The incidence of anterior knee pain following total knee replacement (TKR) is reported to be as high as 49%. The source of the pain is poorly understood but the soft tissues around the patella have been implicated. In theory circumferential electrocautery denervates the patella thereby reducing efferent pain signals. However, there is mixed evidence that this practice translates into improved outcomes. We aimed to investigate the clinical effect of intra-operative circumpatellar electrocautery in patients undergoing TKR using the LCS mobile bearing or Kinemax fixed bearing TKR. A total of 200 patients were randomised to receive either circumpatellar electrocautery (diathermy) or not (control). Patients were assessed by visual analogue scale (VAS) for anterior knee pain and Oxford knee score (OKS) pre-operatively and three months, six months and one year post-operatively. Patients and assessors were blinded. There were 91 patients in the diathermy group and 94 in the control. The mean VAS improvement at one year was 3.9 in both groups (control; -10 to 6, diathermy;. -9 to 8, p < 0.001 in both cases, paired, two-tailed t-test). There was no significant difference in VAS between the groups at any other time. The mean OKS improvement was 17.7 points (0 to 34) in the intervention group and 16.6 (0 to 42) points in the control (p = 0.36). There was no significant difference between the two groups in OKS at any other time. We found no relevant effect of patellar electrocautery on either VAS anterior knee pain or OKS for patients undergoing LCS and Kinemax TKR

The efficacy of circumpatellar electrocautery in reducing the incidence of post-operative anterior knee pain is unknown. We conducted a single-centre, outcome-assessor and patient-blinded, parallel-group, randomised, controlled trial to compare circumpatellar electrocautery with no electrocautery in total knee replacement in the absence of patellar resurfacing. Patients requiring knee replacement for primary osteoarthritis were randomly assigned circumpatellar electrocautery (intervention group) or no electrocautery (control group). The primary outcome measure was the incidence of anterior knee pain. A secondary measure was the standardised clinical and patient-reported outcomes determined by the American Knee Society scores and the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index. A total of 131 knees received circumpatellar electrocautery and 131 had no electrocautery. The overall incidence of anterior knee pain at follow-up at one year was 26% (20% to 31%), with 19% (12% to 26%) in the intervention group and 32% (24% to 40%) in the control group (p = 0.02). The relative risk reduction from electrocautery was 40% (9% to 61%) and the number needed to treat was 7.7 (4.3 to 41.4). The intervention group had a better mean total WOMAC score at follow-up at one year compared with the control group (16.3 (0 to 77.7) versus 21.6 (0 to 76.7), p = 0.04). The mean post-operative American Knee Society knee scores and function scores were similar in the intervention and control groups (knee score: 92.4 (55 to 100) versus 90.4 (51 to 100), respectively (p = 0.14); function score: 86.5 (15 to 100) versus 84.5 (30 to 100), respectively (p = 0.49)). Our study suggests that in the absence of patellar resurfacing electrocautery around the margin of the patella improves the outcome of total knee replacement

The management of the patella during total knee replacement is controversial. In some studies the absence of patellar resurfacing results in residual anterior knee pain in over 10% of patients. One form of treatment which may be used in an endeavour to reduce this is circumferential patellar rim electrocautery. This is believed to partially denervate the patella. However, there is no evidence of the efficacy of this procedure, nor do we know if it results in harm. A retrospective comparative cohort study was performed of 192 patients who had undergone a primary total knee replacement with the porous coated Low Contact Stress rotating platform prosthesis without patellar resurfacing between 2003 and 2007. In 98 patients circumferential electrocautery of the patellar rim was performed and in 94 patients it was not. The two groups were matched for gender and age. The general Oxford Knee Score and the more specific patellar score for anterior knee pain were used to assess patient outcomes a minimum of two years post-operatively. No statistically significant differences were noted between the groups for either scoring system (p = 0.41 and p = 0.87, respectively). Electrocautery of the patella rim did not improve the outcome scores after primary total knee replacement in our patients

In the absence of patellar resurfacing, we have previously shown that the use of electrocautery around the margin of the patella improved the one-year clinical outcome of total knee replacement (TKR). In this prospective randomised study we compared the mean 3.7 year (1.1 to 4.2) clinical outcomes of 300 TKRs performed with and without electrocautery of the patellar rim: this is an update of a previous report. The overall prevalence of anterior knee pain was 32% (95% confidence intervals [CI] 26 to 39), and 26% (95% CI 18 to 35) in the intervention group compared with 38% (95% CI 29 to 48) in the control group (chi-squared test; p = 0.06). The overall prevalence of anterior knee pain remained unchanged between the one-year and 3.7 year follow-up (chi-squared test; p = 0.12). The mean total Western Ontario McMasters Universities Osteoarthritis Indices and the American Knee Society knee and function scores at 3.7 years’ follow-up were similar in the intervention and control groups (repeated measures analysis of variance p = 0.43, p = 0.09 and p = 0.59, respectively). There were no complications. A total of ten patients (intervention group three, control group seven) required secondary patellar resurfacing after the first year. Our study suggests that the improved clinical outcome with electrocautery denervation compared with no electrocautery is not maintained at a mean of 3.7 years’ follow-up. Cite this article: Bone Joint J 2014;96-B:473–8

