Preoperative Knee Range Of Motion Research Articles

Spondylolisthesis and mismatch deformity affect outcomes after total knee arthroplasty

BackgroundLittle published data currently exist regarding the potential relationships between spondylolisthesis, mismatch deformity, and clinical outcomes following total knee arthroplasty (TKA). We hypothesize that preexisting spondylolisthesis will result in decreased functional outcomes after TKA.MethodsThis retrospective cohort comparison of 933 TKAs was performed between January 2017 and 2020. TKAs were excluded if they were not performed for primary osteoarthritis (OA) or if preoperative lumbar radiographs were unavailable/inadequate to measure the degree of spondylolisthesis. Ninety-five TKAs were subsequently available for inclusion and divided into two groups: those with spondylolisthesis and those without. Within the spondylolisthesis cohort, pelvic incidence (PI) and lumbar lordosis (LL) were calculated on lateral radiographs to determine the difference (PI–LL). Radiographs with PI–LL > 10° were then categorized as having mismatch deformity (MD). The following clinical outcomes were compared between the groups: need for manipulation under anesthesia (MUA), total postoperative arc of motion (AOM) both pre-MUA or post-MUA/revision, incidence of flexion contracture, and a need for later revision.ResultsForty-nine TKAs met the spondylolisthesis criteria, while 44 did not have spondylolisthesis. There were no significant differences in gender, body mass index, preoperative knee range of motion (ROM), preoperative AOM, or opiate use between the groups. TKAs with spondylolisthesis and concomitant MD were more likely to have MUA (p = 0.016), ROM < 0–120 (p < 0.014), and a decreased AOM (p < 0.02) without interventions.ConclusionPreexisting spondylolisthesis by itself may not have adverse effect clinical results following TKA. However, spondylolisthesis increases the likelihood of developing MD. In those with both spondylolisthesis and concomitant mismatch deformities, patients had statistically and clinically significantly decreased in postoperative ROM/AOM and increased need for MUA. Surgeons should consider clinical/radiographic assessments of patients with chronic back pain who present for total joint arthroplasty.Level of evidenceLevel 3.

Effect of modified Laprade technique on posterolateral ligament injury of knee

PurposeTo investigate the effect of modified Laprade technique on the reconstruction of posterolateral structure of knee and anterolateral ligament of knee in the treatment of posterolateral injury of knee.MethodsFrom December 2013 to June 2020, multiple ligament injury patients who received surgery in our hospital were collected in this research. These patients underwent a modified Laprade technique for posterolateral structural reconstruction of the knee. Lysholm scores of patients pre- and post-operation were recorded.ResultThe operations of the observation group or the control group patients were completed. There were no significant differences in gender, age, preoperative knee range of motion and preoperative Lysholm score. At the time of follow-up 1 month after operation, there was no significant difference in knee range of motion, dial-up test angle and Lysholm score between the observation and the control group. When followed up 1 year after operation, the Lysholm score of the observation group was higher than that of the control group. The difference was statistically significant. The same situation occurred in the range of motion of the knee in both groups. However, there was still no significant difference between the two groups in the dial-up test 1 year after operation, whether the knee flexion was 30° or 90°.ConclusionFor patients with posterolateral structure injury of knee, the modified Laprade technique is a feasible surgical technique.

Important Factors for Retrograde Nailing Through Total Knee Arthroplasty: A Cadaveric Study.

Evaluate how total knee arthroplasty (TKA) implant design, femoral component size, and preoperative knee range of motion affect retrograde femoral nailing. Cadaveric specimens were prepared for TKA with a single radius (SR) or medial pivot (MP) design and tested with cruciate retaining (CR), cruciate substituting (CS), and posterior stabilizing (PS) 9-mm liners. Knee extension identified the minimum flexion required to pass an opening reamer without impinging on TKA components. The angle between the reamer path and the femoral shaft was calculated from lateral fluoroscopic images. In SR TKA, the average flexion required was 70, 71, and 82 degrees for CR, CS, and PS, respectively. The required flexion in PS was significantly greater (P = 0.03). In MP TKA, the average flexion required was 74, 84, and 123 degrees for CR, CS, and PS, respectively. The required flexion was significantly greater in CS and PS designs (P < 0.0001). Femoral component size did not affect the minimum flexion required. The entry reamer resulted in 9.2 (SR) and 12.5 (MP) degrees of apex anterior deviation. When performing retrograde nailing through either of these TKA designs with a 12-mm opening reamer, at least 70 degrees of knee flexion is required to avoid damage to the polyethylene liner or femoral component. PS implants require significantly more flexion with both TKA designs. Femoral component size did not affect the flexion requirement. Approximately a 10-degree deviation exists between the reamer path and femoral shaft.

