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Abstract

INTRODUCTION

10% of patients with knee osteoarthritis (OA) have disease confined to the patellofemoral joint (PFJ). The main surgical options are total knee replacement (TKR) and PFJ replacement (PFJR). PFJR has advantages over TKR, including being less invasive, bone preserving, allowing faster recovery and better function and more ‘straight forward’ revision surgery. We aim to compare the clinical results of revised PFJR with primary TKR taking into consideration the survival length of the PFJR.

METHODOLOGY

Twenty-five patients (21 female) were retrospectively identified from our arthroplasty database who had undergone revision from PFJR to TKR (2006–2019). These patients were then matched with regards to their age at their primary procedure, sex and total arthroplasty life (primary PFJ survival + Revision PFJ time to follow up) up to point of follow-up with a group of primary TKRs implanted at the same point as the primary PFJR.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_13 | Pages 69 - 69
7 Aug 2023
Kumar A Stevens S Jonas S White S Agarwal S
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Abstract

Introduction

Isolated patellofemoral joint(PFJ) osteoarthritis affects approximately 10% of patients aged over 40 years and treatment remains controversial. Our aim was to evaluate long term functional and radiological outcomes following PFJ arthorplasty with the Femoro Patella Vialli (FPV) prosthesis as this evidence is lacking in literature.

Methodology

A retrospective review of prospectively collected PROMS in patients undergoing Patellofemoral arthroplasty. Single centre trial. Between 2004 and 2008, 101 FPV patellofemoral arthroplasties were performed in 80 patients with isolated patellofemoral joint osteoarthritis. Data was collected as a part of routine follow-up for up to 6 years and additional long term data was collected at 16 years.


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_1 | Pages 27 - 27
1 Jan 2022
De C Kainth N Harbham P Brooks M Agarwal S
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Abstract

Background

This study aims to estimate the risk of acquiring a medical complication or death from COVID-19 infection in patients who were admitted for orthopaedic trauma surgery during the peak and plateau of pandemic. Unlike other recently published studies, where patient-cohort includes a more morbid group and cancer surgeries, we report on a group more akin to those having routine elective orthopaedic surgery.

Methods

The study included 214 patients who underwent orthopaedic trauma surgeries in the hospital between 12th March and 12th May 2020 when the COVID-19 pandemic was on the rise in the United Kingdom. Data was collected on demographic profile including comorbidities, ASA grade, COVID-19 test results, type of procedures and any readmissions, complications or mortality due to COVID-19.


Orthopaedic Proceedings
Vol. 100-B, Issue SUPP_8 | Pages 24 - 24
1 May 2018
Iliopoulos E Agarwal S Khaleel A
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Purpose

Pilon fracture is a severe injury which has a great impact on the patients' lives, but in what extend is not clear yet in the literature. The purpose of this study was to investigate the gait alternations after treatment of patients who had pilon fractures.

Materials & Methods

We have evaluated the gait pattern of patients who were treated with circular Ilizarov frame following pilon fractures in our department. The gait was tested by using a force plate in a walking platform. Ground Reaction Forces (GRF) and timing of gait phases data were collected during level walking at self-selected speeds. The patients performed two walking tasks for each limb and the collected data were averaged for each limb. Demographic, clinical, radiological, trauma outcome (COST) and quality of life questionnaire (SF-12) data were also collected.


Orthopaedic Proceedings
Vol. 100-B, Issue SUPP_8 | Pages 39 - 39
1 May 2018
Gee C Agarwal S Iliopoulos E Khaleel A
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Introduction

Anatomical reduction of articular fragments in tibial plateau fractures often leads to a void and there is a need to fill dead space and support the articular fragment. MIIG X3 is marketed as high strength injectable graft, which resorbs and remodels fast. Efficacy and complications related to the use of this bone graft substitute were evaluated in this study

Methods

Between January 2012 and December 2016 we injected calcium sulphate (MIIGX3) in 50 out of 126 consecutive complete articular (AO type C3) tibial plateau fractures that were stabilised with Ilizarov ring fixator. Postoperative CT scans after weight bearing and sequential radiographs were evaluated for union, graft resorption and subsidence. IOWA functional outcome score and complications were recorded.


