Search

Given the common occurrence of residual laxity and re-injury post anterior cruciate ligament reconstruction (ACLR), additional anterolateral procedures are increasingly used in combination with an ACLR. Despite the perception that there is a risk of over-constraining the lateral tibiofemoral (LTF) compartment, potentially leading to osteoarthritis, assessment on their effect on intra-articular compartment pressures is still lacking. Our objective was therefore, through a pilot biomechanical study, to compare LTF contact pressures after the most commonly used anterolateral procedures.A controlled laboratory pilot study was performed using 4 fresh-frozen cadaveric whole lower limbs. Through 0° to 90° of flexion, LTF contact pressures were measured with a Tekscan sensor, located under the lateral meniscus. Knee kinematics were obtained in 3 conditions of rotation (NR: neutral, ER: external and IR: internal rotation) to record the position of the knees for each loading condition. A Motion Analysis system with a coordinate system based on CT scans 3D bone modelling was used. After an ACLR, defined as the reference baseline, 5 anterolateral procedures were compared: anterolateral ligament reconstruction (ALLR), modified Ellison, deep Lemaire, superficial Lemaire and modified MacIntosh procedures. The last 3 procedures were randomised. For each procedure, the graft was fixed in NR at 30° of flexion and with a tension of 20 N.Compared with isolated ACLR, addition of either ALLR or modified Ellison procedure did not increased the overall LTF contact pressure (all p0.05) through the full range of flexion for the IR condition. Conversely, deep Lemaire, superficial Lemaire and modified MacIntosh procedure (all p0.05) did increase the overall LTF contact pressure compared with ACLR in IR. No significant difference was observed in ER and NR conditions.This pilot study, comparing the main anterolateral procedures, revealed that addition of either ALLR or modified Ellison procedure did not change the overall contact pressure in the LTF compartment through 0° to 90° of knee flexion. In contrast, the deep and superficial Lemaire, and modified MacIntosh procedures significantly increased overall LTF contact pressures when the knee was internally rotated.

Objective The optimal anterolateral procedure to control anterolateral rotational laxity of the knee is still unknown. The objective was to compare the ability of five anterolateral procedures performed in combination with anterior cruciate ligament reconstruction (ACLR) to restore native knee kinematics in the setting of a deficient anterior cruciate ligament (ACL) and anterolateral structures. Methods A controlled laboratory study was performed using 10 fresh-frozen cadaveric whole lower limbs with intact iliotibial band. Kinematics from 0° to 90° of flexion were recorded using a motion analysis three-dimensional (3D) optoelectronic system, allowing assessment of internal rotation (IR) and anteroposterior (AP) tibial translation at 30° and 90° of flexion. Joint centres and bony landmarks were calculated from 3D bone models obtained from CT scans. Intact knee kinematics were assessed initially, followed by sequential section of the ACL and anterolateral structures (anterolateral ligament, anterolateral capsule and Kaplan fibres). After ACLR, five anterolateral procedures were performed consecutively on the same knee: ALLR, modified Ellison, deep Lemaire, superficial Lemaire and modified MacIntosh. The last three procedures were randomised. For each procedure, the graft was fixed in neutral rotation at 30° of flexion and with a tension of 20 N. Results Isolated ACLR did not restore normal overall knee kinematics in a combined ACL plus anterolateral-deficient knee, leaving a residual tibial rotational laxity (p=0.034). Only the ALLR (p=0.661) and modified Ellison procedure (p=0.641) restored overall IR kinematics to the normal intact state. Superficial and deep Lemaire and modified MacIntosh tenodeses overconstrained IR, leading to shifted and different kinematics compared with the intact condition (p=0.004, p=0.001 and p=0.045, respectively). Compared with ACLR state, addition of an anterolateral procedure did not induce any additional control on AP translation at 30° and 90° of flexion (all p>0.05), except for the superficial Lemaire procedure at 90° (p=0.032). Conclusion In biomechanical in vitro setting, a comparison of five anterolateral procedures revealed that addition of either ALLR or modified Ellison procedure restored overall native knee kinematics in a combined ACL plus anterolateral-deficient knee. Superficial and deep Lemaire and modified MacIntosh tenodeses achieved excellent rotational control but overconstrained IR, leading to a change from intact knee kinematics. Level of evidence The level-of-evidence statement does not apply for this laboratory experiments study.

There has been increased use of adjustable suspensory fixation (ASF) for anterior cruciate ligament reconstruction (ACLR). Potential benefits are the ability to use a shorter graft and to prevent graft displacement and damage. The purpose of this study was to establish the efficacy of this fixation method and assess whether it leads to less tunnel widening, and avoids known complications of screw fixation.Thirty-eight patients who underwent ACLR with ASF on both the femoral and tibial sides met the inclusion criteria and were propensity matched demographically with 38 patients who underwent hybrid fixation with femoral suspensory and tibial screw and sheath. At one-year, KT-1000 knee laxity measurements were recorded and detailed MRI analysis looking at tunnel aperture widening, tunnel appearance, graft integration within the tunnels, and graft healing.MRI comparison between ASF and hybrid cohorts revealed no significant differences in graft signal or integration, and clinically there were no differences in knee laxity between cohorts (mean 1.5 mm ± 2.0 and 1.5 mm ± 2.3 (n.s.) in the ASF and hybrid fixation respectively). Significantly less aperture tibial tunnel widening (2.2 mm versus 4.4 mm, p 0.0001) and tibial cysts (2 versus 9, p = 0.047) were observed in the ASF cohort, whilst mean femoral tunnel widening was comparable between both cohorts (ASF 2.8 mm, hybrid 3.2 mm; n.s.).Hamstring autografts for ACLR fixed using either ASF or a hybrid fixation technique provided comparable knee stability and MRI graft signal intensity. Tibial ASF demonstrated significantly less tibial aperture widening and tunnel cyst formation when compared to screw and sheath fixation.