Comparison of the effectiveness of unicompartmental arthroplasty and total knee arthroplasty based on patient scale data

To compare the patient-reported outcomes regarding function, joint amnesia, and the quality of life after unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). The clinical data of patients who received UKA or TKA between September 2017 and June 2018 were retrospectively analyzed. After propensity score matching, 40 patients (40 knees) each in TKA group and UKA group were finally included in the study. There was no significant difference between the two groups in gender, age, body mass index, surgical side, preoperative knee range of motion, Western Ontario and McMaster University Osteoarthritis Index (WOMAC) score, clinical and function scores of knee society score (KSS) ( P>0.05). At 2 years after operation, WOMAC score, KSS clinical and function scores were performed on the two groups of patients, and compared with preoperative ones; knee injury and osteoarthritis outcome score-physical function short form (KOOS-PS), short-form 36 health survey scale (SF-36 scale), and forgotten joint score (FJS) were also performed. At 2 years after operation, the total score of WOMAC, the clinical and function scores of KSS in the two groups significantly improved when compared with preoperative ones ( P<0.05), but there was no significant difference in the total score of WOMAC, the individual score of WOMAC, the clinical and function scores of KSS between the two groups ( P>0.05). The total KOOS-PS score in the UKA group was significantly lower than that in the TKA group ( t=4.243, P=0.000), and the scores of writhing/knee rotation, kneeling, and squatting in the UKA group were significantly lower than those in the TKA group ( P<0.05). The total FJS score in the UKA group was significantly higher than that in the TKA group ( t=-6.334, P=0.000). In the UKA group, the scores of 7 items were significantly lower than those of the TKA group ( P<0.05) including when walking over 15 minutes, when climbing stairs, when walking on uneven ground, when standing for long periods, when doing housework or gardening, when taking a walk or hiking, and when doing your favorite sport. The SF-36 scales of physiological function, energy, social function, emotional function, and mental health in the UKA group were significantly higher than those in the TKA group ( P<0.05). Compared with TKA, patients treated with UKA may have better knee function recovery, joint amnesia, and higher quality of life.

Predictors of Successful Early Discharge for Total Hip and Knee Arthroplasty in Octogenarians.

Background: Decreased length of stay after total joint arthroplasty (TJA) is becoming a more common way to contain healthcare costs and increase patient satisfaction. There is little evidence to support "early" discharge in elderly patients. Purpose: We sought to identify preoperative factors that correlated with early discharge (by postoperative day [POD] 1) in comparison to late discharge (after POD2) in octogenarians after TJA. Methods: In a retrospective cohort study from a single institution, we identified 482 patients ages 80 to 89 who underwent primary TJA from January 2014 to December 2017; 319 had total knee arthroplasty (TKA) and 163 had total hip arthroplasty (THA). Data collected included preoperative knee range of motion (ROM), demographics, and comorbidities; 90-day readmission and mortality rates were also evaluated. P values for continuous data were calculated using student's t test and for categorical data using χ2 testing. Results: Of octogenarian patients, 30.9% were discharged by POD1. Early discharge was associated with being male, married, and nonsmoking, as well as having an American Society of Anesthesiologists (ASA) score of 2, independent preoperative ambulation, and a postoperative caregiver. Type of procedure (TKA vs THA), body mass index, laterality, preoperative range of motion (ROM) for TKA, and single vs multilevel home did not affect the probability of early discharge. Discharge on POD1 was not associated with increased 90-day readmission rates. There were no deaths. Conclusion: Early discharge for octogenarians can be successfully implemented in a select subset of patients without increasing 90-day readmission or death rates. There are multiple factors that predict successful early discharge.

