Aims

Approximately 10% to 20% of knee arthroplasty patients are not satisfied with the result, while a clear indication for revision surgery might not be present. Therapeutic options for these patients, who often lack adequate quadriceps strength, are limited. Therefore, the primary aim of this study was to evaluate the clinical effect of a novel rehabilitation protocol that combines low-load resistance training (LL-RT) with blood flow restriction (BFR).

Aims

The aim of this study was to determine the risk of tibial eminence avulsion intraoperatively for bi-unicondylar knee arthroplasty (Bi-UKA), with consideration of the effect of implant positioning, overstuffing, and sex, compared to the risk for isolated medial unicondylar knee arthroplasty (UKA-M) and bicruciate-retaining total knee arthroplasty (BCR-TKA).

Introduction. The purpose of this study was to characterize the recovery of physical activity following knee arthroplasty by means of step counts and flight counts (flights of stairs) measured using a smartphone-based care platform. Methods. This is a secondary data analysis on the treatment cohort of a multicenter prospective trial evaluating the use of a smartphone-based care platform for primary total and unicondylar joint arthroplasty. Participants in the treatment arm that underwent primary total or unicondylar knee arthroplasty and had at least 3 months of follow-up were included (n=367). Participants were provided the app with an associated smart watch for measuring several different health measures including daily step and flight counts. These measures were monitored preoperatively, and the following postoperative intervals were selected for review: 2–4 days, 1 month, 1.5 month, 3 months and 6 months. The data are presented as mean, standard deviation, median, and interquartile range (IQR). Signed rank tests were used to assess the difference in average of daily step counts over time. As not all patients reported having multiple stairs at home, a separate analysis was also performed on average flights of stairs (n=214). A sub-study was performed to evaluate patients who returned to preoperative levels at 1.5 months (step count) and 3 months (flight count) using an independent samples T test or Fisher's Exact test was to compare demographics between patients that returned to preoperative levels and those that did not. Results. The mean age of the step count population was 63.1 ± 8.3 years and 64.31% were female, 35.69% were male. The mean body mass index was 31.1 ± 5.9 kg/m. 2. For those who reported multiple stairs at home, the mean age was 62.6 ± 8.3 years and 62.3% were female. The mean body mass index was 30.7 ± 5.4 kg/m. 2. . As expected, the immediate post-op (2–4 days) step count (median 1257.5 steps, IQR 523 – 2267) was significantly lower than preop (median 4160 steps, IQR 2669 – 6034, p < 0.001). Approximately 50% of patients returned to preoperative step counts by 1.5 months postoperatively with a median 4,504 steps (IQR, 2711, 6121, p=0.8230, Figure 1). Improvements in step count continued throughout the remainder of follow-up with the 6-month follow-up visit (median 5517 steps, IQR 3888 – 7279) showing the greatest magnitude (p<0.001). In patients who reported stairs in their homes, approximately 64% of subjects returned to pre-op flight counts by 3 months (p=0.085), followed similar trends with significant improvements at 6 months (p=0.003). Finally, there was no difference in age, sex, BMI, or operative knee between those that returned to mean preoperative step or flight counts by 1.5 months and 3 months, respectively. Discussion and Conclusion. These data demonstrated a recovery curve similar to previously reported curves for patient reported outcome measures in the arthroplasty arena. Patients and surgeons may use this information to help set goals for recovery following total and unicondylar knee arthroplasty using objective activity measures. For any figures or tables, please contact the authors directly

Aims

Osteonecrosis (ON) can cause considerable morbidity in young people who undergo treatment for acute lymphoblastic leukaemia (ALL). The aims of this study were to determine the operations undertaken for ON in this population in the UK, along with the timing of these operations and any sequential procedures that are used in different joints. We also explored the outcomes of those patients treated by core decompression (CD), and compared this with conservative management, in both the pre- or post-collapse stages of ON.

Aims

The objectives of this study were to compare postoperative pain, analgesia requirements, inpatient functional rehabilitation, time to hospital discharge, and complications in patients undergoing conventional jig-based unicompartmental knee arthroplasty (UKA) versus robotic-arm assisted UKA.

