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). Methods. We performed a prospective study on patients who underwent primary ACLR by a single surgeon at a single centre between October 2010 and January 2018. Preoperative preinjury scores were collected at time of first assessment after the index injury. Preoperative (pre- and post-injury), one-year, and two-year postoperative functional outcomes were assessed by using the Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm Knee Score, and Tegner Activity Scale. Results. We enrolled 308 males and 263 females of mean age 27 years (19 to 46). The mean preinjury and preoperative post-injury Lysholm Knee Scores were 94 (73 to 100) and 63 (25 to 85), respectively, while the respective mean scores at one and two years postoperatively were 84 (71 to 100) and 89 (71 to 100; p < 0.001). The mean Tegner preinjury and preoperative post-injury scores were 7 (3 to 9) and 3 (0 to 6), respectively, while the respective mean scores at one and two years postoperatively were 6 (1 to 8) and 6 (1 to 9) (p < 0.001). The mean KOOS scores at preinjury versus two years postoperatively were: symptoms (96 vs 84); pain (94 vs 87); activities of daily living (97 vs 91), sports and recreation function (84 vs 71), and quality of life (82 vs 69), respectively (p < 0.001). Conclusion. Functional scores improved following ACLR surgery at two years in comparison to preoperative post-injury scores. However, at two-year follow-up, the majority of patients failed to achieve their preinjury scores. The evaluation of ACLR outcomes needs to consider the preinjury scores rather than the immediate preoperative score that is usually collected. Cite this article: Bone Jt Open 2023;4(1):46–52

Aims. The primary aim was to assess whether robotic total knee arthroplasty (rTKA) had a greater early knee-specific outcome when compared to manual TKA (mTKA). Secondary aims were to assess whether rTKA was associated with improved expectation fulfilment, health-related quality of life (HRQoL), and patient satisfaction when compared to mTKA. Methods. A randomized controlled trial was undertaken, and patients were randomized to either mTKA or rTKA. The primary objective was functional improvement at six months. Overall, 100 patients were randomized, 50 to each group, of whom 46 rTKA and 41 mTKA patients were available for review at six months following surgery. There were no differences between the two groups. Results. There was no difference between rTKA and mTKA groups at six months according to the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) functional score (mean difference (MD) 3.8 (95% confidence interval (CI) -5.6 to 13.1); p = 0.425). There was a greater improvement in the WOMAC pain score at two months (MD 9.5 (95% CI 0.6 to 18.3); p = 0.037) in the rTKA group, although by six months no significant difference was observed (MD 6.7 (95% CI -3.6 to 17.1); p = 0.198). The rTKA group were more likely to achieve a minimal important change in their WOMAC pain score when compared to the mTKA group at two months (n = 36 (78.3%) vs n = 24 (58.5%); p = 0.047) and at six months (n = 40 (87.0%) vs n = 29 (68.3%); p = 0.036). There was no difference in satisfaction between the rTKA group (97.8%; n = 45/46) and the mTKA group (87.8%; n = 36/41) at six months (p = 0.096). There were no differences in EuroQol five-dimension questionnaire (EQ-5D) utility gain (p ≥ 0.389) or fulfilment of patient expectation (p ≥ 0.054) between the groups. Conclusion. There were no statistically significant or clinically meaningful differences in the change in WOMAC function between mTKA and rTKA at six months. rTKA was associated with a higher likelihood of achieving a clinically important change in knee pain at two and six months, but no differences in knee-specific function, patient satisfaction, health-related quality of life, or expectation fulfilment were observed. Cite this article: Bone Joint J 2023;105-B(9):961–970

