Accurate assessment of alignment in pre-operative and post-operative knee radiographs is important for planning and evaluating knee replacement surgery. Existing methods predominantly rely on manual measurements using long-leg radiographs, which are time-consuming to perform and are prone to reliability errors. In this study, we propose a machine-learning-based approach to automatically measure anatomical varus/valgus alignment in pre-operative and post-operative standard AP knee radiographs. We collected a training dataset of 816 pre-operative and 457 one-year post-operative AP knee radiographs of patients who underwent knee replacement surgery. Further, we have collected a separate distinct test dataset with both pre-operative and one-year post-operative radiographs for 376 patients. We manually outlined the distal femur and the proximal tibia/fibula with points to capture the knee joint (including implants in the post-operative images). This included point positions used to permit calculation of the anatomical tibiofemoral angle. We defined varus/valgus as negative/positive deviations from zero. Ground truth measurements were obtained from the manually placed points. We used the training dataset to develop a machine-learning-based automatic system to locate the point positions and derive the automatic measurements. Agreement between the automatic and manual measurements for the test dataset was assessed by intra-class correlation coefficient (ICC), mean absolute difference (MAD) and Bland-Altman analysis.Introduction
Method
Osteochondral allograft (OCA) transplantation is a clinically and cost-effective option for symptomatic cartilage defects. In 2017 we initiated a program for OCA transplantation for complex chondral and osteochondral defects as a UK tertiary referral centre. To characterise the complications, re-operation rate, graft survivorship and clinical outcomes of knee OCA transplantation.Abstract
Background
Aim
Meniscal allograft transplantation (MAT) for patients with symptomatic meniscal loss has demonstrated good clinical results and survivorship. Factors that affect both functional outcome and survivorship have been reported in the literature. These are typically single-centre case series with relatively small numbers and conflicting results. Our aim was to describe an international, two-centre case series, and identify factors that affect both functional outcome and survival. We report factors that affect outcome on 526 patients undergoing MAT across two sites (one in the UK and one in Italy). Outcomes of interest were the Knee injury and Osteoarthritis Outcome Score four (KOOS4) at two years and failure rates. We performed multiple regression analysis to examine for factors affecting KOOS, and Cox proportional hazards models for survivorship.Aims
Methods
Meniscal allograft transplantation is undertaken to improve pain
and function in patients with a symptomatic meniscal deficient knee
compartment. While case series have shown improvements in patient
reported outcome measures (PROMs), its efficacy has not been rigorously
evaluated. This study aimed to compare PROMs in patients having
meniscal transplantation with those having personalized physiotherapy
at 12 months. A single-centre assessor-blinded, comprehensive cohort study,
incorporating a pilot randomized controlled trial (RCT) was performed
on patients with a symptomatic compartment of the knee in which
a (sub)total meniscectomy had previously been performed. They were
randomized to be treated either with a meniscal allograft transplantation
or personalized physiotherapy, and stratified for malalignment of
the limb. They entered the preference groups if they were not willing
to be randomized. The Knee injury and Osteoarthritis Outcome Score (KOOS),
International Knee Documentation Committee (IKDC) score and Lysholm
score and complications were collected at baseline and at four,
eight and 12 months following the interventions.Aims
Patients and Methods
The aim of this study was to compare the effectiveness of a femoral
nerve block and a periarticular infiltration in the management of
early post-operative pain after total knee arthroplasty (TKA). A pragmatic, single centre, two arm parallel group, patient blinded,
randomised controlled trial was undertaken. All patients due for
TKA were eligible. Exclusion criteria included contraindications
to the medications involved in the study and patients with a neurological
abnormality of the lower limb. Patients received either a femoral
nerve block with 75 mg of 0.25% levobupivacaine hydrochloride around
the nerve, or periarticular infiltration with 150 mg of 0.25% levobupivacaine
hydrochloride, 10 mg morphine sulphate, 30 mg ketorolac trometamol
and 0.25 mg of adrenaline all diluted with 0.9% saline to make a
volume of 150 ml.Aims
Patients and Methods
To compare static and dynamic lumbar intervertebral ranges of motion (IV-RoM) in patients with chronic, nonspecific low back pain with upper and lower cut off values derived from healthy controls when variability and measurement errors were reduced. Measurements from functional radiographs suffer from high variability and measurement errors, making cut off values for excessive or insufficient motion problematical. This study compared maximum lumbar IV-RoM and maximum IV-RoM at any point in continuous motion sequences in patients with chronic, non-specific back pain with upper and lower cut off values for L2 to L5 from matched controls using quantitative fluoroscopy, where variation and measurement errors were reduced. Participants underwent passive recumbent examinations in the sagittal and coronal planes. Values based on were developed for both maximum and continuous motion in controls (n=40). Fishers exact test was used to analyse proportions of patients whose IV-RoMs exceeded reference values. For maximum IV-RoM in patients, there were no statistically significant differences between groups for the lower value. Only flexion at L4/5 significantly exceeded the upper value (p=0.03). For continuous IV-RoM, left L3/4 (p=0.01) and right L4/5 (p=0.01) were significantly below the lower cut off values. Both flexion L4/5 (p=0.05) and left L3/4 (p=0.01) were significantly above the upper cut off values.Purpose and Background:
Methods and Results:
Subtotal or total meniscectomy in the medial or lateral compartment
of the knee results in a high risk of future osteoarthritis. Meniscal
allograft transplantation has been performed for over thirty years
with the scientifically plausible hypothesis that it functions in
a similar way to a native meniscus. It is thought that a meniscal
allograft transplant has a chondroprotective effect, reducing symptoms
and the long-term risk of osteoarthritis. However, this hypothesis has
never been tested in a high-quality study on human participants.