Multiple intraoperative strategies are described to achieve full extension in total knee arthroplasty, but only a few studies have assessed the effect of the flexion gap on intraoperative improvement in flexion contracture. The aim of this study was to determine whether posterior condylar offset, in isolation, independently affects extension at the time of total knee arthroplasty.Two hundred and seventy-eight patients who underwent total knee arthroplasty for knee osteoarthritis and flexion contracture ≥ 5 degrees between January 2008 and July 2018 were included in this study. Patients with other factors that could affect knee extension at the time of surgery were excluded. We recorded the thickness of posterior femoral condyle bone resected as well as the thickness of the posterior femoral component chosen for each patient. Patients' knee extension was recorded under anesthetic, prior to resection and intraoperatively after total knee replacement.Average thickness of bone resection for the posteromedial femur was 12.64 ± 1.65 mm and for the posterolateral femur was 10.38 ± 1.52 mm. Using a linear regression model, we found that changes in posterior offset and implant downsizing influenced correction of fixed flexion deformity at the time of surgery. When patients had a combined posteromedial and posterolateral offset 2 mm thinner than the thickness of bone resected, there was an average correction of 3.5 degrees of flexion contracture.Our study demonstrated that posterior femoral condyle offset is an independent variable affecting correction of flexion contracture at the time of surgery in a gap balanced cruciate-retaining total knee arthroplasty. This is a level IV evidence study.

Removing osteophytes from the posterior compartment of the femur eliminates the tenting effects on the joint capsule and consequently increases the extension gap in total knee arthroplasty. However, there is no clear association with the size of osteophytes removed and the potential degree of additional extension achieved at time of surgery. Aims Correlate the size of posterior osteophytes removed with the degree of extension gained intraoperatively in total knee arthroplasty and develop a radiological classification system to grade these osteophytes. Methods Patients who underwent a TKA had pre and post operative sagittal radiographs assessed and classified according to 4 different categories of a proposed classification system. Knee extension was then assessed by a computer navigated system before incision and after implant insertion. Confounding factors were controlled and considered on the analysis. The study was done retrospectively. Results 147 patients were included in the study. Ninety-three (63.2%) patients had osteophytes on the posterior aspect of the femur completely removed and fifty-four patients (36.8%) did not have radiological evidence of osteophytes on the posterior aspect of the femur. There was a positive and linear correlation (Pearson correlation 0.327, p .005) between osteophyte size and degree of extension corrected at time of surgery. On Multivariate Logistic Regression Analysis, we found that small osteophytes (Grade 1) did not seem to affect the extension, while removing Grade 2 or Grade 3 osteophytes lead to a gain in extension of 2.7 and 4.5° respectively. Conclusion Removing large osteophytes (Grade 2 and Grade 3) from the posterior femoral compartment can be used as an adjuvant strategy to ensure that intraoperative extension is optimal. However removing small osteophytes (Grade 1) should not be expected to affect extension at the time of surgery in TKA and could increase intra-operative time and morbidity.

The most commonly used tool for implant positioning are conventional instruments (CI) followed by computer-assisted surgery (CAS). A number of studies have investigated the cutting error of the tibial component when CAS is used, but most of them were focused on the cutting angles. The accuracy of CAS to determine the depth of the cut has not received much attention, even though implications are similar or worse, than with an angle mismatch. This was an ethics board approved, prospective study of 23 consecutive varus TKAs by a single surgeon. Implant positioning was performed using CAS; however, the depth of the tibial cut was determined with both CAS and CI. Targeted alignment was the mechanical axis and 3° of posterior slope. The planned and the achieved cut, as determined by CAS needed to match. The achieved cut was then measured using a caliper and compared to the depth of the cut as per CAS. Medial and lateral cuts were analyzed separately. Analysis of variance and Bland–Altman plots were used for the comparison. Mean medial navigated cut was 6.3 (± 2.2) mm, mean measured medial cut was 6.6 (± 2.3) mm. Mean lateral navigated cut was 8.9 (± 1.8) mm, mean measured lateral cut was 8.8 (± 1.5) mm. There was a statistical significance for both the medial (p

The mortality and risks of bilateral total knee arthroplasty (BTKA) have been reported to be far greater than in unilateral total knee arthroplasty (UTKA). This study aimed to determine whether this remains the case using contemporary anesthetic and surgical techniques for one-stage single anesthetic sequential BTKA.Two cohorts of 394 patients were created by propensity matching for gender, age, body mass index, American Society of Anesthesiologists grade, and Veterans Rand-12 health survey scores. Primary outcome was morbidity and mortality, with satisfaction measures using patient-reported outcome measures.The mortality rate was low with one case after BTKA. Major complications were also low; however, a pulmonary embolism rate of 2% in BTKA patients was significantly higher than 0.3% after UTKA (P.05), and associated with an American Society of Anesthesiologists grade ≥3. The rate of minor complications between the 2 cohorts was comparable (P = .95). Blood transfusions were uncommon and not significantly different between cohorts (2.5% vs 1.3%, P = .3). BTKA patients stayed in hospital a mean 1.3 days longer with greater rehabilitation requirements. At final follow-up, patient satisfaction was high with all patient-reported outcome measures significantly improved and comparable between cohorts.BTKA is safe and effective in the majority of patients. Transfusion rates were far lower than historically reported and major complications were rare after both UTKA and BTKA. A significant increase in the rate of pulmonary embolism after BTKA was observed, especially in high risk patients. At minimum 1-year postoperatively, cohorts had the same significant clinical improvement and high level of satisfaction.

Most of what is known about the biomechanics of unicompartmental knee replacements (UKRs) is derived from finite element analysis (FEA) studies. Clinical results have demonstrated that over-correcting malalignment leads to rapid wear of the non-resurfaced compartment, and this is reflected in the observed loads seen in Radiostereometric Analysis (RSA) work. Such overloading of the un-resurfaced compartment leads to failure—with UKR having a revision rate two to three times higher than total knee replacement (TKR). Consequently, TKR has become the standard surgical management for knee arthritis including disease isolated to a single compartment.