Aims. To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration. Methods. We performed a systematic literature search in MEDLINE, Embase, and Web of Science. The search string included multiple synonyms of the following keywords: "revision TKA", "outcome" and "prognostic factor". We searched for studies assessing the association between at least one prognostic factor and at least one outcome measure after rTKA surgery. Data on sample size, study design, prognostic factors, outcomes, and the direction of the association was extracted and included in an evidence map. Results. After screening of 5,660 articles, we included 166 studies reporting prognostic factors for outcomes after rTKA, with a median sample size of 319 patients (30 to 303,867). Overall, 50% of the studies reported prospectively collected data, and 61% of the studies were performed in a single centre. In some studies, multiple associations were reported; 180 different prognostic factors were reported in these studies. The three most frequently studied prognostic factors were reason for revision (213 times), sex (125 times), and BMI (117 times). Studies focusing on functional scores and patient-reported outcome measures as prognostic factor for the outcome after surgery were limited (n = 42). The studies reported 154 different outcomes. The most commonly reported outcomes after rTKA were: re-revision (155 times), readmission (88 times), and reinfection (85 times). Only five studies included costs as outcome. Conclusion. Outcomes and prognostic factors that are routinely registered as part of clinical practice (e.g. BMI, sex, complications) or in (inter)national registries are studied frequently. Studies on prognostic factors, such as functional and sociodemographic status, and outcomes as healthcare costs, cognitive and mental function, and psychosocial impact are scarce, while they have been shown to be important for patients with osteoarthritis. Cite this article: Bone Jt Open 2023;4(5):338–356

Aims. Simultaneous bilateral total knee arthroplasty (TKA) has been used due to its financial advantages, overall resource usage, and convenience for the patient. The training model where a trainee performs the first TKA, followed by the trainer surgeon performing the second TKA, is a unique model to our institution. This study aims to analyze the functional and clinical outcomes of bilateral simultaneous TKA when performed by a trainee or a supervising surgeon, and also to assess these outcomes based on which side was done by the trainee or by the surgeon. Methods. This was a retrospective cohort study of all simultaneous bilateral TKAs performed by a single surgeon in an academic institution between May 2003 and November 2017. Exclusion criteria were the use of partial knee arthroplasty procedures, staged bilateral procedures, and procedures not performed by the senior author on one side and the trainee on another. Primary clinical outcomes of interest included revision and re-revision. Primary functional outcomes included the Oxford Knee Score (OKS) and patient satisfaction scores. Results. In total, 315 patients (630 knees) were included for analysis. Of these, functional scores were available for 189 patients (378 knees). There was a 1.9% (n = 12) all-cause revision rate for all knees. Overall, 12 knees in ten patients were revised, and both right and left knees were revised in two patients. The OKS and patient satisfaction scores were comparable for trainees and supervising surgeons. A majority of patients (88%, n = 166) were either highly likely (67%, n = 127) or likely (21%, n = 39) to recommend bilateral TKAs to a friend. Conclusion. Simultaneous bilateral TKA can be used as an effective teaching model for trainees without any significant impact on patient clinical or functional outcomes. Excellent functional and clinical outcomes in both knees, regardless of whether the performing surgeon is a trainee or supervising surgeon, can be achieved with simultaneous bilateral TKA. Cite this article: Bone Jt Open 2022;3(1):29–34

Abstract. Purpose. This study aims to compare the clinical and functional outcomes and donor site morbidity of anterior cruciate ligament reconstruction with hamstring tendon autograft and peroneus longus tendon autograft in patients with complete anterior cruciate ligament rupture. Methods. Patients who underwent ACL reconstruction from February 2018 to July 2019 were randomly allocated into two groups (hamstring and peroneus longus). Functional scores (IKDC and Lysholm scores) and pain intensity by visual analogue score were recorded preoperatively, 3, 6months, 1, and 2 years postoperatively. Donor site morbidities were assessed with thigh circumference measurements in hamstring group and ankle scoring with the American foot and ankle score in peroneus longus group. Results. Sixty patients (hamstring n = 30, peroneus n = 30) met the inclusion criteria. The functional scores (IKDC and Lysholm) did not show statistical difference among the two groups at two years follow-up (P- value>0.05). The means values for visual analogue score after two years in the hamstring and Peroneus longus group was 1±0.74 and 1.03± 1.06, respectively. In peroneus longus group, the mean foot and ankle score was 98.63±3.88 (range= 85–100). A significant difference was found in the hamstring group between operated and non-operated thigh circumferences with p- value <0.001. Conclusions. Peroneus longus tendon autograft is an easily accessible tendon for ACL reconstruction and gives comparable functional outcomes as hamstring tendon with no additional donor site morbidity in our study

