Total knee arthroplasty has become an established operation. Cemented fixation of the components has given satisfactory results and is accepted as the gold standard. Cement failure with aseptic loosening, however, is a possible long term complication. This is particularly important in view of the increasing number of younger patients who can benefit from this procedure. Hence the attraction of using implants fixed by direct osseointegration of bone into the implant, by passing the potential weak link of the cement. The objective of this study was to determine the mid-term clinical, radiological and functional outcomes after navigated cementless and cemented implantation of total knee arthroplasties without patella resurfacing done by a single surgeon.Introduction
Objectives
Recent publications have supported the anatomic placement of anterior cruciate grafts to optimise knee function. However, anatomic placement using the anteromedial portal has been shown to have a higher failure rate than traditional graft placement using the transtibial method. This is possibly due to it being more technically difficult and to the short femoral tunnel compromising fixation methods. It also requires the knee to be in hyper flexion. This position is not feasible during with a tourniquet in situ on the heavily muscled thighs of some athletes. Hypothesis: That navigation can be used to place the femoral tunnel in the anatomic position via a more medial transtibial tunnel. 25 patients underwent Navigated Anterior Cruciate reconstruction with quadruple hamstring grafts. The Orthopilot™ 3.0 ACL (BBraun Aesculap, Tuttlingen) software was used. The femoral and tibial ACL footprints were marked on the bones with a radio frequency probe and registered. The pivot shift test, anterior drawer and internal and external rotation were registered. A navigated tibial guide wire was inserted at 25° to the sagittal plane and 45° to the transverse plane exiting through the centre of the tibial footprint. The guide wire was advanced into the joint to just clear of the surface of the femoral footprint with the knee in 90° flexion. Flexion/extension of the knee was done to determine the closest position of the guide wire tip to the centre of the anatomical femoral footprint. If the tip was within 2mm of the centre of footprint, the position was accepted. If not the tibial guide wire was repositioned and the process repeated. The tibial tunnel was drilled, followed by transtibial drilling of the femoral tunnel. A screen shot was done to allow determination of the shape and area of the tunnel aperture relative to the femoral footprint using ImageJ (National Institute of Health). The graft was fixed proximally with an Arthrex ACL Tightrope® and distally with a Genesys™ interference screw. The pivot shift test, anterior drawer and internal and external rotation were repeated and recorded using the software.Background
Methods
Manipulation under anaesthetic (MUA) is an established treatment for frozen shoulder. Frozen shoulder may coexist with other shoulder conditions, whose treatment may differ from MUA. One such condition is calcific tendonitis. Only one study to date documents treatment of patients with frozen shoulder and concurrent calcific tendinitis. The objective was to demonstrate that MUA and injection is a satisfactory treatment for concurrent diagnosis of frozen shoulder and calcific tendinitis. Patients with a clinical diagnosis of frozen shoulder and radiological evidence of calcific tendinitis were prospectively recruited from Jan 1999 – Jan 2009. Treatment by MUA and injection was performed. Clinical examination, Oxford Shoulder Scores and need for further treatment were used as outcome measures. Fourteen patients (median age 53.5 years) were identified with frozen shoulder and concurrent calcific tendinitis. Significant improvement in both Oxford Shoulder Score and range of movement was achieved following MUA (P values < 0.001). Two patients required further treatment (not for calcific tendinitis). This improvement was maintained in the long term (median 107 wks). It is our belief that MUA and injection is a safe and effective treatment, addressing the frozen shoulder with MUA takes priority, and as such frozen shoulder “trumps” other pathologies occurring simultaneously.
Manipulation under anaesthetic (MUA) for the treatment of frozen shoulder is well established and effective however timing of surgery remains controversial. Intervention before 9 months has previously been shown to be associated with improved outcome. We test this theory by measuring Oxford Shoulder Score (OSS), re-MUA and subsequent surgery rate. A retrospective review of a prospectively collected, single surgeon, consecutive patient series revealed 244 primary frozen shoulders treated by MUA within 4 weeks of presentation. The mean duration of antecedent symptoms was 28 weeks (95% CI 4-44 weeks) and time to follow up was 26 days (95% CI 11-41 days). The mean OSS improved by 16 points (2-tailed t test p< 0.001) with a mean follow up OSS of 43 (95% CI 38-48). 195 shoulders were manipulated before 38 weeks (9 months) and had the same mean change in OSS (16) as the 49 shoulders manipulated after 38 weeks. 48 shoulders, including 15 diabetic shoulders required further MUA. 8 shoulders had subsequent surgery. These events were also independent of antecedent symptom duration. Early MUA does not appear to produce improved outcomes when compared to later intervention but we note does result in an earlier return to function.
