Abstract. Background. Performing lateral extra-articular tenodesis (LET) with ACL reconstruction may conflict with the ACLR femoral tunnel. Methods. 12 fresh-frozen cadaveric knees were used: at 120 flexion, an 8mm ACLR femoral tunnel was drilled in the anteromedial bundle position via the anteromedial portal. A modified Lemaire LET was performed using a 1 cm-wide iliotibial band strip left attached to Gerdy's tubercle. The LET femoral fixation point was identified 10mm proximal / 5 mm posterior to the LCL femoral attachment, and a 2.4-mm guide wire was drilled, aiming at 0, 10, 20, or 30 degrees anteriorly in the axial plane, and at 0, 10, or 20 degrees proximally in the coronal plane. The relationship between the LET drilling guide wire and the ACLR femoral tunnel reamer was recorded for each combination. When collision with the femoral tunnel was recorded, the LET wire depth was measured. Results. Tunnel conflict occurred at a mean LET wire depth of 23.6 mm (15–33 mm). No correlation existed between LET wire depth and LET drilling orientation (r=0.066; p=0.67). Drilling angle in the axial plane was significantly associated with the occurrence of tunnel conflict (P < .001). However, no such association was detected when comparing the drilling angle in the coronal plane (P=0.267). Conclusion. Conflict occurred at as little as 15 mm depth. When longer implants are used, the orientation should be at least 30 degrees anterior in the axial plane. Clinical Relevance. This study provides important information for surgeons performing LET in combination with ACLR

Objectives. Our aim was to assess the use of intra-operative fluoroscopy in the assessment of the position of the tibial tunnel during reconstruction of the anterior cruciate ligament (ACL). Methods. Between January and June 2009 a total of 31 arthroscopic hamstring ACL reconstructions were performed. Intra-operative fluoroscopy was introduced (when available) to verify the position of the guidewire before tunnel reaming. It was only available for use in 20 cases, due to other demands on the radiology department. The tourniquet times were compared between the two groups and all cases where radiological images lead to re-positioning of the guide wire were recorded. The secondary outcome involved assessing the tibial interference screw position measured on post-operative radiographs and comparing with the known tunnel position as shown on intra-operative fluoroscopic images. Results. Of the 20 patients treated with fluoroscopy, the imaging led to repositioning of the tibial guide wire before reaming in three (15%). The mean tourniquet time with intra-operative fluoroscopy was 56 minutes (44 to 70) compared with 51 minutes (42 to 67) for the operations performed without. Six patients (30%) had post-operative screw positions that were > 5% more posterior than the known position of the tibial tunnel. Conclusion. Intra-operative fluoroscopy can be effectively used to improve the accuracy of tibial tunnel positions with minimal increase in tourniquet time. This study also demonstrates the potential inaccuracy associated with plain radiological assessment of tunnel position

Aims

Tibial tubercle osteotomy (TTO) facilitates surgical exposure and protects the extensor mechanism during revision total knee arthroplasty (rTKA). The purpose of this study was to determine the rates of bony union, complications, and reoperations following TTO during rTKA, to assess the functional outcomes of rTKA with TTO at two years’ minimum follow-up, and to identify the risk factors of failure.

Aims

This systematic review and meta-analysis aimed to compare the influence of patellar resurfacing following cruciate-retaining (CR) and posterior-stabilized (PS) total knee arthroplasty (TKA) on the incidence of anterior knee pain, knee-specific patient-reported outcome measures, complication rates, and reoperation rates.

Aims

As has been shown in larger animal models, knee immobilization can lead to arthrofibrotic phenotypes. Our study included 168 C57BL/6J female mice, with 24 serving as controls, and 144 undergoing a knee procedure to induce a contracture without osteoarthritis (OA).

