Normal sagittal spine-pelvis-lower extremity alignment is crucial in humans for maintaining an ergonomic upright standing posture, and pathogenesis in any segment leads to poor balance. The present study aimed to investigate how this sagittal alignment can be affected by severe knee osteoarthritis (KOA), and whether associated changes corresponded with symptoms of lower back pain (LBP) in this patient population. Lateral radiograph films in an upright standing position were obtained from 59 patients with severe KOA and 58 asymptomatic controls free from KOA. Sagittal alignment of the spine, pelvis, hip and proximal femur was quantified by measuring several radiographic parameters. Global balance was accessed according to the relative position of the C7 plumb line to the sacrum and femoral heads. The presence of chronic LBP was documented. Comparisons between the two groups were carried by independent samples Objectives
Methods
The December 2015 Children’s orthopaedics Roundup360 looks at: Paediatric femoral fractures: a single incision nailing?; Lateral condylar fractures: open or percutaneous?; Forearm refracture: the risks; Tibial spine fractures; The child’s knee in MRI; The mechanics of SUFE; Idiopathic clubfoot
The purpose of this study was to evaluate the
effect of various non-operative modalities of treatment (transcutaneous
electrical nerve stimulation (TENS); neuromuscular electrical stimulation
(NMES); insoles and bracing) on the pain of osteoarthritis (OA)
of the knee. We conducted a systematic review according to the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses guidelines to identify
the therapeutic options which are commonly adopted for the management
of osteoarthritis (OA) of the knee. The outcome measurement tools used in the different studies were
the visual analogue scale and The Western Ontario and McMaster Universities
Arthritis Index pain index: all pain scores were converted to a
100-point scale. A total of 30 studies met our inclusion criteria: 13 on insoles,
seven on TENS, six on NMES, and four on bracing. The standardised
mean difference (SMD) in pain after treatment with TENS was 1.796,
which represented a significant reduction in pain. The significant
overall effect estimate for NMES on pain was similar to that of
TENS, with a SMD of 1.924. The overall effect estimate of insoles
on pain was a SMD of 0.992. The overall effect of bracing showed
a significant reduction in pain of 1.34. Overall, all four non-operative modalities of treatment were
found to have a significant effect on the reduction of pain in OA
of the knee. This study shows that non-operative physical modalities of treatment
are of benefit when treating OA of the knee. However, much of the
literature reviewed evaluates studies with follow-up of less than
six months: future work should aim to evaluate patients with longer
follow-up. Cite this article:
The purpose of this study was to compare clinical
outcomes of total knee arthroplasty (TKA) after manipulation under
anaesthesia (MUA) for post-operative stiffness with a matched cohort
of TKA patients who did not requre MUA. In total 72 patients (mean age 59.8 years, 42 to 83) who underwent
MUA following TKA were identified from our prospective database
and compared with a matched cohort of patients who had undergone
TKA without subsequent MUA. Patients were evaluated for range of
movement (ROM) and clinical outcome scores (Western Ontario and
McMaster Universities Arthritis Index, Short-Form Health Survey,
and Knee Society Clinical Rating System) at a mean follow-up of
36.4 months (12 to 120). MUA took place at a mean of nine weeks
(5 to 18) after TKA. In patients who required MUA, mean flexion
deformity improved from 10° (0° to 25°) to 4.4° (0° to 15°) (p <
0.001),
and mean range of flexion improved from 79.8° (65° to 95°) to 116°
(80° to 130°) (p <
0.001). There were no statistically significant
differences in ROM or functional outcome scores at three months,
one year, or two years between those who required MUA and those
who did not. There were no complications associated with manipulation At most recent follow-up, patients requiring MUA achieved equivalent
ROM and clinical outcome scores when compared with a matched control
group. While other studies have focused on ROM after manipulation,
the current study adds to current literature by supplementing this
with functional outcome scores. Cite this article:
We have reviewed the literature to establish the role of lateral retinacular release in the management of disorders of the extensor apparatus of the knee. The scientific evidence for intervention is explored and reports on outcome are discussed.
