This randomised trial evaluated the outcome of a single design of unicompartmental arthroplasty of the knee (UKA) with either a cemented all-polyethylene or a metal-backed modular tibial component. A total of 63 knees in 45 patients (17 male, 28 female) were included, 27 in the all-polyethylene group and 36 in the metal-backed group. The mean age was 57.9 years (39.6 to 76.9). At a mean follow-up of 6.4 years (5 to 9.9), 11 all-polyethylene components (41%) were revised (at a mean of 5.8 years; 1.4 to 8.0) post-operatively and two metal-backed components were revised (at one and five years). One revision in both groups was for unexplained pain, one in the metal-backed group was for progression of osteoarthritis. The others in the all-polyethylene group were for aseptic loosening. The survivorship at seven years calculated by the Kaplan–Meier method for the all-polyethylene group was 56.5% (95% CI 31.9 to 75.2, number at risk 7) and for the metal-backed group was 93.8% (95% CI 77.3 to 98.4, number at risk 16) This difference was statistically significant (p <  0.001). At the most recent follow-up, significantly better mean Western Ontario and McMaster Universities Arthritis Index Scores were found in the all-polyethylene group (13.4 vs 23.0, p = 0.03) but there was no difference in the mean Knee injury and Osteoarthritis Outcome scores (68.8; 41.4 to 99.0 vs 62.6; 24.0 to 100.0), p = 0.36). There were no significant differences for range of movement (p = 0.36) or satisfaction (p = 0.23).

This randomised study demonstrates that all-polyethylene components in this design of fixed bearing UKA had unsatisfactory results with significantly higher rates of failure before ten years compared with the metal-back components.

Cite this article: Bone Joint J 2015;97-B:786–92.

Early implants for total knee replacement were fixed to bone with cement. No firm scientific reason has been given for the introduction of cementless knee replacement and the long-term survivorship of such implants has not shown any advantage over cemented forms. In a randomised, prospective study we have compared cemented and uncemented total knee replacement and report the results of 139 prostheses at five years. Outcome was assessed both clinically by independent examination using the Nottingham knee score and radiologically using the Knee Society scoring system.

Independent statistical analysis of the data showed no significant difference between cemented and cementless fixation for pain, mobility or movement. There was no difference in the radiological alignment at five years, but there was a notable disparity in the radiolucent line score. With cemented fixation there was a significantly greater number of radiolucent lines on anteroposterior radiographs of the tibia and lateral radiographs of the femur.

At five years, our clinical results would not support the use of the more expensive cementless fixation whereas the radiological results are of unknown significance. Longer follow-up will determine any changes in the results and conclusions.

Purpose

The purpose was to determine if the use of cold irrigation fluid in routine knee arthroscopy leads to a reduction in post operative pain.

Introduction

There is conflicting evidence about the merits of using mobile bearings at total knee replacement (TKR), partly because most randomised controlled trials (RCTs) have not been adequately powered.

PURPOSE OF STUDY

20-70% of patients need blood transfusion postoperatively. There remain safety concerns regarding allogenic blood transfusion. Tranexamic acid (TA) is a synthetic antifibrinolytic agent that has been successfully used to stop bleeding in other specialties. We applied TA topically prior to the wound closure to find out the effect on blood loss as well as need for subsequent blood transfusion. This method of administration is quick, easy, has less systemic side effect and provides a higher concentration at the bleeding site.

Aim

To compare minimally invasive (MIS) and standard surgical total knee replacement technique through a prospective, randomised, single-centre, multi-surgeon, controlled trial.

STUDY PURPOSES

To evaluate the role of “top up” intra-articular local anaesthetic injection in patients who have had UKR.

The aim of this study was to compare the efficacy of a hyaluronic acid (HA) supplement and a local anaesthetic (Bupivacaine) at providing early and short-term post-operative anagesic control following knee arthroscopy.

Patients were randomised to receive either 10mls of 0.5% Bupivacaine or 10mls of HA into the joint immediately after completion of surgery. WOMAC and Tegner-Lysholm scores were obtained at baseline then at 1, 2, and 6-weeks post surgery. VAS pain scores were obtained at baseline; 1 and 24-hours; and 1, 2 and 6 weeks following surgery.