Comparison of early effectiveness of arthroscopic suture bridge technique and conventional double tunnel suture technique in treatment of avulsion fracture of posterior cruciate ligament insertion

To compare the early effectiveness of arthroscopic suture bridge technique and conventional double tunnel suture technique in the treatment of avulsion fracture of posterior cruciate ligament (PCL) insertion. Between June 2013 and December 2018, 62 patients with tibial avulsion fracture of PCL insertion that met the criteria were selected and randomly divided into trial group (using arthroscopic suture bridge technique) and control group (using conventional double tunnel suture technique), 31 cases in each group. There was no significant difference in gender, age, injured side, cause of injury, time from injury to operation, Meyers & McKeever classification, Kellgren-Lawrence classification, and preoperative knee range of motion, difference of posterior relaxation of bilateral knee joints, International Knee Documentation Committee (IKDC) score, and Lysholm score between the two groups ( P>0.05). The operation time and IKDC score, Lysholm score, knee range of motion, the difference of posterior relaxation of bilateral knee joints (measured by KT-2000 under knee flexion of 90° and 30 lbs) were recorded and compared between the two groups before operation and at 3 and 12 months after operation. Both groups successfully completed the operation, and the operation time of the trial group and the control group were (61.81±6.83) minutes and (80.42±4.22) minutes respectively, showing significant difference between the two groups ( t=12.911, P=0.000). All the incisions healed by first intention, and there was no wound infection and other early postoperative related complications. All patients were followed up 13-18 months (mean, 14.6 months). The fractures in both groups healed at 3 months after operation. No knee pain, limited movement, or other complications occurred. At 3 and 12 months after operation, the IKDC score, Lysholm score, knee range of motion, and the difference of posterior relaxation of bilateral knee joints in both groups were significantly improved when compared with preoperative ones, and further improved at 12 months after operation when compared with at 3 months after operation ( P<0.05). At each time point after operation, the above indexes and the grade of the difference of posterior relaxation of bilateral knee joints in the trial group were significantly better than those in the control group ( P<0.05). Arthroscopic suture bridge technique in the treatment avulsion fracture of PCL insertion is simple and reliable, which can significantly improve the function and stability of the knee joint and obtain satisfactory early effectiveness.

Lumbar Spine Sagittal Mismatch Deformity Negatively Affects Total Knee Arthroplasty Outcomes.

There is currently a paucity of data regarding the potential relationships between preexisting spinal deformity and clinical outcomes following total knee arthroplasty (TKA). We sought to expand upon this deficit. We hypothesize that lumbar sagittal mismatch deformity (MD) will correlate with a decrease in functional outcomes after TKA. This retrospective cohort comparison of 933 TKAs was performed between January 2017 and 2020. TKAs were excluded if they were not performed for primary osteoarthritis (OA) or if preoperative lumbar radiographs were unavailable/inadequate to measure sagittal parameters of interest: pelvic incidence, sacral slope, pelvic tilt, lumbar lordosis, and deformity mismatch. Ninety-four TKAs were subsequently available for inclusion and divided into two groups: those with MD as defined by |PI-LL| > 10 degrees and those without MD. The following clinical outcomes were compared between the groups: total postoperative arc of motion (AOM), incidence of flexion contracture, and need for manipulation under anesthesia (MUA). In total, 53 TKAs met the MD criteria, while 41 did not have MD. There were no significant differences in demographics, body mass index, preoperative knee range of motion (ROM), preoperative AOM, or opiate use between the groups. TKAs with MD were more likely to have MUA (p = 0.026), ROM <0 to 120 (p < 0.001), a decreased AOM by 16 degrees (p < 0.001), and a flexion contracture postoperatively (p = 0.01). Preexisting MD may adversely affect clinical results following TKA. Statistically and clinically significant decreases in postoperative ROM/AOM, increased likelihood of flexion contracture, and increased need for MUA were all noted in those with MD. This is a Level 3 study.

