Abstract. Background. Little scientific evidence is available regarding the effect of knee joint line obliquity (JLO). Methods. 10 fresh-frozen human cadaveric knees were axially loaded to 1500 N in a materials testing machine with the joint line tilted 0, 4, 8, and 12 degrees varus and valgus, at 0, and 20 degrees of knee flexion. The mechanical compression axis was aligned to the centre of the tibial plateau. Contact pressures / areas were recorded by sensors inserted between the tibia and femur below the menisci. Changes in relative femoral and tibial position in the coronal plane were obtained by an optical tracking system. Results. medial and lateral JLO caused significant tibiofemoral subluxation and pressure distribution changes. Medial (varus) JLO caused the femur to sublux medially down the coronal slope of the tibial plateau, and vice versa for lateral (valgus) downslopes (P=0.01). Areas of peak pressure moved 12 mm and 8 mm across the medial and lateral condyles, onto the ‘downhill’ meniscus and the ‘uphill’ tibial spine. Changes in JLO had only small effects on maximum contact pressures. Conclusion. A change of JLO during load bearing caused significant mediolateral tibiofemoral subluxation. The femur slid down the slope of the tibial plateau to abut the tibial eminence and also to rest on the downhill meniscus. Clinical Relevance. These results provide important information for understanding the consequences of creating coronal JLO and for clinical practice in terms of osteotomy planning regarding the effect on JLO

Introduction. Clinical observations suggest mid-flexion instability may occur more commonly with rotating platform (RP) total knee arthroplasty (TKA), including increased revision rates and patient-reported instability and pain. We propose that increased gap laxity leads to liftoff of the lateral femoral condyle with decreased conformity between the femoral component and polyethylene (PE) insert surface leading to PE subluxation or dislocation. The objectives of this study were to define “at risk” loading conditions that predispose patients to PE insert subluxation or spinout, and to quantify the margin of error for flexion/extension gap laxity in preventing these adverse events under physiologic loading conditions. Methods. Biomechanical testing was performed on six fresh frozen cadaveric knees implanted with a posterior stabilized RP TKA using a gap balancing technique. Rotational displacement and torque were measured over time, while stiffness, yield torque, max torque and displacement were calculated using a post-processing, custom MatLab code. Revision with varying size femoral components (size 3–6) and PE insert thicknesses (10–15mm), by downsizing one step, were used to create a spectrum of flexion/extension gap mismatch. Each configuration was subjected to three loaded testing conditions (0°, 30° and 60° flexion) in balanced and eccentric varus loading, known to represent daily clinical function and “at risk” circumstances. Results. PE insert rotational instability was primarily determined by conformity and contact area between the femoral condyle and the upper surface of the PE insert. In this RP design, contact area is known to decrease with flexion greater than 35°, which predisposed to abnormal motion of the femur on PE insert (Figure 1). Under all flexion/extension gap testing conditions, PE insert rotational displacement significantly decreased with increasing knee flexion (differences ranged from 0.42 to 1.01cm, p<0.05), confirming that decreased conformity allows unintended motion to occur on the upper rather than the lower insert surface, as kinematically designed. This decrease in insert rotation was further exacerbated with eccentric medial-sided loading (differences ranged from 0.77 to 1.18cm, p<0.05). Yield torque (19.66±6.79N-m, p=0.033) and max torque (19.76±5.93N-m, p=0.014) significantly increased with increasing flexion from 0° to 60° under gap balanced conditions. Yield torque significantly decreased with greater flexion gap laxity at 60° of flexion (−24.82±5.96N-m, p=0.004). The depth of the lateral PE insert concavity (1.7–3.6mm) varied with insert size and thickness and determined femoral condylar capture. The lateral insert concavity defines a narrow margin of error in flexion/extension gap asymmetry leading to rotational insert instability, especially in smaller sized knees (size 3) where the jump height (1.7mm) is less than the insert sizing increment of 2.5mm. Conclusions. Contact area is known to decrease with flexion greater than 35° in this TKA-RP design. Flexion gap laxity further increased the risk of unintended top-side rotation of the femur on the insert, especially with increasing flexion and smaller components. In RP-TKA, in addition to medial-lateral gap symmetry and flexion-extension balance, a snug flexion gap with less than 2mm lateral laxity is critical to avoid insert instability and condylar escape with insert subluxation. For any figures or tables, please contact authors directly

