Aims. Tibial tubercle osteotomy (TTO) facilitates surgical exposure and protects the extensor mechanism during revision total knee arthroplasty (rTKA). The purpose of this study was to determine the rates of bony union, complications, and reoperations following TTO during rTKA, to assess the functional outcomes of rTKA with TTO at two years’ minimum follow-up, and to identify the risk factors of failure. Methods. Between January 2010 and September 2020, 695 rTKAs were performed and data were entered into a prospective database. Inclusion criteria were rTKAs with concomitant TTO, without extensor mechanism allograft, and a minimum of two years’ follow-up. A total of 135 rTKAs were included, with a mean age of 65 years (SD 9.0) and a mean BMI of 29.8 kg/m. 2. (SD 5.7). The most frequent indications for revision were infection (50%; 68/135), aseptic loosening (25%; 34/135), and stiffness (13%; 18/135). Patients had standardized follow-up at six weeks, three months, six months, and annually thereafter. Complications and revisions were evaluated at the last follow-up. Functional outcomes were assessed using the Knee Society Score (KSS) and range of motion. Results. The mean follow-up was 51 months (SD 26; 24 to 121). Bony union was confirmed in 95% of patients (128/135) at a mean of 3.4 months (SD 2.7). The complication rate was 15% (20/135), consisting of nine tibial tubercle fracture displacements (6.7%), seven nonunions (5%), two delayed unions, one tibial fracture, and one wound dehiscence. Seven patients (5%) required eight revision procedures (6%): three bone grafts, three osteosyntheses, one extensor mechanism allograft, and one wound revision. The functional scores and flexion were significantly improved after surgery: mean KSS knee, 48.8 (SD 17) vs 79.6 (SD 20; p < 0.001); mean KSS function, 37.6 (SD 21) vs 70.2 (SD 30; p < 0.001); mean flexion, 81.5° (SD 33°) vs 93° (SD 29°; p = 0.004). Overall, 98% of patients (n = 132) had no extension deficit. The use of hinge implants was a significant risk factor for tibial tubercle fracture (p = 0.011). Conclusion. TTO during rTKA was an efficient procedure to improve knee exposure with a high union rate, but had significant specific complications. Functional outcomes were improved at mid term. Cite this article: Bone Joint J 2023;105-B(10):1078–1085

The lateral subvastus approach combined with an osteotomy of the tibial tubercle is a recognised, but rarely used approach for total knee replacement (TKR). A total of 32 patients undergoing primary TKR was randomised into two groups, in one of which the lateral subvastus approach combined with a tibial tubercle osteotomy and in the other the medial parapatellar approach were used. The patients were assessed radiologically and clinically using measurement of the range of movement, a visual analogue patient satisfaction score, the Western Ontario McMasters University Osteoarthritis Index and the American Knee Society score. Four patients were lost to the complete follow-up at two years. At two years there were no significant differences between the groups in any of the parameters for clinical outcome. In the lateral approach group there was one complication due to displacement of the tibial tubercle osteotomy and two osteotomies took more than six months to unite. In the medial approach group, one patient had a partial tear of the quadriceps. There was a significantly greater incidence of lateral patellar subluxation in the medial approach group (3 of 12) compared with the lateral approach group (0 of 16) (p = 0.034), but without any apparent clinical detriment. We conclude that the lateral approach with tibial tubercle osteotomy is a safe technique with an outcome comparable with that of the medial parapatellar approach for TKR, but the increased surgical time and its specific complications do not support its routine use. It would seem to be more appropriate to reserve this technique for patients in whom problems with patellar tracking are anticipated

An abnormal lateral position of the tibial tuberosity causes distal malalignment of the extensor mechanism of the knee and can lead to lateral tracking of the patella causing anterior knee pain or objective patellar instability, characterised by recurrent dislocation. Computer tomography is used for a precise pre-operative assessment of the tibial tubercle-trochlear groove distance. A distance of more than 15 mm is considered to be pathological and an indication for surgery in symptomatic patients. In a prospective study we performed a subtle transfer of the tibial tuberosity according to the information gained from the pre-operative CT scan. This method was applied to two groups of patients, those with painful lateral tracking of the patella, and those with objective patellar instability. We evaluated the clinical results in 30 patients in each group. The outcome was documented at 3, 12 and 24 months using the Lysholm scale, the Kujala score, and a visual analogue pain score. Post-operatively, all but one patient in the instability group who had a patellar dislocation requiring further surgery reported good improvement with no further subluxation or dislocation. All patients in both groups had a marked improvement in pain and functional score. Two patients sustained a tibial fracture six and seven weeks after surgery. One patient suffered a per-operative fracture of the tibial tubercle which later required further fixation. If carefully performed, this type of transfer of the tibial tubercle appears to be a satisfactory technique for the treatment of patients with an increased tibial tubercle-trochlear groove distance and who present with symptoms related to lateral maltracking of the patella