The outcome following arthroscopic anterior cruciate (ACL) reconstruction is dependant on a combination of surgical and non-surgical factors. Technical error is the commonest cause for graft failure, with poor tunnel placement accounting for over 80% of those errors. A routine audit of femoral and tibial tunnel positions following single bundle hamstring arthroscopic ACL reconstruction identified apparent inconsistent positioning of the tibial tunnel in the sagittal plane. Intra-operative fluoroscopy was therefore introduced (when available) to verify tibial guide wire position prior to tunnel reaming. This paper reports a comparison of tibial interference screw position measured on post-operative radiographs with known tunnel position as shown on intra-operative fluoroscopic images in 20 patients undergoing routine primary ACL reconstruction between January and June 2009. Surgery took a mean of 5 minutes longer when intra-operative fluoroscopy was used. In 3/20 patients, fluoroscopy led to re-positioning of the tibial guide wire prior to tunnel reaming. The mean tibial tunnel position as indicated by the tunnel reamer was 41 +/− 2.7 % of the total plateau depth (range 37% to 47%). The mean position projected from the tibial screw on post operative radiographs was 46 +/− 9.2% (range 38% to 76%). A paired t-test showed a significant difference (p = 0.022) between true tunnel position and tibial screw position. 6/20 patients had post operative screw positions that were > 5% more posterior than the known position of the tibial tunnel. The position of the tunnel should be measured at its mid-point where this is evident. On most early radiographic images, the margins of the tunnel are not clear and therefore a line projected from the centre of the screw is used. This audit demonstrates the potential inaccuracy associated with this

Aims

To report mid- to long-term results of Oxford mobile bearing domed lateral unicompartmental knee arthroplasty (UKA), and determine the effect of potential contraindications on outcome.

Aims

Metaphyseal cones with cemented stems are frequently used in revision total knee arthroplasty (TKA). However, if the diaphysis has been previously violated, the resultant sclerotic canal can impair cemented stem fixation, which is vital for bone ingrowth into the cone, and long-term fixation. We report the outcomes of our solution to this problem, in which impaction grafting and a cemented stem in the diaphysis is combined with an uncemented metaphyseal cone, for revision TKA in patients with severely compromised bone.

Aims

Metaphyseal fixation during revision total knee arthroplasty (TKA) is important, but potentially difficult when using historical designs of cone. Material and manufacturing innovations have improved the size and shape of the cones which are available, and simplified the required bone preparation. In a large series, we assessed the implant survivorship, radiological results, and clinical outcomes of new porous 3D-printed titanium metaphyseal cones featuring a reamer-based system.

Aims

The aim of this study was to investigate the incidence of knee arthroplasty and arthroscopy following patellar fractures, and to compare this with an age- and gender-matched group without a prior patellar fracture.

Aims

The aim of this study was to compare the outcome of revision total knee arthroplasty (TKA) with and without proximalisation of the tibial tubercle in patients with a failed primary TKA who have pseudo patella baja.

Aim

It has been suggested that the use of a pilot-hole may reduce the risk of fracture to the lateral cortex. Therefore the purpose of this study was to determine the effect of a pilot hole on the strains and occurrence of fractures at the lateral cortex during the opening of a high tibial osteotomy (HTO) and post-surgery loading.

Aims

Open wedge high tibial osteotomy (OWHTO) for medial-compartment osteoarthritis of the knee can be complicated by intra-operative lateral hinge fracture (LHF). We aimed to establish the relationship between hinge position and fracture types, and suggest an appropriate hinge position to reduce the risk of this complication.

A total of 22 patients with a tibial avulsion fracture involving the insertion of the posterior cruciate ligament (PCL) with grade II or III posterior laxity were reduced and fixed arthroscopically using routine anterior and double posteromedial portals. A double-strand Ethibond suture was inserted into the joint and wrapped around the PCL from anterior to posterior to secure the ligament above the avulsed bony fragment. Two tibial bone tunnels were created using the PCL reconstruction guide, aiming at the medial and lateral borders of the tibial bed. The ends of the suture were pulled out through the bone tunnels and tied over the tibial cortex between the openings of the tunnels to reduce and secure the bony fragment. Satisfactory reduction of the fracture was checked arthroscopically and radiographically.

