Mean Hospital For Special Surgery Score Research Articles

A Comparison Between Unstemmed and Stemmed Constrained Condylar Knee Prostheses in Primary Total Knee Arthroplasty: A Propensity Score-Matched Analysis.

ObjectiveTo compare and analyze the clinical outcomes between unstemmed and stemmed constrained condylar knees (CCK) in complex primary total knee arthroplasty (TKA) in terms of implant survivorship, change in outcome evaluations, and complications.MethodsWe reviewed 156 consecutive patients who received primary TKA using PFC®SIGMA®TC3 (TC3) of constrained condylar design between January 2009 and January 2017 at our institution. After removing patients who met exclusion criteria, 25 patients were identified as unstemmed TC3 cases and 81 as stemmed TC3 cases. Propensity score matching was used to select 25 stemmed cases as a control group for the unstemmed group with comparable preoperative conditions including preoperative demographics, preoperative diagnosis, preoperative range of motion, main reason to use TC3, ASA score (American Society of Anesthesiologists), and follow‐up duration. Preoperative and postoperative clinical evaluations including Knee Society Score (KSS), Hospital for Special Surgery (HSS) score, the 12‐Item Short‐Form Health Survey (SF‐12), and the range of motion (ROM) were obtained and compared. The instability, periprosthetic fracture, radiolucent lines, polyethylene wear, and heterotrophic ossification were assessed according to the anteroposterior and lateral radiographs of the knee. The complications and implant survivorship between the two groups were also recorded and compared.Results3After the index surgery, both groups showed substantial improvement in KSS (knee and function), HSS score, SF‐12, and ROM compared with baseline. There was no significant difference in the mean KSS scores (knee and function), HSS score, SF‐12, and ROM between the unstemmed and stemmed group postoperatively. No statistically significant difference was found in the overall complication rate between the two groups. The overall Kaplan–Meier survivorship was 98.0% (95% confidence interval 94.1%–100.0%) at 7 years. No significant difference was found in the survival rate between the unstemmed group (100.0%) and the stemmed group (96.0%) at 7 years (log rank, P = 0.317). The mean duration of follow‐up was 7.0 years for unstemmed group and 7.7 years for stemmed group.ConclusionsIn patients with adequate bone stock receiving complex primary TKA, unstemmed CCK could achieve similar clinical outcomes at mid‐term follow‐up as stemmed CCK.

Salvage of severe knee osteoarthritis: efficacy of tibial condylar valgus osteotomy versus open wedge high tibial osteotomy

IntroductionTo compare the clinical outcomes and the radiographic features between tibial condylar valgus osteotomy (TCVO) and open wedge high tibial osteotomy (OWHTO). New insight into the indication criteria for TCVO was also clarified for achieving satisfactory results.Materials and methodsSixty-three knees with medial-compartment osteoarthritis were retrospectively studied. Thirty-four knees with subluxated lateral joint and depression of the medial tibial plateau underwent TCVO and the rest underwent OWHTO. Among the 63 knees included, 27 knees with a pre-operative femorotibial angle (FTA) ≥ 185° were defined as severe varus (subgroup S, 15 in STCVO group and 12 in SHTO group). Lower limb alignment, intra-, and extra-articular congruency were evaluated according to the radiograph obtained before and 24 months after surgery. The visual analog scale (VAS) score and Hospital for Special Surgery (HSS) score were obtained to assess the clinical results. Opening angle and distance of the opening gap in each group were measured by intra-operative fluoroscopy.ResultsDuring the 2-year follow-up period, the mean HSS score increased from 70.3 to 81.4 in HTO group and 65.9 to 87.3 in TCVO group (p < 0.05). The mean VAS score decreased from 5.9 to 2.6 and 6.0 to 2.1, respectively (p < 0.01). Pre-operative FTA was restored to 172.9° in HTO group and 171.3° in TCVO group, and percentage of mechanical axis (%MA) was improved to 59.7% and 61.2%, respectively. Joint line convergence angle (JLCA) was slightly restored and medial tibial plateau depression (MTPD) was relatively the same before and after OWHTO, while these parameters improved greatly (from 6.4° to 1.2° and − 8.0° to 5.9°, p < 0.01) in TCVO group. More undercorrected knees were observed in SHTO group than STCVO group (58.3% and 13.3%, p < 0.05). Opening angle and distance of the opening gap were larger in TCVO group (19.1° and 14.0 mm) than those in OWHTO group (9.3° and 10.1 mm, p < 0.05).ConclusionCompared to OWHTO, TCVO had priority in treating advanced knee OA with intra-articular deformity. However, TCVO had a limited capacity to correct the varus angle. Besides, TCVO might be suitable for medial-compartment OA with a pre-operative FTA ≥ 185°.

