Aims. Tibial tubercle osteotomy (TTO) facilitates surgical exposure and protects the extensor mechanism during revision total knee arthroplasty (rTKA). The purpose of this study was to determine the rates of bony union, complications, and reoperations following TTO during rTKA, to assess the functional outcomes of rTKA with TTO at two years’ minimum follow-up, and to identify the risk factors of failure. Methods. Between January 2010 and September 2020, 695 rTKAs were performed and data were entered into a prospective database. Inclusion criteria were rTKAs with concomitant TTO, without extensor mechanism allograft, and a minimum of two years’ follow-up. A total of 135 rTKAs were included, with a mean age of 65 years (SD 9.0) and a mean BMI of 29.8 kg/m. 2. (SD 5.7). The most frequent indications for revision were infection (50%; 68/135), aseptic loosening (25%; 34/135), and stiffness (13%; 18/135). Patients had standardized follow-up at six weeks, three months, six months, and annually thereafter. Complications and revisions were evaluated at the last follow-up. Functional outcomes were assessed using the Knee Society Score (KSS) and range of motion. Results. The mean follow-up was 51 months (SD 26; 24 to 121). Bony union was confirmed in 95% of patients (128/135) at a mean of 3.4 months (SD 2.7). The complication rate was 15% (20/135), consisting of nine tibial tubercle fracture displacements (6.7%), seven nonunions (5%), two delayed unions, one tibial fracture, and one wound dehiscence. Seven patients (5%) required eight revision procedures (6%): three bone grafts, three osteosyntheses, one extensor mechanism allograft, and one wound revision. The functional scores and flexion were significantly improved after surgery: mean KSS knee, 48.8 (SD 17) vs 79.6 (SD 20; p < 0.001); mean KSS function, 37.6 (SD 21) vs 70.2 (SD 30; p < 0.001); mean flexion, 81.5° (SD 33°) vs 93° (SD 29°; p = 0.004). Overall, 98% of patients (n = 132) had no extension deficit. The use of hinge implants was a significant risk factor for tibial tubercle fracture (p = 0.011). Conclusion. TTO during rTKA was an efficient procedure to improve knee exposure with a high union rate, but had significant specific complications. Functional outcomes were improved at mid term. Cite this article: Bone Joint J 2023;105-B(10):1078–1085

We have made a retrospective comparison between the results of 49 high tibial osteotomies and 42 unicompartmental replacement arthroplasties performed for the treatment of osteoarthritis of the knee, assessed 5 to 10 years after operation. The type of operation depended on the policy of the consultant responsible for treatment but analysis of the pre-operative findings showed that the two groups were sufficiently similar for direct comparison between them. In the replacement group, 32 (76%) were good, 4 were fair, 3 were poor and 3 had been revised. In the osteotomy group 21 (43%) were good, 11 were fair, 7 were poor and 10 had been revised. It was concluded that, in this series, the results of unicompartmental replacement were significantly better and that this group had shown no sign of late deterioration

We report the outcome of 32 patients (37 knees) who underwent hemicallostasis with a dynamic external fixator for osteoarthritis of the medial compartment of the knee. There were 16 men (19 knees) and 16 women (18 knees) with a mean age at operation of 54.6 years (27 to 72). The aim was to achieve a valgus overcorrection of 2° to 8° or mechanical axis at 62.5% (± 12.5%). At a mean follow-up of 62.8 months (51 to 81) there was no change in the mean range of movement, and no statistically significant difference in the Insall-Salvati index or tibial slope (p = 0.11 and p = 0.15, respectively). The mean hip-knee-ankle angle changed from 190.6 (183° to 197°) to 176.0° (171° to 181°), with a mean final position of the mechanical axis of 58.5% (35.1% to 71.2%).