Total knee arthroplasty (TKA) is a major orthopaedic
intervention. The length of a patient's stay has been progressively
reduced with the introduction of enhanced recovery protocols: day-case
surgery has become the ultimate challenge. This narrative review shows the potential limitations of day-case
TKA. These constraints may be social, linked to patient’s comorbidities,
or due to surgery-related adverse events (e.g. pain, post-operative
nausea and vomiting, etc.). Using patient stratification, tailored surgical techniques and
multimodal opioid-sparing analgesia, day-case TKA might be achievable
in a limited group of patients. The younger, male patient without
comorbidities and with an excellent social network around him might
be a candidate. Demographic changes, effective recovery programmes and less invasive
surgical techniques such as unicondylar knee arthroplasty, may increase
the size of the group of potential day-case patients. The cost reduction achieved by day-case TKA needs to be balanced
against any increase in morbidity and mortality and the cost of
advanced follow-up at a distance with new technology. These factors
need to be evaluated before adopting this ultimate ‘fast-track’
approach. Cite this article:
The August 2015 Research Roundup360 looks at: Lightbulbs, bleeding and procedure durations; Infection and rheumatoid agents; Infection rates and ‘bundles of care’ revisited; ACI: new application for a proven technology?; Hydrogel coating given the thumbs up; Hydroxyapatite as a smart coating?
The August 2015 Oncology Roundup360 looks at: Glasgow prognostic score in soft-tissue sarcoma; Denosumab in giant cell tumour; Timing, complications and radiotherapy; Pigmented villonodular synovitis and arthroscopy; PATHFx: estimating survival in pathological cancer; Prosthetic lengthening of short stumps; Chondrosarcoma and pathological fracture
A series of 100 consecutive osteoarthritic patients was randomised to undergo total knee replacement using a Miller-Galante II prosthesis, with or without a cemented polyethylene patellar component. Knee function was evaluated using the American Knee Society score, Western Ontario and McMaster University Osteoarthritis index, specific patellofemoral-related questions and radiographic evaluation until the fourth post-operative year, then via questionnaire until ten years post-operatively. A ten-point difference in the American Knee Society score between the two groups was considered a significant change in knee performance, with α and β levels of 0.05. The mean age of the patients in the resurfaced group was 71 years (53 to 88) and in the non-resurfaced group was 73 years (54 to 86). After ten years 22 patients had died, seven were suffering from dementia, three declined further participation and ten were lost to follow-up. Two patients in the non-resurfaced group subsequently had their patellae resurfaced. In the resurfaced group one patient had an arthroscopic lateral release. There was no significant difference between the two treatment groups: both had a similar deterioration of scores with time, and no further patellofemoral complications were observed in either group. We are unable to recommend routine patellar resurfacing in osteoarthritic patients undergoing total knee replacement on the basis of our findings.
A patient-centred approach, usually achieved through shared decision
making, has the potential to help improve decision making around
knee arthroplasty surgery. However, such an approach requires an
understanding of the factors involved in patient decision making.
This review’s objective is to systematically examine the qualitative literature
surrounding patients’ decision making in knee arthroplasty. A systematic literature review using Medline and Embase was conducted
to identify qualitative studies that examined patients’ decision
making around knee arthroplasty. An aggregated account of what is
known about patients’ decision making in knee arthroplasties is
provided.Objectives
Methods
Partial knee arthroplasty (PKA), either medial
or lateral unicompartmental knee artroplasty (UKA) or patellofemoral arthroplasty
(PFA) are a good option in suitable patients and have the advantages
of reduced operative trauma, preservation of both cruciate ligaments
and bone stock, and restoration of normal kinematics within the
knee joint. However, questions remain concerning long-term survival.
The goal of this review article was to present the long-term results
of medial and lateral UKA, PFA and combined compartmental arthroplasty
for multicompartmental disease. Medium- and long-term studies suggest
reasonable outcomes at ten years with survival greater than 95% in
UKA performed for medial osteoarthritis or osteonecrosis, and similarly
for lateral Cite this article:
Many radiographic techniques have been described for measuring patellar height. They can be divided into two groups: those that relate the position of the patella to the femur (direct) and those that relate it to the tibia (indirect). This article looks at the methods that have been described, the logic behind their conception and the critical analyses that have been performed to test them.
