Adenosine, lidocaine, and Mg2+ (ALM) therapy exerts differential immuno-inflammatory responses in males and females early after anterior cruciate ligament (ACL) reconstruction (ACLR). Our aim was to investigate sex-specific effects of ALM therapy on joint tissue repair and recovery 28 days after surgery. Male (n = 21) and female (n = 21) adult Sprague-Dawley rats were randomly divided into ALM or Saline control treatment groups. Three days after ACL rupture, animals underwent ACLR. An ALM or saline intravenous infusion was commenced prior to skin incision, and continued for one hour. An intra-articular bolus of ALM or saline was also administered prior to skin closure. Animals were monitored to 28 days, and joint function, pain, inflammatory markers, histopathology, and tissue repair markers were assessed.Aims
Methods
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:
The October 2023 Research Roundup. 360. looks at: Gut microbiota in high-risk individuals for rheumatoid arthritis associated with disturbed metabolome and initiates arthritis by triggering mucosal immunity imbalance; International Consensus on Anaemia Management in Surgical Patients (ICCAMS); Sleep disturbance trends in the short-term postoperative period for patients undergoing total joint replacement; Achilles tendon tissue turnover before and immediately after an acute rupture;
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. A systematic review of MEDLINE, PubMed, and Google Scholar was performed to identify randomized controlled trials (RCTs) according to search criteria. Search terms used included: arthroplasty, replacement, knee (Mesh), TKA, prosthesis, patella, patellar resurfacing, and patellar retaining. RCTs that compared patellar resurfacing versus unresurfaced in primary TKA were included for further analysis. Studies were evaluated using the Scottish Intercollegiate Guidelines Network assessment tool for quality and minimization of bias. Data were synthesized and meta-analysis performed.Aims
Methods
The aim of this study was to determine the effectiveness of home-based prehabilitation on pre- and postoperative outcomes in participants awaiting total knee (TKA) and hip arthroplasty (THA). A systematic review with meta-analysis of randomized controlled trials (RCTs) of prehabilitation interventions for TKA and THA. MEDLINE, CINAHL, ProQuest, PubMed, Cochrane Library, and Google Scholar databases were searched from inception to October 2022. Evidence was assessed by the PEDro scale and the Cochrane risk-of-bias (ROB2) tool.Aims
Methods
The aim of this systematic review and meta-analysis was to gather epidemiological information on selected musculoskeletal injuries and to provide pooled injury-specific incidence rates. PubMed (National Library of Medicine) and Scopus (Elsevier) databases were searched. Articles were eligible for inclusion if they reported incidence rate (or count with population at risk), contained data on adult population, and were written in English language. The number of cases and population at risk were collected, and the pooled incidence rates (per 100,000 person-years) with 95% confidence intervals (CIs) were calculated by using either a fixed or random effects model.Aims
Methods
Recognized anatomic variations that lead to patella instability include patella alta and trochlea dysplasia. Lateralization of the extensor mechanism relative to the trochlea is often considered to be a contributing factor; however, controversy remains as to the degree this contributes to instability and how this should be measured. As the tibial tuberosity-trochlear groove (TT-TG) is one of most common imaging measurements to assess lateralization of the extensor mechanism, it is important to understand its strengths and weaknesses. Care needs to be taken while interpreting the TT-TG value as it is affected by many factors. Medializing tibial tubercle osteotomy is sometimes used to correct the TT-TG, but may not truly address the underlying anatomical problem. This review set out to determine whether the TT-TG distance sufficiently summarizes the pathoanatomy, and if this assists with planning of surgery in patellar instability. Cite this article:
Bi-unicondylar arthroplasty (Bi-UKA) is a bone and anterior cruciate ligament (ACL)-preserving alternative to total knee arthroplasty (TKA) when the patellofemoral joint is preserved. The aim of this study is to investigate the clinical outcomes and biomechanics of Bi-UKA. Bi-UKA subjects (n = 22) were measured on an instrumented treadmill, using standard gait metrics, at top walking speeds. Age-, sex-, and BMI-matched healthy (n = 24) and primary TKA (n = 22) subjects formed control groups. TKA subjects with preoperative patellofemoral or tricompartmental arthritis or ACL dysfunction were excluded. The Oxford Knee Score (OKS) and EuroQol five-dimension questionnaire (EQ-5D) were compared. Bi-UKA, then TKA, were performed on eight fresh frozen cadaveric knees, to investigate knee extensor efficiency under controlled laboratory conditions, using a repeated measures study design.Aims