Dual plating or dual plating combined with compression bolts for bicondylar tibial plateau fractures: a retrospective comparative study

The aim of this study was to compare secondary loss of reduction outcomes in dual plating fixation and dual plating combined with compression bolt fixation for bicondylar tibial plateau fractures (TPFs). We performed a retrospective study from January 2015 to April 2019. A consecutive series of 72 bicondylar TPFs underwent surgical treatment and was divided into two groups: group 1 (dual plating, n = 46) and group 2 (dual plating combined with compression bolts, n = 26). The outcomes collected included demographic characteristics, imaging characteristics, intraoperative indicators, clinical outcomes and reduction quality after surgery. Functional outcome was rated according to the Hospital for Special Surgery (HSS) score and Lysholm score. The secondary loss of reduction rate in group 2 was reduced compared with that in group 1 (P = 0.025), and the mean HSS score of group 2 was higher than that of group 1 (P = 0.013). The rate of complications was 30.4% (14/46) in group 1 and 30.8% (8/26) in group 2 (P = 0.976). Compared with single dual plating fixation, dual plating combined with compressing bolt fixation reduced the secondary loss of reduction rate for patients with bicondylar TPFs and showed better functional outcomes.

Anatomical repair and ligament bracing of Schenck III and IV knee joint dislocations leads to acceptable subjective and kinematic outcomes

PurposeThe aim of this study was to analyze the outcomes of anatomical repair and ligament bracing for Schenck III and IV knee dislocation (KD).MethodsThe results of 27 patients (15 and 12 cases of Schenck III and IV KD, respectively) after a mean follow-up of 18.1 ± 12.1 months (range 6–45 months) were retrospectively reviewed. Twenty-two patients suffered high-kinetic-energy accidents, whereas five patients suffered ultralow-velocity (ULV) trauma due to obesity. The outcome measures were the Lysholm score, Hospital for Special Surgery (HSS) knee score, Knee Society Score (KSS), Knee Injury and Osteoarthritis Outcome Score (KOOS) and Short Form 36 (SF-36) score. A kinematic 3D gait analysis with five walking trials was performed to compare the patients and healthy controls.ResultsThe mean KSS, HSS score, Lysholm score, and KOOS were 77.4 ± 14.4, 84.6 ± 11.2, 81.5 ± 10.4, and 67.3 ± 16.8, respectively. No intra- or postoperative complications occurred. The mean range of motion deficiency compared to the healthy side was 24.4 ± 18.5°. Ten patients had first-degree residual laxity of the anterior cruciate ligament; 12 and 2 patients had first- and second-degree residual laxity of the collateral ligament, respectively. Five patients underwent additional arthroscopic arthrolysis due to arthrofibrosis at an average of 6.2 ± 1.9 months (range 4–9 months) after the initial surgery. The 3D gait analysis showed no major differences in joint stability or movement between the patients and healthy controls. Only the ULV trauma patients had significantly lower outcome scores and showed larger kinematic deviations in joint movement during the gait analysis.ConclusionAnatomical repair with ligament bracing is a suitable surgical procedure in the treatment of KD and provides evidence in clinical practice with the benefit of early, definitive repair and preservation of the native ligaments. Patients reach acceptable subjective and objective functional outcomes, including mainly normalized gait patterns during short-term follow-up, with only minor changes in kinematics and spatial–temporal characteristics. Obese patients who suffered ULV trauma showed significantly inferior outcomes with larger deviations in joint kinematics.Level of evidenceLevel III.

The High Flex Total Knee Arthroplasty\u2014Higher Incidence of Aseptic Loosening and No Benefit in Comparison to Conventional Total Knee Arthroplasty: Minimum 16-Years Follow-Up Results

PurposeThis prospective randomized study compares the clinical and radiographic long-term results at least 16 years after total knee arthroplasty (TKA) between a mobile-bearing high flex and a fixed-bearing posterior-stabilized knee.MethodsIn 2000, we included 60 patients who underwent a TKA. Patients were divided into two groups. At the time of the follow-up after a minimum of 16 years (16.5 years ± 0.6), 16 patients had died for causes unrelated to the operation, 15 were lost to the follow-up. Five patients of the high flex group had a revision. The final evaluation included the hospital for special surgery score (HSS) and radiographs. Using the X-rays and the Knee Society Roentgenographic Evaluation and Scoring System, radiolucent lines and the maximal knee flexion were determined.ResultsNo significant differences between the two groups were found. The mean HSS score of LPS group patients was 87.9 (± 10.6) points and that of the high flex group was 93.1 (± 7.4) points. Five patients of the high flex group had undergone a reoperation. One knee was revised for painful mid-flexion instability and the others for symptomatic aseptic loosening of the components.ConclusionThe long-term follow-up does not show any clear benefits and even a higher incidence of implant loosening using the mobile-bearing high-flex knee.

Clinical outcomes of revision with retrograde intermedullary nailing for failed plating of distal femoral fractures: a retrospective study.

