Revision of partial knee to total knee arthroplasty with use of patient-specific instruments results in acceptable femoral rotation.

PURPOSE: Patient-specific instruments (PSI) were initially developed for the alignment of both total knee- (TKA) and partial knee arthroplasty (PKA). We hypothesize that CT-based PSI for PKA-to-TKA revision surgery can restore biomechanical limb alignment and prosthetic component positioning in vivo as calculated pre-operatively, resulting in a limited percentages of outliers. METHODS: An imaging analysis was performed using CT-based 3D measurement methods based on a pre- and post-revision CT scan. Imaging data were gathered on 10 patients who were operated for PKA-to-TKA revision with the use of PSI based on CT imaging. The planned femur and tibia component position in vivo were compared with the pre-revision planned component position. Outliers were defined as deviations >3.0° from pre-revision planned position for the individual implant components. Adjustments (e.g. resection level and implant size) during surgery were recorded. RESULTS: The HKA axis was restored accurately in all patients with a mean post-operative HKA axis of 178.1° (1.4°). Five femoral (2 varus, 2 internal rotation and 1 extension) and 14 tibial guides (2 varus, 6 anterior slope, 3 internal rotation and 3 external rotation) on a total of 60 outcome measures were identified as outliers. During surgery, an intraoperative tibial resection of 2 mm extra was performed in three patients. In 80 and 70% for, respectively, the femur and tibia, the surgeon-planned size was implanted during surgery. All patient-specific guides fitted well in all patients. No intraoperative or post-operative complications related to surgery were registered. CONCLUSIONS: This study introduced a unique new concept regarding PSI, PKA-to-TKA revision surgery. Based on the results, we were unable to fully confirm our hypothesis. PSI as a "new" tool for PKA-to-TKA revision surgery appears to be an accurate tool for the alignment of the TKA femur component. The tibial guide seems more susceptible to errors, resulting in a substantial percentage of outliers. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

Patient-specific instrumentation in Oxford unicompartmental knee arthroplasty is reliable and accurate except for the tibial rotation.

PURPOSE: Patient-specific instrumentation (PSI) is a technique to plan and position the prosthesis components in unicompartmental knee arthroplasty (UKA) surgery. This study assesses whether the definitive component position in the frontal, sagittal and axial plane is according to the preoperative plan, based on the hypothesis that PSI is accurate. METHODS: Twenty-six patients who had PSI Oxford UKA surgery were included prospectively. The component position in vivo was determined with a postoperative CT-scan and compared with the planned component position using MRI-based digital 3D imaging. Adjustments to the preoperative plan and implanted component sizes during surgery were recorded. RESULTS: Intraoperatively, no femoral adjustments were performed; 12 tibial re-resections were necessary. The median absolute deviation from the plan in degrees (range) in the frontal, sagittal and axial plane was 1.8° (- 1.5°-6.5°), 2.0° (- 6.5°-8.0°) and 1.0° (- 1.5°-5.0°) for the femoral component, and 2.5° (- 1.0°-6.0°), 3.0° (- 1.0°-5.0°) and 5.0° (- 6.5°-12.5°) for the tibial component. The femoral component is positioned 0.5 (- 1°-2.5°) mm more lateral and 0.8 (- 1.0°-2.5°) mm more anterior. The tibial component is positioned 2.0 (- 5.0-0.0) mm more lateral and 1.3 (- 3.0-6.0) mm more distal. The femoral and tibial default plans were changed four times (15.4%) and nine times (34.6%), respectively, before approval by the surgeon. CONCLUSION: PSI in Oxford UKA surgery is reliable and accurately translates the preoperative plan into the in vivo situation, except for the tibial rotational position. The preoperative planning is a crucial step in avoiding re-resections that can cause angular deviations in prosthesis position, especially in tibial component rotational position. It is advised to avoid re-resections and to consider this while planning the PSI procedure. LEVEL OF EVIDENCE: Prospective comparative study Level II.

Cementless versus cemented Oxford unicompartmental knee arthroplasty: early results of a non-designer user group.

PURPOSE: Although fewer tibial radiolucent lines are observed in cementless Oxford unicompartmental knee arthroplasty (UKA) compared with cemented Oxford UKA, an independent comparative study on this topic is lacking. METHODS: In this multicentre retrospective study, a cohort of 60 consecutive cases of cementless Oxford UKA is compared with a cohort of 60 consecutive cases of cemented Oxford UKA. Radiolucent lines, survival, perioperative data and clinical results were compared. RESULTS: No complete tibial radiolucent lines were observed in either group. Seventeen per cent of partial tibial radiolucent lines were observed in the cementless group versus 21 % in the cemented group (n.s.). The percentage of tibial radiolucent zones was 4 versus 9 %, respectively (p = 0.036). Survival rates were 90 % at 34 months for the cementless group and 84 % at 54 months for the cemented group (n.s.). Mean operation time was 10 min shorter in the cementless group (p < 0.001), and clinical results were not significantly different. CONCLUSIONS: Although no significant differences in radiolucent lines were found between both groups, they appear to be more common in the cemented group. This confirms previous results from reports by prosthesis designers. The presence of radiolucent lines after cemented Oxford UKA does not correlate with clinical outcome or survival. LEVEL OF EVIDENCE: III.

