Introduction. While total knee arthroplasty (TKA) improves postoperative function and relieves pain in the majority of patients with end stage osteoarthritis, its ability to restore normal knee kinematics is debated. Cadaveric studies using computer-assisted orthopaedic surgery (CAOS) system [1] are one of the most commonly used methods in the assessment of post-TKA knee kinematics. Commonly, these studies are performed with an open arthrotomy; which may impact the knee kinematics. The purpose of this cadaveric study was to compare the knee kinematics before and after (open or closed) arthrotomy. Materials and Methods. Kinematics of seven non-arthritic, fresh-frozen cadaveric knees (PCL presumably intact) was evaluated using a custom software application in an image-free CAOS system (ExactechGPS, Blue-Ortho, Grenoble, FR). Prior to the surgical incision, one tracker was attached to the diaphysis of each tibia and femur. Native intact knee kinematics was then assessed by performing passive range of motion (ROM) three separate times, from full extension to at least 110 degrees of flexion, with the CAOS system measuring and recording anatomical values, including flexion angle, internal-external (IE) rotation and anterior-posterior (AP) translation of the tibia relatively to the femur, and the hip-knee-ankle (HKA) angle. Next, an anterior incision with a medial parapatellar arthrotomy was performed, followed by acquisition of the anatomical landmarks used for establishing an anatomical coordinate system in which all the anatomical values were evaluated [2]. The passive ROM test was then repeated with closed and then open arthrotomy (patella manually maintained in the trochlea groove). The anatomical values before and after knee arthrotomy were compared over the range of knee flexion using the native knee values as the baseline. Results. Generally, kinematics from the native knee were found to be similar to those with closed and open arthrotomy. Deviations between native knee and arthrotomy groups (open or closed, whichever was the worst case) were 0.49±0.52mm for the AP translation, 0.44±0.41° for the HKA, and 0.86±0.8° for the IE rotation (Figures 1–3). The deviation from native knee kinematics was found to be higher with increased flexion angles in both HKA and AP translation. Closing the arthrotomy had minimal effect on knee kinematics, and no difference was seen in knee kinematics between an open and closed arthrotomy, so long as the patella is manually maintained within the trochlear groove. Discussion. This study demonstrated arthrotomy, whether open or closed, did not affect the tested knee kinematics compared to a native intact knee. The deviation found in the anatomical values was within the typical range of clinical variation. Increased deviation in high flexion for some anatomical values may be due to difficulty in reproducing consistent motion during ROM test. This study showed that an open arthrotomy with the patella maintained in the trochlea groove provides accurate assessment of the intact knee kinematics

Although total knee arthroplasty (TKA) is a largely successful procedure to treat end-stage knee osteoarthritis (OA), some studies have shown postoperative abnormal knee kinematics. Computer assisted orthopaedic surgery (CAOS) technology has been used to understand preoperative knee kinematics with an open joint (arthrotomy). However, limited information is available on the impact of arthrotomy on the knee kinematics. This study compared knee kinematics before and after arthrotomy to the native knee using a CAOS system. Kinematics of a healthy knee from a fresh frozen cadaver with presumably intact PCL were evaluated using a custom software application in an image-free CAOS system (ExactechGPS, Blue-Ortho, Grenoble, FR). At the beginning of the test, four metal hooks were inserted into the knee away from the joint line (one on each side of the proximal tibia and the distal femur) for the application of 50N compressive load to simulate natural knee joint. Prior to incision, one tracker was attached to each tibia and femur on the diaphysis. Intact knee kinematics were recorded using the CAOS system by performing passive range of motion 3 times. Next, a computer-assisted TKA procedure was initiated with acquisition of the anatomical landmarks. The system calculated the previously recorded kinematics within the coordinate system defined by the landmarks. The test was then repeated with closed arthrotomy, and again with open arthrotomy with patella maintained in the trochlea groove. The average femorotibial AP displacement and rotation, and HKA angle before and after knee arthrotomy were compared over the range of knee flexion. Statistical analysis (ANOVA) was performed on the data at ∼0° (5°), 30°, 60°, 90° and 120° flexion. The intact knee kinematics were found to be similar to the kinematics with closed and open arthrotomy. Differences between the three situations were found, in average, as less than 0.25° (±0.2) in HKA, 0.7mm (±0.4) in femorotibial AP displacement and 2.3° (±1.4) in femorotibial rotation. Although some statistically significant differences were found, especially in the rotation of the tibia for low and high knee flexion angles, the majority is less than 1°/mm, and therefore clinically irrelevant. This study suggested that open and closed arthrotomy do not significantly alter the kinematics compared to the native intact knee (low RMS). Maintaining the patella in the trochlea groove with an open arthrotomy allows accurate assessment of the intact knee kinematics