The desired alignment was attained in 31 of 37 (84%) knees. There were 21 excellent, 13 good, two fair and one poor result according to the Oxford knee score with no correlation between age and final score. This score was at its best at one year with a statistically significant deterioration at two years (p = 0.001) followed by a small but not statistically significant deterioration until the final follow-up (p = 0.17). All the knees with Ahlback grade 1 osteoarthritis had excellent or good results. Complications included pin tract infections involving 16.4% of all pins used, delayed union in two, knee stiffness in four, fracture of the lateral cortex in one and ring sequestrum in one.

In conclusion, hemicallostasis provides precision in attaining the desired alignment without interfering with tibial slope or patellar height, and is relatively free of serious complications.

We report the long-term outcome of 33 patients (37 knees) who underwent proximal tibial open-wedge osteotomy with hemicallotasis (HCO) for medial osteoarthritis of the knee between 1995 and 2000. Among these, 29 patients with unilateral HCO were enrolled and 19 were available for review at a mean of 14.2 years (10 to 15.7) post-operatively. For these 19 patients, the mean Hospital for Special Surgery knee score was 60 (57 to 62) pre-operatively and 85 (82 to 87) at final follow-up (p < 0.001; paired t-test). The femorotibial angle and tibial inclination angle (IA) were measured at short-term follow-up, one to four years post-operatively, and showed no significant subsequent changes. The clinical scores and radiological measurements showed little change over time. One patient required conversion to total knee replacement during this time. These results suggest that the coronal angle achieved at operation is maintained at long-term follow up after HCO without alteration of the IA, providing a good long-term clinical outcome. Cite this article: Bone Joint J 2014;96-B:467–72

We report the results of supramalleolar varus osteotomy on seven ankles (in six patients) for haemophilic arthropathy and secondary valgus deformity. The operation reduced pain and the frequency of intra-articular bleeding while preserving joint function for a mean of nine years. The procedure is an attractive alternative to the more commonly used surgical option of arthrodesis.

1. High tibial osteotomy-above the tibial tubercle-gives good results in elderly patients disabled by arthritis of the knee.

2. A technique of operation is described in which fixation is secured by four pins gripped in compression clamps.

3. No other fixation is needed, and knee movements and walking are encouraged within a few days of operation.

4. The early results warrant further trial of the method.

An abnormal lateral position of the tibial tuberosity causes distal malalignment of the extensor mechanism of the knee and can lead to lateral tracking of the patella causing anterior knee pain or objective patellar instability, characterised by recurrent dislocation. Computer tomography is used for a precise pre-operative assessment of the tibial tubercle-trochlear groove distance. A distance of more than 15 mm is considered to be pathological and an indication for surgery in symptomatic patients.

In a prospective study we performed a subtle transfer of the tibial tuberosity according to the information gained from the pre-operative CT scan. This method was applied to two groups of patients, those with painful lateral tracking of the patella, and those with objective patellar instability. We evaluated the clinical results in 30 patients in each group. The outcome was documented at 3, 12 and 24 months using the Lysholm scale, the Kujala score, and a visual analogue pain score.

Post-operatively, all but one patient in the instability group who had a patellar dislocation requiring further surgery reported good improvement with no further subluxation or dislocation. All patients in both groups had a marked improvement in pain and functional score. Two patients sustained a tibial fracture six and seven weeks after surgery. One patient suffered a per-operative fracture of the tibial tubercle which later required further fixation.

If carefully performed, this type of transfer of the tibial tubercle appears to be a satisfactory technique for the treatment of patients with an increased tibial tubercle-trochlear groove distance and who present with symptoms related to lateral maltracking of the patella.