To assess the feasibility and effectiveness of retrograde intramedullary nail (RIN) revision surgeries for locking compression plate (LCP) failure in distal femoral fractures. This retrospective study included 13 patients who suffered from metalwork failures after they initially underwent open reduction and LCP fixation. In patients who eventually underwent RIN revision from January 2014 to December 2016, range of motion (ROM) and Hospital for Special Surgery (HSS) scores obtained before surgery and at the final follow-up time were analysed. The average operative time was 155 minutes (range, 120-210 minutes), and the average blood loss volume was 650ml (range, 200-1350ml). There were two cases of complications (15.38%): one was calf muscle vein thrombosis, and the other was a superficial infection. No deep tissue infection or deep vein thrombosis was observed post-operatively. The average follow-up time was 16months (range, 12-24months). All fractures healed in a mean of 6.5months (range, 4-12months), and one patient underwent an additional bone graft surgery that did not involve a bone graft during the RIN revision operation (this eventually healed at 12months post-operatively). The mean ROM before the operation was 86.92 ± 12.34°. At the final follow-up, the mean ROM was 112.69 ± 9.27°. There was a significant difference between pre-operative and post-operative ROM (P < 0.01). The mean HSS score improved significantly from 38.85 ± 9.62 points pre-operatively to 79.62 ± 5.42 points post-operatively. There was a significant difference between pre-operative and post-operative HSS scores (P < 0.01). RIN revision surgery achieved excellent clinical results in patients with LCP failure.

Pre-operative simulation using a three-dimensional printing model for surgical treatment of old and complex tibial plateau fractures

To investigate the clinical efficacy of pre-operative simulation using a three-dimensional (3D) printing model for surgical treatment of old and complex tibial plateau fractures. Forty-two patients with old and complex tibial plateau fractures were retrospectively reviewed from January 2014 to January 2018, which were divided into a conventional planning group (n = 22) and a planning with 3D printing group (n = 20). In the planning with 3D printing group, preoperative equal-ratio fracture models prepared using the 3D printing technique were used to perform pre-operative simulation and guide the real surgical operation. In the conventional planning group, the operation was performed based on pre-operative computed tomography (CT) images. Surgery duration, blood loss and the number of fluoroscopy during operations were recorded. During follow-up, the quality of fracture reduction and complications were also recorded. Knee functions were evaluated using the hospital for special surgery (HSS) scoring system. The operation time, blood loss and the number of fluoroscopy during operation in the planning with 3D printing group were less than that in the conventional planning group (P < 0.01). All patients were followed up for mean of 24.38 ± 7.62 months. The rate of excellent fracture reduction in the planning with 3D printing group and conventional planning group was 75% and 45.45%, respectively (P = 0.05). The complication rate was 15% in the planning with 3D printing group and 31.82% in the conventional planning group. At the final follow-up evaluation, the mean HSS score was 86.05 ± 7.67 in the planning with 3D printing group and 79.09 ± 6.75 in the conventional planning group (P = 0.003). The rate of excellent results in the planning with 3D printing group was 70% and in the conventional planning group was 45.45% (P = 0.083). In conclusion, pre-operative simulation using a 3D printing model may be helpful for the treatment of old and complex tibial plateau fractures, which may be conducive to the pre-operative planning and to making the surgical procedure accurate and personalized. However, its clinical effectiveness need to be further assessed by a prospective randomized-controlled study.

One-Stage Arthroplasty or Revision for Seronegative Infections in Hip and Knee.

ObjectiveTo assess the safety and effectiveness of one‐stage total joint arthroplasty (TJA) or revision for seronegative infections after total hip arthroplasty (THA) and total knee arthroplasty (TKA).MethodsThis retrospective study included a total of 495 patients who had undergone one‐stage total joint (hip or knee) arthroplasty or revision with a diagnosis of osteoarthritis secondary to sepsis, osteoarthritis or osteonecrosis of the femoral head (ONFH) secondary to internal fixation surgery of the hip joint, and one‐stage revision for prosthesis loosening after THA or TKA from January 2012 to December 2016. Bacterial cultures were taken from all patients (from joint fluid or articular cavity fluid and four to six different parts of soft tissues) during the operation. If the cultures were positive, patients received antibiotic treatment. Microbiology results from surgical samples, clinical evaluations, SF‐12 score (physical component summary [PCS] and mental component summary [MCS]), Harris hip score (HHS) or Hospital for Special Surgery (HSS) score, and patients' satisfaction was recorded at every follow‐up session.ResultsA total of 24 patients had a positive result for bacterial culture (4.85%). The bacterial culture results showed that there were 19 cases (79.16%) of gram‐positive cocci (Staphylococcus aureus), 4 cases (16.67%) of gram‐negative bacilli, and 1 case (4.17%) of fungi. For at least 24 months (mean 35 months) follow‐up, no reinfection was discovered. The mean HHS or HSS score improved significantly from 36.29 points preoperatively to 84.21 points postoperatively (P < 0.001). The mean PCS score improved from 10.15 preoperatively to 20.34 postoperatively, and the mean MCS from 13.22 preoperatively to 21.76 postoperatively, with significant differences. Most of the patients were satisfied.ConclusionOne‐stage arthroplasty or revision with exhaustive debridement, adequate dosage, and duration of sensitive antibiotics is safe and effective for patients who have seronegative infection of hip or knee joints.