Aims. MRI has been suggested as an objective method of assessing anterior crucate ligament (ACL) graft “ligamentization” after reconstruction. It has been proposed that the MRI appearances could be used as an indicator of graft maturity and used as part of a return-to-sport assessment. The aim of this study was to evaluate the correlation between MRI graft signal and postoperative functional scores, anterior knee laxity, and patient age at operation. Methods. A consecutive cohort of 149 patients who had undergone semitendinosus autograft ACL reconstruction, using femoral and tibial adjustable loop fixations, were evaluated retrospectively postoperatively at two years. All underwent MRI analysis of the ACL graft, performed using signal-to-noise quotient (SNQ) and the Howell score. Functional outcome scores (Lysholm, Tegner, International Knee Documentation Committee (IKDC) subjective, and IKDC objective) were obtained and all patients underwent instrumented side-to-side anterior laxity differential laxity testing. Results. Two-year postoperative mean outcome scores were: Tegner 6.5 (2 to 10); Lysholm 89.8 (SD 10.4; 52 to 100); and IKDC subjective 86.8 (SD 11.8; 51 to 100). The objective IKDC score was 86% A (128 patients), 13% B (19 patients), and 1% C (two patients). Mean side-to-side anterior laxity difference (134 N force) was 0.6 mm (SD 1.8; -4.1 to 5.6). Mean graft SNQ was 2.0 (SD 3.5; -14 to 17). Graft Howell scores were I (61%, 91 patients), II (25%, 37 patients), III (13%, 19 patients), and IV (1%, two patients). There was no correlation between either Howell score or SNQ with instrumented anterior or Lysholm, Tegner, and IKDC scores, nor was any correlation found between patient age and ACL graft SNQ or Howell score. Conclusion. The two-year postoperative MRI appearances of four-strand, semitendinosus ACL autografts (as measured by SNQ and Howell score) do not appear to have a relationship with postoperative functional scores, instrumented anterior laxity, or patient age at surgery. Other tools for analysis of graft maturity should be developed. Cite this article: Bone Jt Open 2021;2(8):569–575

Abstract. Purpose. Since arthroscopic reconstruction of the anterior cruciate ligament (ACL) started, the use of peroneus longus grafts for primary ACL reconstruction (ACLR) was never thought of as there is very scant literature on it. So, our study aims to compare the functional outcome and complications in patients with ACL injury managed by ACLR with peroneus longus tendon (PLT) and hamstring tendons (HT) respectively. Materials and Methods. Patients with 16–50 years of either gender presenting with symptomatic ACL deficiency were admitted for arthroscopic single bundle ACLR and allocated into two groups (PLT and HT) operated and observed. Functional scores (IKDC and Lysholm score), clinical knee evaluation, donor site morbidity (AOFAS score) and thigh circumference were recorded preoperatively and at six months, one year post-operatively. The same post-op rehabilitation protocol was followed in both groups. Results. 194 patients (hamstring n=96, peroneus n=98) met the inclusion criteria. There were no significant differences between the pre-op, six months post-op and one-year postoperative score between the hamstring and peroneus longus groups in the IKDC (p=0.356) and Lysholm knee score (p=0.289). The mean for the AOFAS was 99.05±3.56 and 99.80±0.70 in the PLT and HT group respectively showing no statistical difference, with a significant improvement in thigh muscle wasting among the PLT group at final follow-up (p<0.001). Conclusion. We observed similar knee stability, functional outcome and no obvious donor site morbidity among both groups and recommend that a PL graft may be a safe, effective, and viable option for arthroscopic single bundle ACL reconstruction

Aims. Our purpose was to describe an unusual series of 21 patients with fungal osteomyelitis after an anterior cruciate ligament reconstruction (ACL-R). Methods. We present a case-series of consecutive patients treated at our institution due to a severe fungal osteomyelitis after an arthroscopic ACL-R from November 2005 to March 2015. Patients were referred to our institution from different areas of our country. We evaluated the amount of bone resection required, type of final reconstructive procedure performed, and Musculoskeletal Tumor Society (MSTS) functional score. Results. A total of 21 consecutive patients were included in the study; 19 were male with median age of 28 years (IQR 25 to 32). All ACL-R were performed with hamstrings autografts with different fixation techniques. An oncological-type debridement was needed to control persistent infection symptoms. There were no recurrences of fungal infection after median of four surgical debridements (IQR 3 to 6). Five patients underwent an extensive curettage due to the presence of large cavitary lesions and were reconstructed with hemicylindrical intercalary allografts (HIAs), preserving the epiphysis. An open surgical debridement was performed resecting the affected epiphysis in 15 patients, with a median bone loss of 11 cm (IQR 11.5 to 15.6). From these 15 cases, eight patients were reconstructed with allograft prosthesis composites (APC); six with tumour-type prosthesis (TTP) and one required a femoral TTP in combination with a tibial APC. One underwent an above-the-knee amputation. The median MSTS functional score was 20 points at a median of seven years (IQR 5 to 9) of follow-up. Conclusion. This study suggests that mucormycosis infection after an ACL-R is a serious complication. Diagnosis is usually delayed until major bone destructive lesions are present. This may originate additional massive reconstructive surgeries with severe functional limitations for the patients. Level of evidence: IV. Cite this article: Bone Joint Open 2020;2(1):3–8