Introduction: Osteotomy of the distal femur (DFO) to address symptomatic degeneration in the knee is a well-established procedure with good results reported in the literature . Broadly the osteotomy is based on either an opening or a closing wedge alignment technique. Several patient related parameters including age, gender, body mass index (BMI) and surgical factors such as osteotomy site, gap, and fixation technique amongst others have been demonstrated to influence the outcome of DFO. Preoperative planning based on imaging is vital to assess the type and extent of deformity correction to be undertaken in order to achieve optimal alignment. Computer-assisted surgery (CAS) has been extensively used as dynamic intraoperative alignment aid in knee arthroplasty providing good outcomes. Several investigators in the current literature have utilised computer navigation in proximal tibial osteotomy and reported improved accuracy in realising the planned alignment. However there is paucity of studies reporting the long-term outcomes of distal femur lateral opening-wedge (DFLOWO) using computer navigation. Through our study we aim to report on the long-term outcomes and survivorship of computer navigated DFLOWO. Hypotheses: We hypothesize that use of computer navigation will improve the survivorship of distal femoral osteotomy. Methods: Ethics committee approval was obtained for this study. Due consent was taken for the use of data from all the patients for this study. A retrospective analysis of prospectively collected data for patients with lateral compartment arthritis who underwent navigated lateral opening wedge distal femoral osteotomy from December 2006 to November 2012 was performed. Consecutive patients of lateral compartment knee arthrosis aged less than 55 years who failed to respond to conservative management were included in the study. Patients who had end stage arthritis with fixed flexion deformity of > 15 degrees, < 90 degrees of knee flexion or who did not consent for the procedure were excluded. Included patients were operated by one of the three senior surgeons attached to our research institute. The included patients were followed up with clinical and radiological evaluation at regular intervals (6 weeks / 6 months / 1 year / 5years). The final follow-up for the included patients was done using email questionnaire of the patient reported outcomes measures. Conversion to either UKA or TKA during the follow-up was the end point. Additionally, this information was verified from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) database Results: 19 DFLOWO with mean age of 46.6 ± 6.5 years formed the study cohort. The coronal alignment was corrected from a mean of 7.1º (2-11º) valgus to mean 2.1º (0.5º - 3º) varus. IKDC scores improved from mean of 39 pre-op to 53 at the mean long-term follow-up of 9.1 years. KOOS scores at the long-term follow-up were pain-71, symptoms-56, activities of daily living-82, sports and recreation-59, quality of life-43. Survivorship of DFLOWO was 78.9% at a follow-up of 9.1 years. Presence of ≥ grade 2 ICRS cartilage degeneration in the medial compartment of knee and >7⁰ pre-operative valgus deformity strongly correlated with conversion to TKA at the long-term follow-up (r - 0.66). Conclusion: Computer navigated DFLOWO has satisfactory clinical outcomes and 79% survivorship in long-term follow-up. Presence of more than ICRS ≥ grade 2 degenerative changes in the medial compartment of knee with > 7 degrees pre-operative valgus deformity negatively affects the survivorship of DFLOWO in the long-term follow-up.

Objectives Medial compartment osteoarthritis (OA) in the younger patient is technically challenging to treat. Medial opening wedge high tibial osteotomy (MOWHTO) is an option for surgical treatment; however, there remains a lack of evidence to establish the procedure as the preferred treatment option. The literature remains inconsistent with regard to patient characteristics and surgical factors that determine patient outcomes, particularly with respect to procedure survival and pain relief. The purpose of this study is to (i) describe the patient demographics and surgical outcomes of a consecutive series of MOWHTOs for treatment of medial knee OA; (ii) determine the procedure survivorship up to 10 years postsurgery and (iii) identify patient and surgery-related factors associated with pain relief following MOWHTO. Methods A cohort of 210 patients was identified that underwent MOWHTO between 2002 and 2013. Patient demographics and complications were extracted from the clinical research database. Procedure survival analysis was conducted using a Kaplan-Meier analysis. All patients completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire preoperatively and postoperatively with pain relief identified as the difference between pre- and postoperative KOOS-pain subscale. A partial least square regression model was fitted to identify predictors of pain relief. Results Males comprised 84% of the cohort, which had a median age of 51 years (95% CI 42 to 57 years). Patients were overweight on average, with a median BMI of 28.9 kg/m2 (95% CI 23 to 36 kg/m2) and 36% of patients underwent concomitant procedures. A complication rate of 3.8% was observed. Survivorship was 97.7% at 5 years and 80% at 10 years, with median time to conversion in those requiring total knee replacement of 7 years (95% CI 5 to 8). Patients undergoing cartilage treatment and bilateral procedures experienced increased pain relief compared with average, while there was reduced pain relief in patients with lower preoperative pain. Conclusion MOWHTO is an effective procedure for relief of pain associated with medial knee OA, even in older and heavier patients. Patients and clinicians can expect an average procedure survival of 12.5 years and a maximum of 21 years, with effective pain relief influence by cartilage treatment and preoperative pain score. Level of evidence IV. Case series.

The normal alignment of knee joint varies but is approximately 5–7° of tibio-femoral valgus which results in approximately 30–40% of body weight being borne by the lateral compartment [1]. Increased knee valgus leads to overloading of lateral compartment and the development of lateral compartment arthrosis [2]. Increased valgus at the knee joint is most commonly within the distal femur leading to knee joint line obliquity [3, 4].

Success of an osteotomy around the knee relies on the ability to accurately translate a preoperative plan into a postoperative result to give the desired correction of alignment in both the coronal and sagittal planes. In this context of improving precision and adapting the correction to each patient, the use of computer navigation guidance is attractive. Navigation has been successfully implemented in knee arthroplasty with the benefits of giving accurate real-time corrections allowing greater intraoperative control and better management of multiple surgical variables [1]. In reality, if there is a surgical procedure best suited to computer navigation, it is opening wedge high tibial osteotomy. The rationale for its use in HTO is based on understanding the advantages, technical principles, potential pitfalls and limitations. These areas and the current clinical outcomes of this surgical technique for HTO and other knee osteotomies are described in this chapter.

Background Arthroscopic treatment of knee osteoarthritis has declined, in part due to concerns with conversion to arthroplasty. Some studies have investigated the demographic predictors for conversion to arthroplasty, few have assessed the risk factors within the knee itself. Our aim was to analyse the demographics and anatomical wear features of a large cohort of patients undergoing knee arthroscopy. Methods A retrospective analysis of 1760 cases spanning over 17 years undergoing knee arthroscopy was performed. Patients were 36 years or older at time of the index arthroscopy. Each patient received the International Cartilage Regeneration and Joint Preservation Society (ICRS) grade of all regions as well an estimate of the remaining meniscal percentage. Demographic factors as well as intraoperatively collected data were analysed as predictive variables for subsequent conversion to arthroplasty using a multi-step Cox regression analysis. Results A total of 102 patients (6.2%) were converted to arthroplasty. Age at arthroscopy (hazard ratio (HR) 1.073; 95% confidence interval (CI) 1.058–1.088) and ICRS grade of the lateral tibial plateau (HR 1.166; 95% CI 1.066–1.276) were statistically significant predicting variables for conversion to arthroplasty. Conclusions The results of this study indicate that higher ICRS grade of the lateral tibial plateau at arthroscopy is the most significant predictor for conversion to knee arthroplasty, with a hazard equal to an increase in age. The absence of these factors does not justify arthroscopic treatment of patients with knee osteoarthritis. Level of evidence: III.

