Aims. Metal particles detached from metal-on-metal hip prostheses (MoM-THA) have been shown to cause inflammation and destruction of tissues. To further explore this, we investigated the histopathology (aseptic lymphocyte-dominated vasculitis-associated
The treatment of osteochondral
A total of 11 patients (12 knees) with stable
Matrix-induced autologous chondrocyte implantation
(MACI) is an established technique used to treat osteochondral lesions
in the knee. For larger osteochondral
Autologous chondrocyte implantation (ACI) and
mosaicplasty are methods of treating symptomatic articular cartilage
defects in the knee. This study represents the first long-term randomised
comparison of the two techniques in 100 patients at a minimum follow-up
of ten years. The mean age of the patients at the time of surgery was
31.3 years (16 to 49); the mean duration of symptoms pre-operatively
was 7.2 years (9 months to 20 years). The
Mesenchymal stem cells (MSCs) have several properties that may support their use as an early treatment option for osteoarthritis (OA). This study investigated the role of multiple injections of allogeneic bone marrow-derived stem cells (BMSCs) to alleviate the progression of osteoarthritic changes in the various structures of the mature rabbit knee in an anterior cruciate ligament (ACL)-deficient OA model. Two months after bilateral section of the ACL of Japanese white rabbits aged nine months or more, either phosphate buffered saline (PBS) or 1 x 106 MSCs were injected into the knee joint in single or three consecutive doses. After two months, the articular cartilage and meniscus were assessed macroscopically, histologically, and immunohistochemically using collagen I and II.Aim
Materials and Methods
Aims. Meniscal allograft transplantation (MAT) for patients with symptomatic meniscal loss has demonstrated good clinical results and survivorship. Factors that affect both functional outcome and survivorship have been reported in the literature. These are typically single-centre case series with relatively small numbers and conflicting results. Our aim was to describe an international, two-centre case series, and identify factors that affect both functional outcome and survival. Methods. We report factors that affect outcome on 526 patients undergoing MAT across two sites (one in the UK and one in Italy). Outcomes of interest were the Knee injury and Osteoarthritis Outcome Score four (KOOS4) at two years and failure rates. We performed multiple regression analysis to examine for factors affecting KOOS, and Cox proportional hazards models for survivorship. Results. Our results indicate that baseline KOOS4 score affects functional outcome at two years, but no other included factors were significantly related to functional outcome. The only factor that affected failure rate was the presence of cartilage
Aims. To explore the efficacy of extracorporeal shockwave therapy (ESWT) in the treatment of osteochondral defect (OCD), and its effects on the levels of transforming growth factor (TGF)-β, bone morphogenetic protein (BMP)-2, -3, -4, -5, and -7 in terms of cartilage and bone regeneration. Methods. The OCD
Aims. Implantation of ultra-purified alginate (UPAL) gel is safe and effective in animal osteochondral defect models. This study aimed to examine the applicability of UPAL gel implantation to acellular therapy in humans with cartilage injury. Methods. A total of 12 patients (12 knees) with symptomatic, post-traumatic, full-thickness cartilage
Aims. Our purpose was to describe an unusual series of 21 patients with fungal osteomyelitis after an anterior cruciate ligament reconstruction (ACL-R). Methods. We present a case-series of consecutive patients treated at our institution due to a severe fungal osteomyelitis after an arthroscopic ACL-R from November 2005 to March 2015. Patients were referred to our institution from different areas of our country. We evaluated the amount of bone resection required, type of final reconstructive procedure performed, and Musculoskeletal Tumor Society (MSTS) functional score. Results. A total of 21 consecutive patients were included in the study; 19 were male with median age of 28 years (IQR 25 to 32). All ACL-R were performed with hamstrings autografts with different fixation techniques. An oncological-type debridement was needed to control persistent infection symptoms. There were no recurrences of fungal infection after median of four surgical debridements (IQR 3 to 6). Five patients underwent an extensive curettage due to the presence of large cavitary
Aims. There is insufficient evidence to recommend the use of alternative polyethylene bearings in modular, fixed-bearing total knee arthroplasty (TKA). The purpose of this study was to compare standard polyethylene (SP) and highly crosslinked polyethylene (XLP) tibial liners in posterior-stabilized TKA, with osteolysis as the primary outcome and clinical results and the rate of re-operation as the secondary outcomes. Patients and Methods. This is a single-surgeon, prospective randomized study involving one design of modular posterior-stabilized TKA. An analysis of 122 TKAs with an SP compression moulded liner and 123 with an XLP liner was performed, with a mean follow-up of six years (2 to 11). Patients were evaluated clinically using the Knee Society score, Lower Extremity Activity Score (LEAS), and the presence of an effusion, and standard radiographs were assessed for radiolucent lines and osteolytic
Osteochondritis Dissecans (OCD) is a condition
for which the aetiology remains unknown. It affects subchondral bone
and secondarily its overlying cartilage and is mostly found in the
knee. It can occur in adults, but is generally identified when growth
remains, when it is referred to as juvenile OCD. As the condition
progresses, the affected subchondral bone separates from adjacent
healthy bone, and can lead to demarcation and separation of its associated
articular cartilage. Any symptoms which arise relate to the stage
of the disease. Early disease without separation of the
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). 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.Aims
Methods
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. 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.Aims
Methods
The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach. A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. 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 to be unanimous.Aims
Methods
As has been shown in larger animal models, knee immobilization can lead to arthrofibrotic phenotypes. Our study included 168 C57BL/6J female mice, with 24 serving as controls, and 144 undergoing a knee procedure to induce a contracture without osteoarthritis (OA). Experimental knees were immobilized for either four weeks (72 mice) or eight weeks (72 mice), followed by a remobilization period of zero weeks (24 mice), two weeks (24 mice), or four weeks (24 mice) after suture removal. Half of the experimental knees also received an intra-articular injury. Biomechanical data were collected to measure passive extension angle (PEA). Histological data measuring area and thickness of posterior and anterior knee capsules were collected from knee sections.Aims
Methods
Aims. We report the natural course of Baker’s cysts following total knee arthroplasty (TKA) at short- and mid-term follow-up. Methods. In this prospective case series, 105 TKA patients were included. All patients who received surgery had a diagnosis of primary osteoarthritis and had preoperatively presented with a Baker’s cyst. Sonography and MRI were performed to evaluate the existence and the gross size of the cyst before TKA, and sonography was repeated at a mean follow-up time of 1.0 years (0.8 to 1.3; short-term) and 4.9 years (4.0 to 5.6; mid-term) after TKA. Symptoms potentially attributable to the Baker’s cyst were recorded at each assessment. Results. At the one-year follow-up analysis, 102 patients were available. Of those, 91 patients were available for the 4.9-year assessment (with an 86.7% follow-up rate (91/105)). At the short- and mid-term follow-up, a Baker’s cyst was still present in 87 (85.3%) and 30 (33.0%) patients, respectively. Of those patients who retained a Baker’s cyst at the short-term follow-up, 31 patients (35.6%) had popliteal symptoms. Of those patients who continued to have a Baker’s cyst at the mid-term follow-up, 17 patients (56.7%) were still symptomatic. The mean preoperative cyst size was 14.5 cm. 2. (13.1 to 15.8). At the short- and mid-term follow-up, the mean cyst size was 9.7 cm. 2. (8.3 to 11.0) and 10.4 cm. 2. (9.8 to 11.4), respectively. A significant association was found between the size of the cyst at peroperatively and the probability of resolution, with
Aims. Medial unicompartmental knee arthroplasty (UKA) is associated
with successful outcomes in carefully selected patient cohorts.
We hypothesised that severity and location of patellofemoral cartilage
lesions significantly influences functional outcome after Oxford
medial compartmental knee arthroplasty. Patients and Methods. We reviewed 100 consecutive UKAs at minimum eight-year follow-up
(96 to 132). A single surgeon performed all procedures. Patients
were selected based on clinical and plain radiographic assessment.
All patients had end-stage medial compartment osteoarthritis (OA)
with sparing of the lateral compartment and intact anterior cruciate ligaments.