Abstract. Introduction. Surgery in patients with high body mass index (BMI) is more technically challenging and associated with increased complications post-operatively. Inferior clinical and functional mid-term results for high BMI patients undergoing high tibial osteotomy (HTO) relative to normal weight patients have been reported. This study discusses the clinical, radiological and functional outcomes of HTO surgery in patients with a high BMI. Method. This is a retrospective study on patients undergoing HTO surgery using the Tomofix anatomical MHT plate between 2017 and 2022, with follow-up period of up to 5 years. The cohort was divided: non-obese (BMI <30 kg/m2) and obese (BMI>30 kg/m2). Pre and post operative functional scores were collected: Oxford Knee Score (OKS), EuroQol-5D and Tegner. Complications, plate survivorship and Mikulicz point recorded. Results. 32 HTO procedures; 19 patients BMI <30 (average 27.0) and 14 patients BMI >30 (average 36.1). In BMI<30 cohort, one readmission for investigation of venous thromboembolism, doppler negative; two complications: hinge fracture and stitch abscess. The five year survivorship of the plate was 100%. In BMI>30 cohort, one readmission for pulmonary embolism; one complication: hinge fracture. The 5 year survivorship of the plate was 93%, 1 conversion to unicompartmental knee replacement. The average OKS improvement was 17 and 18 for BMI <30 and >30 respectively. Mikulicz point change was identical. Conclusion. The Tomofix anatomical MHT plate achieves good outcomes and minimal complications irrespective of BMI. Reduced plate survivorship, thus earlier conversion may be required in the obese, however higher cohort numbers are needed to confirm this

Abstract. Unicompartment knee replacement (UKR) has been an effective treatment of isolated medial compartment osteoarthritis (OA). There has been several studies which suggest that patellofemoral (PFJ) wear may not be a relative contraindication for UKR with no statistical difference in failure rates. There is currently conflicting evidence on the role of BMI. We will review if BMI and PFJ wear impacts on the post operative functional scores following UKR. A retrospective review of a prospectively collected database was performed. Data was collected between 26/6/2014 and 25/8/2022. 159 UKR procedures were identified. BMI and PFJ cartilage wear were collected. Oxford knee scores (OKS) were collected at > 2 years. PFJ wear was split into International Cartilage Research Society (ICRS) grades I&II and III&IV. 159 UKR procedures were identified, of these 115 had 2 year follow up. There were 77 who had OKS recorded at 2 years. For PFJ wear there was no statistical difference in the median OKS at 2 years 45 vs 43.5 (p=0.408). Assessing the BMI the median was 29kg/m. 2. , range 20–43kg/m. 2. Spearman's rank was performed to assess the correlation between BMI and >2 year OKS, this demonstrated a moderately negative correlation p(df)=−0.339 (CI 95% −0.538, −0.104) p=0.004. There is no statistically significant difference in >2 year OKS following UKR regardless of PFJ wear. There is a moderately negative correlation between BMI and >2 year OKS which was significant p=0.004. Therefore BMI is a more important consideration when counselling patients for UKR

