A total of 10474 unicompartmental knee arthroplasties was performed for medial osteoarthritis in Sweden between 1986 and 1995. We sought to establish whether the number of operations performed in an orthopaedic unit affected the incidence of revision. Three different implants were analysed: one with a high revision rate, known to have unfavourable mechanical and design properties; a prosthesis which is technically demanding with a known increased rate of revision; and the most commonly used unicompartmental device.

Most of the units performed relatively few unicompartmental knee arthroplasties per year and there was an association between the mean number carried out and the risk of later revision. The effect of the mean number of operations per year on the risk of revision varied. The technically demanding implant was most affected, that most commonly used less so, and the outcome of the unfavourable design was not influenced by the number of operations performed.

For unicompartmental arthroplasty, the long-term results are related to the number performed by the unit, probably expressing the standards of management in selecting the patients and performing the operation.

Abstract. Introduction. Traumatic knee dislocations are devastating injuries and there is no single best accepted treatment. This study looked at functional outcome of a single surgeon case series of patients who underwent surgical management of their knee dislocation. Methods. Eighty-seven patients with knee dislocation were treated at a major trauma centre. Acute surgical repair and reconstruction with fracture fixation within 4 weeks was preferred unless the patient was too unstable (Injury severity score>16). The collaterals were repaired and augmented using a variety of autografts, allografts or synthetic grafts. PCL was primarily braced and reconstructed subsequently, if required. Outcome was collected prospectively using IKDC score, KOOS and Tegner score. Results. The mean age of the patients was 33.6yrs (SD 11.9), 66 males and 21 females. According to Schenck classification, 26 were KD-I (30%), 6 KD-II (7%), 13 were KD-III (15%), 7 were KD-IV (8%) and 35 were KD-V (40%). 7 patients had CPN injury (8%), 3 had vascular injury (3.4%), 2 had combined CPN and vascular injury (2.3%). Acute surgical treatment was done in 62 patients while 10 had staged reconstruction. 22 patients had delayed reconstruction. The mean follow-up period was 5.8 years (1- 12 yrs), mean IKDC score was 57.6 (SD 23.6). The mean Tegner activity scale postoperatively was 4.5(SD 2) and the mean KOOS score was 74.9 (SD 19.6). Conclusion. A large proportion of cases were KD-V but still had a good outcome with surgical management. Current classification systems do not cover all dislocation patterns and a modification is proposed

Abstract. Introduction. The paediatric population present unique challenges to the knee surgeon, particularly when treating recurrent patellofemoral instability(PFI), the management of which is poorly standardised. Through the EPPIC BASK National Trainee Collaborative, we aimed to identify which procedures (and in which combination) are being used to surgically manage recurrent PFI in skeletally immature patients across the UK. Methods. A retrospective national service evaluation via a trainee collaborative analysing local trust data between 1st January 2014 and 31st December 2019. Data from institutions registered for EPPIC was compiled and compared to the national guidelines for adults. Results. A total of 333 patients were classified as skeletally immature(radiologically open physes) across 28 hospitals. Mean age was 14.1 years(+/- 4.5) with 64.9% being female. Mean number of procedures performed was 11.9 (+/-16.4). Isolated medial patellofemoral ligament reconstruction (MPFLR) was the most common procedure, performed in 65.8% of patients. Combined MPFLR and TTO was undertaken in 13.2% of patients. Proximal realignment surgery was performed in 5.1% of patients. Lateral releases were performed in 18.3% of patients with 8.4% performed in isolation. Conclusion. This study highlights the national variation in surgical treatment of PFI in skeletally immature patients. The guidance for adults cannot be applied universally to the skeletally immature, and it not always acceptable to delay treatment until physes close. This lack of standardisation within the UK in the management of recurrent PFI in skeletally immature patients highlights the need for a national consensus in appropriate surgical management of this patient population