Orthopaedic Proceedings
Vol. 100-B, Issue SUPP_3 | Pages 94 - 94
1 Apr 2018
Kabariti R Kakar R Agarwal S
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Introduction

As the demand for primary total knee arthroplasty (TKA) has been on the rise, so will be the demand for revision knee surgery. Nevertheless, our knowledge on the modes of failure and factors associated with failure of knee revision surgery is considerably lower to that known for primary TKA. To date, this has been mostly based on case series within the literature. Therefore, the aim of this study was to evaluate the survivorship of revision TKA and determine the reasons of failure.

Methods

A retrospective study was conducted with prior approval of the institutional audit department. This involved evaluation of existing clinical records and radiographs of patients who underwent revision knee surgery at our institution between 2003 and 2015. Re-revision was identified as the third or further procedure on the knee in which at least one prosthetic component was inserted or changed.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_21 | Pages 2 - 2
1 Dec 2017
Agarwal S Iliopoulos E Khaleel A
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Aim

Anatomical reduction and Stable fixation of Lisfranc injuries is considered the gold standard. There is controversy about how it is best achieved. Some surgeons would advocate routine open anatomical reduction, which as a concept was popular in 1980s but the same anatomical reduction and fixation can be achieved percutaneously. We describe our method of close reduction and percutaneous fixation and present our results.

Materials and methods

22 patients with a minimum follow up of 12 months were included. We achieved satisfactory anatomical reduction percutaneously in all patients and internal fixation was performed using cannulated screws for medial and middle columns. Functional outcome was evaluated using Foot and Ankle Disability Index (FADI) and components of this score were analysed individually to assess which domain was most affected. Vertical ground reaction forces were measured using a force plate in a walking platform.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_13 | Pages 3 - 3
1 Jun 2017
Iliopoulos E Agarwal S Gallagher K Khaleel A
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Purpose

Tibia plateau fractures are severe knee injuries which have a great impact on the patients' lives, but in what extend is not clear yet in the literature. The purpose of this study was to investigate the gait alternations after treatment of patients who had severe tibia plateau fractures which were treated with circular ilizarov frame.

Materials & Methods

We have evaluated the gait pattern of patients who were treated with circular Ilizarov frame after severe tibia plateau fractures (Schatzker IV-VI) in our department. The gait was tested by using a force plate in a walking platform. Ground Reaction Forces (GRF) data were collected during level walking at self-selected speeds. The patients performed two walking tasks for each limb and the collected data were averaged for each limb. Demographic, clinical, radiological and quality of life questionnaire (SF-12) data were also collected.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_13 | Pages 2 - 2
1 Jun 2017
Iliopoulos E Agarwal S Khaleel A
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Introduction

Patient Reported Outcome Measures (PROMs) are used as outcome of many surgical treatments such as Hip and knee joint replacements, varicose vein and groin hernia surgery. Outcome scores in orthopaedics tend to be site and/or pathology specific. Trauma related pathology uses a surrogate outcome scores. A unified outcome score for trauma is needed to help with the measurement of outcomes in trauma patients and evaluate the actual impact that trauma inflicts to patients' lives.

Materials & Methods

We have designed a PROM especially for Trauma patients, in order to measure the extent of recovery to pre-injury state. This score uses as baseline the pre-injury status of the patient and has the aim to determine the percentage of rehabilitation after any form of treatment. This PROM is not site specific and can be used for every Trauma condition. It uses simple wording, user friendly and accessed via phone conversation.

The outcome score consists of eleven questions. The first ten questions use the 5-point Likert scale and the final question a scale from zero to ten. The questions are divided into three subgroups (Symptoms, Function and Mental status). The final question assesses the extent of return to pre-injury status.

The SF-12v2 questionnaire was used for the validation of the COST questionnaire. We gathered COST and SF-12v2 questionnaires from patients who were at the end of their follow-up after treatment for various trauma conditions, treated either conservatively either operatively.


