We prospectively randomised 78 patients into two groups, ‘drains’ or ‘no drains’ to assess the effectiveness of suction drains in reducing
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
Knowledge on total knee arthroplasties (TKAs) in patients with a history of poliomyelitis is limited. This study compared implant survivorship and clinical outcomes among affected and unaffected limbs in patients with sequelae of poliomyelitis undergoing TKAs. A retrospective review of our total joint registry identified 94 patients with post-polio syndrome undergoing 116 primary TKAs between January 2000 and December 2019. The mean age was 70 years (33 to 86) with 56% males (n = 65) and a mean BMI of 31 kg/m2 (18 to 49). Rotating hinge TKAs were used in 14 of 63 affected limbs (22%), but not in any of the 53 unaffected limbs. Kaplan-Meier survivorship analyses were completed. The mean follow-up was eight years (2 to 19).Aims
Methods
To identify unanswered questions about the prevention, diagnosis, treatment, and rehabilitation and delivery of care of first-time soft-tissue knee injuries (ligament injuries, patella dislocations, meniscal injuries, and articular cartilage) in children (aged 12 years and older) and adults. The James Lind Alliance (JLA) methodology for Priority Setting Partnerships was followed. An initial survey invited patients and healthcare professionals from the UK to submit any uncertainties regarding soft-tissue knee injury prevention, diagnosis, treatment, and rehabilitation and delivery of care. Over 1,000 questions were received. From these, 74 questions (identifying common concerns) were formulated and checked against the best available evidence. An interim survey was then conducted and 27 questions were taken forward to the final workshop, held in January 2023, where they were discussed, ranked, and scored in multiple rounds of prioritization. This was conducted by healthcare professionals, patients, and carers.Aims
Methods
To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration. We performed a systematic literature search in MEDLINE, Embase, and Web of Science. The search string included multiple synonyms of the following keywords: "revision TKA", "outcome" and "prognostic factor". We searched for studies assessing the association between at least one prognostic factor and at least one outcome measure after rTKA surgery. Data on sample size, study design, prognostic factors, outcomes, and the direction of the association was extracted and included in an evidence map.Aims
Methods
The use of cementless total knee arthroplasty (TKA) components has increased during the past decade. The initial design of cementless metal-backed patellar components had shown high failure rates due to many factors. The aim of this study was to evaluate the clinical results of a second-generation cementless, metal-backed patellar component of a modern design. This was a retrospective review of 707 primary TKAs in 590 patients from a single institution, using a cementless, metal-backed patellar component with a mean follow-up of 6.9 years (2 to 12). A total of 409 TKAs were performed in 338 females and 298 TKAs in 252 males. The mean age of the patients was 63 years (34 to 87) and their mean BMI was 34.3 kg/m2 (18.8 to 64.5). The patients were chosen to undergo a cementless procedure based on age and preoperative radiological and intraoperative bone quality. Outcome was assessed using the Knee Society knee and function scores and range of motion (ROM), complications, and revisions.Aims
Methods
The optimal bearing surface design for medial unicompartmental knee arthroplasty (UKA) remains controversial. The aim of this study was to compare outcomes of fixed-bearing (FB) and mobile-bearing (MB) UKAs from a single high-volume institution. Prospectively collected data were reviewed for all primary cemented medial UKAs performed by seven surgeons from January 2006 to December 2022. A total of 2,999 UKAs were identified, including 2,315 FB and 684 MB cases. The primary outcome measure was implant survival. Secondary outcomes included 90-day and cumulative complications, reoperations, component revisions, conversion arthroplasties, range of motion, and patient-reported outcome measures. Overall mean age at surgery was 65.7 years (32.9 to 94.3), 53.1% (1,593/2,999) of UKAs were implanted in female patients, and demographics between groups were similar (p > 0.05). The mean follow-up for all UKAs was 3.7 years (0.0 to 15.6).Aims
Methods