No difference in clinical outcome between patient-matched positioning guides and conventional instrumented total knee arthroplasty two years post-operatively: a multicentre, double-blind, randomised controlled trial.

AIMS: We wished to compare the clinical outcome, as assessed by questionnaires and the rate of complications, in total knee arthroplasty (TKA) undertaken with patient-matched positioning guides (PMPGs) or conventional instruments. PATIENTS AND METHODS: A total of 180 patients (74 men, 106 women; mean age 67 years) were included in a multicentre, adequately powered, double-blind, randomised controlled trial. The mean follow-up was 44 months (24 to 57). RESULTS: There were no significant or clinically relevant differences between the two groups for all outcome measures (Knee Society Score, p = 0.807; Oxford Knee Score, p = 0.304; Western Ontario and McMaster osteoarthritis index, p = 0.753; visual analogue scale for pain, p = 0.227; EuroQol-5D-3L index score, p = 0.610; EuroQol-5D-3L VAS health, p = 0.968.) There was no difference in the rate of complications (p = 0.291). CONCLUSION: PMPGs are already in relatively common use and their short-term clinical results are equal to conventional instrumented TKA. Cite this article: Bone Joint J 2016;98-B:939-44.

Inter-observer reliability of measurements performed on digital long-leg standing radiographs and assessment of validity compared to 3D CT-scan.

BACKGROUND: Long-leg radiographs (LLR) are often used in orthopaedics to assess limb alignment in patients undergoing total knee arthroplasty (TKA). However, there are still concerns about the adequacy of measurements performed on LLR. We assessed the reliability and validity of measurements on LLR using three-dimensional computed tomography (3D CT)-scan as a gold standard. METHODS: Six different surgeons measured the mechanical axis and position of the femoral and tibial components individually on 24 LLR. Intraclass correlation coefficients (ICC) were calculated to obtain reliability and Bland-Altman plots were constructed to assess agreement between measurements on LLR and measurements on 3D CT-scan. RESULTS: ICC agreement for the six observer measurements on LLR was 0.70 for the femoral component and 0.80 for the tibial component. The mean difference between measurements performed on LLR and 3D CT-scan was 0.3° for the femoral component and -1.1° for the tibial component. Variation of the difference between LLR and 3D CT-scan for the femoral component was 1.1° and 0.9° for the tibial component. 95% of the differences between measurements performed on LLR and 3D CT-scan were between -1.9 and 2.4° (femoral component) and between -2.9 and 0.7 (tibial component). CONCLUSION: Measurements on LLR show moderate to good reliability and, when compared to 3D CT-scan, show good validity. CLINICAL TRIAL REGISTRATION NUMBER: institutional review board Atrium-Orbis-Zuyd, number: 11-T-15. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

Revision from unicompartmental to total knee replacement: the clinical outcome depends on reason for revision.

Although it has been suggested that the outcome after revision of a unicondylar knee replacement (UKR) to total knee replacement (TKR) is better when the mechanism of failure is understood, a comparative study on this subject has not been undertaken. A total of 30 patients (30 knees) who underwent revision of their unsatisfactory UKR to TKR were included in the study: 15 patients with unexplained pain comprised group A and 15 patients with a defined cause for pain formed group B. The Oxford knee score (OKS), visual analogue scale for pain (VAS) and patient satisfaction were assessed before revision and at one year after revision, and compared between the groups. The mean OKS improved from 19 (10 to 30) to 25 (11 to 41) in group A and from 23 (11 to 45) to 38 (20 to 48) in group B. The mean VAS improved from 7.7 (5 to 10) to 5.4 (1 to 8) in group A and from 7.4 (2 to 9) to 1.7 (0 to 8) in group B. There was a statistically significant difference between the mean improvements in each group for both OKS (p = 0.022) and VAS (p = 0.002). Subgroup analysis in group A, performed in order to define a patient factor that predicts outcome of revision surgery in patients with unexplained pain, showed no pre-operative differences between both subgroups. These results may be used to inform patients about what to expect from revision surgery, highlighting that revision of UKR to TKR for unexplained pain generally results in a less favourable outcome than revision for a known cause of pain.

Intra-operative results and radiological outcome of conventional and patient-specific surgery in total knee arthroplasty: a multicentre, randomised controlled trial.