Methods
Recent total knee arthroplasty (TKA) designs have featured more anatomical morphologies and shorter tibial keels. However, several reports have raised concerns about the impact of these modifications on implant longevity. The aim of this study was to report the early performance of a modern, cemented TKA design. All patients who received a primary, cemented TKA between 2012 and 2017 with a minimum two-year follow-up were included. The implant investigated features an asymmetrical tibial baseplate and shortened keel. Patient demographic details, Knee Society Scores (KSS), component alignment, and the presence of radiolucent lines at final follow-up were recorded. Kaplan-Meier analyses were performed to estimate survivorship.Aims
Methods
Robotic-assisted total knee arthroplasty (RA-TKA) is theoretically more accurate for component positioning than TKA performed with mechanical instruments (M-TKA). Furthermore, the ability to incorporate soft-tissue laxity data into the plan prior to bone resection should reduce variability between the planned polyethylene thickness and the final implanted polyethylene. The purpose of this study was to compare accuracy to plan for component positioning and precision, as demonstrated by deviation from plan for polyethylene insert thickness in measured-resection RA-TKA versus M-TKA. A total of 220 consecutive primary TKAs between May 2016 and November 2018, performed by a single surgeon, were reviewed. Planned coronal plane component alignment and overall limb alignment were all 0° to the mechanical axis; tibial posterior slope was 2°; and polyethylene thickness was 9 mm. For RA-TKA, individual component position was adjusted to assist gap-balancing but planned coronal plane alignment for the femoral and tibial components and overall limb alignment remained 0 ± 3°; planned tibial posterior slope was 1.5°. Mean deviations from plan for each parameter were compared between groups for positioning and size and outliers were assessed.Aims
Methods
The integrity of the soft tissue envelope is crucial for successful treatment of infected total knee arthroplasty (TKA). The purpose of this study was to evaluate the rate of limb salvage, infection control, and clinical function following microvascular free flap coverage for salvage of the infected TKA. We retrospectively reviewed 23 microvascular free tissue transfers for management of soft tissue defects in infected TKA. There were 16 men and seven women with a mean age of 61.2 years (39 to 81). The median number of procedures performed prior to soft tissue coverage was five (2 to 9) and all patients had failed at least one two-stage reimplantation procedure. Clinical outcomes were measured using the Knee Society Scoring system for pain and function.Aims
Methods
The aim of this study was to assess the effectiveness of perioperative essential amino acid (EAA) supplementation to prevent rectus femoris muscle atrophy and facilitate early recovery of function after total knee arthroplasty (TKA). The study involved 60 patients who underwent unilateral TKA for primary knee osteo-arthritis (OA). This was a double-blind, placebo-controlled, randomized control trial with patients randomly allocated to two groups, 30 patients each: the essential amino acid supplementation (9 g daily) and placebo (lactose powder, 9 g daily) groups. Supplementation and placebo were provided from one week before to two weeks after surgery. The area of the rectus femoris muscle were measured by ultrasound imaging one month before surgery and one, two, three, and four weeks postoperatively. The serum albumin level, a visual analogue knee pain score, and mobility were also measured at each time point. The time to recovery of activities of daily living (ADLs) was recorded. Postoperative nutrition and physiotherapy were identical in both groups.Aims
Methods
The aim of this study was to examine whether tourniquet use can improve perioperative blood loss, early function recovery, and pain after primary total knee arthroplasty (TKA) in the setting of multiple-dose intravenous tranexamic acid. This was a prospective, randomized clinical trial including 180 patients undergoing TKA with multiple doses of intravenous tranexamic acid. One group was treated with a tourniquet during the entire procedure, the second group received a tourniquet during cementing, and the third group did not receive a tourniquet. All patients received the same protocol of intravenous tranexamic acid (20 mg/kg) before skin incision, and three and six hours later (10 mg/kg). The primary outcome measure was perioperative blood loss. Secondary outcome measures were creatine kinase (CK), CRP, interleukin-6 (IL-6), visual analogue scale (VAS) pain score, limb swelling ratio, quadriceps strength, straight leg raising, range of motion (ROM), American Knee Society Score (KSS), and adverse events.Aims
Methods