Septic arthritis is a therapeutic emergency with a high mortality rate (about 11%)(1). Inadequate treatment can cause permanent joint damage. Management of the septic arthritis includes prompt antibiotic treatment as well as joint-decompression and removal of purulent material(2). It is still discussed controversially and there is little evidence which surgical concept is preferable: arthroscopy with lavage and debridement or open arthrotomy with synovectomy(3,4). The aim of the study was to compare efficacy of arthroscopy and arthrotomy in patients with septic gonarthritis. We evaluated 70 consecutive patients who underwent arthroscopy or arthrotomy at our clinic, because of a bacterial monarthritis of the knee between 2002 and 2010. Our primary outcome was the early recurrence of infection (> 3 months after surgery), which made a second surgery necessary. We compared patients who suffered reinfection and those who did not, in regard to the surgery type as well as potential confounders like comorbidity (measured by Charlson comorbidity index), age, body mass index (BMI), Gächter's -, Kellgren and Lawrence - and Outerbridge classification, duration of symptoms and inflammatory parameters. Furthermore we evaluated differences of the confounders between the surgery groups. From the 70 patients 41 were treated arthroscopic and 29 with arthrotomy. In total eight patients (11.4%) had to undergo a second surgery because of early reinfection. The rate was significantly higher in patients treated with arthrotomy (n=6; 20.7%) compared to those treated with arthroscopy (n=2; 4.9%) (p=0.041). Whereas we found no significant influence of potential confounders between the reinfection group and the group where primary eradication was achieved. Patients who underwent arthrotomy were significantly older, had more comorbidities (both p<0.001) and higher grades of osteoarthritis according to Kellgren and Lawrence classification (p=0.023). In order to adjust the study population towards confounders we performed a subgroup analysis on patients of the second and third age percentile. When we repeated our analysis we still found a significant higher reinfection rate in the arthrotomy group (p=0.036). At the same time there were no differences in prevalence of confounders, neither between the two surgery groups, nor between the reinfection and the primary eradication group. Patients with bacterial monarthritis of the knee who were treated with arthroscopy had a significantly lower reinfection rate than those treated with arthrotomy. As arthroscopy is the less invasive and more sufficient method it should be considered the routine treatment according to our data

Introduction. Success of TKR depends upon soft tissue balance and component alignment. The alteration of quadriceps mechanism while approaching knee for TKR can affect outcome of the surgery. Aim. To analyse the results of Trivector retaining arthrotomy for TKR. Methods. A prospective study of 448 cases between 2008–2011. All the cases were performed by the author. Inclusion criteria: Primary TKR with any degree of deformity. Exclusion criteria: Revision TKR. Patients operated previously with a parapatellar arthrotomy. Surgical Technique – Approach includes dividing distal 30% of VMO along with medial retinaculum 1 cm. medial to patella distally up to the Tibial tuberosity, raised as a single flap. Patella is everted with knee in extension. Knee flexed to expose the knee articulation and rest of the arthroplasty carried out. The closure of the arthrotomy is by 1 no. vicryl interrupted stitches. (video clipping). Results. None of the cases were lost to FU. 258 cases Varus + FFD, 153 Varus alone, 21 Valgus, 11 hyperextension deformity and 5 neutral alignment cases were included. Results showed 87% pt.s at 1. st. postop day and 96% by 4. th. day regained ability to perform unassisted SLR. 4% had 5 to 10 degree quadriceps lag at discharge which recovered to neutral by 4 wks. The surgical field was adequate in all cases and did not have to be extended the arthrotomy incision. KSS score improved from av. Pre op of 54 (38–71) to an average post op of 93 (84–96). All patients by 7 to 10 days were walking unaided or with a single cane in case of Bilateral TKRs. Discussion. Medial parapatellar arthrotomy divides the quadriceps tendon. The alteration in various vector limbs of Quadriceps can change the balance and laterally maltrack the patella. Incidence of Lateral release is higher in this group. Subvastus approach is non extensile and hence poor visibility during surgery. Incidence of malalignment is higher in this group. Trivector retaining arthrotomy approach is extensile and retains 70% strength of vastus medialis. At the closure the quads mechanism is perfectly aligned and hence the incidence of lateral maltracking and lateral release minimised. It is easily reproducible and can be used in stiff knees, severe varus, valgus, obese and post HTO TKRs with consistent results. The 4% cases who had quadriceps lag were probably transient neuropraxia to the muscular branch of the medial superior genicular nerve. They all recovered at 4 wks. Follow up. Conclusion. The extensile nature of the approach and minimal disruption of the quadriceps mechanism encourages us to use this approach for all our cases. It is a true mechanically sound approach for all knees for TKRs