Aims. To compare patients undergoing total knee arthroplasty (TKA) with ≤ 80° range of movement (ROM) operated with a 2 mm increase in the flexion gap with matched non-stiff patients with at least 100° of preoperative ROM and balanced flexion and extension gaps. Methods. In a retrospective cohort study, 98 TKAs (91 patients) with a preoperative ROM of ≤ 80° were examined. Mean follow-up time was 53 months (24 to 112). All TKAs in stiff knees were performed with a 2 mm increased flexion gap. Data were compared to a matched control group of 98 TKAs (86 patients) with a mean follow-up of 43 months (24 to 89). Knees in the control group had a preoperative ROM of at least 100° and balanced flexion and extension gaps. In all stiff and non-stiff knees posterior stabilized (PS) TKAs with patellar resurfacing in combination with adequate soft tissue balancing were used. Results. Overall mean ROM in stiff knees increased preoperatively from 67° (0° to 80°) to 114° postoperatively (65° to 135°) (p < 0.001). Mean knee flexion improved from 82° (0° to 110°) to 115° (65° to 135°) and mean flexion contracture decreased from 14° (0° to 50°) to 1° (0° to 10°) (p < 0.001). The mean Knee Society Score (KSS) improved from 34 (0 to 71) to 88 (38 to 100) (p < 0.001) and the KSS Functional Score from 43 (0 to 70) to 86 (0 to 100). Seven knees (7%) required manipulations under anaesthesia (MUA) and none of the knees had flexion instability. The mean overall ROM in the control group improved from 117° (100° to 140°) to 123° (100° to 130°) (p < 0.001). Mean knee flexion improved from 119° (100° to 140°) to 123° (100° to 130°) (p < 0.001) and mean flexion contracture decreased from 2° (0° to 15°) to 0° (0° to 5°) (p < 0.001). None of the knees in the control group had flexion instability or required MUA. The mean KSS Knee Score improved from 48 (0 to 80) to 94 (79 to 100) (p < 0.001) and the KSS Functional Score from 52 (5 to 100) to 95 (60 to 100) (p < 0.001). Mean improvement in ROM (p < 0.001) and KSS Knee Score (p = 0.017) were greater in knees with preoperative stiffness compared with the control group, but the KSS Functional Score improvement was comparable (p = 0.885). Conclusion. TKA with a 2 mm increased flexion gap provided a significant improvement of ROM in knees with preoperative stiffness. While the improvement in ROM was greater, the absolute postoperative ROM was less than in matched non-stiff knees. PS TKA with patellar resurfacing and a 2 mm increased flexion gap, in combination with adequate soft tissue balancing, provides excellent ROM and knee function when stiffness of the knee had been present preoperatively. Cite this article: Bone Joint J 2020;102-B(4):426–433

Abstract. Purpose. Unicompartmental knee arthroplasty (UKA) is an effective treatment for late knee osteoarthritis (OA). However, its indications remain controversial. Young age (< 60 years) has been associated with worse outcomes. The goal of this systematic review and meta-analysis is to study the effect of age on UKA outcomes. Methods. The primary objective was to compare the UKA revision rate in young patients with that of old patients, using the age thresholds of 60 and 55 years. Secondary objectives were patient-reported outcome measures (PROMs) and implant design. PubMed, Ovid, Web of Science, Google Scholar, and Cochrane library were searched in June 2021. This review was conducted in accordance with the PRISMA guidelines (PROSPERO registration number: CRD42021248322). Results. A total of 12 observational studies with 6,448 knees were included. A mean MINORS score of 19 was assigned to the review. The mean age of patients was 64.32 years, with follow-up ranging from 0.2 to 15 years. There was no significant difference in revision rate, incident or PROMs between young and old patients in the analysis for each age threshold. Further sub-analysis adjusting for implant type in mobile- and fixed-bearing prostheses also showed similar results between those above and under 60 and 55 years. Conclusion. Young age was not associated with a higher revision rate or lower functional scores. Thus, this review provides evidence that performing UKA at a younger age (< 60 years) should not be considered suboptimal. However, this finding should be applied in context, as other confounding factors need to be explored

Abstract. Introduction. Articular cartilage degradation is a defining feature of osteoarthritis. Synovium is a reactive tissue with synovial villae, neoangiogenesis and intimal hyperplasia common to many joint pathologies. The consequences of cartilage debris in osteoarthritis impacting the synovial intima is not well understood. We analysed the immunohistology of synovium from 16 patients with osteoarthritis and 17 patients undergoing knee surgery for non-arthritic pathologies. This data was integrated with imaging and functional scores to correlate synovitis in osteoarthritis. Methodology. Formalin-fixed paraffin embedded synovial biopsy sections were cut in serial sequence and processed for routine staining (H&E or CD3, CD68, CD20, Vimentin, vWF and PCNA IHC) using standardised Dako monoclonal mouse anti-human antibodies. Digital images scanned at x20 were evaluated for fragments of cartilage and aggregates of inflammatory cells. Clinical data (gender, BMI, KL grade, WOMAC & SF-12 scores) was aligned with histopathological data. Results. Cartilage fragments were seen in the synovial intimal layer from end-stage osteoarthritis especially those with BMI<30kg/m2. Macrophages, T-cells and B-cells were identified surrounding cartilage inclusions. Inflammatory aggregates of T-cells, B-cells and macrophages were located peri-cartilage in the intima and peri-vascular in the sub-intimal layer of the synovium. Worse synovitis and function scores were significantly associated with both cartilage inclusions and inflammatory aggregates. X-ray features linked to longer duration of symptoms were associated with inflammatory aggregates. Conclusion. The histological features of the synovium clearly reflect deteriorating joint structures and compromised clinical function