Comparison of curative effect between osteochondral mosaic transplantation and micro-fracture in the treatment of knee joint articular cartilage injury

To compare the clinical outcomes of microfracture and autogenous osteochondral mosaic transplantation in the treatment of knee joint cartilage injury. A retrospective analysis of 71 patients with articular cartilage defects on the femoral condyles who were by autogenous osteochondral mosaic transplantation or microfracture from February 2011 to February 2016, and these patients were followed up for at least 2 years. According to the sugical procedures, the patients were divided into two groups. In the microfracture group, there were 33 patients, 20 males and 13 females, with a mean age of(28.1±4.2) years old; in the mosaicplasty group, there were 38 patients, 26 males and 12 females, with a mean age of(27.8±3.5) years old. The Lysholm knee score, Hospital for Special Surgery (HSS) knee score and the Ahlbäck classification grade were recorded to evaluate the clinical efficacy. Complications were also recorded. The mean Lysholm scores of the microfracture group and the mosaicplasty group improved from 62.9±6.8 and 60.3±7.5 preoperatively to 77.0±5.4 and 85.8±5.6 post-operatively, respectively(P<0.05). Mean HSS scores of the microfracture group and the mosaicplasty group improved from 81.5±7.6 and 79.6±8.6 preoperatively to 88.0±4.7 and 91.9±4.7 post-operatively, respectively(P<0.05). The mean Lysholm score and HSS score were significantly higher in the mosaicplasty group than those in the microfracture group at the latest follow-up. One patient in the mosaicplasty group suffered superficial wound infection. During the follow-up, no knee osteoarthritis was observed in two groups. Autogenous osteochondral mosaicplasty and microfracture are proved to be safe and effective procedures for knee articular cartilage defects. However, the mosaicplasty has better clinical outcome than the microfracture.

A Novel Method of the Treatment for Posterolateral Tibial Plateau Fractures.

Reduction and fixation of posterolateral tibial plateau fracture via a posterolateral approach is challenging, and the posterolateral approach itself may injure the posterolateral ligament complex of the knee and can result in knee instability. We developed a new curved support plate (CSP) that can pass, via traditional anterolateral approach, through the superior tibiofibular interval and effectively support the posterolateral fragments. The purpose of our study was to determine the biomechanical reliability of the new plate and report the preliminary efficacy of the CSP for posterolateral tibial plateau fracture. In the biomechanical experiment, 40 synthetic tibias were used to create posterolateral shearing tibial fracture models, which were randomly assigned to groups A to D. Vertical displacement of the posterolateral fragments was measured under axial loads of 500 to 1,500 N. The new plate and 3.5-mm lateral locking plate exhibited similar control over fragment displacement. From June 2016 to August 2017, eight patients with posterolateral tibial plateau fracture underwent treatment with the CSP. Hospital for Special Surgery (HSS) knee score, knee flexion and extension ranges of motion, and complications were recorded to evaluate treatment effects. Eight patients (five men and three women, mean age 44 years [range, 23-66 years]) were enrolled in the study. Mean follow-up time was 13 months (range, 7-19 months). All patients achieved radiographic bone union by 3.3 months (range, 3-4 months) postoperatively. There were no complications of neurovascular injury, deep vein thrombosis, infection, and implant loosening throughout the follow-up period. At final follow-up, mean HSS score was 92.6 (88-96), with a mean knee flexion of 131.25 degrees (120-135 degrees) and a mean knee extension of 1 degree (0-5 degrees). Fixation of posterolateral tibial plateau fracture was easily and successfully achieved using our newly designed CSP, which may provide a new choice for posterolateral tibial plateau fractures.

Establishment of posterior tibial plateau partition and its clinical significance for surgical approach selection