Introduction:. During TKR it is mandatory to achieve perfect soft tissue balance and component alignment. As knee is covered in front by quadriceps mechanism, there is some manipulation of this structure while approaching knee for an arthroplasty. This alteration in Quadriceps mechanism can affect outcome of the surgery. Aim:. To analyze the results of Trivector arthrotomy for TKR surgery. Methods:. It is a study of 526 cases between 2008–2012. All the cases were performed by the author. Inclusion criteria: Primary TKR with any degree of deformity. Exclusion criteria: Revision TKR. Very fragile and thin patients. Surgical Technique – Approach includes dividing distal 30% of vastus medialis, medial retinaculum 1 cm. medial to patella and patellar tendon distally up to Tibial tuberosity. This is raised as a single flap with knee in flexion. Patella is everted with knee in extension. Knee flexed and routine arthroplasty carried out. The watertight closure of the arthrotomy is by 1 no. vicryl interrupted stitches. (video clipping). Results:. None of the cases were lost to FU. 323 cases Varus + FFD, 149 Varus, 35 Valgus, 14 hyperextension deformity, 5 neutral alignment cases were included. Results showed 87% pt.s at 1. st. postop day and 96% by 4. th. day regained ability to perform unassisted SLR. 4% had 5 to 10 degree quadriceps lag at discharge which recovered to neutral by 4 wks. The surgical field was adequate in all cases. KSS score improved from av. Pre op of 56 (38–71) to an average post op of 92 (84–96). All patients by 7 to 10 days were walking unaided or with a single cane in case of Bilateral TKRs. Discussion:. Medial parapatellar arthrotomy divides the quadriceps tendon. The alteration in various vector limbs of Quadriceps can change the balance and laterally maltrack the patella. Incidence of Lateral release is higher in Medial parapatellar arthrotomy cases. Mid and subvastus approaches are non extensile and hence poor visibility during surgery. Incidence of malalignment is higher when the visibility is poor. Trivector arthrotomy approach is extensile and retains 70% strength of vastus medialis. At the closure the quads mechanism is perfectly aligned and hence the incidence of lateral release minimized. It is easily reproducible and can be used in stiff knees, severe varus, valgus, obese and post HTO TKRs with consistent results. Conclusion:. The extensile nature of the approach and minimal disruption of the quadriceps mechanism encourages us to use this approach for all our cases. It is a true “Gateway” for all knees for TKRs

Introduction. Fifty thousand knee replacements are performed annually in the UK at an estimated cost of £150 million. However, there is uncertainty as to the best surgical approach to the knee joint for knee arthroplasty. We undertook a randomised controlled trial to compare a standard medial parapatellar arthrotomy with sub-vastus arthrotomy for patients undergoing primary total knee arthroplasty in terms of short and long term knee function. Methods. Two hundred and thirty-one patients undergoing primary total knee arthroplasty during 2001-2003 were recruited into the study. Patients were randomised into subvastus (116) or medial parapatellar (115) approaches to knee arthroplasty. The primary outcome measures were the American Knee Society and WOMAC Scores. The secondary outcome measures were patient-based measures of EuroQol and SF-36. All outcomes were measured pre-operatively and 1, 6, 12 and 52 weeks post-operatively. We also looked at a pain diary, analgesia diary, ease of surgical exposure, and complications. Results. Pain as measured by WOMAC was significantly less in the subvastus group but only at 52 weeks. The Knee Society Score showed some early benefit at one week to the subvastus group. There was no difference between the two groups in relation to the knee function score, EuroQol, SF-36, pain diary, analgesia usage and length of hospital stay. Conclusion. There is some benefit to patients receiving sub-vastus arthrotomy relative to medial para-patellar. Although the results show some statistical significance in using the sub-vastus approach the clinical importance of these findings and the costs of the various procedures involved remain to be ascertained

Removal of bullets retained within joints is indicated to prevent mechanical blockade, 3rd body wear and resultant arthritis, plus lead arthropathy and systemic lead poisoning. The literature is sparse on this subject, with mostly sporadic case reports utilizing hip arthroscopy. We report on the largest series of removal of bullets from the hip joints using open surgical. We reviewed prospectively collected data of patients who presented to a single institution with civilian gunshot injuries that breached the hip joint between 01 January 2009 and 31 December 2022. We included all cases where the bullet was retained within the hip joint area. Exclusion criteria: cases where the hip joint was not breached, bullets were not retained around the hip area or cases with isolated acetabulum involvement. One hundred and eighteen (118) patients were identified. One patient was excluded as the bullet embedded in the femur neck was sustained 10 years earlier. Of the remaining 117 patients, 70 had retained bullets around the hip joint. In 44 patients we undertook bullet removal using the followingsurgical hip dislocation (n = 18), hip arthrotomy (n = 18), removal at site of fracture fixation/replacement (n = 2), posterior wall osteotomy (n = 1), direct removal without capsulotomy (tractotomy) (n = 5). In 26 patients we did not remove bullets for the following reasons: final location was extra-capsular embedded in the soft tissues (n=17), clinical decision to not remove (n=4), patients’ clinical condition did not allow for further surgery (n= 4) and patient refusal (n=1). No patients underwent hip arthroscopy. With adequate pre-operative imaging and surgical planning, safe surgical removal of retained bullets in the hip joint can be achieved without the use of hip arthroscopy; using the traditional open surgical approaches of arthrotomy, tractotomy and surgical hip dislocation

