The Fulkerson osteotomy has proved to be a reliable treatment for subluxation of the patella due to malalignment. Aggressive rehabilitation in the early postoperative period is unwise since the proximal tibia is weakened by the oblique osteotomy. Early weight-bearing and unrestricted activity have caused fractures in a few patients. Even late in the postoperative period the osteotomy may adversely influence the biomechanical properties of the proximal tibia. We describe two athletes who sustained a fracture of the proximal tibia, during recreational activities, six months after a Fulkerson osteotomy. Both had been bearing full weight for about ten weeks without complaint. Bony healing of the osteotomy had been demonstrated on plain radiographs at ten and at 12 weeks. After a Fulkerson osteotomy, jogging and activities which impose considerable impact force should be discouraged for at least nine to 12 months

The aim of this study was to analyse the gait pattern, muscle force and functional outcome of patients who had undergone replacement of the proximal tibia for tumour and alloplastic reconstruction of the extensor mechanism using the patellar-loop technique. Between February 1998 and December 2009, we carried out wide local excision of a primary sarcoma of the proximal tibia, proximal tibial replacement and reconstruction of the extensor mechanism using the patellar-loop technique in 18 patients. Of these, nine were available for evaluation after a mean of 11.6 years (0.5 to 21.6). The strength of the knee extensors was measured using an Isobex machine and gait analysis was undertaken in our gait assessment laboratory. Functional outcome was assessed using the American Knee Society (AKS) and Musculoskeletal Tumor Society (MSTS) scores. The gait pattern of the patients differed in ground contact time, flexion heel strike, maximal flexion loading response and total sagittal plane excursion. The mean maximum active flexion was 91° (30° to 110°). The overall mean extensor lag was 1° (0° to 5°). The mean extensor muscle strength was 25.8% (8.3% to 90.3%) of that in the non-operated leg (p < 0.001). The mean functional scores were 68.7% (43.4% to 83.3%) (MSTS) and 71.1 (30 to 90) (AKS functional score). In summary, the results show that reconstruction of the extensor mechanism using this technique gives good biomechanical and functional results. The patients’ gait pattern is close to normal, except for a somewhat stiff knee gait pattern. The strength of the extensor mechanism is reduced, but sufficient for walking. . Cite this article: Bone Joint J 2015;97-B:1063–9

We studied the bone mineral density (BMD) and the bone mineral content (BMC) of the proximal tibia in patients with a well-functioning uncemented Oxford medial compartment arthroplasty using the Lunar iDXA bone densitometer. Our hypothesis was that there would be decreased BMD and BMC adjacent to the tibial base plate and increased BMD and BMC at the tip of the keel. There were 79 consecutive patients (33 men, 46 women) with a mean age of 65 years (44 to 84) with a minimum two-year follow-up (mean 2.6 years (2.0 to 5.0)) after unilateral arthroplasty, who were scanned using a validated standard protocol where seven regions of interest (ROI) were examined and compared with the contralateral normal knee. All had well-functioning knees with a mean Oxford knee score of 43 (14 to 48) and mean Knee Society function score of 90 (20 to 100), showing a correlation with the increasing scores and higher BMC and BMD values in ROI 2 in the non-implanted knee relative to the implanted knee (p = 0.013 and p = 0.015, respectively). The absolute and percentage changes in BMD and BMC were decreased in all ROIs in the implanted knee compared with the non-implanted knee, but this did not reach statistical significance. Bone loss was markedly less than reported losses with total knee replacement. There was no significant association with side, although there was a tendency for the BMC to decrease with age in men. The BMC was less in the implanted side relative to the non-implanted side in men compared with women in ROI 2 (p = 0.027), ROI 3 (p = 0.049) and ROI 4 (p = 0.029). The uncemented Oxford medial compartment arthroplasty appears to allow relative preservation of the BMC and BMD of the proximal tibia, suggesting that the implant acts more physiologically than total knee replacement. Peri-prosthetic bone loss is an important factor in assessing long-term implant stability and survival, and the results of this study are encouraging for the long-term outcome of this arthroplasty. Cite this article: Bone Joint J 2013;95-B:1480–3

