A prospective randomised controlled trial of cemented and uncemented tibial baseplates: functional and radiological outcomes.

INTRODUCTION: With the success of uncemented fixation in younger patients undergoing total hip arthroplasty and the growing demand for total knee arthroplasty (TKA) in a younger cohort of patients, there has been an increasing interest in cementless tibial baseplate fixation. We sought to determine whether there was a clear advantage to the use of three different forms of tibial baseplate fixation. The primary outcome of this study was survivorship and secondary outcomes were functional and radiological outcomes, up until 10 years. MATERIALS AND METHODS: We conducted a randomised controlled trial and recruited 224 patients with 274 knees. Patients underwent TKA by a single surgeon utilising a standard surgical technique. All patients received a cruciate retaining TKA with a cementless femoral component, and were randomised to receive either a cemented tibial component, a pegged porous coated cementless tibial component with screws or a cementless tantalum monoblock tibial component with pegs. Patient reported outcome measures (PROMS), radiological data and survivorship were assessed until 10 years post-operatively. RESULTS: Pre-operative range of motion, alignment and PROMS were similar between the three groups. The use of cemented, cementless with screws or cementless with pegs fixation options, lead to differences in functional outcomes. There was greater improvement in the Oxford score and Knee Society Score in patients who received a cemented baseplate compared to tantalum and the pegged porous groups. However, radiological and survival outcomes were similar in all three groups. Overall survivorship was 99.6%, with one knee with cementless tibial fixation and screws revised for subsidence at 3 years. There were no cases of venous thromboembolism, periprosthetic fracture or infection. CONCLUSIONS: Irrespective of tibial fixation method, functional and radiological outcomes remain similar at follow-up at 10 years, with no clear difference in outcome between each group. Each method of fixation also had excellent survivorship over this period and should reassure surgeons that whichever method of fixation they choose, long-term outcomes are likely to be satisfactory.

Different changes in slope between the medial and lateral tibial plateau after open-wedge high tibial osteotomy.

PURPOSE: In contrast to radiographic measurements, MRI provides multiple slices of the knee joint in the sagittal plane, making it possible to assess the medial and lateral tibial slope separately. The purpose of this study is to investigate the effect of medial open-wedge high tibial osteotomy (MOWHTO) on bony and meniscal slope in the medial and lateral tibiofemoral compartments. It was hypothesised that greater changes on the medial tibial plateau would be observed compared with the lateral one. METHODS: A retrospective analysis of prospectively collected data was performed on pre- and post-operative MRIs from 21 patients (17 men and 4 women; age 52 ± 9 years). Inclusion criteria were varus alignment, medial compartment osteoarthritis and election for a primary MOWHTO. Each patient had a preoperative and a post-operative high-resolution MRI (3Tesla, Magnetom Trio, Siemens AG) at an average follow-up of 2.1 years. A previously published method was used to measure bony and meniscal slope for each compartment. The difference between pre- and post-operative tibial slope for both compartments was calculated and associated with the amount of frontal correction. RESULTS: There was a significant increase in bony tibial slope in both compartments following MOWHTO. When a change in bony tibial slope was detected in an individual patient, the change was larger in the medial compartment, with the average change also significantly greater (p < 0.01) in the medial compartment (2.4° ± 1.3°) compared with the lateral compartment (0.9° ± 1.1°). There was also a significant increase (p < 0.01) in the lateral tibial meniscal slope of 0.9° ± 1.4°, which was equivalent to the change in the bony lateral slope. The amount of frontal correction was not significantly associated with the amount of change in slope. CONCLUSIONS: The results suggest that the modification of the bony slope is larger in the medial compartment after MOWHTO, which is likely related to the location of the hinge on the lateral tibial cortex. These findings suggest that consideration of the medial and lateral tibial slope intra-operatively could be important to identify the optimal location of the hinge. However, further studies are required before recommending any modification to the surgical technique, as the potential clinical consequences of tibial slope alterations remain unknown. LEVEL OF EVIDENCE: IV.

Infectious arthritis of the knee caused by Mycobacterium terrae: a case report.