None of the patients had end-stage patellofemoral OA, but patients
with anterior knee pain or partial thickness chondral loss were
not excluded. There were 57 male and 43 female patients. The mean
age at surgery was 69 years (41 to 82). At surgery the joint was
carefully inspected for patellofemoral chondral loss and this was documented
based on severity of cartilage loss (0 to 4 Outerbridge grading)
and topographic location (medial, lateral, central, and superior
or inferior). Functional scores collected included Oxford Knee Score
(OKS), patient satisfaction scale and University College Hospital
(UCH) knee score. Intraclass correlation was used to compare chondral
damage to outcomes. Results. All patients documented significant improvement in pain and improved
functional scores at mid-term follow-up. There were four revisions
(mean 2.9 years, 2 to 4; standard deviation (. sd). 0.9) in
this cohort, three for tibial loosening and one for femoral loosening.
There was one infection that was treated with debridement and insert exchange.
The mean OKS improved from 23.2 (. sd. 7.1) to 39.1 (. sd. 6.9);
p <
0.001. The cohort with central and lateral grade 3 patellofemoral
OA documented lower mean satisfaction with pain (90, . sd. 11.8)
and function (87.5, . sd. 10.3) on the patient satisfaction
scale. On the UCH scale, patients reported significantly decreased
mean overall scores (7.3, . sd. 1.2 vs 9, . sd. 2.3)
as well as stair climb task (3.5, . sd. 0.3 vs 5, . sd. 0.1)
when cartilage
The aim of this study was to describe the prevalence and patterns of neuropathic pain over one year in a cohort of patients with chronic post-surgical pain at three months following total knee arthroplasty (TKA). Between 2016 and 2019, 363 patients with troublesome pain, defined as a score of ≤ 14 on the Oxford Knee Score pain subscale, three months after TKA from eight UK NHS hospitals, were recruited into the Support and Treatment After Replacement (STAR) clinical trial. Self-reported neuropathic pain and postoperative pain was assessed at three, nine, and 15 months after surgery using the painDETECT and Douleur Neuropathique 4 (DN4) questionnaires collected by postal survey.Aims
Methods
This study aims to identify the top unanswered research priorities in the field of knee surgery using consensus-based methodology. Initial research questions were generated using an online survey sent to all 680 members of the British Association for Surgery of the Knee (BASK). Duplicates were removed and a longlist was generated from this scoping exercise by a panel of 13 experts from across the UK who provided oversight of the process. A modified Delphi process was used to refine the questions and determine a final list. To rank the final list of questions, each question was scored between one (low importance) and ten (high importance) in order to produce the final list.Aims
Methods
The aim of this study was to evaluate whether achieving medial joint opening, as measured by the change in the joint line convergence angle (∆JLCA), is a better predictor of clinical outcomes after high tibial osteotomy (HTO) compared with the mechanical axis deviation, and to find individualized targets for the redistribution of load that reflect bony alignment, joint laxity, and surgical technique. This retrospective study analyzed 121 knees in 101 patients. Patient-reported outcome measures (PROMs) were collected preoperatively and one year postoperatively, and were analyzed according to the surgical technique (opening or closing wedge), postoperative mechanical axis deviation (deviations above and below 10% from the target), and achievement of medial joint opening (∆JLCA > 1°). Radiological parameters, including JLCA, mechanical axis deviation, and the difference in JLCA between preoperative standing and supine radiographs (JLCAPD), an indicator of medial soft-tissue laxity, were measured. Cut-off points for parameters related to achieving medial joint opening were calculated from receiver operating characteristic (ROC) curves.Aims
Methods
This study aimed to explore the biological and clinical importance of dysregulated key genes in osteoarthritis (OA) patients at the cartilage level to find potential biomarkers and targets for diagnosing and treating OA. Six sets of gene expression profiles were obtained from the Gene Expression Omnibus database. Differential expression analysis, weighted gene coexpression network analysis (WGCNA), and multiple machine-learning algorithms were used to screen crucial genes in osteoarthritic cartilage, and genome enrichment and functional annotation analyses were used to decipher the related categories of gene function. Single-sample gene set enrichment analysis was performed to analyze immune cell infiltration. Correlation analysis was used to explore the relationship among the hub genes and immune cells, as well as markers related to articular cartilage degradation and bone mineralization.Aims
Methods
Objectives. Matrix-assisted autologous chondrocyte transplantation (MACT)
has been developed and applied in the clinical practice in the last
decade to overcome most of the disadvantages of the first generation
procedures. The purpose of this systematic review is to document
and analyse the available literature on the results of MACT in the
treatment of chondral and osteochondral
To determine the relationship between articular cartilage status and clinical outcomes after medial opening-wedge high tibial osteotomy (MOHTO) for medial compartmental knee osteoarthritis at intermediate follow-up. We reviewed 155 patients (155 knees) who underwent MOHTO from January 2008 to December 2016 followed by second-look arthroscopy with a mean 5.3-year follow-up (2.0 to 11.7). Arthroscopic findings were assessed according to the International Cartilage Repair Society (ICRS) Cartilage Repair Assessment (CRA) grading system. Patients were divided into two groups based on the presence of normal or nearly normal quality cartilage in the medial femoral condyle: good (second-look arthroscopic) status (ICRS grade I or II; n = 70), and poor (second-look arthroscopic) status (ICRS grade III or IV; n = 85) groups at the time of second-look arthroscopy. Clinical outcomes were assessed using the International Knee Documentation Committee (IKDC) score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and 36-Item Short Form survey.Aims
Methods
This study compared the cobalt and chromium serum ion concentration of patients treated with two different metal-on-metal (MoM) hinged total knee arthroplasty (TKA) systems, as well as a titanium nitride (TiN)-coated variant. A total of 63 patients (65 implants) were treated using either a MoM-coated (n = 29) or TiN-coated (n = 7) hinged TKA (GenuX mobile bearing, MUTARS; Implantcast, Germany) versus the BPKS (Brehm, Germany) hinged TKA (n = 27), in which the weight placed on the MoM hinge is diffused through a polyethylene (PE) inlay, reducing the direct load on the MoM hinge. Serum cobalt and chromium ion concentrations were assessed after minimum follow-up of 12 months, as well as functional outcome and quality of life.Aims
Methods
Autologous chondrocyte implantation is an established method of treatment for symptomatic articular defects of cartilage. CARTIPATCH is a monolayer-expanded cartilage cell product which is combined with a novel hydrogel to improve cell phenotypic stability and ease of surgical handling. Our aim in this prospective, multicentre study on 17 patients was to investigate the clinical, radiological, arthroscopic and histological outcome at a minimum follow-up of two years after the implantation of autologous chondrocytes embedded in a three-dimensional alginate-agarose hydrogel for the treatment of chondral and osteochondral defects. Clinically, all the patients improved significantly. Patients with
We sought to determine the degree of correlation between the condition of the patellar articular cartilage and patellofemoral symptoms and function in osteoarthritic patients undergoing total knee arthroplasty. The depth of the osteoarthritic
MRI has been suggested as an objective method of assessing anterior crucate ligament (ACL) graft “ligamentization” after reconstruction. It has been proposed that the MRI appearances could be used as an indicator of graft maturity and used as part of a return-to-sport assessment. The aim of this study was to evaluate the correlation between MRI graft signal and postoperative functional scores, anterior knee laxity, and patient age at operation. A consecutive cohort of 149 patients who had undergone semitendinosus autograft ACL reconstruction, using femoral and tibial adjustable loop fixations, were evaluated retrospectively postoperatively at two years. All underwent MRI analysis of the ACL graft, performed using signal-to-noise quotient (SNQ) and the Howell score. Functional outcome scores (Lysholm, Tegner, International Knee Documentation Committee (IKDC) subjective, and IKDC objective) were obtained and all patients underwent instrumented side-to-side anterior laxity differential laxity testing.Aims
Methods
Injury to the common peroneal nerve was present in 14 of 55 patients (25%) with dislocation of the knee. All underwent ligament reconstruction. The most common presenting direction of the dislocation was anterior or anteromedial with associated disruption of both cruciate ligaments and the posterolateral structures of the knee. Palsy of the common peroneal nerve was present in 14 of 34 (41%) of these patients. Complete rupture of the nerve was seen in four patients and a
The purpose of this study was to evaluate the
long-term functional and radiological outcomes of arthroscopic removal
