Early failure with the Journey-Deuce bicompartmental knee arthroplasty.

The aim of this study was to evaluate the early functional outcome and survivorship of a bicompartmental knee arthroplasty implant (Journey-Deuce) in a cohort of patients with combined medial and patellofemoral degenerative osteoarthritis. Fifteen patients with a mean age of 57 years were followed up prospectively and evaluated with clinical examination, Oxford knee score and radiology imaging. Poor pain scores, concerns about the tibial fixation, early aseptic loosening of the tibial component and a revision rate of 60 % at a minimum follow-up of 54 months are reported. Implantation of this prosthesis was stopped at our institution well before the first revision due to an unfavourable early clinical response. This was further endorsed by an unacceptable revision rate. The outcome of the Journey-Deuce bicompartmental knee replacement was considerably worse than the published outcome of total knee replacement.

The use of rivaroxaban for chemical thromboprophylaxis following total knee replacement.

BACKGROUND: Pulmonary embolism is a leading cause of fatality in elective orthopaedics. Recently introduced oral thromboprophylaxis (rivaroxaban) has a logistic advantage but has also raised early concerns amongst arthroplasty surgeons AIM: The aim of this study was to evaluate the impact of rivaroxaban as a chemical thromboprophylaxis following knee arthroplasty in reference to radiologically diagnosed PE and return to theatre following wound complication. METHOD: Following the introduction of new NICE guidelines in our institute 266 consecutive TKR receiving rivaroxaban were studied prospectively and compared with retrospectively collected consecutive 596 TKR prior to adoption of the guidelines. Both of these groups were studied for radiologically diagnosed symptomatic VTE episodes within 90days and return to theatre following wound complication. RESULTS: A total of 862 cases were studied, out of which 596 were in the retrospective control group and 266 were in the prospective rivaroxaban group. Both the groups had a female predominance with a mean age at the time of surgery as 68 and 69 in control and prospective cohort respectively. There were 24 radiologically diagnosed symptomatic PE and one DVT in the control group whereas, the rivaroxaban prospective group had 2 PE and 2 DVT cases. The return to theatre following wound complication was 2 and 7 in control and prospective group respectively. CONCLUSION: Following the introduction of rivaroxaban the number of symptomatic radiologically confirmed PE events declined (p=0.0084) but the return to theatre rate due to wound complications increased (p=0.0049). LEVEL OF EVIDENCE: III.

Lateral meniscal tear resulting from the femoral cross-pin used for hamstring graft fixation in anterior cruciate ligament reconstruction.

We report a case of lateral meniscal tear resulting from the femoral cross-pin used for hamstring graft fixation in anterior cruciate ligament (ACL) reconstruction. A 29 year old man presented with symptoms of knee pain, catching and locking, 13 months following an ACL reconstruction. Magnetic resonance imaging (MRI) and arthroscopy confirmed the broken femoral cross-pin abutting the lateral meniscus and the resulting meniscal tear. Removal of the broken femoral cross-pin and repair of the lateral meniscal tear resulted in resolution of symptoms. Distal femoral cross-pin fracture and its intra-articular position are postulated as the cause of this lateral meniscal tear. Hence, we recommend a low threshold to investigate with a MRI scan any new symptoms following ACL reconstruction with cross-pin fixation.

Review of Kinemax total knee replacements performed at the NHS treatment centre, Weston-Super-Mare: five-year results.