PURPOSE: This prospective, double-blind, randomised controlled trial was designed to address the following research questions: firstly, is there a significant difference in outliers in alignment in the frontal and sagittal plane between PSG TKA and conventional TKA. Secondly, is there a significant difference in operation time, blood loss and length of hospital stay between the two techniques. We hypothesise that there will be fewer outliers with PSG TKA and that operation time, blood loss and length of hospital stay can be significantly reduced with PSG. METHODS: A total of 180 patients were randomised for PSG TKA (group 1) or conventional TKA (group 2) in two centres. Patients were stratified per hospital. Alignment of the mechanical axis of the leg and flexion/extension and varus/valgus of the individual prosthesis components were measured on digital, standing, long-leg and standard lateral radiographs by two independent outcome assessors in both centres. Percentages of outliers (>3°) were determined. We compared blood loss, operation time and length of hospital stay. RESULTS: There was no statistically significant difference in mean mechanical axis or outliers in mechanical axis between groups. No statistically significant difference was found for the alignment of the individual components in the frontal plane nor for the percentages of outliers. There was a statistically significant difference in outliers for the femoral component in the sagittal plane, with a higher percentage of outliers in the group 1 (p = 0.017). No such significant result was found for the tibial component in that plane. All interclass correlation coefficients were good. Blood loss was 100 mL less in group 1 (p < 0.001). Operation time was 5 min shorter in group 1 (p < 0.001). Length of hospital stay was identical with a mean of 3.6 days (p = 0.657). CONCLUSIONS: The results in terms of obtaining a neutral mechanical axis and a correct position of the prosthesis components did not differ between groups. A small reduction in operation time and blood loss was found with the PSG system. Future research should especially focus on cost-effectiveness analysis and functional outcome of PSG TKA. LEVEL OF EVIDENCE: I.

Overstuffed medial compartment after mobile-bearing unicompartmental knee arthroplasty.

Overstuffing of the medial compartment in medial compartmental knee arthroplasty is a known pitfall. Attention to the flexion-extension gap should be addressed. If, however, overstuffing is found it can be corrected by revising the femoral component only.

[Atypical tuberculous osteomyelitis of the humeral shaft caused by Mycobacterium avium]. / Atypische tuberculeuze osteomyelitis van de humerusschacht door Mycobacterium avium.

A 41-year-old man underwent skeletal scintigraphy due to chronic pain in the left foot and polyarthralgia. He was taking medication for gout and had previously had sarcoidosis, for which he had received corticosteroids and other therapy that was discontinued 4 years ago. Scintigraphy revealed a mass in the shaft of the left humerus that, according to biopsy, was an asymptomatic osteomyelitis caused by Mycobacterium avium. The shaft of the left humerus is an uncommon site for tuberculous osteomyelitis. A viable fistula remained after the biopsy that persisted despite pharmacologic treatment with ethambutol, rifabutin and clarithromycin. Four months later, sequestrectomy was performed with insertion of gentamicin-impregnated beads, which resulted in rapid resolution. The foot pain resolved spontaneously. The incidence of bone tuberculosis has increased over the last 2 decades. The most commonly affected sites are the spine and large joints. Infection with M. avium is sometimes involved. Because of the increasing incidence it is important to include mycobacterial infections in the differential diagnosis of focal bone lesions, especially when standard cultures are initially negative.

Is minimally invasive surgery less invasive in total hip replacement? A pilot study.

It has been suggested that minimally invasive surgery (MIS) in total hip replacement (THR) is less traumatic than standard techniques. This study was designed to address the question of whether an anterior MIS approach generates less inflammation and muscle damage than the standard posterolateral (PL) approach. Inflammation parameters such as interleukin-6 (IL-6), muscle damage parameters like heart type fatty acid binding protein (H-FABP), and haemoglobin (Hb) levels were determined pre-operatively and at five consecutive points post-operatively in 10 patients operated through a MIS anterior approach and in 10 patients operated through a PL approach. The mean IL-6 concentration increased from 3 pg/ml in both groups pre-operatively to 78.5 pg/ml (PL group) vs 74.8 pg/ml (MIS group) at 6 hours post-operatively and reached a maximum of 100 pg/ml (PL group) vs 90.5 pg/ml pg/ml (MIS group) after 24 hours. Up to this time point, there was a decrease in both groups. The post-operative mean H-FABP concentration increased to 10.7 microg/l in the PL group vs 15.8 microg/l in the MIS group. It formed a plateau and decreased after 24 hours post-operatively. The Hb levels were 14.5 g/dl before surgery and decreased to 10.7 g/dl (PL group) and 10.0 g/dl (MIS group) at 72 hours post-operatively. No significant differences were found between the two approaches either in inflammation and muscle damage or blood loss. Although the absence of a learning curve may explain the lack of a difference between both techniques, we speculate that the term MIS is at least doubtful in terms of being less traumatic.