This study investigated the effects of transcatheter arterial embolization (TAE) on pain, function, and quality of life in people with early-stage symptomatic knee osteoarthritis (OA) compared to a sham procedure. A total of 59 participants with symptomatic Kellgren-Lawrence grade 2 knee OA were randomly allocated to TAE or a sham procedure. The intervention group underwent TAE of one or more genicular arteries. The control group received a blinded sham procedure. The primary outcome was knee pain at 12 months according to the Knee injury and Osteoarthritis Outcome Score (KOOS) pain scale. Secondary outcomes included self-reported function and quality of life (KOOS, EuroQol five-dimension five-level questionnaire (EQ-5D-5L)), self-reported Global Change, six-minute walk test, 30-second chair stand test, and adverse events. Subgroup analyses compared participants who received complete embolization of all genicular arteries (as distinct from embolization of some arteries) (n = 17) with the control group (n = 29) for KOOS and Global Change scores at 12 months. Continuous variables were analyzed with quantile regression, adjusting for baseline scores. Dichotomized variables were analyzed with chi-squared tests.Aims
Methods
Total knee arthroplasty (TKA) with a highly congruent condylar-stabilized (CS) articulation may be advantageous due to increased stability versus cruciate-retaining (CR) designs, while mitigating the limitations of a posterior-stabilized construct. The aim was to assess ten-year implant survival and functional outcomes of a cemented single-radius TKA with a CS insert, performed without posterior cruciate ligament sacrifice. This retrospective cohort study included consecutive patients undergoing TKA at a specialist centre in the UK between November 2010 and December 2012. Data were collected using a bespoke electronic database and cross-referenced with national arthroplasty audit data, with variables including: preoperative characteristics, intraoperative factors, complications, and mortality status. Patient-reported outcome measures (PROMs) were collected by a specialist research team at ten years post-surgery. There were 536 TKAs, of which 308/536 (57.5%) were in female patients. The mean age was 69.0 years (95% CI 45.0 to 88.0), the mean BMI was 32.2 kg/m2 (95% CI 18.9 to 50.2), and 387/536 (72.2%) survived to ten years. There were four revisions (0.7%): two deep infections (requiring debridement and implant retention), one aseptic loosening, and one haemosiderosis.Aims
Methods
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. The OCD lesion was created on the trochlear groove of left articular cartilage of femur per rat (40 rats in total). The experimental groups were Sham, OCD, and ESWT (0.25 mJ/mm2, 800 impulses, 4 Hz). The animals were euthanized at 2, 4, 8, and 12 weeks post-treatment, and histopathological analysis, micro-CT scanning, and immunohistochemical staining were performed for the specimens.Aims
Methods
The aim of this study was to report patient and clinical outcomes following robotic-assisted total knee arthroplasty (RA-TKA) at multiple institutions with a minimum two-year follow-up. This was a multicentre registry study from October 2016 to June 2021 that included 861 primary RA-TKA patients who completed at least one pre- and postoperative patient-reported outcome measure (PROM) questionnaire, including Forgotten Joint Score (FJS), Knee Injury and Osteoarthritis Outcomes Score for Joint Replacement (KOOS JR), and pain out of 100 points. The mean age was 67 years (35 to 86), 452 were male (53%), mean BMI was 31.5 kg/m2 (19 to 58), and 553 (64%) cemented and 308 (36%) cementless implants.Aims
Methods
Endoprosthetic reconstruction with a distal femoral arthroplasty (DFA) can be used to treat distal femoral bone loss from oncological and non-oncological causes. This study reports the short-term implant survivorship, complications, and risk factors for patients who underwent DFA for non-neoplastic indications. We performed a retrospective review of 75 patients from a single institution who underwent DFA for non-neoplastic indications, including aseptic loosening or mechanical failure of a previous prosthesis (n = 25), periprosthetic joint infection (PJI) (n = 23), and native or periprosthetic distal femur fracture or nonunion (n = 27). Patients with less than 24 months’ follow-up were excluded. We collected patient demographic data, complications, and reoperations. Reoperation for implant failure was used to calculate implant survivorship.Aims
Methods
Periprosthetic joint infection (PJI) occurs in approximately 1% to 2% of total knee arthroplasties (TKA) presenting multiple challenges, such as difficulty in diagnosis, technical complexity, and financial costs. Two-stage exchange is the gold standard for treating PJI but emerging evidence suggests 'two-in-one' single-stage revision as an alternative, delivering comparable outcomes, reduced morbidity, and cost-effectiveness. This study investigates five-year results of modified single-stage revision for treatment of PJI following TKA with bone loss. Patients were identified from prospective data on all TKA patients with PJI following the primary procedure. Inclusion criteria were: revision for PJI with bone loss requiring reconstruction, and a minimum five years’ follow-up. Patients were followed up for recurrent infection and assessment of function. Tools used to assess function were Oxford Knee Score (OKS) and American Knee Society Score (AKSS).Aims
Methods
