Boys affected by Duchenne Muscular Dystrophy (DMD) often develop significant scoliosis in the second decade of life and require scoliosis surgery. Our aim was to establish whether cardiac MRI (CMR) improves the preoperative risk assessment in DMD patients and evaluate the current risk of surgery.

Case records were retrospectively reviewed for 62 consecutive DMD boys who underwent pre-surgical evaluation at a single tertiary neuromuscular centre between 2008–2013.

62 DMD patients aged 7–18 years underwent pre-operative assessment for a total of 70 procedures (45 spinal, 19 foot, 6 gastrostomy). Echocardiography data were available for 68 procedures. Echo revealed a median left ventricular (LV) shortening fraction (SF) of 29% (range: 7–44). 34% of boys (23/68) had abnormal SF <25%, 48% (31/65) showed dyskinesia and 22% (14/64) had LV dilatation. CMR was routinely performed on 35 patients. Of those who underwent CMR, median left ventricular ejection fraction (LVEF) was 52% (range: 27–67%), 71% of boys (25/35) had dyskinesia. Echocardiography shortening fraction (SF) correlated significantly with CMR LVEF (r_s = 0.67; p<0.001). Increasing severity of dyskinesia on CMR correlated with reduced CMR LVEF (r_s = −0.64; p<0.001) and reduced echo SF (r_s = −0.47; p = 0.004). Although functional echocardiography and CMR data tended to correlate in 35 DMD boys who underwent both imaging modalities nine (26%) had discrepant results. Seven (20%) had evidence of dysfunction on CMR (LVEF < 55%) not detected on echocardiography (SF ≥ 27%); in two cases echocardiogram measured worse function than CMR.

Based on multi-disciplinary risk assessment, surgery was considered too high risk in 23 out of 67 (34%) cases. In 21 cases (91%) this was due to underlying cardiomyopathy. The highest risk among older boys assessed for spinal surgery; 21 out of 43 (49%). Of 19 boys undergoing spinal surgery, six (32%) experienced complications: two wound infections; three patients required readmission to intensive care; one patient died in the post-operative period with acute heart failure.

Background: The purpose of this study was to assess the anterior femoral cortical line (AFCL) as an additional anatomical landmark for determining intraoperative femoral component rotation in total knee arthroplasty. The AFCL was compared with the Epicondylar axis, the anteroposterior (AP) axis (Whiteside’s line), and the posterior condylar axis. Dry bone, cadaver, MRI and intra-operative measurements were compared.

Methods: Fifty dry bone femora, and 16 wet cadaveric specimens were assessed to identify the AFCL and this was compared against the 3 reference axes discussed above. Photographs were taken of the specimens with K-wires/marker pins secured to the reference axes and then a digital on-screen goniometer was used to determine the mean angular variations with respect to the Epipcondylar axis.

In the clinical trial, 58 consecutive patients undergoing total knee arthroplasty were included. After a routine exposure the AP axis was marked on each distal femur. The AFCL was then identified and the anterior femoral cortical cut was made parallel to this line. The angle between this cortical cut and the perpendicular to the AP axis was measured using a sterile goniometer.

In the MRI study, 50 axial knee images were assessed and the most appropriate slice/s determined in order to identify the AFCL and the other 3 reference axes and then their relationship was measured by an on-screen goniometer.

Results: In the cadaveric study the AFCL was a mean 1° externally rotated to the epicondylar axis (SD = 5°), White-side’s line was 1° externally rotated (SD = 4°) and the posterior condylar axis was 1° internally rotated (SD = 2°)

By MRI and with respect to the epicondylar axis, the AFCL was a mean 5° externally rotated (SD= 3), White-side’s Line was 1° externally rotated (SD = 2) and the posterior condylar axis was 3° internally rotated (SD = 2).

In the clinical study in 8 patients it was impossible to draw the AP axis because of dysplasia or destruction of the trochlea by osteoarthrosis. In the remainder the mean difference between the anterior femoral cortical line and Whiteside’s AP axis was 4.1 degrees internally rotated (SD = 3.8°). The lateral release rate for this cohort was 4%.

Conclusion: The anterior femoral cortical line provides an additional reference point, completing the ‘compass points’ around the knee. It has been shown in this study to be reliable in the laboratory, on MRI and in a clinical setting for assessing rotation of the femoral component. It may prove particularly useful when one or all of the other reference axes are disturbed such as in revision TKR, lateral condylar hypoplasia or where there has been previous epicondylar trauma.