Aims. The aim of this study was to compare the outcome of revision total knee arthroplasty (TKA) with and without proximalisation of the tibial tubercle in patients with a failed primary TKA who have pseudo patella baja. Patients and Methods. All revision TKAs, performed between January 2008 and November 2013 at a tertiary referral University Orthopaedic Department were retrospectively reviewed. Pseudo patella baja was defined using the modified Insall-Salvati and the Blackburne-Peel ratios. A proximalisation of the tibial tubercle was performed in 13 patients with pseudo patella baja who were matched with a control group of 13 patients for gender, age, height, weight, body mass index, length of surgery and Blackburne-Peel ratio. Outcome was assessed two years post-operatively using the Knee Society Score (KSS). Results. The increase in KSS was significantly higher in the osteotomy group compared with the control group. The outcome was statistically better in patients in whom proximalisation of > 1 cm had been achieved compared with those in whom the proximalisation was < 1 cm. Conclusion. In this retrospective case-control study, a proximal transfer of the tibial tubercle at revision TKA in patients with pseudo patella baja gives good outcomes without major complications. Cite this article: Bone Joint J 2017;99-B:912–16

We have reviewed 16 patients with avulsion fractures of the tibial tubercle, mostly boys who sustained left-sided injuries during sport. Two-thirds had type I or II injuries and were treated conservatively. Fractures involving the knee joint (type III) had internal fixation. The final results were good except for minor complications such as a prominent and uncomfortable tibial tubercle

We present the ten- to 15-year follow-up of 31 patients (34 knees), who underwent an Elmslie-Trillat tibial tubercle osteotomy for chronic, severe patellar instability, unresponsive to non-operative treatment. The mean age of the patients at the time of surgery was 31 years (18 to 46) and they were reviewed post-operatively, at four years (2 to 8) and then at 12 years (10 to 15). All patients had pre-operative knee radiographs and Cox and Insall knee scores. Superolateral portal arthroscopy was performed per-operatively to document chondral damage and after the osteotomy to assess the stability of the patellofemoral joint. A total of 28 knees (82%) had a varying degree of damage to the articular surface. At final follow-up 25 patients (28 knees) were available for review and underwent clinical examination, radiographs of the knee, and Cox and Insall scoring. Six patients who had no arthroscopic chondral abnormality showed no or only early signs of osteoarthritis on final radiographs; while 12 patients with lower grade chondral damage (grade 1 to 2) showed early to moderate signs of osteoarthritis and six out of ten knees with higher grade chondral damage (grade 3 to 4) showed marked evidence of osteoarthritis; four of these had undergone a knee replacement. In the 22 patients (24 knees) with complete follow-up, 19 knees (79.2%) were reported to have a good or excellent outcome at four years, while 15 knees (62.5%) were reported to have the same at long-term follow-up. The functional and radiological results show that the extent of pre-operatively sustained chondral damage is directly related to the subsequent development of patellofemoral osteoarthritis. Cite this article: Bone Joint J 2013;95-B:478–85

Bicondylar tibial plateau fractures result from high-energy injuries. Fractures of the tibial plateau can involve the tibial tubercle, which represents a disruption to the extensor mechanism and logically must be stabilised. The purpose of this study was to identify the incidence of an independent tibial tubercle fracture in bicondylar tibial plateau fractures, and to report management strategies and potential complications. We retrospectively reviewed a prospectively collected orthopaedic trauma database for the period January 2003 to December 2008, and identified 392 bicondylar fractures of the tibial plateau, in which 85 tibial tubercle fractures (21.6%) were identified in 84 patients. There were 60 men and 24 women in our study group, with a mean age of 45.4 years (18 to 71). In 84 fractures open reduction and internal fixation was undertaken, either with screws alone (23 patients) or with a plate and screws (61 patients). The remaining patient was treated non-operatively. In all, 52 fractures were available for clinical and radiological assessment at a mean follow-up of 58.5 weeks (24 to 94). All fractures of the tibial tubercle united, but 24 of 54 fractures (46%) required a secondary procedure for their tibial plateau fracture. Four patients reported pain arising from prominent tubercle plates and screws, which in one patient required removal. Tibial tubercle fractures occurred in over one-fifth of the bicondylar tibial plateau fractures in our series. Fixation is necessary and can be reliably performed with screws alone or with a screw and plate, which restores the extensor mechanism and facilitates early knee flexion. Cite this article: Bone Joint J 2013;95-B:1697–1702

The authors wished to determine the late results of the Hauser operation, with special reference to the development of osteoarthritis. Predisposing factors associated with recurrent dislocation of the patella were also investigated. Thirty-five patients with forty-our surgically treated knees attended for review, ten to twenty-fve (aerage sixteen) years after operation. Two patients had subsequently undergone excision of the patella. Ten patients gave a family history of recurrent dislocation of the patella and seven patients showed generalised joint laxity. Pain was present in eight knees before operation and was present in thirty-three knees (75 per cent) at the time of review. Patellar crepitus was present in thirty-seven out of forty-two knees (88 per cent) at review. Osteoarthritis was present in thirty out of forty-two knees (70 per cent). The incidence increases with time since operation and the present age of the patient. It is concluded that the Hauser operation prevents further dislocation but does not prevent the development of osteoarthritis. It is possible that a simple soft-tissue operation which effectively prevents dislocation might achieve the same results.