Varus-valgus constrained (VVC) devices are typically used in revision settings, often with stems to mitigate the risk of aseptic loosening. However, in at least one system, the VVC insert is compatible with the primary posterior-stabilized (PS) femoral component, which may be an option in complex primary situations. We sought to determine the implant survivorship, radiological and clinical outcomes, and complications when this VVC insert was coupled with a PS femur without stems in complex primary total knee arthroplasties (TKAs). Through our institution’s total joint registry, we identified 113 primary TKAs (103 patients) performed between 2007 and 2017 in which a VVC insert was coupled with a standard cemented PS femur without stems. Mean age was 68 years (SD 10), mean BMI was 32 kg/m2 (SD 7), and 59 patients (50%) were male. Mean follow-up was four years (2 to 10).Aims
Methods
Limb alignment in total knee arthroplasty (TKA) influences periarticular soft-tissue tension, biomechanics through knee flexion, and implant survival. Despite this, there is no uniform consensus on the optimal alignment technique for TKA. Neutral mechanical alignment facilitates knee flexion and symmetrical component wear but forces the limb into an unnatural position that alters native knee kinematics through the arc of knee flexion. Kinematic alignment aims to restore native limb alignment, but the safe ranges with this technique remain uncertain and the effects of this alignment technique on component survivorship remain unknown. Anatomical alignment aims to restore predisease limb alignment and knee geometry, but existing studies using this technique are based on cadaveric specimens or clinical trials with limited follow-up times. Functional alignment aims to restore the native plane and obliquity of the joint by manipulating implant positioning while limiting soft tissue releases, but the results of high-quality studies with long-term outcomes are still awaited. The drawbacks of existing studies on alignment include the use of surgical techniques with limited accuracy and reproducibility of achieving the planned alignment, poor correlation of intraoperative data to long-term functional outcomes and implant survivorship, and a paucity of studies on the safe ranges of limb alignment. Further studies on alignment in TKA should use surgical adjuncts (e.g. robotic technology) to help execute the planned alignment with improved accuracy, include intraoperative assessments of knee biomechanics and periarticular soft-tissue tension, and correlate alignment to long-term functional outcomes and survivorship.
The optimal management of an infrapopliteal deep venous thrombosis (IDVT) following total knee arthroplasty (TKA) remains unknown. The risk of DVT propagation and symptom progression must be balanced against potential haemorrhagic complications associated with administration of anticoagulation therapy. The current study reports on a cohort of patients diagnosed with IDVT following TKA who were treated with aspirin, followed closely for development of symptoms, and scanned with ultrasound to determine resolution of IDVT. Among a cohort of 5,078 patients undergoing TKA, 532 patients (695 TKAs, 12.6%) developed an IDVT between 1 January 2014 to 31 December 2019 at a single institution, as diagnosed using Doppler ultrasound at the first postoperative visit. Of the entire cohort of 532 patients with IDVT, 91.4% (486/532) were treated with aspirin (325 mg twice daily) and followed closely. Repeat lower limb ultrasound was performed four weeks later to evaluate the status of IDVT.Aims
Methods
To describe the risk of periprosthetic joint infection (PJI) and reoperation in patients who have an acute, traumatic wound dehiscence following total knee arthroplasty (TKA). From January 2002 to December 2018, 16,134 primary TKAs were performed at a single institution. A total of 26 patients (0.1%) had a traumatic wound dehiscence within the first 30 days. Mean age was 68 years (44 to 87), 38% (n = 10) were female, and mean BMI was 34 kg/m2 (23 to 48). Median time to dehiscence was 13 days (interquartile range (IQR) 4 to 15). The dehiscence resulted from a fall in 22 patients and sudden flexion after staple removal in four. The arthrotomy was also disrupted in 58% (n = 15), including a complete extensor mechanism disruption in four knees. An irrigation and debridement with component retention (IDCR) was performed within 48 hours in 19 of 26 knees and two-thirds were discharged on antibiotic therapy. The mean follow-up was six years (2 to 15). The association of wound dehiscence and the risk of developing a PJI was analyzed.Aims
Methods