Objective To explore the guiding significance of posterior tibial plateau partition for the selection of surgical approach in treatment for posterior column fracture. Methods From June 2008 to May 2015, 46 patients with posterior column fractures of tibial plateaus treated were retrospectively analyzed. There were 31 males and 15 females with an average age of 35.1±12.8 years old (range, 19-62 years). Nineteen patients were left side and twenty-seven patients were right side. Injury was caused by traffic accident in 27 cases, falling from bicycle in 12 cases and falling from height in 7 cases. On the basis of the posterior condyle with anatomical structure in tibial plateau, the posterior column was divided into four parts. All fractures were treated via the optimal approach based on the location of them. The posteromedial approach was used with fractures in zone 1 and 2, posterolateral approach used in zone 3, lateral approach via the fibular head osteotomy was used in zone 4 and combined approaches were used in multiple zones. All the fractures involved the posterior column were treated by anatomical reduction and fixation with plates and screws under direct vision. Results All the patients were followed up with an average of 15.5±3.7 months (range from 12 to 24 months). The healing time of all patients was 11-18 weeks, with an average time of 14.6±2.3 weeks. According to Rasmussen radiographic evaluation, the average score was 15.1 (range from 11 to 18) and clinical outcomes were rated with in 17 cases, in 24 cases, in 5 cases. The excellent and good rate was 89.1% (41/46). The mean HSS (the Hospital for Special Surgery) score of all patients at 12 months operatively were 86.7±8.6 (range from 67 to 98) and the functional scores were excellent in 25 cases, good in 17 cases and fair in 4 cases with the excellent and good rate was 91.3% (42/46). The average range of motion in affected knee was 118°±13.7° (range from 0° to 135°) in 17 cases via posterolateral approach, 123°±15.6° (range from 0° to 135°) in 18 cases via posteromedial approach, 115°±16.7° (range from 0° to 130°) in 18 cases via combined posteromedial and posterolateral approaches and 124°±7.4° (range from 0° to 130°) in 4 cases via the fibular head osteotomy lateral approach. Complications included fat liquefaction in 1 case, anterior tibial artery spasm in 1 case and traumatic arthritis in 1 case. Conclusion The partition of posterior tibial plateau can be used to guide the surgical approach to the posterior column simply and accurately. For the fractures of isolated posterior column and posterior column mainly involved, the partition has a certain guiding significance. Key words: Tibial fractures; Fracture fixation, internal; Treatment outcome

Angle Stable Interlocking Intramedullary Nails for Tibial Plateau Fractures.

Angle stable interlocking intramedullary nail (ASIN), a novel technique, has rarely been used for treatment of tibial plateau fractures (TPF). This retrospective study was designed to introduce this novel technique, ASIN, as well as to describe the initial experience and verify the effectiveness when ASIN was used for the management for TPF. A cohort of 19 cases with closed TPF aged from 18-70 years with at least 23 months follow-up from November 2008 to September 2013 was analyzed retrospectively. All patients underwent the ASIN procedure, which was performed by the same group of surgeons. Perioperative and postoperative parameters like the measurement of radiographic pictures, surgical data, and clinical function were recorded including the changes in treatment. A modified Hohl-Luck radiological and functional score combined with the Hospital for Special Surgery (HSS) score were applied to evaluate the final results and to provide reliable data through the whole procedure when applying the ASIN procedure. The patients were followed up regularly for an average of 26.3 (range, 23-34) months. All patients achieved a bony union at an average of 15.1 weeks with no incidences of malunion, nonunion, or infection. Anatomical reduction of the articular surface was obtained in 16 patients. No secondary failure of fixation occurred. The mean postoperative knee flexion was 122.9°. The modified Hohl-Luck radiological and functional score was excellent and good, respectively, in 16 patients. The mean HSS score was 89.4. The angle stable interlocking intramedullary nail system turned out to be a viable alternative protocol in the treatment of tibia plateau fractures and provided satisfactory results, with good fracture reduction, biomechanical fixation, low rates of complications, and passable postoperative knee function.

Clinical and Radiological Results with Second-Look Arthroscopic Findings after Open Wedge High Tibial Osteotomy without Arthroscopic Procedures for Medial Meniscal Root Tears.

PurposeTo identify the structural integrity of the healing site after medial open wedge high tibial osteotomy (MOWHTO) in patients with a posterior root tear of the medial meniscus (PRTMM) and chondral lesion by second-look arthroscopy and to determine the clinical and radiological findings.Materials and MethodsFrom August 2010 to June 2016, 52 consecutive patients underwent MOWHTO and arthroscopic examination without a chondral resurfacing procedure and meniscal treatment for PRTMM. Twenty-four patients were available for second-look arthroscopic evaluation. The mean follow-up period was 19.5 months (range, 5 to 46 months). Clinical evaluation was based on the Lysholm knee scores and Hospital for Special Surgery (HSS) scores.ResultsThere were 5 lax healing, 6 scar tissue, 13 failed healing of PRTMM. Definite change of chondral lesion was not observed. The Kellgren-Lawrence grade did not improve according to the follow-up plain radiograph. The mean Lysholm score improved from 34.7 preoperatively to 77.1 at the last follow-up, and the mean HSS score significantly increased from 36.5 to 82.4.ConclusionsThis study revealed a low rate of healing potency of PRTMM and chondral lesion after MOWHTO without any attempt for meniscal treatment or chondral resurfacing. The cartilage and healing status of PRTMM was not associated with improved clinical outcomes and radiological findings.

A patellar tendon length conservation method: Biplanar retrotubercle open-wedge proximal tibial osteotomy.