We present the ten- to 15-year follow-up of 31 patients (34 knees), who underwent an Elmslie-Trillat tibial tubercle osteotomy for chronic, severe patellar instability, unresponsive to non-operative treatment. The mean age of the patients at the time of surgery was 31 years (18 to 46) and they were reviewed post-operatively, at four years (2 to 8) and then at 12 years (10 to 15). All patients had pre-operative knee radiographs and Cox and Insall knee scores. Superolateral portal arthroscopy was performed per-operatively to document chondral damage and after the osteotomy to assess the stability of the patellofemoral joint. A total of 28 knees (82%) had a varying degree of damage to the articular surface. At final follow-up 25 patients (28 knees) were available for review and underwent clinical examination, radiographs of the knee, and Cox and Insall scoring. Six patients who had no arthroscopic chondral abnormality showed no or only early signs of osteoarthritis on final radiographs; while 12 patients with lower grade chondral damage (grade 1 to 2) showed early to moderate signs of osteoarthritis and six out of ten knees with higher grade chondral damage (grade 3 to 4) showed marked evidence of osteoarthritis; four of these had undergone a knee replacement. In the 22 patients (24 knees) with complete follow-up, 19 knees (79.2%) were reported to have a good or excellent outcome at four years, while 15 knees (62.5%) were reported to have the same at long-term follow-up. The functional and radiological results show that the extent of pre-operatively sustained chondral damage is directly related to the subsequent development of patellofemoral osteoarthritis.

Cite this article: Bone Joint J 2013;95-B:478–85.

The October 2024 Knee Roundup. 360. looks at: Managing the unexpected: treatment of intraoperative medial collateral ligament injuries; Identifying subgroups of patients that may benefit from robotic arm-assisted total knee arthroplasty: secondary analysis of data from a randomized controlled trial; Cost-effectiveness of enoxaparin versus aspirin in the prevention of venous thromboembolism after total hip or knee arthroplasty: an analysis from the CRISTAL cluster-randomized trial; Cartilage regeneration and long-term survival in medial knee osteoarthritis patients treated with high tibial osteotomy and osteochondral autologous transfer system; Treatment of chronic and complex meniscal tears with arthroscopic meniscus repair augmented with collagen matrix wrapping: failure rate and functional outcomes; Long-term outcomes of multiligament knee injuries in American football players

Aims. The aim of this study was to evaluate the association between chondral injury and interval from anterior cruciate ligament (ACL) tear to surgical reconstruction (ACLr). Methods. Between January 2012 and January 2022, 1,840 consecutive ACLrs were performed and included in a single-centre retrospective cohort. Exclusion criteria were partial tears, multiligament knee injuries, prior ipsilateral knee surgery, concomitant unicompartmental knee arthroplasty or high tibial osteotomy, ACL agenesis, and unknown date of tear. A total of 1,317 patients were included in the final analysis, with a median age of 29 years (interquartile range (IQR) 23 to 38). The median preoperative Tegner Activity Score (TAS) was 6 (IQR 6 to 7). Patients were categorized into four groups according to the delay to ACLr: < three months (427; 32%), three to six months (388; 29%), > six to 12 months (248; 19%), and > 12 months (254; 19%). Chondral injury was assessed during arthroscopy using the International Cartilage Regeneration and Joint Preservation Society classification, and its association with delay to ACLr was analyzed using multivariable analysis. Results. In the medial compartment, delaying ACLr for more than 12 months was associated with an increased rate (odds ratio (OR) 1.93 (95% confidence interval (CI) 1.27 to 2.95); p = 0.002) and severity (OR 1.23 (95% CI 1.08 to 1.40); p = 0.002) of chondral injuries, compared with < three months, with no association in patients aged > 50 years old. No association was found for shorter delays, but the overall dose-effect analysis was significant for the rate (p = 0.015) and severity (p = 0.026) of medial chondral injuries. Increased TAS was associated with a significantly reduced rate (OR 0.88 (95% CI 0.78 to 0.99); p = 0.036) and severity (OR 0.96 (95% CI 0.92 to 0.99); p = 0.017) of medial chondral injuries. In the lateral compartment, no association was found between delay and chondral injuries. Conclusion. Delay was associated with an increased rate and severity of medial chondral injuries in a dose-effect fashion, in particular for delays > 12 months. Younger patients seem to be at higher risk of chondral injury when delaying surgery. The timing of ACLr should be optimally reduced in this population. Cite this article: Bone Joint J 2023;105-B(9):953–960

