Multiple-ligament injured knee

Objective: To explore the clinical characteristic of the multiple-ligament injured knee and evaluate the protocol, technique and outcome of treatment for the multipleligament injured knee. Methods: From October 2001 to March 2005, 9 knees with combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) tears in 9 patients were identified with clinical and arthroscopic examinations. Of them, 5 knees were combined with ruptures of posteromedial corner (PMC) and medial collateral ligament (MCL), 4 with disruptions of posterolateral corner (PLC), 2 with popliteal vascular injuries and 1 with peroneal nerve injuries. Six patients were hospitalized in acute phase of trauma,2 received repairs of popliteal artery and 4 had repairs of PMC and MCL. Reconstructions of ACL and PCL with autografts under arthroscope were performed in all patients at 4 to 10 weeks after trauma, including reconstruction of PLC with the posterior half of biceps femoris tendon tenodesis in 4 patients and reconstructions of PMC and MCL with femoral fascia in 1 patient. Results: No severe complications occurred at early stage after operation in the 9 patients. All of them were followed up for 10-39 months with an average of 23. 00 months±9. 46 months. Lysholm score was 70-95 with an average of 85.00±8.29. International Knee Documentation Committee (IKDC) score was from severely abnormal (Grade D) in 9 knees at initial examination to normal (Grade A) in 2 knees, nearly normal (Grade B) in 6 knees and abnormal in 1 knee at the last follow-up. Of the 9 patients, 7 returned to the same activity level before injury and 2 were under the level. Conclusions:The multiple-ligament injured knee with severe instability is usually combined with other important structure damages. Therefore, careful assessment and treatment of the combined injuries are essential. Reconstructions of ACL and PCL under arthroscope, combined with repairs or reconstructions of the extraarticular ligaments simultaneously or in stages, have advantage of minimal trauma in surgery and satisfactory outcome.     

Does total knee replacement restore normal knee function?

Despite the advanced age of many patients having total knee arthroplasty, previous attempts to quantify patient function postoperatively have not allowed for normal deterioration of musculoskeletal function that occurs with aging. We determined the effects of aging on knee function, thereby providing a realistic level of normal, healthy knee function for patients and surgeons after total knee arthroplasties. A self-administered, validated knee function questionnaire consisting of 55 scaled multiple choice questions was used in this study. Responses were collected from 243 patients at least 1 year after they had total knee arthroplasties, and from 257 individuals (age- and gender-matched) who had no previous history of knee disorders. Many of these latter subjects reported that they could do most of the activities cited in the questionnaire without symptoms attributable to their knees. However, knee symptoms were experienced more frequently during activities that placed greater loads on the extremity. There was no difference in the knee function of men and women, and both groups had continuous deterioration in knee function with increasing age. There were large differences in the functional capacity to do activities involving the knee between the group of patients who had total knee arthroplasties and the age- and gender-matched patients with no previous knee disorders. Overall, 52% of the patients who had total knee arthroplasties reported some degree of limitation in doing functional activities, versus 22% of subjects with no previous knee disorders. Two groups of activities were identified: activities in which the patients and control subjects had essentially similar knee function (swimming, golfing, and stationary biking), and activities in which the function scores of the control group exceeded the scores of the patients who had total knee arthroplasties (kneeling, squatting, moving laterally, turning and cutting, carrying loads, stretching, leg strengthening, tennis, dancing, gardening, and sexual activity). Our data show that many of the limitations reported by patients after total knee arthroplasties are shared by individuals with no previous knee disorders. However, only approximately 40% of the functional deficit present after a total knee arthroplasty seems to be attributable to the normal physiologic effects of aging. Patients who had total knee replacements still experienced substantial functional impairment compared with their age- and gender-matched peers, especially when doing biomechanically demanding activities. This suggests that significant improvements in the procedure and prosthetic designs are needed to restore normal knee function after a total knee arthroplasty.     

Is knee osteotomy still indicated in knee osteoarthritis?