Aims. The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process. Methods. This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous. Results. Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus. Conclusion. Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport. Cite this article: Bone Joint J 2023;105-B(12):1265–1270

Aims. Periprosthetic joint infection (PJI) is a challenging complication of any arthroplasty procedure. We reviewed our use of static antibiotic-loaded cement spacers (ABLCSs) for staged management of PJI where segmental bone loss, ligamentous instability, or soft-tissue defects necessitate a static construct. We reviewed factors contributing to their failure and techniques to avoid these complications when using ABLCSs in this context. Methods. A retrospective analysis was conducted of 94 patients undergoing first-stage revision of an infected knee prosthesis between September 2007 and January 2020 at a single institution. Radiographs and clinical records were used to assess and classify the incidence and causes of static spacer failure. Of the 94 cases, there were 19 primary total knee arthroplasties (TKAs), ten revision TKAs (varus-valgus constraint), 20 hinged TKAs, one arthrodesis (nail), one failed spacer (performed elsewhere), 21 distal femoral endoprosthetic arthroplasties, and 22 proximal tibial arthroplasties. Results. A total of 35/94 patients (37.2%) had spacer-related complications, of which 26/35 complications (74.3%) were because of mechanical failure of the spacer construct, while 9/35 (25.7%) were due to recurrence of infection. Risk factors for internal failure were a construct where the total intramedullary spacer length was less than twice the length of the central osseous defect (p = 0.009), where proximal or distal intraosseous spacer contact was < 10%, and after tibial tubercle osteotomy (p = 0.005). The incidence of spacer complications significantly increased the time to second stage: mean 157 days (42 to 458) in those without complications versus 227 days (11 to 528) with complications (p = 0.014). Conclusion. The failure rate of static antibiotic-loaded cement spacers is much higher than anticipated. Complications of the spacer significantly increased the time to second-stage revision. The risk of mechanical failure is significantly increased if the spacer is less than double the size of the segmental defect, or if inadequate reinforcement is inserted into the residual bone. These findings serve as a guide for surgeons to avoid mechanical complications with static spacers. Cite this article: Bone Joint J 2024;106-B(10):1067–1073

Aims. The Oswestry-Bristol Classification (OBC) is an MRI-specific assessment tool to grade trochlear dysplasia. The aim of this study is to validate clinically the OBC by demonstrating its use in selecting treatments that are safe and effective. Methods. The OBC and the patellotrochlear index were used as part of the Oswestry Patellotrochlear Algorithm (OPTA) to guide the surgical treatment of patients with patellar instability. Patients were assigned to one of four treatment groups: medial patellofemoral ligament reconstruction (MPFLr); MPFLr + tibial tubercle distalization (TTD); trochleoplasty; or trochleoplasty + TTD. A prospective analysis of a longitudinal patellofemoral database was performed. Between 2012 and 2018, 202 patients (233 knees) with a mean age of 24.2 years (SD 8.1), with recurrent patellar instability were treated by two fellowship-trained consultant sports/knee surgeons at The Robert Jones and Agnes Hunt Orthopaedic Hospital. Clinical efficacy of each treatment group was assessed by Kujala, International Knee Documentation Committee (IKDC), and EuroQol five-dimension questionnaire (EQ-5D) scores at baseline, and up to 60 months postoperatively. Their safety was assessed by complication rate and requirement for further surgery. The pattern of clinical outcome over time was analyzed using mixed regression modelling. Results. In all, 135 knees (mean age 24.9 years (SD 9.4)) were treated using a MPFLr. Ten knees (7.4%) required additional surgery. A total of 50 knees (mean age 24.4 years (SD 6.3)) were treated using MPFLr + TTD. Ten (20%) required additional surgery. A total of 20 knees (mean age 19.5 years (SD 3.0)) were treated using trochleoplasty + TTD. Three patients (15%) required additional surgery. In each treatment group, there was a significant improvement in Kujala, IKDC, and EQ-5D at one year postoperatively (p < 0.001) with a recognized level of overall complication rate. Conclusion. The OBC is a valid assessment tool to grade patients with trochlear dysplasia and, when used as part of the OPTA, helps to determine treatments that are safe and effective. This fulfils the requirements for its application in mainstream clinical practice. Cite this article: Bone Joint J 2021;103-B(10):1586–1594