Our objective was to assess clinical and radiological findings following a medial opening wedge high tibial osteotomy using a biphasic calcium phosphate (BCP) synthetic bone substitute, designed as a wedge with two differing zones of density. The in-vivo behaviour of this type of bone substitute over time is currently unknown. Our hypothesis was that BCP synthetic bone would facilitate bone union and undergo replacement with host bone over the study period. Fifteen sequential patients were followed prospectively for minimum 4-years post-operatively. All patients were evaluated clinically using patient reported outcome measures and radiologically to evaluate alignment with maintenance of the osteotomy correction, and bone union with expected BCP dissolution. All patients had good clinical scores with no reported complications at 4 years. In all cases there were radiographic findings of bone union with consolidation and no loss of correction. However the graft remained densely radiopaque at final follow-up. This study demonstrates that a BCP graft in combination with a locking plate for a medial opening wedge HTO allows early weight-bearing, maintains correction and provides good clinical outcomes. Whilst higher densities of BCP are strong, they do not resorb fully, remaining radiographically visible. This may have implications for the performance of a future knee arthroplasty and caution should therefore be taken.

Background: None of the anterolateral procedures used in combination with ACL reconstruction (ACLR) to control rotational laxity have demonstrated superiority. The objective was to compare the capacity of the main anterolateral procedures associated with ACLR to restore intact knee kinematics in case of combined ACL and anterolateral structure injury. Methods: The complete kinematics of 10 cadaveric knees, previously modelled by TDM, were recorded using a 3D Motion Analysis® system. Intact knee kinematics, including internal rotation (IR) of the tibial and anterior-posterior (AP) laxity at 30 and 90° flexion were initially assessed, followed by a sequential section of the ACL and anterolateral complex (ALC) (anterolateral ligament (ALL), ALL capsule and Kaplan fibers). After the ACLR, 5 anterolateral procedures were performed consecutively on the same knee: ALLR; Ellison; Deep Lemaire; Superficial Lemaire; and MacIntosh. The last three procedures were randomized. For each procedure, the graft was fixed in neutral rotation at 30° flexion with a tension of 20 N. Results: ACLR alone did not restore overall knee kinematics when there was an ACL+ALC injury, and resulted in residual rotational laxity of the tibia (p > 0.001). Only the ALLR (p=0.262) and modified Ellison (p=0.081) procedures restored normal global IR kinematics. Superficial/deep Lemaire and MacIntosh procedures resulted in over-constrained kinematic profiles (respectively: p=0.013, p=0.018 and p=0.030). In terms of ACLR, the addition of an anterolateral procedure did not provide additional control over AP translation at 30 and 90° (p > 0.05), exception for the surficial Lemaire procedure at 90° (p = 0.032). Discussion: ACLR alone was not sufficient to restore normal kinematics in ACL and ALC-deficient knees. ALLR and Ellison procedures restored physiological kinematics, unlike the MacIntosh procedure which caused additional control of IR and thereby induced over-constraint. Conclusion: The addition of ALLR or the modified Ellison procedure, which restore intrinsic kinematics, might be useful during primary ACL reconstruction to avoid repeated injury without a risk of over-constraint. The superficial/deep Lemaire and MacIntosh procedures resulted in over-constrained kinetics but provided additional rotation control that could be useful in revision surgery.

Background The purpose of this study was to assess the degree of mismatch between intraoperative navigation data using imageless computer navigation and post-operative CT scan measurements with respect to bone cuts, component and limb alignment during TKA. Methods Intraoperative navigation data including bone cut verification and overall limb alignment during TKA was compared to postoperative CT measurements of component and limb alignment according to the Perth protocol. The proportion of cases with mismatch between navigation and CT measurements at two and three degree thresholds was identified. Results In a total sample of 50 primary TKAs, 20% of cases showed a mismatch of more than two degrees between navigation and CT obtained measurements for coronal femoral alignment, 42% for femoral rotation, 16% for tibial component coronal alignment and 32% for overall limb alignment. Conclusion Mismatch between intraoperative navigation data and postoperative CT measurements suggests that postoperative CT scan alignment data should be interpreted with caution. A surgeon should consider a multitude of factors when analysing component and limb alignment postoperatively.

Objectives: The published rates of dissatisfaction following total knee replacement (TKR) range between 11-18%, with residual symptoms and psychological distress being important features. The aims of this study were to identify the prevalence and causes of dissatisfaction in a cohort of private practice patients, and to describe a post-operative management program which may improve satisfaction with their replaced knee in these patients. Methods: A cohort of 375 patients with unilateral TKR was evaluated to identify patients who were dissatisfied with TKR. Dissatisfied and satisfied patients were matched in terms of age, gender, follow-up duration and BMI. Psychological evaluation was performed using the pain catastrophizing scale (PCS), Depression, Anxiety and Stress Scale (DASS) and the Multidimensional Health Locus of Control (MHLC) scale. The pre and post-operative Oxford knee scores (OKS) and range of motion (ROM), preoperative grade of osteoarthritis, and prevalence of comorbidities were also compared between groups. Patients indicating dissatisfaction with their TKR were then followed up by phone on a second occasion 12months later. Those that indicated enduring dissatisfaction were invited to participate in a chronic pain program utilising cognitive behavioural therapy, desensitisation and coping strategies. Patients referred to the program were screened by the therapists for inclusion and enrolled into a flexible course of therapy. Pre- and post- intervention questionnaires will be used to determine the effect of the program on satisfaction rates (5-point Likert scale) and psychological responses to pain. Results: The final cohort consisted of 301 patients (response rate 80%), with 24 patients (6.5%) dissatisfied with the result of TKR. Persistent pain was the most common reason for dissatisfaction (n=10). Dissatisfied patients reported a significantly (P = 0.03) higher mean PCS score (mean±SD, 11.3±10.3), compared to satisfied patients (5.4±6.3) and a significantly (P = 0.02) higher depression component of the DASS (3.5±3.3 vs 1.4±1.6). In addition, dissatisfied patients returned a significantly (P = 0.02) lower internal locus of control (16.6±8.2 vs 21.3±8.2). The dissatisfied group also exhibited a reduced improvement in the OKS and ROM, as well as a lower preoperative grade of osteoarthritis compared to satisfied patients. Preliminary analysis revealed that five patients (21%) became satisfied with their knee despite no intervention occurring between measurements. Of the remaining patients, five patients (21%) did not think their ongoing issues were severe enough to warrant further intervention, and nine patients (38%) were referred directly to the program. It is expected that these results will shed new light on the potential management options for these patients that identify as dissatisfied after a primary unilateral TKR. Conclusion: Dissatisfied patients exhibit higher scores for catastrophisation and depression, with lower self confidence in managing their knee symptoms. In addition, they have lesser improvements in the OKS and ROM. Thus, both physical as well as psychological factors contribute to dissatisfaction. Identification of these factors can help in planning focused interventions to address dissatisfaction. This is the longest follow-up of such a cohort; our results so far indicate that 21% of such patients can improve spontaneously with time which challenges some conventional beliefs. The results of the 38% of patients who remain dissatisfied and will undergo the program will determine whether such an intervention will be worthwhile in this difficult clinical situation.