The aim of this study was to determine whether closed suction drain (CSD) use influences recovery of quadriceps strength and to examine the effects of drain use on secondary outcomes: quadriceps activation, intra-articular effusion, bioelectrical measure of swelling, range of movement (ROM), pain, and wound healing complications. A total of 29 patients undergoing simultaneous bilateral total knee arthroplasty (TKA) were enrolled in a prospective, randomized blinded study. Patients were randomized to receive a CSD in one limb while the contralateral limb had the use of a subcutaneous drain (SCDRN) without the use of suction (‘sham drain’). Isometric quadriceps strength was collected as the primary outcome. Secondary outcomes consisted of quadriceps activation, intra-articular effusion measured via ultrasound, lower limb swelling measured with bioelectrical impendence and limb girth, knee ROM, and pain. Outcomes were assessed preoperatively and postoperatively at day two, two and six weeks, and three months. Differences between limbs were determined using paired Student’s Aims
Patients and Methods
The aim of this study was to investigate the changes in femoral
trochlear morphology following surgical correction of recurrent
patellar dislocation associated with trochlear dysplasia in children. A total of 23 patients with a mean age of 9.6 years (7 to 11)
were included All had bilateral recurrent patellar dislocation associated
with femoral trochlear dysplasia. The knee with traumatic dislocation
at the time of presentation or that had dislocated most frequently
was treated with medial patellar retinacular plasty (Group S). The
contralateral knee served as a control and was treated conservatively
(Group C). All patients were treated between October 2008 and August
2013. The mean follow-up was 48.7 months (43 to 56). Axial CT scans
were undertaken in all patients to assess the trochlear morphological
characteristics on a particular axial image which was established
at the point with the greatest epicondylar width based on measurements
preoperatively and at the final follow-up.Aims
Patients and Methods
Patellar instability most frequently presents
during adolescence. Congenital and infantile dislocation of the
patella is a distinct entity from adolescent instability and measurable
abnormalities may be present at birth. In the normal patellofemoral
joint an increase in quadriceps angle and patellar height are matched
by an increase in trochlear depth as the joint matures. Adolescent
instability may herald a lifelong condition leading to chronic disability
and arthritis. Restoring normal anatomy by trochleoplasty, tibial tubercle transfer
or medial patellofemoral ligament (MPFL) reconstruction in the young
adult prevents further instability. Although these techniques are
proven in the young adult, they may cause growth arrest and deformity
where the physis is open. A vigorous non-operative strategy may
permit delay of surgery until growth is complete. Where non-operative
treatment has failed a modified MPFL reconstruction may be performed
to maintain stability until physeal closure permits anatomical reconstruction.
If significant growth remains an extraosseous reconstruction of
the MPFL may impart the lowest risk to the physis. If minor growth
remains image intensifier guided placement of femoral intraosseous
fixation may impart a small, but acceptable, risk to the physis. This paper presents and discusses the literature relating to
adolescent instability and provides a framework for management of
these patients. Cite this article:
Osteochondritis Dissecans (OCD) is a condition
for which the aetiology remains unknown. It affects subchondral bone
and secondarily its overlying cartilage and is mostly found in the
knee. It can occur in adults, but is generally identified when growth
remains, when it is referred to as juvenile OCD. As the condition
progresses, the affected subchondral bone separates from adjacent
healthy bone, and can lead to demarcation and separation of its associated
articular cartilage. Any symptoms which arise relate to the stage
of the disease. Early disease without separation of the lesion results
in pain. Separation of the lesion leads to mechanical symptoms and
swelling and, in advanced cases, the formation of loose bodies. Early identification of OCD is essential as untreated OCD can
lead to the premature degeneration of the joint, whereas appropriate
treatment can halt the disease process and lead to healing. Establishing
the stability of the lesion is a key part of providing the correct
treatment. Stable lesions, particularly in juvenile patients, have
greater propensity to heal with non-surgical treatment, whereas
unstable or displaced lesions usually require surgical management. This article discusses the aetiology, clinical presentation and
prognosis of OCD in the knee. It presents an algorithm for treatment,
which aims to promote healing of native hyaline cartilage and to
ensure joint congruity. Take home message: Although there is no clear consensus as to
the best treatment of OCD, every attempt should be made to retain
the osteochondral fragment when possible as, with a careful surgical
technique, there is potential for healing even in chronic lesions Cite this article:
Our objective was to predict the knee extension strength and post-operative function in quadriceps resection for soft-tissue sarcoma of the thigh. A total of 18 patients (14 men, four women) underwent total or partial quadriceps resection for soft-tissue sarcoma of the thigh between 2002 and 2014. The number of resected quadriceps was surveyed, knee extension strength was measured with the Biodex isokinetic dynamometer system (affected side/unaffected side) and relationships between these were examined. The Musculoskeletal Tumor Society (MSTS) score, Toronto Extremity Salvage Score (TESS), European Quality of Life-5 Dimensions (EQ-5D) score and the Short Form 8 were used to evaluate post-operative function and examine correlations with extension strength. The cutoff value for extension strength to expect good post-operative function was also calculated using a receiver operating characteristic (ROC) curve and Fisher’s exact test.Objectives
Methods
The aim of this study was to examine the results of revision
total knee arthroplasty (TKA) undertaken for stiffness in the absence
of sepsis or loosening. We present the results of revision surgery for stiff TKA in 48
cases (35 (72.9%) women and 13 (27.1%) men). The mean age at revision
surgery was 65.5 years (42 to 83). All surgeries were performed
by a single surgeon. Stiffness was defined as an arc of flexion
of <
70° or a flexion contracture of >
15°. The changes in the
range of movement (ROM) and the Western Ontario and McMasters Osteoarthritis
index scores (WOMAC) were recorded.Aims
Patients and Methods
A key to the success of revision total knee arthroplasty
(TKA) is a safe surgical approach using an exposure that minimises
complications. In most patients, a medial parapatellar arthrotomy
with complete synovectomy is sufficient. If additional exposure
is needed, a quadriceps snip performed through the quadriceps tendon
often provides the additional exposure required. It is simple to
perform and does not alter the post-operative rehabilitative protocol.
In rare cases, in which additional exposure is needed, or when removal
of a cemented long-stemmed tibial component is required, a tibial
tubercle osteotomy (TTO) may be used. Given the risk of post-operative
extensor lag, a V-Y quadricepsplasty is rarely indicated and usually
considered only if TTO is not possible. Cite this article:
Bariatric surgery has been advocated as a means
of reducing body mass index (BMI) and the risks associated with total
knee arthroplasty (TKA). However, this has not been proved clinically.
In order to determine the impact of bariatric surgery on the outcome
of TKA, we identified a cohort of 91 TKAs that were performed in
patients who had undergone bariatric surgery (bariatric cohort).
These were matched with two separate cohorts of patients who had not
undergone bariatric surgery. One was matched 1:1 with those with
a higher pre-bariatric BMI (high BMI group), and the other was matched
1:2 based on those with a lower pre-TKA BMI (low BMI group). In the bariatric group, the mean BMI before bariatric surgery
was 51.1 kg/m2 (37 to 72), which improved to 37.3 kg/m2 (24
to 59) at the time of TKA. Patients in the bariatric group had a
higher risk of, and worse survival free of, re-operation (hazard
ratio (HR) 2.6; 95% confidence interval (CI) 1.2 to 6.2; p = 0.02)
compared with the high BMI group. Furthermore, the bariatric group
had a higher risk of, and worse survival free of re-operation (HR
2.4; 95% CI 1.2 to 3.3; p = 0.2) and revision (HR 2.2; 95% CI 1.1
to 6.5; p = 0.04) compared with the low BMI group. While bariatric surgery reduced the BMI in our patients, more
analysis is needed before recommending bariatric surgery before
TKA in obese patients. Cite this article:
In 11 paediatric patients (seven girls and four
boys, from 12 to 15 years old) with unilateral obligatory patellar dislocation
and ligamentous laxity vastus medialis advancement, lateral release,
partial patellar ligament transposition and Galeazzi semitendinosus
tenodesis was undertaken to stabilise the patella. The diagnostic criterion
for ligamentous laxity was based on the Beighton scale. Outcomes
were evaluated radiologically and functionally by measurement of
the range of knee movement and isokinetic testing. The evaluation
also included the Lysholm knee scale. Follow-up studies took place
at a mean of 8.1 years (5 to 15) post-operatively. Normal patellar tracking without any recurrence of dislocation
was obtained in ten out of 11 patients. Pain related to vigorous
activity was reported by nine patients. Compared with the opposite
normal side, the isokinetic tests revealed a statistically significant
decrease in the maximal torque values for the affected quadriceps
muscle (p = 0.003 and p = 0.004), but no difference between the
knee flexors (for angular velocities of 60°/s and 180°/s) (p = 0.858
and p = 0.79). The applied surgical technique generally prevents the recurrence
of the disorder in children with habitual patellar dislocation and
ligamentous laxity.