49 patients received intra-articular Bupivacaine and 49 HA. There was no statistical difference in any of the outcome measures (WOMAC, Tegner-Lysholm, VAS pain scores) at any time point between the groups overall. Patients with grade III-IV chondral defects that received HA reported significantly lower VAS pain scores at rest and movement at all time points.

Use of Bupivacaine and HA intra-articular injection results in equivalent analgesic control in the immediate post-operative period and first six-weeks following surgery when administered immediately at the end of knee arthroscopy. Utilizing HA following knee arthroscopy does not sacrifice analgesic control and minimises exposure to chondrotoxic agents. Selective use of HA may improve pain-control in those with advanced chondral defects.

Introduction

Kneeling ability is better in unicompartmental than total knee arthroplasty. There is also an impression that mobile bearing knees achieve better functional outcome than their fixed bearing cousins in unicompartmental and to a lesser extent total joint arthroplasty. In the UK, the market leading unicompartmental replacement is mobile bearing.

Abstract. Introduction. Multiple strategies, used either in isolation or combination, are available to reduce the need for post-operative blood transfusion in joint replacements. Amongst them, the use of tranexamic acid (TXA) has been rising and this study was conducted to compare the efficacy of topical and intravenous TXA in bilateral total knee replacement patients. Materials and methods. Randomised prospective study with 120 patients (male: female: 25:95) undergoing bilateral TKA. Patients were divided into two groups A and B after computer randomization, who received intravenous or topical (intra-articular) TXA respectively. Results. The average haemoglobin loss in intravenous group was 90.2379 g/L as compared to 39.137 g/L in topical group (p < 0.005). Moreover, there was reduction in blood loss in topical (330.1602 ml) as compared to intravenous group (764.9622 ml). The blood transfusion rate was more for the intravenous group (average 1.73 units) than for the topical group (average 0.75, unit). WOMAC score at 6 weeks in the intravenous group was 12.50, and in the topical group was 7.23 (p value < 0.001). Conclusion. Topical TXA is better than intravenous TXA for reduction of blood loss, which also reduces the need for blood transfusion in bilateral TKA patients

Objective

To compare the clinical outcomes of bone-patellar tendon-bone (BTB) allografts sterilised through a novel sterilisation system with aseptically processed BTB allografts for Anterior Cruciate Ligament (ACL) reconstruction. The following hypotheses were also tested: (1) the cumulative score of the IKDC is not significantly different in the sterilised treatment group than in the aseptic control group, (2) the proportion of normal laxity in patients, as measured by the KT 2000 arthrometer, is not significantly different in the sterilised group than in the aseptic control group.

Abstract. Introduction. In recent years, CTA has been an effective training adjunct for orthopaedic procedures. ACLR is a complex procedure with a steep learning curve. Aim. To design a multimedia CTA learning tool for ACLR using a modified Delphi methodology. Methodology:. CTA generation: A modified Delphi method was used to generate a list of Technical Steps (TS), Decision Points (DP) and errors/solutions for an ACLR that was approved by an expert consensus amongst four, fellowship-trained knee surgeons. A technical workflow was designed to generate the audio-visual tool. Pilot study: 30 novice trainees were granted access to the CTA tool and then performed the ACLR in a cadaveric simulation workshop. A 5-point Likert scale aimed to qualitatively assess if the CTA was useful to their learning. Results:. CTA generation: 156 TS and 79 DP were included for an ACLR procedure which was divided into 7 phases. The audio-visual component was combined with the written tool to design the final CTA tool. Pilot study: 95% of trainees suggested the CTA tool would be useful before carrying out an ACLR in the operating theatre. They agreed it made their ACLR learning more effective. Conclusion:. We have designed a novel and easily accessible CTA tool to standardise teaching of ACLR surgery. Novice surgeons verify the value of the CTA as an adjunct to their apprenticeship training. Future work: A Randomised Controlled Trial (RCT) is currently being planned to evaluate whether there are any objective benefits of this CTA to train surgeons performing an ACLR