Introduction Parmi les differentes procedures anterolaterales utilisees en association avec une reconstruction du LCA (LCAR) et visant a controler la laxite rotatoire, aucune n’a fait preuve de sa superiorite. L’objectif etait de comparer la capacite des principales procedures anterolaterales, combinee a une LCAR, a restaurer une cinematique de genou natif sur des genoux avec une lesion combinee du LCA et des structures anterolaterales. Methodes Les cinematiques completes de 10 genoux cadaveriques, au prealablement modelises par TDM, ont ete enregistrees a l’aide d’un systeme 3D de Motion Analysis®. Les cinematiques de genou intact, incluant la rotation tibiale interne (RI) et la laxite antero-posterieure (AP) a 30 et 90° de flexion ont ete initialement evaluees, suivie d’une section sequentielle du LCA et du complexe anterolateral (CAL) (ligament anterolateral (LAL), capsule AL et fibres de Kaplan). Apres la LCAR, 5 interventions anterolaterales ont ete effectuees consecutivement sur le meme genou : LALR ; Ellison ; Lemaire-profond ; Lemaire-superficiel ; et MacIntosh. Les trois dernieres procedures ont ete randomisees. Pour chaque procedure, le greffe a ete fixee en rotation neutre a 30° de flexion avec une tension 20 N. Resultats La LCAR isolee ne permettait pas de retablir la cinematique globale du genou lorsqu’il existait une lesion combinee du LCA + CAL, laissant une laxite rotatoire tibiale residuelle (p > 0,001). Seules les procedures LALR (p = 0,262) et Ellison modifiee (p = 0,081) ont permis de retablir des cinematiques de RI globale normales. Les interventions de Lemaire superficiel/profond et de MacIntosh, induisaient des profils cinematiques hypercontraints (respectivement : p = 0,013, p = 0,018 et p = 0,030). Par rapport a l’etat LCAR, l’ajout d’une procedure anterolaterale n’induisait pas de controle supplementaire sur la translation AP a 30 et 90° (p > 0,05), a l’exception de la procedure de Lemaire-superficiel a 90° (p = 0,032). Discussion La LCAR isolee n’etait pas suffisante pour restaurer une cinematique normale dans un genou LCA et du CAL deficient. Les procedures de LALR ou d’Ellison permettaient une restauration des cinematiques physiologique, a l’inverse des procedures et de MacIntosh, qui en entrainant un controle supplementaire de la RI, induisaient une hyper-contrainte. Conclusion L’ajout de la procedure LALR ou de l’Ellison modifiee, en retablissant des cinematiques natives, peuvent etre utile lors de la reconstruction primaire du LCA afin d’eviter une lesion iterative sans risquer une hypercontrainte. Les procedures de Lemaire superficiel/profond et de MacIntosh conduisent a des cinematiques hypercontraintes mais permettent un controle de rotation supplementaire pouvant etre utile en chirurgie de revision.

Background: While single shot femoral nerve blocks and indwelling femoral nerve catheters provide significant peri-operative analgesia, there are small but serious risks of neurovascular complications. We aimed to determine the incidence and characterise the nature of neural complications arising from femoral nerve blocks performed for knee surgery. Methods: One thousand eight hundred and two patients receiving a femoral nerve block for knee surgery during the study period were screened. Patients with possible neurological symptoms were evaluated with a detailed physical examination and self-report questionnaires. Also measures of depression, anxiety and tension/stress were collected. Results: In the patients screened, an incidence of 1.94% was found. Of the 24 patients available for testing, 4 had bilateral symptoms following bilateral nerve blocks. All had sensory abnormalities in the distribution of the femoral nerve. The incidence was significantly higher in females (females = 2.5%, males = 0.83% p = 0.01) and in patients receiving a single shot block (single shot = 2.66%, femoral catheter = 0.93, p = 0.01). Conclusions: The incidence of neurological complication after FNB was higher in this series than typically reported and the symptoms significantly influenced the quality of life in the affected cases. The decision to include a femoral nerve block in the peri-operative analgesic regimen should be made on an individual basis considering the risks and benefits. Level of evidence Therapeutic level IV.

This investigation evaluated the Smith and Nephew VISIONAIRE patient-specific cutting block (PSCB) system for total knee arthroplasty. A consecutive series of 60 patients was recruited. Intraoperative computer navigation was used to evaluate the accuracy of the cutting blocks in the coronal and sagittal planes for the tibia, as well as rotational plane for the femur. The PSCB would have placed 79.3% of the sample within ±3° of the preoperative plan in the coronal plane, while the rotational and sagittal alignment results within ±3° were 77.2% and 54.5% respectively. The VISIONAIRE PSCB system achieved unacceptable accuracy when assessed by computer navigation. There might be many sources of error, but caution is recommended before using this system routinely without objective verification of alignment.

