Improved clinical outcomes after high-flexion total knee arthroplasty: a 5-year follow-up study

The purpose of this study was to determine if high-flexion total knee arthroplasty resulted in improved outcomes compared with conventional total knee arthroplasty. This was a prospective, double-blind, randomized controlled trial involving 76 patients over 5 years. We compared the postoperative flexion range, Knee Society scores, Oxford knee scores, and SF-36 scores between 2 groups. The high-flexion group was able to achieve a significant sustainable increase in postoperative knee flexion angle; and this correlated to a significant improvement in the General Health, Vitality, and Physical Functioning scales of SF-36 at 5 years postoperatively. Our results signify that high-flexion total knee arthroplasty has additional benefits to the quality of life in patients who require higher degrees of knee flexion in their activities of daily living.     

Proprioception after an acute knee ligament injury: A longitudinal study on 16 consecutive patients

A defect in proprioception has been found in selected patient groups that have an anterior cruciate ligament deficient knee at different times after the original injury. The time of development and the extent of such defects were studied ongitudinally on 16 consecutive patients. During the first year after a primary knee injury, which included a complete rupture of the anterior cruciate ligament, we repeatedly performed three tests of proprioception: (a) one to determine the threshold for detecting a passive motion from starting positions of 20 and 40°, (b) an active reproduction of a passive angular change, and (c) a visual estimation of a passive angular change. The injured limb was compared with the uninjured limb and with the limbs of an age-matched reference group of healthy subjects. The population did not have a normal distribution, and some patients had consistently extreme recordings in the threshold tests at the various times of testing. Significant differences were found between the groups at the starting position of 20°, when the injured knee was compared with the uninjured knee, after 1 month (p = 0.05), and after 2 months (p = 0.03). There was a trend toward a higher threshold for detecting a passive motion when the injured side was compared with the knees of the reference group at 1 month (p = 0.06) but not later on. A similar pattern was found for the injured knee at the starting position of 40°, but it was not significant. An impaired ability to detect a passive motion was registered for the nearly extended knee 1 and 2 months after a primary injury. In the active reproduction and visual estimation tests, no significant defects were found at any time during the first year in these consecutively studied patients.     

Long-term results after combined medial meniscal allograft transplantation and anterior cruciate ligament reconstruction: minimum 8.5-year follow-up study

PurposeThe purpose of this study was to evaluate the long-term results after medial meniscal allograft transplantation combined with anterior cruciate ligament (ACL) reconstruction.Type of studyRetrospective clinical outcome study.MethodsBetween 1990 and 1992, 9 medial meniscal allograft transplantations were performed in symptomatic knees with a previous total or near-total medial meniscectomy. One of the 9 patients required transplant removal postoperatively because of a presumed low-grade infection versus immune reaction. The remaining 8 patients were evaluated, with an average follow-up time of 9.7 years. All 8 patients underwent an ACL reconstruction. One patient also had a staged high tibial osteotomy.ResultsAll 8 patients were evaluated with the standard International Knee Documentation Committee (IKDC) form with no normal scores: 1 had a nearly normal score, 4 had abnormal scores, and 3 severely abnormal scores. The IKDC symptoms evaluation produced 2 normal scores, 5 nearly normal scores, and 1 abnormal score. The IKDC function test showed 5 normal scores, 1 nearly normal score, and 2 abnormal scores. Six of the 8 patients were extremely pleased with the function of the knee and were active in recreational sports. All 8 patients would recommend the procedure to a friend and would undergo the procedure again given similar circumstances.ConclusionsThe findings of this study agree with several other studies with shorter follow-up times that medial meniscal allograft transplantation can significantly improve knee function in symptomatic medial meniscus-deficient knees. The addition of a ligament-stabilizing procedure probably improved the results in this patient population.Level of evidenceLevel IV, Case Series.     