The rotational alignment of the tibia is an unresolved issue in knee replacement. A poor functional outcome may be due to malrotation of the tibial component. Our aim was to find a reliable method for positioning the tibial component in knee replacement. CT scans of 19 knees were reconstructed in three dimensions and orientated vertically. An axial plane was identified 20 mm below the tibial spines. The centre of each tibial condyle was calculated from ten points taken round the condylar cortex. The tibial tubercle centre was also generated as the centre of the circle which best fitted eight points on the outside of the tubercle in an axial plane at the level of its most prominent point. The derived points were identified by three observers with errors of 0.6 mm to 1 mm. The medial and lateral tibial centres were constant features (radius 24 mm (. sd. 3), and 22 mm (. sd. 3), respectively). An anatomical axis was created perpendicular to the line joining these two points. The tubercle centre was found to be 20 mm (. sd. 7) lateral to the centre of the medial tibial condyle. Compared with this axis, an axis perpendicular to the posterior condylar axis was internally rotated by 6° (. sd. 3). An axis based on the tibial tubercle and the tibial spines was also internally rotated by 5° (. sd. 10). Alignment of the knee when based on this anatomical axis was more reliable than either the posterior surfaces or any axis involving the tubercle which was the least reliable landmark in the region

1. A study has been made of the treatment of recurrent dislocation of the patella in 106 knees in seventy-six patients. 2. In young adults in whom degenerative changes in the knee were not severe at the time of operation transplant of the tibial tubercle gave the best results. 3. In older patients and in those in whom osteoarthritic changes were present in the knee transplant of the tibial tubercle was unsatisfactory, but patellectomy with rerouting of the quadriceps mechanism gave fair results. 4. Tibial tubercle transplant is contra-indicated in children because it may give a recurvatum deformity. 5. When the dislocation is permanent, operation may be unnecessary, but if it becomes inevitable simple patellectomy is the best procedure. 6. The results of plastic operations on the quadriceps expansion and of supracondylar femoral osteotomy are bad. 7. No operation can give consistently good results because the knee is usually congenitally weak, often as part of generalised ligamentous laxity

An increased tibial tubercle–trochlear groove (TT-TG) distance is related to patellar maltracking and instability. Tibial tubercle transfer is a common treatment option for these patients with good short-term results, although the results can deteriorate over time owing to the progression of osteoarthritis. We present a ten-year follow-up study of a self-centring tibial tubercle osteotomy in 60 knees, 30 with maltracking and 30 with patellar instability. Inclusion criteria were a TT-TG ≥ 15 mm and symptoms for > one year. One patient (one knee) was lost to follow-up and one required total knee arthroplasty because of progressive osteoarthritis. Further patellar dislocations occurred in three knees, all in the instability group, one of which required further surgery. The mean visual analogue scores for pain, and Lysholm and Kujala scores improved significantly and were maintained at the final follow-up (repeated measures, p = 0.000, intergroup differences p = 0.449). Signs of maltracking were found in only a minority of patients, with no difference between groups (p > 0.05). An increase in patellofemoral osteoarthritis was seen in 16 knees (31%) with a maximum of grade 2 on the Kellgren–Lawrence scale. The mean increase in grades was 0.31 (0 to 2) and 0.41 (0 to 2) in the maltracking and instability groups respectively (p = 0.2285). This self-centring tibial tubercle osteotomy provides good results at ten years’ follow-up without inducing progressive osteoarthritis. Cite this article: Bone Joint J 2015;97-B:329–36

Patellar instability most frequently presents during adolescence. Congenital and infantile dislocation of the patella is a distinct entity from adolescent instability and measurable abnormalities may be present at birth. In the normal patellofemoral joint an increase in quadriceps angle and patellar height are matched by an increase in trochlear depth as the joint matures. Adolescent instability may herald a lifelong condition leading to chronic disability and arthritis. Restoring normal anatomy by trochleoplasty, tibial tubercle transfer or medial patellofemoral ligament (MPFL) reconstruction in the young adult prevents further instability. Although these techniques are proven in the young adult, they may cause growth arrest and deformity where the physis is open. A vigorous non-operative strategy may permit delay of surgery until growth is complete. Where non-operative treatment has failed a modified MPFL reconstruction may be performed to maintain stability until physeal closure permits anatomical reconstruction. If significant growth remains an extraosseous reconstruction of the MPFL may impart the lowest risk to the physis. If minor growth remains image intensifier guided placement of femoral intraosseous fixation may impart a small, but acceptable, risk to the physis. This paper presents and discusses the literature relating to adolescent instability and provides a framework for management of these patients. Cite this article: Bone Joint J 2017;99-B:159–70