Aims. The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process. Methods. This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous. Results. Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus. Conclusion. Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport. Cite this article: Bone Joint J 2023;105-B(12):1265–1270

Aims. Periprosthetic joint infection (PJI) is a challenging complication of any arthroplasty procedure. We reviewed our use of static antibiotic-loaded cement spacers (ABLCSs) for staged management of PJI where segmental bone loss, ligamentous instability, or soft-tissue defects necessitate a static construct. We reviewed factors contributing to their failure and techniques to avoid these complications when using ABLCSs in this context. Methods. A retrospective analysis was conducted of 94 patients undergoing first-stage revision of an infected knee prosthesis between September 2007 and January 2020 at a single institution. Radiographs and clinical records were used to assess and classify the incidence and causes of static spacer failure. Of the 94 cases, there were 19 primary total knee arthroplasties (TKAs), ten revision TKAs (varus-valgus constraint), 20 hinged TKAs, one arthrodesis (nail), one failed spacer (performed elsewhere), 21 distal femoral endoprosthetic arthroplasties, and 22 proximal tibial arthroplasties. Results. A total of 35/94 patients (37.2%) had spacer-related complications, of which 26/35 complications (74.3%) were because of mechanical failure of the spacer construct, while 9/35 (25.7%) were due to recurrence of infection. Risk factors for internal failure were a construct where the total intramedullary spacer length was less than twice the length of the central osseous defect (p = 0.009), where proximal or distal intraosseous spacer contact was < 10%, and after tibial tubercle osteotomy (p = 0.005). The incidence of spacer complications significantly increased the time to second stage: mean 157 days (42 to 458) in those without complications versus 227 days (11 to 528) with complications (p = 0.014). Conclusion. The failure rate of static antibiotic-loaded cement spacers is much higher than anticipated. Complications of the spacer significantly increased the time to second-stage revision. The risk of mechanical failure is significantly increased if the spacer is less than double the size of the segmental defect, or if inadequate reinforcement is inserted into the residual bone. These findings serve as a guide for surgeons to avoid mechanical complications with static spacers. Cite this article: Bone Joint J 2024;106-B(10):1067–1073

Aims. A number of anti-retroviral therapies (ART) have been implicated in potentially contributing to HIV-associated bone disease. The aim of this study was to evaluate the effect of combination ART on the fracture healing process. Methods. A total of 16 adult male Wistar rats were randomly divided into two groups (n = eight each): Group 1 was given a combination of Tenfovir 30 mg, Lamivudine 30 mg, and Efavirenz 60 mg per day orally, whereas Group 2 was used as a control. After one week of medication preload, all rats underwent a standardized surgical procedure of mid-shaft tibial osteotomy fixed by intramedullary nail with no gap at the fracture site. Progress in fracture healing was monitored regularly for eight weeks. Further evaluations were carried out after euthanasia by micro-CT, mechanically and histologically. Two blinded orthopaedic surgeons used the Radiological Union Scoring system for the Tibia (RUST) to determine fracture healing. Results. The fracture healing process was different between the two groups at week 4 after surgery; only two out of eight rats showed full healing in Group 1 (ART-treated), while seven out of eight rats had bone union in Group 2 (control) (p = 0.040). However, at week eight postoperatively, there was no statistical difference in bone healing; seven out of eight progressed to full union in both groups. Conclusion. This study demonstrated that combination ART resulted in delayed fracture healing at week 4 after surgery in rats, but did not result in the development of nonunion. Cite this article: Bone Joint Res 2022;11(8):585–593

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

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: Bone Jt Open 2022;3(3):268–274

We performed a CT-based computer simulation study to determine how the relationship between any inbuilt posterior slope in the proximal tibial osteotomy and cutting jig rotational orientation errors affect tibial component alignment in total knee replacement. Four different posterior slopes (3°, 5°, 7° and 10°), each with a rotational error of 5°, 10°, 15°, 20°, 25° or 30°, were simulated. Tibial cutting block malalignment of 20° of external rotation can produce varus malalignment of 2.4° and 3.5° with a 7° and a 10° sloped cutting jig, respectively. Care must be taken in orientating the cutting jig in the sagittal plane when making a posterior sloped proximal tibial osteotomy in total knee replacement. Cite this article: Bone Joint J 2013;95-B:1201–3

