Effect of SKI 306X, a new herbal anti-arthritic agent, in patients with osteoarthritis of the knee: a double-blind placebo controlled study.

SKI 306X is a purified extract from a mixture of three oriental herbal medicines (Clematis mandshurica, Trichosanthes kirilowii and Prunella vulgaris) that have been widely used for the treatment of inflammatory diseases such as lymphadenitis and arthritis in far East Asia. A double-blind, controlled study was performed to evaluate the efficacy and safety of SKI 306X with placebo in 96 patients with classical osteoarthritis of the knee. Patients were randomized to four treatment groups: placebo, 200 mg, 400 mg and 600 mg of SKI 306X t.i.d.. Clinical efficacy and safety were evaluated for 4 weeks continuous treatment. SKI 306X demonstrated its clinical efficacy, as assessed by 100 mm visual analogue scale (VAS), Lequesne index and patients' and investigators opinion of the therapeutic effect compared with placebo (p<0.01). No significant adverse events were observed in patients treated with SKI 306X. This study demonstrated that SKI 306X, a new herbal anti-arthritic agent provided clinical efficacy in patients with osteoarthritis.

A new method for arthroscopic treatment of tibial eminence fractures with eyed Steinmann pins.

This report describes a new and simple method to treat tibial eminence fractures. We treated these fractures arthroscopically by using eyed Steinmann pins and pullout sutures of 1-0 polydioxane or 1-0 polypropylene monofilament under local anesthesia. From March 1993 to February 1997, we treated 16 patients with tibial eminence fractures. There were 12 cases of type II and 4 cases of type III fractures, according to the classification of Meyers and McKeever. All of the patients had good results according to the International Knee Documentation Committee and Müller's knee scoring systems, and had good stability by anterior stress radiographs compared with the uninjured side. Advantages of this method are minimal arthrotomy, simple technique, short operation and hospitalization times, early rehabilitation, no need for metal fixation removal, and, this procedure can be done under local anesthesia.

Anomalous insertion of the medial menisci.

Many types of meniscal anomalies have been reported. The authors encountered two cases of anomalous insertion of the anterior horn of the medial menisci to the lateral femoral condyle, which ran up along the course of the anterior cruciate ligament (ACL), but was independent of the ACL. These anomalies were noted during arthroscopic examination and surgery of the ipsilateral knee for a torn discoid meniscus and a patellar fracture. A 34-year-old woman had a horizontal tear of the lateral discoid meniscus. We performed arthroscopic partial meniscectomy of the inner torn portion of the lateral discoid meniscus and contoured it to resemble a normal meniscus. An anomalous insertion of the medial meniscus was found on examination of the joint during surgery. A 32-year-old man had a patellar fracture and we performed reduction under arthroscopy and internal fixation with cannulated screws. The same anomalous insertion of the medial meniscus was also found on examination of the joint during surgery. We report the cases with a review of the literature.

Arthroscopic second look findings of an anterior cruciate ligament bone-patellar tendon-bone autograft.

Nineteen patients who had undergone reconstruction of a deficient anterior cruciate ligament (ACL) by a bone-patellar tendon-bone (BPTB) autograft 12 months or more before (mean: 15.8 months) were evaluated by second-look arthroscopy. Prior to the arthroscopic evaluation the patients underwent a clinical evaluation of the results of ACL reconstruction: Muller's knee rating score and the radiographic results from lateral radiographs of the full extended knees were used. The location of the center of the tibial tunnel from the anterior end of the line of the tibial plateau was 35.2% (range: 22% to 47%) on average. The average intercondylar roof angle was 36.6 degrees (range: 28 degrees to 45 degrees). The mean percentage of roof impingement was -13.5% (range: -55% to +23%; the negative value implies no impingement, while the positive value suggests the presence of impingement). During the second-look arthroscopy the ACL graft had one or more of the following features: nearly normal appearance, incomplete synovial coverage, partially torn fibers at the femoral tunnel site, parallel fragmentation with cyclops lesion, and impingement without the damage of the ACL graft. Biopsy specimens were obtained from the nearly normal ACL graft during the second-look arthroscopy and light microscopic findings showed dense collagen fibers and spindle-shaped fibroblasts with a relatively regular arrangement (H&E, X 200). The electron microscopic findings showed that the fibroblasts had prominent indented nuclei and an abundant rough endoplasmic reticulum (X 10,200) and that the longitudinal sections of extracellular collagen fibrils demonstrated a type I collagen banding pattern (X 50,000).

Medial collateral ligament injuries of the knee: ultrasonographic findings.