This study aims to address this shortfall by performing a pilot
randomised controlled trial within the context of a comprehensive
cohort study design. Patients will be randomised to receive either meniscal transplant
or a non-operative, personalised knee therapy program. MRIs will
be performed every four months for one year. The primary endpoint
is the mean change in cartilage volume in the weight-bearing area
of the knee at one year post intervention. Secondary outcome measures
include the mean change in cartilage thickness, T2 maps, patient-reported
outcome measures, health economics assessment and complications.Objectives
Methods
In August 2007 NICE issued its guidance for the treatment of patients with knee osteoarthritis (OA) with arthroscopic lavage. The recommendations stated that referral for arthroscopic lavage and debridement should not be offered as part of treatment for osteoarthritis, unless the person has osteoarthritis with a clear history of ‘mechanical locking’ (not gelling, giving way, or x-ray evidence of loose bodies). The aim of this study was to assess both the application of these guidelines over a four month period and whether this procedure had improved symptoms at first follow-up. This was a retrospective review from August-December 2011. The total number of arthroscopies performed during this period was obtained from theatre records. Further data was obtained through the hospital's electronic database. The diagnosis of OA was made through the analysis of referral and clinic letters, plain radiographs, MRI reports and operation notes. Only those patients with persisting OA symptoms were included, those with OA and recent history of injury or trauma were excluded. During this time period, 222 knee arthroscopies were performed in total, 99 were identified with persistent OA symptoms. Having identified these patients, referral letters were further analysed to identify the initial presenting symptom. Of the 99, 50 presented with pain, 28 presented with pain plus another symptom other than locking e.g. stiffness/swelling/giving-way, 21 presented with pain plus mechanical locking. According to current guidelines only these 21 patients should have been offered arthroscopic lavage as a form of treatment. In addition to these findings we identified what procedures had been carried out during arthroscopy for each symptom. Of those presenting with pain, 82% had a washout and debridement, 8% had washout, 4% had partial medial meniscectomy, 4% had lateral patellar release and 2% had partial lateral meniscectomy. Those with pain plus other symptoms not including locking, 82% had washout and debridement, 11% had partial medial meniscectomy, and 7% had a washout. Of those presenting with pain plus mechanical locking, 81% had washout and debridement and 19% had partial medial meniscectomy. Following the procedure, we analysed the outcome of symptoms at first-follow up. The mean follow-up time was 8 weeks. Of those presenting with just pain, 44% showed improvement, 52% had no change/on-going symptoms, 2% were unknown. Of those with pain plus other symptoms other than locking, 57% showed improvement, 35% had no change/on-going symptoms, 8% unknown. Of those with pain plus mechanical locking, 80% showed improvement, 10% had no change/on-going symptoms, 10% unknown. The results of this study support the current evidence that unless there are clear mechanical symptoms of locking, the use of arthroscopy in arthritic knee joints should be judicious and the reasons should be clearly documented.
We reviewed all patients that suffered a deep infection following anterior cruciate ligament (ACL) repair kept between January 2007 and April 2011 at our teaching hospital NHS trust, and the two local private hospitals. 18 patients were identified. All patients underwent at least 2 arthroscopic washouts, with limited synovectomy if required. Targeted antibiotics were commenced according to the culture results, and following microbiological advice. These patients were reviewed at a minimum of 1 year following eradication of infection (range 12–46 months). There were 7 surgeons performing the ACL reconstructions. The primary outcome measure was graft failure requiring revision. Our secondary outcome measures were a history of ongoing instability, KT 1000™ measurement, Tegner and Lysholm outcome scores. There were 18 patients identified as having suffered infection after ACL infection (mean age 24.3 years, range 15–38 years). Average C Reactive Protein (CRP) was 217 on admission (range 59–397). The most common organism isolated was coagulase negative staphylococcus in 47.3% of cases. There were 3 graft failures within the infection group. Of the remaining 15 patients there were no episodes of ongoing instability and mean pivot shift grade was 1.1, mean KT 1000™ side-to- side difference was +1.8mm. There was a reported drop on the Tegner activity score of 1.75 (range 0–6) and mean Lysholm score was 89 (range 56–100). The failure rate is slightly higher than that reported in the literature. Patient reported outcome measures in the patients are broadly consistent. We recommend an aggressive approach to the treatment of deep infection following ACL reconstruction, in order to achieve a satisfactory outcome.
