There has been debate about the role of unicompartmental knee replacement in the presence of radiologically identifiable degenerative changes of the patellofemoral joint. We studied 195 knees in 163 patients in whom an Oxford unicompartmental knee replacement had been performed for medial osteoarthritis between January 2004 and July 2007. The mean age of the patients was 66 years (51 to 93). The degree of degenerative change of the patellofemoral joint was assessed using Jones’ criteria. Functional outcome was assessed at a mean of 3.4 years (2 to 7) post-operatively, using the Oxford knee score and the Short-form 12 score. Degenerative changes of the patellofemoral joint were seen pre-operatively in 125 knees (64%) on the skyline radiographs. There was no statistically significant difference in the Oxford knee or Short-form 12 scores between those patients who had patellofemoral osteoarthritis pre-operatively and those who did not (p = 0.22 and 0.54, respectively). These results support the opinion expressed at the designer’s hospital that degenerative changes of the patellofemoral joint in isolation should not be considered to be a contraindication to medial Oxford unicompartmental knee replacement

We reviewed 87 patients who underwent revision anterior cruciate ligament (ACL) reconstruction. The incidence of meniscal tears and degenerative change was assessed and related to the timing from primary ACL graft failure to revision ACL reconstruction. Patients were divided into either an early group (revision surgery within 6 months of graft failure) or a delayed group. Degenerative change was scored using the French Society of Arthroscopy system. There was a significantly higher incidence of articular cartilage degeneration in the delayed group compared to the early group (53.2% vs 24%, p < 0.01, Mann- Whitney U test). No patients in the early group had advanced degenerative change (SFA grades 3 or 4), compared with 12.9% of patients in the delayed group. There was no significant difference in the incidence of meniscal tears between the two groups. In conclusion, the findings of the study support the view that patients with a failed ACL reconstruction and symptomatic instability should have an early revision reconstruction procedure carried out to minimise the risk of articular degenerative change

Aims. This study, using a surgeon-maintained database, aimed to explore the risk factors for surgery-related complications in patients undergoing primary cervical spine surgery for degenerative diseases. Methods. We studied 5,015 patients with degenerative cervical diseases who underwent primary cervical spine surgery from 2012 to 2018. We investigated the effects of diseases, surgical procedures, and patient demographics on surgery-related complications. As subcategories, the presence of cervical kyphosis ≥ 10°, the presence of ossification of the posterior longitudinal ligament (OPLL) with a canal-occupying ratio ≥ 50%, and foraminotomy were selected. The surgery-related complications examined were postoperative upper limb palsy (ULP) with a manual muscle test (MMT) grade of 0 to 2 or a reduction of two grade or more in the MMT, neurological deficit except ULP, dural tear, dural leakage, surgical-site infection (SSI), and postoperative haematoma. Multivariate logistic regression analysis was performed. Results. The significant risk factors (p < 0.050) for ULP were OPLL (odds ratio (OR) 1.88, 95% confidence interval (CI) 1.29 to 2.75), foraminotomy (OR 5.38, 95% CI 3.28 to 8.82), old age (per ten years, OR 1.18, 95% CI 1.03 to 1.36), anterior spinal fusion (OR 2.85, 95% CI 1.53 to 5.34), and the number of operated levels (OR 1.25, 95% CI 1.11 to 1.40). OPLL was also a risk factor for neurological deficit except ULP (OR 5.84, 95% CI 2.80 to 12.8), dural tear (OR 1.94, 95% CI 1.11 to 3.39), and dural leakage (OR 3.15, 95% CI 1.48 to 6.68). Among OPLL patients, dural tear and dural leakage were frequently observed in those with a canal-occupying ratio ≥ 50%. Cervical rheumatoid arthritis (RA) was a risk factor for SSI (OR 10.1, 95% CI 2.66 to 38.4). Conclusion. The high risk of ULP, neurological deficit except ULP, dural tear, and dural leak should be acknowledged by clinicians and OPLL patients, especially in those patients with a canal-occupying ratio ≥ 50%. Foraminotomy and RA were dominant risk factors for ULP and SSI, respectively. An awareness of these risks may help surgeons to avoid surgery-related complications in these conditions. Cite this article: Bone Joint J 2021;103-B(1):157–163