This study was undertaken to investigate whether high tibial osteotomy (HTO) still had a role in the treatment of osteoarthritis of the knee joint. The author has performed photoelasticity studies which confirmed abnormal stress distribution over the joint, as soon as its mechanical axis was deviated and the joint line had an obliquity over 10 degrees. High tibial osteotomy to correct varus or valgus deformity restores a symmetrical stress distribution and represents the only etiological treatment of secondary osteoarthritis of the knee. Two hundred and fifty HTO's were performed between 1971 and 1985 for osteoarthritis of the knee. The short-term result was good or very good in 75%, fair in 20% and poor in 5%. Fair and poor results were related to insufficient correction, to infection or mostly to incorrect indications. In 152 cases with a good or very good short term result, a further evaluation was made between 8 years and 15 years after operation. It was noted that osteoarthritis had been arrested in 105 cases (69%) whereas it had deteriorated in 47 cases. The main factors associated with further deterioration were insufficient correction and persistence of joint line obliquity. Provided on optimal correction is achieved (3 degrees to 6 degrees hypercorrection in valgus osteotomy, 0 degree in varus osteotomy) and provided a horizontal joint line is restored, HTO performed in good indications (Ahlback grade I or II) may provide good results for at least 10 to 15 years.     

Total knee replacement for posttraumatic degenerative arthritis of the knee

Althoughsignificantadvancehasbeenmadeinoperativetreatmentofkneefracturesoverthelasttwodecades,fracturesofthedistalfemurorproximaltibiastillmayleadtoposttraumatic arthritis.13Concomitantly,markedimprovementin totalkneearthroplasty(TKA)hasalsobeenmade durin…     

Mid-term results of Miller−Galante unicompartmental knee replacement for medial compartment knee osteoarthritis

Background

The purpose of this study is to analyse and report the mid-term results of 175 unicompartmental knee replacement (UKR) procedures performed for medial compartment knee arthritis from January 2001 to January 2010.

Materials and methods

The cohort participants were selected after stringent inclusion criteria and the average follow-up was 5.6 years (range 2–10 years). The fixed-bearing UKR procedure was carried out on all patients.

Results

The pre-operative mean knee range of movement improved from 100° ± 11.3° to 118.3° ± 12° (p value <0.001). The pre-operative mean Knee Society (KS) knee and functional score improved from 47 ± 5.5 and 55.1 ± 4.6 to 91.8 ± 9.2 and 92 ± 10.1 (p value <0.001), respectively. The revision rate of the cohort was 4 % (seven knees) and implant survival rate was 96 % at the end of 10 years; 87 % of the cohort were satisfied with the procedure and had a normal gait pattern. In this study, there was no statistical difference between groups with a body mass index (BMI) ≤30 kg/m² and those with a BMI ≥30 kg/m², and between groups aged ≤55 years and those aged ≥55 years, in clinical and functional outcome following UKR.

Conclusion

This study confirms that fixed-bearing UKR gives excellent results in patients with medial compartment knee arthritis who comply with the inclusion criteria. Age and BMI were not considered to influence the clinical and functional outcomes.Level of evidence-III.

     

Does a mobile-bearing, high-flexion design increase knee flexion after total knee replacement?

