The August 2015 Trauma Roundup³⁶⁰ looks at: Thromboprophylaxis not required in lower limb fractures; Subclinical thyroid dysfunction and fracture risk: moving the boundaries in fracture; Posterior wall fractures refined; Neurological injury and acetabular fracture surgery; Posterior tibial plateau fixation; Tibial plateau fractures in the longer term; Comprehensive orthogeriatric care and hip fracture; Compartment syndrome: in the eye of the beholder?

Aims

Oxidised zirconium was introduced as a material for femoral components in total knee arthroplasty (TKA) as an attempt to reduce polyethylene wear. However, the long-term survival of this component is not known.

This randomised trial evaluated the outcome of a single design of unicompartmental arthroplasty of the knee (UKA) with either a cemented all-polyethylene or a metal-backed modular tibial component. A total of 63 knees in 45 patients (17 male, 28 female) were included, 27 in the all-polyethylene group and 36 in the metal-backed group. The mean age was 57.9 years (39.6 to 76.9). At a mean follow-up of 6.4 years (5 to 9.9), 11 all-polyethylene components (41%) were revised (at a mean of 5.8 years; 1.4 to 8.0) post-operatively and two metal-backed components were revised (at one and five years). One revision in both groups was for unexplained pain, one in the metal-backed group was for progression of osteoarthritis. The others in the all-polyethylene group were for aseptic loosening. The survivorship at seven years calculated by the Kaplan–Meier method for the all-polyethylene group was 56.5% (95% CI 31.9 to 75.2, number at risk 7) and for the metal-backed group was 93.8% (95% CI 77.3 to 98.4, number at risk 16) This difference was statistically significant (p <  0.001). At the most recent follow-up, significantly better mean Western Ontario and McMaster Universities Arthritis Index Scores were found in the all-polyethylene group (13.4 vs 23.0, p = 0.03) but there was no difference in the mean Knee injury and Osteoarthritis Outcome scores (68.8; 41.4 to 99.0 vs 62.6; 24.0 to 100.0), p = 0.36). There were no significant differences for range of movement (p = 0.36) or satisfaction (p = 0.23).

This randomised study demonstrates that all-polyethylene components in this design of fixed bearing UKA had unsatisfactory results with significantly higher rates of failure before ten years compared with the metal-back components.

Cite this article: Bone Joint J 2015;97-B:786–92.

The June 2014 Knee Roundup³⁶⁰ looks at: acute repair preferable in hamstring ruptures; osteoarthritis a given in ACL injury, even with reconstruction?; chicken and egg: patellofemoral dysfunction and hip weakness; meniscal root tears as bad as we thought; outcomes in the meniscus; topical NSAIDs have a measurable effect on synovitis; nailing for tibial peri-prosthetic fracture.

The treatment of osteochondral lesions is of great interest to orthopaedic surgeons because most lesions do not heal spontaneously. We present the short-term clinical outcome and MRI findings of a cell-free scaffold used for the treatment of these lesions in the knee. A total of 38 patients were prospectively evaluated clinically for two years following treatment with an osteochondral nanostructured biomimetic scaffold. There were 23 men and 15 women; the mean age of the patients was 30.5 years (15 to 64). Clinical outcome was assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Tegner activity scale and a Visual Analgue scale for pain. MRI data were analysed based on the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring system at three, 12 and 24 months post-operatively. There was a continuous significant clinical improvement after surgery. In two patients, the scaffold treatment failed (5.3%) There was a statistically significant improvement in the MOCART precentage scores. The repair tissue filled most of the defect sufficiently. We found subchondral laminar changes in all patients. Intralesional osteophytes were found in two patients (5.3%). We conclude that this one-step scaffold-based technique can be used for osteochondral repair. The surgical technique is straightforward, and the clinical results are promising. The MRI aspects of the repair tissue continue to evolve during the first two years after surgery. However, the subchondral laminar and bone changes are a concern.

Cite this article: Bone Joint J 2015; 97-B:318–23.

The December 2014 Knee Roundup³⁶⁰ looks at: national guidance on arthroplasty thromboprophylaxis is effective; unicompartmental knee replacement has the edge in terms of short-term complications; stiff knees, timing and manipulation; neuropathic pain and total knee replacement; synovial fluid α-defensin and CRP: a new gold standard in joint infection diagnosis?; how to assess anterior knee pain?; where is the evidence? Five new implants under the spotlight; and a fresh look at ACL reconstruction

Not all questions can be answered by prospective randomised controlled trials. Registries were introduced as a way of collecting information on joint replacements at a population level. They have helped to identify failing implants and the data have also been used to monitor the performance of individual surgeons. This review aims to look at some of the less well known registries that are currently being used worldwide, including those kept on knee ligaments, ankle arthroplasty, fractures and trauma.

