Mechanical Alignment in Total Knee Arthroplasty for Varus Knee Osteoarthritis Leads to Significant Tibial Bone Loss.

Background Obtaining a neutral postoperative alignment is said to be a guiding principle for performing a successful total knee arthroplasty (TKA). There are many different alignment philosophies and surgical techniques to attain the goal of proper alignment. This study aimed to radiologically measure the difference in the amount of tibial bony resection required to perform a mechanical alignment versus an anatomic alignment TKA. Methods Two observers retrospectively reviewed the long leg radiographs of 100 patients (61 females and 39 males) listed for TKA between 2015 and 2018, measuring the amount of tibial bony resection required to achieve mechanical or anatomic alignment TKA. Results These radiographs' overall lower limb mechanical axis ranged between 16° varus and 17.6° valgus (mean 4.4° varus, standard deviation (SD) 6.64). By referencing 4 mm from the worn side, the mean resection needed from the normal side of the tibial plateau is 7.6 mm in the mechanical alignment measurement and 5.2 mm in the anatomical alignment measurement (p<0.0001). Therefore, 17% of mechanical alignment cuts require a tibial cut of more than 10 mm (mean 12.382 mm). No anatomical alignment measurements exceed 10 mm. When a virtual tibial cut >10 mm is required, the medial proximal tibial angle (MPTA) is a stronger predictor of deformity than the mechanical axis. Conclusion This radiological study shows that an anatomical alignment tibial cut is more bone conserving on the tibia than a mechanical alignment tibial cut and may lead to less asymmetry of the bony cuts and greater bony preservation, but clinical correlation is needed.

Medial/central PF arthritis and functionally stable ACL deficiency do not compromise outcomes of fixed-bearing medial UKA.

BACKGROUND: There is limited published data assessing functional scores and patient satisfaction following unicompartmental knee arthroplasty (UKA) in patients with patellofemoral (PF) arthritis or anterior cruciate ligament (ACL) deficiency. The purpose of this study was to determine whether medial/central PF arthritis or functionally stable ACL deficiency compromise outcomes of fixed-bearing medial UKA at a minimum follow-up of 2 years. The hypothesis was that equivalent outcomes can be achieved in patients with substantial medial/central PF arthritis or with functionally stable ACL deficiency. METHODS: The authors studied a consecutive series of 229 patients (240 knees) at 36.9 ± 6.3 months after receiving fixed-bearing medial UKA. Patients completed pre- and post-operative (2 years) clinical outcome questionnaires for Oxford Knee Score (OKS), EQ-5D, Knee injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS), University of California, Los Angeles (UCLA) activity score, and Forgotten Joint Score (FJS). Multivariable analyses were performed to determine associations between clinical scores, patient demographics, PF arthritis and functionally stable ACL deficiency. RESULTS: Of the 240 knees, 125 (54%) had substantial medial/central PF arthritis and 21 (9%) functionally stable ACL deficiency. Multivariable analyses revealed no association between outcomes and medial/central PF arthritis, but knees with functionally stable ACL deficiency were associated with better KOOS-PS (ß = 8.99, p = 0.012). CONCLUSION: Fixed-bearing medial UKA grants satisfactory outcomes at 2 years even in knees with substantial medial/central PF arthritis or functionally stable ACL deficiency. Longer-term prospective studies with larger cohorts are needed to confirm these promising findings regarding outcomes in patients traditionally contraindicated for medial UKA.

Staged meniscal allograft transplantation as a biologic treatment of the meniscal deficient knee: A prospective case series of 26 patients with maximum 88-month follow-up.