Varus-valgus constrained (VVC) implants are often used during revision total knee arthroplasty (TKA) to gain coronal plane stability. However, the increased mechanical torque applied to the bone-cement interface theoretically increases the risk of aseptic loosening. We assessed mid-term survivorship, complications, and clinical outcomes of a fixed-bearing VVC device in revision TKAs. A total of 416 consecutive revision TKAs (398 patients) were performed at our institution using a single fixed-bearing VVC TKA from 2007 to 2015. Mean age was 64 years (33 to 88) with 50% male (199). Index revision TKA diagnoses were: instability (n = 122, 29%), aseptic loosening (n = 105, 25%), and prosthetic joint infection (PJI) (n = 97, 23%). All devices were cemented on the epiphyseal surfaces. Femoral stems were used in 97% (n = 402) of cases, tibial stems in 95% (n = 394) of cases; all were cemented. In total, 93% (n = 389) of cases required a stemmed femoral and tibial component. Femoral cones were used in 29%, and tibial cones in 40%. Survivorship was assessed via competing risk analysis; clinical outcomes were determined using Knee Society Scores (KSSs) and range of movement (ROM). Mean follow-up was four years (2 to 10).Aims
Methods
In patients with a “dry” aspiration during the investigation of prosthetic joint infection (PJI), saline lavage is commonly used to obtain a sample for analysis. The aim of this study was to investigate prospectively the impact of saline lavage on synovial fluid analysis in revision arthroplasty. Patients undergoing revision hip (THA) or knee arthroplasty (TKA) for any septic or aseptic indication were enrolled. Intraoperatively, prior to arthrotomy, the maximum amount of fluid possible was aspirated to simulate a dry tap (pre-lavage) followed by the injection with 20 ml of normal saline and re-aspiration (post-lavage). Pre- and post-lavage synovial white blood cell (WBC) count, percent polymorphonuclear cells (%PMN), and cultures were compared.Aims
Methods
The purpose of this study was to compare outcomes of combined total joint arthroplasty (TJA) (total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed during the same admission) versus bilateral THA, bilateral TKA, single THA, and single TKA. Combined TJAs performed on the same day were compared with those staged within the same admission episode. Data from the National (Nationwide) Inpatient Sample recorded between 2005 and 2014 were used for this retrospective cohort study. Postoperative in-hospital complications, total costs, and discharge destination were reviewed. Logistic and linear regression were used to perform the statistical analyses. p-values less than 0.05 were considered statistically significant.Aims
Patients and Methods
The aim of this study was to determine whether closed suction drain (CSD) use influences recovery of quadriceps strength and to examine the effects of drain use on secondary outcomes: quadriceps activation, intra-articular effusion, bioelectrical measure of swelling, range of movement (ROM), pain, and wound healing complications. A total of 29 patients undergoing simultaneous bilateral total knee arthroplasty (TKA) were enrolled in a prospective, randomized blinded study. Patients were randomized to receive a CSD in one limb while the contralateral limb had the use of a subcutaneous drain (SCDRN) without the use of suction (‘sham drain’). Isometric quadriceps strength was collected as the primary outcome. Secondary outcomes consisted of quadriceps activation, intra-articular effusion measured via ultrasound, lower limb swelling measured with bioelectrical impendence and limb girth, knee ROM, and pain. Outcomes were assessed preoperatively and postoperatively at day two, two and six weeks, and three months. Differences between limbs were determined using paired Student’s Aims
Patients 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
Between 15% and 20% of patients remain dissatisfied following total knee arthroplasty (TKA). The SAIPH knee system (MatOrtho, Surrey, United Kingdom) is a medial ball and socket TKA that has been designed to replicate native knee kinematics in order to maximize the range of movement, stability, and function. This system is being progressively introduced in a stepwise fashion, with this study reporting the mid-term clinical and radiological outcomes. A retrospective review was undertaken of the first 100 consecutive patients with five-year follow-up following SAIPH TKA performed by the senior authors. The data that were collected included the demographics of the patients, clinical findings, the rate of intraoperative ligamentous release, patient-reported outcome measures (PROMS), radiological assessment, complications, and all-cause revision. Revision data were cross-checked with a national registry.Aims
Patients and Methods
As the population ages, there is projected to be an increase in the level of demand for total knee arthroplasty (TKA) in octogenarians. We aimed to explore whether those aged ≥ 80 years achieved similar improvements in physical function to younger patients while also comparing the rates of length of stay (LOS), discharge to rehabilitation, postoperative complications, and mortality following TKA in older and younger patients. Patients from one institution who underwent primary elective TKA between 1 January 2006 and 31 December 2014 were dichotomized into those ≥ 80 years old (n = 359) and those < 80 years old (n = 2479) for comparison. Multivariable regression was used to compare the physical status component of the 12-Item Short-Form Health Survey (SF-12), LOS, discharge to rehabilitation, complications, and mortality between the two groups.Aims