We used three-dimensional movement analysis by computer modelling of knee flexion from 0° to 50° in 14 knees in 12 patients with recurrent patellar dislocation and in 15 knees in ten normal control subjects to compare the in vivo three-dimensional movement of the patella. Flexion, tilt and spin of the patella were described in terms of rotation angles from 0°. The location of the patella and the tibial tubercle were evaluated using parameters expressed as percentage patellar shift and percentage tubercle shift. Patellar inclination to the femur was also measured and patellofemoral contact was qualitatively and quantitatively analysed. The patients had greater values of spin from 20° to 50°, while there were no statistically significant differences in flexion and tilt. The patients also had greater percentage patellar shift from 0° to 50°, percentage tubercle shift at 0° and 10° and patellar inclination from 0° to 50° with a smaller oval-shaped contact area from 20° to 50° moving downwards on the lateral facet. Patellar movement analysis using a three-dimensional computer model is useful to clearly demonstrate differences between patients with recurrent dislocation of the patella and normal control subjects

We measured on the radiographs of 100 knees the length of the patellar ligament and the anterior cruciate ligament, and the distance between the tibial tubercle and the femoral insertion of the anterior cruciate. The length of the patellar ligament was always greater than that of the anterior cruciate ligament, but shorter than the distance between the tibial tubercle and the femoral insertion of the anterior cruciate by a mean of 14.2 mm (3 to 22). We conclude that anatomical, isometric replacement of the anterior cruciate is possible using a free graft, but not by the technique of retaining the tibial attachment originally described by Jones (1970)

The clinical diagnosis of a partial tear of the anterior cruciate ligament (ACL) is still subject to debate. Little is known about the contribution of each ACL bundle during the Lachman test. We investigated this using six fresh-frozen cadaveric lower limbs. Screws were placed in the femora and tibiae as fixed landmarks for digitisation of the bone positions. The femur was secured horizontally in a clamp. A metal hook was screwed to the tibial tubercle and used to apply a load of 150 N directed anteroposteriorly to the tibia to simulate the Lachman test. The knees then received constant axial compression and 3D knee kinematic data were collected by digitising the screw head positions in 30° flexion under each test condition. Measurements of tibial translation and rotation were made, first with the ACL intact, then after sequential cutting of the ACL bundles, and finally after complete division of the ACL. Two-way analysis of variance analysis was performed. During the Lachman test, in all knees and in all test conditions, lateral tibial translation exceeded that on the medial side. With an intact ACL, both anterior and lateral tibial landmarks translated significantly more than those on the medial side (p < 0.001). With sequential division of the ACL bundles, selective cutting of the posterolateral bundle (PLB) did not increase translation of any landmark compared with when the ACL remained intact. Cutting the anteromedial bundle (AMB) resulted in an increased anterior translation of all landmarks. Compared to the intact ACL, when the ACL was fully transected a significant increase in anterior translation of all landmarks occurred (p < 0.001). However, anterior tibial translation was almost identical after AMB or complete ACL division. We found that the AMB confers its most significant contribution to tibial translation during the Lachman test, whereas the PLB has a negligible effect on anterior translation. Section of the PLB had a greater effect on increasing the internal rotation of the tibia than the AMB. However, its contribution of a mean of 2.8° amplitude remains low. The clinical relevance of our investigation suggests that, based on anterior tibial translation only, one cannot distinguish between a full ACL and an isolated AMB tear. Isolated PLB tears cannot be detected solely by the Lachman test, as this bundle probably contributes more resistance to the pivot shift

Component malalignment can be associated with pain following total knee replacement (TKR). Using MRI, we reviewed 50 patients with painful TKRs and compared them with a group of 16 asymptomatic controls to determine the feasibility of using MRI in evaluating the rotational alignment of the components. Using the additional soft-tissue detail provided by this modality, we also evaluated the extent of synovitis within these two groups. Angular measurements were based on the femoral transepicondylar axis and tibial tubercle. Between two observers, there was very high interobserver agreement in the measurements of all values. Patients with painful TKRs demonstrated statistically significant relative internal rotation of the femoral component (p = 0.030). There was relative internal rotation of the tibial to femoral component and combined excessive internal rotation of the components in symptomatic knees, although these results were significant only with one of the observers (p = 0.031). There was a statistically significant association between the presence and severity of synovitis and painful TKR (p < 0.001). MRI is an effective modality in evaluating component rotational alignment

Prophylactic antibiotics are important in reducing the risk of periprosthetic joint infection (PJI) following total knee arthroplasty. Their effectiveness depends on the choice of antibiotic and the optimum timing of their administration, to ensure adequate tissue concentrations. Cephalosporins are typically used, but an increasing number of resistant organisms are causing PJI, leading to the additional use of vancomycin. There are difficulties, however, with the systemic administration of vancomycin including its optimal timing, due to the need for prolonged administration, and potential adverse reactions. Intraosseous regional administration distal to a tourniquet is an alternative and attractive mode of delivery due to the ease of obtaining intraosseous access. Many authors have reported the effectiveness of intraosseous prophylaxis in achieving higher concentrations of antibiotic in the tissues compared with intravenous administration, providing equal or enhanced prophylaxis while minimizing adverse effects. This annotation describes the technique of intraosseous administration of antibiotics and summarizes the relevant clinical literature to date.

