma. Plain radiographs were used to assess the accuracy of achieving the planned limb alignment and implant positioning in both treatment groups. Results. Conventional TKA and robotic TKA had comparable changes in the postoperative systemic inflammatory reaction and localised thermal response at 6 hours, day 1, day 2 and day 28 after surgery. Robotic TKA had reduced levels of interleukin-6 (p<0.001), tumour necrosis factor-α (p=0.021), erythrocyte sedimentation rate (p=0.001), C-reactive protein (p=0.004), and creatine kinase (p=0.004) at day 7 after surgery compared to conventional TKA. Robotic TKA was associated with improved intraoperative preservation of the periarticular soft tissue envelope (p<0.001) and reduced bone trauma (p=0.015) compared to conventional TKA. Robotic TKA improved accuracy of achieving the planned limb alignment (p<0.001), femoral component positioning (<0.001), and tibial component positioning (<0.001) compared to conventional TKA. Conclusion. Robotic TKA was associated with a transient reduction in the early (day 7) postoperative inflammatory response but there was no difference in the immediate (<48 hours) or late (day 28) postoperative systemic inflammatory responses compared to conventional TKA. Robotic TKA was associated with decreased iatrogenic periarticular soft tissue injury, reduced bone trauma and improved accuracy of implant positioning compared to conventional TKA

Objectives. An important measure for the diagnosis and monitoring of knee osteoarthritis is the minimum joint space width (mJSW). This requires accurate alignment of the x-ray beam with the tibial plateau, which may not be accomplished in practice. We investigate the feasibility of a new mJSW measurement method from stereo radiographs using 3D statistical shape models (SSM) and evaluate its sensitivity to changes in the mJSW and its robustness to variations in patient positioning and bone geometry. Materials and Methods. A validation study was performed using five cadaver specimens. The actual mJSW was varied and images were acquired with variation in the cadaver positioning. For comparison purposes, the mJSW was also assessed from plain radiographs. To study the influence of SSM model accuracy, the 3D mJSW measurement was repeated with models from the actual bones, obtained from CT scans. Results. The SSM-based measurement method was more robust (consistent output for a wide range of input data/consistent output under varying measurement circumstances) than the conventional 2D method, showing that the 3D reconstruction indeed reduces the influence of patient positioning. However, the SSM-based method showed comparable sensitivity to changes in the mJSW with respect to the conventional method. The CT-based measurement was more accurate than the SSM-based measurement (smallest detectable differences 0.55 mm versus 0. 82 mm, respectively). Conclusion. The proposed measurement method is not a substitute for the conventional 2D measurement due to limitations in the SSM model accuracy. However, further improvement of the model accuracy and optimisation technique can be obtained. Combined with the promising options for applications using quantitative information on bone morphology, SSM based 3D reconstructions of natural knees are attractive for further development. Cite this article: E. A. van IJsseldijk, E. R. Valstar, B. C. Stoel, R. G. H. H. Nelissen, N. Baka, R. van’t Klooster, B. L. Kaptein. Three dimensional measurement of minimum joint space width in the knee from stereo radiographs using statistical shape models. Bone Joint Res 2016;320–327. DOI: 10.1302/2046-3758.58.2000626

Abstract. Introduction. Coronal plane alignment of the knee (CPAK) classification utilises the native arithmetic hip-knee alignment to calculate the constitutional limb alignment and joint line obliquity which is important in pre-operative planning. The objective of this study was to compare the accuracy and reproducibility of measuring the lower limb constitutional alignment with the traditional long leg radiographs versus computed tomography (CT) used for pre-operative planning in robotic-arm assisted TKA. Methods. Digital long leg radiographs and pre-operative CT scan plans of 42 patients (46 knees) with osteoarthritis undergoing robotic-arm assisted total knee replacement were analysed. The constitutional alignment was established by measuring the medial proximal tibial angle (mPTA), lateral distal femoral angle (LDFA), weight bearing hip knee alignment (WBHKA), arithmetic hip knee alignment (aHKA) and joint line obliquity (JLO). Furthermore, the Coronal Plane Alignment of the Knee (CPAK) classification was utilised to classify the patients based on their coronal knee alignment phenotype. Results. Mean age of the patients was 66 years (SD 9) and mean BMI 31.2 (SD 3.9). There were 27 left and 19 right sided surgeries. The Pearson's corelation coefficient was 0.722 (p=0.008) for WBHKA; 0.729 (p<0.001) for MPTA; 0.618 (p=0.14) for aHKA; 0.502 (p= 0.04) for LDFA and 0.305 (p=0.234) for JLO. CPAK classification was concordant for 53% study participants between the two groups. Conclusion. Three-dimensional CT-based modelling with computer software more accurately predicts constitutional limb alignment and JLO as defined by the CPAK classification compared to plain long-leg radiographs in pre-operative planning of total knee arthroplasty

