Abstract. Introduction. Tibial tubercle osteotomy (TTO) is a complex surgical procedure with a significant risk of complications, which include nonunion and tibial fracture. To determine whether an additional suture tape augmentation can provide better biomechanical stability compared with standard screw fixation. Methods. Five matched pairs of human cadaveric knees were divided into 2 groups: the first group underwent standard TTO fixation with 2 parallel screws. The second group underwent a novel fixation technique, in which a nonabsorbable suture tape (FiberTape) in a figure-of-8 construct was added to the standard screw fixation. Tubercular fragment migration of >50% of the initial distalization length was defined as clinical failure Tubercular fragment displacement during cyclic loading and pull-to-failure force were recorded and compared between the 2 groups. Results. The augmented group showed less cyclic tubercular fragment displacement after every load level compared with the standard group, with statistically significant differences starting from 500 N (P < .05; power > 0.8). Mean ± standard deviation tubercular fragment displacement at the end of cyclic loading was 2.56 ± 0.82 mm for the augmented group and 5.21 ± 0.51 mm for the standard group. Mean ultimate failure load after the pull-to-failure test was 2475 ± 554 N for the augmented group and 1475 ± 280 N for the standard group. Conclusion. The specimens that underwent suture tape augmentation showed less tubercular fragment displacement during cyclic loading and higher ultimate failure forces compared with those that underwent standard screw fixation

Deficiency of the anterior cruciate ligament (ACL) is a common disorder which can lead to changes in lifestyle. We followed 59 patients who had had arthroscopic reconstruction of the ACL using a central-third patellar-tendon autograft for seven years to assess the long-term effectiveness of recent advances in reconstruction of the ACL. The standard criteria for evaluation of the International Knee Documentation Committee, the Lysholm knee score and measurements using the KT 1000 arthrometer all showed satisfactory results. Deterioration in the clinical performance after seven years was associated with osteoarthritic changes and correlated with chronic ligament injuries and meniscectomy. There were three traumatic and three spontaneous ruptures.

We believe that the procedure can be successful, but remain concerned about failure of the graft and osteoarthritis. The results raise questions about the best time to operate and suggest that early surgery may reduce the risk of osteoarthritis.

Abstract. Methodology. Prospective single-surgeon case-series evaluating patients undergoing surgery by this technique. 76 cases (mean age of 33.2 years) who had primary ACL reconstruction with BTB or quadriceps tendon with bone block, were divided into 2 matched groups (age, sex and type of graft) of 38 each based on the method of femoral fixation used (interference screw or adjustable cortical suspension). Patients were followed up clinically and using PROMS from NLR with EQ-5D, KOOS, IKDC and Tegner scores. Complications and return to theatre were noted. Paired two-tailed student t-tests and Chi-square tests were employed for statistical analysis. Results. At a mean follow-up of 82 months, peri-operative mean EQ-5D VAS, EQ-5D Index, KOOS, IKDC and Tegner activity scores showed significant improvement (p<0.05), but no significant difference between the two groups (p>0.05). Mean graft length and diameter was 77mm and 9.3 respectively. Mean interval from injury to surgery was 10.5 months. 18(23.7%) patients had associated meniscal tear with 73.3 % undergoing repair. 10 cases (13.2 %) returned to theatre including, MUA for arthrofibrosis (n=2) and intra-substance graft failure (n=2). 3 cases had to be converted to interference screw fixation due to the tightrope cutting through from the femoral bone block as a result of a technical pitfall. Conclusion. Primary ACL reconstruction using adjustable cortical suspension on femoral side for BTB or quadriceps bone-block tendon graft is a safe technique with added advantages of 360 degree bone ingrowth and no screw in the femoral tunnel

Aims

The purpose of this study was to compare reoperation and revision rates of double plating (DP), single plating using a lateral locking plate (SP), or distal femoral arthroplasty (DFA) for the treatment of periprosthetic distal femur fractures (PDFFs).

Aims

The purpose of this study was to compare the clinical outcomes, mortalities, implant survival rates, and complications of total knee arthroplasty (TKA) in patients with or without hepatitis B virus (HBV) infection over at least ten years of follow-up.