Background: There is limited evidence on long-term outcome following ACL reconstruction. Concern has been raised that degenerative joint disease is common in the long-term and this may be associated with use of patellar tendon autograft.

Methods: 162 patients underwent single-surgeon arthroscopic ACL reconstruction (1991–1993) were identified from our prospective database. Patient-centred outcome was by Lysholm and Subjective IKDC score, objective outcome measures were clinical examination, arthrometry and X-rays.

Results: 13 year outcome (10–15 years) is known in 115/161 patients (71%). The median subjective scores were 94% (Lysholm) and 90% (IKDC). Ipsilateral graft rupture rate was 4%, with contralateral ACL injury in 8%. Mean manual maximum KT 1000 was 9mm in the grafted knee and 8mm in the contralateral knee. Clinical laxity scores of grade 0 or 1 were found in over 93% patients. Radiographically 66% were normal or near normal (Grade A or B). When compared to the contra-lateral uninjured knee we found no significant difference in the proportion of normal/near normal x-rays (grade A/B) versus abnormal/severe (grade C/D) for the medial, lateral nor patellofemoral compartments. There was no significant difference in the radiological IKDC grades in the medial compartment when compared to the contra-lateral uninjured knee, but there was a difference in the lateral and patellofemoral joints.

Conclusions: At 13 years patellar tendon ACLR provides excellent patient satisfaction, with clinically objective knee stability and low risk of re-rupture. Radiographically degenerative change was seen in 34%. There was no significant side to side difference to the uninjured contralateral medial knee joint, but there was a small but significant difference in the lateral and patellofemoral joints. The lateral joint differences may reflect underlying bone bruising at the time of injury. We do not believe that the patellar tendon autograft is the cause of arthrosis after BTB ACLR.

Introduction: Stiffness following Total Knee Arthroplasty is a serious and debilitating complication. There are many different patient and surgical factors implicated in it cause. Previous studies have suggested that it will occur in approximately 1% of TKR patients. Arthrofibrosis is an uncommon but potentially debilitating cause in an otherwise well positioned implant. The cause of this abnormal scar formation is as yet unknown. The treatment of this condition remains difficult and controversial. Revision of the TKR has been suggested as the gold standard treatment as other operative strategies have had limited success. Our approach to this problem has been to conserve the prosthesis and try to release the scar tissue.

Aim: The aim of this study is to assess the results of open arthrolysis in the treatment of established arthrofibrosis.

Method: 1522 patients undergoing primary uncemented TKR have been prospectively followed up (2022 TKR’s) using the International Knee Society Scores. 13 patients underwent open Arthrolysis for stiffness post-op (Incidence 0.64%). The average age was 65 (range 50–78). 6 cases were simultaneous bilateral procedures (Incidence 1.2% of simultaneous bilateral procedures). The average time between TKR and arthrolysis was 14 months. Our average follow-op was 7.2 years (range 2 – 10 years)

Results: The average ROM just prior to Arthrolysis was 58°. The average ROM six months after surgery had improved to 91° (p< 0.05). The average ROM at last follow-up was 95° (p< 0.05) with an average Knee Society score of 155 (pain 83, function 72).

No patients have required revision of their components.

Conclusions: We have found open arthrolysis a successful approach to post-op arthrofibrosis. Although a large procedure it has been well tolerated by our patients. They have had an improvement in range of movement by six months which has been maintained up to 10 years.

Introduction The efficacy of total knee replacement (TKR) surgery is well documented throughout the literature. Results from cemented and cementless series reveal similar long-term reliable results in terms of function and survival. Less, however, is known of the long-term results of uncemented TKR with the use of hydroxyapatite (HA). The purpose of this paper is to present the long-term results of a series of TKR using an uncemented, HA-coated, PCL retaining prosthesis.

Method During the period from August 1992 to December 1994 all patients undergoing TKR surgery were prospectively recorded in a consecutive series. Results were recorded pre- and post-surgery at regular intervals (both clinically and radiographically). The combined clinical Knee Society Score was used to evaluate outcome with routine radiographic evaluation done at 10 years.