Injuries to the quadriceps muscle group are common in athletes performing high-speed running and kicking sports. The complex anatomy of the rectus femoris puts it at greatest risk of injury. There is variability in prognosis in the literature, with reinjury rates as high as 67% in the severe graded proximal tear. Studies have highlighted that athletes can reinjure after nonoperative management, and some benefit may be derived from surgical repair to restore function and return to sport (RTS). This injury is potentially career-threatening in the elite-level athlete, and we aim to highlight the key recent literature on interventions to restore strength and function to allow early RTS while reducing the risk of injury recurrence. This article reviews the optimal diagnostic strategies and classification of quadriceps injuries. We highlight the unique anatomy of each injury on MRI and the outcomes of both nonoperative and operative treatment, providing an evidence-based management framework for athletes.

Cite this article: Bone Joint J 2023;105-B(12):1244–1251.

Aims

This systematic review and meta-analysis aimed to compare the influence of patellar resurfacing following cruciate-retaining (CR) and posterior-stabilized (PS) total knee arthroplasty (TKA) on the incidence of anterior knee pain, knee-specific patient-reported outcome measures, complication rates, and reoperation rates.

The use of tourniquets in lower limb trauma surgery to control bleeding and improve the surgical field is a long established practice. In this article, we review the evidence relating to harms and benefits of tourniquet use in lower limb fracture fixation surgery and report the results of a survey on current tourniquet practice among trauma surgeons in the UK.

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We evaluated a large database with mechanical failure of a single uncemented modular femoral component, used in revision hip arthroplasty, as the end point and compared them to a control group treated with the same implant. Patient- and implant-specific risk factors for implant failure were analyzed.

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The aim of this study was to assess the effect of posterior cruciate ligament (PCL) resection on flexion-extension gaps, mediolateral soft-tissue laxity, fixed flexion deformity (FFD), and limb alignment during posterior-stabilized (PS) total knee arthroplasty (TKA).

Aims

The objectives of this study were to assess the effect of anterior cruciate ligament (ACL) resection on flexion-extension gaps, mediolateral soft tissue laxity, maximum knee extension, and limb alignment during primary total knee arthroplasty (TKA).

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To describe and analyze the mid-term functional outcomes of a large series of patients who underwent the Hoffer procedure for brachial plexus birth palsy (BPBP).

Aims

The aim of this study was to report a retrospective, consecutive series of patients with adolescent idiopathic scoliosis (AIS) who were treated with posterior minimally invasive surgery (MIS) with a mean follow-up of two years (sd 1.4; 0.9 to 0 3.7). Our objectives were to measure the correction of the deformity and record the peri-operative morbidity. Special attention was paid to the operating time (ORT), estimated blood loss (EBL), length of stay (LOS) and further complications.

We present our early experience of arthroscopic reduction of the dislocated hip in very young infants with developmental dysplasia of the hip (DDH).

Eight dislocated hips, which had failed attempts at closed reduction, were treated by arthroscopy of the hip in five children with a mean age of 5.8 months (4 to 7). A two-portal technique was used, with a medial sub-adductor portal for a 2.7 mm cannulated system with a 70° arthroscope and an anterolateral portal for the instruments. Following evaluation of the key intra-articular structures, the hypertrophic ligamentum teres and acetabular pulvinar were resected, and a limited release of the capsule was performed prior to reduction of the hip. All hips were reduced by a single arthroscopic procedure, the reduction being confirmed on MRI scan. None of the hips had an inverted labrum. The greatest obstacle to reduction was a constriction of the capsule. At a mean follow-up of 13.2 months (9 to 24), all eight hips remained stable. Three developed avascular necrosis. The mean acetabular index decreased from 35.5° (30° to 40°) pre-operatively to 23.3° (17° to 28°).

This study demonstrates that arthroscopic reduction is feasible using two standardised portals. Longer follow-up studies are necessary to evaluate the functional results.

During the last ten years, greater attention has been given to the management of peri-operative blood loss after total knee arthroplasty (TKA), as it is a modifiable outcome that has a significant effect on the rate of complications, the recovery, and the economic burden. Blood loss after TKA has been greatly reduced during this time, thereby dramatically reducing the rates of allogeneic transfusion. This has significantly reduced the complications associated with transfusion, such as fluid overload, infection, and increased length of stay.