Mycobacterium terrae is ubiquitous in our environment. M terrae infections most commonly involve tendon sheaths, bones, bursae, and joints. We report a case of infectious arthritis of the knee caused by M terrae in a 21-year-old man who had non-specific chronic synovitis. No organism was seen on microscopy or isolated from cultures until months later. Initially the M terrae culture was considered a contaminant and specific anti-mycobacterial treatment was not advised. The patient was commenced on suppressive therapy for persistent effusion and discomfort. Eventually, the M terrae infection was confirmed and he was commenced on clarithromycin, ciprofloxacin, and ethambutol. The triple antibiotic regimen was continued for 2 years. The knee improved but never completely settled. The patient chose to cease all antibiotic medication. The knee remained swollen and irritable, with little chance of eradicating the organism.

Complex regional pain syndrome complicating total knee arthroplasty.

PURPOSE: To compare the long-term outcome of patients diagnosed with complex regional pain syndrome-type 1 (CRPS-1) after total knee arthroplasty (TKA) with those of uncomplicated TKA knees and preoperative osteoarthritic knees. METHODS: Medical records of 1280 patients who underwent TKA for osteoarthritis were retrospectively reviewed; 8 were diagnosed as having symptoms and signs consistent with CRPS after TKA. Patients with primary inflammatory arthritis, signs of component loosening, malpositioning, or of infected arthroplasty were excluded. No patient had signs of CRPS prior to operative intervention. The 8 patients were compared with 2 groups of age- and sex-matched controls: uncomplicated TKA knees and preoperative osteoarthritic knees. Patients were followed up for a mean of 54 (range, 13-111) months and their range of movement, Western Ontario and McMaster Universities Osteoarthritis Index, SF-36 questionnaire scores, and Knee Society scores were assessed and compared. RESULTS: After appropriate treatment, most CRPS complicated patients had similar scores on SF-36, Western Ontario and McMaster Universities Osteoarthritis Index, and Knee Society scores when compared with uncomplicated TKA patients. Scores for CRPS complicated patients were significantly improved when compared with preoperative osteoarthritic patients. The incidence of CRPS after TKA was 0.7%. CONCLUSION: When managed early, patients complicated with CRPS after TKA have a similar prognosis to patients with uncomplicated TKA.

Two knees or not two knees? Patient costs and outcomes following bilateral and unilateral total knee joint replacement surgery for OA.

AIMS: This study aims to address medical and non-medical direct costs and health outcomes of bilateral and unilateral total knee replacement from the patients' perspective during the first year post-surgery. METHODS: Osteoarthritis patients undergoing primary unilateral total knee or bilateral total knee replacement (TKR) surgery at three Sydney hospitals were eligible. Patients completed questionnaires pre-operatively to record expenses during the previous three months and health status immediately prior to surgery. Patients then maintained detailed prospective cost diaries and completed SF-36 and WOMAC Index each three months for the first post-operative year. RESULTS: Pre-operatively, no significant differences in health status were found between patients undergoing unilateral TKR and bilateral TKR. Both unilateral and bilateral TKR patients showed improvements in pain, stiffness and function from pre-surgery to 12 months post-surgery. Patients who had bilateral TKR spent an average of 12.3 days in acute hospital and patients who had unilateral TKR 13.6 days. Totally uncemented prostheses were used in 6% of unilateral replacements and 48% of bilateral replacements. In hospital, patients who had bilateral TKR experienced significantly more complications, mainly thromboembolic, than patients who had unilateral TKR. Regression analysis showed that for every one point increase in the pre-operative SF-36 physical score (i.e. improving physical status) out-of-pocket costs decreased by 94%. Out-of-pocket costs for female patients were 3.3 times greater than for males. CONCLUSION: Patients undergoing bilateral TKR and unilateral TKR had a similar length of stay in hospital and similar out-of-pocket expenditures. Bilateral replacement patients reported better physical function and general health with fewer health care visits one year post procedure. Patients requiring bilateral TKR have some additional information to aid their decision making. While their risk of peri-operative complications is higher, they have an excellent chance of good health outcomes at 12 months and are not going to be doubly "out-of-pocket" for the experience.

Primary health-care physicians: vital roles in organ and tissue donation.