The aims of this study were to identify the prevalence and causes of dissatisfaction in a cohort of private practice patients, and to compare the psychological characteristics of dissatisfied patients to matched, satisfied controls.Unilateral TKR patients were evaluated to identify those dissatisfied with their TKR. Dissatisfied and satisfied patients were matched in terms of age, gender, follow-up duration and body mass index (BMI). Psychological evaluation was performed using the Pain Catastrophizing Scale (PCS), Depression, Anxiety and Stress Scale (DASS) and the Multidimensional Health Locus of Control (MHLC) scale. The preoperative grade of osteoarthritis, prevalence of comorbidities, and postoperative functional outcomes, were also compared.A cohort comprised 301 patients (response rate 71%), with 24 patients (eight percent) dissatisfied at a mean follow-up of 37months (range eight to 74months). Persistent pain was the most common reason for dissatisfaction (n=10). Dissatisfied patients reported a significantly higher mean PCS score (P=0.03), higher depression component of the DASS (P=0.02) and lower internal locus of control (P=0.02). The dissatisfied group exhibited reduced improvement (P0.05) in the Oxford Knee Score (OKS) and range of motion (ROM), as well as a lower preoperative grade of osteoarthritis compared to satisfied patients.Dissatisfied patients exhibit an altered psychological profile to matched satisfied controls. In addition, they have lesser improvements in the OKS and ROM. Thus, both physical as well as psychological factors contribute to dissatisfaction. Identification of these factors may help in planning focused interventions to address dissatisfaction.

There remains a lack of randomized controlled trials comparing methods of perioperative analgesia for total knee arthroplasty. To address this deficiency, a blinded, randomized controlled trial was conducted to compare the use of femoral nerve block (group F) and local anesthetic (group L). A sample of 55 patients who met the inclusion criteria were randomized to either group. No significant differences in the most severe pain score or 36-Item Short Form Health Survey, The Western Ontario and McMaster Universities Arthritis Index (WOMAC), or Oxford scores were observed between groups. However, the Knee Society score was significantly higher in group F. In addition, group F used significantly fewer micrograms of intravenous fentanyl in the first 24 hours. Balancing the risks of femoral nerve block with those of increased systemic narcotic delivery should be performed on a case-by-case basis.

Despite increasing interest in the functional anatomy of the menisci, little information is available regarding the relationship between the tibial slope and the menisci. It was hypothesized that the meniscus would reduce the differences in slope between the medial and lateral compartments and would mitigate the effects of age and gender on the tibial slope.MRI sagittal images from 101 patients were used in this study. The angle between a line tangent to the medial and lateral tibial bony slope and the proximal tibial anatomical axis was measured on sagittal MRI images (bony slope). The angle between the tangent line to the highest point of the anterior and posterior horn of the meniscus and the proximal tibial anatomical axis was also determined (soft tissue slope). The measurements were carried out twice by two observers. The influence of gender and age on these parameters was analysed.Repeated measures analysis of variance showed good inter- and intra-observer reliability for both bony and soft tissue slope (ICC (0.87-0.93) and (0.91-0.97) for inter- and intra-observer reliability, respectively). In both compartments, the soft tissue significantly reduced the tibial slope towards the horizontal plane. In addition, the soft tissue slope was significantly more horizontal in the lateral compartment compared to the medial compartment (p 0.01). These differences were not influenced by age or gender.The menisci of the knee generate a more horizontal tibial slope when measured on MRI. The soft tissue slope is more horizontal in the lateral compartment of the knee compared to the medial compartment.Diagnostic, Level III.

Background: The use of hamstring tendons for anterior cruciate ligament reconstruction has increased in popularity over recent years. However, concerns with the stability of graft fixation on the tibial side remain. Centrally placed interference screw/sheath implants have demonstrated promising results in biomechanical studies. Hypothesis: Centrally placed, polyethylene screw and sheath implants will provide clinically equivalent fixation to the standard metal interference screw and supplemental staple fixation. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 113 consecutive patients undergoing isolated, unilateral, primary anterior cruciate ligament reconstruction with hamstring autografts were randomized to tibial fixation with metal interference screw and staples (RCI) or with a centrally placed polyethylene screw and sheath implant (INTRAFIX). Prospective assessment of subjective outcomes was performed using Lysholm, Mohtadi, and International Knee Documentation Committee (IKDC) scores. Results: At minimum 2-year follow-up, there were no significant differences between the 2 groups in terms of instrumented stability testing (KT-1000 arthrometer) or subjective assessment of knee outcomes (IKDC, Lysholm, Mohtadi). Both fixation methods demonstrated a significant, but not different, increase in outcomes scores from preoperative to postoperative evaluation. There were 7 failures (5 INTRAFIX, 2 RCI) caused by reinjury, but no statistically significant differences were observed between the 2 fixation methods. Conclusion: The centrally placed polyethylene screw and sheath provided equivalent clinical outcomes at minimum 2-year follow-up to standard tibial fixation with metal interference screw and staples.

Background: High tibial osteotomy (HTO) is a method used to treat medial compartmental osteoarthritis in the knee. The realignment of the knee changes the loading patterns within the joint and may allow for regeneration of articular cartilage. Magnetic resonance imaging methods can be used to assess the quality of the regenerated cartilage. Hypothesis: Altering mechanical alignment through HTO will have predictable effects on articular cartilage, allowing cartilage preservation and possible regeneration. Quality of regenerated cartilage will be inferior to normal articular cartilage. Study Design: Case series; Level of evidence, 4. Methods: Ten patients undergoing medial opening wedge HTO were evaluated using dGEMRIC methods (ie, delayed gadolinium-enhanced magnetic resonance imaging of cartilage) preoperatively and at 6 months, 1 year, and 2 years after HTO. Magnetic resonance images were evaluated by hand segmentation, and T1Gd relaxation times reflective of glycosaminoglycan content were determined for these regions of interest using magnetic resonance imaging analysis software. Results: The lateral compartment displayed higher T1Gd values than the medial compartment at baseline. Initially, a decrease in T1Gd values on the medial side were observed for all patients at 6 months and remained reduced for all but 2 participants at 1 year and 2 years after HTO. However, on the medial side after 6 months, the rate of change for T1Gd values shifted from being negative (−9.6 milliseconds per month) to being positive (1.7 milliseconds per month). A positive change in the T1Gd of the medial tibial plateau was responsible for the positive overall change in the medial compartment. There was no significant difference in the rate of change on the lateral side ( P = .141), with the average over the 2-year period being a decrease of 2.28 milliseconds per month. Conclusion: Medial opening wedge HTO provides subjective improvements in pain and quality of life, but the potential benefit of allowing articular cartilage preservation and possible regeneration is not well established. Results showed that after a nonweightbearing period, the rate of change in the medial compartment changes from negative to positive, indicating the potential for articular cartilage recovery secondary to an improved mechanical environment.