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:
The December 2013 Knee Roundup. 360 . looks at: Conflict of interest and hyaluronic acid; Will time indeed tell in microfracture?; Contralateral knee pain and joint replacement outcomes; Patient satisfaction and knee replacement?; Hope in the cytokines for painful TKRs?; Pain severity, cytokines and osteoarthritis?;
The goals of this study were: 1) to determine if high-fat diet
(HFD) feeding in female mice would negatively impact biomechanical
and histologic consequences on the Achilles tendon and quadriceps
muscle; and 2) to investigate whether exercise and branched-chain
amino acid (BCAA) supplementation would affect these parameters
or attenuate any negative consequences resulting from HFD consumption. We examined the effects of 16 weeks of 60% HFD feeding, voluntary
exercise (free choice wheel running) and BCAA administration in
female C57BL/6 mice. The Achilles tendons and quadriceps muscles
were removed at the end of the experiment and assessed histologically
and biomechanically.Objectives
Methods
Disruption of the extensor mechanism in total
knee arthroplasty may occur by tubercle avulsion, patellar or quadriceps
tendon rupture, or patella fracture, and whether occurring intra-operatively
or post-operatively can be difficult to manage and is associated
with a significant rate of failure and associated complications.
This surgery is frequently performed in compromised tissues, and
repairs must frequently be protected with cerclage wiring and/or
augmentation with local tendon (semi-tendinosis, gracilis) which
may also be used to treat soft-tissue loss in the face of chronic
disruption.
The current indications for functional restoration
of extension of the knee following quadriceps resection or loss require
reappraisal. The contribution of pedicled and free functional muscle
transfer is likely to be over-emphasised in many studies, with good
functional outcomes predominantly reported only in the context of
cases with residual quadriceps function. In cases with total quadriceps
resection or loss, all forms of reconstruction perform poorly. Furthermore,
in smaller resections with loss of two or fewer components of the
quadriceps, minimal impairment of function occurs in the absence
of functional reconstruction, suggesting that functional restoration
may not be warranted. Thus there is a paradox in the current approach
to quadriceps reconstruction, in that small resections are likely
to be over-treated and large resections remain under-treated. This review suggests a shift is required in the approach and
rationale for reconstructing functional extension of the knee after
quadriceps resection or loss. A classification based on current
evidence is suggested that emphasises more clearly the indications
and rationale for functional transfers.
The April 2012 Knee Roundup360 looks at the torn ACL, ACL reconstruction, the risk of ACL rupture, the benefit of warm-ups before exercise, glucosamine and tibiofemoral osteoarthritis, sensitisation and sporting tendinopathy, pain relief after TKR, the long-term results of the Genesis I, the gender specific recovery times after TKR, and the accuracy of the orthopaedic eyeball
Reconstructive acetabular osteotomy is a well established and effective procedure in the treatment of acetabular dysplasia. However, the dysplasia is frequently accompanied by intra-articular pathology such as labral tears. We intended to determine whether a concomitant hip arthroscopy with peri-acetabular rotational osteotomy could identify and treat intra-articular pathology associated with dysplasia and thereby produce a favourable outcome. We prospectively evaluated 43 consecutive hips treated by combined arthroscopy and acetabular osteotomy. Intra-operative arthroscopic examination revealed labral lesions in 38 hips. At a mean follow-up of 74 months (60 to 97) the mean Harris hip score improved from 72.4 to 94.0 (p < 0.001), as did all the radiological parameters (p < 0.001). Complications included penetration of the joint by the osteotome in one patient, a fracture of the posterior column in another and deep-vein thrombosis in one further patient. This combined surgical treatment gave good results in the medium term. We suggest that arthroscopy of the hip can be performed in conjunction with peri-acetabular osteotomy to provide good results in patients with symptomatic dysplasia of the hip, and the arthroscopic treatment of intra-articular pathology may alter the progression of osteoarthritis.