The involvement of primary-care physicians is integral to the success of organ and tissue donation and transplantation. Primary-care physicians have a vital role to play in educating patients and encouraging family discussion about organ and tissue donation. A study to determine the practice of Connecticut primary-care physicians relative to providing donation information to patients during routine care was conducted in three phases: 1) validation of current practice of primary-care physicians regarding educating patients about donation, 2) development and distribution of educational materials requested by primary-care physicians, 3) evaluation of primary-care physician practice and educational materials. Most (69% N = 310) responding primary-care physicians never discuss organ/tissue donation with patients during routine care and only 5% (N = 24) had donation information available. When provided with donation materials, most primary-care physicians left these materials in the waiting room and did not personally discuss donation with the patient. Collaboration between primary-care physicians and organ procurement staff needs to be increased so that primary-care physician's more readily discuss donation with their patients and encourage patients to discuss donation decisions with family members.

Programs for families of organ and tissue donors.

Until recently, the families of patients who have given the gift of life have been the invisible group in the transplant circle. They donated the organs and tissues of their loved ones to unknown transplant recipients and then were to grieve alone. As transplantation has matured and become the treatment of choice for end stage organ failure and for other life-enhancing procedures, the importance of the donor and the donor family is being recognised and their needs and expectations identified.

Public perceptions of an appropriate donor card/brochure.

Donor card/brochures have not had a major impact on donation, though considerable resources have been invested in their development and distribution. One reason for this may be that they have not been evaluated by the people expected to sign them: the American public. A focus group format was used to develop a quantitative survey to assess the public's perception of an appropriate donor card/brochure. Several donor card/brochures were studied to compare and evaluate their effectiveness, content, format, and acceptance of the message. A donor card/brochure was designed that was based on the results of the survey: it included a business reply card for further evaluation. The newly developed donor card/brochure continues to be viewed positively by those returning business reply cards. Most have signed the card and discussed donation with family members.

Perspectives on communication issues among transplant and procurement professionals, transplant recipients, and donor families.

Communication among professionals, donor families, and transplant recipients is a controversial topic. Traditionally, transplant and procurement professionals have made the decision about the type and frequency of information that a donor family and transplant recipient receive regarding one another, and relationships that might develop as a result. Information obtained through questionnaires demonstrated inconsistency in addressing donor family and transplant recipient needs for initial and follow-up information and communication-not only between clinical transplant and procurement donation coordinators, but within organizations involved in the care and support of these people. This wide variance regarding communication among all disciplines demonstrated a need for standardization of practice guidelines. Guidelines are being developed through collaboration of the major organizations involved in the care of donor families and transplant recipients to standardize communication practices throughout the United States.

After care bereavement program.

Every year, 200 to 250 patients suffer the sudden death of a loved one in the emergency department at Hartford Hospital. Many families are not prepared for the grief they will experience and are left to grieve their loss alone. Recognizing the needs of these families led to the development of the Trauma Support After Care Program, which is described in this article.

Education about death, dying, and bereavement in nursing programs.

The authors report the results of a March 1992 survey of 650 baccalaureate nursing education programs concerning the education that they provide in the area of death, dying, and bereavement. The survey inquired about death education content in the curriculum, theoretic models, and whether organ/tissue donation is addressed. Results indicate that many schools are using outdated models. The authors suggest ways to address these issues more adequately.

Families: facing the sudden death of a loved one.

As health care professionals, critical care nurses have a responsibility to assist families through the bereavement process. This article discusses how the critical care nurse can offer support to families facing the sudden death of a loved one.

Donor family programs.

This article explores how the critical care nurse can support donor families. Some of the many programs currently available to assist families after the death of a loved one and after the donation of organs and tissues are described.

What is the rationale for or against contacts between donor families and transplant recipients?

This article examines the intellectual foundations for policies and practices concerning contacts between organ and tissue donor families and transplant recipients. Should there be contacts between donor families and transplant recipients? What might be an example of the form such contacts could or should take? These questions are explored, with the goal of stimulating open discussion and rationalizing the theoretical foundations behind policies and practices in this field.

Recent advances in arthroscopy.

The use of diagnostic and therapeutic arthroscopy has increased considerably in the past decade. Initially applied only to the knee joint, arthroscopy now has an established place in the treatment of shoulder, elbow and ankle disorders. Its use in the hand and the wrist is also expanding.