Aims. The patient-acceptable symptom state (PASS) is a level of wellbeing, which is measured by the patient. The aim of this study was to determine if the proportion of patients who achieved an acceptable level of function (PASS) after medial unicompartmental knee arthroplasty (UKA) was different based on the status of the anterior cruciate ligament (ACL) at the time of surgery. Methods. A total of 114 patients who underwent UKA for isolated medial osteoarthritis (OA) of the knee were included in the study. Their mean age was 65 years (SD 10). No patient underwent a bilateral procedure. Those who had undergone ACL reconstruction during the previous five years were excluded. The Knee injury Osteoarthritis Outcome Score Activities of Daily Living (KOOS ADL) function score was used as the primary outcome measure with a PASS of 87.5, as described for total knee arthroplasty (TKA). Patients completed all other KOOS subscales, Lysholm score, the Western Ontario and McMaster Universities Osteoarthritis Index, and the Veterans Rand 12-item health survey score. Failure was defined as conversion to TKA. Results. Survivorship at ten years was 97% in both the ACL-deficient and ACL-intact groups. The mean survival was 16.1 years (95% confidence interval (CI) 15.3 to 16.8) for the ACL-deficient group and 15.6 years (95% CI 14.8 to 16.361) for the ACL-intact group (p = 0.878). At a mean of nine years (SD 3.5) in the ACL-deficient group, 32 patients (87%) reached the PASS for the KOOS ADL. In the ACL-intact group, at a mean of 8.6 years (SD 3) follow-up, 63 patients (85%) reached PASS for the KOOS ADL. There was no significant difference in the percentage of patients who reached PASS for all KOOS subscales and Lysholm between the two groups. Conclusion. PASS was achieved in 85% of all UKAs for KOOS ADL, similar to reports for TKA. Fixed-bearing, medial, non-robotically-assisted UKA resulted in 97% survival at ten years in both the ACL-deficient and ACL-intact groups. There was no significant difference in all outcomes between the two groups. Understanding PASS will allow better communication between surgeons and patients to improve the surgical management of patients with single compartment OA of the knee. This study provides mid- to long-term data supporting the use of PASS to document outcomes following UKA. PASS was met in more than 85% of patients with no differences between ACL-deficient and ACL-intact knees at a mean follow-up of nine years. Cite this article: Bone Joint J 2021;103-B(8):1367–1372

Aims. Trochlear dysplasia is a significant risk factor for patellofemoral instability. The Dejour classification is currently considered the standard for classifying trochlear dysplasia, but numerous studies have reported poor reliability on both plain radiography and MRI. The severity of trochlear dysplasia is important to establish in order to guide surgical management. We have developed an MRI-specific classification system to assess the severity of trochlear dysplasia, the Oswestry-Bristol Classification (OBC). This is a four-part classification system comprising normal, mild, moderate, and severe to represent a normal, shallow, flat, and convex trochlear, respectively. The purpose of this study was to assess the inter- and intraobserver reliability of the OBC and compare it with that of the Dejour classification. Methods. Four observers (two senior and two junior orthopaedic surgeons) independently assessed 32 CT and axial MRI scans for trochlear dysplasia and classified each according to the OBC and the Dejour classification systems. Assessments were repeated following a four-week interval. The inter- and intraobserver agreement was determined by using Fleiss’ generalization of Cohen’s kappa statistic and S-statistic nominal and linear weights. Results. The OBC showed fair-to-good interobserver agreement and good-to-excellent intraobserver agreement (mean kappa 0.68). The Dejour classification showed poor interobserver agreement and fair-to-good intraobserver agreement (mean kappa 0.52). Conclusion. The OBC can be used to assess the severity of trochlear dysplasia. It can be applied in clinical practice to simplify and standardize surgical decision-making in patients with recurrent patella instability. Cite this article: Bone Joint J 2020;102-B(1):102–107