Excellent outcome with modified thompson quadricepsplasty for knee extension contracture: Case report and review of the literature

The daily life routine activities require a good range of knee motion, losing that after femur fracture is a common problem that can be triggered by extension contracture, flexion contracture, or combined contractures. This case report is about a 19-year-old male with unremarkable medical history who suffered from extension contracture with no flexion following a wrongly applied plate for distal femur fracture, which was treated successfully surgically by modified Thompson's quadricepsplasty after 21 months from the initial injury. The final outcome was no extension lag and 120° active flection. The aim of reporting this case was to increase the awareness about the modified Thompson's quadricepsplasty, which is an excellent solution to the debilitating extension contracture complication and present a review of the literature of this procedure. The aim of the literature review is to evaluate the correlation and the influence of the patient's age, the interval to quadricepsplasty after the initial trauma, preoperative knee range of motion, surgical approach, and the postoperative care on the outcome of Thompson's quadricepsplasty and its modifications for the treatment of posttraumatic knee contractures besides that, to answer the question: Is Thompson's quadricepsplasty an excellent procedure to treat knee extension contracture?

Increased joint obliquity after open-wedge high tibial osteotomy induces pain in the lateral compartment: a comparative analysis of the minimum 4-year follow-up outcomes using propensity score matching.

To analyze the effects of increased medial proximal tibial angle (MPTA) on the clinical outcomes and cartilage deterioration in the lateral compartment after a mean follow-up period of 4years following open-wedge high tibial osteotomy (OWHTO) using propensity score matching (PSM) analysis. Among 376 knees treated with OWHTO for medial unicompartmental osteoarthritis with varus deformity, 36 knees with MPTA increase of > 95° and 108 knees with MPTA increase of < 95° at the final follow-up were included. The baseline prognostic factors [age, sex, preoperative hip-knee-ankle (HKA) angle, body mass index, and preoperative knee range of motion] were equalized between the 2 groups using PSM; consequently, 31 pairs of patients were compared. The radiographic and clinical outcomes, including lateral compartment pain, were assessed. For 18 patients in each group, second-look arthroscopy and cartilage status assessment were performed. The preoperative demographics were similar between the groups. At the final follow-up, the HKA angle and joint line obliquity were significantly higher in the increased MPTA group. No significant differences were observed in the clinical outcomes between the groups. On second-look arthroscopy, significant cartilage deterioration of the lateral compartment was not observed in either group. Pain in the lateral compartment was experienced significantly more frequently in the increased MPTA group (p < 0.01). Although excessively increased MPTA after HTO had no significant effects on the clinical outcomes and cartilage deterioration in the lateral compartment at the minimum 4-year follow-up, lateral compartment pain was experienced significantly more frequently in the increased MPTA group.

Treatment with posterior capsular release, botulinum toxin injection, hamstring tenotomy, and peroneal nerve decompression improves flexion contracture after total knee arthroplasty: minimum 2-year follow-up.

No definite treatment option with reasonable outcome has been presented for old and refractory flexion contracture after total knee arthroplasty (TKA). We describe a surgical technique for 21 refractory cases of knee flexion contracture, including 12 patients with history of failed manipulation under anesthesia (MUA). Retrospective review was conducted for procedures performed by a single surgeon between 2005 and 2016. Twenty-one knees (19 patients) with knee flexion contracture after primary TKA were treated with all the following procedures: posterior capsular release, hamstring tenotomy, prophylactic peroneal nerve decompression, and botulinum toxin type A injections. Twelve of the 21 knees had at least 1 prior unsuccessful MUA before this soft-tissue release procedure. Mean age at intervention was 60years (range 46-78years). Mean preoperative knee range of motion (ROM) was - 27° extension (range - 20° to - 40°) to 100° flexion (range 90°-115°). All radiographs were evaluated for proper component sizing and signs of loosening. Full extension was achieved immediately after surgery in all patients. Only one knee required repeat botulinum toxin type A injection. All patients had full extension at mean follow-up of 31months (range 24-49months). No significant change was observed in knee flexion after the procedure (n.s.). Significant improvement was noted in the postoperative Knee Society Score (KSS) (mean 80, range 70-90) when compared with preoperative KSS (mean 45, range 25-65) (p = 0.008). The proposed surgical technique is efficacious in treating patients with refractory knee flexion contracture following TKA to gain and maintain full extension at minimum 2-year follow-up. IV, retrospective case series.