Aims

The role of high tibial osteotomy (HTO) is being questioned by the use of unicompartmental knee arthroplasty (UKA) in the treatment of medial compartment femorotibial osteoarthritis. Our aim was to compare the outcomes of revision HTO or UKA to a total knee arthroplasty (TKA) using computer-assisted surgery in matched groups of patients.

A number of advantages of unicondylar arthroplasty (UKA) over total knee arthroplasty in patients presenting osteoarthritis in only a single compartment have been identified in the literature. However, accurate implant positioning and alignment targets, which have been shown to significantly affect outcomes, are routinely missed by conventional techniques. Computer Assisted Orthopaedic Surgery (CAOS) has demonstrated its ability to improve implant accuracy, reducing outliers. Despite this, existing commercial systems have seen extremely limited adoption. Survey indicates the bulk, cost, and complexity of existing systems as inhibitive characteristics. We present a concept system based upon small scale head mounted tracking and augmented reality guidance intended to mitigate these factors. A visible-spectrum stereoscopic system, able to track multiple fiducial markers to 6DoF via photogrammetry and perform semi-active speed constrained resection, was combined with a head mounted display, to provide a video-see-through augmented reality system. The accuracy of this system was investigated by probing 180 points upon a 110×110×50 mm known geometry and performing controlled resection upon a 60×60×15 mm bone phantom guided by an overlaid augmented resection guide that updated in real-time. The system produced an RMS probing accuracy and precision of 0.55±0.04 and 0.10±0.01 mm, respectively. Controlled resection resulted in an absolute resection error of 0.34±0.04 mm with a general trend of over-resection of 0.10±0.07 mm. The system was able to achieve the sub-millimetre accuracy considered necessary to successfully position unicondylar knee implants. Several refinements of the system, such as pose filtering, are expected to increase the functional volume over which this accuracy is obtained. The presented system improves upon several objections to existing commercial CAOS UKA systems, and shows great potential both within surgery itself and its training. Furthermore, it is suggested the system could be readily extended to additional orthopaedic procedures requiring accurate and intuitive guidance

Anatomical total knee arthroplasty alignment versus conventional mechanical alignment; or a combination?

Difficulties arise when counselling younger patients on the long-term sequelae of a minor knee chondral defect. This study assesses the natural history of patients with grade 2 Outerbridge chondral injuries of the medial femoral condyle at arthroscopy. We reviewed all arthroscopies performed by one surgeon over 12 years with Outerbridge grade 2 chondral defects. Patients aged 30 to 59 were included. Meniscal injuries found were treated with partial menisectomy. All patients had five-year follow up minimum. Primary outcome measure was further interventions of total or unicondylar arthroplasty or high tibial osteotomy. We analysed 3,344 arthroscopies. Average follow up was 10 years (Range 5–17 years). A total of 357 patients met inclusion criteria of which 86 had isolated medial femoral condyle disease. Average age was 50 at the time of arthroscopy. Average BMI at surgery was 31.7 and average chondral defect area was 450 mm. 2. Isolated MFC chondral disease had a 10.5% intervention rate. Intervention occurred at a mean of 8.5 years post primary arthroscopy. In young patients Outerbridge II chondral injuries affecting ≥2 compartments have a high rate of further intervention within a decade. This information is crucial in counselling young patients on long-term sequelae of benign chondral lesions