The aims of our study were (1) to describe the ultrasonographic findings of the injured medial collateral ligament of the knee and (2) to assess the usefulness of ultrasonography in both evaluating the presence and location of the medial collateral ligament injuries and predicting the prognoses for the patients. The study group consisted of 16 patients with the clinical diagnosis of medial collateral ligament injury. We also examined 20 knee joints in 10 volunteers who had no history of injury to the knee. To predict prognoses, we divided the patients into two groups on the basis of the location of medial collateral ligament injuries. A thickened and heterogeneously hypoechoic appearance of the medial collateral ligament was considered abnormal. The normal medial collateral ligament was a thin and moderately homogeneous hypoechoic band with an average thickness of 4.3 mm (range, 3.3 to 5.6 mm) at the femoral attachment and of 2.3 mm (range, 1.3 to 3.2 mm) at the tibial attachment. All injured medial collateral ligament structures were thickened and heterogeneously hypoechoic. According to the criteria for grading of medial collateral ligament injury with stress view, 10 patients had grade III medial collateral ligament tears, three had grade II tears, and none had grade I injuries. In 15 (94%) of 19 knees, a correct diagnosis could be made with ultrasonography. Ultrasonography is useful in evaluating isolated medial collateral ligament injuries and in predicting patient outcome on the basis of the location of the medial collateral ligament injuries.

Noncemented stem tibial component in total knee replacement: the 2- to 6-year results.

OBJECTIVE: To determine if the addition of a stem to the tibial component in noncemented total knee replacement affects sinkage of that component or micromotion. DESIGN: A cohort of 176 consecutive cases with no exclusions. Follow-up ranged from 2 to 6 years. SETTING: A university-affiliated institution specializing in elective orthopedic surgery. PARTICIPANTS: All 176 patients had arthritis of the knee, mainly osteoarthritis. All agreed preoperatively to prolonged postoperative follow-up. INTERVENTION: Noncemented total knee replacement with the Tricon M long-stem tibial component. MAIN OUTCOME MEASURES: Hospital for Special Surgery rating system for clinical results and degree of tibial sinkage and stem lucency seen radiologically. RESULTS: Eight (4.5%) of the 176 prostheses required revision, none for sinkage. Of the remaining 168 knees, 156 (92.9%) scored good or excellent, 6% fair and 1.2% poor. Sinkage occurred in 3%, but was not of sufficient severity to require revision. No lucency was visible in 33.8% of stems, partial lucency in 62%, complete lucency with the lines being parallel to the stem in 3.5% and complete lucency with divergent lines, indicating a loose implant, in 1.7%. Lucency, when present, was seen mainly in the lateral view, seldom in the anteroposterior view. There was no correlation between radiologic results and clinical results. CONCLUSIONS: The addition of a metaphyseal stem reduces the incidence of sinkage of the tibial component in total knee replacement. The stem largely solves the problem of mediolateral micromotion but does not completely prevent anteroposterior micromotion.

Noncemented, porous ingrowth knee prosthesis: the 3- to 8-year results.

OBJECTIVE: To determine the principal long-term problems encountered in noncemented total knee replacement. DESIGN: A cohort of 252 consecutive cases of total knee replacement with no exclusions. Follow-up ranged from 3 to 8 years. SETTING: A university-affiliated institution specializing in orthopedic surgery. PARTICIPANTS: All 252 patients had arthritis of the knee, mainly osteoarthritis. All agreed preoperatively to prolonged postoperative follow-up. INTERVENTION: Noncemented total knee replacement with the Tricon M prosthesis, which has a metal-backed patella. MAIN OUTCOME MEASURES: The Hospital for Special Surgery rating system for clinical results and the radiologic results, including reasons for revision surgery. RESULTS: Thirty-five prostheses were revised: 11 prostheses because of patellar wear only; in 13 prostheses the tibial component (mainly a 6-mm unit) and patella were revised because of wear; 6 prostheses were revised for sepsis, 4 for reflex sympathetic dystrophy and 1 only for sinkage of the tibial component. Of the remaining 217 prostheses, 88% scored good or excellent, 6% fair and 6% poor. CONCLUSIONS: The single most common cause of failure was polyethylene wear. This was associated with the metal backing of the patella and the use of thin, polyethylene tibial components.

Repair of nonunion of tibial osteotomy.

Nonunion after high tibial osteotomy is an uncommon complication. Ten cases have been treated with a single plate; failure occurred twice in five. Double plates, bolted together, healed in all five attempts. Although the healed osteotomies had only "fair" functional results, none have as yet required total knee arthroplasty (TKA).

Prosthetic replacement of the arthritic knee after patellectomy.

The results of total knee replacement with a semiconstrained prosthesis after patellectomy are poor because the stabilizing effect of the patella is lost. A series of bicompartmental unicompartmental knee replacements (five patients) carried out for this condition was compared with a series of Insall-Burstein posterior stabilized knee prostheses (six patients). If both cruciate ligaments are present the results are not notably different, but those with an Insall-Burstein prosthesis generally fared better at stair-climbing using the replaced side as the lead leg. Since the Insall-Burstein knee is technically easier to implant there seems little to recommend the bicompartmental unicompartmental prosthesis in this condition.

Hinged total knee replacement: indications and results.