OBJECTIVE:The early-period results of our technique for performing a medial biplanar retrotubercle open-wedge proximal tibial osteotomy for the surgical treatment of varus gonarthrosis were evaluated and compared with those reported in the literature.METHODS:The clinical and radiological results of a medial biplanar retrotubercle open-wedge proximal tibial osteotomy performed on 23 knees in 22 patients with medial gonarthrosis with varus alignment were analyzed.RESULTS:Twenty patients were female and 2 were male. At the time of surgery, the mean age was 56.22 years (44–66 years), the mean body mass index was 31.95 kg/m2 (23.4–44.9 kg/m2), and the mean Hospital for Special Surgery (HSS) score was 68.7 (48–83). The mean preoperative femorotibial anatomical axis angle was 186.39° (173–194°), and the mean Insall-Salvati index value was 1.04 (0.94–1.171). The mean length of follow-up was 30.19 months (6–42 months). At the last follow-up examination, the mean HSS score was 86.48 (74–100), the mean femorotibial anatomical axis angle was 175° (168–171°), and the mean Insall-Salvati index value was 1.06 (0.857–1.32). Comparison of the final follow-up values with the preoperative values demonstrated significant improvement in the HSS score and femorotibial anatomical axis angle, but no significant difference in the Insall-Salvati index value.CONCLUSION:The results of this study indicated that frontal and sagittal plane deformities in patients with varus gonarthrosis can be treated with biplanar retrotubercle open-wedge proximal tibial osteotomy with good clinical results that achieve patellar tendon length stability and avoid patellofemoral problems.

Treatment of complex tibial plateau fractures with improved three combined approaches

Objective To evaluate the outcomes of open reduction and internal fixation of complex tibial plateau frac-tures with improved three combined approaches. Methods In the period from July 2014 to February 2016, 7 complex tibial pla-teau fractures underwent surgical treatment. These patients included 5 male and 2 female, aged from 24 to 68 years old (average, 39.7±15.3 years). According to Schatzker classification, they were all of type V. And all of type 41B-3.1 by AO/OTA classification. All these fractures were exposed and reduction via three combined approaches. First let the patients lied in lateral prone position, expose the anterolateral and the posterolateral of the tibial plateau, and fix the fractures of the posterior in the posterolateral ap-proach, then fix the fractures of the lateral in the anterolateral approach. Then turn the patients to supine position, fix the fractures of the medial in the anteromedial incision. All patients received regular reexamination. The knee function was evaluated at the fi-nal follow-up using The Hospital for Special Surgery (HSS) score, the activity of the knee was evaluated by Lysholm score, and the stability of the knee was checked by Lachmantest and Pivot-shift test. The tibial plateau angle, the posterior slope angle and Ras-mussen X-ray score were assessed on the X-ray films. Results The average time of operation is (3.3±0.9) h, and the hemorrhage volume in operation was (341±106) ml for the 7 patients. The wounds of 6 patients healed by (11.8±1.3) days, while the wound of the rest one of them occurred fat liquefaction after operation who is very fat (BMI>30) and suffered from diabetes. His wound healed by 21 days. These patients obtained follow-ups of 8 to 14 months (average, 11.4±2.8 months). The average full weight-bear-ing time was 2-3 months (average, 2.5±0.4 months). The fractures healed after 8 to 16 weeks (average, 11.1±2.8 weeks). No dis-placement of the fractures or breakage of the implants occurred in our series. Nobody has activity limitation of the knee or pain be-cause of the implant, and no never symptoms were noted postoperatively, so we would not take out the implant for these patients. The mean HSS score was 93.1±4.8 (range, from 85 to 100) at the final follow-up, and the excellent rate is 100%. The Lysholm score was 97.1±3.6 (range, from 90 to 100) at the final follow-up. The Lachman test and the Pivot-shift test were negative in our pa-tients, and the mean knee flexion was 128.6±12.8°(range, from 105°to 140°). The fractures were all anatomical reduction by the X-ray after operation, and there had being no displacement of the fractures or breakage of the implants occurred during the follow-up period. The mean posterior slope angle was 8.29±2.87° (range, from 4 °to 12°), which was 8.71±2.63° (range, from 5 °to 14°) 6 months after operation. The mean tibial plateau angle was 86.00±1.41° (range, from 84 °to 88°), which was 86.43±1.62° (range, from 84 °to 89°) 6 months after operation. The mean Rasmussen X-ray score was 16.86±1.57 (range, from 14 to 18), which was 16.57±1.51 (range, from 14 to 18) 6 months after operation, and the excellent rate are 100%. Conclusion For the complex tibial plateau fractures which simultaneous involved the medial, the lateral and the posterior, the improved three combined approaches showed the advantages of the convenient operation, the satisfactory results of reduction and fixation, and the less trauma and sec-ondary damage, and could be worth for clinic. Key words: Tibial fractures; Knee joint; Fracture fixation, internal

Combined surgical approaches in the treatment of complex tibial plateau fractures