We present detailed information about early morbidity after aseptic revision knee replacement from a nationwide study. All aseptic revision knee replacements undertaken between 1st October 2009 and 30th September 2011 were analysed using the Danish National Patient Registry with additional information from the Danish Knee Arthroplasty Registry. The 1218 revisions involving 1165 patients were subdivided into total revisions, large partial revisions, partial revisions and revisions of unicondylar replacements (UKR revisions). The mean age was 65.0 years (27 to 94) and the median length of hospital stay was four days (interquartile range: 3 to 5), with a 90 days re-admission rate of 9.9%, re-operation rate of 3.5% and mortality rate of 0.2%. The age ranges of 51 to 55 years (p = 0.018), 76 to 80 years (p < 0.001) and ≥ 81 years (p < 0.001) were related to an increased risk of re-admission. The age ranges of 76 to 80 years (p = 0.018) and the large partial revision subgroup (p = 0.073) were related to an increased risk of re-operation. The ages from 76 to 80 years (p < 0.001), age ≥ 81 years (p < 0.001) and surgical time > 120 min (p <  0.001) were related to increased length of hospital stay, whereas the use of a tourniquet (p = 0.008) and surgery in a low volume centre (p = 0.013) were related to shorter length of stay. . In conclusion, we found a similar incidence of early post-operative morbidity after aseptic knee revisions as has been reported after primary procedures. This suggests that a length of hospital stay ≤ four days and discharge home at that time is safe following aseptic knee revision surgery in Denmark. Cite this article: Bone Joint J 2014;96-B:1649–56

Current analysis of unicondylar knee replacements (UKRs) by national registries is based on the pooled results of medial and lateral implants. Consequently, little is known about the differential performance of medial and lateral replacements and the influence of each implant type within these pooled analyses. Using data from the National Joint Registry for England and Wales (NJR) we aimed to determine the proportion of UKRs implanted on the lateral side of the knee, and their survival and reason for failure compared with medial UKRs. By combining information on the side of operation with component details held on the NJR, we were able to determine implant laterality (medial versus lateral) for 32 847 of the 35 624 unicondylar replacements (92%) registered before December 2010. Of these, 2052 (6%) were inserted on the lateral side of the knee. The rates of survival at five years were 93.1% (95% confidence interval (CI) 92.7 to 93.5) for medial and 93.0% (95% CI 91.1 to 94.9) for lateral UKRs (p = 0.49). The rates of failure remained equivalent after adjusting for patient age, gender, American Society of Anesthesiologists (ASA) grade, indication for surgery and implant design using Cox’s proportional hazards method (hazard ratio for lateral relative to medial replacement = 0.88 (95% CI 0.69 to 1.13); p = 0.32). Aseptic loosening/lysis and unexplained pain were the main reasons for revision in both groups, although the reasons did vary depending on whether a mobile- or a fixed-bearing design was used. At a maximum of eight years the mid-term survival rates of medial and lateral UKRs are similar

Introduction. Kneeling ability is better in unicompartmental than total knee arthroplasty. There is also an impression that mobile bearing knees achieve better functional outcome than their fixed bearing cousins in unicompartmental and to a lesser extent total joint arthroplasty. In the UK, the market leading unicompartmental replacement is mobile bearing. Aim. To analyse kneeling ability after total and unicompartmental knee replacement using mobile and fixed bearing inserts. Methods. In our department there are two prospective randomised studies (fixed versus mobile) in this area. For total knee arthroplasty, 207 TKR patients receiving the same prosthesis (Rotaglide, Corin, UK) were randomised into mobile bearing (102 patients, mean age of 53 years) or fixed bearing (105 patients, mean age of 55 years). Regarding unicondylar knees, data was collected on 352 UKR patients who received the same implant (Uniglide - previously known as AMC - Corin, UK). Within this group there was a randomised controlled trial of fixed v mobile bearings: 52 patients (mean age 62 years) had a mobile insert and 57 (mean age 65 yrs) had a fixed insert. Data was also collected on patients undergoing fixed bearing lateral unicondylar replacement (Uniglide). All patients completed the Oxford Knee Questionnaire preoperatively, 1 year and 2 years postoperatively, (where 0 = bad and 48 = good). There kneeling ability (question 7) and total Oxford scores were analysed. We are currently collecting objective data on post-operative kneeling ability with force plate analysis and subjective anterior knee-specific scoring systems. Results. Subjective kneeling ability: Oxford Knee Score Question 7 as range 0-4, where 4 = good. Conclusion. Both fixed and mobile UKR and TKR have good outcome. No group produced good kneeling ability, but there was a modest improvement in all groups from the preoperative kneeling scores. Fixed bearing knee replacement showed better outcome than mobile bearing knees, in both UKR and TKR groups