Aims. Patients with osteoarthritis of the knee commonly have degenerative meniscal tears. Arthroscopic meniscectomy is frequently performed, although the benefits are debatable. Recent studies have concluded that there is no role for arthroscopic washout in osteoarthritis of the knee. Our aim was to perform a systematic review to assess the evidence for the efficacy of arthroscopic meniscectomy in patients with meniscal tears and degenerative changes in the knee. Patients and Methods. A literature search was performed, using the PubMed/MEDLINE database, for relevant articles published between 1975 and 2015. A total of six studies, including five randomised controlled trials and one cross-sectional study of a prospective cohort, met the inclusion criteria. Relevant information including study design, operations, the characteristics of the patients, outcomes, adverse events and further operations were extracted. Results. The degree of osteoarthritis in the patients who were included and the rate of cross over from one form of treatment to another varied in the studies. Two randomised controlled trials showed a benefit of arthroscopic surgery in patients with limited degenerative joint disease, compared with conservative treatment. One cross-sectional study showed that patients with less severe degenerative changes had better outcomes. Conclusion. Patients with symptomatic meniscal tears and degenerative changes in the knee can benefit from arthroscopic meniscectomy, particularly if the osteoarthritis is mild. A trial of conservative management may be effective and should be considered, especially in patients with moderate osteoarthritis. Cite this article: Bone Joint J 2016;98-B:934–8

A distinctive and consistent pattern of degenerative change was seen in 560 acromioclavicular joints from dry bone skeletons of subjects over 40 years of age. An appreciation of this characteristic configuration is helpful at operation or when introducing a needle into the joint

Examination was made of 486 skeletons of subjects over the age of 60 years to study patterns of degenerative change in the glenohumeral joint. Three distinct types were found. Useful clinical implications are drawn from these distinctions

Over 5 years we gave 84 patients epidural cortisone (80 mg depomedrol and local anaesthesia) for back and/or leg pain due to degenerative disease of the spine. The mean age of the 35 men and 49 women was 65.2 years (37 to 86). All patients had back pain and 77% had neurogenic leg pain. Spinal radiographs demonstrated degenerative changes, including intervertebral disc space narrowing and/or facet joint arthritis, in 84%. MRI, performed in 80 patients (95%), confirmed degenerative disease of the lumbar spine and demonstrated neural compression in 78 of the 80 (97%). Five patients received a second epidural injection and one a third. Complete resolution of back and/or leg pain occurred in 32 patients (38%), and 34 (40%) had relief for between 1 and 12 months. There was no change in the symptoms of 18 patients (21%). Surgery was undertaken in 17 patients (20%), with seven undergoing spinal decompression alone and 10 decompression and a fusion. After surgery, four of the seven patients who did not have a fusion still had back pain. All 10 of the patients who underwent decompression and fusion had a good outcome. One patient developed an epidural haematoma following the epidural injection. Epidural steroid injection had a favourable outcome in 78% of our patients, with a low incidence of complications. Patients who failed to respond to the epidural injection did poorly with spinal decompression alone

Aims

Shoulder arthroplasty is effective in the management of end-stage glenohumeral joint arthritis. However, it is major surgery and patients must balance multiple factors when considering the procedure. An understanding of patients’ decision-making processes may facilitate greater support of those considering shoulder arthroplasty and inform the outcomes of future research.