To explore the early clinical efficacy of a posteromedial inverted "L" shape approach combined an assisted antero lateral assisted approach for the treatment of complex fractures of tibial plateau. From March 2011 to June 2014, the posteromedial inverted "L" shape approach combined with the antero lateral assisted approach in the treatment of Schatzker type IV, V, VI tibial plateau fracture were performed in 34 cases. There were 23 males and 11 females, ranging in age from18 to 67 years old, averaged 34.9 years old; 19 patients had fractures on the left and 15 patients had fractures on the right. According to Schatzker classification, 11 cases of type IV, 15 cases of type V and 8 cases of type VI. According to the three column classification, 23 cases of double column fractures, 11 cases of three column fractures. The X-ray healing time and knee joint mobility were recorded. The mean tibial plateau angle(TPA) and the mean posterior slope angle (PA) were measured and recorded immediately after operation, 6 and 12 months after operation. The knee function was evaluated using the Hospital for Special Surgery Score(HSS) 3, 6 and 12 months after operation. Among all the patients, 28 patients were followed up, and the duration time ranged from 8 to 39 months with a mean of(21.6±8.7) months. All the fractures were healed. The healing time in terms of X-ray ranged from 12 to 24 weeks, with a mean of (14.5±3.6) weeks. The range of knee activity ranged from 105° to 135°, with a mean of (121.5±5.5)°. Immediately after operation, 6 and 12 months after operation, the mean tibial plateau angle (TPA) was (84.3±1.8)°, (85.1±1.3)°, (85.6±1.6)°, and the mean posterior slope angle (PA) was (7.8±1.6)°, (7.8±1.3)°, (7.7±2.3)°, respectively, showing no significant difference between the 3 time points. The mean HSS score at 3, 6 and 12 months after operation was 71.4±1.4, 76.7±1.7, 81.6±1.2 respectively, showing no significant differences between the 3 time points. One patient with early knee joint stiffness had 6° of the restricted straight range after the active functional exercise, 1 year after operation. Anterolateral wound dehiscence occurred in 1 cases but was cured by dressing without deep wound infection occurred. The pain occurred in 4 cases when the weather changed. At the end of follow-up, no case of knee joint instability, knee valgus, loosening or breakage occurred. The posteromedial inverted "L" shape approach combined assisted anterior lateral approach for the treatment of complex fractures of tibial plateau can expose the operation area, repair the fracture under the direct vision, and implant a full amount of bone graft for the collapse of the platform.Thus, the smoothness of the articular surface is restored, and the fixation is firm, which is beneficial to the early functional exercise, less complications, and satisfactory clinical curative effects.

Preoperative planning using the picture archiving and communication system technique in high tibial osteotomy.

This study aimed to evaluate the accuracy of the picture archiving and communication system (PACS) method in order to select the correction angle and gap in open-wedge high tibial osteotomy (HTO) and clinical results of the patients. This retrospective study analyzed 27 consecutive patients (30 knees) underwent open-wedge HTO using the PACS method between April 2013 and March 2015. Full-length lower limb radiographs obtained preoperatively and at the final follow-up were used to the percentages of crossing points of the weight-bearing line and tibial plateau with respect to the medial border and mechanical femur-tibia angle. Preoperatively predicted and postoperatively measured wedge angles and gaps were compared. The clinical results were evaluated using the Hospital for Special Surgery (HSS) knee score and the Knee Society score. At the 20.5 months (12-26.5) follow-up, the weight-bearing line on the tibial plateau was corrected from 17.3% to 61.3%, and the mechanical femur-tibia angle was corrected from 7.3° varus to 3.1° valgus. No significant difference in preoperative and postoperative measured values was observed ( p = 0.440 and p = 0.505). The mean HSS score increased from 66.7 to 88.8 ( p < 0.001). The knee score and function score of Knee Society increased from 62.0 to 88.7 ( p < 0.001) and from 60.2 to 91.7 ( p < 0.001), respectively. In open-wedge HTO, correction of angular deformity based on the PACS method could be an accurate correction method and the good clinical results could be obtained.

Treatment of posterolateral depression fractures of tibial plateau with improved posterolateral ap-proach and 2.4 mm distal radius locking plate