Patients and Methods
The aim of this study was to identify the most effective regimen
of multiple doses of oral tranexamic acid (TXA) in achieving maximum
reduction of blood loss in total knee arthroplasty (TKA). In this randomized controlled trial, 200 patients were randomized
to receive a single dose of 2.0 g of TXA orally two hours preoperatively
(group A), a single dose of TXA followed by 1.0 g orally three hours
postoperatively (group B), a single dose of TXA followed by 1.0 g
three and nine hours postoperatively (group C), or a single dose
of TXA followed by 1.0 g orally three, nine, and 15 hours postoperatively
(group D). All patients followed a routine enhanced-recovery protocol.
The primary outcome measure was the total blood loss. Secondary
outcome measures were hidden blood loss (HBL), reduction in the
level of haemoglobin, the rate of transfusion and adverse events.Aims
Patients and Methods
The aim of this study was to evaluate the effects of using a
portable, accelerometer-based surgical navigation system (KneeAlign2)
in total knee arthroplasty (TKA) on the alignment of the femoral
component, and blood loss. A total of 241 consecutive patients with primary osteoarthritis
of the knee were enrolled in this prospective, randomised controlled
study. There were 207 women and 34 men. The mean age of the patients
was 74.0 years (57 to 89). The KneeAlign2 system was used for distal
femoral resection in 121 patients (KA2 group) and a conventional intramedullary
femoral guide was used in 120 patients (IM group).Aims
Patients and Methods
The length of the tourniquet time during total knee arthroplasty (TKA) is related to the incidence of post-operative deep vein thrombosis (DVT). Our aim in this study was to investigate the effect of the early release of the tourniquet on the incidence of DVT in patients undergoing TKA. A total of 200 patients who underwent TKA between November 2015 and November 2016 were prospectively enrolled. The tourniquet was inflated before surgery and released immediately after the introduction of the components (early release group). This group was compared with a retrospective cohort of 200 primary TKAs, in which the tourniquet was released after the dressings had been applied (late release group). The presence of a DVT was detected using bilateral lower limb ultrasonography. Peri-operative clinical and follow-up data were collected for analysis.Objectives
Methods
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 number of revision total knee arthroplasties (TKA) that are
performed is expected to increase. However, previous reports of
the causes of failure after TKA are limited in that they report
the causes at specific institutions, which are often dependent on
referral patterns. Our aim was to report the most common indications
for re-operations and revisions in a large series of posterior-stabilised
TKAs undertaken at a single institution, excluding referrals from
elsewhere, which may bias the causes of failure. A total of 5098 TKAs which were undertaken between 2000 and 2012
were included in the study. Re-operations, revisions with modular
component exchange, and revisions with non-modular component replacement
or removal were identified from the medical records. The mean follow-up
was five years (two to 12).Aims
Patients and Methods
The aim of this study was to compare the effectiveness of a femoral
nerve block and a periarticular infiltration in the management of
early post-operative pain after total knee arthroplasty (TKA). A pragmatic, single centre, two arm parallel group, patient blinded,
randomised controlled trial was undertaken. All patients due for
TKA were eligible. Exclusion criteria included contraindications
to the medications involved in the study and patients with a neurological
abnormality of the lower limb. Patients received either a femoral
nerve block with 75 mg of 0.25% levobupivacaine hydrochloride around
the nerve, or periarticular infiltration with 150 mg of 0.25% levobupivacaine
hydrochloride, 10 mg morphine sulphate, 30 mg ketorolac trometamol
and 0.25 mg of adrenaline all diluted with 0.9% saline to make a
volume of 150 ml.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 aim of this to study was to compare the previously unreported
long-term survival outcome of the Oxford medial unicompartmental
knee arthroplasty (UKA) performed by trainee surgeons and consultants. We therefore identified a previously unreported cohort of 1084
knees in 947 patients who had a UKA inserted for anteromedial knee
arthritis by consultants and surgeons in training, at a tertiary
arthroplasty centre and performed survival analysis on the group
with revision as the endpoint.Aims
Patients and Methods
Haematomas, drainage, and other non-infectious
wound complications following total knee replacement (TKR) have
been associated with long-term sequelae, in particular, deep infection.