of unstable osteochondral
We have shown in a previous study that patients with combined
The aims of this study were to investigate the ability to kneel after total knee arthroplasty (TKA) without patellar resurfacing, and its effect on patient-reported outcome measures (PROMs). Secondary aims included identifying which kneeling positions were most important to patients, and the influence of radiological parameters on the ability to kneel before and after TKA. This prospective longitudinal study involved 209 patients who underwent single radius cruciate-retaining TKA without patellar resurfacing. Preoperative EuroQol five-dimension questionnaire (EQ-5D), Oxford Knee Score (OKS), and the ability to achieve four kneeling positions were assessed including a single leg kneel, a double leg kneel, a high-flexion kneel, and a praying position. The severity of radiological osteoarthritis (OA) was graded and the pattern of OA was recorded intraoperatively. The flexion of the femoral component, posterior condylar offset, and anterior femoral offset were measured radiologically. At two to four years postoperatively, 151 patients with a mean age of 70.0 years (SD 9.44) were included. Their mean BMI was 30.4 kg/m2 (SD 5.36) and 60 were male (40%). They completed EQ-5D, OKS, and Kujala scores, assessments of the ability to kneel, and a visual analogue scale for anterior knee pain and satisfaction.Aims
Methods
Osteonecrosis of the knee comprises two separate disorders, primary spontaneous osteonecrosis which is often a self-limiting condition and secondary osteonecrosis which is associated with risk factors and a poor prognosis. In a series of 61 knees (38 patients) we analysed secondary osteonecrosis of the knee treated by a new technique using multiple small percutaneous 3 mm drillings. Total knee replacement was avoided in 59 knees (97%) at a mean follow-up of 3 years (2 to 4). Of the 61 knees, 56 (92%) had a successful clinical outcome, defined as a Knee Society score greater than 80 points. The procedure was successful in all 24 knees with small
A limited number of investigations with conflicting results have described perivascular lymphocytic infiltration (PVLI) in the setting of total knee arthroplasty (TKA). The purpose of this study was to determine if PVLI found in TKAs at the time of aseptic revision surgery was associated with worse clinical outcomes and survivorship. A retrospective review was conducted on 617 patients who underwent aseptic TKA revision who had histological analysis for PVLI at the time of surgery. Clinical and radiological data were obtained pre- and postoperatively, six weeks postoperatively, and then every year thereafter.Aims
Methods
We have reviewed 22 patients from a total of 135 treated by autologous chondrocyte implantation (ACI) who had undergone further surgery for pain in the knee and mechanical symptoms after a mean of 10.5 months. There were 31 grafted
To report mid- to long-term results of Oxford mobile bearing domed lateral unicompartmental knee arthroplasty (UKA), and determine the effect of potential contraindications on outcome. A total of 325 consecutive domed lateral UKAs undertaken for the recommended indications were included, and their functional and survival outcomes were assessed. The effects of age, weight, activity, and the presence of full-thickness erosions of cartilage in the patellofemoral joint on outcome were evaluated.Aims
Methods
The operative treatment of
This study aims to determine the proportion of patients with end-stage knee osteoarthritis (OA) possibly suitable for partial (PKA) or combined partial knee arthroplasty (CPKA) according to patterns of full-thickness cartilage loss and anterior cruciate ligament (ACL) status. A cross-sectional analysis of 300 consecutive patients (mean age 69 years (SD 9.5, 44 to 91), mean body mass index (BMI) 30.6 (SD 5.5, 20 to 53), 178 female (59.3%)) undergoing total knee arthroplasty (TKA) for Kellgren-Lawrence grade ≥ 3 knee OA was conducted. The point of maximal tibial bone loss on preoperative lateral radiographs was determined as a percentage of the tibial diameter. At surgery, Lachman’s test and ACL status were recorded. The presence of full-thickness cartilage loss within 16 articular surface regions (two patella, eight femoral, six tibial) was recorded.Aims
Methods
Stiffness is a common complication after total knee arthroplasty (TKA). Pathogenesis is not understood, treatment options are limited, and diagnosis is challenging. The aim of this study was to investigate if MRI can be used to visualize intra-articular scarring in patients with stiff, painful knee arthroplasties. Well-functioning primary TKAs (n = 11), failed non-fibrotic TKAs (n = 5), and patients with a clinical diagnosis of fibrosisAims
Methods
We describe injuries to the posterior root of the medial meniscus in patients with spontaneous osteonecrosis of the medial compartment of the knee. We identified 30 consecutive patients with spontaneous osteonecrosis of the medial femoral condyle. The radiographs and MR imaging were reviewed. We found tears of the posterior root of the medial meniscus in 24 patients (80%). Of these, 15 were complete and nine were partial. Complete tears were associated with >
3 mm of meniscal extrusion. Neither the presence of a root tear nor the volume of the osteonecrotic
We prospectively examined the physical and imaging findings, including MRI, of 23 patients with spontaneous osteonecrosis of the knee after obtaining informed consent to acquire tissue specimens at surgery. There were four men and 19 women, with a mean age of 67.5 years (58 to 77). Plain radiographs were designated as stages 1, 2, 3 or 4 according to the classification of Koshino. Five knees were classified as stage 1, five as stage 2, seven as stage 3 and six as stage 4. The histological specimens were stained with haematoxylin and eosin and tetrachrome. In the early stages of the condition, a subchondral fracture was noted in the absence of any features of osteonecrosis, whereas in advanced stages, osteonecrotic
With medial unicompartmental osteoarthritis (OA) there is occasionally a full-thickness ulcer of the cartilage on the medial side of the lateral femoral condyle. It is not clear whether this should be considered a contraindication to unicompartmental knee replacement (UKR). The aim of this study was to determine why these ulcers occur, and whether they compromise the outcome of UKR. Case studies of knees with medial OA suggest that cartilage
Metaphyseal cones with cemented stems are frequently used in revision total knee arthroplasty (TKA). However, if the diaphysis has been previously violated, the resultant sclerotic canal can impair cemented stem fixation, which is vital for bone ingrowth into the cone, and long-term fixation. We report the outcomes of our solution to this problem, in which impaction grafting and a cemented stem in the diaphysis is combined with an uncemented metaphyseal cone, for revision TKA in patients with severely compromised bone. A metaphyseal cone was combined with diaphyseal impaction grafting and cemented stems for 35 revision TKAs. There were two patients with follow-up of less than two years who were excluded, leaving 33 procedures in 32 patients in the study. The mean age of the patients at the time of revision TKA was 67 years (32 to 87); 20 (60%) were male. Patients had undergone a mean of four (1 to 13) previous knee arthroplasty procedures. The indications for revision were aseptic loosening (80%) and two-stage reimplantation for prosthetic joint infection (PJI; 20%). The mean follow-up was four years (2 to 11).Aims
Methods
The aim of this study was to analyze the true costs associated with preoperative CT scans performed for robotic-assisted total knee arthroplasty (RATKA) planning and to determine the value of a formal radiologist’s report of these studies. We reviewed 194 CT reports of 176 sequential patients who underwent primary RATKA by a single surgeon at a suburban teaching hospital. CT radiology reports were reviewed for the presence of incidental findings that might change the management of the patient. Payments for the scans, including the technical and professional components, for 330 patients at two hospitals were also recorded and compared.Aims
Methods
A pragmatic, single-centre, double-blind randomized clinical trial was conducted in a NHS teaching hospital to evaluate whether there is a difference in functional knee scores, quality-of-life outcome assessments, and complications at one-year after intervention between total knee arthroplasty (TKA) and patellofemoral arthroplasty (PFA) in patients with severe isolated patellofemoral arthritis. This parallel, two-arm, superiority trial was powered at 80%, and involved 64 patients with severe isolated patellofemoral arthritis. The primary outcome measure was the functional section of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at 12 months. Secondary outcomes were the full 24-item WOMAC, Oxford Knee Score (OKS), American Knee Society Score (AKSS), EuroQol five dimension (EQ-5D) quality-of-life score, the University of California, Los Angeles (UCLA) Physical Activity Rating Scale, and complication rates collected at three, six, and 12 months. For longer-term follow-up, OKS, EQ-5D, and self-reported satisfaction score were collected at 24 and 60 months.Aims
Methods