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_15 | Pages 60 - 60
1 Dec 2015
Agarwal S Hughes H
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A multimodality approach is needed for management of infected joint replacement prostheses and infected skeletal metalwork. We present our results in six patients managed surgically with standard techniques, with the addition of a local antibiotic delivery system using absorbable Calcium Sulphate beads.

A retrospective study was undertaken of 6 patients with established musculoskeletal infection in relation to existing metalwork. Two patients had infection in the hip replacement prosthesis, three had infected prosthetic knee joints and one had infection in a femoral locking plate. All were treated with extensive debridement, revision / retention of implants, parenteral antibiotics and local antibiotics.

Patients were followed up in clinic for resolution of inflammatory markers and subsidence of signs of infection. Control of infection was achieved in five patients at average 19 months followup. One patient had persistent infection and has undergone further surgery.

In this preliminary study, we found local antibiotic delivery using absorbable calcium sulphate beads to be an effective adjuvant to standard debridement, parenteral antibiotics and revision of implants.


The Bone & Joint Journal
Vol. 95-B, Issue 12 | Pages 1640 - 1644
1 Dec 2013
Agarwal S Azam A Morgan-Jones R

Bone loss in the proximal tibia and distal femur is frequently encountered in revision knee replacement surgery. The various options for dealing with this depend on the extent of any bone loss. We present our results with the use of cementless metaphyseal metal sleeves in 103 patients (104 knees) with a mean follow-up of 43 months (30 to 65). At final follow-up, sleeves in 102 knees had good osseointegration. Two tibial sleeves were revised for loosening, possibly due to infection.

The average pre-operative Oxford Knee Score was 23 (11 to 36) and this improved to 32 (15 to 46) post-operatively. These early results encourage us to continue with the technique and monitor the outcomes in the long term.

Cite this article: Bone Joint J 2013;95-B:1640–4.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIX | Pages 86 - 86
1 Sep 2012
Azam A Agarwal S Morgan-Jones R
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Introduction

This study was undertaken to evaluate the early results of a new implant system - the metaphyseal sleeve - in revision total knee replacement. The femoral and tibial metaphyseal sleeves are a modular option designed to deal with metaphyseal bone loss and achieve cementless fixation over a relatively wide area in the metaphysis.

Methods

Over three years, femoral and/or tibial metaphyseal sleeves were implanted in 104 knees in 103 patients (54 male and 49 female). The clinical notes and radiographs of these patients were reviewed retrospectively. Thirty one patients had revision for infection, 42 for aseptic loosening, and 31 for instability, pain or stiffness. Eighty nine knees were revised as a single stage and 15 were done as two stage procedure. Minimum follow up is 12 months (average 18.5 months).


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXIX | Pages 56 - 56
1 Jul 2012
Azam A Agarwal S Morgan-Jones R
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Purpose of the study

This study was undertaken to evaluate the early results of a new implant system - the metaphyseal sleeve - in revision total knee replacement. The femoral and tibial metaphyseal sleeves are a modular option designed to deal with metaphyseal bone loss and achieve cementless fixation over a relatively wide area in the metaphysis.

Methods

Over three years, femoral and/or tibial metaphyseal sleeves were implanted in 104 knees in 103 patients (54 male and 49 female). The clinical notes and radiographs of these patients were reviewed retrospectively. Thirty one patients had revision for infection, 42 for aseptic loosening, and 31 for instability, pain or stiffness. Eighty nine knees were revised as a single stage and 15 were done as two stage procedure. Minimum follow up is 12 months (average 18.5 months).


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXIX | Pages 98 - 98
1 Jul 2012
Bansal GJ Kamath S Agarwal S
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Purpose of the study

Release of tight lateral structures is an integral part of balancing the valgus knee during knee replacement surgery. The posterolateral capsule is released through an inside-out technique. The common peroneal nerve is in close proximity to the capsule during this step. This study was undertaken to determine the distance of the nerve and the safe level for the posterolateral release.