We studied whether the presence of lateral osteophytes on plain radiographs was a predictor for the quality of cartilage in the lateral compartment of patients with varus osteoarthritic of the knee (Kellgren and Lawrence grade 2 to 3). The baseline MRIs of 344 patients from the Osteoarthritis Initiative (OAI) who had varus osteoarthritis (OA) of the knee on hip-knee-ankle radiographs were reviewed. Patients were categorised using the Osteoarthritis Research Society International (OARSI) osteophyte grading system into 174 patients with grade 0 (no osteophytes), 128 grade 1 (mild osteophytes), 28 grade 2 (moderate osteophytes) and 14 grade 3 (severe osteophytes) in the lateral compartment (tibia). All patients had Kellgren and Lawrence grade 2 or 3 arthritis of the medial compartment. The thickness and volume of the lateral cartilage and the percentage of full-thickness cartilage defects in the lateral compartment was analysed. There was no difference in the cartilage thickness or cartilage volume between knees with osteophyte grades 0 to 3. The percentage of full-thickness cartilage defects on the tibial side increased from < 2% for grade 0 and 1 to 10% for grade 3. The lateral compartment cartilage volume and thickness is not influenced by the presence of lateral compartment osteophytes in patients with varus OA of the knee. Large lateral compartment osteophytes (grade 3) increase the likelihood of full-thickness cartilage defects in the lateral compartment. Cite this article: Bone Joint J 2015;97-B:1634–9

Background. Implant loosening is a common cause of a poor outcome and pain after total knee arthroplasty (TKA). Despite the increase in use of expensive techniques like arthrography, the detection of prosthetic loosening is often unclear pre-operatively, leading to diagnostic uncertainty and extensive workup. The objective of this study was to evaluate the ability of a machine learning (ML) algorithm to diagnose prosthetic loosening from pre-operative radiographs, and to observe what model inputs improve the performance of the model. Methods. 754 patients underwent a first-time revision of a total joint at our institution from 2012–2018. Pre-operative X-Rays (XR) were collected for each patient. AP and lateral X-Rays, in addition to demographic and comorbidity information, were collected for each patient. Each patient was determined to have either loose or fixed prosthetics based on a manual abstraction of the written findings in their operative report, which is considered the gold standard of diagnosing prosthetic loosening. We trained a series of deep convolution neural network (CNN) models to predict if a prosthesis was found to be loose in the operating room from the pre-operative XR. Each XR was pre-processed to segment the bone, implant, and bone-implant interface. A series of CNN models were built using existing, proven CNN architectures and weights optimized to our dataset. We then integrated our best performing model with historical patient data to create a final model and determine the incremental accuracy provided by additional layers of clinical information fed into the model. The models were evaluated by its accuracy, sensitivity and specificity. Results. The CNN we built demonstrated high performance at detecting prosthetic loosening from radiographs alone. Our first model built from scratch on just the image as an input had an accuracy of 70%. Our final model which was built by fine-tuning and optimizing a publicly available model named DenseNet, combining the AP and lateral radiographs, incorporating information from the patient history, had an accuracy, sensitivity, and specificity of 98.5%, 93.9%, and 99.5% on the patients that it was trained on, and an accuracy, sensitivity, and specificity of 88.3%, 70.2%, and 95.6% on the patients it was tested on. Conclusions. The use of machine learning (ML) can accurately detect the presence of prosthetic loosening based on plain radiographs. Its accuracy is progressively enhanced when additional clinical data is added to the loosening analysis algorithm. While this type of machine learning may not be sufficient in its present state of development as a standalone metric of loosening, it is clearly a useful augment for clinical decision making in its present state. Further study and development will be needed to determine the feasibility of applying machine learning as a more definitive test in the clinical setting. For figures, tables, or references, please contact authors directly

We studied the intra- and interobserver reliability of measurements of the position of the components after total knee replacement (TKR) using a combination of radiographs and axial two-dimensional (2D) and three-dimensional (3D) reconstructed CT images to identify which method is best for this purpose. A total of 30 knees after primary TKR were assessed by two independent observers (an orthopaedic surgeon and a radiologist) using radiographs and CT scans. Plain radiographs were highly reliable at measuring the tibial slope, but showed wide variability for all other measurements; 2D-CT also showed wide variability. 3D-CT was highly reliable, even when measuring rotation of the femoral components, and significantly better than 2D-CT. Interobserver variability in the measurements on radiographs were good (intraclass correlation coefficient (ICC) 0.65 to 0.82), but rotational measurements on 2D-CT were poor (ICC 0.29). On 3D-CT they were near perfect (ICC 0.89 to 0.99), and significantly more reliable than 2D-CT (p < 0.001). 3D-reconstructed images are sufficiently reliable to enable reporting of the position and orientation of the components. Rotational measurements in particular should be performed on 3D-reconstructed CT images. When faced with a poorly functioning TKR with concerns over component positioning, we recommend 3D-CT as the investigation of choice

