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 describe the application of a non-invasive extendible endoprosthetic replacement in skeletally-mature patients undergoing revision for failed joint replacement with resultant limb-length inequality after malignant or non-malignant disease. This prosthesis was developed for tumour surgery in skeletally-immature patients but has now been adapted for use in revision procedures to reconstruct the joint or facilitate an arthrodesis, replace bony defects and allow limb length to be restored gradually in the post-operative period.

We record the short-term results in nine patients who have had this procedure after multiple previous reconstructive operations. In six, the initial reconstruction had been performed with either allograft or endoprosthetic replacement for neoplastic disease and in three for non-neoplastic disease. The essential components of the prosthesis are a magnetic disc, a gearbox and a drive screw which allows painless lengthening of the prosthesis using the principle of electromagnetic induction. The mean age of the patients was 37 years (18 to 68) with a mean follow-up of 34 months (12 to 62). They had previously undergone a mean of six (2 to 14) open procedures on the affected limb before revision with the non-invasive extendible endoprosthesis.

The mean length gained was 56 mm (19 to 107) requiring a mean of nine (3 to 20) lengthening episodes performed in the outpatient department. There was one case of recurrent infection after revision of a previously infected implant and one fracture of the prosthesis after a fall. No amputations were performed. Planned exchange of the prosthesis was required in three patients after attainment of the maximum lengthening capacity of the implant. There was no failure of the lengthening mechanism. The Mean Musculoskeletal Tumour Society rating score was 22 of 30 available points (18 to 28).

The use of a non-invasive extendible endoprosthesis in this manner provided patients with good functional results and restoration of leg-length equality, without the need for multiple open lengthening procedures.

Incomplete avulsion of the proximal hamstrings can be a severely debilitating injury that causes weakness, pain while sitting and inability to run. The results of the surgical treatment of 23 consecutive patients with such injuries at least two years after surgery are described. The surgery consisted of the repair of the hamstrings directly onto the ischial tuberosity. At review, using a visual analogue scale (VAS, 0 to 100), pain while sitting improved from a mean of 40 (0 to 100) to 64 (0 to 100) (p = 0.024), weakness from a mean of 39 (0 to 90) to 76 (7 to 100) (p = 0.0001) and the ability to run from a mean of 24 (0 to 88) to 64 (0 to 95) (p = 0.0001). According to a VAS, satisfaction was rated at a mean of 81 (0 to 100) and 20 patients (87%) would have the same procedure again. Hamstring strength measured pre- and post-operatively had improved significantly from a mean of 64% (0% to 95%) to 88% (50% to 114%) compared with the normal side.

Most of these patients with symptomatic incomplete hamstring avulsions unresponsive to conservative treatment had an improved outcome after surgical repair.

We investigated fixed flexion deformity (FFD) after total knee replacement (TKR). Data relating to 369 cruciate-retaining unilateral TKRs performed at a single institution were collected prospectively. Fixed flexion was measured pre-operatively and at one week, six months, 18 months, three years and five years after surgery.

Using binary logistic regression, pre-operative FFD was a predictor of post-operative FFD > 10° at one week (p = 0.006) and six months (p = 0.003) following surgery. Gender was a predictor at one week (p = 0.0073) with 24% of women showing a FFD > 10° compared with 37% of men.

We have shown that a gradual improvement in knee extension can be expected up to three years after surgery in knees with FFD. By this time residual FFD is mild or absent in the majority of patients, including those who had a severe pre-operative FFD.

Deformity after slipped upper femoral epiphysis (SUFE) can cause cam-type femoroacetabular impingement (FAI) and subsequent osteoarthritis (OA). However, there is little information regarding the radiological assessment and clinical consequences at long-term follow-up. We reviewed 36 patients (43 hips) previously treated by in situ fixation for SUFE with a mean follow-up of 37 years (21 to 50). Three observers measured the femoral head ratio (FHR), lateral femoral head ratio (LFHR), α-angle on anteroposterior (AP) and frog-leg lateral views, and anterior femoral head–neck offset ratio (OSR). A Harris hip score < 85 and/or radiologically diagnosed osteoarthritis (OA) was classified as a poor outcome. Patients with SUFE had significantly higher FHR, LFHR and α-angles and lower OSR than a control group of 22 subjects (35 hips) with radiologically normal hips. The interobserver agreement was less, with wider limits of agreement (LOA), in hips with previous SUFE than the control group. At long-term follow-up abnormal α-angles correlated with poor outcome, whereas FHR, LFHR and OSR did not.