Introduction. Bicompartmental osteoarthritis involving the medial tibiofemoral and the patellofemoral compartments is often treated with total knee replacement. Improved implants and surgical techniques have led to renewed interest in bicompartmental arthroplasty. This study evaluates the radiographic and early clinical results of bicompartmental arthroplasty with separate unlinked components implanted with the assistance of a robotic surgical arm. In addition, we examine the amount of bone resected using unlinked bicompartmental components compared to total knee replacement. Finally, a retrospective review of total knee cases examines the applicability of this early intervention procedure. Methods. 97 patients received simultaneous but geometrically separate medial tibiofemoral and patellofemoral arthroplasties with implants specifically designed to take advantage of a new bone and tissue sparing implantation technique using haptic robotics. These patients came from four surgeons at four different hospitals. The average follow-up was 9 months. Pre- and post-operative radiographs were taken. ROM, KSS and WOMAC scores were recorded. The patients had an average age of 67 yrs (range: 45-95), BMI of 29 ± 4kg/m. 2. 47% of the patients were male. We retrospectively reviewed pre and post operative notes from 406 consecutive TKA patients from a single surgeon. Intraoperative data included the integrity of the three compartments and the ACL. Results. At only six weeks follow-up, patients recovered their pre-operative ROM (p=0.37). Knee Society Knee scores (knee and function) and WOMAC scores (pain, function and total) significantly improved from pre-operative values at every follow-up of 6 weeks, 6 months and 1 year (p<0.05). Radiographically, there was no evidence of loosening, wear or progression of OA. There were also no perioperative complications. Using computer simulation, the amount of bone removed using bicompartmental arthroplasty compared to traditional TKA was predicted. Total bone removed on the femur and the tibia using a standard TKA implant is 3.5 times the bone removed using a bicompartmental onlay implant and 4 times the bone removed when using a bicompartmental inlay implant. In the review of 406 TKA cases, the ACL was intact in 66% of these cases. Based on these data alone, 16% of these TKA patients were indicated for a unicondylar arthroplasty, 12% medial UKA, 3% lateral UKA and 1% PFA. In addition, 31% were indicated for bicompartmental arthroplasty with 4% bicondylar (medial and lateral UKA), 6% lateral UKA and PFA and 21% medial UKA and PFA. While these data don't yet account for fixed versus flexible deformities, excessive osteophytes or other contraindications, it seems clear that the disease often treated with a TKA does not actually involve all three compartments. Conclusions. Modular bicompartmental arthroplasty is an effective method for treating arthritis of the knee restricted to the medial and patellofemoral compartments. Early results using contemporary prostheses are encouraging and should prompt further mid- and long-term study. Robotic assistance of bicompartmental arthroplasty has shown good early clinical and radiographic success. In addition, bicompartmental arthroplasty removes significantly less bone than total knee arthroplasty. Also, data indicates that may total knee patients have healthy cruciates and disease in only two of the three compartments, indicating that TKA is an overtreatment of earlier stage osteoarthritis. Longer term studies will determine the clinical significance of preserving healthy cartilage and ligaments routinely resected with traditional tricompartmental TKA

Recently in the literature the indications of unicompartmental knee arthroplasty have been extended by the inclusion of patients with arthritis which is predominantly but not exclusively effecting the medial compartment. The aim of this study is to evaluate the outcome of MAKO unicondylar replacement in the treatment of knee osteoarthritis after the initial surgical insult is worn off to evaluate the impact of residual patellofemoral and lateral osteoarthritis on the outcome of medial unicompartmental knee replacement. 135 patients who underwent uncomplicated 144 MAKO medial unicondylar replacements for knee arthritis were identified and studied. Original radiographs were used to classify severity of patellofemoral and lateral compartmental osteoarthritis in these patients. Severity of patellofemoral and lateral compartmental osteoarthritis was analyzed against Oxford and Knee Society (AKSS) scores and amount of ipsilateral residual knee symptoms at 6 months post-operative period. Pre-operative Oxford and Knee Society scores, and other comorbidities and long term disability were studied as confounding variables. We found significant improvement in symptoms and scores in spite of other compartment disease. Poorer outcome was seen in association with comorbidities and long term disability but not when radiographic signs of arthritis in the other compartments were present. Six patients required revision of which three had (lateral facet) patellofemoral disease in the original x-rays. In conclusion there is no direct relationship between postoperative symptoms and poor outcome and radiographic disease in the other compartments. However when symptoms are severe enough to necessitate revision this is due to patellofemoral and not lateral compartment disease