Methods

MR scans of the knee of 100 patients were evaluated. The age range of selected patients was 50 to 70 years. The distance of the nerve was measured to the closest point on the posterolateral capsule. Two separate measurements were taken - one 9mm above the joint line indicating the distal femoral resection level and the other 9mm distal to the joint line indicating the level of tibial resection. A third point was at the joint line level. The position of the nerve was also recorded in relation to the cross section of the femur/tibia on a ‘clock-like’ reference.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_IV | Pages 441 - 441
1 Nov 2011
Sharma RK Kumar Y Kumar R Agarwal S
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Fixed flexion deformity is common in neglected cases of advanced arthritis of the knee.

The need and means of complete correction of fixed flexion deformity remains controversial. We analysed 60 patients of advanced arthritis with severe flexion deformity > 300 who underwent total knee arthroplasty between January 2002 to January 2008. The age ranged from 54 to 78 years (mean age of 62 years). All surgeries were performed using posterior cruciate substituting implant. Patients were followed for an average period of 42 months.

All patients were operated in a single stage. Distal femoral over-resection was done in addition to posterior, postero-medial and postero-lateral release. Posterior release was done upto the linea aspera. In 2 cases posterior capsular was released directly. A criteria was developed for sequential release on the basis of degree of flexion deformity.

Flexion deformity was fully corrected in 48 cases where as 50 of residual flexion remained in 5 cases with preoperative deformity of 40–600 and 100 residual flexion remained in 6 cases with preoperative deformity > 600. One patient with pre op fixed flexion deformity of 90* had to be treated with arthrodesis.

Our experience suggest that predetermined routine femoral over-resection in moderate to severe flexion deformity prior to balancing knee is not fraught with complications if our criteria are followed. Additional bony cuts (over-resection) and posterior soft tissue release is complementary to each other in correction of flexion deformity and it should be a sequential release. This technique saves time, reduces intraoperative difficulties and helps to correct flexion deformity maximally.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_I | Pages 26 - 26
1 Mar 2010
Tornetta P Siegel J Burke P Kaseje N Agarwal S Soto J Anderson S
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Purpose: In patients with pelvic trauma, the need to quickly and accurately rule out sources of bleeding is paramount. We sought to determine the predictive value of CT angiography in determining the need for therapeutic angiography and to ascertain if definable arterial bleeding correlated with anatomic injury.

Method: Over a 2 year period 58 patients with a high-energy mechanism and pelvic injury underwent pelvic CT angiography as part of their initial trauma CT scan. This was performed as a 25 second delayed scan (after contrast introduction) using a GE light speed VCT64 scanner. The decision to proceed to therapeutic angiography was made on clinical grounds and was later compared with the CT angiographic findings. The anatomic location of bleeding on CT angio and interventional angio were compared.

Results: There were 36 male and 22 female patients, aged 43 (17 – 86), with average ISS of 18.6. The 18 (31%) patients with positive extravasation on CT angiography had higher initial blood requirements compared to those without extravasation. Two of the CT(+) group died prior to therapeutic angiography being performed. 11 of the remaining 16 had interventional angiography; 8 had (+) findings, including 7 major vessels coiled and 1 cutoff vessel observed. 1 patient of 40 with negative CT angiogram met clinical criteria had an interventional angiography; no arterial bleeding was discovered. The negative predictive value of CT angiography for pelvic arterial bleeding requiring therapeutic angiography was 100%; the positive predictive value of angiographically treatable bleeding was 70% (counting the two early deaths). The vessel location on CT angio and therapeutic angio was consistent in all cases. The CT angio (+) group had a higher percentage of unstable pelvic injuries (67% vs. 40%).

Conclusion: In this pilot study, CT angiography added to the initial trauma scan in patients with pelvic trauma demonstrated a 100% NPV for arterial bleeding that required therapeutic angiography on clinical grounds. Positive findings correlated well with the anatomic location of pelvic injury and had a 70% PPV for angio-graphically treatable bleeding. Further study of this technique is warranted.