Introduction. Both mobile bearing and fixed bearing unicompartmental knee arthroplasty (UKA) have demonstrated clinical success. However, much debate persists about the superiority of a single design. Currently most clinical data is based on high volume centers data, however to reduce bias, we undertook a through review of retrospective national joint registries. In this study, we aim to investigate UKA implant utilization and survivorship between 2000 and 2018. Methods. Ten annual joint registry reports of various nations were reviewed. Due to the variable statistical methods of reporting implant use and survivorship we focused on three registries: Australia (AOANJRR), New Zealand (NZJR), United Kingdom (NJR) for uniformity. We evaluated UKA usage, survivorship, utilization and revision rates for each implant. Implant survivorship was reported in the registries and was compared within nations due to variation in statistical reporting. Results. UKAs accounted for 7.24–10.3% of all primary knee surgeries. The most popular implants were, in order of popularity, the Oxford (ZimmerBiomet, Warsaw IN), ZUK (Smith & Nephew, Memphis TN / LimaCorporate, Udine, Italy), Sigma HP (DePuy, Warsaw IN), Miller-Galante (ZimmerBiomet Warsaw IN), and Preservation (DePuy, Warsaw IN) models. UKA revision rates varied by nation and ranged from 8.22%–12.8%. The Sigma HP and ZUK designs had the lowest total percent revised in the registries-Australian (3.6% and 5.1%, respectively) and New Zealand (2.5% and 1.96%, respectively)-and demonstrated among the highest 10-year survivorship in the United Kingdom registry. The United Kingdom registry reports a greater number of mobile versus fixed bearing UKA undergoing revision for dislocation and/or subluxation and instability. Conclusion. Preference for implant design as well as survivorship rates varied significantly by nation. The fixed bearing ZUK and Sigma HP implants were among the highest performing implants across the three registries

Aims

The aim of this study was to evaluate medium- to long-term outcomes and complications of the Stanmore Modular Individualised Lower Extremity System (SMILES) rotating hinge implant in revision total knee arthroplasty (rTKA) at a tertiary unit. It is hypothesized that this fully cemented construct leads to satisfactory clinical outcomes.

While injury to the posterolateral corner is accepted as a relatively common occurrence associated with rupture of the anterior cruciate ligament, posteromedial meniscocapsular injury has not previously been recognised as such. In a prospective assessment of 183 consecutive reconstructions of the anterior cruciate ligament this injury was observed in 17 cases, giving it an incidence of 9.3%. Clinically, it was associated with a mild anteromedial rotatory subluxation and it is important not to confuse this with posterolateral rotatory subluxation. In no case was this injury identified by MRI. The possible long-term clinical relevance is discussed

Aims

The optimal bearing surface design for medial unicompartmental knee arthroplasty (UKA) remains controversial. The aim of this study was to compare outcomes of fixed-bearing (FB) and mobile-bearing (MB) UKAs from a single high-volume institution.