Abstract. Introduction. The postoperative inflammatory response may be implicated in the aetiology of patient dissatisfaction following Total Knee Arthroplasty. Robotic-arm assisted TKA has been associated with reduced bone and soft tissue trauma. The objective of this Randomised Controlled Trial was to compare the inflammatory response in conventional Jig-based versus robotic arm-assisted TKA and examine the relationship with patient reported outcome measures and functional outcomes. Methodology. 30 patients with knee osteoarthritis were randomised to either conventional or robotic-arm assisted TKA. Blood samples were collected for up to 28 days post-operatively and intraarticular drain samples at 6 and 24 hours, to ascertain the systemic and local inflammatory responses. The Spearman's correlation was utilised to evaluate the relationship with PROMs and functional outcomes. Results. Reduced IL-6 drain fluid levels were noted at 6 hours [798.54 vs. 5699.2, p=0.026] and 24 hours and IL-8 at 6 hours. Patients in the robotic group had lower pain scores on post-operative day 1, 2 and 7. PROM scores were comparable at 2 years. Statistically significant correlations were evident between all serum markers except IL-1b on the 7th postoperative day and self-reported pain; between drain IL-8 levels and self-reported pain; between drain IL-6, IL-8 and TNF-a levels (6-hours) and knee flexion and extension. Conclusion. Robotic-arm assisted TKA was associated with a reduced postoperative local and systemic inflammatory responses. A moderate correlation with self-reported pain, knee flexion and extension was also demonstrated. Longer-term data and further validation on a larger scale, will be key to developing the optimal TKA procedure

Abstract. Introduction. Higher than expected rates of tibial loosening with the ATTUNE® total knee arthroplasty (TKA) implant has been reported. Component loosening can be associated with the development of radiolucency lines (RLL) and our study aim was to systematically assess the reported rates of these. Methodology. A systematic search was undertaken using the Cochrane methodology in four online databases. Identified studies were assessed and screened against predetermined inclusion criteria. Meta-analysis was conducted using a random-effects model. Results. Nine studies (n=2,727 TKAs) from 6,590 titles met the inclusion criteria: 1 Randomised Controlled Trial (n=74), 1 prospective cohort (n=200), 4 retrospective cohort (n=1,639), and 3 case-series (n=814). All used the 2013 ATTUNE® design. In meta-analysis: 8 studies (n=1,440 ATTUNE TKAs) reported an overall prevalence of 11% (95%CI: 6.4-18.3%) for medial tibia RLL; 7 studies (n=940) a 12.3% (95%CI: 4.0-32%) rate of any tibia RLL.; 5 studies (n=736) femoral RLL in 11% (95%CI: 7.2-106.5%) and 7 studies (n=896) any RLL in 20.7% (95%CI: 13.4-30.6%). Meta-analysis of 4 studies (n=1,036) comparing the ATTUNE® with another implant (PFC Sigma®, LCS®, or PERSONA®) showed a higher risk of medial tibia RLL (OR: 2.538; 95%CI: 1.397-4.611, P=0.002) and any RLL (OR: 2.725; 95%CI: 1.302-5.703, P=0.008) in the ATTUNE® group. Conclusions. The 2013 ATTUNE® TKA system is associated with high rates of radiolucency around the tibial and femoral components. Comparative studies suggesting these rates are more than double those of other systems. Radiolucency may be a herald of component loosening, therefore, close surveillance of this implant is recommended

Aims

The aim was to assess whether robotic-assisted total knee arthroplasty (rTKA) had greater knee-specific outcomes, improved fulfilment of expectations, health-related quality of life (HRQoL), and patient satisfaction when compared with manual TKA (mTKA).