Animal studies have shown that implanted anterior cruciate ligament (ACL) grafts initially undergo a process of revascularisation prior to remodelling, ultimately increasing mechanical strength. We investigated whether minimal debridement of the intercondylar notch and the residual stump of the ruptured ACL leads to earlier revascularisation in ACL reconstruction in humans. We undertook a randomised controlled clinical trial in which 49 patients underwent ACL reconstruction using autologous four-strand hamstring tendon grafts. Randomised by the use of sealed envelopes, 25 patients had a conventional clearance of the intercondylar notch and 24 had a minimal debridement method. Three patients were excluded from the study. All patients underwent MR scanning postoperatively at 2, 6 and 12 months, together with clinical assessment using a KT-1000 arthrometer and International Knee Documentation Committee (IKDC) evaluation. All observations were made by investigators blinded to the surgical technique. Signal intensity was measured in 4 mm diameter regions of interest along the ACL graft and the mid-substance of the posterior cruciate ligament. Our results indicate that minimal debridement leads to earlier revascularisation within the mid-substance of the ACL graft at two months (paired t-test, p = 0.002). There was a significant reduction of mid-substance signal six months after the minimal debridement technique (paired t-test, p = 0.00007). No statistically significant differences were found in tunnel placement, incidence of Cyclops
We analysed at a mean follow-up of 7.25 years the clinical and radiological outcome of 117 patients (125 knees) who had undergone a primary, cemented, modular Freeman-Samuelson total knee replacement. While the tibial and femoral components were cemented, the patellar component was uncemented. A surface-cementing technique was used to secure the tibial components. A total of 82 knees was available for radiological assessment. Radiolucent lines were seen in 41 knees (50%) and osteolytic
We report the results of a prospective study of the surgical release of 45 knee flexion contractures in 28 patients with myelomeningocele. The neurosegmental level was thoracic in ten patients, L1/2 in one, L3/4 in 11, and L5/S1 in six. In walkers the indication for surgery was a fixed flexion contracture impeding walking, and in non-walking patients it was a flexion contracture impeding transfers or sitting balance, or likely to do so with increasing deformity. The mean age at surgery was 6.4 years (3 to 21) and the mean period of follow-up 13 years (4 to 20). The mean knee flexion contracture before surgery was 39° (25 to 70) which improved to 5° at maximum correction and to 13° at latest follow-up. We conclude that surgical release of knee flexion contractures in myelomeningocele improves gait in all children who walk, particularly those with low lumbar
Little is known about the risk factors that predispose to a rupture of the posterior cruciate ligament (PCL). Identifying risk factors is the first step in trying to prevent a rupture of the PCL from occurring. The morphology of the knee in patients who rupture their PCL may differ from that of control patients. The purpose of this study was to identify any variations in bone morphology that are related to a PCL. We compared the anteroposterior (AP), lateral, and Rosenberg view radiographs of 94 patients with a ruptured PCL to a control group of 168 patients matched by age, sex, and body mass index (BMI), but with an intact PCL after a knee injury. Statistical shape modelling software was used to assess the shape of the knee and determine any difference in anatomical landmarks.Aims
Patients and Methods
Autologous chondrocyte implantation (ACI) and mosaicplasty are both claimed to be successful for the repair of defects of the articular cartilage of the knee but there has been no comparative study of the two methods. A total of 100 patients with a mean age of 31.3 years (16 to 49) and with a symptomatic
The aim of the British Association for Surgery of the Knee (BASK) Meniscal Consensus Project was to develop an evidence-based treatment guideline for patients with meniscal lesions of the knee. A formal consensus process was undertaken applying nominal group, Delphi, and appropriateness methods. Consensus was first reached on the terminology relating to the definition, investigation, and classification of meniscal lesions. A series of simulated clinical scenarios was then created and the appropriateness of arthroscopic meniscal surgery or nonoperative treatment in each scenario was rated by the group. The process was informed throughout by the latest published, and previously unpublished, clinical and epidemiological evidence. Scenarios were then grouped together based upon the similarity of clinical features and ratings to form the guideline for treatment. Feedback on the draft guideline was sought from the entire membership of BASK before final revisions and approval by the consensus group.Aims
Materials and Methods
Knee osteonecrosis in advanced stages may lead to joint degeneration. Total knee arthroplasty (TKA) for osteonecrosis has traditionally been associated with suboptimal results. We analyzed outcomes of contemporary TKAs for osteonecrosis, with particular emphasis on: survivorship free from aseptic loosening, any revision, and any reoperation plus the clinical outcomes, complications, and radiological results. In total, 156 patients undergoing 167 primary TKAs performed for osteonecrosis between 2004 and 2014 at a single institution were reviewed. The mean age at index TKA was 61 years (14 to 93) and the mean body mass index (BMI) was 30 kg/m2 (18 to 51) The mean follow-up was six years (2 to 12). A total of 110 TKAs (66%) were performed for primary osteonecrosis and 57 TKAs (34%) for secondary osteonecrosis. Overall, 15 TKAs (9%) had tibial stems, while 12 TKAs (7%) had femoral stems. Posterior-stabilized designs were used in 147 TKAs (88%) of TKAs. Bivariate Cox regression analysis was conducted to identify risk factors for revision and reoperation.Aims
Patients and Methods
Altered alignment and biomechanics are thought to contribute to the progression of osteoarthritis (OA) in the native compartments after medial unicompartmental knee arthroplasty (UKA). The aim of this study was to evaluate the bone activity and remodelling in the lateral tibiofemoral and patellofemoral compartment after medial mobile-bearing UKA. In total, 24 patients (nine female, 15 male) with 25 medial Oxford UKAs (13 left, 12 right) were prospectively followed with sequential 99mTc-hydroxymethane diphosphonate single photon emission CT (SPECT)/CT preoperatively and at one and two years postoperatively, along with standard radiographs and clinical outcome scores. The mean patient age was 62 years (40 to 78) and the mean body mass index (BMI) was 29.7 kg/m2 (23.6 to 42.2). Mean osteoblastic activity was evaluated using a tracer localization scheme with volumes of interest (VOIs). Normalized mean tracer values were calculated as the ratio between the mean tracer activity in a VOI and background activity in the femoral diaphysis.Aims
Patients and Methods
Delayed rather than early reconstruction of the anterior cruciate ligament is the current recommended treatment for injury to this ligament since it is thought to give a better functional outcome. We randomised 105 consecutive patients with injury associated with chondral
The aim of this study was to report the outcome of femoral condylar fresh osteochondral allografts (FOCA) with concomitant realignment osteotomy with a focus on graft survivorship, complications, reoperation, and function. We identified 60 patients (16 women, 44 men) who underwent unipolar femoral condylar FOCA with concomitant realignment between 1972 and 2012. The mean age of the patients was 28.9 years (10 to 62) and the mean follow-up was 11.4 years (2 to 35). Failure was defined as conversion to total knee arthroplasty, revision allograft, or graft removal. Clinical outcome was evaluated using the modified Hospital for Special Surgery (mHSS) score.Aims
Patients and Methods
The aim of this study was to evaluate cartilaginous patellotrochlear congruence and patellofemoral alignment parameters after deepening trochleoplasty in severe trochlear dysplasia. The study group comprised 20 patients (two male, 18 female; mean age 24 years (16 to 39)) who underwent deepening trochleoplasty and medial patellofemoral ligament (MPFL) reconstruction for the treatment of recurrent lateral patellar dislocation due to severe trochlear dysplasia (Dejour type B to D). Pre- and postoperative MRI investigations of the study group were compared with MRI data of 20 age- and gender-matched control patients (two male, 18 female; mean age 27 years (18 to 44)) regarding the patellotrochlear contact ratio, patellotrochlear contact area, posterior patellar edge-trochlear groove ratio, and patellar tilt.Aims
Patients and Methods
Primary (or spontaneous) and secondary osteonecrosis of the knee
can lead to severe joint degeneration, for which either total or
unicompartmental arthroplasty may be considered. However, there
are limited studies analyzing outcomes of unicompartmental knee arthroplasties
(UKAs) for osteonecrosis involving an isolated compartment of the
knee. The aims of this study were to analyze outcomes of UKAs for
osteonecrosis with specific focus on 1) survivorship free of any
revision or reoperation, 2) risk factors for failure, 3) clinical outcomes,
and 4) complications. A total of 45 patients underwent 46 UKAs for knee osteonecrosis
between 2002 and 2014 at our institution (The Mayo Clinic, Rochester,
Minnesota). Twenty patients (44%) were female; the mean age of the
patients was 66 years, and mean body mass index (BMI) was 31 kg/m2. Of
the 46 UKAs, 44 (96%) were medial UKAs, and 35 (76%) were fixed-bearing
design. Mean mechanical axis postoperatively was 1.5° varus (0°
to 5° varus); 41 UKAs (89%) were performed for primary osteonecrosis.