To critically evaluate exciting new technology to reconstruct menisci for the treatment of post menisectomy pain and relate results to indication and surgical technique in a non-inventor's general knee practice. We present our early experience of two non-comparative series with different meniscal implants. Series 1: Thirteen patients received a Menaflex implant (Regen Bio, USA). Mean age 30, male/female 11/2, mean length of implant 44mm, mean chondral grade 1.9 (Outerbridge). At 24 months clinical scores showed improvement in 12. Second look arthroscopy in 5 however showed disappointing amounts of regenerative tissue. One patient has been revised. Series 2: Twelve patients received an Actifit implant (Orteq, UK). Mean age 38, male/female 8/4, mean length implant 43 mm, mean chondral grade 1.3. At 12 months all have improved clinical scores. We have performed two second looks, one of these showed excellent integration. However one showed only 50% regeneration. Critical review of the initial implantation shows that there may not have been adequate preparation of the host meniscus tissue.Purpose
Methods
Recent advances in understanding of ACL insertional anatomy has led to new concepts of anatomical positioning of tunnels for ACL reconstruction. Femoral tunnel position has been defined in terms of the lateral intercondylar ridge and the bifurcate ridge but these can be difficult to identify at surgery. Measurements of the lateral wall either using C-arm x-ray control or specific arthroscopic rulers have also been advocated. 30 patients undergoing ACL reconstruction before and after introduction of a new anatomical technique of ACL reconstruction were evaluated using 3D CT scan imaging with cut away views of the lateral aspect of the femoral notch and the radiological quadrant grid. In the new technique, with the knee at 90 degrees flexion, the femoral tunnel was centred 50% from deep to shallow as seen from the medial portal (Group A). Group B consisted of patients where the femoral tunnel was drilled through the antero-medial portal and offset from the posterior wall using a 5mm jig.Hypothesis
Method
There are numerous surgical techniques for medial patellofemoral ligament (MPFL) reconstruction. Problems with certain techniques include patellar fracture and re-rupture. To investigate the functional outcomes of MPFL reconstructions performed using a free gracillis tendon graft, oblique medial patella tunnel and interference screw femoral fixation. Patients were selected for MPFL reconstruction if they had recurrent patellar dislocations, and with the use of clinical and radiographic evaluation.Introduction
Aim
Current problem – Multiple surgical interventions for patellar instability and no defined criteria for use of medial patellofemoral ligament (MPFL) reconstruction. Investigate the functional outcomes of MPFL reconstructions that had been performed following selection for treatment based on a defined patellar instability algorithm.Introduction
Aims
We aim to assess the clinical and radiological outcome following cartilage repair in the knee using the TruFit plug (Smith &
Nephew). Eleven active sporting patients underwent cartilage repair using TruFit plugs between February 2006 and August 2007. Postoperatively patients were touch weight bearing for 2 weeks and partial until 4 weeks. Data was collected prospectively, patients underwent clinical review and completed Lysholm, IKDC subjective, Tegner, KOOS and SF-36 scores pre-operatively and at 6 monthly intervals. One patient has been excluded from the analysis as she emigrated and was lost to follow up. The remaining 10 patients (mean age 35 years (21–49)) had defects on the medial femoral condyle (n=6), lateral femoral condyle (n=3), and lateral trochlea (n=1). Patients received one (n=5), two (n=3) or three (n=2) plugs and four were primary procedures, and six revision procedures (1 failed OATS, 5 failed microfracture). Eight implantations were performed arthroscopically and, and two were mini-open. All patients were reviewed at 12 months, five were reviewed at 18 months and four have also been reviewed at 24 months. Statistically significant improvements from mean pre-operative scores are seen at 12 months; Lysholm (48.3 to 71), IKDC Subjective (37.7 to 65.1), Tegner (2.4 to 4.6), SF36 physical (39.5 to 50.3) and all components of KOOS. These improvements are maintained at the latest follow up. MRI evaluation including T2 mapping demonstrates reformation of the subchondral lamina, resorption of the graft and a similar signal from neo-cartilage as that of adjacent native cartilage. TruFit plugs offer an exciting novel solution for cartilage repair in the knee with advantages of low morbidity and rapid recovery without the need for prolonged non-weight bearing. The implant may be suitable for small lesions only and further prospective study is required to establish long-term outcome.
All patients were male, 4 patients had deficiencies in the right knee, 2 the left knee and the mean patient age was 28.8years (range 17–45). Four CMI were inserted for lateral meniscal deficiencies, two medial. The mean length of implant sutured in place was 41mm (range 35–55). Median pre op scores were KOOS P/S/ADL/QOL 53/100, 54/100, 66/100, 25/100, 44/100, IKDC 49.43%, Tegner 3, SF-36 35.38 PCS and 27.48 MCS and Lysholm 87/100. The mean elapsed time post meniscectomy was 20 months (range 2–51). All but one of the implants used were 9.5mm in width and sizes ranged 35–45mm. At early follow up there have been no complications and background pain has improved in all 6. MIR imaging has shown that none have separated. Post operative follow up suggest improved outcome.
The purpose of this study was to assess the accuracy of a modified version of the pivot shift test in detecting ruptures of the anterior cruciate (ACL) ligament.