Aims. Delayed postoperative inoculation of orthopaedic implants with persistent wound drainage or bacterial seeding of a haematoma can result in periprosthetic joint infection (PJI). The aim of this in vivo study was to compare the efficacy of vancomycin powder with vancomycin-eluting calcium sulphate beads in preventing PJI due to delayed inoculation. Methods. A mouse model of PJI of the knee was used. Mice were randomized into groups with intervention at the time of surgery (postoperative day (POD) 0): a sterile control (SC; n = 6); infected control (IC; n = 15); systemic vancomycin (SV; n = 9); vancomycin powder (VP; n = 21); and vancomycin bead (VB; n = 19) groups. Delayed inoculation was introduced during an arthrotomy on POD 7 with 1 × 10. 5. colony-forming units (CFUs) of a bioluminescent strain of Staphylococcus aureus. The bacterial burden was monitored using bioluminescence in vivo. All mice were killed on POD 21. Implants and soft-tissue were harvested and sonicated for analysis of the CFUs. Results. The mean in vivo bioluminescence in the VB group was significantly lower on POD 8 and POD 10 compared with the other groups. There was a significant 1.3-log. 10. (95%) and 1.5-log. 10. (97%) reduction in mean soft-tissue CFUs in the VB group compared with the VP and IC groups (3.6 × 10. 3. vs 7.0 × 10. 4. ; p = 0.022; 3.6 × 10. 3. vs 1.0 × 10. 5. ; p = 0.007, respectively) at POD 21. There was a significant 1.6-log. 10. (98%) reduction in mean implant CFUs in the VB group compared with the IC group (1.3 × 10. 0. vs 4.7 × 10. 1. , respectively; p = 0.038). Combined soft-tissue and implant infection was prevented in 10 of 19 mice (53%) in the VB group as opposed to 5 of 21 (24%) in the VP group, 3 of 15 (20%) in the IC group, and 0% in the SV group. Conclusion. In our in vivo mouse model, antibiotic-releasing calcium sulphate beads appeared to outperform vancomycin powder alone in lowering the bacterial burden and preventing soft-tissue and implant infections. Cite this article: Bone Joint J 2024;106-B(6):632–638

Gunshot-induced fractures of the proximal femur typically present with severe comminution and bone loss. These fractures may also be associated with local damage to soft tissue, neurovascular structures and injuries to abdominal organs. The aim was to evaluate the outcomes of civilian gunshot injuries to the proximal femur at a major trauma center in South Africa. A retrospective review of all patients who sustained gunshot-induced proximal femur fractures between January 2014 and December 2017 was performed. Patients with gunshot injuries involving the hip joint, neck of femur or pertrochanteric fractures were included. Patient demographics, clinical- treatment and outcome data were collected. Results are reported as appropriate given the distribution of continuous data or as frequencies and counts. Our study included 78 patients who sustained 79 gunshot-induced proximal femur fractures. The mean age of patients was 31 ± 112, and the majority of patients were male (93.6%). Pertrochantenteric fractures were the most common injuries encountered (73.4%). Treatment included cephalomedullary nail (60.8%), arthrotomy and internal fixation (16.4%) and interfragmentary fixation with cannulated screws (6%). One case of complete neck of femur fracture had fixation failure, which required conversion to total hip arthroplasty. The overall union rate was 69.6%, and 6.3% of patients developed a fracture-related infection in cases who completed follow-up. The study shows an acceptable union rate when managing these fractures and a low risk of infection. As challenging as they are, individual approaches for each fracture and managing each fracture according to their merits yield acceptable outcomes

Acetabulum fractures caused by civilian firearms represent a unique challenge for orthopaedic surgeons. Treatment strategies should include the assessment of infection risk due to frequently associated abdominal injuries and maintenance of joint function. Still, internationally accepted treatment algorithms are not available. The aim of the study was to increase knowledge about civilian gunshot fractures of the acetabulum by describing their characteristics and management at a high-volume tertiary hospital. All adult patients admitted to our hospital between January 2009 and December 2022 with civilian gunshot fractures of the acetabulum were included in this descriptive retrospective study. In total our institution treated 301 patients with civilian gunshot fractures of the hip joint and pelvis during the observation period, of which 54 involved the acetabulum. Most patients were young males (88,9%) with a mean age of 29 years. Thirty patients (55,6%) had associated intraabdominal or urological injuries. Fracture patterns were mostly stable fractures with minor joint destruction amenable to conservative fracture treatment (n=48, 88,9%). Orthopaedic surgical interventions were performed in 21 patients (38,9%) with removal of bullets in contact with the hip joint via arthrotomy or surgical hip dislocation as most frequent procedures. Most patients received antibiotics on admission (n=49, 90,7%). Fracture related infections of the acetabulum were noted in six patients (11,1%) while the mortality in the study population was low with one demised patient (1,9%) due to the trauma burden. Most civilian acetabulum gunshot fractures are associated with intraabdominal or urological injuries. In comparison to the literature on extremity gunshot fractures, there is an increased risk of infection in our study population. The decision for surgical wash-out and bullet removal should be based on contamination and anticipated joint destruction, while osteosynthesis or primary arthroplasty are rarely necessary for these injuries