Mean follow-up was five years (2 to 12)Aims
Patients and Methods
Lipoma arborescens is a rare intra-articular
We studied 19 videotaped knee arthroscopies in 19 patients with mild to moderate osteoarthritis (OA) of the knee in order to compare the intraobserver and interobserver reliability and the patterns of disagreement between four orthopaedic surgeons. The classifications of OA of Collins, Outerbridge and the French Society of Arthroscopy were used. Intraobserver and interobserver agreements using kappa measures were 0.42 to 0.66 and 0.43 to 0.49, respectively. Only 6% to 8% of paired intraobserver classifications differed by more than one category. Observer-specific disagreement was evident both within and between observers. A small, but significant, occasional variation was also seen. Although reliability may improve by an analysis of disagreement, it appears that the arthroscopic grading of early osteoarthritic
The radiological and MRI appearances of 24 knees with patellar tendonitis resistant to conservative therapy were analysed to identify the characteristic MRI appearance and to determine if the patellar morphology was abnormal. A significant thickening of the tendon was found in all cases; this was a more reliable diagnostic feature than a high signal within the superior posterior and central aspect of the tendon at its proximal attachment. The site of the
For the purpose of investigating the effect of an insole with a lateral wedge, we studied 30 patients (31 knees) aged from 46 to 78 years with idiopathic osteonecrosis of the knee for at least three years. The 18 knees treated with an insole (group I) were matched by age, gender, obesity index, area of
Between 1989 and 1993 we implanted a matrix support prosthesis made of carbon fibre for the treatment of chronic painful articular defects of the patella in 27 patients. The mean period of follow-up was 33 months (11 to 54) with clinical and arthroscopic evaluation of the implant. Overall, there were four excellent, three good, seven fair and 13 poor results. Nine patients subsequently had a patellectomy for persistent pain at a mean of 27 months after surgery (14 to 47). The mean visual analogue pain scores in those who retained their patella were 7.6 before operation and 5.5 at the time of the latest follow-up. Patient satisfaction for the entire group was 41%. There appeared to be good incorporation of the prosthesis and a satisfactory ingrowth of fibrocartilage, but the poor results in 48% and low patient satisfaction discourage us from recommending the procedure for
In a prospective randomised trial 76 knees with isolated degenerative changes in the medial femoral condyle of grades 3 or 4 were treated by either arthroscopic debridement (40) or washout (36). All knees were followed up for at least one year and 58 for five years. The mean follow-up time was 4.5 years in the debridement group and 4.3 years in the washout group. At one year 32 of the debridement group and five of the washout group were painfree and at five years 19 of a total of 32 survivors in the debridement group and three of the 26 in the washout group were also free from pain. The mean improvement in a modified Lysholm score was 28 for the debridement group at one year and 21 at five years. In the washout group it was only 5 at one year and 4 at five years. For knees with
We have measured anterior and posterior displacement in 563 normal knees and 487 knees with chronic deficiency of the anterior cruciate ligament (ACL). We performed stress radiography using a simple apparatus which maintained the knee at 20° of flexion while a 9 kg load was applied. There was no significant difference in posterior translation dependent on the condition of the ACL. Measurement of anterior translation in the medial compartment proved to be more reliable than in the lateral compartment for the diagnosis of rupture of the ACL, with better specificity, sensitivity and predictive values. We have classified anterior laxity based on the differential anterior translation of the medial compartment and identified four grades in each of which we can further distinguish four subgrades for laxity of the lateral compartment. Within each of these subgroups, either internal or external rotation may dominate and sometimes there is a major translation of both compartments. Radiological evaluation of displacement of the knee in 20° of flexion provides conclusive evidence of rupture of the ACL. A detailed study of pathological displacement is the basis for a classification of laxity. It is then possible to decide for each type of laxity, the surgical treatment which is specifically adapted to the
We carried out percutaneous, arthroscopically- and fluoroscopically-assisted osteosynthesis of fractures of the tibial plateau in 52 patients, of whom 38 were assessed using the HSS knee score and standing radiographs. We reviewed 31 AO type-B fractures and seven type-C fractures after a mean follow-up of five years (1 to 14). Fixation was achieved using percutaneous screws and/or an external frame; 33 associated intra-articular injuries, diagnosed in 21 out of the 38 patients, were treated arthroscopically. Subjectively, 94.7% of the patients reviewed were satisfied. According to the HSS knee score 78.9% of the results were excellent, 13.2% good, 7.9% fair and none was poor. Narrowing of the joint space was found in 28.9% of the injured and 5.3% of the unaffected knees and axial deviation of 5° to 10° in 15.8% of the injured and 10.5% of the unaffected knees. Of the 52 fractures, reduction was incomplete in one, and in two secondary displacement occurred, of which one required corrective osteotomy. Deep-venous thrombosis occurred in four cases. The technique has proved to be safe but demanding. It facilitates diagnosis and appropriate treatment of associated intra-articular
The natural history of spontaneous osteonecrosis of the medial tibial plateau remains controversial and incomplete. We have studied 21 patients (aged between 53 and 77 years) with clinical and scintigraphic features of spontaneous osteonecrosis of the medial tibial plateau who were observed prospectively for at least three years (37 months to 8.5 years). The mean duration of follow-up was 5.6 years. The mean duration of symptoms at presentation was 4.7 weeks (3 days to 12 weeks). Radiographs of the affected knee at the first visit were normal in 15 patients and mildly arthritic in six. The characteristic radiographic
The final results up to 15 years are reported of clinical trials of the management of tuberculosis of the spine in Korea and Hong Kong. In Korea, 350 patients with active spinal tuberculosis were randomised to ambulatory chemotherapy or bed rest in hospital (in Masan) or a plaster-of-Paris jacket for nine months (in Pusan). Patients in both centres were also randomised to either PAS plus isoniazid for 18 months or to the same drugs plus streptomycin for the first three months. In Hong Kong, all 150 patients were treated with the three-drug regime and randomised to either radical excision of the spinal
Different methods of anterior cruciate ligament (ACL) reconstruction
have been described for skeletally immature patients before closure
of the growth plates. However, the outcome and complications following
this treatment remain unclear. The aim of this systematic review
was to analyse the outcome and complications of different techniques
which may be used for reconstruction of the ACL in these patients. We performed a systematic review of the literature according
to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses
guidelines. This involved a comprehensive search of PubMed, Medline,
CINAHL, Cochrane, Embase and Google Scholar databases using the
following combinations of keywords, “knee”, “anterior cruciate ligament”,
“reconstruction”, “injury”, “children”, “adolescent”, “skeletally
immature”, “open physis” and “surgery”.Aims
Materials and Methods
The Bereiter trochleoplasty has been used in our unit for 12
years to manage recurrent patellar instability in patients with
severe trochlea dysplasia. The aim of this study was to document
the outcome of a large consecutive cohort of patients who have undergone
this operation. Between June 2002 and August 2013, 214 consecutive trochleoplasties
were carried out in 185 patients. There were 133 women and 52 men
with a mean age of 21.3 years (14 to 38). All patients were offered
yearly clinical and radiological follow-up. They completed the following
patient reported outcome scores (PROMs): International Knee Documentation
Committee subjective scale, the Kujala score, the Western Ontario
and McMaster Universities Arthritis Index score and the short-form
(SF)-12. Aims
Patients and Methods
The aim of this consensus was to develop a definition of post-operative
fibrosis of the knee. An international panel of experts took part in a formal consensus
process composed of a discussion phase and three Delphi rounds.Aims
Patients and Methods
We aimed to investigate factors related to the technique of medial
opening wedge high tibial osteotomy which might predispose to the
development of a lateral hinge fracture. A total of 71 patients with 82 osteotomies were included in the
study. Their mean age was 62.9 years (37 to 80). The classification
of the type of osteotomy was based on whether it extended beyond
the fibular head. The level of the osteotomy was classified according
to the height of its endpoint.Aims
Patients and Methods
Our aim was to examine the clinical and radiographic outcomes
in 257 consecutive Oxford unicompartmental knee arthroplasties (OUKAs)
(238 patients), five years post-operatively. A retrospective evaluation was undertaken of patients treated
between April 2008 and October 2010 in a regional centre by two
non-designing surgeons with no previous experience of UKAs. The
Oxford Knee Scores (OKSs) were recorded and fluoroscopically aligned
radiographs were assessed post-operatively at one and five years.Aims
Patients and Methods
The purpose of this study was to report the experience of dynamic
intraligamentary stabilisation (DIS) using the Ligamys device for
the treatment of acute ruptures of the anterior cruciate ligament
(ACL). Between March 2011 and April 2012, 50 patients (34 men and 16
women) with an acute rupture of the ACL underwent primary repair
using this device. The mean age of the patients was 30 years (18
to 50). Patients were evaluated for laxity, stability, range of
movement (ROM), Tegner, Lysholm, International Knee Documentation Committee
(IKDC) and visual analogue scale (VAS) scores over a follow-up period
of two years.Aims
Patients and Methods
Fractures around total knee arthroplasties pose
a significant surgical challenge. Most can be managed with osteosynthesis
and salvage of the replacement. The techniques of fixation of these
fractures and revision surgery have evolved and so has the assessment
of outcome. This specialty update summarises the current evidence
for the classification, methods of fixation, revision surgery and
outcomes of the management of periprosthetic fractures associated
with total knee arthroplasty. Cite this article:
The role of arthroscopy in the treatment of soft-tissue
injuries associated with proximal tibial fractures remains debatable.