We conclude that persistent deformity with radiological cam FAI after SUFE is associated with poorer clinical and radiological long-term outcome. Although the radiological measurements had quite wide limits of agreement, they are useful for the diagnosis of post-slip deformities in clinical practice.

Stems improve the mechanical stability of tibial components in total knee replacement (TKR), but come at a cost of stress shielding along their length. Their advantages include resistance to shear, reduced tibial lift-off and increased stability by reducing micromotion. Longer stems may have disadvantages including stress shielding along the length of the stem with associated reduction in bone density and a theoretical risk of subsidence and loosening, peri-prosthetic fracture and end-of-stem pain. These features make long stems unattractive in the primary TKR setting, but often desirable in revision surgery with bone loss and instability. In the revision scenario, stems are beneficial in order to convey structural stability to the construct and protect the reconstruction of bony defects. Cemented and uncemented long stemmed implants have different roles depending on the nature of the bone loss involved.

This review discusses the biomechanics of the design of tibial components and stems to inform the selection of the component and the technique of implantation.

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.

In this cross-over study, we evaluated two types of knee brace commonly used in the conservative treatment of osteoarthritis of the medial compartment. Twelve patients confirmed radiologically as having unilateral osteoarthritis of the medial compartment (Larsen grade 2 to grade 4) were studied. Treatment with a simple hinged brace was compared with that using a valgus corrective brace. Knee kinematics, ground reaction forces, pain and function were assessed during walking and the Hospital for Special Surgery scores were also determined.

Significant improvements in pain, function, and loading and propulsive forces were seen with the valgus brace. Treatment with a simple brace showed only significant improvements in loading forces. Our findings suggest that although both braces improved confidence and function during gait, the valgus brace showed greater benefit.

A total of 218 patients with unilateral anterior cruciate ligament deficiency were randomly assigned to one of four groups. In group A an anatomical double bundle anterior cruciate ligament reconstruction was performed; group B were treated by a single bundle using an Endobutton for femoral fixation; in group C by a single bundle using RigidFix cross pins for femoral fixation; and in group D by a single bundle using a bioabsorbable TransFix II screw for femoral fixation. For tibial fixation a bioabsorbable Intrafix interference screw was used for all the groups and the graft was fashioned from the semitendinosus and gracilis tendons in all patients. In all, 18 patients were lost to follow-up. The remaining 200 were subjected to a clinical evaluation, with assessment of the anterior drawer, Lachman’s and the pivot-shift tests, and KT-1000 arthrometer measurement. They also completed the International Knee Documentation Committee, Lysholm knee and Tegner activity scores.

At a mean of 29 months (25 to 38) follow-up there were no significant differences concerning time between injury and range of movement and Lysholm knee scores among the four groups. However, the double bundle method showed significantly better results for the pivot-shift test (p = 0.002). The KT 1000 measurements showed a mean difference between the reconstructed knee and the patients’ normal knee of 1.4 mm in the double bundle group and 2.4 mm in the single bundle group; which was statistically significant. The Lachman and anterior drawer tests also showed superior results for the double bundle method. The International Knee Documentation Committee scale showed no significant difference among the groups (p < 0.001).

On clinical evaluation the double bundle group showed less laxity than the single bundle groups. However, regardless of the technique, all knees were improved by anterior cruciate ligament reconstruction compared with their pre-operative status.

The June 2012 Trauma Roundup³⁶⁰ looks at: nerve injuries of warfare; the medical complications of earthquakes; the measuring of tissue pressures in compartment syndrome; the risk of plunging through the bone when drilling; bony nonunion and negative pressure therapy; surgery for the posteriorly dislocated hip; whether to use the sliding screw or intramedullary nail for the trochanteric fracture; antegrade interlocking nailing for the distal femoral fracture; and gunshot wounds to the pancreas.