With medial unicompartmental osteoarthritis (OA) there is occasionally a full-thickness ulcer of the cartilage on the medial side of the lateral femoral condyle. It is not clear whether this should be considered a contraindication to unicompartmental knee replacement (UKR). The aim of this study was to determine why these ulcers occur, and whether they compromise the outcome of UKR. Case studies of knees with medial OA suggest that cartilage lesions on the medial side of the lateral condyle are caused by impingement on the lateral tibial spine as a result of the varus deformity and tibial subluxation. Following UKR the varus and the subluxation are corrected, so that impingement is prevented and the damaged part of the lateral femoral condyle is not transmitting load. An illustrative case report is presented. Out of 769 knees with OA of the medial compartment treated with the Oxford UKR, 59 (7.7%) had partial-thickness cartilage loss and 20 (2.6%) had a full-thickness cartilage deficit on the medial side of the lateral condyle. The mean Oxford Knee Score (OKS) at the last follow-up at a mean of four years was 41.9 (13 to 48) in those with partial-thickness cartilage loss and 41.0 (20 to 48) in those with full-thickness loss. In those with normal or superficially damaged cartilage the mean was 39.5 (5 to 48) and 39.7 (8 to 48), respectively. There were no statistically significant differences between the pre-operative OKS, the final review OKS or of change in the score in the various groups. We conclude that in medial compartment OA, damage to the medial side of the lateral femoral condyle is caused by impingement on the tibial spine and should not be considered a contraindication to an Oxford UKR, even if there is extensive full-thickness ulceration of the cartilage

Aims

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

Aims

The mid-term results of kinematic alignment (KA) for total knee arthroplasty (TKA) using image derived instrumentation (IDI) have not been reported in detail, and questions remain regarding ligamentous stability and revisions. This paper aims to address the following: 1) what is the distribution of alignment of KA TKAs using IDI; 2) is a TKA alignment category associated with increased risk of failure or poor patient outcomes; 3) does extending limb alignment lead to changes in soft-tissue laxity; and 4) what is the five-year survivorship and outcomes of KA TKA using IDI?

Aims

The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process.

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.

Aims

Periprosthetic joint infection (PJI) is a challenging complication of any arthroplasty procedure. We reviewed our use of static antibiotic-loaded cement spacers (ABLCSs) for staged management of PJI where segmental bone loss, ligamentous instability, or soft-tissue defects necessitate a static construct. We reviewed factors contributing to their failure and techniques to avoid these complications when using ABLCSs in this context.

Aims

The aim of this study was to evaluate whether achieving medial joint opening, as measured by the change in the joint line convergence angle (∆JLCA), is a better predictor of clinical outcomes after high tibial osteotomy (HTO) compared with the mechanical axis deviation, and to find individualized targets for the redistribution of load that reflect bony alignment, joint laxity, and surgical technique.

Aims

The goal was to evaluate tibiofemoral knee joint kinematics during stair descent, by simulating the full stair descent motion in vitro. The knee joint kinematics were evaluated for two types of knee implants: bi-cruciate retaining and bi-cruciate stabilized. It was hypothesized that the bi-cruciate retaining implant better approximates native kinematics.

Aims

The aim of this study was to identify variables associated with time to revision, demographic details associated with revision indication, and type of prosthesis employed, and to describe the survival of hinge knee arthroplasty (HKA) when used for first-time knee revision surgery and factors that were associated with re-revision.

Aims

The aim of this study was to evaluate medium-term outcomes and complications of the S-ROM NOILES Rotating Hinge Knee System (DePuy, USA) in revision total knee arthroplasty (rTKA) at a tertiary unit.

Axial radiographs were obtained under valgus and external rotation stress at 45° of knee flexion with and without contraction of the quadriceps muscle in order to assess the dynamics of patellar subluxation or dislocation. The radiography was performed on 82 knees in 61 patients with patellofemoral instability, and on 44 normal knees. The lateral patellofemoral angle and the congruence angle were measured and compared with the conventional Merchant views. Both parameters showed greater differences between symptomatic and normal knees on the stress radiographs obtained without quadriceps contraction. There was a major difference in the lateral patellofemoral angles between the groups, which clearly distinguished symptomatic knees from normal controls. Congruence angles on stress radiography had a significant correlation with the functional scores obtained after a period of conservative treatment and a positive correlation with the frequency of patellar subluxation. When the quadriceps contracted, two patterns of patellar shift were observed. While the patella reduced into the trochlear groove in all normal knees and about 70% of the symptomatic knees, contraction of the quadriceps caused further subluxation of the patella in the remaining symptomatic knees. All the knee joints which showed this displacement failed to respond to conservative treatment and eventually required surgical treatment. Thus, this technique of stress radiography is a simple, cost-effective and useful method of evaluating patellar instability and predicting the prognosis