Our hypothesis was that MRI over-diagnoses clinically relevant associated
soft-tissue injuries. This prospective study involved 50 consecutive
patients who underwent surgical treatment for a split-depression fracture
of the lateral tibial condyle (AO/OTA type B3.1). The mean age of
patients was 50 years (23 to 86) and 27 (54%) were female. All patients
had MRI and arthroscopy. Arthroscopy identified 12 tears of the
lateral meniscus, including eight bucket-handle tears that were
sutured and four that were resected, as well as six tears of the
medial meniscus, of which five were resected. Lateral meniscal injuries
were diagnosed on MRI in four of 12 patients, yielding an overall
sensitivity of 33% (95% confidence interval (CI) 11 to 65). Specificity
was 76% (95% CI 59 to 88), with nine tears diagnosed among 38 menisci
that did not contain a tear. MRI identified medial meniscal injuries
in four of six patients, yielding an overall sensitivity of 67%
(95% CI 24 to 94). Specificity was 66% (95% CI 50 to 79), with 15
tears diagnosed in 44 menisci that did not contain tears. MRI appears to offer only a marginal benefit as the specificity
and sensitivity for diagnosing meniscal injuries are poor in patients
with a fracture. There were fewer arthroscopically-confirmed associated
lesions than reported previously in MRI studies. Cite this article:
The purpose of this study was to clarify the appearance of the reparative tissue on the articular surface and to analyse the properties of the reparative tissue after hemicallotasis osteotomy (HCO) using MRI T1ρ and T2 mapping. Coronal T1ρ and T2 mapping and three-dimensional gradient-echo images were obtained from 20 subjects with medial knee osteoarthritis. We set the regions of interest (ROIs) on the full-thickness cartilage of the medial femoral condyle (MFC) and medial tibial plateau (MTP) of the knee and measured the cartilage thickness (mm) and T1ρ and T2 relaxation times (ms). Statistical analysis of time-dependent changes in the cartilage thickness and the T1ρ and T2 relaxation times was performed using one-way analysis of variance, and Scheffe’s test was employed for Objectives
Methods
A total of 22 patients with a tibial avulsion
fracture involving the insertion of the posterior cruciate ligament
(PCL) with grade II or III posterior laxity were reduced and fixed
arthroscopically using routine anterior and double posteromedial
portals. A double-strand Ethibond suture was inserted into the joint
and wrapped around the PCL from anterior to posterior to secure
the ligament above the avulsed bony fragment. Two tibial bone tunnels
were created using the PCL reconstruction guide, aiming at the medial
and lateral borders of the tibial bed. The ends of the suture were
pulled out through the bone tunnels and tied over the tibial cortex
between the openings of the tunnels to reduce and secure the bony
fragment. Satisfactory reduction of the fracture was checked arthroscopically and
radiographically. The patients were followed-up for a mean of 24.5 months (19 to
28). Bone union occurred six weeks post-operatively. At final follow-up,
all patients had a negative posterior drawer test and a full range
of movement. KT-1000 arthrometer examination showed that the mean
post-operative side-to-side difference improved from 10.9 mm (standard
deviation ( We conclude that this technique is convenient, reliable and minimally
invasive and successfully restores the stability and function of
the knee. Cite this article:
To examine the rates of hamstring graft salvage with arthroscopic
debridement of infected anterior cruciate ligament (ACL) reconstruction
as reported in the literature and discuss functional outcomes. A search was performed without language restriction on PubMed,
EMBASE, Ovid, CINAHL and Cochrane Register of Controlled Trials
(CENTRAL) databases from their inception to April 2015. We identified
147 infected hamstring grafts across 16 included studies. Meta-analysis
was performed using a random-effects model to estimate the overall
graft salvage rate, incorporating two different definitions of graft
salvage.Aims
Materials and Methods
The aim of this study was to evaluate the risk
factors for dislocation of the bearing after a mobile-bearing Oxford medial
unicompartmental knee replacement (UKR) and to test the hypothesis
that surgical factors, as measured from post-operative radiographs,
are associated with its dislocation From a total of 480 UKRs performed between 2001 and 2012, in
391 patients with a mean age of 66.5 years (45 to 82) (316 female,
75 male), we identified 17 UKRs where bearing dislocation occurred.
The post-operative radiological measurements of the 17 UKRs and
51 matched controls were analysed using conditional logistic regression analysis.
The post-operative radiological measurements included post-operative
change in limb alignment, the position of the femoral and tibial
components, the resection depth of the proximal tibia, and the femoral component-posterior
condyle classification. We concluded that a post-operative decrease in the posterior
tibial slope relative to the pre-operative value was the only significant
determinant of dislocation of the bearing after medial Oxford UKR
(odds ratio 1.881; 95% confidence interval 1.272 to 2.779). A post-operative
posterior tibial slope <
8.45° and a difference between the pre-operative
and post-operative posterior tibial slope of >
2.19° may increase
the risk of dislocation. Cite this article:
The management of failed autologous chondrocyte
implantation (ACI) and matrix-assisted autologous chondrocyte implantation
(MACI) for the treatment of symptomatic osteochondral defects in
the knee represents a major challenge. Patients are young, active
and usually unsuitable for prosthetic replacement. This study reports
the results in patients who underwent revision cartilage transplantation
of their original ACI/MACI graft for clinical or graft-related failure.
We assessed 22 patients (12 men and 10 women) with a mean age of
37.4 years (18 to 48) at a mean of 5.4 years (1.3 to 10.9). The
mean period between primary and revision grafting was 46.1 months
(7 to 89). The mean defect size was 446.6 mm2 (150 to
875) and they were located on 11 medial and two lateral femoral condyles,
eight patellae and one trochlea. The mean modified Cincinnati knee score improved from 40.5 (16
to 77) pre-operatively to 64.9 (8 to 94) at their most recent review
(p <
0.001). The visual analogue pain score improved from 6.1
(3 to 9) to 4.7 (0 to 10) (p = 0.042). A total of 14 patients (63%)
reported an ‘excellent’ (n = 6) or ‘good’ (n = 8) clinical outcome,
5 ‘fair’ and one ‘poor’ outcome. Two patients underwent patellofemoral
joint replacement. This study demonstrates that revision cartilage
transplantation after primary ACI and MACI can yield acceptable
functional results and continue to preserve the joint. Cite this article:
The aim of this study was to assess the effect
of injecting genetically engineered chondrocytes expressing transforming
growth factor beta 1 (TGF-β1) into the knees of patients with osteoarthritis.
We assessed the resultant function, pain and quality of life. A total of 54 patients (20 men, 34 women) who had a mean age
of 58 years (50 to 66) were blinded and randomised (1:1) to receive
a single injection of the active treatment or a placebo. We assessed
post-treatment function, pain severity, physical function, quality
of life and the incidence of treatment-associated adverse events. Patients
were followed at four, 12 and 24 weeks after injection. At final follow-up the treatment group had a significantly greater
improvement in the mean International Knee Documentation Committee
score than the placebo group (16 points; -18 to 49, This technique may result in improved clinical outcomes, with
the aim of slowing the degenerative process, leading to improvements
in pain and function. However, imaging and direct observational
studies are needed to verify cartilage regeneration. Nevertheless,
this study provided a sufficient basis to proceed to further clinical testing. Cite this article:
Because there have been no standard methods to determine pre-operatively
the thickness of resection of the proximal tibia in unicompartmental
knee arthroplasty (UKA), information about the relationship between
the change of limb alignment and the joint line elevation would
be useful for pre-operative planning. The purpose of this study
was to clarify the correlation between the change of limb alignment
and the change of joint line height at the medial compartment after
UKA. A consecutive series of 42 medial UKAs was reviewed retrospectively.
