Achilles tendinopathy can be a debilitating condition affecting 2–3 in 1000 of the population, rising to 1 in 20 in runners. A variety of non-operative and operative treatments are available for both insertional and non-insertional tendinopathy. This review summarises the current management options of these different pathologies.
Osteochondral lesions of the talus (OLTs) are a common complication following trauma, involving both the articular cartilage and the underlying subchondral bone, with variable aetiologies and often presenting with non-specific symptoms. Diagnosis of OLTs requires a combination of clinical assessment and imaging and despite many different treatment options, there is no generalised consensus regarding which option is the most effective. Left untreated, OLTs risk progressing to osteoarthritis. Acute non-displaced OLTs can be treated non-operatively. However, OLTs refractory to non-surgical care for three to six months may be suitable for surgical care. In these cases, conservative treatments are often unsuccessful, particularly for larger and more severe defects and so the majority require surgical intervention. Although bone marrow stimulation techniques remain the “gold standard” for lesions <150 mm2, there still requires a need for better long term clinical data and cost-benefit analyses compared with other treatment options. Biological attempts at either regenerating or replacing the articular cartilage are however demonstrating some promising results, but each with their own advantages and disadvantages. In this review, we summarise the clinical management of OLTs and present the current concepts of different treatment regimes.
New TKA are designed to optimize patient outcomes and improve implant longevity such as the Attune TKA. Concerns have been raised regarding a potentially high rate of early de-bonding at the implant–cement interface of the tibial component. Our study aimed to prospectively assess the clinical outcomes and radiographs of a consecutive series of patients undergoing either Attune TKA or another modern TKA for OA to establish failure rates and compare radiological abnormalities.
96 Attune TKA performed by three surgeons at our local center were matched to 96 control TKA (PFC/Vanguard) performed between 2015 and 2017. Day one, one year and two year post surgery radiographs were analyzed by two independent, blinded assessors. Clinical outcome was assessed using the Oxford Knee Score and survival of the implant recorded. Patients were contacted two years from surgery, 93 Attune and 92 control TKAs attended for clinical and radiological assessment by the same independent assessors.
No TKA in either group were revised. No significant radiolucencies (≥2 mm) at the cement-bone or implant-cement interfaces were encountered in either group. The incidence of radiolucencies (<2 mm) across both interfaces was similar between both groups and did not affect clinical outcome. There was no significant difference between the incidence, progression and extent of radiolucencies at two years follow-up in either of the groups as compared with one year. No clinically relevant adverse radiographic features were found in this prospective cohort study comparing a consecutive series of Attune TKA with a matched group of established, modern TKA designs.
No studies to date have compared the outcome of isolated medial patellofemoral ligament reconstruction (MPFLR) surgery with MPFLR plus re-alignment procedures (MPFLR+) in the paediatric population, making it unclear when additional re-alignment procedures are required.
By retrospectively reviewing and comparing our MPFLR patient cohorts’ we aim to generate guidance to aid surgical planning.
University of Salford ethical approval was secured and theatre records were retrospectively reviewed, identifying all patients less than 18 years-of-age who received MPFLR surgery between October 01, 2015 and October 01, 2019.
All patients were contacted for documented consent. Pre-operative and post-operative outcome questionnaires were reviewed in conjunction with patient’s medical records and radiological imaging.
A total of 75 MPFLR surgeries were identified and 33 patients (40 knees) consented for inclusion in the study; 23 MPFLR and 17 MPFLR+. Mean improvement in outcome scores achieved statistical significance (P < 0.05) in almost all questionnaire subtypes for both groups. A greater improvement in Quality of life (QoL) correlated with an increased tibial tuberosity–trochlear groove distance (TT-TG) in the MPFLR group 0.557 (P = 0.025) and a lower Patellotrochlear index (PTI) - 0.549 (P = 0.034) in the MPFLR + group.
Increased Body Mass Index (BMI) correlated with worse outcomes in numerous questionnaire subtypes (P = 0.05 and P = 0.01) for the MPFLR + group.
Increased Trochlear dysplasia correlated – 0.541 (P = 0.03) with less improvement in symptoms following MPFLR + surgery and an increased need for revision surgery 0.312 (P = 0.053) in both groups.
Both groups achieved good outcomes and statistically significant improvements in almost all mean outcome scores following MPFLR surgery, suggesting that our current described selection criteria are appropriate. While we were unable to identify any absolute radiological cut off figures in this diverse population with changing anatomy, we recommend additional procedures be considered for high TT-TG distances and or significant patella alta.