This prospective randomised controlled double-blind trial compared two types of PFC Sigma total knee replacement (TKR), differing in three design features aimed at improving flexion. The outcome of a standard fixed-bearing posterior cruciate ligament-preserving design (FB-S) was compared with that of a high-flexion rotating-platform posterior-stabilised design (RP-F) at one year after TKR. The study group of 77 patients with osteoarthritis of the knee comprised 37 men and 40 women, with a mean age of 69 years (44.9 to 84.9). The patients were randomly allocated either to the FB-S or the RP-F group and assessed pre-operatively and at one year post-operatively. The mean post-operative non-weight-bearing flexion was 107° (95% confidence interval (CI) 104° to 110°)) for the FB-S group and 113° (95% CI 109° to 117°) for the RP-F group, and this difference was statistically significant (p = 0.032). However, weight-bearing range of movement during both level walking and ascending a slope as measured during flexible electrogoniometry was a mean of 4° lower in the RP-F group than in the FB-S group, with 58° (95% CI 56° to 60°) versus 54° (95% CI 51° to 57°) for level walking (p = 0.019) and 56° (95% CI 54° to 58°) versus 52° (95% CI 48° to 56°) for ascending a slope (p = 0.044). Further, the mean post-operative pain score of the Western Ontario and McMaster Universities Osteoarthritis Index was significantly higher in the RP-F group (2.5 (95% CI 1.5 to 3.5) versus 4.2 (95% CI 2.9 to 5.5), p = 0.043). Although the RP-F group achieved higher non-weight-bearing knee flexion, patients in this group did not use this during activities of daily living and reported more pain one year after surgery.     

Recovery of knee function in the isolated MCL and combined ACL–MCL deficient knee

Background

The MCL is the prime medial stabiliser of the knee and is a commonly injured structure which leads to valgus instability of the knee.

Objectives

We aim to analyse differences in recovery of knee motion and muscle function over one year follow up in the isolated MCL and combined ACL–MCL injured knee. We hypothesized that combined ACL–MCL injuries lead to greater knee motion and muscle function deficits at 1 year.

Methods

Isolated MCL (Group I) or combined ACL–MCL injuries (Group II) from 2006–2010 were included. Those with a previous MCL injury, injury to contralateral limb or presenting 2 weeks post-injury were excluded. At certain outpatient follow up intervals, we recorded pre-determined parameters of knee function. Follow-up was at weeks 2, 6, 12, 26, 52.

Results

The cohort included 82 patients (54 males:28 females) with a mean age of 32 (range 16–56). Group II showed a deficit in Total Range of Movement (TROM) and flexion at 6 month follow up (p < 0.05). Group II showed an extension deficit at week 2 (p < 0.05). The Peak Torque Deficit (PTD) and Average Power Deficit (APD) improved for quadriceps and hamstrings across all follow up intervals (p > 0.05).

Conclusion

There is a TROM and flexion deficit at 6 months in group II, resolving by 1 year. There was no difference in PTD or APD in either group.     

Does knee position at the time of tourniquet inflation affect knee range of motion?

Pneumatic tourniquets about the thigh are commonly employed in lower extremity orthopaedic surgery to maintain a bloodless operative field. The purpose of this study was to determine whether the position of the knee at the time of tourniquet inflation has an impact on knee range of motion (ROM). Passive ROM of the knees of 30 patients was measured with the tourniquet deflated, with the tourniquet inflated while the knees were in extension, and with the tourniquet inflated while the knees were in flexion. The average knee ROM with a deflated tourniquet was 143.0 degrees with a standard deviation of 8.1 degrees (range, 125 degrees -160 degrees ). When the tourniquet was inflated with the knees in extension, the average knee ROM was 143.0 degrees with a standard deviation of 7.8 degrees (range, 125 degrees -159 degrees ). When the tourniquet was inflated with the knees in flexion, the average knee ROM was 143.7 degrees with a standard deviation of 7.8 degrees (range, 124 degrees -160 degrees ). There was a statistically significant difference between the ROM of knees with tourniquet inflation in flexion versus extension (p = .0011.) Although there was a statistical difference, it was concluded that a difference of approximately 1 degrees in knee ROM is not clinically relevant.     

Single incision nailing of the floating knee—do we ignore the knee ligaments?

The incidence of knee ligament injuries in the floating knee is as high as 53% documented in the literature. The single incision technique (antegrade tibial and retrograde femoral nailing through a single incision at the knee) although a good technique in terms of speed and ease, has its own disadvantages. Repair or reconstruction of a torn anterior or posterior cruciate ligament after a single incision technique can be a difficult proposition. Antegrade femoral and tibial nailing (two incisions) makes treatment of knee ligament injuries easier.This comment refers to the article available at: .     