Shoulder septic arthritis is uncommon and frequently misdiagnosed, resulting in severe consequences. This study evaluated the demographics, bacteriological profile, antibiotic susceptibility, treatment regimens, and clinical outcomes. This is a 10-year retrospective observational analysis of 30 patients (20 males and 10 females) who were treated for septic arthritis of the shoulder. The data collecting process utilised clinical records, laboratory archives, and x-ray archives. We gathered demographic information, pre- and post-intervention clinical data, serum biochemical markers, and the results of imaging examinations. All patients had a surgical arthrotomy and joint debridement in the operating room, and specimens were taken for culture and sensitivity testing. The specimens were cultivated for at least seventy-two hours. Shoulder joint ranges of motion, comorbidities, and the presence of osteomyelitis were assessed clinically to determine the outcome. All statistical analyses were conducted using the STATA 17 statistical software. Analysis of correlation between categorical variables was performed using the chi-squared test. The majority of the study patients were black Africans (97%). The age range of the group was from 8 days to 17 years. At presentation, 33% of patients had a low-grade fever, whereas the majority (60%) had normal body temperature. The average length of symptoms was 3.9 days (ranged from 1 day to 15 days), and the majority of patients had an increased white cell count (83%) and C-reactive protein (98%). There was accumulation of fluid in the joint of all individuals who received shoulder ultrasound imaging. We noted a significant incidence of gram-positive cocci, which were mostly susceptible to first-line antibiotics. Shoulder stiffness affected 63% of patients and chronic osteomyelitis affected 50% of individuals. Neither the severity nor the duration of the symptoms was related to an increased risk of osteomyelitis. The results of this study revealed that the clinical characteristics and bacterial profile of septic arthritis of the shoulder conform to typical patterns. The likelihood of osteomyelitis and an unfavourable prognosis is considerable

In 2019, the incidence of fractures were 178 million globally, South Africa accounting for close to 600 000 of these fractures, an 18.53% increase since 1990. South Africa does not have the public infrastructure to adequately facilitate the optimal surgical management of this burden. This forces intensive labour practices among orthopaedic surgeons, often performing complex surgeries throughout the night. There is a direct correlation between “after-hour”operations and the increase in morbidities. A retrospective review of the orthopaedic surgical cases and orthopaedic surgical emergencies done at a tertiary institution in Johannesburg between 8th of August 2021 to 12th December 2022. The nature of the orthopaedic interventions, the date of booking of the surgical procedures, date of surgical procedures, as well as start and end time of the orthopaedic interventions were analysed. “After-Hours” orthopaedic interventions were defined as interventions done between 16:00 and 07:00. Orthopaedic emergencies were defined as: Open fracture debridements, external Fixator insertion, arthrotomies, fasciotomies and the insertion of steinmann pins. 1483 (27.92%) of 5310 operative cases done on the emergency board were orthopaedic cases. 1098 (74.04%) hardware-related cases and 535 (36.08%) orthopaedic emergencies were done. 854 (57.58%) cases were done “After-Hours” of which 433 (29.20%) cases were done during “Dead-Hours” (23:00–07:00). Of these 433 cases, only 173 (39.95%) were true orthopaedic emergencies. Although the proportion of emergencies done after hours were greater than during working hours, there is still a large proportion of intricate orthopaedic cases done between 16:00– 07:00 that should not be prioritized, due to an associated higher morbidity. Enhanced strategic planning is advisable in future in order to prioritize complex hardware cases during working hours, and due to the burden, prioritize minor relooks and simple skin- grafts for the latter aspects of the night. A dedicated Orthopaedic Trauma theatre is recommended

Acute septic arthritis of the knee can lead to joint damage or sepsis, if early diagnosis and treatment fail to occur, which includes drainage of the joint, adequate antibiotic coverage and resting of the knee. Classically, drainage of the knee was performed either with multiple aspirations or open arhtrotomy. The arthroscopic approach has becoming widely accepted, as it allows adequate drainage of the pus and debridement with partial or total sinovectomy of the joint. The aim of this study was to evaluate the differences between arthroscopy and open arthrotomy in the clinical outcomes and rate of recurrence in patients with septic arthritis of the knee joint. We reviewed patients with acute septic arthritis of the knee admitted in our center between January 2010 and December 2014. The criteria for diagnosis was report of purulent material when arhtrotomy or arthroscopy was performed or a positive culture of the joint fluid. Patients with recent surgery or documented osteomyelitis of the femur or tíbia were excluded. We used the Oxford Knee Score (OKS) to classify the clinical outcomes in the end of follow-up, and registered the rate of recurrence in each group. The statistical evaluation of the results was performed using Student's t-test. 65 patients were treated during this period, 37 by an open arthrotomy through a lateral supra-patellar aproach, and 28 by arthroscopy through 2 standard anterior portals. All the patients were imobilized with a cast or orthosis in the immediate post-operation period for a mean period of 13 days in the arthrotomy group (8–15) and 9 days in the arthroscopy group (6–12) and received endovenous antibiotics for at least 10 days, followed by oral antibiotics for a mean total of 36 days in the the arthrotomy group (30–48) and 32 days in the arthroscopy group (22–36). The mean follow-up was 22 months in the arthrotomy group (8–28 months) and 18 months in the arthroscopy group (14–24). The mean OKS was 31 in the the arthrotomy group (21–39) and 35 in the arthroscopy group (25–44). There was 1 recurrence in the arthrotomy group and 1 recurrence in the arthroscopic group, both managed by knee arthrotomy. Drainage is a key step in treatment of knee pyoarthrosis, either through an open or an arthroscopic approach. Both seem to be equally effective, with no significant statistical difference in terms of recurrence. The functional results tend to favour the arthroscopic approach, but with no statistical significance

