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 mean age of patients undergoing total knee arthroplasty (TKA) has reduced with time. Younger patients have increased expectations following TKA. Aseptic loosening of the tibial component is the most common cause of failure of TKA in the UK. Interest in cementless TKA has re-emerged due to its encouraging results in the younger patient population. We review a large series of tantalum trabecular metal cementless implants in patients who are at the highest risk of revision surgery.

Aims

Cementless total knee arthroplasty (TKA) offers the potential for strong biological fixation compared with cemented TKA where fixation is achieved by the mechanical integration of the cement. Few mid-term results are available for newer cementless TKA designs, which have used additive manufacturing (3D printing). The aim of this study was to present mid-term clinical outcomes and implant survivorship of the cementless Stryker Triathlon Tritanium TKA.

Aims. To compare time dependent functional improvement for patients with medial, respectively lateral knee osteoarthritis (OA) after treatment with opening wedge osteotomy relieving the pressure on the osteoarthritic part of the knee. Methods. In all, 49 patients (52 knees) with a mean age of 47 years (31 to 64) underwent high tibial osteotomies (HTO), and 24 patients with a mean age of 48 years (31 to 62) low femoral osteotomies (LFO) with opening wedge technique due to medial, respectively lateral knee OA with malalignment. All osteotomies were stabilized with a Puddu plate and bone grafting performed in the same time period (2000 to 2008). The patients were evaluated by the Knee Injury and Osteoarthritis Outcome Score (KOOS) pre-operatively and at six months, and at one, two, five, and ten years postoperatively. The knee OA was graded according to the Ahlbäck and Kellgren-Lawrence radiological scoring systems. Results. The mean angular corrections were 8.0° (4° to 12°) for the HTO and 9.6° (4° to 20°) for the LFO. Both the pre-operative KOOS and the osteoarthritic gradings were similar for the two patient groups. The five subscores of KOOS increased significantly during the postoperative period (p < 0.001 to 0.029) levelling out after one year in both groups. The KOOS subscore symptoms was significantly higher for patients with HTO than those with LFO at all follow-up times, for sport and recreation in the period one to five years, and for pain and quality of life at two to five years (p < 0.001 to 0.009). Eight HTOs (15%) and five LFOs (21%) were converted to total knee arthroplasty after mean 6.7 years (2.0 to 9.8) and 5.4 years (4.0 to 8.0) respectively. The ten-year osteotomy survival rates were 88% for the HTO and 79% for the LFO (p = 0.745). Conclusion. Patients with unicompartmental knee OA improved after a corrective opening wedge osteotomy, but four of the five subscores of KOOS were significantly higher for those with medial than those with lateral OA in most of the ten-year follow-up period. Cite this article: Bone Joint Open 2020;1-7:346–354

Aims

Although knee osteoarthritis (OA) is diagnosed and monitored radiologically, actual full-thickness cartilage loss (FTCL) has rarely been correlated with radiological classification. This study aims to analyze which classification system correlates best with FTCL and to assess their reliability.

We continued a prospective longitudinal follow-up study of 53 remaining patients who underwent open total meniscectomy as adolescents and who at that time had no other intra-articular pathology of the knee. Their clinical, radiological and patient-reported outcomes are described at a mean follow-up of 40 years (33 to 50). The cohort of patients who had undergone radiological evaluation previously after 30 years were invited for clinical examination, radiological evaluation and review using two patient-reported outcome measures.

A total of seven patients (13.2%) had already undergone total knee replacement at the time of follow-up. A significant difference was observed between the operated and non-operated knee in terms of range of movement and osteoarthritis of the tibiofemoral joint, indicating a greater than fourfold relative risk of osteoarthritis at 40 years post-operatively. All patients were symptomatic as defined by the Knee Injury and Osteoarthritis Outcome Score.

This study represents the longest follow-up to date and it can be concluded that meniscectomy leads to symptomatic osteoarthritis of the knee later in life, with a resultant 132-fold increase in the rate of total knee replacement in comparison to their geographical and age-matched peers.