Total knee arthroplasty in younger patients: a 13-year follow-up study

Total knee arthroplasty (TKA) is a well-established treatment at the end stage of a degenerated knee joint. This operative treatment generally relieves pain, improves physical function, and has a high level of patient satisfaction, especially in the elderly. Younger patients, however, are demanding and have a higher level of physical activity compared to elderly patients. One could therefore expect more mechanical problems such as prosthetic loosening and polyethylene wear after long-term follow-up. The goal of this retrospective cohort study was to determine the survival and long-term results of TKA in young patients. Patients who received a TKA at age 60 years or younger for any reason were included. Minimum follow-up was 10 years. Thirty-nine TKAs (Anatomic Graduate Components; Biomet, Warsaw, Indiana) in 31 patients were included. Average patient age was 52.6 years. There were 3 revisions because of infection; in 1 knee the patella was revised because of aseptic loosening. After an average 13-year follow-up, the survival rate was 89.7% and function scores showed a reasonably functioning TKA. There was no difference in survival rate and function scores between patients with rheumatoid arthritis and those with primary or secondary (posttraumatic) osteoarthritis. Our experience with TKA in a younger patient population has been encouraging. The risk of loosening and wear of the implant in our study is low, and this type of TKA also seems to be an effective and safe treatment for younger patients.     

Decrease of osteosclerosis in subchondral bone of medial compartmental osteoarthritic knee seven to nineteen years after high tibial valgus osteotomy

Osteosclerosis of the subchondral bone was measured by densitometer on plain radiographs in 55 medial compartmental osteoarthritic knees of 40 patients who were treated with high tibial valgus osteotomy for correction of varus deformity. The ratio of the osteosclerosis value of the medial side of the knee to that of the lateral side (Medial/Lateral ratio) was calculated and used as a parameter. The Medial/Lateral ratio of osteosclerosis decreased rapidly within three years after osteotomy at the reference points of the femur and the tibia. Even 7 to 19 years after osteotomy, a decrease of the ratio was noted in 16 knees with a standing femorotibial angle (FTA) less than 168 degrees (12 degrees of anatomical valgus angulation). This was interpreted to mean that osteosclerosis of the medial condyle decreased compared with that of the lateral condyle after overcorrection of varus deformity. In the cases of more than 7 years after high tibial osteotomy, a positive straight regression line was drawn by calculation between Medial/Lateral ratio and postoperative limb alignment expressed by standing femorotibial angle, with coefficient of correlation (gamma) of 0.295 (p < 0.01).     

Bone mineral and migratory patterns in uncemented total knee arthroplasties: A randomized 5-year follow-up study of 38 knees

We measured the amount of bone mineral in the medial tibial condyle 1 week postoperatively, after 1 year and after 4-5 years in 38 arthrotic knees randomized to a Freeman-Samuelson hydroxyapatite-coated (FS HA) or a Miller-Galante II (MGII) total knee arthroplasty. Clinically excellent results were recorded in both groups after 5 years. At the last follow-up, the overall decrease in bone mineral was 26%, as measured by triple-energy X-ray absorptiometry. The decrease was larger in FS HA knees than in MG II knees after 4-5 years, indicating stress-shielding of the proximal tibia. Radiostereometry at 1 and 5 years showed smaller maximum total point motion, maximum subsidence and varus or valgus tilt in the FS HA group. There was a tendency towards a reversed relationship between subsidence and change in bone mineral after 1 year, but not after 4-5 years. Distal fixation of the stem in the Freeman-Samuelson hydroxyapatite-coated (FS HA) components might explain the more pronounced loss of bone mineral in the medial tibial condyle.     

A 5-year follow-up study after knee disarticulation in two cases of Gollop-Wolfgang complex

The Gollop-Wolfgang Complex is a very rare anomaly, which has its essential features in congenital absence of the tibia and ipsilateral bifurcation of the femur. Surgical treatment of two patients with a follow-up of 5 years is reported.     

Internal bracing with an artificial ligament for superficial medial collateral ligament injury impairs the mechanical property of repaired native ligament: A porcine study