Between 1986 and 1991, 106 patients (127 knees) underwent uncemented knee arthroplasty for osteoarthritis. There were 106 total knee arthroplasties and 21 medial unicompartmental knee arthroplasties. The arthroplasties were evaluated for aseptic loosening during the year 2000. For total arthroplasty we used 77 porous-coated anatomic prostheses and 29 press-fit condylar prostheses. The mean bone mineral content of the proximal tibia, measured the day before surgery using dual-photon absorptiometry was 5.48 g/cm for the porous-coated anatomic prostheses which were revised for aseptic loosening (n = 9). This was significantly higher (p = 0.02) than the mean of 4.33 g/cm for those which were not revised. Values for the two revised press-fit condylar knees (4.78 and 4.93 g/cm) were above the mean value (4.23 g/cm) for those which were not revised. We found no statistically significant (p = 0.38) difference between the bone mineral content of the 12 revised and nine unrevised unicompartmental arthroplasties. Low trabecular bone quality, measured as the pre-operative bone mineral content of the proximal tibia, was not a predictor for later revision surgery following uncemented total knee or unicompartmental knee arthroplasty

We report the long-term outcome of 33 patients (37 knees) who underwent proximal tibial open-wedge osteotomy with hemicallotasis (HCO) for medial osteoarthritis of the knee between 1995 and 2000. Among these, 29 patients with unilateral HCO were enrolled and 19 were available for review at a mean of 14.2 years (10 to 15.7) post-operatively. For these 19 patients, the mean Hospital for Special Surgery knee score was 60 (57 to 62) pre-operatively and 85 (82 to 87) at final follow-up (p < 0.001; paired t-test). The femorotibial angle and tibial inclination angle (IA) were measured at short-term follow-up, one to four years post-operatively, and showed no significant subsequent changes. The clinical scores and radiological measurements showed little change over time. One patient required conversion to total knee replacement during this time. These results suggest that the coronal angle achieved at operation is maintained at long-term follow up after HCO without alteration of the IA, providing a good long-term clinical outcome.

Cite this article: Bone Joint J 2014;96-B:467–72.

Conventional high tibial osteotomy for osteoarthritis of the medial compartment of the knee with closed-wedge or dome osteotomy (DMO) may produce shortening of the patellar tendon and loss of inclination of the proximal tibial plateau or of the offset of the tibial condyle relative to its bony axis. This can make subsequent total knee arthroplasty technically demanding.

We undertook a prospective study comparing these changes after DMO with those after using open-wedge osteotomy hemicallotasis (HCO). A total of 50 knees with arthritis of the medial compartment in 46 consecutive patients was randomly allocated to either DMO or HCO. There were no significant differences between the groups with regard to age, gender, femorotibial angle before operation or the angle of correction.

Radiological studies showed that HCO caused little change in the length of the patellar tendon or the inclination angle of the tibial plateau, while after DMO both gradually decreased. The degree of tibial condylar offset increased in both groups, but less so in the HCO group.

Aims. Infection complicating primary total knee arthroplasty (TKA) is a common reason for revision surgery, hospital readmission, patient morbidity, and mortality. Increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) is a particular concern. The use of vancomycin as prophylactic agent alone or in combination with cephalosporin has not demonstrated lower periprosthetic joint infection (PJI) rates, partly due to timing and dosing of intravenous (IV) vancomycin administration, which have proven important factors in effectiveness. This is a retrospective review of a consecutive series of primary TKAs examining incidence of PJI, adverse reactions, and complications using IV versus intraosseous (IO) vancomycin at 30-day, 90-day, and one-year follow-up. Methods. A retrospective review of 1,060 patients who underwent TKA between May 2016 to July 2020 was performed. There were 572 patients in the IV group and 488 in the IO group, with minimal 30 days of follow-up. Patients were followed up at regularly scheduled intervals (two, six, and 12 weeks). No differences between groups for age, sex, BMI, or baseline comorbidities existed. The IV group received an IV dose of 15 mg/kg vancomycin given over an hour preceding skin incision. The IO group received a 500 mg dose of vancomycin mixed in 150 ml of normal saline, injected into proximal tibia after tourniquet inflation, before skin incision. All patients received an additional dose of first generation cephalosporin. Evaluation included preoperative and postoperative serum creatinine values, tourniquet time, and adverse reactions attributable to vancomycin. Results. Incidence of PJI with minimum 90-day follow-up was 1.4% (eight knees) in the IV group and 0.22% (one knee) in IO group (p = 0.047). This preliminary report demonstrated an reduction in the incidence of infection in TKA using IO vancomycin combined with a first-generation cephalosporin. While the study suffers from limitations of a retrospective, multi-surgeon investigation, early findings are encouraging. Conclusion. IO delivery of vancomycin after tourniquet inflation is a safe and effective alternative to IV administration, eliminating the logistical challenges of timely dosing. Cite this article: Bone Joint J 2021;103-B(6 Supple A):13–17