Purpose. To examine how patients viewed the outcome of their joint replacement at least one year post surgery. Emphasis was placed on investigating the relative influence of ongoing pain and functional limitation on patient satisfaction. Method. Questionnaire based assessment of the Oxford Knee Score (OKS), patient satisfaction, and need for reoperation in a group of 10,000 patients who had undergone primary unilateral knee replacement between April and December 2003. Questionnaires were linked to the NJR database to provide data on background demographics, clinical parameters and intraoperative surgical information for each patient. Data was analysed to investigate the relationship between the OKS, satisfaction rate and the background factors. Multivariable logistic regression was performed to establish which factors influenced patient satisfaction. Results. 87.4% patients returned questionnaires. Overall 81.8% indicated they were satisfied with their knee replacement, with 7.0% unsatisfied and 11.2% unsure. The mean OKS varied dependent upon patients' satisfaction (satisfied=22.0, unsatisfied=41.7, unsure=35.2). These differences were statistically significant (p<0.001). Regression modelling showed that patients with higher scores relating to the pain and function elements of the OKS had lower levels of satisfaction (p<0.001) and that ongoing pain was a stronger predictor of lower levels of satisfaction. Other predictors of lower levels of satisfaction included female gender (p<0.05), a primary diagnosis of osteoarthritis (p=0.02) and unicondylar replacement (p=0.002). Differences in satisfaction rate were also observed dependent upon age and ASA grade. 609 patients (7.4%) had undergone further surgery and 1476 patients (17.9%) indicated another procedure was planned. Both the OKS and satisfaction rates were significantly better in patients who had not suffered complications. Conclusion. This study highlights a number of clinically important factors that influence patient satisfaction at one year following TKR. These should act as a benchmark of UK practice and be a baseline for peer comparison between institutions

We carried out a prospective investigation into the radiological outcomes of uncemented Oxford medial compartment unicondylar replacement in 220 consecutive patients (231 knees) performed in a single centre with a minimum two-year follow-up. The functional outcomes using the mean Oxford knee score and the mean high-activity arthroplasty score were significantly improved over the pre-operative scores (p < 0.001). There were 196 patients with a two-year radiological examination performed under fluoroscopic guidance, aiming to provide images acceptable for analysis of the bone–implant interface. Of the six tibial zones examined on each knee on the anteroposterior radiograph, only three had a partial radiolucent line. All were in the medial aspect of the tibial base plate (zone 1) and all measured < 1 mm. All of these patients were asymptomatic. There were no radiolucent lines seen around the femoral component or on the lateral view. There was one revision for loosening at one year due to initial inadequate seating of the tibial component. These results confirm that the early uncemented Oxford medial unicompartmental compartmental knee replacements were reliable and the incidence of radiolucent lines was significantly decreased compared with the reported results of cemented versions of this implant. These independent results confirm those of the designing centre.

Aim: Cementation of tibial implants in total knee arthroplasty is a gold-standard considering the high loosening rates of cementless implants. In contrast, only sparse data exist regarding unicondylar arthroplasty due to limited use. In this study, we compare cemented with cementless unicondylar knee arthroplasty and aim to define both clinical and radiological differences in treatment outcome. Materials and Methods: In a retrospective study, 106 patients who had undergone a medial unicondylar replacement were examined after a mean postoperative period of 8 years. Of these, 42 patients (median age 81±7 years) had received a cemented and 64 (median age 73±7 years) a cementless knee arthroplasty by the same surgeon while 7 patients were deceased or could not be reached. Well-established clinical (VAS, HSS, KSS, UCLA, WOMAC) and quality of life (SF-36) scores were used to evaluate treatment outcome. X-rays were performed to evaluate periprosthetic loosening zones, according to Ewald’s criteria. Results: The cementless patient group presented significantly better clinical scores (HSS, KSS, UCLA, WOMAC), except in the Visual Analogue Scale (VAS) for pain assessment. The quality of life was significantly better in the cementless group except in the subgroups concerning physical function, vitality and social role, which resembled normal population. Moreover, radiographic analysis using antero-posterior X-rays revealed significantly more and larger periprosthetic loosening areas in tibial zone 2 in the cementless group. Conclusion: The inferior clinical results characterising the cemented group could be attributed to the higher mean age. Regarding the radiological loosening zones, we did not detect any differences in the techniques of fixation, although physical activity and mechanical stresses were higher in the cementless group