Animal studies have shown that implanted anterior cruciate ligament (ACL) grafts initially undergo a process of revascularisation prior to remodelling, ultimately increasing mechanical strength. We investigated whether minimal debridement of the intercondylar notch and the residual stump of the ruptured ACL leads to earlier revascularisation in ACL reconstruction in humans. We undertook a randomised controlled clinical trial in which 49 patients underwent ACL reconstruction using autologous four-strand hamstring tendon grafts. Randomised by the use of sealed envelopes, 25 patients had a conventional clearance of the intercondylar notch and 24 had a minimal debridement method. Three patients were excluded from the study. All patients underwent MR scanning postoperatively at 2, 6 and 12 months, together with clinical assessment using a KT-1000 arthrometer and International Knee Documentation Committee (IKDC) evaluation. All observations were made by investigators blinded to the surgical technique. Signal intensity was measured in 4 mm diameter regions of interest along the ACL graft and the mid-substance of the posterior cruciate ligament. Our results indicate that minimal debridement leads to earlier revascularisation within the mid-substance of the ACL graft at two months (paired t-test, p = 0.002). There was a significant reduction of mid-substance signal six months after the minimal debridement technique (paired t-test, p = 0.00007). No statistically significant differences were found in tunnel placement, incidence of Cyclops lesions, blood loss, IKDC scores, range of movement or Lachman test between the two groups

We conducted a meta-analysis, including randomised controlled trials (RCTs) and cohort studies, to examine the effect of patient-specific instruments (PSI) on radiological outcomes after total knee replacement (TKR) including: mechanical axis alignment and malalignment of the femoral and tibial components in the coronal, sagittal and axial planes, at a threshold of > 3º from neutral. Relative risks (RR) for malalignment were determined for all studies and for RCTs and cohort studies separately.

Of 325 studies initially identified, 16 met the eligibility criteria, including eight RCTs and eight cohort studies. There was no significant difference in the likelihood of mechanical axis malalignment with PSI versus conventional TKR across all studies (RR = 0.84, p = 0.304), in the RCTs (RR = 1.14, p = 0.445) or in the cohort studies (RR = 0.70, p = 0.289). The results for the alignment of the tibial component were significantly worse using PSI TKR than conventional TKR in the coronal and sagittal planes (RR = 1.75, p = 0.028; and RR = 1.34, p = 0.019, respectively, on pooled analysis). PSI TKR showed a significant advantage over conventional TKR for alignment of the femoral component in the coronal plane (RR = 0.65, p = 0.028 on pooled analysis), but not in the sagittal plane (RR = 1.12, p = 0.437). Axial alignment of the tibial (p = 0.460) and femoral components (p = 0.127) was not significantly different.

We conclude that PSI does not improve the accuracy of alignment of the components in TKR compared with conventional instrumentation.

Cite this article: Bone Joint J 2014; 96-B:1052–61.

Aims

Different methods of anterior cruciate ligament (ACL) reconstruction have been described for skeletally immature patients before closure of the growth plates. However, the outcome and complications following this treatment remain unclear. The aim of this systematic review was to analyse the outcome and complications of different techniques which may be used for reconstruction of the ACL in these patients.

Aims

This non-blinded randomised controlled trial compared the effect of patient-controlled epidural analgesia (PCEA) versus local infiltration analgesia (LIA) within an established enhanced recovery programme on the attainment of discharge criteria and recovery one year after total knee arthroplasty (TKA). The hypothesis was that LIA would increase the proportion of patients discharged from rehabilitation by the fourth post-operative day but would not affect outcomes at one year.

There is conflicting evidence about the benefit of using corticosteroid in periarticular injections for pain relief after total knee arthroplasty (TKA). We carried out a double-blinded, randomised controlled trial to assess the efficacy of using corticosteroid in a periarticular injection to control pain after TKA.

A total of 77 patients, 67 women and ten men, with a mean age of 74 years (47 to 88) who were about to undergo unilateral TKA were randomly assigned to have a periarticular injection with or without corticosteroid. The primary outcome was post-operative pain at rest during the first 24 hours after surgery, measured every two hours using a visual analogue pain scale score. The cumulative pain score was quantified using the area under the curve.

The corticosteroid group had a significantly lower cumulative pain score than the no-corticosteroid group during the first 24 hours after surgery (mean area under the curve 139, 0 to 560, and 264, 0 to 1460; p = 0.024). The rate of complications, including surgical site infection, was not significantly different between the two groups up to one year post-operatively.

The addition of corticosteroid to the periarticular injection significantly decreased early post-operative pain. Further studies are needed to confirm the safety of corticosteroid in periarticular injection.

Take home message: The use of corticosteroid in periarticular injection offered better pain relief during the initial 24 hours after TKA.

Cite this article: Bone Joint J 2016;98-B:194–200.