Isolated patellofemoral osteoarthritis can be a disabling disease. When conservative treatment fails, surgical options can be unpredictable and may be considered too aggressive for middle-aged and active people. We analysed the clinical and radiological results of a new coronal osteotomy involving thinning of the patella in a selected group of patients with isolated patellofemoral osteoarthritis. Since 1991, 31 patients (35 knees) have been treated, of whom 34 were available for follow-up at a mean of 9.1 years. The Knee Society Score, the Patellar score and the Short-form-36 questionnaire were used for clinical evaluation. We also examined the radiological features to confirm bone consolidation and assess the progression of osteoarthritis. A significant improvement in the functional scores and radiological parameters was noted. All patients except one were satisfied with the operation. Radiological progression of the patellofemoral osteoarthritis was slowed but radiological femorotibial osteoarthritis progressed in 23 (65%) cases, with a total knee replacement becoming necessary in four cases without technical problems in resurfacing the patella. We compared the results with other forms of surgical treatment reported in the literature. This treatment offers good clinical and radiological results, presenting an alternative method of managing patellofemoral osteoarthritis.
The management of patients with a painful total knee replacement requires careful assessment and a stepwise approach in order to diagnose the underlying pathology accurately. The management should include a multidisciplinary approach to the patient’s pain as well as addressing the underlying aetiology. Pain should be treated with appropriate analgesia, according to the analgesic ladder of the World Health Organisation. Special measures should be taken to identify and to treat any neuropathic pain. There are a number of intrinsic and extrinsic causes of a painful knee replacement which should be identified and treated early. Patients with unexplained pain and without any recognised pathology should be treated conservatively since they may improve over a period of time and rarely do so after a revision operation.
We investigated the association between the radiological findings and the symptoms arising from the patellofemoral joint in advanced osteoarthritis (OA) of the knee. Four radiological features, joint space narrowing, osteophyte formation, translation of the patella and focal attrition were assessed in 151 consecutive osteoarthritic knees in 107 patients undergoing total knee replacement. The symptoms which were assessed included anterior knee pain which was scored, the ability to rise from a chair and climb stairs, and quadriceps weakness. Among the radiological features, only patellar translation and obliteration of the joint space had a statistically significant association with anterior knee pain (odds ratio (OR) 4.85; 95% confidence interval (CI) 1.83 to 12.88 and OR 11.23; 95% CI 2.44 to 51.62) respectively. Patellar translation had a statistically significant association with difficulty in rising from a chair (OR 9.06; 95% CI 1.75 to 45.11). Other radiological features, including osteophytes, joint space narrowing, and focal attrition had no significant association. Our study indicates that the radiological findings of patellar translation and significant loss of cartilage are predictive of patellofemoral symptoms and functional limitation in advanced OA of the knee.
Interest in football continues to increase, with ever younger age groups participating at a competitive level. Football academies have sprung up under the umbrella of professional clubs in an attempt to nurture and develop such talent in a safe manner. However, increased participation predisposes the immature skeleton to injury. Over a five-year period we have prospectively collected data concerning all injuries presenting to the medical team at Newcastle United football academy. We identified 685 injuries in our cohort of 210 players with a mean age of 13.5 years (9 to 18). The majority of injuries (542;79%) were to the lower limb. A total of 20 surgical procedures were performed. Contact injuries accounted for 31% (210) of all injuries and non-contact for 69% (475).The peaks of injury occurred in early September and March. The 15- and 16-year-old age group appeared most at risk, independent of hours of participation. Strategies to minimise injury may be applicable in both the academy setting and the wider general community.