Total Knee Arthroplasty (TKA) necessitates disruption of well-vascularised tissue during exposure and soft tissue release as well as from the cutting of bone, and thus bleeding into the joint space routinely occurs to some degree following TKA. Defining a complication from bleeding is not necessarily straightforward, but includes 3 different conditions: hemarthrosis, hematoma, and bloody wound drainage. All of these conditions can be seen in the normal postoperative setting, and when mild, may be simply observed. However, persistent swelling resulting in clinical symptoms should be appropriately treated. A hemarthrosis is defined as blood being contained in the knee capsule. Although some bleeding is expected, “excessive” hemarthrosis results in increased pain limiting or difficulty regaining motion. If high levels of fluid pressure are present, rupture of the arthrotomy may occur. A hematoma occurs when intra-articular blood escapes the arthrotomy and drains into the overlying soft tissues. This may occur following performance of a large lateral release or an insufficient arthrotomy closure or simply secondary to a large hemarthrosis under tension. Symptoms include ecchymosis, soft tissue swelling, and potential skin complications. Increased pain and limited range of motion frequently accompany these symptoms. Wound drainage may present as a knee that continues to have bloody or serous drainage that continues long after the first or second dressing change. It is this continued wound drainage that is most worrisome, with increased wound infection rates when prolonged drainage is allowed to persist. While excessive bleeding during the early postoperative period is most common, isolated or recurrent hemarthrosis may occur long after recovery from surgery. The incidence of postoperative hemarthrosis is not well studied, but the need for surgical treatment is uncommon. Recurrent hemarthrosis is also relatively rare after TKA and has been reported at rates between 0.3% and 1.6%. The etiology of this complication can be systemic or local, and initial workup should include coagulation studies to rule out any underlying systemic coagulopathy. Conservative therapy including rest, cooling, and elevation is the preferred treatment for mild cases. If conservative treatment is not successful, or the acute hemarthrosis is clinically tense, interfering with recovery, or threatening wound healing, drainage may be the preferable option. This can be done by opening the arthrotomy in the operating room or through large bore arthroscopy cannulae. Careful attention to debridement of clotted blood must be followed by a meticulous search for potential sources of bleeding which should be managed appropriately. Recurrent hemarthrosis may occur at any time but is not commonly diagnosed until the patient has left the early recovery period. Repeated bleeding episodes may lead to an inflammatory cascade that propagates bleeding events more readily. If coagulation studies are normal, the most common source is the impingement of proliferative synovium or other retained soft tissue between the articulating components of the knee prosthesis. Other causes may be multifactorial and synergistic but are not well understood, making diagnosis and treatment more difficult. If symptoms persist, classical treatment has consisted of open or arthroscopic synovectomy. Over the past decade angiography and angiographic embolization of the source of bleeding has been successful. In a recent meta-analysis including 99 patients, technical success rates of 99% were noted, though 2 cases became infected and 10 cases suffered recurrent bleeding episodes. Radio-active synovectomy has also been successful

Introduction:. Repair of the arthrotomy is a performed at the end of every total knee arthroplasty (TKA). After the arthrotomy is performed, most surgeons attempt to close the arthrotomy with the medial and lateral edges anatomically approximated. If no landmarks are made prior to performing the arthrotomy however, there is a risk that anatomic approximation may not be obtained. This study looked into the biomechanical changes in stiffness of the knee before and after a medial parapatellar approach repaired with an anatomic, and shifted capsular repair with the medial side of the arthrotomy shifted up or down when repaired to determine if capsular closure may have an effect on the stiffness of the joint. Methods:. Fourteen cadaveric TKA specimens were retrieved through the Medical Education and Research Institute (Memphis TN). For each specimen tested, the skin and muscle tissue was removed, and the femur and tibia were cut transversely 180 mm from the joint center. Specimens were fixed in extension in a custom knee testing platform (Little Rock AR) and subjected to a 10 Nm varus and valgus torque and a 1.5 Nm internal and external rotational torque. The angle at which these moments occurred was recorded, and each test was repeated for 0, 30, 60, and 90 degrees of flexion. After tests were performed on retrieved TKA specimens, a fellowship trained orthopedic surgeon vented the knee capsule by making an incision with a number 10 scalpel blade in a horizontal nature to provide a landmark for anatomic reapproximation. Tests were repeated as before, after which the surgeon performed a standard arthrotomy and repaired it using #0 suture and a neutral alignment. Sutures were cut and the repair was repeated using upward 5 mm shift and downward 5 mm shift of the medial side of the arthrotomy during the repair. All tests were repeated after each repair technique. Any increase or decrease in laxity after capsule repair was referenced to the TKA laxity tested prior to an arthrotomy being performed. Results:. Simply venting the capsule did increase laxity of the TKA in midflexion to varus torque by 3 degrees under the same torque. Otherwise, when the medial limb of the arthrotomy was shifted up during closure by 5 mm, the knee joint tended to be stiffer in flexion compared to the neutral repair measurements under varus torque, while it was closer to the measurements of the neutral or anatomic closure when the medial limb was shifted down during closure. These changes seemed to be seen in flexion more than full extension. Discussion and Conclusion:. Small changes were measured in the stiffness of the joint after venting the capsule and under different degrees of non-anatomic closure. The results stress the fact that the capsule can be measurably tightened during arthrotomy repair and may impact post-operative rehabilitation or range of motion