The Journal of Bone & Joint Surgery British Volume
Vol. 88-B, Issue 8 | Pages 1097 - 1101
1 Aug 2006
Jambhekar NA Kulkarni SP Madur BP Agarwal S Rajan MGR

A retrospective series of 45 cases of chronic osteomyelitis collected over a period of 14 years was histologically classified into tuberculous osteomyelitis (25) and chronic non-granulomatous osteomyelitis (20). The tuberculous osteomyelitis group was divided into three subgroups: a) typical granulomas (13 cases); b) ill-defined granulomas (seven cases), and c) suspected granulomas (five cases). An in-house polymerase chain reaction amplifying the 245 bp nucleotide sequence, and capable of detecting 10 fg of DNA of Mycobacterium tuberculosis, was used on the DNA extracted from the paraffin blocks. The polymerase chain reaction was positive in 72% of cases (18) of tuberculous osteomyelitis, but when typical cases of tuberculous osteomyelitis with confirmed granulomas were considered (13), this increased to 84.6% (11). The chronic non-granulomatous osteomyelitis group gave positive polymerase chain reaction results in 20% of the cases (4).

Our preliminary study on tuberculous osteomyelitis shows that the polymerase chain reaction can be a very useful diagnostic tool, since a good correlation was seen between typical granulomas and polymerase chain reaction with a sensitivity of 84.6% and a specificity of 80%. In addition, our study shows that tuberculous osteomyelitis can be diagnosed in formalin-fixed paraffin-embedded tissues in the absence of typical granulomas.


The Journal of Bone & Joint Surgery British Volume
Vol. 86-B, Issue 8 | Pages 1221 - 1221
1 Nov 2004
AGARWAL S


Orthopaedic Proceedings
Vol. 85-B, Issue SUPP_II | Pages 154 - 154
1 Feb 2003
Agarwal S Giannoudis P Smith R
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To evaluate the results of management of urological injury and the impact on final outcome in patients with pelvic fractures.

Out of 554 patients with pelvic fractures, 39 (7%)(8 female) were identified with urinary tract injuries. The mean age of the patients was 30.9 yrs (range 15–71) and the mean ISS was 12.9 (range 9–22). Seven (18 %) had upper tract injury, 6 (15.4 %) had extraperitoneal bladder rupture, 9 (23.1 %) had intraperitoneal rupture, 3 (7.6 %) had bladder neck injury and 14 (35.9 %) had urethral injury. Timing of urological intervention, complications and long term result in terms of incontinence, stricture and sexual dysfunction were assessed. All patients were assessed based on Orthopaedic, urological and the Euroqol (EQ5D) generic health questionnaire and compared to age and sex matched control group of 47 patients with similar pelvic injuries and ISS but no urological injury. The mean follow up period was 2.3 years.

Upper urinary tract injuries: All were managed non-operatively and had a uniformly good outcome except one patient who had a traumatic renal vein thrombosis and required nephrectomy.

Lower tract injuries: 14 out of 15 patients with bladder rupture had a repair of bladder within 24 hours of arrival at our center. One with a small extraperitoneal tear was managed nonoperatively. Three patients reported failure of erection. Two were managed by immediate repair (day 1 and day 2) and had normal continence. One repair was delayed due to delay in transfer and was done on the 4th day. He developed faecal and urinary incontinence and loss of sexual function.

Thirteen males had urethral injury. Three patients had a primary urethrostomy for a gap defect and two of these developed erectile dysfunction. Two were referred late to our center and were managed by continent urinary diversion. The rest had a catheter railroaded to maintain alignment of the two urethral ends and delayed repair was done for three patients. One patient in this group had sexual dysfunction while 5 developed a stricture.

We found no significant difference between the study and the control group in the outcome on comparing patients with upper tract and bladder injuries but the urethral injury group had a poorer result in all 5 parameters of the EQ5D.

Upper tract and bladder injuries do not add significant morbidity compared to the control group. In contrast urethral injuries significantly affected the outcome after pelvic fracture in terms of general health and return to normal function.