The purpose of this study was to report the outcome of ‘isolated’ anterior cruciate ligament (ACL) ruptures treated with anatomical endoscopic reconstruction using hamstring tendon autograft at a mean of 15 years (14.25 to 16.9). A total of 100 consecutive men and 100 consecutive women with ‘isolated’ ACL rupture underwent four-strand hamstring tendon reconstruction with anteromedial portal femoral tunnel drilling and interference screw fixation by a single surgeon. Details were recorded pre-operatively and at one, two, seven and 15 years post-operatively. Outcomes included clinical examination, subjective and objective scoring systems, and radiological assessment. At 15 years only eight of 118 patients (7%) had moderate or severe osteo-arthritic changes (International Knee Documentation Committee Grades C and D), and 79 of 152 patients (52%) still performed very strenuous activities. Overall graft survival at 15 years was 83% (1.1% failure per year). Patients aged < 18 years at the time of surgery and patients with > 2 mm of laxity at one year had a threefold increase in the risk of suffering a rupture of the graft (p = 0.002 and p = 0.001, respectively). There was no increase in laxity of the graft over time. ACL reconstructive surgery in patients with an ‘isolated’ rupture using this technique shows good results 15 years post-operatively with respect to ligamentous stability, objective and subjective outcomes, and does not appear to cause osteoarthritis

Recently biodegradable synthetic scaffolds (Trufit plug) have provided novel approach to the management of chondral and osteochondral lesions. The aim of this study was to assess our 2 year experience with the Trufit plug system. 22 patients aged 20 to 50 years old all presenting with knee pain over a 2 year period were diagnosed either by MRI or arthroscopically with an isolated chondral or osteochondral lesion and proceeded to either arthroscopic or mini arthrotomy Trufit plug implantation. In 5 patients plug implantation was undertaken along with ACL reconstruction (3), medial meniscal repair (1) and contralateral knee OCD screw fixation (1). Pre and post operative IKDC scores were obtained to assess change in knee symptoms and function. At a mean follow up of 15 months (range 2 – 24 months) improved IKDC scores were achieved with the scores improving with time. 2 patients have had a poor result and have had further surgery for their chondral lesions. One patient had failure of graft incorporation at second look arthroscopy and went onto to have a good result after ACI. The second patient had good graft incorporation on second look but had progression of osteoarthritic degeneration throughout the other compartments of the knee which were not initially identified at the time of Trufit plugging. We conclude that Trufit plug is an alternative method for managing isolated chondral and osteochondral lesions of the knee which avoids harvest site morbidity or the need for staged surgery

The aim of this study was to determine current practice in anterior cruciate ligament reconstruction amongst BASK members. This was an internet-based survey where members were invited to complete a questionnaire on ACL reconstruction. Of the 365 BASK surgeons performing ACL reconstruction, 241 completed the questionnaire (response rate 66%). 147(61%) of surgeons used both hamstring and patellar tendon grafts, 71(29%) used only hamstrings and 21(9%) used patellar tendon only. All surgeons used ipsilateral autograft. 157 (65%) used the transtibial technique for femoral tunnel placement with 80(33%) using the anteromedial portal technique. Of those using the anteromedial portal, the most common femoral fixation devices were the Endobutton (34%) and RCI screw (34%). Interference screw fixation (81%) was the most common tibial fixation in the same group of surgeons with the RCI screw being the most common (63%). 19% (45/241) of surgeons were performing double bundle ACL reconstructions in select cases. Hamstring femoral fixation was with a suspension device in 79% and interference screw in 18%. Of those using a suspension device the Endobutton was most common (48%) followed by Transfix (26%) and Rigidfix (19%). Tibial fixation was most commonly achieved by interference screw (57%) followed by Intrafix (30%). With patellar tendon graft the most popular femoral fixation was with an interference screw (66%) followed by suspension (34%). All surgeons used interference screw for tibial fixation. 90% of surgeons (217) allow immediate full weight-bearing as tolerated irrespective of fixation type with 8% delaying full weight bearing between 1 and 3 weeks. The results show the wide spread of variation in practice of ACL reconstruction. With recent renewed interest in a more anatomic placement of tunnels, the use of the anteromedial portal may continue to increase. With such a wide variation in techniques, grafts and fixation implants used, a register may help assess outcomes