This single-blinded randomised controlled trial investigated whether one design of mobile-bearing (MB) total knee replacement (TKR) has any advantage over a fixed-bearing (FB) design on long-term fixation as measured by radiostereometry. The amount of wear underneath the mobile bearing was also evaluated. A series of 42 knees was randomised to MB or FB tibial components with appropriate polyethylene inserts and followed for between ten and 12 years, or until the death of the patient. The polyethylene in the MB group was superior in that it was gamma-irradiated in inert gas and was calcium-stearate free; the polyethylene in the FB group was gamma-irradiated in air and contained calcium stearate. In theory this should be advantageous to the wear rate of the MB group. At final follow-up the overall mean migration was 0.75 mm (. sd. 0.76) in the MB group and 0.66 mm (. sd. 0.4) in the FB group, with the FB group demonstrating more posterior tilt and the MB group more internal rotation. In the FB group there was one revision for aseptic loosening, but none in the MB group. There were no significant differences in clinical or radiological scores. . For the MB group, the mean linear wear rate on the under-surface was 0.026 mm/year (. sd.  0.014). This was significantly smaller than the wear rate of 0.11 mm/year (. sd. 0.06) in the MB between femur and polyethylene (p < 0.001). Nevertheless, even in a best-case setting the mobile bearings of this TKR design had no apparent advantage in terms of fixation over the FB knee prosthesis at ten to 12 years. The wear underneath the mobile bearing was small and is unlikely to be clinically relevant

Radiological assessment of total and unicompartmental knee replacement remains an essential part of routine care and follow-up. Appreciation of the various measurements that can be identified radiologically is important. It is likely that routine plain radiographs will continue to be used, although there has been a trend towards using newer technologies such as CT, especially in a failing knee, where it provides more detailed information, albeit with a higher radiation exposure.

The purpose of this paper is to outline the radiological parameters used to evaluate knee replacements, describe how these are measured or classified, and review the current literature to determine their efficacy where possible.

Patients with skeletal dysplasia are prone to developing advanced osteoarthritis of the knee requiring total knee replacement (TKR) at a younger age than the general population. TKR in this unique group of patients is a technically demanding procedure owing to the deformity, flexion contracture, generalised hypotonia and ligamentous laxity. We retrospectively reviewed the outcome of 11 TKRs performed in eight patients with skeletal dysplasia at our institution using the Stanmore Modular Individualised Lower Extremity System (SMILES) custom-made rotating-hinge TKR. There were three men and five women with mean age of 57 years (41 to 79). Patients were followed clinically and radiologically for a mean of seven years (3 to 11.5). The mean Knee Society clinical and function scores improved from 24 (14 to 36) and 20 (5 to 40) pre-operatively, respectively, to 68 (28 to 80) and 50 (22 to 74), respectively, at final follow-up. Four complications were recorded, including a patellar fracture following a fall, a tibial peri-prosthetic fracture, persistent anterior knee pain, and aseptic loosening of a femoral component requiring revision. Our results demonstrate that custom primary rotating-hinge TKR in patients with skeletal dysplasia is effective at relieving pain, with a satisfactory range of movement and improved function. It compensates for bony deformity and ligament deficiency and reduces the likelihood of corrective osteotomy. Patellofemoral joint complications are frequent and functional outcome is worse than with primary TKR in the general population.

There has been debate about the role of unicompartmental knee replacement in the presence of radiologically identifiable degenerative changes of the patellofemoral joint. We studied 195 knees in 163 patients in whom an Oxford unicompartmental knee replacement had been performed for medial osteoarthritis between January 2004 and July 2007. The mean age of the patients was 66 years (51 to 93). The degree of degenerative change of the patellofemoral joint was assessed using Jones’ criteria. Functional outcome was assessed at a mean of 3.4 years (2 to 7) post-operatively, using the Oxford knee score and the Short-form 12 score.

Degenerative changes of the patellofemoral joint were seen pre-operatively in 125 knees (64%) on the skyline radiographs. There was no statistically significant difference in the Oxford knee or Short-form 12 scores between those patients who had patellofemoral osteoarthritis pre-operatively and those who did not (p = 0.22 and 0.54, respectively).

These results support the opinion expressed at the designer’s hospital that degenerative changes of the patellofemoral joint in isolation should not be considered to be a contraindication to medial Oxford unicompartmental knee replacement.