Results 217 patients (126 female, 91 male) were included in the study with 322 knees in total (75 simultaneous bilateral, 23 staged bilateral and 126 unilateral). The mean age was 70 years (range 34–88 years) with a mean follow-up of 11 years (range 10–12 years). 47 (21.7%) patients were deceased at 10 years. The principle indication for surgery was osteoarthritis. There has been 1 revision (0.3%) for infection in this series to date. There have been 7 (2.2%) deep infections requiring surgical intervention and 4 (1.2%) supracondylar fractures.

At 10 years, mean knee score was 174 with range of movement 0–111 degrees. 95.4% of the series has currently been successfully followed up. 9 patients were unable to be contacted and lost to follow up. With revision as an end point, the rate of survival for the prosthesis at 10 years is 99.4%. Assuming worst case scenario for patients lost to follow up, survivorship is 95.4%.

Conclusion The survival of this prosthesis has shown to compare favourably to other published results. A low rate of revision and infection combined with excellent clinical and functional outcomes suggests the use of HA with an uncemented TKR produces reliable long-term results.

Introduction and Aims: Use of bioceramic coatings to enhance fixation of joint arthroplasties is a relatively new concept that has yet to prove long-term, reliable results in knee arthroplasty. The purpose of this study was to prospectively report on the medium- to long-term outcomes of an uncemented, hydroxyapatite coated total knee replacement (TKR).

Method: Between August 1992 and 2002 all patients in a consecutive series requiring primary TKR were treated with an uncemented, hydroxyapatite coated, posterior cruciate ligament retaining prosthesis implanted by the senior author. A combined Knee Society Clinical rating score (producing a maximum score of 200) was prospectively collected prior to surgery and post-operatively at three and six months and one, two, five and 10 years thereafter. Fluoroscopically controlled interface images were obtained from the first 161 knees immediately and again at two years post-operatively to evaluate the progression of osseointergration.

Results: One thousand two hundred and thirty-five patients (M:F; 605:630) with a mean age of 67 years (range 34–97 years) underwent TKR mainly for osteoarthritis (94%) and inflammatory arthropathies (3%). Mean follow-up was 78 months (range 20–145 months). There were 720 unilateral and 1030 bilateral replacements (824 simultaneous, 206 staged) with 1750 replacements in total. Mean pre-operative knee score was 97 with a range of movement (ROM) from seven to 114 degrees. At five and 10 years, scores were 182 and 178 with a ROM of one to 114 and zero to 112 degrees respectively. Sixty-one (4.9%) patients have died since surgery including two peri-operative deaths for MI. There have been 12 (0.7%) cases requiring revision, primarily for septic loosening (six cases). There have been 16 deep infections (0.9%), 29 proven pulmonary emboli (1.7%) and five periprosthetic fractures (0.3%). There has been one (0.06%) case of aseptic loosening requiring revision.

Conclusion: These results reveal with an adequately designed prosthesis the use of hydroxyapatite in TKR produces reliable osseointergration that is comparable to other methods of fixation as demonstrated with minimal revision rate and incidence of loosening. The clinical results produce excellent ROM with good medical and functional outcomes in the long term.

Introduction The decision to perform bilateral total knee replacement (TKR) either simultaneously or as a staged procedure is made depending on the level of disease severity, comorbidities, total anaesthetic time and cost. We compared the outcomes of these two bilateral groups of patients with unilateral TKR.

Methods Between August 1992 and December 2002 all patients requiring primary TKR received an uncemented, hydroxyapatite-coated, posterior cruciate ligament retaining prosthesis implanted by the senior author. All peri-operative complications were recorded prospectively, as were pre-operative and post-operative knee scores (Knee Society Clinical Rating Score) at three and six months, and one, two, five, and 10 years thereafter. Patients were divided into three groups being; simultaneous bilateral TKR (SIM), staged bilateral TKR (STA), and unilateral TKR (SIN) with the outcomes of each group compared for statistical significance. One thousand one hundred and forty patients (1638 knees) were included in the study. The majority of patients were female in the STA and SIN groups (60% and 53% respectively) and males in the SIM group (57%). There were 790 (SIM), 206 (STA), and 642 (SIN) knees with mean ages of 67 (SIM), 65 (STA), and 67 years (SIN). The primary diagnosis was OA in each of the groups (> 93%).

