Correction to: Unconstrained total knee arthroplasty in significant valgus deformity: a modified surgical technique to balance the knee and avoid instability.

The author would like to correct the following errors in the publication of the original article.

Knee manipulation for reduced flexion after Total Knee Arthroplasty. Is timing critical?

BACKGROUND: Reduced flexion following knee arthroplasty (TKA) may compromise patient's function and outcome. The timing of manipulation under anaesthesia (MUA) has been controversial. We present our experience in a high volume practice and analyse the impact of timing. METHODS: All TKA patients requiring MUA from February 1996 to June 2015 under the care of a single surgeon were analysed. MUA was offered to patients who had ≤ 75° of flexion post-op, providing that they had 30° more flexion preoperatively. To address the impact of timing from primary surgery to MUA on flexion gain we looked at 3 groups: Group I ≤ 90 days, Group II 91-180 days and Group III > 180 days. RESULTS: Sixty two out of 7,423 (0.84%) underwent MUA. The MUA patients were significantly younger than the overall TKA cohort 61.2 vs 70.5 years (p = < 0.01). The median duration between arthroplasty and MUA was 3.9 months (IQR 3.4, Range 1.6-72.5 months). Overall flexion gained at 6-12 Weeks and 1 year post MUA showed significant improvements of 20.9° (p = <0.01) and 25° respectively (p = < 0.01). The flexion gain in group I (≤ 90 days) was significantly better than group III ( > 180 days) both at 6 weeks and 1 year following MUA but not better than group II (90-180 days). CONCLUSIONS: MUA is an effective treatment for reduced flexion following TKA and should be the first line of management after failed physiotherapy. It can still have benefit beyond 6 months but the gains become less effective with time.

Bilateral fixation of a periprosthetic intertrochanteric hip fracture below Birmingham hip resurfacing.

This case report involves a 59-year-old woman with a traumatic right intertrochanteric hip fracture below a previous Birmingham hip resurfacing (BHR). This woman had almost an identical fracture on the left hip 3 years before which was treated with a proximal femoral locking compression plate. Of note periprosthetic fractures following hip resurfacing are usually subcapital and treated with a revision or conservative management. We present an unusual surgical problem that has occurred twice in the same patient and has been treated effectively on both occasions using proximal femoral plating. To the best of our knowledge, there have been no other reports of bilateral periprosthetic fractures being treated in this way.

Unconstrained total knee arthroplasty in significant valgus deformity: a modified surgical technique to balance the knee and avoid instability.

PURPOSE: Correction of valgus deformity in total knee arthroplasty (TKA) is technically challenging and has produced variable results. A modified surgical technique involving adapting the distal femoral cut with minimal soft tissue release is proposed. The authors hypothesise that using this technique would result in satisfactory radiological and functional outcome. METHODS: The technique involves balancing the knee in extension by changing the distal femoral resection angle and confining soft tissue release to only the posterolateral capsule if required. Retrospective analysis of 276 consecutive TKAs performed using this technique under the care of a single surgeon in patients with valgus knee deformity ≥10° was undertaken. An unconstrained mobile bearing implant was used in all knees with a medial para-patellar approach, and outcome scores were collected prospectively. Seventy-five percent of the knees were cementless. [corrected] RESULTS: Mean coronal alignment of the lower limb was corrected from 15.6° (±5.7°) to 3.8° (±2.5°). 97.8 % knees had their coronal alignment restored to ≤7°. Seventy-eight knees (28 %) were balanced by only changing the distal femoral resection angle. One hundred and ninety-eight knees (72 %) had release of the posterolateral capsule. Sixteen knees (5.8 %) also had release of iliotibial band. Lateral patellar release was performed in 39 knees (14 %). 93.1 % had central patello-femoral alignment. At between 5.8 and 10.5 year follow-up, there has been one spinout, managed by closed reduction, and one revision of tibial tray for subsidence. The mean American Knee Society clinical score improved from 19.1 to 86.5 (±12.2). CONCLUSION: Adequate correction of valgus knee deformity was successfully achieved using this modified technique with satisfactory medium-term outcome and avoidance of instability.

An audit of consent for allograft use in elective orthopaedic surgery.

Introduction Patients receiving musculoskeletal allografts may be at risk of postoperative infection. The General Medical Council guidelines on consent highlight the importance of providing patients with the information they want or need on any proposed investigation or treatment, including any potential adverse outcomes. With the increased cost of defending medicolegal claims, it is paramount that adequate, clear informed patient consent be documented. Methods We retrospectively examined the patterns of informed consent for allograft bone use during elective orthopaedic procedures in a large unit with an onsite bone bank. The initial audit included patients operated over the course of 1 year. Following a feedback session, a re-audit was performed to identify improvements in practice. Results The case mix of both studies was very similar. Revision hip arthroplasty surgery constituted the major subgroup requiring allograft (48%), followed by foot and ankle surgery (16.3%) and revision knee arthroplasty surgery (11.4%) .On the initial audit, 17/45 cases (38%) had either adequate preoperative documentation of the outpatient discussion or an appropriately completed consent form on the planned use of allograft. On the re-audit, 44/78 cases (56%) had adequate pre-operative documentation. There was little correlation between how frequently a surgeon used allograft and the adequacy of consent (Correlation coefficient -0.12). Conclusions Although the risk of disease transmission with allograft may be variable, informed consent for allograft should be a routine part of preoperative discussions in elective orthopaedic surgery. Regular audit and feedback sessions may further improve consent documentation, alongside the targeting of high volume/low compliance surgeons.

Photographic measurement of the inclination of the acetabular component in total hip replacement using the posterior approach.

The angle of inclination of the acetabular component in total hip replacement is a recognised contributing factor in dislocation and early wear. During non-navigated surgery, insertion of the acetabular component has traditionally been performed at an angle of 45 degrees relative to the sagittal plane as judged by the surgeon's eye, the operative inclination. Typically, the method used to assess inclination is the measurement made on the postoperative anteroposterior radiograph, the radiological inclination. The aim of this study was to measure the intra-operative angle of inclination of the acetabular component on 60 consecutive patients in the lateral decubitus position when using a posterior approach during total hip replacement. This was achieved by taking intra-operative photographs of the acetabular inserter, representing the acetabular axis, and a horizontal reference. The results were compared with the post-operative radiological inclination. The mean post-operative radiological inclination was 13 degrees greater than the photographed operative inclination, which was unexpectedly high. It appears that in the lateral decubitus position with a posterior approach, the uppermost hemipelvis adducts, thus reducing the apparent operative inclination. Surgeons using the posterior approach in lateral decubitus need to aim for a lower operative inclination than when operating with the patient supine in order to achieve an acceptable radiological inclination.