Cite this article: Bone Joint J 2023;105-B(11):1135–1139.

A simple procedure of using a Smillie knife to release the lateral patellar retinaculum and the capsule in the unstable patella syndrome is described. The syndrome includes recurrent dislocation, recurrent subluxation and acute dislocation of the patella. Arthroscopy, to exclude any other pathology such as chondromalacia patellae, is performed before proceeding to closed lateral release. The results of this procedure are as good as those after more major surgical procedures. In a small percentage of patients a second operation such as tibial tubercle transfer or patellectomy may be necessary, especially in patients with an underlying congenital abnormality; but in many patients this type of major surgery has proved unnecessary

Total knee arthroplasty (TKR) using a medial capsular approach gives worse results in arthritic knees with valgus deformity than in those in varus, usually because of swelling, poor wound healing and stiffness, instability, recurrent valgus deformity and poor patellar tracking. A technique for replacement TKR of valgus knees using a lateral capsular approach was described several years ago, but was not routinely adopted because of the difficulties with and complexity of the procedure which included deliberate elevation of the tibial tubercle. In order to avoid this we have modified and simplified the procedure. Our preliminary results suggest that this lateral approach is safe and may give a better outcome than that through the medial capsule for the replacement of valgus knees

Aims

The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach.

Aims

Obtaining solid implant fixation is crucial in revision total knee arthroplasty (rTKA) to avoid aseptic loosening, a major reason for re-revision. This study aims to validate a novel grading system that quantifies implant fixation across three anatomical zones (epiphysis, metaphysis, diaphysis).

Orthopaedic surgeons are currently faced with an overwhelming number of choices surrounding total knee arthroplasty (TKA), not only with the latest technologies and prostheses, but also fundamental decisions on alignment philosophies. From ‘mechanical’ to ‘adjusted mechanical’ to ‘restricted kinematic’ to ‘unrestricted kinematic’ — and how constitutional alignment relates to these — there is potential for ambiguity when thinking about and discussing such concepts. This annotation summarizes the various alignment strategies currently employed in TKA. It provides a clear framework and consistent language that will assist surgeons to compare confidently and contrast the concepts, while also discussing the latest opinions about alignment in TKA. Finally, it provides suggestions for applying consistent nomenclature to future research, especially as we explore the implications of 3D alignment patterns on patient outcomes.

Cite this article: Bone Joint J 2023;105-B(2):102–108.

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

In the UK, the agricultural, military, and construction sectors have stringent rules about the use of hearing protection due to the risk of noise-induced hearing loss. Orthopaedic staff may also be at risk due to the use of power tools. The UK Health and Safety Executive (HSE) have clear standards as to what are deemed acceptable occupational levels of noise on A-weighted and C-weighted scales. The aims of this review were to assess the current evidence on the testing of exposure to noise in orthopaedic operating theatres to see if it exceeds these regulations.

Aims

Malreduction of the syndesmosis has been reported in up to 52% of patients after fixation of ankle fractures. Multiple radiological parameters are used to define malreduction; there has been limited investigation of the accuracy of these measurements in differentiating malreduction from inherent anatomical asymmetry. The purpose of this study was to identify the prevalence of positive malreduction standards within the syndesmosis of native, uninjured ankles.

Aims

Cementless total knee arthroplasty (TKA) offers the potential for strong biological fixation compared with cemented TKA where fixation is achieved by the mechanical integration of the cement. Few mid-term results are available for newer cementless TKA designs, which have used additive manufacturing (3D printing). The aim of this study was to present mid-term clinical outcomes and implant survivorship of the cementless Stryker Triathlon Tritanium TKA.

Aims

The objective of this study is to assess the use of ultrasound (US) as a radiation-free imaging modality to reconstruct 3D anatomy of the knee for use in preoperative templating in knee arthroplasty.

Aims

The extensive variation in axial rotation of tibial components can lead to coronal plane malalignment. We analyzed the change in coronal alignment induced by tray malrotation.

Aims

The primary aim of this study was to compare the postoperative systemic inflammatory response in conventional jig-based total knee arthroplasty (conventional TKA) versus robotic-arm assisted total knee arthroplasty (robotic TKA). Secondary aims were to compare the macroscopic soft tissue injury, femoral and tibial bone trauma, localized thermal response, and the accuracy of component positioning between the two treatment groups.

Aims

Enhanced perioperative protocols have significantly improved patient recovery following primary total knee arthroplasty (TKA). Little has been investigated the effectiveness of these protocols for revision TKA (RTKA). We report on a matched group of aseptic revision and primary TKA patients treated with an identical pain and rehabilitation programmes.