Twenty-seven hinged (Guepar II) knee replacements were performed on 26 patients with a follow-up of 1 to 7 years (mean 3 years). Indications for the procedure were bone loss (nine cases) nonunion of tibial or femoral fractures (four), anteroposterior instability (five), mediolateral instability (eight) and recurvatum instability (one). Results were good or excellent in 66.6%. Two patients required revision and there were three other implant-related complications. All press-fit stems were radiolucent to some extent and some radiolucency was present close to the knee in all revisions of stem components. No radiolucency was present in revisions of non-stem cemented components. Although the introduction of variable stem length, semi-constrained knees has reduced the need for implants such as the Guepar II prosthesis, the results, especially in terms of radiolucency, are surprisingly good. The authors conclude that a hinged knee remains of value in desperate situations.

Acetabular revision with a bipolar prosthesis.

In using bipolar prostheses for selected acetabular revision two groups were identified, those with an intact ring with thin flexible walls and those requiring massive allografting. In the intact ring group (15 cases), the largest possible bipolar head was used with minimal grafting. These have uniformly been trouble-free with acetabular reconstitution with minimal to no migration. In the massive allograft group (22 cases), the results have not been so spectacular, with only 55% good or excellent results. This is not necessarily a function of the acetabulum, since many of the femurs in this group also required allografting. No major migration has occurred, but the follow-up period is less than three years, and some migration is probably to be anticipated. It is concluded that, in these two situations, use of a bipolar prosthesis is a simple technique for dealing, at least in the short term, with a very difficult problem.

An examination of factors contributing to failure of bipolar prostheses.

Preoperative factors that may lead to poor results in bipolar prostheses were examined in 34 patients with aseptic failures of their prostheses. Nineteen cases were revised for acetabular pain, seven for failure of the bearing insert, seven for a loose stem, and one for dislocation. The single significant factor that predicted a poor outcome was the angle of the sourcil of the acetabular roof. The group with acetabular pain had an average sourcil angle of 15.6 degrees compared with 5 degrees in those that failed for other reasons.

A comparison of unicompartmental knee replacement with total knee replacement.

The knees of 20 patients with a unicompartmental arthroplasty on one s ide and a total replacement on the other were compared at follow-ups of over two years. Length of hospitalization was slightly less with the unicompartmental knees and recovery was faster. By one year, however, there was essentially no difference between the unicompartmental knees and the total replacements in spite of the fact that the former had a better range of movement. This suggests that flexion beyond 105 degrees is not of great significance to elderly people living in the West. It also suggests that, as the posterior cruciate was resected or lengthened in the majority of the total knee replacements, the presence or absence of this ligament does not affect the activities of daily living. Complications both early and late were more frequent with a unicompartmental knee, possibly implicating inferior patient selection, instrumentation, and implant design.

Clinical results with an uncemented plastic tibial component in unicompartmental knee replacement.

To determine the role of unicompartmental knee replacement in knee arthroplasty and, in particular, the design and function of the ICLH (Finsbury Prosthetics Ltd., London, UK) knee prosthesis, the authors report their experience with 18 patients (15 women and 3 men, mean age 73 years), who underwent unicompartmental knee replacement with this prosthesis. The prosthesis failed in five (27.8%) cases, but in the remainder the results were good to excellent over a follow-up extending to 6 years (mean 4.5 years). The main problem with the ICLH prosthesis is the linear wear of the plastic of the tibial component, caused by a sharp radius at the edge of the femoral component. This leads to fracture and breakdown of the tibial portion. Because the short-term results are good but the long-term results are poor, the authors suggest that the ICLH unicompartmental knee prosthesis should be reserved for use in patients whose life expectancy is short.

Patella baja complicating total knee arthroplasty. A report of two cases.

Severe noniatrogenic patella baja is a rare condition. Two cases were seen accompanying severe osteoarthritis of the knee. In both cases, following total knee arthroplasty the patella failed to make contact with the femoral component. The tibial tubercle had to be shifted proximally 2 cm to restore the normal joint mechanics. In one case, dislocation of the patella to gain access to the knee could be achieved only with osteotomy of the tibial tubercle. The technique of tibial tubercle elevation adopted was to raise a long bone flap. This allowed the tibial tubercle to be moved proximally and anchored securely.

Results of total hip arthroplasty without trochanteric osteotomy following hip fusion.

Other than the results of the Charnley group, using a transtrochanteric approach, there is little in the literature regarding the techniques and results of total hip arthroplasty following hip fusion. Thirteen cases carried out via an anterior Smith-Peterson approach have been performed by the senior author over the last few years. These cases have been studied to determine pitfalls and outcomes using this method. At one year, seventy-five percent of the cases became Trendelenberg negative. The average range of flexion at one year was 88 degrees and the Harris Hip Score was 2 poor, 2 fair, and 9 good or excellent. Retrospectively, one patient would rather not have had surgery. Nerve and vessel damage was not a problem and neither was myositis ossificans. Where possible, existing hardware was removed six months prior to arthroplasty. However, three femoral shaft splits occurred where noncemented femoral components were used. While it is a technically demanding exercise, the results of total hip replacement following hip fusion are acceptable.