Background: In a recent publication from the National Joint Registry it was suggested that prosthesis type influenced patient satisfaction at one year following knee arthroplasty. In this report Unicondylar Replacement (UKR) was associated with lower levels of patient satisfaction when compared to cemented TKR. The unicondylar group did however have a significantly lower Oxford Knee Score (OKS) than the TKR group and this occurred irrespective of patient age. A common perception is that UKR is only offered to patients with lesser disease, with a decreased clinical profile. This may explain their higher levels of dissatisfaction as the overall change in their OKS from pre to post operation would be relatively smaller than for TKR. Aim: We hypothesised that patients listed for UKR have less severe disease and therefore a lower preoperative OKS when compared to TKR. Methods: After sample size calculation we retrospectively analysed 76 patients who underwent either UKR or TKR under the care of a single surgeon. OKS was recorded at a dedicated pre-assessment clinic. The decision to offer UKR was based on clinical and radiological criteria as outlined by the Oxford group. Results: There were 38 patients in either group. The mean pre-operative OKS was 39.5 (26–56, SD 7.6) in the UKR group and 41.6 (31–51, SD 5.7) in the TKR group. There was no statistical difference between these two groups (p=0.18). Discussion: Patients listed for knee replacement have significant pain and functional impairment. In our population those suitable for UKR have similarly severe symptoms to those who do not meet the criteria for UKR and are only eligible for TKR. It remains unclear why patients undergoing UKR should be less satisfied when they have better post operative patient reported outcome scores. It emphasizes the need for careful patient selection and counselling in patient undergoing UKR

Purpose: To examine how patients viewed the outcome of their joint replacement at least one year post surgery. Emphasis was placed on investigating the relative influence of ongoing pain and functional limitation on patient satisfaction. Method: Questionnaire based assessment of the Oxford Knee Score (OKS), patient satisfaction, and need for reoperation in a group of 10,000 patients who had undergone primary unilateral knee replacement between April and December 2003. Questionnaires were linked to the NJR database to provide data on background demographics, clinical parameters and intraoperative surgical information for each patient. Data was analysed to investigate the relationship between the OKS, satisfaction rate and the background factors. Multivariable logistic regression was performed to establish which factors influenced patient satisfaction. Results: 87.4% patients returned questionnaires. Overall 81.8% indicated they were satisfied with their knee replacement, with 7.0% unsatisfied and 11.2% unsure. The mean OKS varied dependent upon patients’ satisfaction (satisfied=22.04 (S.D 7.87), unsatisfied=41.70 (S.D 8.32), unsure=35.17 (S.D 8.24)). These differences were statistically significant (p< 0.001). Regression modelling showed that patients with higher scores relating to the pain and function elements of the OKS had lower levels of satisfaction (p< 0.001) and that ongoing pain was a stronger predictor of lower levels of satisfaction. Other predictors of lower levels of satisfaction included female gender (p< 0.05), a primary diagnosis of osteoarthritis (p=0.02) and unicondylar replacement (p=0.002). Differences in satisfaction rate were also observed dependent upon age and ASA grade. 609 patients (7.4%) had undergone further surgery and 1476 patients (17.9%) indicated another procedure was planned. Both the OKS and satisfaction rates were significantly better in patients who had not suffered complications. Conclusion: This study highlights a number of clinically important factors that influence patient satisfaction following knee replacement. This information could be used when planning surgery to counsel patients and help form realistic expectations of the anticipated postoperative result