Aims

The removal of the cruciate ligaments in total knee arthroplasty (TKA) has been suggested as a potential contributing factor to patient dissatisfaction, due to alteration of the in vivo biomechanics of the knee. Bicruciate retaining (BCR) TKA allows the preservation of the cruciate ligaments, thus offering the potential to reproduce healthy kinematics. The aim of this study was to compare in vivo kinematics between the operated and contralateral knee in patients who have undergone TKA with a contemporary BCR design.

Dissatisfaction following total knee arthroplasty is a well-documented phenomenon. Although many factors have been implicated, including modifiable and nonmodifiable patient factors, emphasis over the past decade has been on implant alignment and stability as both a cause of, and a solution to, this problem. Several alignment targets have evolved with a proliferation of techniques following the introduction of computer and robotic-assisted surgery. Mechanical alignment targets may achieve mechanically-sound alignment while ignoring the soft tissue envelope; kinematic alignment respects the soft tissue envelope while ignoring the mechanical environment. Functional alignment is proposed as a hybrid technique to allow mechanically-sound, soft tissue-friendly alignment targets to be identified and achieved.

Cite this article: Bone Joint J 2020;102-B(3):276–279.

Aims

Dual plating of distal femoral fractures with medial and lateral implants has been performed to improve construct mechanics and alignment, in cases where isolated lateral plating would be insufficient. This may potentially compromise vascularity, paradoxically impairing healing. This study investigates effects of single versus dual plating on distal femoral vascularity.

Aims

The objectives of this study were to assess the effect of anterior cruciate ligament (ACL) resection on flexion-extension gaps, mediolateral soft tissue laxity, maximum knee extension, and limb alignment during primary total knee arthroplasty (TKA).

Aims

Trochlear dysplasia is a significant risk factor for patellofemoral instability. The Dejour classification is currently considered the standard for classifying trochlear dysplasia, but numerous studies have reported poor reliability on both plain radiography and MRI. The severity of trochlear dysplasia is important to establish in order to guide surgical management. We have developed an MRI-specific classification system to assess the severity of trochlear dysplasia, the Oswestry-Bristol Classification (OBC). This is a four-part classification system comprising normal, mild, moderate, and severe to represent a normal, shallow, flat, and convex trochlear, respectively. The purpose of this study was to assess the inter- and intraobserver reliability of the OBC and compare it with that of the Dejour classification.

Aims

The Bereiter trochleoplasty has been used in our unit for 12 years to manage recurrent patellar instability in patients with severe trochlea dysplasia. The aim of this study was to document the outcome of a large consecutive cohort of patients who have undergone this operation.

Aims

The aim of this study was to assess the effect of posterior cruciate ligament (PCL) resection on flexion-extension gaps, mediolateral soft-tissue laxity, fixed flexion deformity (FFD), and limb alignment during posterior-stabilized (PS) total knee arthroplasty (TKA).

We have investigated iatrogenic popliteal artery injuries (PAI) during non arthroplasty knee surgery regarding mechanism of injury, treatment and outcomes, and to identify successful strategies when injury occurs.

In all, 21 iatrogenic popliteal artery injuries in 21 patients during knee surgery other than knee arthroplasty were identified from the Swedish Vascular Registry (Swedvasc) between 1987 and 2011. Prospective registry data were supplemented with case-records, including long-term follow-up. In total, 13 patients suffered PAI during elective surgery and eight during urgent surgery such as fracture fixation or tumour resection. Nine injuries were detected intra-operatively, five within 12 to 48 hours and seven > 48 hours post-operatively (two days to 23 years).

There were 19 open vascular and two endovascular surgical repairs. Two patients died within six months of surgery. One patient required amputation. Only six patients had a complete recovery of whom had the vascular injury detected at time of injury and repaired by a vascular surgeon. Patients sustaining vascular injury during elective procedures are more likely to litigate (p = 0.029).

We conclude that outcomes are poorer when there is a delay of diagnosis and treatment, and that orthopaedic surgeons should develop strategies to detect PAI early and ensure rapid access to vascular surgical support.

Cite this article: Bone Joint J 2015;97-B:192–6.

A key to the success of revision total knee arthroplasty (TKA) is a safe surgical approach using an exposure that minimises complications. In most patients, a medial parapatellar arthrotomy with complete synovectomy is sufficient. If additional exposure is needed, a quadriceps snip performed through the quadriceps tendon often provides the additional exposure required. It is simple to perform and does not alter the post-operative rehabilitative protocol. In rare cases, in which additional exposure is needed, or when removal of a cemented long-stemmed tibial component is required, a tibial tubercle osteotomy (TTO) may be used. Given the risk of post-operative extensor lag, a V-Y quadricepsplasty is rarely indicated and usually considered only if TTO is not possible.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):113–15.