Purpose The purpose of our study was to evaluate the impact of preoperative magnetic resonance imaging (MRI) assessment of articular knee pathology on the clinical management of patients presenting with joint line pain. Methods A preliminary study on 100 patients was performed to assess the accuracy of specific MRI sequences, using arthroscopy as a gold standard. Six hundred and eighteen consecutive patients with knee symptoms presenting to 2 specialist knee surgeons were then recruited. A clinical diagnosis of an arthroscopically treatable lesion was made in all cases. Clinical assessment data were correlated to subsequent MRI findings, recording any discrepancy and in particular whether or not MRI findings influenced management decisions. Results In the preliminary study, MRI sequences had an overall sensitivity of 83.2% and a specificity of 94.3% for the detection of chondral lesions. However, when considering arthroscopic grade III and IV lesions, MRI sensitivity and specificity were improved to 84.5% and 97.1%. In the second phase of the study, 141 (22.8%) of the 618 patients presenting with knee symptoms had an altered clinical management subsequent to MRI. The presence of unexpected chondral lesions was found in 77 of these patients. Conversely, 22 patients with clinical symptoms suspicious for simple chondral degeneration had unstable meniscal tears. Conclusions We suggest that preoperative MRI scanning identifies a group of patients who have more advanced degenerative joint disease than the clinical assessment and the plain radiographs suggest. This would expedite definitive surgery in patients with advanced osteoarthritis on MRI scans. Level of Evidence Level II, development of diagnostic criteria on basis of consecutive patients with universally applied gold standard.

We assessed the validity of the hip-knee-ankle angle measured statically during three-dimensional (3-D) gait analysis and the tibial angle using an inclinometer compared with the mechanical axis on radiographs. Eleven individuals (20 knees) with radiographic knee osteoarthritis (OA) participated in this study. We determined the following: the lower-limb mechanical axis using weightbearing long-leg radiographs; hip-knee-ankle angle using the techniques of 3-D gait analysis in a static standing position; and tibial alignment using an inclinometer. The mean mechanical axis (+/- standard deviation) for this cohort was 0.7 degrees +/- 7.2 degrees (range, -13 degrees-16 degrees). The tibial alignment and hip-knee-ankle angle correlated with the mechanical axis but the correlation between the mechanical axis and the hip-knee-ankle angle was stronger. Our data suggest the inclinometer and 3-D gait analysis are valid ways to estimate mechanical alignment of the knee.

ObjectiveObjective To explore the relationship between preoperative patient expectations and postoperative health status in patients undergoing joint replacement surgery, with particular emphasis on the types of expectations held by patients. Abstract: MethodsMethods Respondents completed the Hospital for Special Surgery (HSS) Hip/Knee Replacement Expectations Questionnaires pre-surgery, in addition to the Western Ontario and McMaster Osteoarthritis Index (WOMAC™) and the Short-Form 36-Item (SF-36) Health Survey and the Arthritis Self-Efficacy Scale. The WOMAC™ Index and SF-36 were also completed 3 and 6 months post-surgery. Abstract: ResultsResults A total of 106 patients (total hip replacement &lsqb;THR&rsqb; - 28; total knee replacement &lsqb;TKR&rsqb; - 78) completed questionnaires. No differences were seen in overall expectations between males and females or older or younger patients, although some differences between the age groups were seen for individual expectations on the HSS expectations questionnaires. For THR, a higher rating of the importance of expectations was correlated with a lesser improvement in pain from pre-surgery to 3 months post-surgery, whereas for TKR, a higher rating of expectations was associated with a greater improvement in function to 6 months post-surgery. Abstract: ConclusionsConclusions Patients have high expectations of surgery, which are correlated with post-surgery pain and function. Identifying the broad range of expectations may be helpful in preparation for surgery and gaining greater satisfaction with outcomes.

The objective of the study was to evaluate the biomechanical and biological consequences of posterior cruciate ligament deficiency, determine compensatory mechanisms and assess the efficacy of non-operative treatment. Medline, CINAHL, SPORTdiscus, Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews were searched at 30th October 2006 for the terms "PCL" and "posterior cruciate ligament" both independently and including the terms "injury", "deficiency" and "insufficiency". Literature searches identified 598 potentially relevant articles, after exclusions there were 47 articles that fulfilled the inclusion criteria: 30 articles analyzing PCL deficiency and 17 studies on the outcomes for non-operative treatment. The authors reviewed all selected articles and abstracted data into predetermined tables depending upon classification. Studies indicate that posterior cruciate ligament deficiency results in posterior tibial translation with combined injuries displaying greater laxity. Results were inconsistent for rotational stability but deficiency increases joint contact pressure and may result in articular damage. A loss of proprioception occurs but the effect on strength and kinetics is inconclusive. There is a lack of evidence for compensatory muscle activity. Return to activity is possible for the majority of non-operatively treated grade I and II isolated injuries. Comparative analysis was not possible in many instances due to study design or experimental protocols. Further research is required to establish the compensatory mechanisms stabilizing the posterior cruciate ligament deficient knee and to investigate the outcomes for non-operatively treated patients.

This chapter presents evidence to help answer the question as to whom, if anyone, with knee arthritis should undergo knee arthroscopy and provides recommendations on alternative treatments.