BackgroundSuperficial medial collateral ligament (sMCL) injury is common, but there are no in vivo studies describing the biomechanical efficacy of anatomic repair with internal bracing for grade 3 injuries.MethodsWe used a porcine model to evaluate the efficacy of internal bracing using an artificial ligament for the early repair of acute, grade 3 sMCL injuries. Sixteen male castrated pigs were randomly assigned to a repair group: (1) anatomic repair using two suture anchors (Group R; n = 9) or (2) anatomic repair with internal bracing augmentation (Group IB; n = 7). The left knees were allocated to a sham surgery group (Group S; n = 16). All animals were sacrificed 4 weeks after surgery. The right and left femur-sMCL-tibia complexes were mounted on a tensile tester and stretched to failure using the same conditions as preconditioning at a cross-head speed of 50 mm/min. The internal bracing in Group IB was removed prior to the biomechanical testing. The failure mode and structural properties (upper yield load, maximum load, linear stiffness, and elongation at failure) were determined.ResultsSignificant differences in failure mode were observed among the three groups. All sMCLs repaired with just the suture anchors (Group R) were avulsed from the femoral attachment, while most of the sMCLs repaired with internal bracing augmentation (Group IB) exhibited mid-substance tears (Group R vs Group IB, P = 0.0023). In Group S, 14 sMCLs were avulsed from the femoral attachment and two were avulsed from the tibial attachment (Group IB vs Group S, P < 0.001). No significant difference was observed between Group R and Group S. There were no significant differences in the upper yield load, maximum load, linear stiffness, or elongation at failure among the groups.ConclusionsLoading of an artificial ligament for internal bracing did not result in better structural properties of the repaired sMCL itself.     

Return to sports after valgus osteotomy of the knee joint in patients with medial unicompartmental osteoarthritis

Purpose

The aim of this article was to evaluate the resumption of physical activity and sports after valgus osteotomy for medial femorotibial osteoarthritis.

Methods

This series is composed of 83 patients, with 27 females and 56 males. The mean age was 50.4 ± 9.53 years (32–67) at the time of operation. Before the onset of symptoms of knee osteoarthritis, four (4.8 %) patients practiced a competitive sport, 44 (53 %) one (or more) recreational sport on a regular basis, 17 (20 %) occasionally and 18 (21.6 %) did not practice any sport but were active. Sixty-two opening wedge high tibial osteotomies were performed as well as 21 double level osteotomies for severe deformity. All the osteotomies were computer-assisted in order to reach the best overcorrection.

Results

At a mean follow up of 5.75 ± 1.3 years (five to nine years), 71 patients (85.5 %) resumed sporting activities and 66 (79.5 %) felt they had found a sporting level equal to the level prior surgery. The mean Lysholm score increased from 62.51 ± 15.53 points (30-100) pre-operatively to 90.49 ± 8.62 points (55–100) postoperatively (p?p?=?0.07 and 0.09). The mean postoperative KOO score was 73.52 ± 17.20. The frequency of sports sessions per week (2.36 ± 1.6) did not decrease significantly after surgery (2.13 sessions, p?=?0.34). On the other hand, the duration of activities decreased significantly from 4.68 hours/week ± 4.25 to 3.48 hours/week (p?=?0.04). Of the patients who practiced running before surgery 85 % (17 of 20) were able to resume this activity.

Conclusion

This study demonstrates that knee osteotomies for medial femorotibial osteoarthritis allow the resumption of sustained physical activity such as jogging or skiing downhill in a majority of patients.     

Stability of employment after brain injury: a 7-year follow-up study

Forty-three patients with severe traumatic brain injury (n = 24), cerebrovascular diseases (n = 15), or other acquired brain damage (n = 4) were followed-up 7-8 years after neuropsychological rehabilitation including a vocational re-entry programme. Current vocational status and work history since rehabilitation were investigated by means of a structured interview. Before interview, the patients were classified on the basis of medical records into four groups: (A) patients with minor residual neuropsychological impairments, (B) patients with minor impairments but psychopathological symptoms, (C) patients with persistent neuropsychological impairments showing no psychopathological symptoms, and (D) patients with persistent impairments and psychopathological symptoms. For patients in group A, a good, and for those in group D, a poor long-term employment outcome was predicted, while no predictions were made for the intermediate groups. Of the 43 interviewed subjects, 16 (37%) reported a stable return to work at pre-morbid level and seven (16%) at a lower level. In eight patients (19%), persisting difficulties in maintaining work were documented. Twelve subjects (28%) had retired within a period of 2 years after work trial. The relationship between patient classification and long-term employment outcome was only weak. Four out of 11 patients with a good prognosis (group A) experienced vocational adjustment problems or had retired. Three out of 10 patients with a poor prognosis (group D) were able to continue successfully with their previous jobs. These cases are described in detail. The employment outcome of the intermediate groups was very heterogeneous. The results suggest that particular attention should be paid to the long-term consequences of a reduced capacity for work, even if minor in degree. The success of patients despite a poor prognosis illustrate unsolved problems in relation to the ecological validity of neuropsychological measures of executive dysfunctions.     