These patients were assessed radiographically both pre- and post-operatively
with standing anteroposterior radiographs. The thickness of bone
resection at the proximal tibia and the distal femur was measured
radiographically. The relationship between the change of femorotibial
angle (δFTA) and the change of joint line height, was analysed.Objectives
Methods
Focal femoral inlay resurfacing has been developed
for the treatment of full-thickness chondral defects of the knee. This
technique involves implanting a defect-sized metallic or ceramic
cap that is anchored to the subchondral bone through a screw or
pin. The use of these experimental caps has been advocated in middle-aged
patients who have failed non-operative methods or biological repair
techniques and are deemed unsuitable for conventional arthroplasty
because of their age. This paper outlines the implant design, surgical
technique and biomechanical principles underlying their use. Outcomes
following implantation in both animal and human studies are also reviewed. Cite this article:
The aim of this study was to compare the maximum
laxity conferred by the cruciate-retaining (CR) and posterior-stabilised
(PS) Triathlon single-radius total knee arthroplasty (TKA) for anterior
drawer, varus–valgus opening and rotation in eight cadaver knees
through a defined arc of flexion (0º to 110º). The null hypothesis
was that the limits of laxity of CR- and PS-TKAs are not significantly
different. The investigation was undertaken in eight loaded cadaver knees
undergoing subjective stress testing using a measurement rig. Firstly
the native knee was tested prior to preparation for CR-TKA and subsequently
for PS-TKA implantation. Surgical navigation was used to track maximal
displacements/rotations at 0º, 30º, 60º, 90º and 110° of flexion.
Mixed-effects modelling was used to define the behaviour of the
TKAs. The laxity measured for the CR- and PS-TKAs revealed no statistically
significant differences over the studied flexion arc for the two
versions of TKA. Compared with the native knee both TKAs exhibited
slightly increased anterior drawer and decreased varus-valgus and
internal-external roational laxities. We believe further study is required
to define the clinical states for which the additional constraint
offered by a PS-TKA implant may be beneficial. Cite this article:
Total knee replacement (TKR) is an operation
that can be performed with or without the use of a tourniquet. Meta-analyses
of the available Level-1 studies have demonstrated that the use
of a tourniquet leads to a significant reduction in blood loss.
The opponents for use of a tourniquet cite development of complications
such as skin bruising, neurovascular injury, and metabolic disturbance
as drawbacks. Although there may certainly be reason for concern
in arteriopathic patients, there is little evidence that routine
use of a tourniquet during TKR results in any of the above complications.
The use of a tourniquet, on the other hand, provides a bloodless
field that allows the surgeon to perform the procedure with expediency
and optimal visualisation. Blood conservation has gained great importance
in recent years due to increased understanding of the problems associated
with blood transfusion, such as increased surgical site infection
(due to immunomodulation effect), increased length of hospital stay
and increased cost. Based on the authors’ understanding of the available
evidence, the routine use of a tourniquet during TKR is justified
as good surgical practice. Cite this article:
We attempted to characterise the biological quality
and regenerative potential of chondrocytes in osteochondritis dissecans
(OCD). Dissected fragments from ten patients with OCD of the knee
(mean age 27.8 years (16 to 49)) were harvested at arthroscopy.
A sample of cartilage from the intercondylar notch was taken from
the same joint and from the notch of ten patients with a traumatic
cartilage defect (mean age 31.6 years (19 to 52)). Chondrocytes
were extracted and subsequently cultured. Collagen types 1, 2, and
10 mRNA were quantified by polymerase chain reaction. Compared with
the notch chondrocytes, cells from the dissecate expressed similar
levels of collagen types 1 and 2 mRNA. The level of collagen type
10 message was 50 times lower after cell culture, indicating a loss
of hypertrophic cells or genes. The high viability, retained capacity
to differentiate and metabolic activity of the extracted cells suggests
preservation of the intrinsic repair capability of these dissecates.
Molecular analysis indicated a phenotypic modulation of the expanded
dissecate chondrocytes towards a normal phenotype. Our findings
suggest that cartilage taken from the dissecate can be reasonably
used as a cell source for chondrocyte implantation procedures.
Injury to the anterior cruciate ligament (ACL)
is one of the most devastating and frequent injuries of the knee. Surgical
reconstruction is the current standard of care for treatment of
ACL injuries in active patients. The widespread adoption of ACL
reconstruction over primary repair was based on early perception
of the limited healing capacity of the ACL. Although the majority
of ACL reconstruction surgeries successfully restore gross joint stability,
post-traumatic osteoarthritis is commonplace following these injuries,
even with ACL reconstruction. The development of new techniques
to limit the long-term clinical sequelae associated with ACL reconstruction
has been the main focus of research over the past decades. The improved
knowledge of healing, along with recent advances in tissue engineering
and regenerative medicine, has resulted in the discovery of novel
biologically augmented ACL-repair techniques that have satisfactory
outcomes in preclinical studies. This instructional review provides
a summary of the latest advances made in ACL repair. Cite this article:
A small proportion of patients have persistent
pain after total knee replacement (TKR). The primary aim of this study
was to record the prevalence of pain after TKR at specific intervals
post-operatively and to ascertain the impact of neuropathic pain.
The secondary aim was to establish any predictive factors that could
be used to identify patients who were likely to have high levels
of pain or neuropathic pain after TKR. A total of 96 patients were included in the study. Their mean
age was 71 years (48 to 89); 54 (56%) were female. The mean follow-up
was 46 months (39 to 51). Pre-operative demographic details were
recorded including a Visual Analogue Score (VAS) for pain, the Hospital
Anxiety and Depression score as well as the painDETECT score for neuropathic
pain. Functional outcome was assessed using the Oxford Knee score. The mean pre-operative VAS was 5.8 (1 to 10); and it improved
significantly at all time periods post-operatively (p <
0.001):
(from 4.5 at day three to five (1 to 10), 3.2 at six weeks (0 to
9), 2.4 at three months (0 to 7), 2.0 at six months (0 to 9), 1.7
at nine months (0 to 9), 1.5 at one year (0 to 8) and 2.0 at mean
46 months (0 to 10)). There was a high correlation (r >
0.7; p <
0.001) between the mean VAS scores for pain and the mean painDETECT
scores at three months, one year and three years post-operatively.
There was no correlation between the pre-operative scores and any
post-operative scores at any time point. We report the prevalence of pain and neuropathic pain at various
intervals up to three years after TKR. Neuropathic pain is an underestimated
problem in patients with pain after TKR. It peaks at between six
weeks and three-months post-operatively. However, from these data
we were unable to predict which patients are most likely to be affected. Cite this article:
We analysed whether a high body mass index (BMI)
had a deleterious effect on outcome following autologous chondrocyte
implantation (ACI) or matrix-carried autologous chondrocyte implantation
(MACI) for the treatment of full-thickness chondral defects of the
knee from a subset of patients enrolled in the ACI vs MACI trial
at The Royal National Orthopaedic Hospital. The mean Modified Cincinnati scores (MCS) were significantly
higher (p <
0.001) post-operatively in patients who had an ideal
body weight (n = 53; 20 to 24.9 kg/m2) than in overweight
(n = 63; 25 to 30 kg/m2) and obese patients (n = 22;
>
30 kg/m2). At a follow-up of two years, obese patients
demonstrated no sustained improvement in the MCS. Patients with
an ideal weight experienced significant improvements as early as
six months after surgery (p = 0.007). In total, 82% of patients
(31 of 38) in the ideal group had a good or excellent result, compared
with 49% (22 of 45) of the overweight and 5.5% (one of 18) in the
obese group (p <
0.001). There was a significant negative relationship between
BMI and the MCS 24 months after surgery (r = -0.4, p = 0.001). This study demonstrates that obese patients have worse knee function
before surgery and experience no sustained benefit from ACI or MACI
at two years after surgery. There was a correlation between increasing
BMI and a lower MCS according to a linear regression analysis. On
the basis of our findings patient selection can be more appropriately
targeted.