The characteristic findings of an inverted-type discoid lateral meniscus tear: a hidden tear pattern

BackgroundThe purpose of this study was to reveal the clinical history and physical and magnetic resonance imaging (MRI) findings of patients with an inverted-type discoid lateral meniscus (DLM) tear compared with those with a symptomatic and torn discoid meniscus without inverted tear patterns.Materials and methodsBetween 2014 and 2016, 12 patients underwent arthroscopic partial meniscectomy for an inverted-type DLM tear (inverted group). We age-matched these patients with 12 controls who were extracted from many normal DLM tear cases in the same period (non-inverted group). The assessment items were traumatic history with the onset of pain, the mean duration between the appearance of symptoms and surgery, preoperative knee range of motion (ROM), positive findings on the McMurray test, knee locking or catching, and characteristic MRI findings. These items were compared between the two groups using χ2 and Student’s t-tests.ResultAll patients in the inverted group had clear trauma with the onset of pain during sports or daily life activities, and 7 of the 12 patients with a non-inverted type of DLM tear had clear trauma. There was a significantly higher rate of traumatic history in the inverted group than in the non-inverted group (P = 0.03). The mean duration between the appearance of symptoms and surgery, preoperative knee ROM, positive findings on the McMurray test, and knee locking or catching were not significantly different between the inverted and non-inverted groups. On MRI, the diagnosis ratio of DLM was significantly higher in the non-inverted group (9/12 cases) than in the inverted group (3/12 cases, P = 0.04). Nine of the 12 inverted-type patients had the characteristic findings of an inverted-type DLM tear, including a duplicated or enlarged posterior horn and blunting of the inner rim, on the sagittal plane of an MRI.ConclusionPatients with inverted-type DLM tears had clear trauma and infrequently had the characteristic MRI findings that are observed in patients with normal DLM tears. Physicians should suspect that an inverted-type DLM tear is present during diagnosis and focus on the posterior horn to find the inverted sign on the MRI sagittal plane.Level of evidenceLevel III.

The effect of a preoperative education class on the rate of manipulation under anesthesia after total knee arthroplasty in a veterans population.

BackgroundArthrofibrosis after total knee arthroplasty (TKA) is a common complication, potentially occurring in up to 25% of patients, and may be treated during the early recovery period by manipulation under anesthesia (MUA). The majority of preoperative factors that predispose patients to postoperative stiffness are patient specific and not modifiable. The United States Veteran Affairs is a particularly challenging group given a higher baseline rate of medical comorbidities and opioid dependence than the general population. Patient education about postoperative expectations and complications has been shown to improve outcomes in certain orthopedic procedures. This retrospective study aims to determine if preoperative counseling for veterans undergoing primary TKA reduces the rate of postoperative stiffness, and consequently MUA, in this subset of patients.MethodsWe evaluated the medical records of 244 veterans at a single veteran affairs hospital who underwent 278 TKAs during a 6-year period under one surgeon. Patients were separated into groups based on attendance in the preoperative counseling session. Effects of various factors, including age, sex, body mass index, preoperative knee range of motion, and history of previous knee surgery, were compared between these 2 cohorts.ResultsAttendance in the preoperative course did not have a statistically significant impact on the rate of manipulation (odds ratio [OR], 1.07). Female gender and prior manipulation had an increased OR of knee manipulation, whereas age > 65 years had a decreased OR that did not reach significance.ConclusionsOur results show that preoperative counseling did not have a benefit in terms of postoperative MUA rates in veterans. Preoperative education may be helpful for setting appropriate expectations of pain, recovery, and function after total joint arthroplasty and may be useful in an online or video format in small practices in which cost may be prohibitive. Further studies are needed to determine whether they provide any benefit in postoperative arthrofibrosis rates.