Patients with a high BMI should be supported in losing weight prior to surgery and patients with trochlear dysplasia need counselling with regard to potential lesser improvements in symptoms, a higher risk of failure and need for revision surgery. Additional realignment procedures did not appear to offer any improved outcome in the presence of trochlear dysplasia.
Level of Evidence IV: Case series.
Lateral epicondyle osteotomy is one of the surgical choices when seeking a proper equalization and balance of the flexion and extension gaps during the correction of a valgus knee deformity, when performing a total knee arthroplasty (TKA). However, its use is not frequent, and the reports described in literature are scarce. The aim of this study was to describe the clinical outcomes of the patients in which lateral epicondyle osteotomy was performed during TKA in a consecutive group of patients with valgus deformity.
Retrospective study of 18 patients with valgus deformity, who had lateral epicondyle osteotomy during TKA, from January 2016 to December 2018. The type of valgus deformity was assessed with Ranawat’s classification. The femorotibial angle was measured with a panoramic leg standing X-rays before and after the TKA; The function was evaluated with the Knee Society Score-KSS and Oxford Knee Score scale.
The average age was 71.8 ± 6.1 years and 13 cases were women. According to Ranawat’s classification, 11 knees had Grade III (>20°) valgus deformity. The mean preoperative and postoperative femorotibial angles were 25.8° ± 9.9° and 7.1° ± 1.8°, respectively. Functional improvement was observed through the KSS and Oxford scales, with an average increase of 37.4 ± 13.4 and 32.4 ± 6.7 points compared to preoperative. No evidence of intraoperative or postoperative complications associated with the procedure was found.
In these patients, the osteotomy of the lateral epicondyle proved to be an effective surgical option for the correction of valgus deformity during TKA, allowing proper alignment of the limb with good functional results.
Since the mid-twentieth century, solid organ transplantation has become established worldwide and conferred immense benefit to hundreds of thousands of patients. Comorbidities associated with end stage organ failure and the use of immunosuppressive treatment result in solid organ transplant patients (SOTP) commonly developing bone disease necessitating joint replacement. The increasing life span of SOTPs has also resulted in an increase in age related osteoarthritis. The aim of this literature review was to summarise the evidence available on outcomes following total knee replacements (TKR) in SOTP's.
A systematic search of the literature was performed by authors using PRISMA guidelines. A total of 10 papers were reviewed for this article. Data was extracted from the papers regarding complications specifically related to TKR.
SOTP's are more susceptible to post-operative complications following TKR. Infection was the most common post-operative complication encountered (6.99%). Overall complication rate reported was 22.58%. Renal transplant patients have shown to have a higher infection rate when compared to liver patients. Mortality rate is increased in this patient group (5.91%). Post-operative knee scores show good to excellent clinical results.
This review of the literature has highlighted from the limited data that there is an increased risk of post-operative complications following TKR in SOTP's. Further data is required to more accurately quantify this risk. Despite this, the benefit to be gained from TKR may outweigh the proven increased risk.
When counselling solid organ transplant patients for TKR, information regarding the increased post-operative risk should be discussed. This may become a more common scenario as life expectancy following SOT increases.
Proper sizing of the femoral and tibial components is an important step in total knee replacement (TKA). When performing bilateral TKA, there is often an opinion that the same size prosthesis as the opposite side will suffice, even though there are reports of anatomical differences between sides. In this study, we quantify the incidence of asymmetry in femoral and tibial component sizes in staged bilateral TKA in a Middle East population.
This is a retrospective observational study of all patients who underwent uncomplicated bilateral TKA with the same type of prosthesis by two surgeons at the same institute, between January 2013 and January 2019.
There were 123 patients, femoral and tibial component size variationswerepresent in 42patients (34.1%) and 30 patients (24.4%) respectively. The variation was evident in both posterior substituting (PS) and cruciate retaining (CR) designs. The femoral components had a higher variation in size between the sides for both PS and CR designs than the tibial components for both designs. The percentage variation in the size of the femoral component was similar for PS and CR subgroups (32.7% and 33.3% respectively). However, for the tibial component, the size variation was higher for PS design (24.5%) than for CRdesign (18.7%). 7.3% had a side-to-side variation by 2 or more sizes in both femoral and tibial components.
Variations in the size of the femoral and tibial components is common in patients undergoing bilateral TKA. Contralateral component size should not be used as the determinant of component sizes on the other side.