Aims

A fracture of the medial tibial plateau is a serious complication of Oxford mobile-bearing unicompartmental knee arthroplasty (OUKA). The risk of these fractures is reportedly lower when using components with a longer keel-cortex distance (KCDs). The aim of this study was to examine how slight varus placement of the tibial component might affect the KCDs, and the rate of tibial plateau fracture, in a clinical setting.

The aim of this study was to evaluate the risk factors for dislocation of the bearing after a mobile-bearing Oxford medial unicompartmental knee replacement (UKR) and to test the hypothesis that surgical factors, as measured from post-operative radiographs, are associated with its dislocation. From a total of 480 UKRs performed between 2001 and 2012, in 391 patients with a mean age of 66.5 years (45 to 82) (316 female, 75 male), we identified 17 UKRs where bearing dislocation occurred. The post-operative radiological measurements of the 17 UKRs and 51 matched controls were analysed using conditional logistic regression analysis. The post-operative radiological measurements included post-operative change in limb alignment, the position of the femoral and tibial components, the resection depth of the proximal tibia, and the femoral component-posterior condyle classification. We concluded that a post-operative decrease in the posterior tibial slope relative to the pre-operative value was the only significant determinant of dislocation of the bearing after medial Oxford UKR (odds ratio 1.881; 95% confidence interval 1.272 to 2.779). A post-operative posterior tibial slope < 8.45° and a difference between the pre-operative and post-operative posterior tibial slope of > 2.19° may increase the risk of dislocation. Cite this article: Bone Joint J 2014; 96-B:914–22

Aims

Obtaining solid implant fixation is crucial in revision total knee arthroplasty (rTKA) to avoid aseptic loosening, a major reason for re-revision. This study aims to validate a novel grading system that quantifies implant fixation across three anatomical zones (epiphysis, metaphysis, diaphysis).

Aims

The aim of this study was to evaluate whether achieving medial joint opening, as measured by the change in the joint line convergence angle (∆JLCA), is a better predictor of clinical outcomes after high tibial osteotomy (HTO) compared with the mechanical axis deviation, and to find individualized targets for the redistribution of load that reflect bony alignment, joint laxity, and surgical technique.

We prospectively assessed the benefits of using either a range-of-movement technique or an anatomical landmark method to determine the rotational alignment of the tibial component during total knee replacement. We analysed the cut proximal tibia intraoperatively, determining anteroposterior axes by the range-of-movement technique and comparing them with the anatomical anteroposterior axis. We found that the range-of-movement technique tended to leave the tibial component more internally rotated than when anatomical landmarks were used. In addition, it gave widely variable results (mean 7.5°; 2° to 17°), determined to some extent by which posterior reference point was used. Because of the wide variability and the possibilities for error, we consider that it is inappropriate to use the range-of-movement technique as the sole method of determining alignment of the tibial component during total knee replacement

Bone loss in the proximal tibia and distal femur is frequently encountered in revision knee replacement surgery. The various options for dealing with this depend on the extent of any bone loss. We present our results with the use of cementless metaphyseal metal sleeves in 103 patients (104 knees) with a mean follow-up of 43 months (30 to 65). At final follow-up, sleeves in 102 knees had good osseointegration. Two tibial sleeves were revised for loosening, possibly due to infection. The average pre-operative Oxford Knee Score was 23 (11 to 36) and this improved to 32 (15 to 46) post-operatively. These early results encourage us to continue with the technique and monitor the outcomes in the long term. . Cite this article: Bone Joint J 2013;95-B:1640–4

Aims

The primary objective of this study was to compare the five-year tibial component migration and wear between highly crosslinked polyethylene (HXLPE) inserts and conventional polyethylene (PE) inserts of the uncemented Triathlon fixed insert cruciate-retaining total knee arthroplasty (TKA). Secondary objectives included clinical outcomes and patient-reported outcome measures (PROMs).