Introduction. Surgical management of PJI remains challenging with patients failing treatment despite the best efforts. An important question is whether these later failures reflect reinfection or the persistence of infection. Proponents of reinfection believe hosts are vulnerable to developing infection and new organisms emerge. The alternative hypothesis is that later failure is a result of an organism that was present in the joint but was not picked up by initial culture or was not a pathogen initially but became so under antibiotic pressure. This multicenter study explores the above dilemma. Utilizing next-generation sequencing (NGS), we hypothesize that failures after two stage exchange arthroplasty can be caused by an organism that was present at the time of initial surgery but not isolated by culture. Methods. This prospective study involving 15 institutions collected samples from 635 revision total hip (n=310) and knee (n=325) arthroplasties. Synovial fluid, tissue and swabs were obtained intraoperatively for NGS analysis. Patients were classified per 2018 Consensus definition of PJI. Treatment failure was defined as reoperation for infection that yielded positive cultures, during minimum 1-year follow-up. Concordance of the infecting pathogen cultured at failure with NGS analysis at initial revision was determined. Results. Among the total cohort, 203 revisions were considered infected and 432 were aseptic (based on ICM-criteria). Of the infected cases, 157 were NGS-positive and 46 NGS-negative. Twenty-nine ICM-positive patients (29/157;18.5%) failed by reoperation with an organism confirmed on culture. In 23 of these (23/29;79.3%), the organism at failure was present on NGS at initial revision. The remaining 6 cases detected discordant organisms between initial NGS and culture at failure. Of the 432 ICM-negative patients, NGS identified microbes in 48.1% (208/432) of “aseptic” revisions, and 17 of these failed. Thirteen of the 17 failures (76.5%) were due to an organism previously detected by NGS at initial revision. Conclusion. Our collaborative findings suggest that most failures (79.3%) by infection recurrence could be attributed to an organism previously detected by NGS at index revision surgery. For any figures or tables, please contact the authors directly

Aims

The aim of this study was to estimate the incremental use of resources, costs, and quality of life outcomes associated with surgical reconstruction compared to rehabilitation for long-standing anterior cruciate ligament (ACL) injury in the NHS, and to estimate its cost-effectiveness.

Introduction. Periprosthetic infection (PJI) after primary total knee arthroplasty (TKA) remains a challenging issue affecting 1–2% of cases. Locally delivered prophylactic antibiotics, including tobramycin or gentamicin mixed in polymethylmethacrylate (PMMA) bone cement and vancomycin powder, are increasingly used despite a lack of high quality evidence for either practice. In this study, we report the antibiotic susceptibility of organisms recovered in culture from patients with acute prosthetic joint infection after primary TKA to gentamicin, tobramycin and vancomycin. Methods. Using a retrospective database of all primary TKA performed at a single institution between January, 1 2014 and July 1, 2018, we identified 18 cases of acute PJI after primary TKA, as defined by the Musculoskeletal Infection Society 2011 guidelines as less than 3 months from symptoms or index surgery to presentation. The use of antibiotic bone cement during the index procedure and time to surgical management of the infection were recorded. Fluid cultures and tissue cultures were obtained intraoperatively at the time of revision. The organisms from positive cultures underwent MIC testing to gentamicin, tobramycin and vancomycin using a gradient diffusion method (ETEST). MIC breakpoints for susceptibility were based on Clinical and Laboratory Standards Institute definitions. Results. 18 cases of PJI after TKA were identified, including 4 polymicrobial infections (22.2%) (Table 1). Average time to revision for infection was 38 days (range: 6–84 days). 34.8% of bacterial isolates were resistant to gentamicin, 39.1% were resistant to tobramycin and 17.4% were resistant to vancomycin. Of the 8 bacterial isolates resistant to gentamicin, 7 (87.5%) were susceptible tobramycin. Of the 9 bacterial isolates resistant to tobramycin, (88.9%) were susceptible to vancomycin. One bacterial isolate, a Fusobacterium nucleatum from a polymicrobial infection was resistant to gentamicin, tobramycin and vancomycin. Conclusion. Over one third of bacteria causing acute PJI after primary TKA were resistant to the aminoglycosides pre-mixed in commercially available bone cements. All but one of the bacteria resistant to gentamicin and tobramycin were susceptible to vancomycin. The addition of vancomycin to bone cement or as powder in the surgical field has the potential to expand antibiotic coverage to include most organisms responsible for acute PJI after TKA. For figures, tables, or references, please contact authors directly

Aims

The aim of this study was to compare the preinjury functional scores with the postinjury preoperative score and postoperative outcome scores following anterior cruciate ligament (ACL) reconstruction surgery (ACLR).