We have investigated whether shape of the knee
can predict the clinical outcome of patients after an anterior cruciate
ligament rupture. We used statistical shape modelling to measure
the shape of the knee joint of 182 prospectively followed patients
on lateral and Rosenberg view radiographs of the knee after a rupture
of the anterior cruciate ligament. Subsequently, we associated knee
shape with the International Knee Documentation Committee subjective
score at two years follow-up. The mean age of patients was 31 years
(21 to 51), the majority were male (n = 121) and treated operatively
(n = 135). We found two modes (shape variations) that were significantly
associated with the subjective score at two years: one for the operatively
treated group (p = 0.002) and one for the non-operatively treated
group (p = 0.003). Operatively treated patients who had higher subjective
scores had a smaller intercondylar notch and a smaller width of
the intercondylar eminence. Non-operatively treated patients who
scored higher on the subjective score had a more pyramidal intercondylar
notch as opposed to one that was more dome-shaped. We conclude that
the shape of the femoral notch and the intercondylar eminence is predictive
of clinical outcome two years after a rupture of the anterior cruciate
ligament. Cite this article:
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.
Cartilage repair in terms of replacement, or
regeneration of damaged or diseased articular cartilage with functional tissue,
is the ‘holy grail’ of joint surgery. A wide spectrum of strategies
for cartilage repair currently exists and several of these techniques
have been reported to be associated with successful clinical outcomes
for appropriately selected indications. However, based on respective
advantages, disadvantages, and limitations, no single strategy, or
even combination of strategies, provides surgeons with viable options
for attaining successful long-term outcomes in the majority of patients.
As such, development of novel techniques and optimisation of current techniques
need to be, and are, the focus of a great deal of research from
the basic science level to clinical trials. Translational research
that bridges scientific discoveries to clinical application involves
the use of animal models in order to assess safety and efficacy
for regulatory approval for human use. This review article provides
an overview of animal models for cartilage repair. Cite this article:
We reviewed 5086 patients with a mean age of
30 years (9 to 69) undergoing primary reconstruction of the anterior cruciate
ligament (ACL) in order to determine the incidence of secondary
pathology with respect to the time between injury and reconstruction.
There was an increasing incidence of medial meniscal tears and chondral damage,
but not lateral meniscal tears, with increasing intervals before
surgery. The chances of requiring medial meniscal surgery was increased
by a factor of two if ACL reconstruction was delayed more than five
months, and increased by a factor of six if surgery was delayed
by >
12 months. The effect of delaying surgery on medial meniscal injury
was also pronounced in the patients aged <
17 years, where a
delay of five to 12 months doubled the odds of medial meniscal surgery
(odds ratio (OR) 2.0, p = 0.001) and a delay of >
12 months quadrupled
the odds (OR 4.3, p = 0.001). Increasing age was associated with
a greater odds of chondral damage (OR 4.6, p = 0.001) and medial meniscal
injury (OR 2.9, p = 0.001), but not lateral meniscal injury. The
gender split (3251 men, 1835 women) revealed that males had a greater
incidence of both lateral (34% (n = 1114) Cite this article:
Between 2003 and 2007, 99 knees in 77 patients
underwent opening wedge high tibial osteotomy. We evaluated the effect
of initial stable fixation combined with an artificial bone substitute
on the mid- to long-term outcome after medial opening-wedge high
tibial osteotomy (HTO) for medial compartmental osteoarthritis or
spontaneous osteonecrosis of the knee in 78 knees in 64 patients
available for review at a minimum of five years (mean age 68 years;
49 to 82). The mean follow-up was 6.5 years (5 to 10). The mean
Knee Society knee score and function score improved from 49.6 ( Opening-wedge HTO using a stable plate fixation system combined
with a bone substitute is a reliable procedure that provides excellent
results. Although this treatment might seem challenging for older
patients, our results strongly suggest that the results are equally
good. Cite this article:
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.
Mortality rates reported by the National Joint Registry for England
and Wales (NJR) were higher following cemented total knee replacement
(TKR) compared with uncemented procedures. The aim of this study
is to examine and compare the effects of cemented and uncemented
TKR on the activation of selected markers of inflammation, endothelium,
and coagulation, and on the activation of selected cytokines involved
in the various aspects of the systemic response following surgery. This was a single centre, prospective, case-control study. Following
enrolment, blood samples were taken pre-operatively, and further
samples were collected at day one and day seven post-operatively.
One patient in the cemented group developed a deep-vein thrombosis
confirmed on ultrasonography and was excluded, leaving 19 patients
in this cohort (mean age 67.4, (Objective
Methods
We investigated the role of a functional brace worn for four months in the treatment of patients with an acute isolated tear of the posterior cruciate ligament to determine whether reduction of the posterior tibial translation during the healing period would give an improved final position of the tibia. The initial and follow-up stability was tested by Rolimeter arthrometry and radiography. The clinical outcome was evaluated using the Lysholm score, the Tegner score and the International Knee Documentation Committee scoring system at follow-up at one and two years. In all, 21 patients were studied, 21 of whom had completed one-year and 17 a two-year follow-up. The initial mean posterior sag (Rolimeter measurement) of 7.1 mm (5 to 10) was significantly reduced after 12 months to a mean of 2.3 mm (0 to 6, p <
0.001) and to a mean of 3.2 mm (2 to 7, p = 0.001) after 24 months. Radiological measurement gave similar results. The mean pre-injury Lysholm score was normal at 98 (95 to 100). At follow-up, a slight decrease in the mean values was observed to 94.0 (79 to 100, p = 0.001) at one year and 94.0 (88 to 100, p = 0.027, at two years). We concluded that the posterior cruciate ligament has an intrinsic healing capacity and, if the posteriorly translated tibia is reduced to a physiological position, it can heal with less attentuation. The applied treatment produces a good to excellent functional result.
Popliteal artery injury (PAI) is a feared complication
during knee replacement. Our aim was to investigate those injuries
that occurred in association with knee replacement in terms of the
type of injury, treatment and outcomes. From our national vascular registry (Swedvasc) and the Swedish
Patient Insurance databases a total of 32 cases were identified.
Prospective data from the registries was supplemented with case-records,
including long-term follow-up. We estimated the incidence during 1998 to 2010 to be 0.017%.
In our series of 32 patients with PAI occurring between 1987 and
2011, 25 (78%) were due to penetrating trauma and seven were caused
by blunt trauma. The patients presented in three ways: bleeding
(14), ischaemia (7) and false aneurysm formation (11), and five
occurred during revision surgery. A total of 12 injuries were detected
intra-operatively, eight within 24 hours (3 to 24) and 12 at more
than 24 hours post-operatively (2 to 90 days). Treatment comprised
open surgery in 28 patients. Patency of the vascular repair at 30
days was 97% (31 of 32, one amputation). At the time of follow-up
(median 546 days, mean 677 days (24 to 1251)), 25 patients had residual
symptoms. Of seven patients with a complete recovery, six had had
an early diagnosis of the PAI during the procedure, and were treated
by a vascular surgeon in the same hospital. PAI is a rare adverse event during knee replacement surgery.
The outcome following such events is often adversely affected by
diagnostic and therapeutic delay. Bleeding and false aneurysm were
the most common clinical presentations. Cite this article:
In an initial randomised controlled trial (RCT)
we segregated 180 patients to one of two knee positions following total
knee replacement (TKR): six hours of knee flexion using either a
jig or knee extension. Outcome measures included post-operative
blood loss, fall in haemoglobin, blood transfusion requirements,
knee range of movement, limb swelling and functional scores. A second
RCT consisted of 420 TKR patients randomised to one of three post-operative
knee positions: flexion for three or six hours post-operatively,
or knee extension. Positioning of the knee in flexion for six hours immediately
after surgery significantly reduced blood loss (p = 0.002). There
were no significant differences in post-operative range of movement,
swelling, pain or outcome scores between the various knee positions
in either study. Post-operative knee flexion may offer a simple
and cost-effective way to reduce blood loss and transfusion requirements
following TKR. We also report a cautionary note regarding the potential risks
of prolonged knee flexion for more than six hours observed during
clinical practice in the intervening period between the two trials,
with 14 of 289 patients (4.7%) reporting lower limb sensory neuropathy
at their three-month review. Cite this article:
The Oxford Unicompartmental Knee replacement (UKR) was introduced as a design to reduce polyethylene wear. There has been one previous retrieval study involving this implant, which reported very low rates of wear in some specimens but abnormal patterns of wear in others. There has been no further investigation of these abnormal patterns. The bearings were retrieved from 47 patients who had received a medial Oxford UKR for anteromedial osteoarthritis of the knee. None had been studied previously. The mean time to revision was 8.4 years ( These results show that very low rates of polyethylene wear are possible if the device functions normally. However, if the bearing displays suboptimal function (extra-articular, intra-articular impingement or incongruous articulation) the rates of wear increase significantly.