The October 2014 Knee Roundup360 looks at: microfracture equivalent to OATS; examination better than MRI in predicting hamstrings re-injury; a second view on return to play with hamstrings injuries; dislocation risks in the Oxford Unicompartmental Knee; what about the tibia?; getting on top of lateral facet pain post TKR; readmission in TKR; patient-specific instrumentation; treating infrapatellar saphenous neuralgia; and arthroscopy in the middle-aged.
We reviewed 183 patients who had undergone reconstruction of the anterior cruciate ligament. The incidence of meniscal tears and degenerative change was assessed and related to the timing from injury to surgery. Degenerative change was scored using the French Society of Arthroscopy system. The patients were divided into an early (surgery within 12 months of injury) and a late group (surgery more than 12 months from injury). The late group was also subdivided into four groups of 12-month periods ranging from one year to more than four years after injury. There was a significantly higher incidence of meniscal tears in patients undergoing reconstruction after 12 months compared with those in the early group (71.2%
This study evaluated the results of a physeal-sparing technique of intra-articular anterior cruciate ligament (ACL) reconstruction in skeletally immature patients, with particular reference to growth disturbance. Between 1992 and 2007, 57 children with a mean age of 12.2 years (6.8 to 14.5) underwent ACL reconstruction using the same technique. At a mean of 5.5 years (2 to 14) after surgery, 56 patients underwent clinical and radiological evaluation. At that time, 49 patients (87.5%) had reached bony maturity and 53 (95%) achieved A or B according to the IKDC 2000 classification. Four patients had stopped participation in sports because of knee symptoms, and three patients (5.4%) had a subsequent recurrent ACL injury. There was no clinical or radiological evidence of growth disturbance after a mean growth in stature of 20.0 cm (3 to 38). This study demonstrates that ACL reconstruction sparing the physes in children is a safe technique protecting against meniscal tears and giving better results than reconstruction in adults, without causing significant growth disturbance.
We performed A total of 12 cadaveric lower limbs were tested with a commercial
image-free navigation system using trackers secured by bone screws.
We then tested a non-invasive fabric-strap system. The lower limb
was secured at 10° intervals from 0° to 60° of knee flexion and
100 N of force was applied perpendicular to the tibia. Acceptable
coefficient of repeatability (CR) and limits of agreement (LOA)
of 3 mm were set based on diagnostic criteria for anterior cruciate
ligament (ACL) insufficiency.Objectives
Methods
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 June 2013 Knee Roundup360 looks at: knee arthroplasty in diabetic patients; whether TKR is a timebomb; the use of antidepressants for knee OA; trochleoplasty; articulated spacers; mental health and joint replacement; and the use of physiotherapy for meniscal tear.
We report on the long-term results of 163 bicruciate-retaining
Hermes 2C total knee replacements in 130 patients at a mean follow-up
of 22.4 years (20.3 to 23.5). Even when the anterior cruciate ligament
had a partially degenerative appearance it was preserved as long
as the knee had a normal anterior drawer and Lachman’s test pre-operatively. The
description and surgical technique of this minimally constrained
prosthesis were published in 1983 and the ten-year clinical results
in 1999. A total of 12% of the knees (20 of 163) in this study were revised
because of wear of the polyethylene tibial insert. Excellent stability
was achieved and the incidence of aseptic component loosening was
4.3% (seven of 163). The survival rate using revision for any reason
as the endpoint was 82% (95% confidence interval 76.2 to 88.0). Although this series included a relatively small number of replacements,
it demonstrated that the anterior cruciate ligament, even when partially
degenerated at the time of TKR, remained functional and provided
adequate stability at a long-term follow-up. Cite this article:
The use of platelet-rich plasma (PRP) as an adjuvant
to tissue repair is gaining favour in orthopaedic surgery. Tunnel widening
after anterior cruciate ligament (ACL) reconstruction is a recognised
phenomenon that could compromise revision surgery. The purpose of
this study was to determine whether PRP might prevent tunnel widening
in ACL reconstruction. Patients undergoing ACL reconstruction using a hamstring graft
were randomly allocated either to have PRP introduced into the tunnels
peri-operatively or not. CT scanning of the knees was carried out
on the day after surgery and at three months post-operatively and
the width of the tunnels was measured. Patients were also evaluated
clinically at three months, when laxity was also measured. Each group comprised 25 patients, and at three months post-operatively
all were pain-free with stable knees, a negative Lachman test and
a good range of movement. Arthrometric results had improved significantly
in both groups (p <
0.001). Despite slightly less tunnel widening
in the PRP group, there was no significant difference between the
groups at the femoral opening or the mid-tunnel (p = 0.370 and p
= 0.363, respectively) nor at the tibial opening or mid-tunnel (p
= 0.333 and p = 0.177, respectively). We conclude that PRP has no significant effect in preventing
tunnel widening after ACL reconstruction. Cite this article:
The April 2013 Trauma Roundup360 looks at: ankle sprains; paediatric knee haemarthroses; evidence to support a belief; ‘Moonboot’ saves the day; pamphlets and outcomes; poor gait in pilons; lactate and surgical timing; and marginal results with marginal impaction.