As part of the national initiative to reduce waiting times for joint replacement surgery in Wales, the Cardiff and Vale NHS Trust referred 224 patients to the NHS Treatment Centre in Weston-Super-Mare for total knee replacement (TKR). A total of 258 Kinemax TKRs were performed between November 2004 and August 2006. Of these, a total of 199 patients (232 TKRs, 90%) have been followed up for five years. This cohort was compared with 258 consecutive TKRs in 250 patients, performed at Cardiff and Vale Orthopaedic Centre (CAVOC) over a similar time period. The five year cumulative survival rate was 80.6% (95% confidence interval (CI) 74.0 to 86.0) in the Weston-Super-Mare cohort and 95.0% (95% CI 90.2 to 98.2) in the CAVOC cohort with revision for any reason as the endpoint. The relative risk for revision at Weston-Super-Mare compared with CAVOC was 3.88 (p < 0.001). For implants surviving five years, the mean Oxford knee scores (OKS) and mean EuroQol (EQ-5D) scores were similar (OKS: Weston-Super-Mare 29 (2 to 47) vs CAVOC 29.8 (3 to 48), p = 0.61; EQ-5D: Weston-Super-Mare 0.53 (-0.38 to 1.00) vs CAVOC 0.55 (-0.32 to 1.00), p = 0.79). Patients with revised TKRs had significantly lower Oxford knee and EQ-5D scores (p < 0.001). The results show a higher revision rate for patients operated at Weston-Super-Mare Treatment Centre, with a reduction in functional outcome and quality of life after revision. This further confirms that patients moved from one area to another for joint replacement surgery fare poorly.

Aseptic loosening of the patellar component at the cement-implant interface.

We present four cases of aseptic loosening at the implant-cement interface following patellar resurfacing. All patients initially had good results, but then presented with onset of a new anterior knee pain. The radiographs including flexed lateral and skyline view of the knee were normal in all the cases. After carefully ruling out infection, aseptic loosening at the cement-implant interface was diagnosed on further investigation. Aseptic loosening of the patellar button at the implant-cement interface can be difficult to diagnose with standard knee radiographs. During flexed lateral radiograph of the knee and the skyline view radiograph of the patellofemoral joint, the patella is compressed on the femur and thereby reducing the loose patellar button. This phenomenon has not been previously described. Patients presenting with new onset of knee pain after an initial good results following patellar resurfacing require further investigation to exclude loosening at the cement-implant interface as plain radiographs can be misleading.

The reliability and accuracy of digital templating in total knee replacement.

We aimed to determine the reliability, accuracy and the clinical role of digital templating in the pre-operative work-up for total knee replacement. Initially a sample of ten pre-operative digital radiographs were templated by four independent observers to determine the inter- and intra-observer reliability of the process. Digital templating was then performed on the radiographs of 40 consecutive patients undergoing total knee replacement by a consultant surgeon not involved with the operation, who was blinded to the size of the implant inserted. The Press Fit Condylar Sigma Knee system was used in all the patients. The size of the implant as judged by templating was then compared to that of the size used. Good inter- and intra-observer agreement was demonstrated for both femoral and tibial templating. However, the correct size of the implant was predicted in only 48% of the femoral and 55% of the tibial components. Albeit reproducible, digital templating does not currently predict the correct size of component often enough to be of clinical benefit.

Review of Kinemax knee arthroplasty performed at the NHS Treatment Centre, Weston-Super-Mare.

As part of the government's initiative to reduce waiting times for major joint surgery in Wales, the Cardiff and Vale NHS Trust sent 224 patients (258 knees) to the NHS Treatment Centre in Weston-Super-Mare for total knee replacement. The Kinemax total knee replacement system was used in all cases. The cumulative survival rate at three years was 79.2% (95% confidence interval (CI) 69.2 to 86.8) using re-operation for any cause as an endpoint and 85.3% (95% CI 75.9 to 91.8) using aseptic revision as an endpoint. This is significantly worse than that recorded in the published literature. These poor results have resulted in a significant impact on our service.

Lateral unicompartmental knee replacement: fixed or mobile bearing?

Between May 2001 and May 2003, 233 consecutive Preservation unicompartmental knee replacements (UKR) were performed. Of these, 30 were lateral UKRs (13%) performed in 12 men and 16 women (2 bilateral cases) with a mean age of 67 years (range 36-93 years). A metal-backed mobile bearing tibial component was used in 13 knees and an all-polyethylene fixed bearing tibial component in 17 knees. The patients were reviewed prospectively at 1 and 2 years. The 2 year results show no difference in range of motion or function between the mobile and fixed bearing versions of the Preservation knee when used on the lateral side. There were three early revisions, all in the mobile bearing group.

A retrospective comparative study of bilateral total knee replacement staged at a one-week interval.