Purpose of the study: Glenohumeral dysplasia is an uncommon cause of degenerative disease of the shoulder joint. In this context, arthroplasty is a therapeutic challenge due to the bony deformations. Material and methods: Between 1998 and 2004, simple humeral prostheses were implanted in eight shoulders (seven patients, two men and five women, mean age 49.5 years). There was no procedure on the glenoid cavity. A Neer II was used for four shoulders (two dysplasic cases with short 63 mm stems) and a Neer III for four shoulders. Results: At mean follow-up of 4.5 years (maximum 7 yers) the Neer outcome was satisfactory for five patients and non-satisfactory for two. Five of the seven patients were satisfied with their operation. The Constant scores improved: from 3.5 to 11.8 for pain, 9.8 to 16.6 for activity, and 13.8 to 24.4 for active mobility. Active anterior elevation was 114° on average, external rotation 25°, and internal rotation at level L3. The overall constant score was 52.8 points with a weighted score of 43%. Radiographically, there were no lucent lines around the humeral implant. Anterior dislocation occurred in one shoulder six months after the initial operation. Capsuloligament revision was performed but the implant was left in place. For one other shoulder, secondary rotator cuff tears limited the function outcome, but the prosthesis was not revised. Discussion and conclusion: The results were average, but did allow our patients to resume nearly normal activity without pain. Looking at the failures in this small series suggests that the status of the rotator cuff is the main prognostic factor. Neither glenoid deformation nor the lack of replacement appeared to have an effect on the final outcome. Deformation of the proximal end of the humerus may require use of a shorter stem which should be available at the time of the operation

Late degenerative changes are known to follow meniscectomy, but there is little agreement on their incidence or on which patients are most at risk. A total of 210 patients have been reviewed 10 to 22 years after meniscectomy, and long leg radiographs taken of both knees. Radiological degeneration was seen in 18%, while 7% had significant symptoms and signs. Statistical analysis showed increased changes in older patients, in those with abnormal leg alignment, and in those who had undergone lateral as against medial meniscectomy. Our findings emphasise the important mechanical function of the meniscus and support the current cautious approach to meniscectomy, especially for patients in high risk groups. They also indicate the value of early high tibial osteotomy for symptomatic varus deformity after medial meniscectomy

To assess adverse events related to XLIF approach in lumbar degenerative disease. Recently novel minimally disruptive spine procedure eXtreme lateral Interbody Fusion i.e XLIF has been developed. It is 90 (off the midline true lateral approach, which allows large graft placement, excellent disc height restoration and indirect decompression at the stenotic motion segment. We describe our experience in 28 patients. Retrospective review of records of patients undergoing surgery between July 2008- Jan 2010. Presenting complaints, number of levels performed and complications (medical, approach, or implant related) were audited. Results: 28 patients (17 female: 11 male) with median age of 47 yrs, range (38-75) formed the study group. Average stay was 4 days. All patients had MRI of lumbar spine. 2/3 rd patients had low back pain as their presenting complaint. All patients had nerve monitoring through out the procedure. There were 12 single, 15 two level and 1 three level cases (total 45 levels). 14/28 patients underwent plating at the same time. EBL was 100ml. There were 11/45 adverse events (24.4%). 6 events were approach, 4 were implant bone interface and 1 medical related. Major complication occurred in 1 patient (3.6%). 2/3 rd of patients, were better after the surgery. Almost negligible blood loss, low infection rate and short average stay seemed to work in favour of this approach. Complications are there as (with any new procedure) our results indicate, but these are manageable and less common with this technique. This did not require Ethics approval and there was no grant or industry support for the above