Total Knee Arthroplasty (TKA) necessitates disruption of well vascularised tissue during exposure and soft tissue release as well as from the cutting of bone, and thus bleeding into the joint space routinely occurs to some degree following TKA. Defining a complication from bleeding is not necessarily straightforward, but includes 3 different conditions: hemarthrosis, hematoma, and bloody wound drainage. All of these conditions can be seen in the normal post-operative setting, and when mild may be simply observed. However, persistent swelling resulting in clinical symptoms should be appropriately treated. A hemarthrosis is defined as blood being contained in the knee capsule. Although some bleeding is expected, “excessive” hemarthrosis results in increased pain limiting or difficulty regaining motion. If high levels of fluid pressure are present, rupture of the arthrotomy may occur. A hematoma occurs when intra-articular blood escapes the arthrotomy and drains into the overlying soft tissues. This may occur following performance of a large lateral release or an insufficient arthrotomy closure or simply secondary to a large hemarthrosis under tension. Symptoms include ecchymosis, soft tissue swelling, and potential skin complications. Increased pain and limited range of motion frequently accompany these symptoms. Wound drainage may present as a knee that continues to have bloody or serous drainage that continues long after the first or second dressing change. It is this continued wound drainage that is most worrisome with increased wound infection rates when prolonged drainage is allowed to persist. The incidence of post-operative hemarthrosis as a clinical problem is not well studied, but the need for surgical treatment is uncommon. Recurrent hemarthrosis is also relatively rare after total knee arthroplasty and has been reported at rates between 0.3% and 1.6%. The etiology of this complication can be systemic or local, and initial work-up should include coagulation studies to rule out any underling systemic coagulopathy. Conservative therapy including rest, cooling, and elevation is the preferred treatment for mild cases. If conservative treatment is not successful, or the acute hemarthrosis is clinically tense, interfering with recovery, or threatening wound healing, drainage may be the preferable option. This can be done by opening the arthrotomy in the operating room or through a large bore arthroscopy cannulae. Careful attention to debridement of clotted blood must be followed by a meticulous search for potential sources of bleeding which should be managed appropriately. Recurrent hemarthrosis may occur at any time after surgery. Repeated bleeding episodes may lead to an inflammatory cascade that propagates bleeding events more readily. If coagulation studies are normal, the most common source is the impingement of proliferative synovium or other retained soft tissue between the articulating components of the knee prosthesis. Other causes include damage to the geniculate or popliteal vessels with pseudo aneurysm formation. Mild to moderate clinical knee instability may be associated with bloody synovial effusions but limited clinical complaint specific to instability. Other causes may be multifactorial and synergistic but are not well understood, making diagnosis and treatment more difficult. If symptoms persist, and the resulting disability is sufficient, classical treatment has consisted of open or arthroscopic synovectomy. Over the past decade angiography and angiographic embolization of the source of bleeding has been shown to be successful. Radio-active synovectomy has also been successful

Introduction. Autologous Chondrocyte Implantation (ACI) is an effective surgical treatment for chondral defects. ACI involves arthrotomy for cell implantation. We describe the development of an intra-articular injection of cultured MSC, progressing from in-vitro analysis, through animal model, clinical and radiological outcome at five years follow up. Materials and Methods. We prospectively investigated sixteen patients with symptomatic ICRS grade III and IV lesions. These patients underwent cartilage repair using cultured mesenchymal stem cell injections and are followed up for five years. Results. Statistically significant clinical improvement was noted by two years and was sustained for five years of the study. At five years, mean Lysholm score was 80, compared to 44 pre-operatively. Symptomatic KOOS improved to 88 from 55. Subjective IKD Calso showed improvement from 42 to 76. On morphological MRI MOCART score was 76 and qualitative MRI showed the mean T2relaxation-times were 28 and 31 for their pair tissue and native cartilage respectively. Discussion. Cultured MSC provides a good number of uncommitted stem cells to the previously prepared chondral defects of the knee by “homing on” phenomenon. Cultured cells, suspended in serum can be delivered by an intra-articular injection. Conclusion. Use of cultured MSC is less invasive, avoids complications associated with arthrotomy, compared to ACI technique. Good clinical results were found to be sustained at five years of follow-up with a regenerate that appears like surrounding native cartilage. The use of Cultured Mesenchymal Stem Cells (MSC) has represented a promising treatment to restore the articular cartilage

Following a careful in-depth preoperative plan for revision TKA, the first surgical step is adequate exposure. It is crucial to plan your exposure for all contingencies. Prior incisions have tremendous implications and care must be taken to consider their impact. Due to the medially based vascular supply to the skin and superficial tissues about the knee, consideration for use of the most LATERAL incision should be made. It is essential to avoid the development of flaps which may compromise the skin and soft tissue which can have profound implications. Exposure options can be broken down into either PROXIMALLY based techniques or DISTALLY based options. The proximal based techniques involve a medial parapatella arthrotomy followed by the establishment of medial and lateral gutters. An assessment of the ability to evert or subluxate the patella should be made. Care must be taken to protect the insertion of the patella tendon into the tibial tubercle. If the patella is unable to be mobilised, then extension of arthrotomy proximal is performed. If this is not adequate, then consider inside out lateral release. If still unable to mobilise, then a QUAD SNIP is performed. In rare instances, you can connect the lateral release with quad snip resulting in a V-Y quadplasty, which results in excellent exposure. Another option is to employ DISTALLY based techniques such as the tibial tubercle osteotomy technique described by Whiteside. A roughly 8cm osteotomy segment with distal bevel is performed. The osteotomy must be at least 1.5–2cm thick: too thin and risk of fracture increases. This approach leaves the lateral soft tissues intact and then a “greenstick” of the lateral cortex is performed with eversion of patella and the lateral sleeve of tissue. This technique is excellent for not only exposure but also in instances where tibial cement or a cementless tibial stem needs to be removed. Closure is accomplished with wires either through the canal or around the posterior cortex of the tibia