OBJECTIVE: To review acute spinal cord injuries (ASCIs) in all Australian codes of football (rugby union [RU], rugby league [RL], Australian Rules football [ARF] and soccer) for 1997-2002 and to compare data with those of a 1986-1996 survey. DESIGN: Retrospective review of hospital records, and structured interviews with injured players. PARTICIPANTS AND SETTING: Patients admitted to any of the six Australian spinal cord injury units with a documented football-related ASCI over the period 1997-2002. OUTCOME MEASURES: Average annual incidence of ASCIs per 100 000 players in the different codes, final Frankel grading of injuries, and wheelchair status. RESULTS: Fifty-two footballers (45 adult men and seven schoolboys) suffered ASCIs between 1997 and 2002. The average annual incidence of ASCIs per 100 000 players was 3.2 for RU, 1.5 for RL, 0.5 for ARF and 0.2 for soccer. While there has been little change in incidence since the 1986-1996 survey, there has been a trend towards less severe injuries in RU and RL, but not in ARF. There have been no scrum injuries in RL since 1996, when the scrum stopped being contested. Seven injuries occurred in RU scrums, six at the moment of engagement of the opposing teams. The incidence of 2-on-1 and "gang" tackles (involving multiple tacklers) in RL is disturbing. Overall, 39% of injured players became permanently wheelchair-dependent. CONCLUSIONS: There continues to be good reason to revise the laws of scrum engagement in RU. The laws relating to multiple tacklers in RL should be examined. The insurance cover for injured players is grossly inadequate. The longstanding need for a registry of spinal cord injuries for all football codes regrettably remains unmet.

Patellar resurfacing has been a debatable topic over the years. It is being increasingly used in certain countries and has fallen out of favour in some, due to conflicting registry and medical literature. The advantages have been well documented and are possibly the reason why many surgeons prefer doing it. There are a myriad of implants that are in the market with the dome-shaped, ultra-high molecular weight polyethylene implants being most favoured. Though initially introduced to decrease the incidence of anterior knee pain, the problem continues to exist in resurfaced patellae too.

Purpose The introduction of patient-specific instruments (PSI) for guiding bone cuts could increase the incidence of malalignment in primary total knee arthroplasty. The purpose of this study was to assess the agreement between one type of patient-specific instrumentation (Zimmer PSI) and the pre-operative plan with respect to bone cuts and component alignment during TKR using imageless computer navigation.MethodsA consecutive series of 30 femoral and tibial guides were assessed in-theatre by the same surgeon using computer navigation. Following surgical exposure, the PSI cutting guides were placed on the joint surface and alignment assessed using the navigation tracker. The difference between in-theatre data and the pre-operative plan was recorded and analysed.ResultsThe error between in-theatre measurements and pre-operative plan for the femoral and tibial components exceeded 3° for 3 and 17 % of the sample, respectively, while the error for total coronal alignment exceeded 3° for 27 % of the sample.ConclusionThe present results indicate that alignment with Zimmer PSI cutting blocks, assessed by imageless navigation, does not match the pre-operative plan in a proportion of cases. To prevent unnecessary increases in the incidence of malalignment in primary TKR, it is recommended that these devices should not be used without objective verification of alignment, either in real-time or with post-operative imaging. Further work is required to identify the source of discrepancies and validate these devices prior to routine use.Level of evidenceII.

This investigation evaluated the Smith and Nephew VISIONAIRE patient-specific cutting block (PSCB) system for total knee arthroplasty. A consecutive series of 60 patients were recruited. Intraoperative computer navigation was used to evaluate the accuracy of the cutting blocks in the coronal and sagittal planes for the tibia, as well as rotational plane for the femur. The PSCB would have placed 79.3% of the sample within +3° of neutral in the coronal plane, while the rotational and sagittal alignment results within +3° were 77.2% and 54.5% respectively. The VISIONAIRE PSCB system achieved unacceptable accuracy in the coronal plane and even less in the sagittal and rotational planes compared to computer navigation. Caution is recommended before PSCB are used routinely without objective verification of alignment.

Flexion contracture has been shown to impair function and reduce satisfaction following total knee arthroplasty (TKA). The aim of this study was to identify modifiable intra-operative variables that predict post-TKA knee extension.Data was collected prospectively on 95 patients undergoing total knee arthroplasty, including pre-operative assessment, intra-operative computer assisted surgery (CAS) measurements and functional outcome including range of motion at one year. Patients were divided into two groups: those with mild flexion contracture (5°) at the one-year follow-up and those achieving full extension.The sagittal orientation of the distal femoral cut differed significantly between groups at the one-year follow-up (p = 0.014). Sagittal alignment of greater than 3.5° from the mechanical axis was shown to increase the relative risk of a mild flexion contracture at one-year follow-up by 2.9 times, independent of other variables.Increasing the sagittal alignment of the distal femoral cut more than 3.5° from the mechanical axis is an independent risk factor for clinically detectable flexion contracture one year from index procedure.

Background Different patterns of bone bruising are seen on magnetic resonance imaging in acute anterior cruciate ligament ruptures. These patterns may relate to the mechanism of injury. Hypothesis There is a correlation between the mechanism of anterior cruciate ligament injury and bone bruise patterns on magnetic resonance imaging. Study Design Cohort study; Level of evidence, 2. Methods Data regarding the mechanism of anterior cruciate ligament rupture were collected prospectively on patients who had anterior cruciate ligament reconstructions. Inclusion criteria included a clear history of mechanism, magnetic resonance imaging within 6 weeks of injury, and no previous knee injury. Patients were divided into noncontact and contact mechanism groups. Bone bruise frequency, location, depth, and intensity were analyzed using magnetic resonance imaging and correlated with the mechanism of injury. Results Two hundred fifty-six patients were identified; 100 met the inclusion criteria, 86 were in the noncontact mechanism group, and 14 were in the contact mechanism group. The proportion of bone bruises in the lateral compartment in both groups was higher ( P < .001) than in the medial compartment. Bone bruising was more frequent, deeper, and more intense in the non-contact group, with frequency ( P = .019) and intensity ( P < .001) scores reaching significance at the lateral tibial plateau. Medial compartment bone bruising was seen more frequently than previously reported, particularly in the noncontact group. Conclusion The noncontact mechanism appears to cause more severe bone bruising in both the medial and lateral compartments.

Injection of local anesthetic during total knee arthroplasty (TKA) has been shown to aid postoperative pain relief. Reinfusion drains have also proven useful in decreasing allogenic blood transfusion. Combined use carries the risk of reinfusion of local anesthetic from drainage bag. We examined plasma ropivacaine concentrations from 20 patients undergoing TKA, who were treated with these 2 techniques. Samples were taken from a dedicated venous cannula and from the reinfusion drainage bag. The average amount of ropivacaine reinfused was 1.9 mg, a fraction of the injected dose (150 mg), and venous plasma concentrations reached peaks of 0.5 to 1.5 μ g/mL, well below demonstrated levels of toxicity. Patients tolerated the treatment well, with no adverse outcomes. This study demonstrates the safety of combining these 2 techniques in TKA.