Objective To report the clinical results of treating posterolateral depression fractures of tibial plateau with improved posterolateral approach and 2.4 mm distal radius locking plate. Methods In the period from November 2013 to December 2015, 11 posterolateral depression fractures of tibial plateau underwent surgical treatment. They were 7 men and 4 women, aged from 23 to 75 years (average, 35.9 years). Based on the CT three-column classification, all were simple depression fractures of the posterolateral column; based on the AO/OTA classification, all were type 41B-2.2.4. All the fractures were exposed and reduced via the posterolateral approach. Following bone graft, 2.4 mm distal radius locking plates were used to fix the fractures. The knee function was evaluated at the final follow-up using The Hospital for Special Surgery (HSS) score. Lachman tests were conducted. The articular surfaces and the posterior slope angles were assessed on the X-ray films. Results No nerve symptoms were noted postoperatively. All the in-cisions got primary healing. The patients obtained follow-ups of 6 to 18 months (average, 10.4 months). The fractures united after 8 to 12 weeks (average, 9 weeks). Anatomical reduction was shown on the postoperative X-ray films. The mean posterior slope angle of the lateral tibial plateau was 7.7° (range, from 5° to 9°) im-mediately after operation, which was 7.8° (range, from 5° to 10°) 6 months after operation. The mean HSS score was 92.5 (range, from 90 to 97) at the final follow-up. The mean knee flexion was 128° (range, from 120° to 140°) 6 months after operation. All the Lachman tests gave a negative result. No breakage of the implants occurred in this series. Conclusion Internal fixation can be done safely, reliably and effectively with improved posterolateral approach and 2.4 mm distal radius locking plates in the treatment of posterolateral depression fractures of tibial plateau via a modified posterolateral approach. Key words: Tibial fractures; Knee joint; Fracture fixation, internal; Bone plates

Results of a Second-generation Constrained Condylar Prosthesis in Complex Primary and Revision Total Knee Arthroplasty: A Mean 5.5-Year Follow-up.

Background:The application of second-generation constrained condylar knee (CCK) prostheses has not been widely studied. This retrospective study was carried out to evaluate the clinical and radiographic outcomes of a second-generation CCK prosthesis for complex primary or revision total knee arthroplasty (TKA).Methods:In total, 51 consecutive TKAs (47 patients) were performed between June 2003 and June 2013 using second-generation modular CCK prostheses. The follow-up was conducted at 3rd day, 1st, 6th, and 12th months postoperatively and later annually. Anteroposterior (AP), lateral, skyline, and long-standing AP radiographs of the affected knees were taken. The Hospital for Special Surgery (HSS) Knee Score, the Knee Society Knee Score (KSKS), the Knee Society Function Score (KSFS), and range of motion (ROM) were also recorded. Heteroscedastic two-tailed Student's t-tests were used to compare the HSS score and the Knee Society score between primary and revision TKAs. A value of P < 0.05 was considered statistically significant.Results:Four knees (two patients) were lost to follow-up, and 47 knees (31 primary TKAs and 16 revision TKAs) had a mean follow-up time of 5.5 years. The mean HSS score improved from 51.1 ± 15.0 preoperatively to 85.3 ± 8.4 points at the final follow-up (P < 0.05). Similar results were observed in terms of the KSKS and KSFS, which improved from 26.0 ± 13.0 to 80.0 ± 12.2 and from 40.0 ± 15.0 to 85.0 ± 9.3 points, respectively (P < 0.05). No significant difference in the HSS, KSKS, KSFS, or ROM was found between primary and revision TKAs (P > 0.05). Two complications were observed in the revision TKA group (one intraoperative distal femur fracture and one recurrence of infection) while one complication (infection) was observed in the primary TKA group. No prosthesis loosening, joint dislocation, patella problems, tibial fracture, or nerve injury were observed. Radiolucent lines were observed in 4% of the knees without progressive osteolysis.Conclusions:Second-generation modular CCK prostheses are a safe and practical treatment for both primary and revision knees that cannot be balanced. However, further studies focusing on different types of constrained prostheses are required to validate these results.

Total knee arthroplasty in patients with Charcot joints.

Although total knee arthroplasty (TKA) entails diverse operative techniques and achieves varying results in patients with different knee pathologies, few studies have discussed TKA for Charcot joints. This study aimed to investigate the efficacy of TKA in patients with Charcot knees. From 2009 to 2013, seven patients with eight Charcot knees were admitted to our institution. They were confirmed by pre-operative examination and subsequently underwent TKAs. The pre-operative clinical and imaging characteristics of their knees indicated that all were in the Charcot stages of reconstruction or coalescence. Rotating hinge prostheses were selected for three knees with severe bone deficiency and soft tissue imbalance, whereas long stem condylar-constrained prostheses were implanted in the remaining five cases. Autogenous bone grafts were used in three patients to repair residual defects after osteotomy. Clinical data, including Hospital for Special Surgery (HSS) knee scores, range of motion (ROM), complications, and radiographic data, were used to assess surgical efficacy. The mean HSS score increased from 45.8±14.2 (24-60) points pre-operatively to 84.6±4.8 (75-90) points at final follow-up (P<0.01). ROM was 65°±25° (30°-100°) pre-operatively and 92°±11° (75°-110°) after arthroplasty (P<0.05), indicating satisfactory outcomes. Radiographic findings, including assessment for prosthetic loosening and alignment changes, suggested favourable outcomes. TKA using constrained condylar or rotating hinge prostheses and autografts for massive bone defects is effective for Charcot knees in the reconstruction or coalescence stage. IV.