Abstract. Background. With the increasingly accepted method of suprapatellar tibial nailing for tibial shaft fractures, we aimed to compare intraoperative and postoperative outcomes of infrapatellar (IP) vs suprapatellar (SP) tibial nails. Methods. A retrospective cohort analysis of 58 patients. 34 SP tibial nails over 3 years versus 24 IP tibial nails over a similar time frame. We compared; radiation exposure, patient positioning time (PPT), non-union rate and follow-up time. Knee pain in the SP group was evaluated, utilising the Hospital for Special Surgery (HSS) Knee injury and Osteoarthritis outcome score (KOOS). Results. 58 patients with a mean age of 43 years were included. Mean intraoperative radiation dose for SP nails was 61.78cGy (range 11.60 to 156.01cGy) vs 121.09cGy (range 58.01 to 18.03cGy) for IP nails (p < 0.05). Mean PPT for SP nails was 10 minutes vs 18 minutes for IP nails (p < 0.05). All fractures united in the SP group vs one non-union in the IP group. Mean follow-up was 5.5 months vs 11 months in the SP and IP group respectively. Mean KOOS was 7 (range 0 to 22) at 6 months for the SP group. Conclusion. The semi extended position (SP group) leads to reduced radiation exposure because of ease of imaging. All Patients in the SP group showed improved outcomes, with shorter follow-up and fracture union. The KOOS revealed SP nail patients had minimal pain and good knee function. This study establishes a management and PROMs baseline for ongoing evaluation of SP nails

Aims. The aticularis genu (AG) is the least substantial and deepest muscle of the anterior compartment of the thigh and of uncertain significance. The aim of the study was to describe the anatomy of AG in cadaveric specimens, to characterize the relevance of AG in pathological distal femur specimens, and to correlate the anatomy and pathology with preoperative magnetic resonance imaging (MRI) of AG. Methods. In 24 cadaveric specimens, AG was identified, photographed, measured, and dissected including neurovascular supply. In all, 35 resected distal femur specimens were examined. AG was photographed and measured and its utility as a surgical margin examined. Preoperative MRIs of these cases were retrospectively analyzed and assessed and its utility assessed as an anterior soft tissue margin in surgery. In all cadaveric specimens, AG was identified as a substantial structure, deep and separate to vastus itermedius (VI) and separated by a clear fascial plane with a discrete neurovascular supply. Mean length of AG was 16.1 cm ( ± 1.6 cm) origin anterior aspect distal third femur and insertion into suprapatellar bursa. In 32 of 35 pathological specimens, AG was identified (mean length 12.8 cm ( ± 0.6 cm)). Where AG was used as anterior cover in pathological specimens all surgical margins were clear of disease. Of these cases, preoperative MRI identified AG in 34 of 35 cases (mean length 8.8 cm ( ± 0.4 cm)). Results. AG was best visualized with T1-weighted axial images providing sufficient cover in 25 cases confirmed by pathological findings.These results demonstrate AG as a discrete and substantial muscle of the anterior compartment of the thigh, deep to VI and useful in providing anterior soft tissue margin in distal femoral resection in bone tumours. Conclusion. Preoperative assessment of cover by AG may be useful in predicting cases where AG can be dissected, sparing the remaining quadriceps muscle, and therefore function. Cite this article: Bone Joint Open 2020;1-9:585–593