Introduction. Tibial tuberosity and trochlear groove (TT-TG) distance has been investigated for the patients with primary patellofemoral subluxation/dislocation. To date, TT-TG distance after TKA has not been evaluated, and the effect of postoperative TT-TG distance on patellar tracking is unknown. The purpose of the current study was to investigate the effect of TT-TG distance and rotational position of the femoral and tibial components on patellar tilt after TKA. Methods. Consecutive 115 knees for the diagnosis of osteoarthritis were included in the current study. TKA was performed using posterior cruciate ligament sacrificed prosthesis. A total of 17 men and 96 women with an average age of 75.3 years were included at the time of the surgery. Computed tomography (CT) was taken after TKA in full extension. Postoperative TT-TG distance was measured as a reference of surgical epicondylar axis (SEA) of the femur. Patellar tilt was defined as the angle of the patellar component relative to SEA. Femoral and tibial component rotation was measured as the angle relative to SEA and tibial antero-posterior (AP) axis. Tibial AP axis was defined as the line connecting medial one-third of the tibial tuberosity and center of medial-lateral width. Pearson correlation coefficients were calculated to determine the correlations between patellar tilt and TT-TG distance and between patellar tilt and femoral and tibial component rotation. Results. TT-TG distance had significant correlation with patellar tilt (Figure 1; r = 0.254, p = 0.006), whereas femoral component rotation (p = 0.092) and tibial component rotation (p = 0.062) were not correlated with patellar tilt. Concerning the effect on TT-TG distance, femoral component rotation (r = 0.248, p = 0.008) and tibial component rotation (r = −0.567, p < 0.001) were correlated with TT-TG distance. Conclusion. The current study investigated the effect of TT-TG distance on patellar tilt with postoperative CT scan. Greater TT-TG distance resulted in more patellar tilt, which might have negative effects on patellar tracking. In previous clinical studies, femoral component and tibial component rotation affected patellar maltracking. In the current study, however, component rotation itself did not affect patellar tilt. Postoperative TT-TG distance includes information of rotational and medial-lateral positioning of the femoral and tibial components, and can be a useful indicator to predict patellar maltracking after TKA. For any figures or tables, please contact authors directly

Aims

Wear of the polyethylene (PE) tibial insert of total knee arthroplasty (TKA) increases the risk of revision surgery with a significant cost burden on the healthcare system. This study quantifies wear performance of tibial inserts in a large and diverse series of retrieved TKAs to evaluate the effect of factors related to the patient, knee design, and bearing material on tibial insert wear performance.

We report a prospective analysis of clinical outcome in patients treated with medial patellofemoral ligament (MPFL) reconstruction using an autologous semitendinosus graft. The technique includes superolateral portal arthroscopic assessment before and after graft placement to ensure correct graft tension and patellar tracking before fixation. Between October 2005 and October 2010, a total of 201 consecutive patients underwent 219 procedures. Follow-up is presented for 211 procedures in 193 patients with a mean age of 26 years (16 to 49), and mean follow-up of 16 months (6 to 42). Indications were atraumatic recurrent patellar dislocation in 141 patients, traumatic recurrent dislocation in 50, pain with subluxation in 14 and a single dislocation with persistent instability in six. There have been no recurrent dislocations/subluxations. There was a statistically significant improvement between available pre- and post-operative outcome scores for 193 patients (all p < 0.001). Female patients with a history of atraumatic recurrent dislocation and all patients with history of previous surgery had a significantly worse outcome (all p < 0.05). The indication for surgery, degree of dysplasia, associated patella alta, time from primary dislocation to surgery and evidence of associated cartilage damage at operation did not result in any significant difference in outcome. This series adds considerably to existing evidence that MPFL reconstruction is an effective surgical procedure for selected patients with patellofemoral instability