The clinical results of bilateral total knee replacement staged at a one-week interval during a single hospital admission were compared with bilateral total knee replacements performed under the same anaesthetic and with bilateral total knee replacements performed during two separate admissions. The data were retrospectively reviewed. All operations had been performed by the same surgeon using the same design of prosthesis at a single institution. The operative time and length of stay for the one-week staged group were comparable with those of the separate admission group but longer than for the patients treated under one anaesthetic. There was a low rate of complications and good clinical outcome in all groups at a mean follow-up of four years (1 to 7.2). The group staged at a one-week interval had the least blood loss (p = 0.004). With appropriate patient selection, bilateral total knee replacement performed under a single anaesthetic, or staged at a one-week interval, is a safe and effective method to treat bilateral arthritis of the knee.

Distal femoral fractures: a review of fixation methods.

The treatment of distal femoral fractures has evolved; nevertheless, these fractures remain difficult to treat and carry an unpredictable prognosis. Over the years, many different strategies have been used with varying success. This review outlines the problems presented by distal femoral fractures and the results of current surgical techniques.

Should the tibia be reamed when nailing?

A systematic review was performed to assess reamed and unreamed tibial nailing. Only prospective, randomised studies comparing reamed and unreamed tibial nailing in adults were included. A literature search found 1200 possible articles. There were seven comparative studies. These articles were independently assessed by all three authors. Three studies met the inclusion criteria. Each outcome measure tested was assessed for heterogeneity. If significant heterogeneity was present, data from the studies was not combined. If there was no significant heterogeneity, a combined odds ratio was calculated using a fixed effects model and a Z-test was performed to test the overall effect. Two hundred and ninety-one tibial shaft fractures were entered into the included studies. Two hundred and eighty (96%) were followed up (148 reamed; 132 unreamed). There was an increased non-union rate when the tibia was not reamed (p = 0.02). Screw breakage was more common in the unreamed group (p<0.0001). This study could find little difference in the incidence of other complications following reamed or unreamed tibial nailing.

Reaming during anterograde femoral nailing: is it worth it?

A systematic review was performed to assess the relative merits of reamed and unreamed antegrade femoral nailing. To be included, a study had to be prospective, randomised or pseudorandomised, comparing reamed and unreamed antegrade femoral nailing in adults. Where more than one study from the same institution was available, only the study with longest follow-up was included. A literature search found 2044 possible articles. Of these, eight studies compared reamed and unreamed femoral nailing. The methodology of these articles was independently assessed by all the three authors. Five studies met the inclusion criteria. Each outcome measure tested was assessed for heterogeneity. If significant heterogeneity was present, the data were not combined. If there was no significant heterogeneity, a combined odds ratio or weighted mean difference was calculated using a fixed effects model, and a Z-test was performed to test the overall effect. Six hundred and forty-seven femoral fractures (315 reamed; 332 unreamed) were entered into the included studies. Unreamed nailing was quicker and associated with significantly less blood loss (P < 0.00001). Reaming significantly reduced the time to union (P = 0.00001), non-union (P = 0.002), delayed union (P = 0.005), technical problems (P = 0.01) and reoperation rate (P = 0.001). The use of reamed femoral nails gives significant advantages over unreamed femoral nails.

Patellar resurfacing in total knee arthroplasty for osteoarthritis: a systematic review.

A systematic review was performed to determine the advantages and disadvantages of patellar resurfacing during total knee replacement for osteoarthritis. Three randomised controlled studies were analysed. These studies recruited 302 knees and 235 knees (78%) were reviewed at least 5 years postoperatively (range 5 10 years). Patients undergoing patellar resurfacing received a cemented all polyethylene patella component. A patelloplasty was performed in some of the unresurfaced knees. For the dichotomous data, odds ratios and 95% confidence intervals were calculated. Each outcome measure tested was assessed for heterogeneity using the Cochran Q test. If significant heterogeneity was present (p < 0.10), data from the studies were not combined. If there was no significant heterogeneity, a combined odds ratio was calculated using a fixed effects model and a Z test was performed to test the overall effect. Reoperation for patellofemoral problems was significantly more likely in the unresurfaced group (p = 0.003). The overall rate for reoperation for a patellofemoral problem was 0.7% in the resurfaced group and 11% in the unresurfaced group. Study data on anterior knee pain could not be analysed together as there was significant heterogeneity. There was no difference between the two groups in terms of revision. This study found no mid- to long-term benefit to leaving the patella unresurfaced.