Aim. Diagnosis and isolation of a causative organism is imperative for successful treatment of periprosthetic joint infections (PJI). While there are several diagnostic algorithms using microbiology, serum and synovial markers, the preoperative diagnosis of a low-grade infection remains a challenge, particularly in patients with unsuccessful aspiration. An incisional biopsy may be used in these cases as additional diagnostic tool. In this retrospective study we evaluated microbiological findings, sensitivity, and specificity of open synovial biopsies in cases of inconclusive preoperative diagnostics. Methods. In a retrospective databank analysis (2010–2018), we identified 80 TKAs that underwent an open biopsy because of inconclusive results after applying the CDC Criteria (2010) or the MSIS (2011–2018) for PJI. Infection makers in the serum (C-reactive protein [CRP], leucocytes count and interleukin-6 [IL-6]) and in the synovial aspirate (leucocyte count, percentage of neutrophiles) prior to the biopsy were analyzed. All biopsies were performed by suprapatellar mini-arthrotomy. If a subsequent revision surgery was performed, the isolated organisms in the open biopsy were compared to the results in the revision surgery and sensitivity and specificity were calculated. Serum markers were checked for correlation with a positive result in the open biopsy using Cramer-V and Chi. 2. -Test. Results. A positive result in the open biopsy occurred in 32 cases (40%) while 48 cases (60%) showed no growth of microorganisms. A preoperative elevated serum CRP (≥1mg/dl) showed a significant correlation for a positive biopsy (p=0.04). The odds ratio for a positive biopsy was 2.57 (95% CI 1.02–6.46) with elevated serum CRP. A revision surgery of the TKA with additional tissue sampling was performed in 27 (84%) cases with a positive biopsy and in 32 (67%) cases with a negative biopsy. The intraoperative tissue samples from the revision surgery showed microbial growth in only 52% of cases that were believed to be culture positive from the biopsy results, while positive cultures occurred in 41% of the cases with an initially negative biopsy. Patients with ≥ two cultures of the same microorganism in the biopsy presented a positive result in 73% of their revision surgeries. The open biopsy showed a sensitivity of 48% with a specificity of 62% in our collective if revision surgery was performed. Conclusion. Open biopsy may be considered with inconclusive preoperative serum and synovial fluid diagnostics for PJI, but sensitivity and specificity were rather low in this special collective. Further studies with bigger collectives should be performed to determine potential markers with a higher sensitivity

Introduction and aim. TKR remains one of the most successful surgeries in orthopedics. Still a sizeable number of patients remain dissatisfied reaching to a level of 30%. Our aim was to examine the excised synovium from the suprapatellar region in all osteoarthritic knees and evaluate the histopathological report to know if in a few cases the unrelenting pain and discomfort could be due to some undiagnosed pathology within the joint. Materials and Methods. We selected 40 consecutive knees at our institution operated from Oct 2014 to Jan 2015. Of the total knees 7 patients were operated as single stage bilateral TKR. Supra patellar synovium was thoroughly excised and sent for histopathology examination. Patients who were clinically, serologically and radiologically diagnosed as rheumatoid arthritis or sero negative arthritis were excluded. The implant used was Maxx Freedom knee (PS design). Results. We found abnormal reports in 8 of our 40 knees (20%). 6 of these were proven to be rheumatoid arthritis whilst 2 of the knees showed chronic villous synovitis. Conclusion. 20% of our patients exhibited result which were totally unexpected. This could be one of the many causes in persistently dissatisfied patient after a technically well done TKR. So as a routine we advocate all surgeons to send the excised synvoium for histopathology during a routine TKR. Also a large multi-centric study undertaken at various centers would definitely help to throw more light on this not so well understood topic and thus help reduce this lot of dissatisfied patients