We used single-photon emission computed tomography (SPECT) to determine the long-term risk of degenerative change after reconstruction of the anterior cruciate ligament (ACL). Our study population was a prospective series of 31 patients with a mean age at injury of 27.8 years (18 to 47) and a mean follow-up of ten years (9 to 13) after bone-patellar tendon-bone reconstruction of the ACL. The contralateral normal knee was used as a control. All knees were clinically stable with high clinical scores (mean Lysholm score, 93; mean Tegner activity score, 6). Fifteen patients had undergone a partial meniscectomy and ACL reconstruction at or before reconstruction of their ACL. In the group with an intact meniscus, clinical symptoms of osteoarthritis (OA) were found in only one patient (7%), who was also the only patient with marked isotope uptake on the SPECT scan compatible with OA. In the group which underwent a partial meniscectomy, clinical symptoms of OA were found in two patients (13%), who were among five (31%) with isotope uptake compatible with OA. Only one patient (7%) in this group had evidence of advanced OA on plain radiographs. The risk of developing OA after ACL reconstruction in this series is very low and lower than published figures for untreated ACL-deficient knees. There is a significant increase (p < 0.05) in degenerative change in patients who had a reconstruction of their ACL and a partial meniscectomy compared with those who had a reconstruction of their ACL alone

We prospectively examined the physical and imaging findings, including MRI, of 23 patients with spontaneous osteonecrosis of the knee after obtaining informed consent to acquire tissue specimens at surgery. There were four men and 19 women, with a mean age of 67.5 years (58 to 77). Plain radiographs were designated as stages 1, 2, 3 or 4 according to the classification of Koshino. Five knees were classified as stage 1, five as stage 2, seven as stage 3 and six as stage 4. The histological specimens were stained with haematoxylin and eosin and tetrachrome. In the early stages of the condition, a subchondral fracture was noted in the absence of any features of osteonecrosis, whereas in advanced stages, osteonecrotic lesions were confined to the area distal to the site of the fracture which showed impaired healing. In such cases, formation of cartilage and fibrous tissue, occurred indicating delayed or nonunion. These findings strongly suggest that the histopathology at each stage of spontaneous osteonecrosis is characterised by different types of repair reaction for subchondral fractures

We report a patient with a subperiosteal ganglion cyst of the tibia which was imaged by radiography, arthrography, CT and MRI. The images were correlated with the arthroscopic surgical and histological findings. Spiculated formation of periosteal new bone on plain radiographs led to the initial suspicion of a malignant tumour. Demonstration of the cystic nature of the tumour using cross-sectional imaging was important for the precise diagnosis. Communication between the ganglion cyst and the knee was shown by a delayed arthrographic technique, and the presence of this communication was confirmed at arthroscopy and surgically

The Fulkerson osteotomy has proved to be a reliable treatment for subluxation of the patella due to malalignment. Aggressive rehabilitation in the early postoperative period is unwise since the proximal tibia is weakened by the oblique osteotomy. Early weight-bearing and unrestricted activity have caused fractures in a few patients. Even late in the postoperative period the osteotomy may adversely influence the biomechanical properties of the proximal tibia. We describe two athletes who sustained a fracture of the proximal tibia, during recreational activities, six months after a Fulkerson osteotomy. Both had been bearing full weight for about ten weeks without complaint. Bony healing of the osteotomy had been demonstrated on plain radiographs at ten and at 12 weeks. After a Fulkerson osteotomy, jogging and activities which impose considerable impact force should be discouraged for at least nine to 12 months

Aims

This study aims to determine the rate of and risk factors for total knee arthroplasty (TKA) after operative management of tibial plateau fractures (TPFs) in older adults.

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To perform an incremental cost-utility analysis and assess the impact of differential costs and case volume on the cost-effectiveness of robotic arm-assisted unicompartmental knee arthroplasty (rUKA) compared to manual (mUKA).

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The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach.

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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).

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Obtaining solid implant fixation is crucial in revision total knee arthroplasty (rTKA) to avoid aseptic loosening, a major reason for re-revision. This study aims to validate a novel grading system that quantifies implant fixation across three anatomical zones (epiphysis, metaphysis, diaphysis).

Aims

The rate of day-case total knee arthroplasty (TKA) in the UK is currently approximately 0.5%. Reducing length of stay allows orthopaedic providers to improve efficiency, increase operative throughput, and tackle the rising demand for joint arthroplasty surgery and the COVID-19-related backlog. Here, we report safe delivery of day-case TKA in an NHS trust via inpatient wards with no additional resources.