Introduction: Energy storing tendons, such as the human Achilles tendon, suffer a much higher incidence of rupture than non- energy storing positional tendons, such as the anterior tibialis tendon. Similarly, in the horse partial rupture of the energy storing superficial digital flexor tendon (SDFT) and suspensory ligament (SL) occurs much more frequently than to the deep digital flexor tendon (DDFT) and common digital extensor tendon (CDET) which are not involved in energy storage. In order to function effectively, energy storing tendons experience strains during high speed locomotion which are much closer to failure strain than non-energy storing tendons. Therefore, these tendons are likely to sustain high levels of microdamage, hence cell metabolism may also be higher in order to repair damage and maintain matrix integrity. Maintenance of the matrix requires not only synthesis of new matrix components but also degradation of matrix macromolecules which is achieved, in part, by a family of matrix metalloproteinase enzymes (MMPs). In this study we test the hypothesis that the energy storing equine SDFT and SL which are prone to degenerative changes have higher levels of MMP2 and MMP9 than the positional DDFT and CDET that are rarely injured. Methods: Tendons (SDFT, DDFT, SL, CDET) were harvested from the distal part of the forelimbs of 18 month old Thoroughbred horses (n = 12). Tissue from the mid-metacarpal region of each tendon was snap frozen, lyophilised, powdered and MMPs extracted. Gelatin zymography was used to determine levels of the pro and active forms of the gelatinase enzymes, MMP2 and MMP 9. Proteolytic activity (units per mg dry weight tissue) was quantified based on densitometry measurements and standardised between gels using an equine neutrophil MMP extract. Statistical significance was evaluated using a general linear model (SPSS software). Results: The main activity observed in all tendon samples was that of proMMP2. Quantification showed that the energy storing SDFT (23.4 ± 10.95) and SL (18.9 ± 5.3) had significantly higher levels than the non-energy storing DDFT (2.90 ± 0.99) and CDET (4.06 ± 2.06). Active MMP2 levels were lower than the pro form and were not sufficient to quantify. However, there appeared to be more in the energy storing structures compared with the non energy storing structures. MMP9 activity was detected in some samples. A higher number of the CDET extracts contained MMP9 activity compared to extracts from the other structures. Discussion: The results of this study show higher levels of MMPs in energy storing structures than in non-energy storing structures. This suggests that there may be an increased demand for repair of micro-damage in these tendons and hence an increased capacity for matrix degradation. Previous studies on energy storing structures in the horse have shown that they do not undergo adaptive hypertrophy or a change in structural architecture in response to mechanical demand, unlike non-energy storing structures. The results of this study indicate that this lack of adaptation in energy storing structures is not due to a general deficiency in cell activity but may be a means of preventing increase in tendon stiffness and a subsequent decrease in efficiency. In order to maintain tendon integrity MMP activity must be matched by mechanisms to inhibit activity and/or to synthesize new matrix components. Degeneration may therefore occur when there is an imbalance between these processes

Anterior cruciate ligament (ACL) of four major knee ligaments is most crucial ligament to maintain normal knee kinematics. It is well know that ACL dysfunction causes secondary osteoarthritis of the knee. The influence of age on the biomechanical properties of the ACL was examined. The structural properties of 27 pairs of human cadaver knees without OA were evaluated. Specimens were equally divided into three groups of nine pairs each based on age: younger (22 to 35 years), middle (40 to 50 years), and older (60 to 97 years). Tensile tests of the femur-ACL-tibia complex were performed at 30 degrees of knee flexion with the ACL aligned vertically along the direction of applied tensile load. Structural properties of the femur-ACL-tibia complex, as represented by the linear stiffness, ultimate load, and energy absorbed, were found to decrease significantly with specimen age.

On the other hand, little has been written about the arthritic ACL. This study was designed to evaluate the relationship among ROM, cross sections of the intercondylar notch and the macroscopic condition of ACL degeneration. Fifty osteoarthritic patients who underwent TKA as a result of severe osteoarthritis were randomly selected. Occupation rate of the osteophytes to the notch width were measured at the anterior 1/3, middle 1/3, and posterior 1/3 notche images obtained from preoperative tunnel view. ROM was measured preoperatively and under anesthesia. Macroscopic conditions of the ACL and PCL were classified into four types of Normal, Frayed, Partial rupture, and Absent.

