Introduction

Virtual fracture clinics (VFC's) aim to reduce the number of outpatient appointments while improving the clinical effectiveness and patients experience through standardisation of treatment pathways. With 4.6% of ED admissions due to trauma the VFC prevents unnecessary face to face appointments providing a cost savings benefit to the NHS.

Graphene is a two-dimensional structure that is made of a single-atom-thick sheet of carbon atoms organised in hexagonal shapes. It is considered to be the mother of all graphite or carbon-based structures. It has shown exceptional physical and chemical properties which possess potential future applications. Graphene has an elasticity index similar to rubber and a hundred times tensile strength of steel and is even sturdier than diamonds. It is a very efficient biosensor with its exceptional electronic conductivity far greater than even copper. It is a potential future low cost material and its scalable production ability makes it even more attractive. The rediscovery of Graphene in 2008 saw few potential medical applications, specifically in the field of drug delivery, gene and cancer therapy.

Nao graphene has extensive thermal conductivity and reflexivity, which can conceivably change imaging especially muskeloskeletal imaging and notably as a contrast material. It has been found to be a safe and a cheaper IV contrast agent in USA in 2012. Being an efficient biosensor especially in conducting electricity, it could assist in prosthetic and bionic limbs or prosthesis. Its durable stubborn properties, a composition which exceeds the strength of steel and light weight structure may create a potential material to develop into a new generation of a low profile internal fixing devices like plats. Most importantly, its scaffolding cell culturing assets could change the whole concept of prosthesis from mechanical press fit fixation to more dependence on bio adhesiveness.

Objective

The aim of the study was to evaluate inter observer reliability and intra observer reproducibility between the three column classification using 3D CT reconstruction models and schatzker classification systems using 2D CT models.

Multiple reports suggest good outcome results following unicompartmental knee replacement (UKR). However, several authors report technically difficult revision surgery secondary to osseous defects. We reviewed clinical outcomes following revision total knee replacement for failed UKR and analysed the reasons for failure and the technical aspects of the revision surgery.

Between 2003 and 2009, thirty three revisions from unicompartmental knee replacement to total knee replacement were performed in thirty two patients at a single centre. Demographics, indications for the primary and revision procedures, details of the revised prosthesis including augments and any technical difficulties or complications were noted. Patient assessment included range of motion and the functional status of the affected knee in the form of the Oxford knee score questionnaire. Statistical analysis was performed with the Student t test.

All 33 revision knees were available for prospective clinical and radiological follow-up. The minimum duration of follow-up after revision surgery was 1 year (mean 3 years, range 1 – 7 years). The median interval between the original unicompartmental knee replacements to revision surgery was 19 months (range 2 – 159 months). The predominant cause of failure was aseptic loosening (50%). Other reasons included persistent pain (21%), dislocated meniscus (18%), mal-alignment (7%) and progression of symptomatic osteoarthritis in another compartment (4%). 18 of the 33 revision procedures required additional augments. During the revision surgery, 11 knees required a long tibial stem while 1 required a long femoral stem. 10 knees required medial tibial wedge augmentation; bone graft was used in 6 knees while a metal wedge augment was used in 4 to fill significant osseous defects. At the time of follow-up, range of movement averaged 103 degrees (range 70 – 120). The mean one year Oxford knee score, was 29 compared to 39 for primary total knee replacements performed during the same period in a comparable sample group of patients at our institute (p < 0.001). Three patients continued to have pain and two required re-revision; one for infection and one for loosening.

Aseptic loosening was the commonest mode of failure. Of the UKRs revised to TKRs, 90% were revised within 5 years. The majority of revisions required additional constructs. Oxford Knee Scores after revision surgery were inferior to those for primary TKR. The role of UKR needs to be more clearly defined.

Data was collected on 139 eligible patients a minimum of 18 months post surgery who had had 2 or more ligaments reconstructed. 63 patients were available for clinical follow up. It is the largest single surgeon series studied.

27% of injuries were high energy traffic accidents. 73% were low energy, mainly sports related. 63% of patients were delayed referrals to our unit. Of these nearly 48% had already undergone knee surgery, often more than 6 months post injury. 17% of all cases presented with failed ligament reconstructions. Of those patients followed up 19% were operated upon within 3 weeks of injury, 56% were delayed reconstructions with a mean time to surgery of 21 months and 25% were revision reconstructions. Time to follow up ranged from 18 months to 10 years.

The median KOS ADL, KOS Sports Activity and Lysholm scores for uni-cruciate surgery were all better than those for bi-cruciate surgery. All results were better for acute rather than chronic cases, which in turn were better than those for revision cases. The Tegner score showed that only acute uni-cruciate reconstructions returned to their pre-injury level.

TELOS stress radiographs demonstrated a mean post drawer of 5.9 mm side-to-side difference after reconstructions involving the PCL. IKDC grades showed 6% of knees were normal and 57% were nearly normal.

37% required further surgery, mainly to increase movement or for hardware removal. There was 1 deep infection and 2 cases of thrombosis. There were no vascular complications but 2 had transient nerve injuries.

Multi-ligament surgery can produce good functional outcomes but the knee is never normal. There is an increased risk of PCL laxity post op. Early referral to a specialist unit is suggested as delayed referral to a specialist unit potentially subjects the patient to unnecessary surgery and may affect outcome.

Patellofemoral unicompartmental joint replacement is a controversial subject with a relatively small evidence base. Of the 50,000 total knee arthroplasties performed each year in the UK, approximately 10% are performed for predominantly patellofemoral arthritis. There are several patellofemoral unicompartmental prostheses on the market with the National Joint Registry recording 745 such prostheses used in 2007. Most evidence in favour of this procedure comes from experience with the Avon prosthesis (Stryker) predominantly from designer-surgeons.

The FPV patellofemoral joint replacement (Wright Medical) has been in use in Europe for several years. The instruments have recently been redesigned and the device marketed in the UK. In 2007 the FPV had 5.9% market share (n=44). We present our early experience with the FPV patellofemoral joint replacement, which to our knowledge, is the first clinical outcome series for this prosthesis.

33 consecutive FPV joint replacements in 29 patients were performed between April 2007 and September 2009 for unicompartmental patellofemoral OA. All cases were performed or directly supervised by the senior author. Results are presented with a minimum follow-up of six months.

Oxford and American Knee Society scores (AKSS) were obtained on all patients preoperatively and at subsequent outpatient visits. Mean preoperative AKSS knee score was 49.7 points and postoperative scores at 6 months and 1 year were 82.5 and 86.4 respectively. Mean Oxford score preoperatively was 30.4 (37%) and at 6 months and 1 year were 21.3 (56%) and 11.2 (77%) respectively.

There were no complications related to the implant. One knee required a secondary open lateral release due to inadequate balancing at the index procedure.

Further medium to long-term follow up data are required, but our initial experience with this device is encouraging.