Achievement of adequate exposure in revision total knee arthroplasty is critical as it reduces the surgical time, enhances the ability for both component removal and reconstruction, and avoids devastating complications such as extensor mechanism disruption. However, this can be challenging as prior multiple surgeries and limited mobility contribute to a loss of tissue elasticity, thickened capsular envelope, and peri-articular soft tissue adhesions. A thorough pre-operative assessment of a patient's past surgical history, comorbidities, pre-operative radiographs (i.e. the presence of severe patella baja), and physical examination including range of motion, prior incisions, and soft tissue pliability are useful in determining the appropriate surgical techniques necessary for a successful revision. A systematic approach to the ankylosed knee is critical. Most techniques are geared towards mobilization of the extensor mechanism to safely displace the patella for component exposure. The initial exposure should consist of a long skin incision, a subperiosteal medial release, and debridement of suprapatellar, medial, and lateral adhesions to the femoral condyles. A lateral capsular release can prove helpful in further mobilization of the extensor mechanism. When performing a medial parapatellar arthrotomy it's important to keep in mind further extensile exposure techniques that may be required. For example, the arthrotomy should not extend proximally into the vastus intermedius or rectus femoris in the event that a quadriceps snip technique is to be used as this can compromise the ability to repair this exposure. Despite a large exposure and release of adhesions, sometimes the extensor mechanism remains at risk of rupture and adequate visualization cannot be obtained. In this event, extensile exposures such as a quadriceps snip, quadriceps turndown or tibial tubercle osteotomy are considered. The location of the patella often dictates the best exposure option as severe patella baja may not be overcome with a proximally based release. The quadriceps snip is most commonly used and provides improved exposure without the necessity of modifying the patient's post-operative rehabilitation. In addition, it can be extended to a quadriceps turndown which vastly improves visualization, but at the expense of needing to immobilise the knee post-operatively. A tibial tubercle osteotomy can also be used and provides excellent exposure especially in the case of severe patella baja or when removal of a cemented tibial stem is required. It preserves the extensor muscles, but risks include increased post-operative wound drainage due to limited soft tissue coverage, failure of fixation, or fracture of the tibial tubercle fragment or tibial shaft. Exposure in revision total knee arthroplasty is critical. Fortunately, this can be reliably achieved with a systematic approach to the knee and through the use of several extensile exposures at the surgeon's discretion

The process by which pathologic scar tissue forms after TKA and restricts functional range of motion is relatively poorly understood. Arthrofibrosis may develop in patients who have normal intra-operative range of motion (ROM). However, passive flexion, extension, or both can become restricted and painful, sometimes several weeks after surgery following an early post-operative period of normal motion. The response to both nonsurgical and surgical treatment is often unsatisfactory. Arthrofibrotic scar contains dense fibrous tissue with abundant fibroblasts. Heterotopic bone is frequently found in patients with arthrofibrosis. Stiffness may result from inadequate postsurgical pain management or rehabilitation or from a biologic process that causes rapid proliferation of scar tissue. Genetic factors also may play a role, although it is difficult to predict which patients are at increased risk for arthrofibrosis after TKA. Surgical technique also can contribute; oversizing the femoral component, overstuffing the patella, or rotational malalignment can play a role. Manipulation can be helpful, particularly during the first three months after surgery. However, maintaining motion long term also requires an effective pain management and physical therapy program after manipulation. Arthroscopy may also have a role to remove scar tissue in the suprapatellar pouch and medial and lateral gutters usually between six months and one year after TKA. After one year following TKA, open surgical release or revision surgery is the most effective method to increase motion. However, only modest gains are likely to be achieved and pain may not be improved

Aims

As an alternative to external fixators, intramedullary lengthening nails (ILNs) can be employed for distraction osteogenesis. While previous studies have demonstrated that typical complications of external devices, such as soft-tissue tethering, and pin site infection can be avoided with ILNs, there is a lack of studies that exclusively investigated tibial distraction osteogenesis with motorized ILNs inserted via an antegrade approach.

Aims

Distraction osteogenesis with intramedullary lengthening devices has undergone rapid development in the past decade with implant enhancement. In this first single-centre matched-pair analysis we focus on the comparison of treatment with the PRECICE and STRYDE intramedullary lengthening devices and aim to clarify any clinical and radiological differences.

The aim of this study was to investigate the effect of laboratory-based simulator training on the ability of surgical trainees to perform diagnostic arthroscopy of the knee.

A total of 20 junior orthopaedic trainees were randomised to receive either a fixed protocol of arthroscopic simulator training on a bench-top knee simulator or no additional training. Motion analysis was used to assess performance objectively. Each trainee then received traditional instruction and demonstrations of diagnostic arthroscopy of the knee in theatre before performing the procedure under the supervision of a blinded consultant trainer. Their performance was assessed using a procedure-based assessment from the Orthopaedic Competence Assessment Project and a five-point global rating assessment scale.

In theatre the simulator-trained group performed significantly better than the untrained group using the Orthopaedic Competence Assessment Project score (p = 0.0007) and assessment by the global rating scale (p = 0.0011), demonstrating the transfer of psychomotor skills from simulator training to arthroscopy in the operating theatre. This has implications for the planning of future training curricula.