A biomechanical study of stability of the elbow to valgus stress before and after reconstruction of the medial collateral ligament

The purpose of this study was to assess the stability of the elbow to valgus loads after reconstruction of the anterior bundle of the medial collateral ligament (MCL). The MCL in 14 human cadaveric elbows was exposed with a muscle-splitting approach. Each sample was secured in a materials test frame,5 N-m valgus moments were applied in 30 degrees, 60 degrees, 90 degrees, and 120 degrees of flexion, and baseline stability was measured. This sequence was performed after the anterior bundle was sectioned and again after ligamentous reconstruction was done with the Jobe technique. At 30 degrees, 60 degrees, 90 degrees, and 120 degrees of flexion, reconstruction reproduced an average of 99%, 102%, 97%, and 89%, respectively, of the stability of the intact ligament. The only significant difference between intact and reconstructed samples was at 120 degrees of flexion (P <.05). We concluded that this procedure reliably restores stability to a ruptured MCL throughout the flexion arc in the immediate postoperative period.     

Prognosis for patients with medial gonarthrosis. A 16-year follow-up study of 189 knees

All 189 knees (157 patients) that had had primary medial compartment arthrosis in 1972 were followed until 1988. After 14 years, tibial osteotomy had been performed in 85 knees and arthroplasty in 33 knees. No major surgery had been performed in 71 knees; of these 71 knees, 31 patients (40 knees) had died. Of the remaining 23 patients (31 knees), the majority had an unsatisfactory knee and managed only on a low activity level. In 20 of 24 knees, progress of the arthrosis was recorded roentgenographically. Because natural course of medial gonarthrosis has a poor prognosis, the majority of patients suffering from this condition will eventually have major knee surgery.     

Non-operative management of acute grade III medial collateral ligament injury of the knee: a prospective study

In a prospective study, 25 patients who had acute complete rupture of the medial collateral ligament of the knee with associated anterior cruciate ligament injury were treated by cast bracing and physiotherapy. Their average age was 27.6 years (range 15-53 years) with average follow-up of 24.2 months (range 12-48 months). All 25 patients had good or excellent results, with return to the pre-injury level of sporting activities by 1 year and with restoration of medial stability. This study shows that conservation treatment of this injury can restore stability to the medial side of the knee, even in the presence of anterior cruciate ligament damage.     

Injury location affects ligament healing: A morphologic and mechanical study of the healing rabbit medial collateral ligament

Based on the heterogeneity of the rabbit medial collateral ligament (MCL) along its length, we tested the hypothesis that injury location would affect its healing response. The right MCL of 80 skeletally mature New Zealand white rabbits was sectioned adjacent to bone at the femoral end (40 rabbits) or the tibial end (40 rabbits) and reapposed with sutures. Animals were killed after 3, 6, 14, or 40 weeks of healing to examine wounds histologically (2 rabbits per healing interval) and mechanically (8 rabbits per healing interval). Results of the mechanical tests were compared to midsubstance MCL repairs (24 rabbits) and to uninjured normal MCLs (20 rabbits). The morphology of the near-insertion repairs was characterized by abnormal callus-like formation and patchy bone resorption, particularly at the tibial insertion. Mechanically, insertional injuries remodeled towards normal MCL low-load, viscoelastic and failure properties more slowly than midsubstance injuries at the early healing intervals. After 40 weeks of healing, few injury-specific differences persisted. All injured ligaments had ultimate strengths 15-35 percent short of normal at 40 weeks and the femo-rally-injured ligaments were weaker than normal at this time. These results suggest that rabbit MCLs, injured near either end, heal more slowly that those injured in their midsubstance and develop abnormal insertion morphology.     