Aims

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

We treated 90 patients with an isolated injury to the anterior cruciate ligament (ACL) by reconstruction using a patellar tendon autograft and interference screw fixation. Of these, 82 (91%) were available for review at 24 months. Two grafts and two contralateral ACLs had ruptured during sport and there was one case of atraumatic graft resorption. Using the assessment of the International Knee Documentation Committee (IKDC), 86% of the remaining patients were normal or nearly normal. The median Lysholm knee score was 95/100 and 84% of patients were participating in moderate to strenuous activity. All had grade-0 or grade-1 Lachman, pivot-shift and anterior-drawer tests. Measurement with the KT1000 arthrometer gave a side-to-side difference of < 3 mm of anterior tibial displacement in 90%. Sixty-six radiographs were IKDC grade A and one was grade B. Pain on kneeling was present in 31% and graft site pain in 44%. At 24 months after operation all patients had excellent knee stability, a high rate of return to sport and minimal radiological evidence of degenerative change. Our series therefore represents a basis for comparison of results using other techniques and after more severe injuries

In a two-centre study, 164 patients with unilateral instability of the anterior cruciate ligament were prospectively randomised to arthroscopic reconstruction with either a patellar tendon graft using interference screw fixation or a quadruple semitendinosus graft using an endobutton fixation technique. The same postoperative rehabilitation protocol was used for all patients and follow-up at a median of 31 months (24 to 59) was carried out by independent observers. Four patients (2%) were lost to follow-up. No significant differences were found between the groups regarding the Stryker laxity test, one-leg hop test, Tegner activity level, Lysholm score, patellofemoral pain score, International Knee Documentation Committee (IKDC) score or visual analogue scale, reflecting patient satisfaction and knee function. Slightly decreased extension, compared with the non-operated side, was found in the patellar tendon group (p < 0.05). Patients with associated meniscal injuries had lower IKDC, visual analogue (p < 0.01) and Lysholm scores (p < 0.05) than those without such injuries. Patients in whom reconstruction had been carried out less than five months after the injury had better final IKDC scores than the more chronic cases (p < 0.05). We conclude that patellar tendon and quadruple semitendinous tendon grafts have similar outcomes in the medium term. Associated meniscal pathology significantly affects the final outcome and early reconstruction seems to be beneficial

Aims

The aim of this study was to report the outcome of femoral condylar fresh osteochondral allografts (FOCA) with concomitant realignment osteotomy with a focus on graft survivorship, complications, reoperation, and function.

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.

Patellar instability most frequently presents during adolescence. Congenital and infantile dislocation of the patella is a distinct entity from adolescent instability and measurable abnormalities may be present at birth. In the normal patellofemoral joint an increase in quadriceps angle and patellar height are matched by an increase in trochlear depth as the joint matures. Adolescent instability may herald a lifelong condition leading to chronic disability and arthritis.

Restoring normal anatomy by trochleoplasty, tibial tubercle transfer or medial patellofemoral ligament (MPFL) reconstruction in the young adult prevents further instability. Although these techniques are proven in the young adult, they may cause growth arrest and deformity where the physis is open. A vigorous non-operative strategy may permit delay of surgery until growth is complete. Where non-operative treatment has failed a modified MPFL reconstruction may be performed to maintain stability until physeal closure permits anatomical reconstruction. If significant growth remains an extraosseous reconstruction of the MPFL may impart the lowest risk to the physis. If minor growth remains image intensifier guided placement of femoral intraosseous fixation may impart a small, but acceptable, risk to the physis.

This paper presents and discusses the literature relating to adolescent instability and provides a framework for management of these patients.

Cite this article: Bone Joint J 2017;99-B:159–70.

The objective of this study was to validate the efficacy of Takeuchi classification for lateral hinge fractures (LHFs) in open wedge high tibial osteotomy (OWHTO). In all 74 osteoarthritic knees (58 females, 16 males; mean age 62.9 years, standard deviation 7.5, 42 to 77) were treated with OWHTO using a TomoFix plate. The knees were divided into non-fracture (59 knees) and LHF (15 knees) groups, and the LHF group was further divided into Takeuchi types I, II, and III (seven, two, and six knees, respectively). The outcomes were assessed pre-operatively and one year after OWHTO. Pre-operative characteristics (age, gender and body mass index) showed no significant difference between the two groups. The mean Japanese Orthopaedic Association score was significantly improved one year after operation regardless of the presence or absence of LHF (p = 0.0015, p < 0.001, respectively). However, six of seven type I cases had no LHF-related complications; both type II cases had delayed union; and of six type III cases, two had delayed union with correction loss and one had overcorrection. These results suggest that Takeuchi type II and III LHFs are structurally unstable compared with type I.

Cite this article: Bone Joint J 2015;97-B:1226–31.