The April 2013 Knee Roundup³⁶⁰ looks at: graft tension and outcome; chondrocytes at the midterm; pre-operative deformity and failure; the designer effect; whether chondroitin sulphate really does work; whether ACL reconstruction is really required; analgesia after TKR; and degenerative meniscus.

The June 2012 Knee Roundup³⁶⁰ looks at: ACI and mosaicplasty; ACI after microfracture; exercise therapy and the degenerate medial meniscal tear; intra-articular bupivacaine or ropivacaine at knee arthroscopy; lateral trochlear inclination and patellofemoral osteoarthritis; bone loss and ACL reconstruction; assessing stability using the contralateral knee; tranexamic acid and a useful review of knee replacement.

The August 2012 Knee Roundup³⁶⁰ looks at: meniscal defects and a polyurethane scaffold; which is best between a single or double bundle; OA of the knee; how to resolve anterior knee pain; whether yoga can be bad for your menisci; metal ions in the serum; whether ACI is any good; the ACL; whether hyaluronic acid delays collagen degradation; and hyaluronan and patellar tendinopathy.

This annotation considers the place of extra-articular reconstruction in the treatment of anterior cruciate ligament (ACL) deficiency. Extra-articular reconstruction has been employed over the last century to address ACL deficiency. However, the technique has not gained favour, primarily due to residual instability and the subsequent development of degenerative changes in the lateral compartment of the knee. Thus intra-articular reconstruction has become the technique of choice. However, intra-articular reconstruction does not restore normal knee kinematics. Some authors have recommended extra-articular reconstruction in conjunction with an intra-articular technique.

The anatomy and biomechanics of the anterolateral structures of the knee remain largely undetermined. Further studies to establish the structure and function of the anterolateral structures may lead to more anatomical extra-articular reconstruction techniques that supplement intra-articular reconstruction. This might reduce residual pivot shift after an intra-articular reconstruction and thus improve the post-operative kinematics of the knee.

We retrospectively evaluated eight patients who underwent arthrodesis of the knee using cannulated screws. There were six women and two men, with a mean age of 53 years. The indications for arthrodesis were failed total knee arthroplasty, septic arthritis, tuberculosis, and recurrent persistent infection. Solid union was achieved in all patients at a mean of 6.1 months. One patient required autogenous bone graft for delayed union. One suffered skin necrosis which was treated with skin grafting. The mean limb-length discrepancy was 3.1 cm. On a visual analogue scale, the mean pain score improved from 7.9 to 3.3. According to the Knee Injury and Osteoarthritis Outcome score quality of life items, the mean score improved from 38.3 pre-operatively to 76.6 at follow-up. Cannulated screws provide a high rate of union in arthrodesis of the knee with minimal complications, patient convenience, and a simple surgical technique.

We compared patient-reported outcomes of the Kinemax fixed- and mobile-bearing total knee replacement in a multi-centre randomised controlled trial. Patients were randomised to the fixed- or the mobile-bearing prosthesis via a sealed envelope method after the bone cuts had been made in the operating theatre. Randomisation was stratified by centre and diagnosis. Patients were assessed pre-operatively and at eight to 12 weeks, one year and two years post-operatively. Validated questionnaires were used which included the Western Ontario MacMasters University, Short-Form 12, Mental Health Index-5, Knee Injury and Osteoarthritis Outcome Score for Knee-Related Quality of Life and Function in Sport and Recreation scales and a validated scale of satisfaction post-operatively. In total, 242 patients (250 knees) with a mean age of 68 years (40 to 80) were recruited from four NHS orthopaedic centres. Of these, 132 patients (54.5%) were women.

No statistically significant differences could be identified in any of the patient-reported outcome scores between patients who received the fixed-bearing or the mobile-bearing knee up to two-years post-operatively.

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.

This study validates the short-form WOMAC function scale for assessment of conservative treatment of osteoarthritis of the knee. Data were collected before treatment and six and nine months later, from 100 patients with osteoarthritis of the knee to determine the validity, internal consistency, test-retest reliability, floor and ceiling effects, and responsiveness of the short-form WOMAC function scale. The scale showed high correlation with the traditional WOMAC and other measures. The internal consistency was good (Cronbach α: 0.88 to 0.95) and an excellent test-retest reliability was found (Lin’s concordance correlation coefficient (ρ_c): 0.85 to 0.94). The responsiveness was adequate and comparable to that of the traditional WOMAC (standardised response mean 0.56 to 0.44 and effect size 0.64 to 0.57) and appeared not to be significantly affected by floor or ceiling effects (0% and 7%, respectively).

The short-form WOMAC function scale is a valid, reliable and responsive alternative to the traditional WOMAC in the evaluation of patients with osteoarthritis of the knee managed conservatively. It is simple to use in daily practice and is therefore less of a burden for patients in clinical trials.