Surgical treatment for knee osteoarthritis subsequent to previous femur fractures

Objective To investigate the indications and clinical outcomes of total knee arthroplasty or osteotomy for knee osteoarthritis subsequent to previous femur fractures. Methods Six patients (three male and three female) with knee osteoarthritis subsequent to previous femur fractures were analyzed retrospectively between February 2006 and February 2017. The average age of patients was 58.2±10.3 years old, ranged from 51 to 79 years. Four patients underwent total joint replacement and two underwent osteotomy. The average age of patients in joint replacement group was 60.5±12.3 years old. The age of the two patients in the osteotomy group was 51 and 55 years old, respectively. The extra-articular deformity angle of the coronal plane of the femur, lateral distal femur angle of mechanical axis, hip-knee-ankle angle (HKA) of preoperative and postoperative were determined on long-standing radiography. The mean angle of the extra-articular deformity in the joint replacement group was 17.0±7.7 degrees. The angle of the extra-articular deformity in the osteotomy group was 34 and 20 degrees. Lateral distal femur angle of mechanical axis in the joint replacement group was within the range of 87±7 degrees. Lateral distal femur angle of mechanical axis in the osteotomy group was out of the range of 87±7 degrees. The mean preoperative HKA of the joint replacement group was 161.8±8.0 degrees. The preoperative HKA of the osteotomy group was 155 and 160 degrees, respectively. Knee function was estimated according to knee range of motion and Knee Society Score (KSS). The results of postoperative hip-knee-ankle angle, knee range of motion (ROM) and knee society score were compared between the two groups. Results The mean HKA of the joint replacement group reached 176.0±2.8 degrees at one year postoperatively. The HKA of the osteotomy group improved to 177 and to 175 degrees at one year postoperatively. The average preoperative knee ROM improved significantly from 71±16 degrees preoperatively to 113±5 degrees postoperatively. The mean knee ROM of the joint replacement group was 113.0±6.8 degrees. The knee ROM of two patients in the osteotomy group was 110 and 115 degrees, respectively. The average preoperative KSS score improved significantly from 46±3 preoperatively to 88±3 postoperatively. The mean KSS of the joint replacement group was 88.8±3.0, while the KSS of the osteotomy group was 85 and 82. No bone nonunion was observed in the two patients in osteotomy group. Conclusion For patients with knee osteoarthritis subsequent to previous femur fractures, satisfactory short-term clinical outcomes could be obtained by total knee arthroplasty or osteotomy with the strict selection of proper operative indications. Key words: Femoral fractures; Osteoarthritis; Arthroplasty, replacement, knee

Effect of continuous and single shot adductor canal blocks for postoperative analgesia and early rehabilitation after total knee arthroplasty

To compare the analgesia effect and clinical rehabilitation between continuous adductor canal block (ACB) and single shot ACB in total knee arthroplasty (TKA)．. Between October 2016 and February 2017, 60 patients with severe knee osteoarthritis undergoing primary unilateral TKA were prospectively recruited in the study. All the patients were randomly allocated into 2 groups and received ultrasound-guided continuous ACB (group A, n=30) or single shot ACB (group B, n=30), respectively. There was no significant difference in gender, age, body mass index, nationality, American Society of Anesthesiology (ASA) grading, and preoperative knee range of motion and quadriceps strength between 2 groups ( P>0.05). After operation, the tourniquet time, postoperative drainage volume, hospitalization time, and adverse events in 2 groups were recorded. Visual analogue scale (VAS) scores at rest and during activity, the quadriceps strength, the knee range of motion, and the time of 90° knee flexion in 2 groups were also recorded and compared. There was no significant difference in tourniquet time, postoperative drainage volume, and incidence of adverse events between 2 groups ( P>0.05). But the hospitalization time was significant shorter in group A than in group B ( P<0.05). VAS scores at rest and during activity were lower in group A than in group B, with significant differences in VAS score at rest after 12 hours and in VAS score during activity after 8 hours between 2 groups ( P<0.05). The quadriceps strength was higher in group A than in group B, with significant difference at 24, 48, and 72 hours ( P<0.05). The knee range of motion was significantly better in group A than in group B at 24, 48, 72 hours and on discharge ( P<0.05). The time of 90° knee flexion was significantly shorter in group A than in group B ( t=-2.951, P=0.016). There were 4 patients in group A and 7 patients in group B requiring meperidine hydrochloride (50 mg/time) within 24 hours, and 3 patients in group A and 7 patients in group B at 24 to 48 hours, and 1 patient in group A and 3 patients in group B at 48 to 72 hours. Effusion in the catheter site occurred in 2 cases of group A, but no catheter extrusion occurred. Continuous ACB is superior in analgesia both at rest and during activity and opioid consumption compared with single shot ACB after TKA. And the quadriceps strength could be reserved better in continuous ACB group, which can perform benefits in early rehabilitation.