The role of arthroscopy in the treatment of soft-tissue injuries associated with proximal tibial fractures remains debatable. Our hypothesis was that MRI over-diagnoses clinically relevant associated soft-tissue injuries. This prospective study involved 50 consecutive patients who underwent surgical treatment for a split-depression fracture of the lateral tibial condyle (AO/OTA type B3.1). The mean age of patients was 50 years (23 to 86) and 27 (54%) were female. All patients had MRI and arthroscopy. Arthroscopy identified 12 tears of the lateral meniscus, including eight bucket-handle tears that were sutured and four that were resected, as well as six tears of the medial meniscus, of which five were resected. Lateral meniscal injuries were diagnosed on MRI in four of 12 patients, yielding an overall sensitivity of 33% (95% confidence interval (CI) 11 to 65). Specificity was 76% (95% CI 59 to 88), with nine tears diagnosed among 38 menisci that did not contain a tear. MRI identified medial meniscal injuries in four of six patients, yielding an overall sensitivity of 67% (95% CI 24 to 94). Specificity was 66% (95% CI 50 to 79), with 15 tears diagnosed in 44 menisci that did not contain tears.

MRI appears to offer only a marginal benefit as the specificity and sensitivity for diagnosing meniscal injuries are poor in patients with a fracture. There were fewer arthroscopically-confirmed associated lesions than reported previously in MRI studies.

Cite this article: Bone Joint J 2014;96-B:1631–6.

We are entering a new era with governmental bodies taking an increasingly guiding role, gaining control of registries, demanding direct access with release of open public information for quality comparisons between hospitals. This review is written by physicians and scientists who have worked with the Swedish Knee Arthroplasty Register (SKAR) periodically since it began. It reviews the history of the register and describes the methods used and lessons learned.

Cite this article: Bone Joint Res 2014;3:217–22.

Objectives

We performed in vitro validation of a non-invasive skin-mounted system that could allow quantification of anteroposterior (AP) laxity in the outpatient setting.

A consecutive series of patients with a hydroxyapatite-coated uncemented total knee replacement (TKR) performed by a single surgeon between 1992 and 1995 was analysed. All patients were invited for clinical review and radiological assessment. Revision for aseptic loosening was the primary outcome. Assessment was based on the Knee Society clinical score (KSS) and an independent radiological analysis. Of 471 TKRs performed in 356 patients, 432 TKRs in 325 patients were followed for a mean of 16.4 years (15 to 18). The 39 TKRs in 31 patients lost to follow-up had a mean KSS of 176 (148 to 198) at a mean of ten years. There were revisions in 26 TKRs (5.5%), of which 11 (2.3%) were for aseptic loosening. Other further surgery was carried out on 49 TKRs (10.4%) including patellar resurfacing in 20, arthrolysis in 19, manipulation under anaesthetic in nine and extensor mechanism reconstruction in one.

Survivorship at up to 18 years without aseptic loosening was 96% (95% confidence interval 91.9 to 98.1), at which point the mean KSS was 176 (134 to 200). Of 110 knees that underwent radiological evaluation, osteolysis was observed in five (4.5%), one of which was revised.

These data indicate that uncemented hydroxyapatite-coated TKR can achieve favourable long-term survivorship, at least as good as that of cemented designs.

We sought to determine whether smoking affected the outcome of reconstruction of the anterior cruciate ligament. We analysed the results of 66 smokers (group 1 with a mean follow-up of 5.67 years (1.1 to 12.7)) and 238 non-smokers (group 2 with a mean follow-up of 6.61 years (1.2 to 11.5)), who were statistically similar in age, gender, graft type, fixation and associated meniscal and chondral pathology. The assessment was performed using the International Knee Documentation Committee form and serial cruciometer readings.

Poor outcomes were reported in group 1 for the mean subjective International Knee Documentation Committee score (p < 0.001), the frequency (p = 0.005) and intensity (p = 0.005) of pain, a side-to-side difference in knee laxity (p = 0.001) and the use of a four-strand hamstring graft (p = 0.015). Patients in group 1 were also less likely to return to their original level of pre-injury sport (p = 0.003) and had an overall worse final 7 International Knee Documentation Committee grade score (p = 0.007).

Despite the well-known negative effects of smoking on tissue healing, the association with an inferior outcome after reconstruction of the anterior cruciate ligament has not previously been described and should be included in the pre-operative counselling of patients undergoing the procedure.