Aims

Robotic arm-assisted surgery offers accurate and reproducible guidance in component positioning and assessment of soft-tissue tensioning during knee arthroplasty, but the feasibility and early outcomes when using this technology for revision surgery remain unknown. The objective of this study was to compare the outcomes of robotic arm-assisted revision of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA) versus primary robotic arm-assisted TKA at short-term follow-up.

Radiographs of 110 patients who had undergone 120 high tibial osteotomies (60 closed-wedge, 60 open-wedge) were assessed for posterior tibial slope before and after operation, and before removal of the hardware. In the closed-wedge group the mean slope was 5.7° (. sd. 3.8) before and 2.4° (. sd. 3.9) immediately after operation, and 2.4° (. sd. 3.4) before removal of the hardware. In the open-wedge group, these values were 5.0° (. sd. 3.7), 7.7° (. sd. 4.3) and 8.1° (. sd. 3.9) respectively, when stabilised with a non-locking plate, and 7.7° (. sd. 3.5), 9.4° (. sd. 4.1) and 9.1° (. sd. 3.8), when stabilised with a locking plate. The reduction in slope (−2.7° (. sd. 4.1)) in the closed-wedge group and the increase (+2.5° (. sd. 3.4), in the open-wedge group was significantly different before and after operation (p = 0.002, p = 0.003). In no group were the changes in slope directly after operation and before removal of the hardware significant (p > 0.05). There was no correlation between the amount of correction in the frontal plane and the post-operative change in slope. Posterior tibial slope decreases after closed-wedge high tibial osteotomy and increases after an open-wedge procedure because of the geometry of the proximal tibia. The changes in the slope are stable over time, emphasising the influence of the operative procedure rather than of the implant

Aims

Thresholds of acceptable early migration of the components in total knee arthroplasty (TKA) have traditionally ignored the effects of patient and implant factors that may influence migration. The aim of this study was to determine which of these factors are associated with overall longitudinal migration of well-fixed tibial components following TKA.

We studied 37 patients with varus osteoarthritis of the knee to determine the influence of the bone mineral density (BMD) on the varus deformity. There were 15 men (21 knees) and 22 women (38 knees). The mean age of the men was 69 years and of the women 68 years. BMD was measured in the L1–L4 spinal region using dual X-ray absorptiometry. In the women a low level of BMD was associated with varus deformity originating at the proximal tibia, but a high level was predominantly linked with deformity originating in the joint space. Similar findings were obtained in the men. Our results suggest that a low BMD predisposes to trabecular microfractures and consequently increased stress on the articular cartilage. A low BMD does not preclude osteoarthritic change in the knee

The Ilizarov apparatus was used to carry out opening-wedge callotasis of the proximal tibia in ten patients who had suffered premature asymmetrical closure of the proximal tibial physis and subsequent genu recurvatum. In four knees, the genu recurvatum was entirely due to osseous deformity, whereas in six it was associated with capsuloligamentous abnormality. Preoperatively, the angle of recurvatum averaged 19.6° (15 to 26), the angle of tilt of the tibial plateau, 76.6° (62 to 90), and the ipsilateral limb shortening, 2.7 cm (0.5 to 8.7). The average time for correction was 49 days (23 to 85). The average duration of external fixation was 150 days (88 to 210). Three patients suffered complications including patella infera, pin-track infection and transient peroneal nerve palsy. At a mean follow-up of 4.4 years, all patients, except one, had achieved an excellent or good radiological and functional outcome

Aims

Stemmed tibial components are frequently used in revision total knee arthroplasty (TKA). The purpose of this study was to evaluate patient satisfaction, overall pain, and diaphyseal tibial pain in patients who underwent revision TKA with cemented or uncemented stemmed tibial components.