The aim of this study was to find anatomical landmarks for rotational alignment of the tibial component in total knee replacement (TKR) in a CT-based study. Pre-operative CT scanning was performed on 94 South Korean patients (nine men, 85 women, 188 knees) with osteoarthritis of the knee joint prior to TKR. The tibial anteroposterior (AP) axis was defined as a line perpendicular to the femoral surgical transepicondylar axis and passing through the centre of the posterior cruciate ligament (PCL). The angles between the defined tibial AP axis and anatomical landmarks at various levels of the tibia were measured. The mean values of the angles between the defined tibial AP axis and the line connecting the anterior border of the proximal third of the tibia to the centre of the PCL was -0.2° (-17 to 14.1, sd 4.1). This was very close to the defined tibial axis, and remained so regardless of lower limb alignment and the degree of tibial bowing. Therefore, AP axis defined as described, is a reliable anatomical landmark for rotational alignment of tibial components.

Cite this article: Bone Joint J 2014; 96-B:1485–90.

Patella subluxation assessed on dynamic MRI has previously been shown to be associated with anterior knee pain. In this MRI study of 60 patients we investigated the relationship between subluxation and multiple bony, cartilaginous and soft-tissue factors that might predispose to subluxation using discriminant function analysis.

Patella engagement (% of patella cartilage overlapping with trochlea cartilage) had the strongest relationship with subluxation. Patellae with > 30% engagement tended not to sublux; those with < 30% tended to sublux. Other factors that were associated with subluxation included the tibial tubercle-trochlea notch distance, vastus medialis obliquus distance from patella, patella alta, and the bony and cartilaginous sulcus angles in the superior part of the trochlea. No relationship was found between subluxation and sulcus angles for cartilage and bone in the middle and lower part of the trochlea, cartilage thicknesses and Wiberg classification of the patella.

This study indicates that patella engagement is a key factor associated with patellar subluxation. This suggests that in patients with anterior knee pain with subluxation, resistant to conservative management, surgery directed towards improving patella engagement should be considered. A clinical trial is necessary to test this hypothesis.

Chronic patellofemoral instability can be a disabling condition. Management of patients with this condition has improved owing to our increased knowledge of the functional anatomy of the patellofemoral joint. Accurate assessment of the underlying pathology in the unstable joint enables the formulation of appropriate treatment. The surgical technique employed in patients for whom non-operative management has failed should address the diagnosed abnormality. We have reviewed the literature on the stabilising features of the patellofemoral joint, the recommended investigations and the appropriate forms of treatment.

Aims

The aims of this study were to determine the proportion of patients with outlier varus or valgus alignment in kinematically aligned total knee arthroplasty (TKA), whether those with outlier varus or valgus alignment have higher forces in the medial or lateral compartments of the knee than those with in-range alignment and whether measurements of the alignment of the limb, knee and components predict compartment forces.

This study reports the clinical outcome of reconstruction of deficient abductor muscles following revision total hip arthroplasty (THA), using a fresh–frozen allograft of the extensor mechanism of the knee. A retrospective analysis was conducted of 11 consecutive patients with a severe limp because of abductor deficiency which was confirmed on MRI scans. The mean age of the patients (three men and eight women) was 66.7 years (52 to 84), with a mean follow-up of 33 months (24 to 41).

Following surgery, two patients had no limp, seven had a mild limp, and two had a persistent severe limp (p = 0.004). The mean power of the abductors improved on the Medical Research Council scale from 2.15 to 3.8 (p < 0.001). Pre-operatively, all patients required a stick or walking frame; post-operatively, four patients were able to walk without an aid. Overall, nine patients had severe or moderate pain pre-operatively; ten patients had no or mild pain post-operatively.

At final review, the Harris hip score was good in five patients, fair in two and poor in four.

We conclude that using an extensor mechanism allograft is relatively effective in the treatment of chronic abductor deficiency of the hip after THA when techniques such as local tissue transfer are not possible.

Longer-term follow-up is necessary before the technique can be broadly applied.

Cite this article: Bone Joint J 2015;97-B:1050–5.

Seven stiff total knee arthroplasties are presented to illustrate the roles of: 1) manipulation under general anesthesia; 2) multiple concurrent diagnoses in addition to stiffness; 3) extra-articular pathology; 4) pain as part of the stiffness triad (pain and limits to flexion or extension); 5) component internal rotation; 6) multifactorial etiology; and 7) surgical exposure in this challenging clinical problem.

Primary total knee arthroplasty (TKA) is a reliable procedure with reproducible long-term results. Nevertheless, there are conditions related to the type of patient or local conditions of the knee that can make it a difficult procedure. The most common scenarios that make it difficult are discussed in this review. These include patients with many previous operations and incisions, and those with severe coronal deformities, genu recurvatum, a stiff knee, extra-articular deformities and those who have previously undergone osteotomy around the knee and those with chronic dislocation of the patella.

Each condition is analysed according to the characteristics of the patient, the pre-operative planning and the reported outcomes.

When approaching the difficult primary TKA surgeons should use a systematic approach, which begins with the review of the existing literature for each specific clinical situation.

Cite this article: Bone Joint J 2015;97-B(10 Suppl A):30–9.