INTRODUCTION: The meniscal deficient knee often exists within the setting of associated pathology including instability, malalignment and chondral injury. The aim of this study was to establish the role of meniscal allograft transplantation (MAT) as part of a staged approach to treatment of the previously menisectomised knee and report: (a) primary data endpoints (pre and post-operative Knee Injury and Osteoarthritis outcome scores (KOOS), Tegner scores, satisfaction scores and graft survival), and (b) secondary endpoints:(complication/reoperation rates, and meniscal extrusion measurements as determined by MRI). MATERIAL AND METHODS: This prospective study included all patients that underwent arthroscopic fresh frozen allograft MAT at our institution (2010-2017) using a soft tissue fixation technique. RESULTS: Twenty-seven MAT procedures were performed in 26 patients (16 lateral, 11 medial). Ten patients underwent ACL reconstruction, three ACI and two osteotomy in the pre-MAT phase. Seven patients underwent ACI within the post-operative phase. Post-operative mean KOOS scores improved significantly in all subscales (p < .002) as did Tegner scores (p < .05). Graft survival was 100%, satisfaction rate 92%, and mean meniscal extrusion 3.04 mm. Post operatively, three patients required meniscal repair and a single patient, partial menisectomy of graft. Two patients underwent arthroscopic arthrolysis following MAT. CONCLUSIONS: This series highlights the multifactorial profile of the meniscal deficient knee and the role of MAT as a safe and reliable technique in the staged and comprehensive biologic treatment available to minimise symptoms and maximise outcomes. LEVEL OF EVIDENCE: 4.

Excellent survival and outcomes with fixed-bearing medial UKA in young patients (≤ 60 years) at minimum 10-year follow-up.

PURPOSE: To evaluate whether long-term (10-year minimum) patient outcomes and survival of fixed-bearing medial unicompartmental knee arthroplasty (UKA) in patients aged ≤ 60 years were favorable despite non-conventional age criteria. METHODS: The authors reviewed the records of 91 consecutive medial UKAs performed in patients aged ≤ 60 by a single surgeon. All patients received the same fixed-bearing M/G Unicompartmental Knee System. Patients records were updated, noting complications or revisions, and Oxford Knee Scores and overall satisfaction collected. If deceased, the general practitioner or next of kin provided data. RESULTS: Of the initial 91 knees, 10 were revised, 6 were deceased, and 1 was lost to follow-up. The final cohort of 74 knees was aged 54.3 ± 4.3 years (range 41.8-60.6) at index surgery. Using revision of any component as endpoint, the present series had a KM survival of 92.9% (CI 84.8-96.7%) at 10 years, and 87.8% (CI 78.4-93.2%) at 15 years, and a single non-fatal DVT was reported. At final follow-up of 15 ± 1.3 years (range 11-18), OKS (available for all 74 knees) was 38.4 ± 8.4 (range 18-48). Overall patients were pleased or very pleased with 72 of the knees (97%). CONCLUSION: Fixed-bearing medial UKA yields favorable results in the treatment of single compartment osteoarthritis of the knee in patients ≤ 60 years. The present study demonstrates low complication rates, good-to-excellent long-term patient outcomes, and satisfactory implant survival for this age group considering the advantages of UKA. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Increased precision of coronal plane outcomes in robotic-assisted total knee arthroplasty: A systematic review and meta-analysis.

BACKGROUND: Inaccuracy of component alignment in total knee arthroplasty adversely impacts outcomes. Robotic systems improve translation of pre-operative planning to intra-operative steps, theoretically resulting in greater accuracy and precision. In this study we systematically review literature data of alignment outcomes and apply meta-analysis methods to assess whether robotic-assisted knee arthroplasty provides superior outcomes when compared to conventional knee prostheses. METHODS: A PRISMA compliant search comparing alignment outcomes in robotic vs conventional knee arthroplasty was performed. Primary outcome measures were; number of three degree outliers and mean deviation from a neutral post-operative mechanical axis. RESULTS: In total, from five studies reporting upon 402 knees, a post-operative mechanical axis malalignment of >3° occurred in 1/181 (0.006%) of robotic knees, and 42/159 (26.4%) of conventional knees with a meta-analysis odds ratio of 0.04 (95% CI 0.01-0.14), p < 0.00001 favouring robotic-assisted instrumentation. Meta-analysis also demonstrated weighted mean differences of post-operative mechanical axis alignment to be significantly more accurate in the robotic knee group: mean difference -0.63 (95% CI: -1.18,-0.08), z = 2.25, p = 0.02. Sensitivity analysis with inclusion of only Level 1 studies showed similar findings. CONCLUSIONS: This systematic review and meta-analysis demonstrates clear evidence of increased accuracy of alignment in robotic-assisted knee arthroplasty with specific regard to reconstituting a neutral mechanical axis and minimising number of outliers in the coronal plane. Further studies and long term data is required in order to conclude on survivorship and functional outcomes.

