Aims

The best surgical strategy for the management of displaced bucket-handle (BH) meniscal tears in an anterior cruciate ligament (ACL)-deficient knee is unclear. Combining meniscal repair with ACL reconstruction (ACLR) is thought to improve meniscal healing rates; however, patients with displaced BH meniscal tears may lack extension. This leads some to advocate staged surgery to avoid postoperative stiffness and loss of range of motion (ROM) following ACLR.

Aims

This study reports on the medium- to long-term implant survivorship and patient-reported outcomes for the Avon patellofemoral joint (PFJ) arthroplasty.

We present the ten- to 15-year follow-up of 31 patients (34 knees), who underwent an Elmslie-Trillat tibial tubercle osteotomy for chronic, severe patellar instability, unresponsive to non-operative treatment. The mean age of the patients at the time of surgery was 31 years (18 to 46) and they were reviewed post-operatively, at four years (2 to 8) and then at 12 years (10 to 15). All patients had pre-operative knee radiographs and Cox and Insall knee scores. Superolateral portal arthroscopy was performed per-operatively to document chondral damage and after the osteotomy to assess the stability of the patellofemoral joint. A total of 28 knees (82%) had a varying degree of damage to the articular surface. At final follow-up 25 patients (28 knees) were available for review and underwent clinical examination, radiographs of the knee, and Cox and Insall scoring. Six patients who had no arthroscopic chondral abnormality showed no or only early signs of osteoarthritis on final radiographs; while 12 patients with lower grade chondral damage (grade 1 to 2) showed early to moderate signs of osteoarthritis and six out of ten knees with higher grade chondral damage (grade 3 to 4) showed marked evidence of osteoarthritis; four of these had undergone a knee replacement. In the 22 patients (24 knees) with complete follow-up, 19 knees (79.2%) were reported to have a good or excellent outcome at four years, while 15 knees (62.5%) were reported to have the same at long-term follow-up. The functional and radiological results show that the extent of pre-operatively sustained chondral damage is directly related to the subsequent development of patellofemoral osteoarthritis.

Cite this article: Bone Joint J 2013;95-B:478–85.

Patients with severe knee instability remain a surgical challenge. Furthermore, in the presence of extensive bone loss, constrained condylar implants may be unsuitable.

Hinged knee replacements have served an important role in the management of such complex knee pathologies.

A combined prospective and retrospective study of 138 consecutive hinge knee arthroplasties (42 primary and 96 revisions) of 8 different models performed in our institution between 2004 and 2010 at a mean follow up of 4.2years.

Outcomes were reviewed and knee scores preoperatively and postoperatively at 1, 2 and 5 years using the American knee scoring system.

The mean preoperative American knee score of 31 improved to 87 postoperatively.

Complication rate was 19%, 15% of which required re-revisions for: loosening (4%), Infection (4%), periprosthetic fracture (3%), Implant fracture (2%), Component disassembly (1%) and dislocation (1%). Overall implant failure rate was 9% and implant survivorship was greater than 80% at 4 years.

In our study, hinge prostheses provided good stability and symptom relief with a lower complication rate compared to some previous studies.

In addition, we believe hinge prostheses can also serve as reasonable alternatives to amputation and arthrodesis in many complex knees cases.

Purpose

The purpose of this study was to determine whether intra-operative identification of osseous ridge anatomy (lateral intercondylar “residents” ridge and lateral bifurcate ridge) could be used to reliably define and reconstruct individuals' native femoral ACL attachments in both single-bundle (SB) and double-bundle (DB) cases.

Purpose: Revision patellofemoral arthroplasty (PFA) is a relatively uncommon procedure, with no published reviews identified in the literature. Revision PFAs performed at our institution were reviewed to determine the reasons for PFA failure, the technical ease of revision and to document patient-reported outcomes after revision.

Methods: A prospective review of a cohort of 411 Avon PFA patients identified 31 subsequent revision knee procedures in 27 patients. Data was collected from the institution’s prospective data base, operative reports, X-rays and medical records. Post-operative knee scores (Oxford Knee Score, WOMAC Osteoarthritis Index, Bristol Knee Score) were available on 26 knees.

Results: The commonest reason for revision was progression of osteoarthritis (18 cases) followed by undetermined pain (7 cases). Patients with undetermined pain were found to be revised sooner than patients with disease progression (33 months vs 63 months) and also reported poorer outcome scores at 2 years post revision than the disease progression group.

Only two trochlea components were loose at the time of revision and one patella had a large amount of macroscopic wear. All other components were found to be well fixed with minimal wear at the time of revision. There were no difficulties in removing either component. No cases required augments or stemmed femoral components due to bone loss.

Patients undergoing revision surgery did report improvement in their post revision outcome scores compared with their pre-operative scores. The average Oxford Knee Score improved from 17 to 23, Bristol Knee Pain Scores improved from 11 to 20 and Bristol Knee Functional Scores improved from 15 to 16. These results are poorer than those recorded by the overall cohort of primary PFA.