The macroscopic ACL conditions were Normal: 12 cases, Frayed: 15 cases, Partial rupture: 14 cases, and Absent: 9 cases. The macroscopic PCL conditions were Normal: 34 cases, Frayed: 9 cases, Partial rupture: 7 cases, and Absent: 0 case. Occupation rate of the osteophytes to the notch correlated to the preoperative varus deformity (p < 0.05). In terms of ACL, the occupation rate of the osteophytes to the notch were 22.9%, 28.8%, 46.0%, and 81.8% in Normal, Frayed, partial ruptured, and Absent, respectively. The patients with more than 40% occupation rate and less than 110 degree of knee flexion angle showed either partial rupture or absent of the ACL during the surgery. Those results correlated with the degree of OA deterioration. We conclude that occupation rate of the osteophytes to the notch poor preoperative ROM is a good predictor of evaluating the ACL degeneration in osteoarthritic knee. We also conclude that ACL dysfunction due to joint space narrowing accelerates the advancement of the knee OA.

Introduction

Degeneration of the cervical spine can lead to neurological symptoms that require surgical intervention. Often, an anterior cervical discectomy (ACD) with fusion is performed with interposition of a cage. However, a cage substantially increases health care costs. The polymer polymethylmethacrylate (PMMA) is an alternative to cages, associated with lower costs. The reported high-occurrence of non-fusion with PMMA is often seen as a drawback, but evidence for a correlation between radiological fusion and clinical outcome is absent. To investigate if the lower rate of fusion with PMMA has negative effects on long-term clinical outcome, we assessed the clinical results of ACD with PMMA as a intervertebral spacer with a 5–10 year follow-up.

Patellofemoral joint degeneration is often considered a contraindication to medial unicompartmental knee replacement. We examined the validity of this preconception using information gathered prospectively on the intra-operative status of the patellofemoral joint in 824 knees in 793 consecutive patients who underwent Oxford unicondylar knee replacement for anteromedial osteoarthritis. All operations were performed between January 1998 and September 2005. A five-point grading system classified degeneration of the patellofemoral joint from none to full-thickness cartilage loss. A subclassification of the presence or absence of any full-thickness cartilage loss was subsequently performed to test selected hypotheses. Outcome was evaluated independently by physiotherapists using the Oxford and the American Knee Society Scores with a minimum follow-up of one year.

Full-thickness cartilage loss on the trochlear surface was observed in 100 of 785 knees (13%), on the medial facet of the patella in 69 of 782 knees (9%) and on the lateral facet in 29 of 784 knees (4%). Full-thickness cartilage loss at any location was seen in 128 knees (16%) and did not produce a significantly worse outcome than those with a normal or near-normal joint surface. The severity of the degeneration at any of the intra-articular locations also had no influence on outcome.

We concluded that, provided there is not bone loss and grooving of the lateral facet, damage to the articular cartilage of the patellofemoral joint to the extent of full-thickness cartilage loss is not a contraindication to the Oxford mobile-bearing unicompartmental knee replacement.

Purpose

Posterior lumbar fusion using minimally invasive surgical (MIS) techniques are reported to minimise postoperative pain, soft tissue damage and length of hospital stay when compared to the traditional open procedure.

Introduction: Disc Replacement has been described as 21st Century revolution in spinal surgery that preserves mobility and prevents adjacent segment degeneration. Numerous short-term studies are available on clinical outcome but to date there are no published long term clinical, radiological and survival data on disc replacement.

Aim: To analyse clinical, radiological & survival results of Charite III Disc Replacement.

Study Design: Ethical committee approved retrospective study.

Methodology: 160 patients (Av. Age 46yrs; Std.Dev 8.06; 62 Males & 98 Females) underwent disc replacement surgery between Jan1990 and Dec2000. An independent observer reviewed case notes, radiographs and administered a questionnaire that included Oswestry Disability Index, and Pain Score.

Results: Clinical: At an average follow up of 79 (range 31 to 161) months, mean improvement in ODI and pain score were 18.01(p< 0.001) and 1.69(p< 0.001) respectively.

Radiological: average movement at replaced disc, defined as greater than 4 degrees on flexion-extension lateral view was 1.5 degrees for L3L4, 4.01 degrees for L4L5 and 4.8 degrees for L5S1 disc replacement.