Medial collateral ligament healing one year after a concurrent medial collateral ligament and anterior cruciate ligament injury: An interdisciplinary study in rabbits

The optimal treatment for concurrent injuries to the medial collateral and anterior cruciate ligaments has not been determined, despite numerous clinical and laboratory studies. The objective of this study was to examine the effect of surgical repair of the medial collateral ligament on its biomechanical and biochemical properties 52 weeks after such injuries. In the left knee of 12 skeletally mature New Zealand White rabbits, the medial collateral ligament was torn and the anterior cruciate ligament was transected and then reconstructed. This is an experimental model previously developed in our laboratory. In six rabbits, the torn ends of the medial collateral ligament were repaired, and in the remaining six rabbits, the ligament was not repaired. Fifty-two weeks after injury, we examined varus-valgus and anterior-posterior knee stability; structural properties of the femur-medial collateral ligament-tibia complex; and mechanical properties, collagen content, and mature collagen crosslinking of the medial collateral ligament. We could not detect significant differences between repair and nonrepair groups for any biomechanical or biochemical property. Our data support clinical findings that when the medial collateral and anterior cruciate ligaments are injured concurrently and the anterior cruciate ligament is reconstructed, conservative treatment of the ruptured medial collateral ligament can result in successful healing.     

Efficacy of foot orthoses as nonoperative treatment for hallux valgus: A 2-year follow-up study

BackgroundThe purpose of this study was to clarify the 2-year clinical and radiological outcomes of nonoperative treatment using foot orthosis for hallux valgus patients.MethodsPatients who underwent nonoperative treatment using foot orthosis were surveyed prospectively. Foot orthoses were made by one certified orthotist using the standardized method. Pain and quality of life were evaluated using subjective and objective assessment measures at 3, 6, 12, 18, and 24 months. Furthermore, radiological outcomes, patient satisfaction, and adherence to treatment were surveyed.ResultsA total of 53 patients (50 women and 3 men; median age, 63 years) were included for analysis. The pain visual analogue scale score significantly decreased over time, with the lowest score observed at 12 months. The treatment effect was maintained over 24 months (median score, 52, 21, and 27 points at baseline, 12 months, and 24 months, respectively; P < .001). The Japanese Society for Surgery of the Foot hallux scale, American Academy of Orthopaedic Surgeons Foot and Ankle Scale, and 36-Item Short-Form Health Survey bodily pain subscale also improved, although the treatment effects were maximal at 6 months and decreased thereafter. At 24 months, 43 (81%) patients continued to use the orthosis, with the median visual analogue scale score for patient satisfaction of 76 points. The hallux valgus angle and intermetatarsal angle did not change during the 24-month period.ConclusionNonoperative treatment using foot orthoses decreased pain in patients with hallux valgus. The effect of treatment was maintained up to 2 years with a relatively high degree of patient satisfaction. However, treating physicians should inform patients to set realistic expectations and be aware that a limited degree of pain reduction is expected.     

Bone mineral and migratory patterns in uncemented total knee arthroplasties: a randomized 5-year follow-up study of 38 knees

We measured the amount of bone mineral in the medial tibial condyle 1 week postoperatively, after 1 year and after 4-5 years in 38 arthrotic knees randomized to a Freeman-Samuelson hydroxyapatite-coated (FS HA) or a Miller-Galante II (MG II) total knee arthroplasty. Clinically excellent results were recorded in both groups after 5 years. At the last follow-up, the overall decrease in bone mineral was 26%, as measured by triple-energy X-ray absorptiometry. The decrease was larger in FS HA knees than in MG II knees after 4-5 years, indicating stress-shielding of the proximal tibia. Radiostereometry at 1 and 5 years showed smaller maximum total point motion, maximum subsidence and varus or valgus tilt in the FS HA group. There was a tendency towards a reversed relationship between subsidence and change in bone mineral after 1 year, but not after 4-5 years. Distal fixation of the stem in the Freeman-Samuelson hydroxyapatite-coated (FS HA) components might explain the more pronounced loss of bone mineral in the medial tibial condyle.     

15-year follow-up study of total knee arthroplasty in patients with rheumatoid arthritis

In 25 patients with rheumatoid arthritis, 36 cases of cemented Kinematic total knee arthroplasty were reviewed clinically and radiographically at 13 to 19 years after surgery. The mean age at the time of surgery was 51.6 +/- 8.9 years. According to the follow-up results evaluated with the Hospital for Special Surgery knee scoring system, 28 knees (77.7%) were classified as good or excellent. The mean flexion angle at follow-up evaluation was 99 degrees +/- 24 degrees (10 degrees -140 degrees ). At the tibial or femoral bone-cement interfaces, a radiolucent line was seen in 10 of 36 knees (27.8%) at follow-up evaluation. The survival rate of prostheses with revision as the endpoint was estimated to be 93.7% at 15 years. Kinematic total knee arthroplasty in rheumatoid arthritis patients provided a good long-term outcome.