The Cementless Oxford Unicompartmental Knee Replacement
(OUKR) was developed to address problems related to cementation,
and has been demonstrated in a randomised study to have similar
clinical outcomes with fewer radiolucencies than observed with the
cemented device. However, before its widespread use it is necessary
to clarify contraindications and assess the complications. This
requires a larger study than any previously published. We present a prospective multicentre series of 1000 cementless
OUKRs in 881 patients at a minimum follow-up of one year. All patients
had radiological assessment aligned to the bone–implant interfaces
and clinical scores. Analysis was performed at a mean of 38.2 months
(19 to 88) following surgery. A total of 17 patients died (comprising
19 knees (1.9%)), none as a result of surgery; there were no tibial
or femoral loosenings. A total of 19 knees (1.9%) had significant
implant-related complications or required revision. Implant survival
at six years was 97.2%, and there was a partial radiolucency at
the bone–implant interface in 72 knees (8.9%), with no complete radiolucencies.
There was no significant increase in complication rate compared
with cemented fixation (p = 0.87), and no specific contraindications
to cementless fixation were identified. Cementless OUKR appears to be safe and reproducible in patients
with end-stage anteromedial osteoarthritis of the knee, with radiological
evidence of improved fixation compared with previous reports using
cemented fixation. Cite this article:
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.
While injury to the posterolateral corner is accepted as a relatively common occurrence associated with rupture of the anterior cruciate ligament, posteromedial meniscocapsular injury has not previously been recognised as such. In a prospective assessment of 183 consecutive reconstructions of the anterior cruciate ligament this injury was observed in 17 cases, giving it an incidence of 9.3%. Clinically, it was associated with a mild anteromedial rotatory subluxation and it is important not to confuse this with posterolateral rotatory subluxation. In no case was this injury identified by MRI. The possible long-term clinical relevance is discussed.
The clinical diagnosis of a partial tear of the
anterior cruciate ligament (ACL) is still subject to debate. Little
is known about the contribution of each ACL bundle during the Lachman
test. We investigated this using six fresh-frozen cadaveric lower
limbs. Screws were placed in the femora and tibiae as fixed landmarks
for digitisation of the bone positions. The femur was secured horizontally
in a clamp. A metal hook was screwed to the tibial tubercle and
used to apply a load of 150 N directed anteroposteriorly to the
tibia to simulate the Lachman test. The knees then received constant
axial compression and 3D knee kinematic data were collected by digitising
the screw head positions in 30° flexion under each test condition.
Measurements of tibial translation and rotation were made, first with
the ACL intact, then after sequential cutting of the ACL bundles,
and finally after complete division of the ACL. Two-way analysis
of variance analysis was performed. During the Lachman test, in all knees and in all test conditions,
lateral tibial translation exceeded that on the medial side. With
an intact ACL, both anterior and lateral tibial landmarks translated
significantly more than those on the medial side (p <
0.001).
With sequential division of the ACL bundles, selective cutting of
the posterolateral bundle (PLB) did not increase translation of
any landmark compared with when the ACL remained intact. Cutting the
anteromedial bundle (AMB) resulted in an increased anterior translation
of all landmarks. Compared to the intact ACL, when the ACL was fully
transected a significant increase in anterior translation of all
landmarks occurred (p <
0.001). However, anterior tibial translation
was almost identical after AMB or complete ACL division. We found that the AMB confers its most significant contribution
to tibial translation during the Lachman test, whereas the PLB has
a negligible effect on anterior translation. Section of the PLB
had a greater effect on increasing the internal rotation of the
tibia than the AMB. However, its contribution of a mean of 2.8°
amplitude remains low. The clinical relevance of our investigation
suggests that, based on anterior tibial translation only, one cannot distinguish
between a full ACL and an isolated AMB tear. Isolated PLB tears
cannot be detected solely by the Lachman test, as this bundle probably
contributes more resistance to the pivot shift.
We have shown in a previous study that patients with combined lesions of the anterior cruciate (ACL) and medial collateral ligaments (MCL) had similar anteroposterior (AP) but greater valgus laxity at 30° after reconstruction of the ACL when compared with patients who had undergone reconstruction of an isolated ACL injury. The present study investigated the same cohort of patients after a minimum of three years to evaluate whether the residual valgus laxity led to a poorer clinical outcome. Each patient had undergone an arthroscopic double-bundle ACL reconstruction using a semitendinosus-gracilis graft. In the combined ACL/MCL injury group, the grade II medial collateral ligament injury was not treated. At follow-up, AP laxity was measured using a KT-2000 arthrometer, while valgus laxity was evaluated with Telos valgus stress radiographs and compared with the uninjured knee. We evaluated clinical outcome scores, muscle girth and time to return to activities for the two groups. Valgus stress radiographs showed statistically significant greater mean medial joint opening in the reconstructed compared with the uninjured knees (1.7 mm (
This prospective study describes the outcome of the first 1000 phase 3 Oxford medial unicompartmental knee replacements (UKRs) implanted using a minimally invasive surgical approach for the recommended indications by two surgeons and followed up independently. The mean follow-up was 5.6 years (1 to 11) with 547 knees having a minimum follow-up of five years. At five years their mean Oxford knee score was 41.3 ( The incidence of implant-related re-operations was 2.9%; of these 29 re-operations two were revisions requiring revision knee replacement components with stems and wedges, 17 were conversions to a primary total knee replacement, six were open reductions for dislocation of the bearing, three were secondary lateral UKRs and one was revision of a tibial component. The most common reason for further surgical intervention was progression of arthritis in the lateral compartment (0.9%), followed by dislocation of the bearing (0.6%) and revision for unexplained pain (0.6%). If all implant-related re-operations are considered failures, the ten-year survival rate was 96% (95% confidence interval, 92.5 to 99.5). If only revisions requiring revision components are considered failures the ten-year survival rate is 99.8% (confidence interval 99 to 100). This is the largest published series of UKRs implanted through a minimally invasive surgical approach and with ten-year survival data. The survival rates are similar to those obtained with a standard open approach whereas the function is better. This demonstrates the effectiveness and safety of a minimally invasive surgical approach for implanting the Oxford UKR.