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. Methods. Between January 2010 and September 2020, 695 rTKAs were performed and data were entered into a prospective database. Inclusion criteria were rTKAs with concomitant TTO, without extensor mechanism allograft, and a minimum of two years’ follow-up. A total of 135 rTKAs were included, with a mean age of 65 years (SD 9.0) and a mean BMI of 29.8 kg/m. 2. (SD 5.7). The most frequent indications for revision were infection (50%; 68/135), aseptic loosening (25%; 34/135), and stiffness (13%; 18/135). Patients had standardized follow-up at six weeks, three months, six months, and annually thereafter. Complications and revisions were evaluated at the last follow-up. Functional outcomes were assessed using the Knee Society Score (KSS) and range of motion. Results. The mean follow-up was 51 months (SD 26; 24 to 121). Bony union was confirmed in 95% of patients (128/135) at a mean of 3.4 months (SD 2.7). The complication rate was 15% (20/135), consisting of nine tibial tubercle fracture displacements (6.7%), seven nonunions (5%), two delayed unions, one tibial fracture, and one wound dehiscence. Seven patients (5%) required eight revision procedures (6%): three bone grafts, three osteosyntheses, one extensor mechanism allograft, and one wound revision. The functional scores and flexion were significantly improved after surgery: mean KSS knee, 48.8 (SD 17) vs 79.6 (SD 20; p < 0.001); mean KSS function, 37.6 (SD 21) vs 70.2 (SD 30; p < 0.001); mean flexion, 81.5° (SD 33°) vs 93° (SD 29°; p = 0.004). Overall, 98% of patients (n = 132) had no extension deficit. The use of hinge implants was a significant risk factor for tibial tubercle fracture (p = 0.011). Conclusion. TTO during rTKA was an efficient procedure to improve knee exposure with a high union rate, but had significant specific complications. Functional outcomes were improved at mid term. Cite this article: Bone Joint J 2023;105-B(10):1078–1085

Abstract. Aims. We studied the outcomes following arthroscopic primary repair of bucket handle meniscus tears to determine the incidence of re-tears and the functional outcomes of these patients. Methodology. Prospective cohort study. Over a 4-year period (2016 to 2020), 35 adult patients presented with a bucket handle tear of the meniscus. Arthroscopic meniscal repair was performed using either the all inside technique or a combination of all-inside and inside-out techniques. 15 patients also underwent simultaneous arthroscopic anterior cruciate ligament reconstruction. Functional knee scores were assessed using IKDC and Lysholm scores. Results. Mean patient age at surgery was 27 years (range, 17 to 53years). Medial meniscus was torn in 20 and lateral in 15 cases. Zone of tear was white on white in 19, red on white in 9 and red on red in 7 cases. Average delay from injury to surgery was 4 months. At a mean follow-up of 4.5 years, the meniscus repair failed in 3 patients (8.5 %). Outcome following re-tear was meniscus excision. Average IKDC scores in patients with intact repair were 74.04 against 56.67 in patients with a failed repair (p< 0.0001). Similarly, Lyshlom scores were 88.96 and 67.333, respectively (p<0.0001). Conclusion. The survivorship of primary repair of bucket handle meniscus tears in our series was 91.5% at medium term follow-up. Functional outcomes were significantly poor in patients with a failed repair compared to those with an intact repair