Introduction. The issue regarding whether suction drainage should be used during TKA continues to be debated as both methods have disadvantages. The use of a drain may increase estimated blood loss and incidence of blood transfusion, while no drainage may be associated with ecchymosis formation surrounding the surgical site and wound problems. This prospective randomized study aimed to clarify the need for suction drainage in TKA by assessing the short-term postoperative outcome. Patients and Methods. We randomized 39 patients undergoing TKAs either with or without an intra-articular suction drain and divided to two groups. All the TKAs were performed by a single surgeon using cemented prostheses. As the perioperative blood management, air tourniquet was used during surgery, the knee arthrotomy was closed water-tightly, and all the patients were received both intra-articular and intra-venous administrations of tranexamic acid. After the surgery, a bulky compression dressing was applied to prevent the third space leakage of the blood for four days and rivaroxaban was used for venous thromboembolism prophylaxis for one week. The two groups were compared in terms of hemoglobin decrease, recovery of knee flexion, postoperative pain, and examined both the knee circumference and knee swelling. The incidence of short-term complications also evaluated. Results. TKAs were performed in 24 patients with (Group 1) and 15 patients without (Group 2) suction drain and there was no major complication in both groups. We found no significant differences in the mean postoperative blood loss, postoperative pain, and ROM during two weeks after TKA between the two groups. The amount of the intra-articular fluid measured with computed tomography as the postoperative knee swelling was similar between the two groups. Discussion and Conclusions. Recently, as the pharmacologic agents have been routinely used for venous thromboembolism prophylaxis after TKA for more than one week, perioperative bleeding should be managed more intensively. The administration of tranexamic acid has been widely reported to decrease the postoperative blood loss, and water-tightness of the arthrotomy closure can reduce hemarthrosis and arthrotomy leakage to the third space by a tamponade effect. The advantage of the bulky compression dressing reportedly is to reduce soft tissue edema and bleeding in an effort to promote venous drainage. Furthermore, this study did not demonstrate that intra-articular suction drain contributed to decrease the amount of intra-articular fluid at two weeks after the surgery. In conclusion, under the condition of routine pharmacologic VTE prophylaxis with intensive perioperative blood management, intra-articular suction drain has no advantage in TKA

The purpose of this study was to determine the effect of sectioning the relevant soft tissues and a TKA on the medial and lateral knee joint gap. Twelve intact lower extremity cadaveric specimens (mean (SD) age 76.5 (11.6) years) were tested. A custom designed knee tensioner was developed that allowed the separate application of forces to the medial and lateral components of the knee. The distance between the bottom of the load cell and the top of a compression rod was measured with digital calipers (precision = 0.1mm). Loads of 100N and 200N were then applied to each compartment and the resulting displacement was measured. The two loads were applied to the knee in the following conditions: i) All soft tissues intact; ii) an arthrotomy; iii) ACL sectioned; iv) PCL sectioned; v) release of the mid-coronal tissues; and vi) TKA. Finally, tensions were applied for all conditions from 90° to 0° of knee flexion in 30° increments. There was a significant effect of soft tissue release on the magnitude of the gap at the 100N load application, such that there was an increase in the when the mid-coronal MCL release was performed compared to the intact (2.2mm) and arthrotomy (1.75mm) conditions. With respect to the 200N load application there was a statistically significant tissue release effect, where differences were detected between the mid-coronal MCL release and intact (3.04mm) and arthrotomy conditions (2.31mm). At the 100N load there was a significance increase in the gap compared to the intact knee. There was also a significant condition by knee angle interaction where the gap was approximately 4mm larger following the TKA compared to the intact condition when the knee was flexed at 90°. Furthermore, there was a statistically significant 4.8mm and 3.8mm difference between 90° and 0° and 60° and 0° of knee flexion respectively, for the TKA condition only. At the 200N load application the gap width increased significantly by 2.5mm following the TKA. Finally, there was a significant condition by knee angle interaction where the change in gap width increased significantly from the intact (7.54mm) to the TKA condition (13.88mm) at 90° of knee flexion. There was a statistically significant difference in the TKA condition between 60° and 0° of knee flexion. Releasing the soft tissues increases the gap between the tibia and femur, when compared to the intact condition, with significance occurring only following the mid-coronal release. Furthermore, the TKA did not return the knee to its intact state as was evident by the significant difference between the TKA and intact conditions. This suggests that the resulting kinematics may not accurately match those pre-surgery resulting in un-physiological motion patterns and the possibility of early failure and revision