The lateral subvastus approach combined with an osteotomy of the tibial tubercle is a recognised, but rarely used approach for total knee replacement (TKR). A total of 32 patients undergoing primary TKR was randomised into two groups, in one of which the lateral subvastus approach combined with a tibial tubercle osteotomy and in the other the medial parapatellar approach were used. The patients were assessed radiologically and clinically using measurement of the range of movement, a visual analogue patient satisfaction score, the Western Ontario McMasters University Osteoarthritis Index and the American Knee Society score. Four patients were lost to the complete follow-up at two years. At two years there were no significant differences between the groups in any of the parameters for clinical outcome. In the lateral approach group there was one complication due to displacement of the tibial tubercle osteotomy and two osteotomies took more than six months to unite. In the medial approach group, one patient had a partial tear of the quadriceps. There was a significantly greater incidence of lateral patellar subluxation in the medial approach group (3 of 12) compared with the lateral approach group (0 of 16) (p = 0.034), but without any apparent clinical detriment. We conclude that the lateral approach with tibial tubercle osteotomy is a safe technique with an outcome comparable with that of the medial parapatellar approach for TKR, but the increased surgical time and its specific complications do not support its routine use. It would seem to be more appropriate to reserve this technique for patients in whom problems with patellar tracking are anticipated

Aims. The role of high tibial osteotomy (HTO) is being questioned by the use of unicompartmental knee arthroplasty (UKA) in the treatment of medial compartment femorotibial osteoarthritis. Our aim was to compare the outcomes of revision HTO or UKA to a total knee arthroplasty (TKA) using computer-assisted surgery in matched groups of patients. Patients and Methods. We conducted a retrospective study to compare the clinical and radiological outcome of patients who underwent revision of a HTO to a TKA (group 1) with those who underwent revision of a medial UKA to a TKA (group 2). All revision procedures were performed using computer-assisted surgery. We extracted these groups of patients from our database. They were matched by age, gender, body mass index, follow-up and pre-operative functional score. The outcomes included the Knee Society Scores (KSS), radiological outcomes and the rate of further revision. Results. There were 20 knees in 20 patients in each group. The mean follow-up was 4.1 years (2 to 18.7). The mean total KSS at last follow-up was 185.7 (standard deviation (. sd. ) 5) in group 1 compared with 176.5 (. sd. 11) for group 2 (p = 0.003). The mean hip-knee-ankle angle was 180.2° (. sd. 3.2°) in group 1 and 179.0° (. sd. 2.2°) in group 2. No revision was required. Conclusion. We found that good functional and radiological outcomes followed revision of both HTO and UKA to TKA. Revision of HTO showed significantly better functional outcomes. These results need to be further investigated by a prospective randomised controlled trial involving a larger group of patients. Cite this article: Bone Joint J 2016;98-B:1620–4

The development of lateral tibial torsion in the paralysed lower limb is well documented, but its pathogenesis is poorly understood. This paper attempts to provide an explanation for its development when it is associated with a varus or equinovarus deformity of the hindfoot. Correction of the lateral tibial torsion by supramalleolar derotation tibial osteotomy and reorientation of the ankle mortise appear to unlock the talus from the laterally rotated position, correcting a mobile hindfoot varus deformity and altering soft-tissue tensions about the ankle so that the correction achieved is maintained. In the presence of a fixed hindfoot deformity, supramalleolar derotation tibial osteotomy is useful as a first-stage procedure before corrective osteotomies of the foot. The operation described is technically simple and carries a low morbidity. Twenty supramalleolar derotation tibial osteotomies in 18 patients have been performed with satisfactory results and few complications