We tested four types of surgical repair for load to failure and distraction in a bovine model of Achilles tendon repair. A total of 20 fresh bovine Achilles tendons were divided transversely 4 cm proximal to the calcaneal insertion and randomly repaired using the Dresden technique, a Krackow suture, a triple-strand Dresden technique or a modified oblique Dresden technique, all using a Fiberwire suture. Each tendon was loaded to failure. The force applied when a 5 mm gap was formed, peak load to failure, and mechanism of failure were recorded. The resistance to distraction was significantly greater for the triple technique (mean 246.1 N (205 to 309) to initial gapping) than for the Dresden (mean 180 N (152 to 208); p = 0.012) and the Krackow repairs (mean 101 N (78 to 112; p < 0.001). Peak load to failure was significantly greater for the triple-strand repair (mean 675 N (453 to 749)) than for the Dresden (mean 327.8 N (238 to 406); p < 0.001), Krackow (mean 223.6 N (210 to 252); p <  0.001) and oblique repairs (mean 437.2 N (372 to 526); p < 0.001). Failure of the tendon was the mechanism of failure for all specimens except for the tendons sutured using the Krackow technique, where the failure occurred at the knot.

The triple-strand technique significantly increased the tensile strength (p = 0.0001) and gap resistance (p = 0.01) of bovine tendon repairs, and might have advantages in human application for accelerated post-operative rehabilitation.

The patellar clunk syndrome describes painful catching, grinding or jumping of the patella when the knee moves from a flexed to an extended position after total knee replacement (TKR). The posterior stabilised TKR had been noted to have a higher incidence of this problem. Mobile-bearing posteriorly stabilised TKRs have been introduced to improve patellar tracking and related problems by a mechanism of self-alignment. We evaluated the patellar clunk syndrome in 113 knees in 93 patients with such a TKR at a mean follow-up of 2.3 years (2.0 to 3.2). The syndrome was identified in 15 knees (13.3%).

Logistic regression analysis showed that the absolute value of the post-operative angle of patellar tilt was significantly associated with the occurrence of patellar clunk (p = 0.025). Patellar tracking should be carefully checked during surgery.

Objectives

The goal of this study was to determine whether intra-articular administration of the potentially anti-fibrotic agent decorin influences the expression of genes involved in the fibrotic cascade, and ultimately leads to less contracture, in an animal model.

We present a retrospective review of a single-surgeon series of 30 consecutive lengthenings in 27 patients with congenital short femur using the Ilizarov technique performed between 1994 and 2005.

The mean increase in length was 5.8 cm/18.65% (3.3 to 10.4, 9.7% to 48.8%), with a mean time in the frame of 223 days (75 to 363). By changing from a distal to a proximal osteotomy for lengthening, the mean range of knee movement was significantly increased from 98.1° to 124.2° (p = 0.041) and there was a trend towards a reduced requirement for quadricepsplasty, although this was not statistically significant (p = 0.07). The overall incidence of regenerate deformation or fracture requiring open reduction and internal fixation was similar in the distal and proximal osteotomy groups (56.7% and 53.8%, respectively). However, in the proximal osteotomy group, pre-placement of a Rush nail reduced this rate from 100% without a nail to 0% with a nail (p < 0.001). When comparing a distal osteotomy with a proximal one over a Rush nail for lengthening, there was a significant decrease in fracture rate from 58.8% to 0% (p = 0.043).

We recommend that in this group of patients lengthening of the femur with an Ilizarov construct be carried out through a proximal osteotomy over a Rush nail. Lengthening should also be limited to a maximum of 6 cm during one treatment, or 20% of the original length of the femur, in order to reduce the risk of complications.

We retrospectively reviewed the operative treatment carried out between 1988 and 1994 of eight patients with habitual patellar dislocation. In four the condition was bilateral. All patients had recurrent dislocation with severe functional disability. The surgical technique involved distal advancement of the patella by complete mobilisation of the patellar tendon, lateral release and advancement of vastus medialis obliquus. The long-term results were assessed radiologically, clinically and functionally using the Lysholm knee score, by an independent observer.