Our study aimed to examine if a mobile-bearing total knee replacement
(TKR) offered an advantage over fixed-bearing designs with respect
to rates of secondary resurfacing of the patella in knees in which
it was initially left unresurfaced. We examined the 11-year report of the New Zealand Joint Registry
and identified all primary TKR designs that had been implanted in
>
500 knees without primary resurfacing of the patella. We examined
how many of these were mobile-bearing, fixed-bearing cruciate-retaining
and fixed-bearing posterior-stabilised designs. We assessed the rates
of secondary resurfacing of the patella for each group and constructed
Kaplan-Meier survival curves.Objectives
Methods
One of the most controversial issues in total knee replacement is whether or not to resurface the patella. In order to determine the effects of different designs of femoral component on the conformity of the patellofemoral joint, five different knee prostheses were investigated. These were Low Contact Stress, the Miller-Galante II, the NexGen, the Porous-Coated Anatomic, and the Total Condylar prostheses. Three-dimensional models of the prostheses and a native patella were developed and assessed by computer. The conformity of the curvature of the five different prosthetic femoral components to their corresponding patellar implants and to the native patella at different angles of flexion was assessed by measuring the angles of intersection of tangential lines. The Total Condylar prosthesis had the lowest conformity with the native patella (mean 8.58°; 0.14° to 29.9°) and with its own patellar component (mean 11.36°; 0.55° to 39.19°). In the other four prostheses, the conformity was better (mean 2.25°; 0.02° to 10.52°) when articulated with the corresponding patellar component. The Porous-Coated Anatomic femoral component showed better conformity (mean 6.51°; 0.07° to 9.89°) than the Miller-Galante II prosthesis (mean 11.20°; 5.80° to 16.72°) when tested with the native patella. Although the Nexgen prosthesis had less conformity with the native patella at a low angle of flexion, this improved at mid (mean 3.57°; 1.40° to 4.56°) or high angles of flexion (mean 4.54°; 0.91° to 9.39°), respectively. The Low Contact Stress femoral component had the best conformity with the native patella (mean 2.39°; 0.04° to 4.56°). There was no significant difference (p >
0.208) between the conformity when tested with the native patella or its own patellar component at any angle of flexion. The geometry of the anterior flange of a femoral component affects the conformity of the patellofemoral joint when articulating with the native patella. A more anatomical design of femoral component is preferable if the surgeon decides not to resurface the patella at the time of operation.
Worldwide rates of primary and revision total
knee arthroplasty (TKA) are rising due to increased longevity of
the population and the burden of osteoarthritis. Revision TKA is a technically demanding procedure generating
outcomes which are reported to be inferior to those of primary knee
arthroplasty, and with a higher risk of complication. Overall, the
rate of revision after primary arthroplasty is low, but the number
of patients currently living with a TKA suggests a large potential
revision healthcare burden. Many patients are now outliving their prosthesis, and consideration
must be given to how we are to provide the necessary capacity to
meet the rising demand for revision surgery and how to maximise
patient outcomes. The purpose of this review was to examine the epidemiology of,
and risk factors for, revision knee arthroplasty, and to discuss
factors that may enhance patient outcomes. Cite this article:
We suggest that different mechanisms underlie joint pain at rest and on movement in osteoarthritis and that separate assessment of these two features with a visual analogue scale (VAS) offers better information about the likely effect of a total knee replacement (TKR) on pain. The risk of persistent pain after TKR may relate to the degree of central sensitisation before surgery, which might be assessed by determining the pain threshold to an electrical stimulus created by a special tool, the Pain Matcher. Assessments were performed in 69 patients scheduled for TKR. At 18 months after operation, separate assessment of pain at rest and with movement was again carried out using a VAS in order to enable comparison of pre- and post-operative measurements. A less favourable outcome in terms of pain relief was observed for patients with a high pre-operative VAS score for pain at rest and a low pain threshold, both features which may reflect a central sensitisation mechanism.
Although it has been suggested that the outcome
after revision of a unicondylar knee replacement (UKR) to total knee
replacement (TKR) is better when the mechanism of failure is understood,
a comparative study on this subject has not been undertaken. A total of 30 patients (30 knees) who underwent revision of their
unsatisfactory UKR to TKR were included in the study: 15 patients
with unexplained pain comprised group A and 15 patients with a defined
cause for pain formed group B. The Oxford knee score (OKS), visual
analogue scale for pain (VAS) and patient satisfaction were assessed before
revision and at one year after revision, and compared between the
groups. The mean OKS improved from 19 (10 to 30) to 25 (11 to 41) in
group A and from 23 (11 to 45) to 38 (20 to 48) in group B. The
mean VAS improved from 7.7 (5 to 10) to 5.4 (1 to 8) in group A
and from 7.4 (2 to 9) to 1.7 (0 to 8) in group B. There was a statistically
significant difference between the mean improvements in each group
for both OKS (p = 0.022) and VAS (p = 0.002). Subgroup analysis
in group A, performed in order to define a patient factor that predicts
outcome of revision surgery in patients with unexplained pain, showed
no pre-operative differences between both subgroups. These results may be used to inform patients about what to expect
from revision surgery, highlighting that revision of UKR to TKR
for unexplained pain generally results in a less favourable outcome
than revision for a known cause of pain. Cite this article:
The February 2015 Trauma Roundup360 looks at: Evaluating the syndesmosis in ankle fractures; Calcaneal fracture management an ongoing problem; Angular stable locking in low tibial fractures did not improve results; Open fractures: do the seconds really count?; Long-term outcomes of tibial fractures; Targeted performance improvements in pelvic fractures