We identified a series of 128 patients who had unilateral open reconstruction of the anterior cruciate ligament (ACL) by a single surgeon between 1993 and 2000. In all, 79 patients were reviewed clinically and radiologically eight to 15 years after surgery. Assessment included measurement of the Lysholm and Tegner scores, the ACL quality-of-life score and the Short Form-12 score, as well as the International Knee Documentation Committee clinical assessment, measurement of laxity by the KT-1000 arthrometer, a single-leg hop test and standardised radiography of both knees using the uninjured knee as a control.

Of the injured knees, 46 (57%) had definite radiological evidence of osteoarthritis (Kellgren-Lawrence grade 2 or 3), with a mean difference between the injured and non-injured knees of 1.2 grades. The median ACL quality-of-life score was 80 (interquartile range (IQR) 60 to 90), the Lysholm score 84 (IQR 74 to 95), the Short Form-12 physical component score 54 (IQR 49 to 56) and the mean Hop Index 0.94 (0.52 to 1.52). In total 58 patients were graded as normal, 20 as nearly normal and one as abnormal on the KT-1000 assessment and pivot-shift testing. Taking the worst-case scenario of assuming all non-attenders (n = 48), two septic failures and one identified unstable knee found at review to be failures, the failure rate was 40%. Only two of the patients reviewed stated that they would not have similar surgery again.

Open reconstruction of the ACL gives good, durable functional results, but with a high rate of radiologically evident osteoarthritis.

We report the clinical and radiological results of a two- to three-year prospective randomised study which was designed to compare a minimally-invasive technique with a standard technique in total knee replacement and was undertaken between January 2004 and May 2007. The mini-midvastus approach was used on 50 patients (group A) and a standard approach on 50 patients (group B). The mean follow-up in both groups was 23 months (24 to 35).

The functional outcome was better in group A up to nine months after operation, as shown by statistically significant differences in the mean function score, mean total score and the mean Oxford knee score (all, p = 0.05). Patients in group A had statistically significant greater early flexion (p = 0.04) and reached their greatest mean knee flexion of 126.5° (95° to 135°) 21 days after operation. However, at final follow-up there was no significant difference in the mean maximum flexion between the groups (p = 0.08). Technical errors were identified in six patients from group A (12%) on radiological evaluation.

Based on these results, the authors currently use minimally-invasive techniques in total knee replacement in selected cases only.

We have examined the results obtained with 72 NexGen legacy posterior stabilised-flex fixed total knee replacements in 47 patients implanted by a single surgeon between March 2003 and September 2004.

Aseptic loosening of the femoral component was found in 27 (38%) of the replacements at a mean follow-up of 32 months (30 to 48) and 15 knees (21%) required revision at a mean of 23 months (11 to 45). We compared the radiologically-loose and revised knees with those which had remained well-fixed to identify the factors which had contributed to this high rate of aseptic loosening.

Post-operatively, the mean maximum flexion was 136° (110° to 140°) in the loosened group and 125° (95° to 140°) in the well-fixed group (independent t-test, p = 0.022). Squatting, kneeling, or sitting cross-legged could be achieved by 23 (85%) of the loosened knees, but only 22 (49%) of the well-fixed knees (chi-squared test, p = 0.001). The loosened femoral components were found to migrate into a more flexed position, but no migration was detected in the well-fixed group.

These implants allowed a high degree of flexion, but showed a marked rate of early loosening of the femoral component, which was associated with weight-bearing in maximum flexion.

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.

We report a study of 112 patients with primary anteromedial osteoarthritis of the knee and their families. Sibling risk was determined using randomly selected single siblings. Spouses were used as controls. The presence of symptomatic osteoarthritis was determined using an Oxford knee score of ≥ 29 supported by a Kellgren and Lawrence radiological score of II or greater. Using Fisher’s exact test we found that there was a significant increased risk of anteromedial osteoarthritis (OA) relative to the control group (p = 0.031). The recurrence risk of anteromedial OA to siblings was 3.21 (95% confidence interval 1.12 to 9.27). These findings imply that genetic factors may play a major role in the development of anteromedial OA of the knee