The greatest advent in lowering peri-operative blood loss after TKA has been the introduction of tranexamic acid, which reduces blood loss without increasing the risk of thromboembolic events.

This paper discusses the ways of reducing blood loss after TKA, for which a multimodal algorithm, with pre-, intra- and post-operative measures, has been adopted at our institution.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):98–100.

Aims

In a multicentre, randomised study of adolescents undergoing posterior spinal fusion for idiopathic scoliosis, we investigated the effect of adding gelatine matrix with human thrombin to the standard surgical methods of controlling blood loss.

We used a goat model of a contaminated musculoskeletal defect to determine the effectiveness of rapidly-resorbing calcium-sulphate pellets containing amikacin to reduce the local bacterial count. Our findings showed that this treatment eradicated the bacteria quickly, performed as well as standard polymethylmethacrylate mixed with an antibiotic and had many advantages over the latter. The pellets were prepared before surgery and absorbed completely. They released all of the antibiotic and did not require a subsequent operation for their removal. Our study indicated that locally administered antibiotics reduced bacteria within the wound rapidly. This method of treatment may have an important role in decreasing the rate of infection in contaminated wounds.

Aims

The purpose of this prospective study was to evaluate the outcomes of coccygectomy for patients with chronic coccydynia.

Our aim was to compare the outcome of arthroscopic release for frozen shoulder in patients with and without diabetes. We prospectively compared the outcome in 21 patients with and 21 patients without diabetes, two years post-operatively. The modified Constant score was used as the outcome measure. The mean age of the patients was 54.5 years (48 to 65; male:female ratio: 18:24), the mean pre-operative duration of symptoms was 8.3 months (6 to 13) and the mean pre-operative modified Constant scores were 36.6 (standard deviation (sd) 4.6) and 38.4 (sd 5.7) in the diabetic and non-diabetic groups, respectively. The mean modified Constant scores at six weeks, six months and two years post-operatively in the diabetics were 55. 6 (sd 4.7), 67. 4 (sd 5.6) and 84. 4 (sd 6.8), respectively; and in the non-diabetics 66.8 (sd 4.5), 79.6 (sd 3.8) and 88.6 (sd 4.2), respectively. A total of 15 (71%) of diabetic patients recovered a full range of movement as opposed to 19 (90%) in the non-diabetics. There was significant improvement (p < 0.01) in the modified Constant scores following arthroscopic release for frozen shoulder in both groups. The results in diabetics were significantly worse than those in non-diabetics six months post-operatively (p < 0.01) with a tendency towards persistent limitation of movement two years after operation. These results may be used when counselling diabetic patients for the outcome after arthroscopic treatment of frozen shoulder.

Cite this article: Bone Joint J 2014;96-B:1355–8.

In order to achieve satisfactory reduction of complex distal humeral fractures, adequate exposure of the fracture fragments and the joint surface is required. Several surgical exposures have been described for distal humeral fractures. We report our experience using the anconeus pedicle olecranon flip osteotomy approach. This involves detachment of the triceps along with a sliver of olecranon, which retains the anconeus pedicle. We report the use of this approach in ten patients (six male, four female) with a mean age of 38.4 years (28 to 51). The mean follow-up was 15 months (12 to 18) with no loss to follow-up. Elbow function was graded using the Mayo Score. The results were excellent in four patients, good in five and fair in one patient. The mean time to both fracture and osteotomy union was 10.6 weeks (8 to 12) and 7.1 weeks (6 to 8), respectively. We found this approach gave reliably good exposure for these difficult fractures enabling anatomical reduction and bicondylar plating without complications.

Cite this article: Bone Joint J 2014;96-B:1252–7.

Total hip replacement (THR) still is a rare intervention in many African countries. In Burkina Faso it is not performed on a regular basis. A visiting programme for THR was started in a district hospital with no previous relevant experience. In this paper we present an analysis of the surgical technical problems and peri-operative complications of 152 THRs in 136 patients and three bipolar hemiarthroplasties in three patients undertaken in this new programme with limited orthopaedic equipment. There were 86 male and 53 female patients with a mean age of 49 years (21 to 78). We identified 77 intra-operative technical problems in 51 operations. There were 24 peri-operative complications in 21 patients, 17 of which were bony in nature. So far, ten revision THRs have been performed in nine patients.

Regular analysis of the technical problems and complications was used to improve quality, and we identified patient selection adapted to the local circumstances as important to avoid complications. Our reflections on the problems encountered in initiating such a programme may be of help to other teams planning similar projects.

Cite this article: Bone Joint J 2014;96-B:177–80.