Conclusion: PFA is easy to revise to a primary total knee. Results of revision knees are improved from pre-operative scores but not as good as expected.

Background: 10 years ago Bollen reported that, in the UK, the diagnosis of ACL injury was made by the primary treating physician in only 9% of cases and that the mean delay from injury to diagnosis was 21 months.

Aim: To assess if accuracy and delay of diagnosis of ACL rupture, and delay to surgery, have improved with time and with the implementation of local measures to address these issues.

Methods: The records of 100 patients who had undergone ACL reconstruction by the senior author at a single NHS hospital, were reviewed to assess: date of injury, date of first presentation, initial physician’s diagnosis, delay from initial presentation to correct diagnosis and date of surgery.

Results: When an diagnosis was made by the primary treating physician, it was correct in 43% of cases. 19 patients had arthroscopies and 53 had MRI scans. Mean delay from injury to presentation was 3.2 months and from presentation to diagnosis was 4.3 months (influenced by NHS MRI waiting times). Mean time from diagnosis to surgery was 11.3 months (reflecting the NHS waiting list during the study period). Mean time from injury to surgery was 17.3 months (range 2.3 to 97 months).

Patients referred electively by their GP’s had longer delays to correct diagnosis and to surgery. Patients attending A& E and referred to an Acute Knee Injury clinic were diagnosed more accurately and had shorter waits for diagnosis and surgery.

Conclusion: Correct diagnosis rates and delays from injury to diagnosis have improved substantially (compared with Bollen 1996). Patient awareness needs to be improved to decrease the delay to presentation. Acute Knee Injury clinics improve speed and accuracy of diagnosis. Decreasing NHS waits for MRI scans and surgery should further decrease delays from diagnosis to surgery in future.

We identified 148 patients who had undergone a revision total knee replacement using a single implant system between 1990 and 2000. Of these 18 patients had died, six had developed a peri-prosthetic fracture and ten had incomplete records or radiographs. This left 114 with prospectively-collected radiographs and Bristol knee scores available for study. The height of the joint line before and after revision total knee replacement was measured and classified as either restored to within 5 mm of the pre-operative height or elevated if it was positioned more than 5 mm above the pre-operative height. The joint line was elevated in 41 knees (36%) and restored in 73 (64%).

Revision surgery significantly improved the mean Bristol knee score from 41.1 (sd 15.9) pre-operatively to 80.5 (sd 15) post-operatively (p < 0.001). At one year post-operatively both the total Bristol knee score and its functional component were significantly better in the restored group than in the elevated group (p < 0.01). Overall, revision from a unicondylar knee replacement required less use of bone graft, fewer component augments, restored the joint line more often and gave a significantly better total Bristol knee score (p < 0.02) and functional score (p < 0.01) than revision from total knee replacement.

Our findings show that restoration of the joint line at revision total knee replacement gives a significantly better result than leaving it unrestored by more than 5 mm. We recommend the greater use of distal femoral augments to help to achieve this goal.

Aim: To assess the results of aseptic and aseptic cases using the PFC/TC3 system, and to correlate this with the restoration of joint line height.

Method: 148 patients underwent revision TKR using the PFC/TC3 system. No re-revision cases were included in this series. Data was prospectively collected (using the Bristol Knee Score) pre-operatively and at a mean of 4.2 years post-revision. 31 revisions were for infection and 53 revisions were for aseptic loosening. Revision for infection was done as a two-stage procedure and aseptic as a single operation. Measurements of the joint line height were made pre and post-operatively using Figgie’s method. The cases were divided into 3 groups on the basis of joint line restoration:

Lowered by more than 5 mm

Results: The mean pre-op total score for the infection group was 35/100 and 40/100 for the aseptic loosening group. The total score post-operatively was 67 for the infection group and 73 for the aseptic loosening group. The joint line was restored in 50% of infected cases and in 60% of aseptic loosening cases.

Conclusion: although the overall results were slightly less satisfactory for the infected revision group, there was no significant difference between the two groups either in total BKS scores or in reproduction of the joint line. The average outcome was much less good than for primary TKR.

Introduction Cold therapy is known to reduce pain and swelling after surgical procedures on the knee. We hypothesised that if cold therapy is started earlier, then there would be a reduction in pain and swelling in patients undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction

Methods We prospectively randomised 40 patients undergoing arthroscopic ACL reconstruction with hamstring autograft, to receive either room temperature (19°C) or cold (4°C) arthroscopy irrigation fluid.Patients were then assessed over the following 7 days, with regard to pain (measured on a visual analogue scale), and swelling (measured with limb girth at 4 points around the knee).

Results Pain scores were consistently reduced in the cold fluid group compared to the room temperature group throughout the post operative period, and this difference was significant (p< =0.05) from 6 hours until 7 days post-operatively

At day 7 the swelling measured at 5cm below the joint and 5cm above the joint were significantly lower in the cold group compared with the room temperature group.