The aim of this study was to compare the results in patients having a quadriceps sparing total knee replacement (TKR) with those undergoing a standard TKR at a minimum follow-up of two years. All patients who had a TKR with a high-flex posterior-stabilised prosthesis prior to December 2002 were reviewed retrospectively. There were 57 patients available for follow-up. Those with a quadriceps sparing TKR had less pain peri-operatively with a greater degree of flexion at all the post-operative visits and at the final follow-up, but their operations took longer, with less accurate radiological alignment. There was no difference in the complications and in the Knee Society scores between the two groups at the final follow-up. Total knee replacement through a quadriceps sparing approach has some peri-operative advantages over the standard incision. At a minimum follow-up of two years the clinical results were similar to those with a standard incision, but the radiological outcomes of the quadriceps sparing group were inferior.
We carried out a prospective study of 71 patients who had undergone reconstruction of the anterior cruciate ligament with the ABC scaffold. Their mean age was 28 years (18 to 50). All had either sub-acute or chronic traumatic deficiency of the ligament. The mean period of follow-up was five years (four to seven). Assessment included the use of the International Knee Documentation Committee score, the modified Lysholm score, the Tegner Activity score, the Knee Injury and Osteoarthritis Outcome score and measurement with the KT-1000 arthrometer. Two patients had mild recurrent synovitis. There were no infections and no failures of the ligament. During the period of study, two patients sustained a traumatic fracture of a femoral condyle. The implants retained their integrity in both cases. All patients returned to their previous or enhanced levels of daily activity by three months after operation and 56 (79%) achieved their pre-injury level of sporting activity by six months. The patients who were competing in National level sports returned to play at one level less after operation than before. The Lysholm score showed that 58% of the patients (41) were excellent, 34% (24) good, and 8% (6) fair, with a mean post-operative score of 93. According to the International Knee Documentation Committee score, 35% of knees (25) were ‘normal’, 52% (37) ‘nearly normal’ and 13% (9) ‘abnormal’. Complete satisfaction was noted in 90% of patients (64). The development of osteoarthritis and the management of anterior cruciate deficiency associated with laxity of the medial collateral ligament remains uncertain. Our results indicate that in the medium-term, the ABC ligament scaffold is suitable and effective when early and safe return to unrestricted activities is demanded. We acknowledge the current general hostility towards reconstruction of the anterior cruciate ligament with artificial materials following reports of early failure and chronic synovitis associatiated with the production of particulate debris. We did not encounter these problems.
We have investigated the changes in anterior laxity of the knee in response to direct electrical stimulation of eight normal and 45 reconstructed anterior cruciate ligaments (ACLs). In the latter, the mean time from reconstruction was 26.7 months (24 to 32). The ACL was stimulated electrically using a bipolar electrode probe during arthroscopy. Anterior laxity was examined with the knee flexed at 20° under a force of 134 N applied anteriorly to the tibia using the KT-2000 knee arthrometer before, during and after electrical stimulation. Anterior tibial translation in eight normal and 17 ACL-reconstructed knees was significantly decreased during stimulation, compared with that before stimulation. In 28 knees with reconstruction of the ACL, in 22 of which the grafts were found to have detectable somatosensory evoked potentials during stimulation, anterior tibial translation was not decreased. These findings suggest that the ACL-hamstring reflex arc in normal knees may contribute to the functional stability and that this may not be fully restored after some reconstructions of the ACL.
We reviewed 13 patients with infected nonunion of the distal femur and bone loss, who had been treated by radical surgical debridement and the application of an Ilizarov external fixator. All had severely restricted movement of the knee and a mean of 3.1 previous operations. The mean length of the bony defect was 8.3 cm and no patient was able to bear weight. The mean external fixation time was 309.8 days. According to Paley’s grading system, eight patients had an excellent clinical and radiological result and seven excellent and good functional results. Bony union, the ability to bear weight fully, and resolution of the infection were achieved in all the patients. The external fixation time was increased when the definitive treatment started six months or more after the initial trauma, the patient had been subjected to more than four previous operations and the initial operation had been open reduction and internal fixation.
Our aim was to compare the biomechanical properties of suturing methods to determine a better method for the repair of lacerated skeletal muscle. We tested Kessler stitches and the combination of Mason-Allen and perimeter stitches. Individual stitches were placed in the muscle belly of quadriceps femoris from a pig cadaver and were tensioned mechanically. The maximum loads and strains were measured and failure modes recorded. The mean load and strain for the Kessler stitches were significantly less than those for combination stitches. All five Kessler stitches tore out longitudinally from the muscle. All five combination stitches did not fail but successfully elongated. Our study has shown that the better method of repair for suturing muscle is the use of combination stitches.