A prospective randomised trial comparing intra-articular Hyalgan injection and arthroscopic washout for knee osteoarthritis.

Thirty-eight patients with symptomatic knee osteoarthritis without mechanical symptoms were randomised after informed consent to receive either a course of intra-articular Hyalgan injections or an arthroscopic washout. The patients were prospectively assessed pre-intervention, 6 weeks, 3 months, 6 months and 1 year using a 10 cm visual analogue pain score, the Knee Society function score and the Lequesne index. There was no significant difference between the two groups at 6 weeks, 3 months, 6 months or 1 year. The use of intra-articular Hyalgan injections in patients with knee osteoarthritis without mechanical symptoms gives results comparable with arthroscopic washout. Hyalgan is an alternative to arthroscopy in this patient group. Further study is needed to confirm these findings and improve patient selection.

Survival analysis of primary cemented total knee arthroplasty: which designs last?

Both posterior stabilization and metal backing of the tibial component are design changes that could alter the longevity of total knee arthroplasties (TKAs). Survival analysis data from 16 articles (5,950 knees) were combined to compare design features. No difference was found in survival between posterior stabilized implants and implants that were not stabilized or between metal-backed and all-polyethylene tibial components. Those all-polyethylene tibial components that were not stabilized showed significantly better survival than metal-backed, nonstabilized tibial components and posterior stabilized, metal-backed components (P<.05) but not posterior stabilized, all-polyethylene components. According to the currently available literature, posterior stabilization or metal backing of the tibial component does not improve the longevity of primary cemented fixed bearing condylar-type TKAs.

Arthroscopic meniscal repair.

Although the first meniscal repair was performed over 100 years ago, many aspects of meniscal repair remain controversial. This article reviews the structure and function of the menisci, the rationale for repair and the clinical results of arthroscopic meniscal repair.

Elbow osteoarthritis: prognostic indicators in ulnohumeral debridement--the Outerbridge-Kashiwagi procedure.

A consecutive series of 43 patients (44 elbows) underwent ulnohumeral debridement for elbow osteoarthritis. Thirty-five patients (36 elbows) were reviewed after a mean follow-up of 39 months. Eighty-one percent of patients were satisfied, with 12 good, 19 fair, and 5 poor outcomes. The mean flexion/extension arc, pain score, and locking were all significantly improved, but a significant number of patients had rest pain. Patients who had symptoms for less than 2 years, considerable preoperative pain, or cubital tunnel syndrome had a significantly increased chance of a good outcome. The absence of preoperative locking was associated with a significantly increased chance of a poor outcome. A history of trauma, preoperative range of movement, and radiograph score did not predict outcome.

Mortality following surgery for proximal femoral fractures in centenarians.

Although the number of centenarians in our population is increasing, mortality rates following hip fracture in this group of patients has not yet been reported. The medical records of a consecutive series of 13 centenarians with proximal femoral fractures who presented to the Derbyshire Royal Infirmary over a 20 year period were retrospectively reviewed. The majority of patients were female (M:F 2:11) and had suffered intertrochanteric fractures. The recorded incidence of surgical complications was low. The mortality at 30 days, 6 months and 1 year were 31%, 50% and 56%, respectively representing a 20% increase in mortality at 1 year when compared to the expected mortality rates among their non-injured peers. When compared with over 1000 hip fracture patients of all ages in previous prospective studies, the centenarians in this series were found to have a significantly higher mortality during hospital admission (p<0.001) and at 1 year (p=0.002). The treatment of hip fractures in centenarians poses a challenge. Optimal anaesthesia, expeditious surgery and a co-ordinated multidisciplinary approach to care is essential in these patients.