Quadriceps Tendon-Bone or Patellar Tendon-Bone Autografts When Reconstructing the Anterior Cruciate Ligament: A Meta-analysis.

OBJECTIVE: We aimed to quantitatively assess the outcomes of studies, comparing the use of Bone-patellar tendon-bone (BPTB) and the quadriceps tendon-bone (QTB) autografts when reconstructing the anterior cruciate ligament (ACL). DATA SOURCES: MEDLINE, Embase, and CINAHL databases were searched for relevant articles published between January 1980 and January 2015 for the purpose of identifying studies comparing BPTB and QTB autografts for ACL reconstruction. Included studies were assessed regarding their methodological quality before analysis. Outcomes analyzed were graft failure rates, objective and subjective stability assessments, as well as the presence and severity of donor site morbidity. MAIN RESULTS: Five studies contributed to the quantitative analysis of 806 patients with 452 patients included in the BPTB group and 354 patients in the QTB group. Graft failure rates were similar between the 2 groups [odds ratio (OR) = 0.61; confidence interval (CI) = 0.17-2.15; Z = 0.78, P = 0.44]. There were no significant differences between the 2 groups when testing anteroposterior stability using an arthrometer (standardized mean difference = 0.07; CI = -0.12-0.25; Z = 0.70, P = 0.48). At 1 year postoperatively, there was no difference in the percentage of patients with a positive pivot shift test between the 2 groups (OR = 1.0; CI = 0.85-1.18; Z = 0.01, P = 0.99). However, significantly less patients had graft site pain 1 year after surgery in the QTB group (OR = 0.10; CI = 0.02-0.43; Z = 3.12, P = 0.002). Similarly, fewer patients reported moderate to severe pain while kneeling, in the QTB group (OR = 0.16; CI = 0.07-0.37; Z = 4.26, P < 0.001). CONCLUSIONS: This study demonstrates comparable survival rates and joint stability when BPTB and QTB grafts are used. However, fewer adverse donor site symptoms are evident with QTB grafts. LEVEL OF EVIDENCE: III.

A Meta-analysis of Functional Outcomes in Patient-Specific Instrumented Knee Arthroplasty.

Alignment data in patient-specific instrumented (PSI) knee arthroplasty have been examined in several meta-analyses, with demonstration of comparative but not improved restitution of a neutral mechanical axis and favorable outcomes in femoral implant axial alignment. To date, no comprehensive synthesis of data has been conducted specifically for functional outcomes. Relevant databases were searched according to Preferred Reporting Items for Systematic reviews and Meta-analyses guidelines during the period 2000 to 2015 of Levels 1 and 2 studies comparing functional outcomes of patient-specific instrumentation (PSI) versus conventional instrumentation. Outcomes of interest included postoperative Knee Society score (KSS) (function), KSS (knee), range of movement (ROM), Oxford knee scores (OKS), and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores. Five randomized controlled trials and three prospective-comparative studies were included reporting on a total of 828 knees. All eight studies reported postoperative KSS (function) and seven studies reported KSS (knee). Three studies reported postoperative OKS, four documented ROM, and two reported WOMAC scores. Meta-analysis demonstrated equivalent KSS (function) scores 3 months postsurgery (Z = 1.71, p = 0.09). In addition, no significant differences were found for KSS (function) at 6 months (Z = 0.51, p = 0.61) or 12 to 24 months postsurgery (Z = 0.05, p = 0.96). In addition, no significant differences were found between PSI and conventional instrumentation for postoperative KSS (knee), ROM, or OKS. In summary, this systematic review and meta-analysis demonstrates no conclusive evidence for or against PSI when considering short-term functional outcomes. Further high-quality studies are required to investigate both mid- and long-term outcomes as well as survivorship data.

The use of the free vascularised bone graft for nonunion of the scaphoid: a systematic review.