We present a case of disruption of the posterolateral corner of the knee with avulsion of the tendon of biceps femoris. Repair and reconstruction included an allogenic tendon graft to replace the posterior cruciate ligament. Surgery was followed by a complete common peroneal nerve palsy. Revision surgery revealed that the nerve had been displaced anteriorly by avulsion of the biceps tendon and the tendon graft encircled it. Release of the nerve restored normal function at five months.
We evaluated the long-term outcome of isolated endoscopically-assisted posterior cruciate ligament reconstruction in 26 patients using hamstring tendon autografts after failure of conservative management. At ten years after surgery the mean International Knee Documentation Committee subjective knee score was 87 ( At ten years endoscopic reconstruction of the posterior cruciate ligament with hamstring tendon autograft is effective in reducing knee symptoms. Of the series, 22 patients underwent radiological assessment for the development of osteoarthritis using the Kellgren-Lawrence grading scale. In four patients, grade 2 changes with loss of joint space was observed and another four patients showed osteophyte formation with moderate joint space narrowing (grade 3). These findings compared favourably with non-operatively managed injuries of the posterior cruciate ligament. This procedure for symptomatic patients with posterior cruciate ligament laxity who have failed conservative management offers good results.
Perilesional changes of chronic focal osteochondral defects were assessed in the knees of 23 sheep. An osteochondral defect was created in the main load-bearing region of the medial condyle of the knees in a controlled, standardised manner. The perilesional cartilage was evaluated macroscopically and biopsies were taken at the time of production of the defect (T0), during a second operation one month later (T1), and after killing animals at three (T3; n = 8), four (T4; n = 8), and seven (T7; n = 8) months. All the samples were histologically assessed by the International Cartilage Repair Society grading system and Mankin histological scores. Biopsies were taken from human patients (n = 10) with chronic articular cartilage lesions and compared with the ovine specimens. The ovine perilesional cartilage presented with macroscopic and histological signs of degeneration. At T1 the International Cartilage Repair Society ‘Subchondral Bone’ score decreased from a mean of 3.0 ( The perilesional cartilage in the animal model became chronic at one month and its histological appearance may be considered comparable with that seen in human osteochondral defects after trauma.
The options for treatment of the young active patient with isolated symptomatic osteoarthritis of the medial compartment and pre-existing deficiency of the anterior cruciate ligament are limited. The potential longevity of the implant and levels of activity of the patient may preclude total knee replacement, and tibial osteotomy and unicompartmental knee arthroplasty are unreliable because of the ligamentous instability. Unicompartmental knee arthroplasties tend to fail because of wear or tibial loosening resulting from eccentric loading. Therefore, we combined reconstruction of the anterior cruciate ligament with unicompartmental arthroplasty of the knee in 15 patients (ACLR group), and matched them with 15 patients who had undergone Oxford unicompartmental knee arthroplasty with an intact anterior cruciate ligament (ACLI group). The clinical and radiological data at a minimum of 2.5 years were compared for both groups. The groups were well matched for age, gender and length of follow-up and had no significant differences in their pre-operative scores. At the last follow-up, the mean outcome scores for both the ACLR and ACLI groups were high (Oxford knee scores of 46 (37 to 48) and 43 (38 to 46), respectively, objective Knee Society scores of 99 (95 to 100) and 94 (82 to 100), and functional Knee Society scores of 96 and 96 (both 85 to 100). One patient in the ACLR group needed revision to a total knee replacement because of infection. No patient in either group had radiological evidence of component loosening. The radiological study showed no difference in the pattern of tibial loading between the groups. The short-term clinical results of combined anterior cruciate ligament reconstruction and unicompartmental knee arthroplasty are excellent. The previous shortcomings of unicompartmental knee arthroplasty in the presence of deficiency of the anterior cruciate ligament appear to have been addressed with the combined procedure. This operation seems to be a viable treatment option for young active patients with symptomatic arthritis of the medial compartment, in whom the anterior cruciate ligament has been ruptured.