Abstract. Introduction. Derby technique for posterolateral corner (PLC) reconstruction uses a doubled gracilis autograft to reconstruct the popliteo-fibular ligament (PFL) and a split biceps tendon transfer to reconstruct the lateral collateral ligament (LCL). We report midterm outcomes of a case series who underwent PLC reconstruction. Methodology. A retrospective review of 27 patients who underwent PLC reconstruction from 2012 until 2018 was performed (6 females, 21 males, median age 26). Median time interval from injury to primary procedure was 10 months. Outcomes were recorded as per clinical assessment and outcome scores. Results. All patients had no varus laxity in full knee extension. Similarly, at 30° of knee flexion, 25 patients (92.5%) had no varus laxity and 2 patients (7.5%) had grade 1 laxity. No patients demonstrated abnormal external rotation at final follow up. Outcome scores were obtained from 17 patients who underwent primary ligament reconstruction at a mean follow up of 72 months postoperatively. The mean Lysholm score was 94 +/-5.5 (72–100) and mean subjective IKDC score was 78/87 (89.6%) (51–87). 90% of our patients had gained normal or nearly normal IKDC scores on returning to routine activities of daily living and sports following surgery compared to their pre-injury status. Conclusion. Our technique enables an anatomical LCL & PFL reconstruction in isolation or in combination with ACL/PCL reconstruction or to augment an acute repair without contralateral graft harvest or allograft. The functional knee scores demonstrated in this cohort are comparable and in fact superior to previously published knee scores after PLC reconstruction

Introduction. The purpose of this study was to determine if better outcomes occur with use of robotic-arm assistance by comparing consecutive series of non-robotic assisted (NR-TKA) and robotic-arm assisted (NR-TKA) total knee arthroplasties with the same implant. Methods. 80 NR-TKAs and then 101 RA-TKAs were performed consecutively. 70 knees in each group that had a minimum two-year follow-up were retrospectively reviewed. Range of motion, Knee Society (KS) scores, and forgotten joint scores (FJS) were compared using Mann-Whitney U tests. Tourniquets, used for all cases, had their inflation time recorded. Component realignment to minimize soft tissue releases was used in both groups with the goal to stay within a mechanical alignment of 3° of varus to 2° of valgus. The use of soft tissue releases for balance were compared. Results. There were no statistical differences in baseline characteristics including pre-operative Knee Society scores between cohorts. The two-year NR-TKA and RA-TKA median KS knee and functional scores were 99.0 and 90.0 and 100.0 and 100.0 respectively. Mann-Whitney U test indicated a statistically significant difference in KS-KS (p<.00001) and near statistically significant difference in KS-FS (p=0.075). The 10-point higher KS-FS is considered a minimal clinically important difference. The median FJS at two years for the NR-TKA was 61.5 and the RA-TKA was 75.0. Although not statistically significant (p=0.1556), the 13.5-point increase in the RA-TKA cohort also represents a minimal clinically important difference. RA-TKA patients had statistically significant 5° higher knee flexion (p<.00001). Desired post-operative coronal alignment was present in 92.9% of NR-TKAs and 94.3% of RA-TKAs. 28.6% more of the RA-TKA cases were able to be balanced without a soft tissue release. Median tourniquet time was only 3.9 minutes longer for the robotic-arm assisted cohort. Conclusion. This comparison study demonstrates potential benefits in use of robotic-arm assistance over manual instrumentation in TKA

Introduction. The use of intraoperative liposomal bupivacaine (LB) peri-articular injection has been highly debated for total knee arthroplasty (TKA). We evaluated the effect of an institutional-wide discontinuation of intraoperative LB on immediate postoperative pain scores, opioid consumption, and objective functional outcomes. Material and Methods. Between July 1, 2019 and November 30, 2019, an institutional policy discontinued use of intraoperative LB, while the volume of non-LB with epinephrine was increased from 40-ml to 60-ml. A historical cohort was derived from patients undergoing TKA between January 1, 2019 and June 30, 2019. All patients received the same opioid sparing protocol, minimizing variability in prescribing habits. No adductor canal blocks/pumps were utilized. Nursing documented verbal rating scale (VRS) pain scores were collected from our electronic data warehouse and averaged per patient per 12-hour interval. Opiate administration events were derived as Morphine Milligram Equivalences (MMEs) per patient per 24-hour interval. To assess immediate postoperative functional status, the validated Activity Measure for Post-Acute Care (AM-PAC) tool was utilized. All time events were calculated relative to TKA completion instant. Results. 789 primary TKAs did not receive intraoperative LB, while 888 patients acted as controls. Age was significantly greater in patients that did not receive intraoperative liposomal bupivacaine (66.80±8.97 vs 65.57±9.46; p<.01). Gender, BMI, ASA physical status score, race, smoking status, marital status, surgical time, length of stay and discharge disposition were similar between the two groups (p>.05). Compared to historical controls, discontinuation of LB demonstrated no significant difference in postoperative inpatient VRS pain scores up to 72 hours (p>.05), opioid administration up to 96 hours (p>.05), or AM-PAC scores within the first 24 hours (p>.05). Discussion. Subjective pain scores, opioid consumption, and functional scores were unchanged in the early postoperative period following the discontinuation of intraoperative liposomal delivery of bupivacaine in TKA