Results Pre-operative and post-operative scores revealed no significant differences (p> .05) between the groups. Mean scores ranged from 94 to 98 pre-operatively and increased up to 182 to 187 at five years. Post-operative complications were significantly higher (p< .01) in both bilateral groups. There were 68 (17.2%) and 16 (15.5%) cases of thrombi in the SIM and STA groups respectively compared to 60 (9.3%) cases in the SIN group. Pulmonary emboli were also significantly higher in the bilateral groups compared to the unilateral group (p< .01). The rate of deep infection was higher (p=.09) in the STA group compared to the SIM and SIN groups (2.9% of patients compared to 1.1% and 1.4% respectively). There have been 10 revisions (four SIM, one STA, and five SIN) and two cases of peri-operative death (one STA, one SIM) both due to MI.

Conclusions While simultaneous TKR has higher rates of post-operative complication compared to unilateral TKR, it is less than staged TKR. Therefore simultaneous bilateral knee replacements, when indicated, are the ideal treatment of choice compared to staged procedures.

Although hydroxyapatite (HA) coating is known to enhance fixation in THR, its role in the fixation of Total Knee Replacements is less well appreciated. This study was performed to assess the medium-term results of an HA-coated TKR.

Between August 1992 and 1998 all patients requiring a primary TKR were treated with a hydroxyapatite-coated, PCL-retaining prosthesis implanted by the senior author. The HA coating used was 70 microns thick with 75% crystallinity and 20% porosity. It is deposited on a beaded heat-sintered surface. A combined Hospital for Special Surgery and Knee Society Score was recorded pre-operatively and at three, six, 12, 24 and 60 months post-operatively. Fluoroscopically-controlled interface views were performed on the first 161 knees immediately post-operatively and repeated 24 months postoperatively.

Six hundred and ninety two patients (Male:Female 335:357) with a mean age of 68 years (31–88 years) underwent 1 000 TKR mainly for OA (93%) and inflammatory arthropathies (RA 3%, psoriasis 1%). The mean follow up was 75 months (40–115). There were 461 unilateral (R:L 256:205) and 539 bilateral replacements (462 simultaneous and 77 staged).

The pre-operative knee score was 95/200, ROM 6–115 degrees and at latest review was 182/200, ROM 1–113 degrees.

Forty four patients have died (mean age 73 years, range 54 to 88). There have been 14 deep infections (1.4%), 22 proven pulmonary emboli (2.2%) and five periprosthetic fractures (0.5%). Six revisions have been performed. Visible gaps between bone and implant were present in 91% of femora and 58% of tibiae initially and in 6% of femora and 8% of tibiae at two years on interface views. There have been no cases of clinical loosening.

Currently, this study comprises the largest known series of HA-coated total knee replacements. These results demonstrate that HA appears to enhance fixation of uncemented knee prostheses which maintain good clinical outcomes.

The purpose of study was to investigate kneeling ability after total knee replacement.

100 patients who were at least one year following routine uncemented primary total knee replacement were identified.

32% of patients stated they were able to kneel without significant discomfort. 64 (64%) of patients were actually able to demonstrate kneeling ability without pain or discomfort or with mild discomfort only. 24 (24%) of patients were therefore unable to demonstrate the ability to kneel because of discomfort in the knee.

There was no difference in the “kneelers” and “non-kneelers” with regard to overall knee score, range of motion and the presence of patella resurfacing.

Introduction: The Motus (Osteo) total knee replacement design is an uncemented, stemless, hydroxyapatite-coated prosthesis designed as a low profile resurfacing implant.

Aim: To review the results after five to eight years of the use of this prosthesis by one surgeon and to discuss the perceived advantages of its design.

Methods: Between 1992 and 1996 the Motus (Osteo) prosthesis was used in 606 primary total knee replacements in 409 patients. The evaluation was undertaken using a clinical knee score based on the Knee Society Score and the Hospital for Special Surgery (HSS) score, which produces a maximum score of 200/200.

Results: The mean age was 69 years (range: 31 to 88 years) with 53% of the patients being female. Osteoarthritis was the underlying pathology in the majority of the cases. The minimum time to follow up was 60 months (mean: 79, range: 60 to 104 months). The mean pre-operative knee score was 98/200 with a range of movement from six degrees to 122 degrees. After five years, the mean knee score was 180/200 with a range of movement from one degree to 113 degrees. To date only two patients have required a revision procedure, both for deep infection. Twenty-six patients have died and six have been lost to follow-up as they are overseas.

Conclusion: At a minimum five-year review, the Motus (Osteo) total knee replacement prosthesis produced excellent functional and clinical results with a low rate of complications.