Usage of Patient Specific Instrumentation (PSI) or Patient Specific Guides (PSG) in TKA has evolved rapidly in the past decade. Restoration of Mechanical axis in TKA is vital to achieve good functional outcome and long term implant survival. We carried out a comparative study to assess the efficacy of PSG in achieving neutral axial alignment and its impact on early functional outcomes compared to Conventional Instrumentation (CI).
Patients eligible as per study design (n = 100) undergoing TKA were randomized and divided in two equal groups which were matched in baseline demographics and clinical profile. All the patients in the PSG group (n = 50) and conventional instrumentation (CI) group (n = 50) underwent TKA with same implant. Pre-operative CT scans done as per specified protocol to acquire image data for 3D printing PSG. Duration of surgery and post-operative Hip-Knee-Ankle (HKA) angles achieved in the two groups was compared. Post-operative functional outcomes were assessed using WOMAC scores.
There was statistically significant difference in the mean post-operative axial alignment achieved between the two groups (p = 0.041). Outliers (180 ± 3 deg) of HKA angle were more in the CI Group (p = 0.007). There was no difference in functional outcomes between the two groups at one year. Duration of surgery was significantly less in PSG Group (p < 0.001).
3D printed PSG are superior in achieving neutral HKA axis as compared to CI in TKA. Better axial alignment of TKA components does not correlate with better patient reported functional outcomes. PSG use significantly reduces surgical time.
This study was conducted to compare the efficacy of preoperative intravenous (IV) and intraoperative topical administration of tranexamic acid versus intraoperative topical administration of tranexamic acid along in reducing blood loss in primary total knee arthroplasty (TKA) subjects. The hypothesis of this study was the combined use of intravenous and Intra-articular injection of Tranexamic acid will be more efficacious than intra-articular administration alone in reducing blood loss in Primary Total Knee Arthroplasty.
A total of 31 subjects were selected and randomized into intervention and control group. The intervention group received both intravenous and intra articular tranexamic acid i.e. Trenexamic acid 1 gm IV injection 15 min before skin incision and Trenexamic acid 1 gm intra articular application intraoperatively after joint capsule closure. Subjects in the control group received only intra articular tranexamic acid i.e. Trenexamic acid 1 gm in 20 ml normal saline using intra articular application after joint capsule closure. Outcome measurements included postoperative surgical site drain output, drop in haemoglobin levels and transfusion rate. Ethics approval was taken from the Medical Research Unit, Armed Forces Medical College, Pune.
The mean total blood (drain output) in the intervention group was 354.5 (±208.22) ml vs. 397.65 (±125.00) ml in the control group. T-test between the two groups on the volume drained post-operatively was not significant (p = 0.482). No subjects in the intervention group required post-operative blood transfusion but one subject from the control group required blood transfusion.
Combined use of intravenous and intraarticular injection tranexamic acid had lesser surgical site bleeding compared to only topical administration, however this was not statistically significant.
Unicompartmental knee arthroplasty (UKA) is a surgical option for patients with medial compartment osteoarthritis (OA). The objective of this study was to describe the functional outcomes and long-term survival rates of cemented medial mobile-bearing UKA according to the compliance with current indications.
Retrospective study of 78 patients with medial unicompartimental knee OA treated with mobile-bearing cemented UKA (Oxford phase-III) between 2002 and 2012, with an average follow-up of 10.4 ± 3.4 years. Preoperative radiographs and clinical records were reviewed to assess the compliance with current indications (isolated medial compartment OA, flexion ≥ 90°, integrity of all ligaments, varus deformity<15°). Patients who met all criteria were classified with appropriate indication. The function was measured using the knee society score (KSS).
Nineteen (24.3%) patients did not meet the current indications for UKA. Non-isolated OA of the medial compartment was the most frequent inappropriate indication (16 patients), followed by range of flexion<90° (2 patients) and lack of integrity of the ligaments (1 patient). A significant improvement was found on the KSS after surgery [preoperative KSS: 50.0 (Interquartile range-IQR: (35.0–60.0); postoperative KSS: 70.0 (IQR:60.0–70.0), p < 0.05]. Survival after 15 years of follow-up in cases without and with appropriate indication was 55.8% and 89.7%, respectively. A higher risk of revision surgery was found in cases with inappropriate indication (hazard ratio: 4.87, 95% Confidence Interval: 1.54–15.38, p:0.007).
When proper patient selection is carried out, cemented medial mobile-bearing UKA offers good functional outcomes with a survival rate of 89.7% at 15 years of follow-up.
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