The mean age at operation was 10.3 years (7 to 14) with a mean follow-up of 13.5 years (11 to 16). One patient required revision. At the latest follow-up, all patellae were stable and knees functional with a mean Lysholm knee score of 98 points (95 to 100). In those aged younger than ten years at operation there was a statistically significant improvement in the sulcus angle at the latest follow-up (Student’s t-test, p = 0.001). Two patients developed asymptomatic patella infera as a late complication.

This technique offers a satisfactory treatment for the immature patient presenting with habitual patellar dislocation associated with patella alta. If performed early, we believe that remodelling of the shallow trochlea may occur, adding intrinsic patellofemoral stability.

Most injuries to the medial collateral ligament (MCL) heal well after conservative treatment. We have identified a subgroup of injuries to the deep portion of the MCL which is refractory to conservative treatment and causes persistant symptoms. They usually occur in high-level football players and may require surgical repair.

We describe a consecutive series of 17 men with a mean age of 29 years (18 to 44) who were all engaged in high levels of sport. Following a minor injury to the MCL there was persistent tenderness at the site of the proximal attachment of the deep MCL. It could be precipitated by rapid external rotation at the knee by clinical testing or during sport. The mean time from injury to presentation was 23.6 weeks (10 to 79) and none of the patients had responded to conservative treatment. The surgical finding was a failure of healing of a tear of the deep MCL at its femoral origin which could be repaired. After a period of postoperative protective bracing and subsequent rehabilitation the outcome was good. All the patients returned to their sports and remained asymptomatic at a mean of 48 weeks (28 to 60) post-operatively.

Recognition of this subgroup is important since the clinical features, the course of recovery and surgical requirement differ from those of most injuries to the MCL.

We have managed 21 patients with a fracture of the tibia complicated by bone and soft-tissue loss as a result of an open fracture in 10, or following debridement of an infected nonunion in 11, by resection of all the devitalised tissues, acute limb shortening to close the defect, application of an external fixator and metaphyseal osteotomy for re-lengthening. The mean bone loss was 4.7 cm (3 to 11). The mean age of the patients was 28.8 years (12 to 54) and the mean follow-up was 34.8 months (24 to 75).

All the fractures united with a well-aligned limb. The mean duration of treatment for the ten grade-III A+B open fractures (according to the Gustilo-Anderson classification) was 5.7 months (4.5 to 8) and for the nonunions, 7.6 months (5.5 to 12.5). Complications included one refracture, one transient palsy of the peroneal nerve and one equinus contracture of 10°.

We describe the mid-term results of a prospective study of total knee replacement in severe valgus knees using an osteotomy of the lateral femoral condyle and computer navigation. There were 15 knees with a mean valgus deformity of 21° (17° to 27°) and a mean follow-up of 28 months (24 to 60). A cemented, non-constrained fixed bearing, posterior-cruciate-retaining knee prosthesis of the same design was used in all cases (Columbus-B. Braun; Aesculap, Tuttlingen, Germany).

All the knees were corrected to a mean of 0.5° of valgus (0° to 2°). Flexion of the knee had been limited to a mean of 85° (75° to 110°) pre-operatively and improved to a mean of 105° (90° to 130°) after operation. The mean Knee Society score improved from 37 (30 to 44) to 90 points (86 to 94).

Osteotomy of the lateral femoral condyle combined with computer-assisted surgery gave an excellent mid-term outcome in patients undergoing total knee replacement in the presence of severe valgus deformity.

At least four ways have been described to determine femoral component rotation, and three ways to determine tibial component rotation in total knee replacement (TKR). Each method has its advocates and each has an influence on knee kinematics and the ultimate short and long term success of TKR. Of the four femoral component methods, the author prefers rotating the femoral component in flexion to that amount that establishes a stable symmetrical flexion gap. This judgement is made after the soft tissues of the knee have been balanced in extension.

Of the three tibial component methods, the author prefers rotating the tibial component into congruency with the established femoral component rotation with the knee is in extension. This yields a rotationally congruent articulation during weight-bearing and should minimise the torsional forces being transferred through a conforming tibial insert, which could lead to wear to the underside of the tibial polyethylene. Rotating platform components will compensate for any mal-rotation, but can still lead to pain if excessive tibial insert rotation causes soft-tissue impingement.

Cite this article: Bone Joint J 2013;95-B, Supple A:140–3.