BACKGROUND: Fractures of the scaphoid are well known to be problematic especially when complicated by avascular necrosis, nonunion and carpal collapse. Fixation techniques have involved nonvascularised bone grafting; however, in the presence of avascular necrosis, generally poor union rates (47%) occur as identified by a meta-analysis performed by Merrell et al. The introduction of pedicled vascularised bone grafts showed further improvement; however, in the presence of carpal collapse, union rates as low as 50% have been reported by Chang et al. amongst others using the 1,2-intercompartmental supraretinacular artery pedicled graft. The difficulty lies in having a short pedicle with limited manoeuvrability to correct a humpback deformity and insert into the scaphoid cavity. Prior trauma to the soft tissues or distal radius may prohibit the use of pedicled grafts. The aim of this systematic review is to examine the published evidence for the use of free vascularised bone grafts in cases of scaphoid nonunion. METHODS: A systematic review was performed with the following defined search strategy on MEDLINE and Google Scholar: ((scaphoid nonunion) OR scaphoid pseudarthrosis) AND bone graft. Articles were reviewed and data compiled into tables for analysis. Statistical analysis was performed with determination of descriptive statistics, and differences between the groups were calculated using categorical variables and chi-square test. A p value of 0.05 or less was considered to be statistically significant. RESULTS: Two hundred and sixty-three articles were identified with a total of 12 articles meeting the inclusion criteria. Two hundred and forty-five cases of scaphoid nonunion were identified through the articles included in this systematic review. Fifty-six patients underwent free vascularised bone grafts from the medial femoral condyle with a 100% union rate and correction of humpback deformity, and 188 patients underwent free vascularised bone grafting from the iliac crest with an 87.7% union rate. The difference between the two similar groups was statistically significant (p = 0.006). CONCLUSIONS: The promising data suggests that the medial femoral condylar free graft based on the descending genicular vessels can be considered in cases of proximal pole avascular necrosis and humpback deformity or in situations where other flaps are precluded or deemed unlikely to cause union.

Facial motion analysis of acid burn victims--development of a new facial motion impairment index.

OBJECTIVES: Evaluation of facial movement is necessary for the assessment of motor deficits and planning reconstructive surgery in facial burns. Clinicians recognise the need for an accurate and reproducible method of functional assessment. We propose a new facial functional impairment index (FFII) for assessing facial motor dysfunction due to severe burn injury and provide inter/intra-patient comparison for documenting rehabilitation. METHODS: The maximal static response assay (MSRA) was used to compare facial movement in 20 acid burn victims with 20 control subjects. Data compiled from 12 soft tissue landmarks was used to quantify rest and dynamic asymmetry, anatomic and non-anatomic motion and calculate the FMII. The Katz score, Nottingham index and number of affected aesthetic units provided insight into FFII efficacy. RESULTS: Patients with greater aesthetic disfigurement demonstrated significantly poorer anatomic function (c=0.62; p=0.03) as well as larger global facial functional impairment (c=0.52; p=0.08). CONCLUSION: Acid burns caused severe asymmetry and functional impairment. The FFII is a composite score of global function based on a reproducible method of data collection and it differentiated between acid burn victims and provided objective comparative measures. Software automation, integration of video and 3D data, appropriate graphical and pictorial depiction of variables and measurements, and further research into the accuracy of FFII as a marker of clinical recovery and assessment of function in facial burns, will enhance future clinical applications and potentially aid surgical reconstruction.

Cases of chemical assault worldwide: a literature review.

We reviewed 24 studies of chemical burns by means of assault in the last 40 years. We describe 771 cases of chemical assault in total. Jamaica had the largest absolute number of cases. Bangladesh had the highest reported incidence. Male victims were more common, with the exception of Bangladesh and Taiwan. The youngest cohort was from Bangladesh. The role of gender, agents used and legislation were discussed. We identified two broad motives; increases in violent crime and use as a crime of passion in disputes between men and women.

Superficial ulnar artery terminating in a normal ulnar artery.

Routine dissection of the left upper limb of an 86-year-old male cadaver showed a superficial ulnar artery that anastomosed with the ulnar artery. The superficial ulnar artery arose from the third part of the axillary artery, coursed distally over the flexor muscles of the forearm, and terminated by anastomosing with the ulnar artery in the distal third of the forearm. Arterial and neural variations were also observed on the contralateral side. The presence of a superficial ulnar artery is important clinically when raising forearm flaps in reconstructive surgery.