However, the impact of these wound complications on clinical outcome
is unknown. This study compares results in 15 patients re-admitted
for wound complications within 90 days of TKR to 30 matched patients
who underwent uncomplicated total knee replacements. Patients with
wound complications had a mean age of 66 years (49 to 83) and mean
body mass index (BMI) of 37 (21 to 54), both similar to that of
patients without complications (mean age 65 years and mean BMI 35). Those
with complications had lower mean Knee Society function scores (46
(0 to 100 Cite this article:
This non-blinded randomised controlled trial compared the effect
of patient-controlled epidural analgesia (PCEA) A total of 242 patients were randomised; 20 were excluded due
to failure of spinal anaesthesia leaving 109 patients in the PCEA
group and 113 in the LIA group. Patients were reviewed at six weeks
and one year post-operatively.Aims
Patients and Methods
The objective of this study was to determine if the use of fascia lata as a tendon regeneration guide (placed into the tendon canal following harvesting the semitendinosus tendon) would improve the incidence of tissue regeneration and prevent fatty degeneration of the semitendinosus muscle. Bilateral semitendinosus tendons were harvested from rabbits using a tendon stripper. On the inducing graft (IG) side, the tendon canal and semitendinosus tibial attachment site were connected by the fascia lata, which was harvested at the same width as the semitendinosus tendon. On the control side, no special procedures were performed. Two groups of six rabbits were killed at post-operative weeks 4 and 8, respectively. In addition, three healthy rabbits were killed to obtain normal tissue. We evaluated the incidence of tendon tissue regeneration, cross-sectional area of the regenerated tendon tissue and proportion of fatty tissue in the semitendinosus muscle.Objectives
Materials and Methods
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:
Satisfactory primary wound healing following
total joint replacement is essential. Wound healing problems can
have devastating consequences for patients. Assessment of their healing
capacity is useful in predicting complications. Local factors that
influence wound healing include multiple previous incisions, extensive
scarring, lymphoedema, and poor vascular perfusion. Systemic factors
include diabetes mellitus, inflammatory arthropathy, renal or liver
disease, immune compromise, corticosteroid therapy, smoking, and
poor nutrition. Modifications in the surgical technique are necessary
in selected cases to minimise potential wound complications. Prompt
and systematic intervention is necessary to address any wound healing
problems to reduce the risks of infection and other potential complications. Cite this article:
Total knee replacement (TKR) is one of the most
common operations in orthopaedic surgery worldwide. Despite its
scientific reputation as mainly successful, only 81% to 89% of patients
are satisfied with the final result. Our understanding of this discordance
between patient and surgeon satisfaction is limited. In our experience,
focus on five major factors can improve patient satisfaction rates:
correct patient selection, setting of appropriate expectations,
avoiding preventable complications, knowledge of the finer points
of the operation, and the use of both pre- and post-operative pathways.
Awareness of the existence, as well as the identification of predictors
of patient–surgeon discordance should potentially help with enhancing
patient outcomes. Cite this article:
In this paper, we consider wound healing after
total knee arthroplasty.