Aims

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.

Aims

Classifying trochlear dysplasia (TD) is useful to determine the treatment options for patients suffering from patellofemoral instability (PFI). There is no consensus on which classification system is more reliable and reproducible for the purpose of guiding clinicians’ management of PFI. There are also concerns about the validity of the Dejour Classification (DJC), which is the most widely used classification for TD, having only a fair reliability score. The Oswestry-Bristol Classification (OBC) is a recently proposed system of classification of TD, and the authors report a fair-to-good interobserver agreement and good-to-excellent intraobserver agreement in the assessment of TD. The aim of this study was to compare the reliability and reproducibility of these two classifications.

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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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The outcome of repeat septic revision after a failed one-stage exchange for periprosthetic joint infection (PJI) in total knee arthroplasty (TKA) remains unknown. The aim of this study was to report the infection-free and all-cause revision-free survival of repeat septic revision after a failed one-stage exchange, and to determine whether the Musculoskeletal Infection Society (MSIS) stage is associated with subsequent infection-related failure.

Aims

The Oswestry-Bristol Classification (OBC) is an MRI-specific assessment tool to grade trochlear dysplasia. The aim of this study is to validate clinically the OBC by demonstrating its use in selecting treatments that are safe and effective.

Osteochondritis Dissecans (OCD) is a condition for which the aetiology remains unknown. It affects subchondral bone and secondarily its overlying cartilage and is mostly found in the knee. It can occur in adults, but is generally identified when growth remains, when it is referred to as juvenile OCD. As the condition progresses, the affected subchondral bone separates from adjacent healthy bone, and can lead to demarcation and separation of its associated articular cartilage. Any symptoms which arise relate to the stage of the disease. Early disease without separation of the lesion results in pain. Separation of the lesion leads to mechanical symptoms and swelling and, in advanced cases, the formation of loose bodies. Early identification of OCD is essential as untreated OCD can lead to the premature degeneration of the joint, whereas appropriate treatment can halt the disease process and lead to healing. Establishing the stability of the lesion is a key part of providing the correct treatment. Stable lesions, particularly in juvenile patients, have greater propensity to heal with non-surgical treatment, whereas unstable or displaced lesions usually require surgical management. This article discusses the aetiology, clinical presentation and prognosis of OCD in the knee. It presents an algorithm for treatment, which aims to promote healing of native hyaline cartilage and to ensure joint congruity. Take home message: Although there is no clear consensus as to the best treatment of OCD, every attempt should be made to retain the osteochondral fragment when possible as, with a careful surgical technique, there is potential for healing even in chronic lesions. Cite this article: Bone Joint J 2016;98-B:723–9

Aims

Periprosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA). Two-stage revision has traditionally been considered the gold standard of treatment for established infection, but increasing evidence is emerging in support of one-stage exchange for selected patients. The objective of this study was to determine the outcomes of single-stage revision TKA for PJI, with mid-term follow-up.

The lateral compartment is predominantly affected in approximately 10% of patients with osteoarthritis of the knee. The anatomy, kinematics and loading during movement differ considerably between medial and lateral compartments of the knee. This in the main explains the relative protection of the lateral compartment compared with the medial compartment in the development of osteoarthritis. The aetiology of lateral compartment osteoarthritis can be idiopathic, usually affecting the femur, or secondary to trauma commonly affecting the tibia. Surgical management of lateral compartment osteoarthritis can include osteotomy, unicompartmental knee replacement and total knee replacement. This review discusses the biomechanics, pathogenesis and development of lateral compartment osteoarthritis and its management. Cite this article: Bone Joint J 2013;95-B:436–44