The patients were followed-up for a mean of 24.5 months (19 to 28). Bone union occurred six weeks post-operatively. At final follow-up, all patients had a negative posterior drawer test and a full range of movement. KT-1000 arthrometer examination showed that the mean post-operative side-to-side difference improved from 10.9 mm (standard deviation (sd) 0.7) pre-operatively to 1.5 mm (sd 0.6) (p = 0.001). The mean Tegner and the International Knee Documentation Committee scores improved significantly (p = 0.001). The mean Lysholm score at final follow-up was 92.0 (85 to 96).

We conclude that this technique is convenient, reliable and minimally invasive and successfully restores the stability and function of the knee.

Cite this article: Bone Joint J 2015;97-B:1220–5.

Aims

The aim of this prospective randomised study was to compare the time course of clinical improvement during the first two years following a closing or opening wedge high tibial osteotomy (HTO). It was hypothesised that there would be no differences in clinical outcome between the two techniques.

Aims

The purpose of this study was to report the experience of dynamic intraligamentary stabilisation (DIS) using the Ligamys device for the treatment of acute ruptures of the anterior cruciate ligament (ACL).

Aims

To present our experience of using a combination of intra-articular osteotomy and external fixation to treat different deformities of the knee.

Graft-tunnel mismatch of the bone-patellar tendon-bone (BPTB) graft is a major concern during anatomical anterior cruciate ligament (ACL) reconstruction if the femoral tunnel is positioned using a far medial portal technique, as the femoral tunnel tends to be shorter compared with that positioned using a transtibial portal technique. This study describes an accurate method of calculating the ideal length of bone plugs of a BPTB graft required to avoid graft–tunnel mismatch during anatomical ACL reconstruction using a far medial portal technique of femoral tunnel positioning.

Based on data obtained intra-operatively from 60 anatomical ACL reconstruction procedures, we calculated the length of bone plugs required in the BPTB graft to avoid graft–tunnel mismatch. When this was prevented in all the 60 cases, we found that the mean length of femoral bone plug that remained in contact with the interference screw within the femoral tunnel was 14 mm (12 to 22) and the mean length of tibial bone plug that remained in contact with the interference screw within the tibial tunnel was 23 mm (18 to 28). These results were used to validate theoretical formulae developed to predict the required length of bone plugs in BPTB graft during anatomical ACL reconstruction using a far medial portal technique.

Cite this article: Bone Joint J 2015;97-B:324–8.

We have investigated iatrogenic popliteal artery injuries (PAI) during non arthroplasty knee surgery regarding mechanism of injury, treatment and outcomes, and to identify successful strategies when injury occurs.

In all, 21 iatrogenic popliteal artery injuries in 21 patients during knee surgery other than knee arthroplasty were identified from the Swedish Vascular Registry (Swedvasc) between 1987 and 2011. Prospective registry data were supplemented with case-records, including long-term follow-up. In total, 13 patients suffered PAI during elective surgery and eight during urgent surgery such as fracture fixation or tumour resection. Nine injuries were detected intra-operatively, five within 12 to 48 hours and seven > 48 hours post-operatively (two days to 23 years).

There were 19 open vascular and two endovascular surgical repairs. Two patients died within six months of surgery. One patient required amputation. Only six patients had a complete recovery of whom had the vascular injury detected at time of injury and repaired by a vascular surgeon. Patients sustaining vascular injury during elective procedures are more likely to litigate (p = 0.029).

We conclude that outcomes are poorer when there is a delay of diagnosis and treatment, and that orthopaedic surgeons should develop strategies to detect PAI early and ensure rapid access to vascular surgical support.

Cite this article: Bone Joint J 2015;97-B:192–6.

Objectives

Subtotal or total meniscectomy in the medial or lateral compartment of the knee results in a high risk of future osteoarthritis. Meniscal allograft transplantation has been performed for over thirty years with the scientifically plausible hypothesis that it functions in a similar way to a native meniscus. It is thought that a meniscal allograft transplant has a chondroprotective effect, reducing symptoms and the long-term risk of osteoarthritis. However, this hypothesis has never been tested in a high-quality study on human participants. This study aims to address this shortfall by performing a pilot randomised controlled trial within the context of a comprehensive cohort study design.