We assessed the functional outcome following fracture of the tibial plateau in 63 consecutive patients. Fifty-one patients were treated by internal fixation, five by combined internal and external fixation and seven non-operatively. Measurements of joint movement and muscle function were made using a muscle dynamometer at three, six and 12 months following injury. Thirteen patients (21%) had a residual flexion contracture at one year. Only nine (14%) patients achieved normal quadriceps muscle strength at 12 months, while 19 (30%) achieved normal hamstring muscle strength. Recovery was significantly slower in patients older than 40 years of age. We conclude that there is significant impairment of movement and muscle function after fracture of the tibial plateau and that the majority of patients have not fully recovered one year after injury.
We sought to determine the degree of correlation between the condition of the patellar articular cartilage and patellofemoral symptoms and function in osteoarthritic patients undergoing total knee arthroplasty. The depth of the osteoarthritic lesion, as graded by the Outerbridge classification and its size and location were assessed to determine the condition of the patellar cartilage in 80 consecutive osteoarthritic knees undergoing total knee arthroplasty. The association between the condition of the cartilage and patellofemoral symptoms and function was investigated by correlation analysis. The depth and size of the lesion had a significant but weak correlation with anterior knee pain (r = −0.300 and −0.289; p = 0.007 and 0.009, respectively), whereas location had no significant association (p >
0.05). None had a significant association with patellofemoral functional parameters (chair-rising, stair-climbing, and quadriceps power) (p >
0.05). Our study indicates that patellofemoral symptoms and function are not completely determined by the condition of the cartilage. Caution should be taken when the symptoms and functional limitations are attributed to a lesion in the patellofemoral joint in making a decision regarding patellar resurfacing in total knee arthroplasty.
We randomised 31 patients with acute tears of the anterior cruciate ligament (ACL) to receive either early (within 2 weeks) or delayed (8 to 12 weeks) reconstruction using a quadruple hamstring graft in order to determine if there was any functional advantage to early reconstruction. Outcome measures included return of knee movement, muscle dynamometry, International Knee Documentation Committee (IKDC) scores and Tegner activity levels. Two cases of symptomatic deep-venous thrombosis occurred in the early group. The mean range of movement was significantly greater at two weeks in the delayed group.
Thirty-five patients with habitual dislocation of the patella in flexion were reviewed; eight were bilaterally affected. Each had undergone quadricepsplasty with an average follow-up of 6 years 9 months. Bands or contractures, most commonly in vastus lateralis, the iliotibial tract and rectus femoris were seen in each. Redislocation was seen in 12 knees. At review, 79% of the knees were normal.
1. A case of bilateral spontaneous and simultaneous rupture of the quadriceps tendons is described. 2. The underlying cause was found to be gouty affection of the tendons. 3. So far as is known, a similar case has not previously been recorded.
1. Previous reports of the role of the quadriceps in producing limitation of movement or dislocation of the patella have tended to implicate one particular part of the complex. Experience gained in thirty-five quadricepsplasties in children has shown that all parts of the quadriceps (except vastus medialis) and the ilio-tibial band also may play a part and that each of these must be attended to if a satisfactory result is to be obtained. 2. A simple technique of operation is described and illustrated. 3. Since this paper was prepared, a patient showing features of particular interest has been seen and treated.
1. Six cases of quadriceps contracture in children are described. All were either premature or suffered severe illnesses soon after birth. 2. Some additional information is given about cases of the same condition previously published by other authors. 3. It is suggested that injections and infusions given to newborn babies are sometimes the cause of the condition. 4. Some of the therapeutic substances and measures which may be responsible are discussed. These include antibiotics, vitamin K preparations and "subcutaneous" fluid therapy.
1. Contracture of parts of the quadriceps muscle is not uncommon and is often accompanied by tightness of the ilio-tibial tract. It is suggested that this may follow intramuscular injections. 2. Recurrent dislocation of the patella can be a consequence of this muscle contracture. 3. Division of the ilio-tibial tract and lengthening of the fibrotic elements of the quadriceps can prevent further dislocation and restore good function.