Drainage from the intra-articular drain was significantly lower in the cold group.

Conclusion The use of cold irrigation fluid is a simple and safe measure by which pain and swelling (at day 7), can be reduced in the early post-operative period for arthroscopic ACL reconstruction.

The aim of this study was to assess the value of plain AP and lateral radiographs in determining ACL condition in medial unicompartmental osteoarthritis.

Background: A functioning ACL has been shown to be important in the success of certain unicompartmental knee replacements. White (2001) has shown MRI to be too sensitive in this age group of patients. Keyes (1992) suggested that stress radiographs were necessary to accurately assess ACL integrity.

Method: One hundred and twenty-six patients undergoing knee arthroplasty for medial osteoarthritis, had their ACL’s graded as Normal, Frayed or Absent intra-operatively. Standard pre-operative AP and lateral standing radiographs were graded by the Ahlback system. On the lateral view, the plateau was divided into 5 zones from anterior to posterior. The zone, in which the point of deepest wear occurred, was recorded.

Results: There was a significant difference between the occurrence of deepest wear in the anterior three zones versus the posterior two zones for ACL normal and absent knees (² = 46.85, P< 0.001). There was a significant difference between the occurrence of normal and absent ACL’s in Ahlback grades ≤3 versus ≥4 (² = 53.8, P< 0.001). There was a moderately strong correlation between both zone of deepest wear on lateral radiograph and Ahlback grade with ACL condition (Spearman’s rho = 0.62 and 0.69 respectively). The Positive Predictive Values for the ACL being normal are 64% for Ahlback grades 3 or less and 67% for Zone of deepest wear in the anterior 3 zones. The Positive Predictive Values for the ACL being intact (but not necessarily normal) are 95% for Ahlback grade 3 or less; 91% for Zone of deepest wear in the anterior 3 zones; and 97% if these criteria are combined.

Combining Ahlback grade ≤3 with wear in the anterior 3 zones also gave a Negative Predictive Value of 92% for the ACL not being normal.

Conclusion: There is a “watershed” in ACL condition between Ahlback grade 3 and 4. Prostheses requiring Normal or Intact ACL’s should only be performed if Ahlback grade is ≤3. Standard radiographs can reliably predict ACL condition with high Positive and Negative predictive values.

Nine patients underwent arthrodesis of the knee using a customised coupled nail (the Mayday arthrodesis nail), five after infected arthroplasty, one following failed arthrodesis, one for intractable anterior knee pain, one for Charcot instability and one after trauma. Comparison was made with 17 arthrodeses, eight undertaken using external fixation, four with dual compression plates, and five with long Küntscher nails. Union was achieved in all patients (100%) at a mean time of ten months using the customised implant. There were no complications despite early weight-bearing. No further procedures were required. This contrasted with a rate of union of 53% and a complication rate of 76% with alternative techniques. Of this second group, 76% required a further operative procedure.

We compared the Mayday arthrodesis nail with other techniques of arthrodesis of the knee. The differences in the need for further surgery and occurrence of complications were statistically significant (p < 0.001), and differences in the rate of nonunion and inpatient stay of less than three weeks were also significant (p < 0.05) using Fisher’s exact test.

We conclude that a customised coupled intramedullary nail can give excellent stability allowing early weight-bearing, and results in a high rate of union with minimal postoperative complications.

The aim of this study was to assess the distribution of wear down to bone in lateral compartment osteoarthritis and to analyse the effect of ACL condition and Ahlbach grading on this distribution.

Background: The distribution of medial compartment wear is now well described and shows posterior progression and increased area of wear with worsening AhIback grade and ACL condition (Porteous 2000). Harman (1998) described wear situated more posteriorly in the lateral compartment but did not show any change to this with altering ACL function, and did not assess the severity of the arthritis.

Method: Forty two tibial plateaus resected at total or unicompartmental replacement for lateral compartment osteoarthritis were analysed for the anterior and posterior extent of wear, as well as the point of deepest wear and the size of lesion. The plateau was divided into five zones from anterior to posterior. The ACL condition at surgery was graded as Normal, Frayed or Absent. Radiographs were classified by Ahlbach grade. Analysis using Mann-Whitney U-test, Fisher’s exact test and Spearman’s rank correlation were performed.

Results: The significant changes with increasing Ahlbach grade were that: the point of deepest wear moved posteriorly, the posterior extent of wear moved posteriorly and the size of the lesion increased. With ACL deterioration and rupture, the anterior extent of the wear moved forward and the size of lesion increased, but this did not occur through posterior migration of the posterior extent of the wear. There was a significant difference between the Ahlbach grade of ACL Normal and Absent knees.

Conclusion: In early disease, the wear is situated more posteriorly than in medial disease. The wear size increases with ACL insufficiency, but the further posterior progression of wear associated with posterior femoral subluxation seen in advanced disease seems to be more dependant on the loss of bone reflected in the Ahlbach grading.