This study was designed to evaluate the performance of a new patient specific interpositional knee device. Treatment of osteoarthritis is evolving, allowing surgical treatment options at an earlier stage. The interpositional knee device is a recently developed patient specific implant used for the treatment of mild to moderate uni-compartmental osteoarthritis. The benefits over traditional methods of surgical management are: it's less invasive, can be a day procedure and does not limit future options. Young Adults with early uni-compartmental arthritis are suitable. A MRI scan of the patient's knee is reviewed by local and US radiologists to decide if the patient is suitable for the implant. A bespoke implant is produced. Prior to insertion an arthroscopic procedure is undertaken to allow proper positioning of the implant. We treated 27 patients with the iForma Conformis interpositional knee implant in South Wales at the Princess of Wales Hospital, Bridgend and the Royal Glamorgan Hospital, Llantrisant since November 2007. The pre- and post-operative WOMAC scores were recorded. The average age was 54.7 years, BMI 32; 10 females and 20 males. The average pre-operative WOMAC score was 42.2 improving to 62.9 post-operatively. 35 implants were used. 7 patients experienced post-operative problems. No dislocations were reported. Average follow-up was 12.6 months. Our early experience suggests patient selection plays a role in the outcome following surgery. It indicates that this device is a viable and safe alternative to a uni-compartmental knee replacement

A 5 year review of factors instigating malpractice claims and likely to result in a payout. Possible lessons for the future. Background. During 2002-2007 over 300,000 patients underwent knee arthroplasty (KA) in England and Wales, from which 204 cases of litigation were processed costing in excess of £5million. The complications associated with primary KA are well documented, however those instigating litigation in the UK are not known. This study assessed trends in litigation over the past 5 years identifying instigating factors and success rates to highlight areas for further improvement in patient information and surgical management. Methods. Data from the NHS Litigation Authority on claims following KA unrelated to trauma between 2002 and 2007 were obtained and analysed. Results. 246 claims were made, 171 (70%) were settled of which 81 (47%) resulted in a successful claim. The total cost to the NHS was £5,257,228. The number of claims has increased from 26 in 2002 to 67 in 2007, while the rate of successful claims decreased from 58% to 9%. The three most common instigating factors were ongoing pain(24%), operator error(23%) and infection(10%). The factors with greatest successful claims were operator error(80%), vascular injuries(75%), failure of post-operative care(55%). Conclusion. Litigation claims following KA are increasing, although there rate of success is decreasing. Operator error, vascular injuries and failure of post-operative care are predictors of a successful claim. However failure to consent adequately, adhere to policies and standard practice can result in a successful claim. Protecting patients intra-operatively and maintaining high technical expertise while implementing policies and informed consent decreases the litigation burden to the NHS

The early surgical management of the anterior cruciate ligament (ACL) tears in children remains controversial. The argument for nonoperative treatment is driven by concerns about the risk of growth arrest caused by a transphyseal procedure. On the other hand, early surgical reconstruction is favoured because of poor compliance with conservative treatment and increased risk of secondary damage due to instability. This paper reports a series of 39 very young children who had an ACL reconstruction using a transphyseal procedure with a hamstring graft. Patients were followed to skeletal maturity or for a minimum of three years. Only those patients with either a chronological age less than 14 years or with a Tanner stage of 1 and 2 of puberty were included in the study. Thirty children were Tanner 1 or 2 and nine were Tanner 3-4 but were younger than 14. The mean age at operation was 12.2 years (Range 9.5-14.2, Median 12.4). The mean follow up was 60.7 months (range 36-129, median: 51) months. Thirty four patients had attained skeletal maturity at the last follow up. The mean Lysholm score improved from 72.4 pre-operatively to 95.86 postoperatively (p<0.0001). The mean Tegner activity scale was 4.23 after injury and it improved to 7.52 after operation (p<0.0001)) which was a reasonable comparison to the pre- injury score of 8.0. One patient had a mild valgus deformity with no functional disturbance. No other growth related abnormalities including limb length discrepancy were noted. There has been one re-rupture but all others had good or excellent outcome. This is one of the largest series reporting the long term results of ACL reconstruction in very young children. Most other studies include children up to the age of 16. Based on our results we can conclude that transphyseal ACL reconstruction modified for very young patients is a safe procedure