Tibial and femoral loosening are major causes for implant failure in total knee arthroplasty. Jefferey (1991) reported a significantly lower rate of loosening when varus or valgus was within 3 degrees of mechanical axis in an eight year follow up. Coulle (Dec1999) reported 48% unacceptable alignment in non-navigated knees and Reed (Aug 2002) reported 35% alignments deviating more than 3 degrees from mechanical axis when navigation was not used.

We report our series of 286 navigated knee replacements using the Aesculap Search system (21 cases) and the Aesculap e-motion versions 4.2, 4.3 and 4.4 (265 cases) between April 2003 and December 2012 by the author (A.D) and analysed the correction achieved against the zero mechanical axis. Postoperative measurement of the angles on long length films was done in 23 cases. This matched with the intraoperative corrections achieved as studied using per-operative computer data stored for every case. We continued to use the data stored in the AESCULAP System to correlate the findings in the rest of the cases. The average mechanical axis achieved was 1.3 degrees. All cases had mechanical axes within 3 degrees.

We were thus able to achieve a high level of correction of the mechanical axes predictable to achieve better clinical outcomes.

Introduction

Viscosupplementation is used widely to provide symptomatic relief to patients with knee OA. This study aimed to compare the efficacy and safety of the standard (3×2ml) and single (1×6ml) dosing regimens of hylan G-F 20

Aim

To compare the clinical effectiveness, functional outcome and patient satisfaction following intra articular injection with Synvisc^¯ and Hyalgan^¯ in patients with osteoarthritis (OA) of the knee.

Aim: To compare the clinical effectiveness, functional outcome and patient satisfaction following intra articular injection with Hylan G-F-20 and Sodium Hyaluro-nate in patients with osteoarthritis (OA) of the knee.

Methods: In this independent study, 382 consecutive patients with OA of the knee were prospectively randomized into two groups to receive Hylan G-F-20 -Syn-visc (n=196) or Sodium Hyaluronate -Hyalgan (n=186) and reviewed by blinded independent assessors at pre injection, 6 weeks, 3, 6, 12 months. Knee pain, patient satisfaction was measured on a VAS. Functional outcome was assessed using WOMAC, UCLA, Tegner, Oxford knee score and EuroQol- 5D scores. Mean follow up was 14 months.

Results: Patients in both groups predominantly had grade III OA. Knee pain on VAS improved from 6.7 to 3.2 by 6 weeks (p=0.02) and was sustained until 12 months (3.7, p=0.04) with Synvisc. In the Hyal-gan group, pain improved from 6.6 to 5.7 at 6 weeks (p> 0.05) and to 4.1 at 3 months (p=0.04) but was sustained only until 6 months (5.9, p> 0.05). Improvements in the WOMAC pain and physical activity subscales were significantly superior in the Synvisc group at 3 months (p=0.02), 6 months (p=0.01) and 12 months (p=0.02). General patient satisfaction was better in the Synvisc group at all times although statistically significant at 3 months (p=0.01) and 6 months (p=0.02). There was local increase in knee pain in one patient who received Synvisc, which settled by 4 weeks. Total treatment cost was 23% more in the Hyalgan group due to the two additional visits.

Conclusion: Although both treatments offered significant pain reduction, it was achieved earlier and sustained for a longer period in patients with Synvisc with early increase in activity levels. However, a local reaction of pseudo sepsis was observed with Synvisc in one patient. The total treatment cost, both for the patient and the hospital are higher with Hyalgan. From this study, it appears that the clinical effectiveness and general patient satisfaction are better amongst patients who received Synvisc.

Background: Aseptic loosening of the tibial component is the one of the commonest cause of failure following a TKR. Good cement penetration into bone can reduce this and this has led to the development of new devices and techniques to improve the pressurisation during the cementing process.

We have conducted a case controlled study on a novel cementing technique and compared the results with published optimum levels.

Methods: 104 patients that underwent TKR at our institution were studied. Half of these were cemented using a double mix of cement inserted under pressure via an inexpensive alternative to the cement gun. The data was collected prospectively and included patient information, knee outcome scores and radiological assessment and there was a minimum 4 years follow-up.

