Patellar resurfacing in total knee replacement: a ten-year randomised prospective trial.

A series of 100 consecutive osteoarthritic patients was randomised to undergo total knee replacement using a Miller-Galante II prosthesis, with or without a cemented polyethylene patellar component. Knee function was evaluated using the American Knee Society score, Western Ontario and McMaster University Osteoarthritis index, specific patellofemoral-related questions and radiographic evaluation until the fourth post-operative year, then via questionnaire until ten years post-operatively. A ten-point difference in the American Knee Society score between the two groups was considered a significant change in knee performance, with alpha and beta levels of 0.05. The mean age of the patients in the resurfaced group was 71 years (53 to 88) and in the non-resurfaced group was 73 years (54 to 86). After ten years 22 patients had died, seven were suffering from dementia, three declined further participation and ten were lost to follow-up. Two patients in the non-resurfaced group subsequently had their patellae resurfaced. In the resurfaced group one patient had an arthroscopic lateral release. There was no significant difference between the two treatment groups: both had a similar deterioration of scores with time, and no further patellofemoral complications were observed in either group. We are unable to recommend routine patellar resurfacing in osteoarthritic patients undergoing total knee replacement on the basis of our findings.

A long-term review of a modified Evans procedure.

Of 111 primary ankle ligament arthroplasties (modified Evans procedure) performed between 1983 and 1994, we were able to identify 89 patients (94 ankles) for follow-up. All were under 50 years of age. Two had died and one refused to co-operate; 86 patients (91 ankles) were therefore reviewed, 25 by telephone and the remainder by clinical examination with all but three also undergoing radiological review. Of the 91 ankles, 70 had no or very mild pain and 72 had no or rare episodes of instability and when considered together only 59 (65%) had no or mild pain and minimal instability. The results were supported by the Karlsson grading system. Clinical examination showed that 17 of the 66 ankles examined had increased inversion, while 21 had some limitation of inversion. Early degenerative changes were seen in 11 ankles, although only four had subtalar changes. These results show that this procedure does not give universally good clinical results. Patient satisfaction, however, was high with 97.7% being willing to undergo the same procedure if their other ankle became similarly affected.

Early patellofemoral revision following total knee arthroplasty.

A consecutive series of 289 Miller-Galante (Zimmer, Warsaw, IN) total knee arthroplasties were studied, with particular reference to the patellofemoral joint. Sixteen knees were initially excluded; the remaining 273 arthroplasties were followed for 14 to 44 months. Thirty patients (11%) had patellofemoral pain. Twenty patients (7.3%) had revision patellofemoral surgery. Fourteen patients had revision surgery for patellar maltracking, of which 10 had resolution of their symptoms, 2 were improved, 1 had no change, and 1 developed a prosthetic infection. Six patients who had no evidence of patellar maltracking had revision surgery with a cemented metal-backed patellar component. Only two of these patients had symptom improvement from their revision surgery. A higher than usual incidence of patellar maltracking (5%) is reported. The first-generation Miller-Galante femoral component may contribute to the relative instability of patellofemoral tracking. Those patients with patellar maltracking were greatly improved by revision surgery; the results of revision surgery for anterior knee pain without associated patellar maltracking were disappointing.

Tourniquet failure and arterial calcification. Case report and theoretical dangers.

A patient with Mönckeberg's calcinosis is presented in whom a pneumatic limb tourniquet failed to be effective because of calcification of the femoral artery wall. Bleeding from the operation site was noticed to be appreciably greater while the tourniquet was inflated since the cuff, though not occluding the femoral artery, acted as a very effective venous tourniquet. Theoretical risks which might be associated with the use of tourniquets in the presence of arterial calcification are fracture of the calcified vessel wall and systemic overdose of local anaesthetic agent following attempted regional intravenous block. The problem of tourniquet failure in general, and the dangers which might be associated with the use of tourniquets in patients with incompressible arteries, are briefly discussed.

Fractures of the upper limb. Part 2.

Fractures of the upper limb from the elbow downwards constitute the biggest group of bone injuries in both children and adults. The pattern of fractures sustained, however, varies between the two age groups as does the type of treatment required. It is not possible in an article of this type to consider all the different fractures which occur in the upper limb, and an attempt will be made to concentrate on those fractures where problems with diagnosis and treatment are prone to occur.

Fractures of the upper limb. Part 1.

Fractures of the upper limb from the elbow downwards constitute the biggest group of bone injuries in both children and adults. The pattern of fractures sustained, however, varies between the two age groups as does the type of treatment required. It is not possible in an article of this type to consider all the different fractures which occur in the upper limb, and an attempt will be made to concentrate on those fractures where problems with diagnosis and treatment are prone to occur.

Forearm fractures in children.

A prospective survey of over 1,000 forearm fractures in children is presented. Individual fracture patterns are considered and specific complications and methods of treatment are discussed. Conservative treatment produces satisfactory results in the majority of fractures, provided that it is done with care and the patients are adequately followed up.