Is above knee bypass defunct?

As endovascular treatments improve, the inevitable progress will result in the abandonment of conventional bypasses. First and foremost in this regard is the use of above knee bypass, particularly with prosthetic graft material. Already, endovascular success approaches or exceeds the patency seen with this bypass technique. As a result, in centers with endovascular expertise in infrainguinal intervention, bypass surgery is increasingly being replaced by these techniques and conventional bypass surgery is disappearing. Over the next few years, above knee bypass will be replaced by endovascular techniques in most centers as our results with these techniques improve.     

How does laxity after single radius total knee arthroplasty compare with the native knee?

Patients with total knee arthroplasties (TKAs) continue to report dissatisfaction in functional outcome. Stability is a major factor contributing to functionality of TKAs. Implants with single‐radius (SR) femoral components are proposed to increase stability throughout the arc of flexion. Using computer navigation and loaded cadaveric legs, we characterized the “envelope of laxity” (EoL) offered by a SR cruciate retaining (CR)‐TKA compared with that of the native knee through the arc of flexion in terms of anterior drawer, varus/valgus stress, and internal/external rotation. In both the native knee and the TKA laxity increased with increasing knee flexion. Laxities measured in the three planes of motion were generally comparable between the native knee and TKA from 0° to 110° of flexion. Our results indicate that the SR CR‐TKA offers appropriate stability in the absence of soft tissue deficiency. © 2014 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 32:1208–1213, 2014.     

Is extreme flexion of the knee after total knee replacement a prerequisite for patient satisfaction?

The focus of this study was to evaluate the functional result and to specifically ascertain whether the absence of the ability to squat and sit cross-legged altered the patient's satisfaction level after a successful standard total knee replacement. Squatting and sitting cross-legged are common practices in Asia. These activities are not possible following standard total knee replacement. Patients were followed-up for a minimum of 12 months post surgery. Their level of satisfaction was assessed using a Likert scale. The Knee Society Score (KSS) was used to assess range of motion and function of the knee. Twenty-one out of 25 patients were satisfied with the surgical result in spite of an inability to squat. Deep knee flexion may not be an essential prerequisite for patient satisfaction after total knee replacement, even in a population where squatting and sitting cross-legged are part of the normal lifestyle.     

Do high flexion posterior stabilised total knee arthroplasty designs increase knee flexion? A meta analysis

Purpose  

This systematic literature review analysed the change in range of knee flexion from pre-operative values, following conventional posterior stabilised (PS) and high-flexion (H-F) PS total knee arthroplasty (TKA).     

The clinical outcome of revision knee replacement after unicompartmental knee arthroplasty versus primary total knee arthroplasty: 8–17 years follow-up study of 49 patients

When unicompartmental knee arthroplasty (UKA) failure occurs, a revision procedure to total knee arthroplasty (TKA) is often necessary. We compared the long-term results of this procedure to primary TKA and evaluated whether they are clinically comparable. Twenty-one patients underwent UKA conversion to TKA between 1991 and 2000. The results of these patients were compared to the group of 28 primary TKA patients with the same age, sex and operation time point. The long-term outcomes were evaluated using clinical and radiological analysis. The mean follow-up period of the patients was 10.5 years. The UKA revision patients were more dissatisfied, as measured by the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) scale (0–100 mm) compared to the primary TKA patients (pain 18.1/7.8; p = 0.014; stiffness 25.7/14.4, p = 0.024; physical function 19.0/14.8, p = 0.62). Two patients were revised twice in the UKA revision group. There was one revision in the primary TKA group (p = 0.39). Improvement in range of motion (ROM) was better in the TKA patients compared to the UKA revision patients (8.2°/–2.6°, p = 0.0001). We suggest that UKA conversion to TKA is associated with poorer clinical outcome as compared to primary TKA.