Osteosynthesis of a periprosthetic patella fracture with a locked mesh plate

Periprosthetic patellar fractures continue to be associated with poor functional outcomes and low rates of bony union. We present a patient with a periprosthetic patellar fracture treated with a novel mesh locking plate technique. In this technique, Kirshner wires were used to help reduce the patellar fracture and an interfragmentary compression screw was placed. The fracture was then neutralized with a locked mesh plate compressed anteriorly onto the patella with cortical screws. By two months follow-up, the patient had return to preoperative knee range of motion, mild knee pain, and a Knee Outcome Score – Activities of Daily Living Scale of 88.6.

High Rate of Local Recurrence and Complications Following Total Knee Arthroplasty in the Setting of Synovial Chondromatosis

BackgroundSynovial chondromatosis is a rare, monoarticular arthropathy due to synovial metaplasia. There is a paucity of data examining the outcome of total knee arthroplasty (TKA) in the setting of synovial chondromatosis. The purpose of this study is to investigate the outcome and function in patients undergoing TKA for management of synovial chondromatosis. MethodsTwenty patients who received TKA for synovial chondromatosis over a 25-year period were identified for analysis and followed for a mean of 7 years. There were 12 males and 8 females, with a mean age and body mass index of 63 years and 30.7 kg/m2. Seventeen patients had “active” disease at the time of surgery. ResultsThe 5-year disease-free survival was 73%. Five patients sustained a recurrence that was treated with synovectomy and revision TKA (n = 2), observation (n = 2), and transfemoral amputation (n = 1) due to malignant degeneration to chondrosarcoma. One of the revision TKA patients underwent a transfemoral amputation 4 months later for recurrence. The overall rate of amputation was 10%. Nine patients (45%) sustained a complication, most commonly decreased knee motion (n = 7), leading to a revision TKA in 3 patients (15%). Mean preoperative knee range of motion was 73°, which improved to 97° postoperatively. The Knee Society Score and functional assessment improved from 35 and 42 preoperatively to 74 and 67 following TKA. ConclusionTKA in the setting of synovial chondromatosis improves patient function and knee range of motion; however, there is a high rate of local recurrence and complications.

Osteosynthesis of a Periprosthetic Patella Fracture With a Locked Mesh Plate

Periprosthetic patellar fractures continue to be associated with poor functional outcomes and low rates of bony union. We present a patient with a periprosthetic patellar fracture treated with a novel mesh locking plate technique. In this technique, Kirshner wires were used to help reduce the patellar fracture and an interfragmentary compression screw was placed. The fracture was then neutralized with a locked mesh plate compressed anteriorly onto the patella with cortical screws. By two months follow-up, the patient had return to preoperative knee range of motion, mild knee pain, and a Knee Outcome Score – Activities of Daily Living Scale of 88.6.

Tibial Tubercle Osteotomy to Aid Exposure for Revision Total Knee Arthroplasty.