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:
The aims of this retrospective study were to
compare the mid-term outcomes following revision total knee replacement
(TKR) in 76 patients (81 knees) <
55 years of age with those
of a matched group of primary TKRs based on age, BMI, gender and
comorbid conditions. We report the activity levels, functional scores,
rates of revision and complications. Compared with patients undergoing
primary TKR, those undergoing revision TKR had less improvement
in the mean Knee Society function scores (8.14 (–55 to +60) Young patients undergoing revision TKR should be counselled that
they can expect somewhat less improvement and a higher risk of complications
than occur after primary TKR. Cite this article:
The aim of this study was to examine the functional
outcome at ten years following lateral closing wedge high tibial osteotomy
for medial compartment osteoarthritis of the knee and to define
pre-operative predictors of survival and determinants of functional
outcome. 164 consecutive patients underwent high tibial osteotomy between
2000 and 2002. A total of 100 patients (100 knees) met the inclusion
criteria and 95 were available for review at ten years. Data were
collected prospectively and included patient demographics, surgical
details, long leg alignment radiographs, Western Ontario and McMaster Universities
osteoarthritis index (WOMAC) and Knee Society scores (KSS) pre-operatively
and at five and ten years follow-up. At ten years, 21 patients had been revised at a mean of five
years. Overall Kaplan–Meier survival was 87% (95% confidence interval
(CI) 81 to 94) and 79% (95% CI 71 to 87) at five and ten years,
respectively. When compared with unrevised patients, those who had
been revised had significantly lower mean pre-operative WOMAC Scores
(47 (21 to 85) This study has shown that improved survival is associated with
age <
55 years, pre-operative WOMAC scores >
45 and, a BMI <
30. In patients over 55 years of age with adequate pre-operative
functional scores, survival can be good and functional outcomes
can be significantly better than their younger counterparts. We
recommend the routine use of pre-operative functional outcome scores
to guide decision-making when considering suitability for high tibial osteotomy. Cite this article:
We present detailed information about early morbidity
after aseptic revision knee replacement from a nationwide study.
All aseptic revision knee replacements undertaken between 1st October
2009 and 30th September 2011 were analysed using the Danish National
Patient Registry with additional information from the Danish Knee
Arthroplasty Registry. The 1218 revisions involving 1165 patients
were subdivided into total revisions, large partial revisions, partial
revisions and revisions of unicondylar replacements (UKR revisions).
The mean age was 65.0 years (27 to 94) and the median length of
hospital stay was four days (interquartile range: 3 to 5), with
a 90 days re-admission rate of 9.9%,
re-operation rate of 3.5% and mortality rate of 0.2%. The age ranges
of 51 to 55 years (p = 0.018), 76 to 80 years (p <
0.001) and ≥ 81
years (p <
0.001) were related to an increased risk of re-admission.
The age ranges of 76 to 80 years (p = 0.018) and the large partial
revision subgroup (p = 0.073) were related to an increased risk
of re-operation. The ages from 76 to 80 years (p <
0.001), age ≥ 81
years (p <
0.001) and surgical time >
120 min (p <
0.001)
were related to increased length of hospital stay, whereas the use
of a tourniquet (p = 0.008) and surgery in a low volume centre (p
= 0.013) were related to shorter length of stay. In conclusion, we found a similar incidence of early post-operative
morbidity after aseptic knee revisions as has been reported after
primary procedures. This suggests that a length of hospital stay ≤ four
days and discharge home at that time is safe following aseptic knee
revision surgery in Denmark. Cite this article:
We have previously reported the short-term radiological
results of a randomised controlled trial comparing kinematically
aligned total knee replacement (TKR) and mechanically aligned TKR,
along with early pain and function scores. In this study we report
the two-year clinical results from this trial. A total of 88 patients
(88 knees) were randomly allocated to undergo either kinematically
aligned TKR using patient-specific guides, or mechanically aligned
TKR using conventional instruments. They were analysed on an intention-to-treat
basis. The patients and the clinical evaluator were blinded to the
method of alignment. At a minimum of two years, all outcomes were better for the kinematically
aligned group, as determined by the mean Oxford knee score (40 (15
to 48) In this study, the use of a kinematic alignment technique performed
with patient-specific guides provided better pain relief and restored