Results: We found a significant difference in the number of early lucent lines as well as the size of the cement mantle particularly in the most important Zones. Despite pressurisation 1 of the 14 zones did not improve and we have examined the reasons for this.

In order to achieve optimum cement penetration we recommend that attention is paid to good pressurization and cement penetration and describe our technique for doing this.

We undertook the current study to analyze the factors involved with failed previous stabilization surgery for patients with anterior or anteroinferior glenohumeral instability. Between 1997 and 2003 we treated seventy-four patients with traumatic unidirectional instability. The average age was thirty-two and the average follow up was fifty-eight months. There were sixteen females and fifty-eight males. All patients underwent a primary diagnostic arthroscopy followed by arthroscopic stabilization in forty-seven and open stabilization in twenty-seven cases. Ten had a recurrence of instability. Of these two had significant trauma. Of the remaining, six were in the arthroscopic group and two in the open procedure group.

Analyze the factors involved with failed previous stabilization surgery for patients with anterior or anteroinferior glenohumeral instability.

Between 1997 and 2003 we treated seventy-four patients with traumatic unidirectional instability. The average age was thirty-two years (range nineteen to forty-seven). There were sixteen females and fifty-eight males. The average follow up was fifty-eight months (range seven to eighty-three). All patients underwent a primary diagnostic arthroscopy followed by arthroscopic stabilization in forty-seven and open stabilization in twenty-seven cases. The arthroscopic procedure involved two Suretac II labral reattachment and capsular shrinkage using electrocautery. The open procedure involved a Bristow/Latarjet procedure using a delto-pectoral approach and reattachment of coracoid process using a single malleolar screw.

Ten patients had a recurrence of instability. Of these two had significant trauma, one each group. Of the remaining eight, six were in the arthroscopic group and two in the open procedure group. In the arthroscopic recurrence group, three had a large Hill Sach’s lesion and one a large Bankart Lesion. In the open procedure group, both had a large Hill Sach’s and Bankart’s lesion. This gave a recurrence rate of 12.7% in the arthroscopic group and 7.4% in the open group.

A large Hill-Sach lesion > 2mm is a contra-indication to arthroscopic repair and the optimum stabilisation procedure is an open repair (Bristow/Laterjet). Without a significant Hill-Sach’s lesion an arthroscopic Suretac II labral re-attachment is an effective way of achieving stability. Those who have a large Hill-Sach and significant Bankart’s lesion may need a combination of Bankart’s repair plus an extra-articular procedure like a Bristow/Laterjet procedure.

To evaluate large/Jumbo acetabular cups in revision surgery, 52 cups in 48 patients were reviewed; mean age was 71. 6 years and mean follow up 6 years.

Average Harris Hip Score was 85. Excellent bony incorporation was seen in all but the failures, of which there were three, 1 due to infection and 2 due to aseptic loosening. Major complications included 2 intraoperative fractures.

Intermediate results of acetabular revisions, using large cups, without bone grafting are encouraging.

Aim: to evaluate the use of large acetabular cup in revision surgery without structural bone graft.

Materials/methods: Patients who had revision hip surgery at Greenwich Hospital between 1991 and 1994 were reviewed. All patients had complete clinical and radiological follow up.

Large cup was the press fit Mathys Isoelastic cup.

No patient had any structural bone grafting.

Failure was defined as need for surgery and/or poor clinical outcome.

Objective clinical assessment was done using the Harris Hip score.

Radiological assessment was carried out using RC Johnston’s criteria for uncemented cups.

Results: 52 revised cups in 48 patients were reviewed. Mean age was 71.6yrs, 21 males and 27 females. Mean follow up was 6 years (4 to 8 years). Average cup size was 64 mm (62 to 66).

Diagnosis at index operation was 10 Rheumatoid, and 42 osteoarthrosis. Average Harris Hip Score was 85 (excellent 35, good 11, fair 3, poor 3)

Radiological assessment showed excellent bony incorporation in all but the failures. There were 3 failures, 1 due to infection (revision was for infected primary THR), and 2 due to aseptic loosening in rheumatoid patients (both had significant cup malposition at revision). The major complications included 2 intraoperative fractures.

Conclusion: Intermediate term results of acetabular revisions, using large cups, without structural bone grafting, in our hands, are encouraging. Cup position at revision appears crucial for long-term survival.