A tibial tubercle osteotomy can provide reliable and safe exposure during revision total knee arthroplasty with a high union rate, low complication rate, and predictable outcomes. Determine the need for an extensile approach on the basis of the preoperative knee range of motion; position of the patella; bone quality; medical comorbidities; and cement mantle, tibial keel or stem, and thickness of the anterior tibial cortex. Create full-thickness subcutaneous flaps and perform a medial parapatellar arthrotomy with complete synovectomy and careful excision of scar tissue from the medial and lateral gutters. Extend the skin and subcutaneous dissection distal to the tibial tubercle and mark the chevron osteotomy using electrocautery. Perform the osseous cut for the tibial tubercle osteotomy with a thin saw blade in a medial-to-lateral direction, such that the fragment hinges on the lateral soft tissue and musculature. With the knee maximally flexed and lateral subluxation of the extensor mechanism, for full visualization of the femoral and tibial components, remove the components and perform the knee revision. The final tibial component should have a diaphyseal stem long enough to bypass the distal extent of the tibial tubercle osteotomy by at least 2 cortical diameters. When cementing the final tibial component, take care to remove cement anterior to the tibial stem that would otherwise impede complete reduction of the osteotomy fragment and interfere with osseous union at the osteotomy site. Manually position the osteotomized bone fragment over the tibia and obtain an anatomic reduction either freehand or using bone clamps, depending on the soft-tissue tension. Obtain rigid fixation with a 6.5-mm screw proximally and 2 sets of doubled-over 18-gauge wires distally. Stress the osteotomy site by flexing the knee 90°, deflate the tourniquet, place a drain if needed, and close. Allow weight-bearing as tolerated and a 0° to 90° range of motion in a hinged knee brace. Tibial tubercle osteotomy to aid in exposure during revision total knee arthroplasty has been reported to yield favorable outcomes in the orthopaedic literature7-18.

The influence of area level social deprivation on preoperative disease severity and postoperative outcomes following unicompartmental knee joint replacement

BackgroundThis study investigated the effect of socioeconomic deprivation on preoperative disease and outcome following unicompartmental knee replacement (UKR). Methods307 Oxford UKRs implanted between 2008 and 2013 under the care of one surgeon using the same surgical technique were analysed. Deprivation was quantified using the Northern Ireland Multiple Deprivation Measure. Preoperative disease severity and postoperative outcome were measured using the Oxford Knee Score (OKS). ResultsThere was no difference in preoperative OKS between deprivation groups. Preoperative knee range of motion (ROM) was significantly reduced in more deprived patients with 10° less ROM than least deprived patients. Postoperatively there was no difference in OKS improvement between deprivation groups (p=0.46), with improvements of 19.5 and 21.0 units in the most and least deprived groups respectively. There was no significant association between deprivation and OKS improvement on unadjusted or adjusted analysis. Preoperative OKS, Short Form 12 mental component score and length of stay were significant independent predictors of OKS improvement. A significantly lower proportion of the most deprived group (15%) reported being able to walk an unlimited distance compared to the least deprived group (41%) one year postoperatively. ConclusionMore deprived patients can achieve similar improvements in OKS to less deprived patients following UKR. Level of evidence2b — retrospective cohort study of prognosis.

Stiffness after total knee arthroplasty.

Stiffness after total knee arthroplasty (TKA) adversely affects outcome and impacts patient function. Various risk factors for stiffness after TKA have been identified, including reduced preoperative knee range of motion, history of prior knee surgery, etiology of arthritis, incorrect positioning or oversizing of components, and incorrect gap balancing. Mechanical and associated causes, such as infection, arthrofibrosis, complex regional pain syndrome, and heterotopic ossification, secondary gain issues have also been identified. Management of stiffness following TKA can be challenging. The condition needs to be assessed and treated in a staged manner. A nonsurgical approach is the first step. Manipulation under anesthesia may be considered within the first 3 months after the index TKA, if physical therapy fails to improve the range of motion. Beyond this point, consideration should be given to surgical intervention such as lysis of adhesions, either arthroscopically or by open arthrotomy. If the cause of stiffness is deemed to be surgical error, such as component malpositioning, revision arthroplasty is indicated. The purpose of this article is to evaluate the various aspects of management of stiffness after TKA.