Introduction. The management of early OA in young patients with joint preservation techniques utilizing cartilage repair remains challenging and a suitable treatment remains unclear. The management of bipolar chondral lesions in the patello-femoral (PF) and in the tibio-femoral (TF) compartment with cartilage repair is especially troublesome. The purpose of this study was to evaluate the clinical outcomes and survivorship after ACI for the treatment of bipolar chondral lesions in the PF and TF compartment. Methods. This was an IRB approved, prospectively collected case series, level 4 study. We evaluated 115 patients. 58 patients who had ACI for the treatment of symptomatic bipolar chondral lesions in the PF compartment and 57 in the TF compartment with a minimum 2-year follow up. A single surgeon performed all the surgeries between October 1995 and June 2014. In the PF group, all 58 patients (60 knees; mean age, 36.6 years) were included, and for the TF group one patient did not return for follow-up, 56 patients (58 knees) were included. For the PF group, an average size of the patella and trochlea lesions were 5.6 ± 2.7 cm2 and 4.2 ± 2.8 cm2, respectively. For the TF group, an average of 3.1 lesions per knee were treated, representing a total surface area of 16.1 cm2 (range, 3.2 – 44.5 cm2) per knee. Patients were evaluated with the modified Cincinnati Knee Rating Scale, Visual Analogue Scale, Western Ontario and McMaster Universities Osteoarthritis Index, and the Short Form 36. Patients also answered questions regarding self-rated knee function and satisfaction with the procedure. Standard radiographs were evaluated for progression of OA. Results. Patients did well for bipolar ACI in both compartments. In the PF compartment overall, the survival rate was 83% and 79% at 5 and 10 years, respectively. Of the 49 (82%) knees with retained grafts, all functional scores significantly improved postoperatively with a very high satisfaction rate (88%) at a mean of 8.8 years after ACI (range, 2 – 16 years). Outcomes for 11 patients were considered as failures at a mean of 2.9 years. In the TF group, the overall survival rate was 80% at 5 years and 76% at 10 years. Significantly better survival rate in patients with the use of collagen membrane than periosteum (97% vs. 61% at 5 years, P = 0.0014) was found. Of 46 knees with retained grafts, all functional scores significantly improved postoperatively with a very high satisfaction rate (85%) at a mean of 8.3 years after ACI (range, 2–20 years). Outcomes for 12 patients were considered as failures at a mean of 4.1 years. Of them, 9 patients were converted to a partial or total knee arthroplasty at a mean of 4.4 years. Two patients had revision ACI at 5 and 17 months. The other one patient did not require a revision surgery. At the most recent follow-up for both groups there was no radiographic progression to OA. Conclusions. Our study showed that ACI for the treatment of bipolar chondral lesions in the PF and TF compartments provided successful clinical outcomes in patients with retained grafts and could possibly prevent or delay OA progression. The best results in the PF joint are as primary repairs and not after failed osteotomy or cartilage repair with a 91% 10-year survival. Collagen membrane is more encouraging than periosteum for bipolar lesions in both the PF and TF compartments. ACI could be an adequate salvage procedure for bipolar chondral lesions in the TF compartment for the relatively young arthritic patient who wishes to avoid an arthroplasty

Aims

With up to 40% of patients having patellofemoral joint osteoarthritis (PFJ OA), the two arthroplasty options are to replace solely the patellofemoral joint via patellofemoral arthroplasty (PFA), or the entire knee via total knee arthroplasty (TKA). The aim of this study was to assess postoperative success of second-generation PFAs compared to TKAs for patients treated for PFJ OA using patient-reported outcome measures (PROMs) and domains deemed important by patients following a patient and public involvement meeting.