better function and range of movement than the mechanical alignment
technique performed with conventional instruments. Cite this article:
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:
The outcome of high tibial osteotomy (HTO) deteriorates
with time, and additional procedures may be required. The aim of
this study was to compare the clinical and radiological outcomes
between unicompartmental knee replacement (UKR) and total knee replacement
(TKR) after HTO as well as after primary UKR. A total of 63 patients (63
knees) were studied retrospectively and divided into three groups:
UKR after HTO (group A; n = 22), TKR after HTO (group B; n = 18)
and primary UKR (group C; n = 22). The Oxford knee score (OKS),
Knee Society score (KSS), hip–knee–ankle angles, mechanical axis
and patellar height were evaluated pre- and post-operatively. At
a mean of 64 months (19 to 180) post-operatively the mean OKS was
43.8 (33 to 49), 43.3 (30 to 48) and 42.5 (29 to 48) for groups
A, B and C, respectively (p = 0.73). The mean KSS knee score was
88.8 (54 to 100), 88.11 (51 to 100) and 85.3 (45 to 100) for groups
A, B and C, respectively (p = 0.65), and the mean KSS function score
was 85.0 (50 to 100) in group A, 85.8 (20 to 100) in group B and
79.3 (50 to 100) in group C (p = 0.48). Radiologically the results
were comparable for all groups except for patellar height, with
a higher incidence of patella infra following a previous HTO (p
= 0.02). Cite this article:
We evaluated the impact of pre-coating the tibial
component with polymethylmethacrylate (PMMA) on implant survival
in a cohort of 16 548 primary NexGen total knee replacements (TKRs)
in 14 113 patients. In 13 835 TKRs a pre-coated tray was used while
in 2713 TKRs the non-pre-coated version of the same tray was used.
All the TKRs were performed between 2001 and 2009 and were cemented.
TKRs implanted with a pre-coated tibial component had a lower cumulative
survival than those with a non-pre-coated tibial component (p =
0.01). After adjusting for diagnosis, age, gender, body mass index,
American Society of Anesthesiologists grade, femoral coupling design, surgeon
volume and hospital volume, pre-coating was an independent risk
factor for all-cause aseptic revision (hazard ratio 2.75, p = 0.006).
Revision for aseptic loosening was uncommon for both pre-coated
and non-pre-coated trays (rates of 0.12% and 0%, respectively).
Pre-coating with PMMA does not appear to be protective of revision
for this tibial tray design at short-term follow-up. Cite this article:
Intra-operative, peri-articular injection of
local anaesthesia is an increasingly popular way of controlling
pain following total knee replacement. The evidence from this study suggests that it is safe to use
peri-articular injection in combination with auto-transfusion of
blood from peri-articular drains during knee replacement surgery.
The lateral compartment is predominantly affected
in approximately 10% of patients with osteoarthritis of the knee. The
anatomy, kinematics and loading during movement differ considerably
between medial and lateral compartments of the knee. This in the
main explains the relative protection of the lateral compartment
compared with the medial compartment in the development of osteoarthritis.
The aetiology of lateral compartment osteoarthritis can be idiopathic,
usually affecting the femur, or secondary to trauma commonly affecting
the tibia. Surgical management of lateral compartment osteoarthritis
can include osteotomy, unicompartmental knee replacement and total
knee replacement. This review discusses the biomechanics, pathogenesis
and development of lateral compartment osteoarthritis and its management. Cite this article:
Matrix-induced autologous chondrocyte implantation
(MACI) is an established technique used to treat osteochondral lesions
in the knee. For larger osteochondral lesions (>
5 cm2)
deeper than approximately 8 mm we have combined the use of two MACI
membranes with impaction grafting of the subchondral bone. We report
our results of 14 patients who underwent the ‘bilayer collagen membrane’
technique (BCMT) with a mean follow-up of 5.2 years (2 to 8). There
were 12 men and two women with a mean age of 23.6 years (16 to 40).
The mean size of the defect was 7.2 cm2 (5.2 to 12 cm2)
and were located on the medial (ten) or lateral (four) femoral condyles.
The mean modified Cincinnati knee score improved from 45.1 (22 to
70) pre-operatively to 82.8 (34 to 98) at the most recent review
(p <
0.05). The visual analogue pain score improved from 7.3
(4 to 10) to 1.7 (0 to 6) (p <
0.05). Twelve patients were considered
to have a good or excellent clinical outcome. One graft failed at
six years. The BCMT resulted in excellent functional results and durable
repair of large and deep osteochondral lesions without a high incidence
of graft-related complications.