Survival: A mean survival time of 147(95% C.I. 140 to 154) months was observed with cumulative survival of 55% with implant removal as an endpoint. A mean survival time of 124(95% C.I. 116 to 133) months with cumulative survival of 35% was observed with all radiological failures as an endpoint.

Complications: were post-operative incisional hernia seen in 17(10.6%), wound infection 9(5.6%) and retrograde ejaculation in 5(3.1%) patients.

Conclusion: Charite III Disc Replacement results in clinically significant (> 15, p< 0.001) improvement in ODI, but does not result in clinical significant (> 2 points) improvement in back pain. Motion is preserved at L4L5 and L5S1 level. It has low survival rate and does not seem to prevent onset of facet arthritis. This study does not support the use of this device for management of back pain.

The value of arthroscopic partial meniscectomy in the severely arthritic knee has been questioned. Some authors suggest that it may result in progression of osteoarthritis precipitating the need for joint replacement and that symptomatic improvement may occur from lavage alone.

126 patients with a torn meniscus and Outerbridge grade IV changes in the same compartment underwent arthroscopic partial meniscectomy and limited debridement of unstable articular cartilage. The indication for surgery was a symptomatic meniscal tear not osteoarthritis. A control group consisted of 13 patients with grade IV changes and intact but frayed menisci who underwent washout alone. Mean age and follow up were similar in the two groups.

Initially meniscectomy improved symptoms in 82 cases (65%). Symptoms were unchanged in 26 cases (21%) and were made worse in 18 cases (14%). At a mean follow up of 55 months, 50 patients (40%) felt their knees were better than they were preoperatively. Their mean Lysholm score was 75. 5. 35 knees (28%) were not improved (mean Lysholm socre 59). 41 patients (32%) had undergone further surgery: 39 total knee replacements, 1 unicompartmental knee replacement and 1 tibial osteotomy. Older patients, those with varus/ valgus malalignment, and those with exposed bone on both articular surfaces fared worse.

Outcome following meniscectomy was better than outcome following washout alone: more patients reported an improvement after meniscectomy and fewer had undergone further surgery on their knees (p=0. 04). The median time between arthroscopy and the decisions for joint replacement was the same in both groups (8 months in the meniscectomy group and 7. 5 months in the washout group) indicating meniscectomy did not precipitate joint replacement.

These results suggest that arthroscopic partial men-iscectomy in the presence of Outerbridge grade IV changes can result in satisfactory long term outcomes for many patients, is more effective than washout alone and does not precipitate the need for joint replacement.

A clinical retrospective study was conducted. Results of isolated decompression for degenerative lumbar stenosis was compared with the outcome in patients who underwent decompression-stabilisation.

From January 1992 to December 2002, 127 patients (average age 65.5) with lumbar degenerative stenosis surgically treated were studied. In all patients the Roy-Camille technique was used for decompression; in 41 patients decompression and posterior stabilisation procedures were carried out. Average follow-up was 6 years (range 2–11 years).

The outcomes, evaluated according to Lassale classification, were satisfactory in 81% of the decompressed group while improved to 88% in the stabilised–decompressed group. Three patients of the first group required stabilisation for intractable low back pain (one patient) and lumboradicular symptoms (two patients), while problems related to the device (one hardware failure) and two instances of adjacent segmental instability were seen in the second group.

Decompression alone is associated with an increased rate of residual low back pain (one patient in this cohort required fusion). The decompression–stabilisation procedure reduces the incidence of low back pain but is associated with other complications such as significant blood loss, possible wound infections, urinary tract infections (due to increased surgical time), device failures, root impingement and late adjacent segmental pathologies.

The Roy Camille technique is effective for achieving adequate decompression. The surgeon should always be aware of patients who might require fusion. The instrumented stabilisation should be reserved for patients with chronic low back pain and evident instability, degenerative spondylolisthesis and spine deformities such as scoliosis or kyphosis.