Medium-term results of patellofemoral joint arthroplasty.

The results of a multi-surgeon, multi-implant series of patellofemoral joint arthroplasties performed over a ten year period are presented. All patellofemoral joint arthroplasties performed from 1997 to 2006 were retrospectively reviewed using case notes, radiographs and clinic appointments until their latest follow-up period. One hundred and one arthroplasties in 91 patients were followed up for an average period of 48 months (range 6-96 months). The average age was 57 years with female patients thrice as common as male patients. There were 5 (5%) complications with 1 deep infection and 4 stiff knees. Thirty five subsequent procedures were performed in 28 patients including arthroscopic debridement in 18, arthroscopic lateral retinacular release in 8, tibial tuberosity transfer in 3, manipulation for stiffness in 2, and revision to total knee arthroplasty in 4 patients (3 for progression of tibiofemoral osteoarthritis and 1 for infection). The necessity of further surgeries in one third of the study group suggests that close follow-up of these patients is needed to address any concerns that can be easily resolved.

Chronic irreducible posterolateral knee dislocation: two-stage surgical approach.

Posterolateral knee dislocation is a small subset of knee dislocations. Irreducible posterolateral dislocation has been reported and is caused by buttonholing of the medial femoral condyle into the anteromedial knee capsule, with interposition of the medial retinacular structures between the femoral and tibial condyles. Open reduction has been advocated to reduce the knee. We present a case of chronic irreducible posterolateral dislocation of the knee for 14 months associated with anterior and posterior cruciate ligament (ACL, PCL) and medial collateral ligament (MCL) rupture. The patient presented with continued instability. The classic dimple sign was absent in this case because of chronicity, but the limb was in valgus alignment compared with the other side. The magnetic resonance imaging (MRI) report commented only on the torn cruciates and the MCL, but missed the tissues preventing reduction. A 2-stage surgical procedure was performed. The first stage included arthroscopic debridement of the intervening tissues, which were thickened and resembled meniscal tissue, followed by reduction of the knee and open MCL repair to maintain the reduction. The second stage was done for ACL and PCL reconstruction. In conclusion we bring the attention of the surgeon to the clinical, radiographic, and MRI findings associated with this chronic irreducible posterolateral knee dislocation.

Survey of the management of acute traumatic first-time anterior shoulder dislocation among trauma clinicians in the UK.

INTRODUCTION: The aim of this work was to survey how acute traumatic first-time anterior shoulder dislocation (AFSD) is managed among trauma clinicians in UK using a postal questionnaire. PATIENTS AND METHODS: A total of 150 questionnaires were sent out to active consultant members of the British Trauma Society in the UK. Questions were laid out in two 'workgroups'. In Workgroup One, an assortment of questions was included regarding choices and methods of analgesia, methods of monitoring used, methods of reduction, and position of immobilisation. In Workgroup Two, three different case scenarios were analysed to look into the 'post-reduction' management. RESULTS: The response rate was 60%. Of respondents, 22% have a local protocol for managing AFSD. Almost all respondents recommended pre- and post-reduction X-rays as standard practice. Most respondents favoured systemic analgesia and sedation with airways' monitoring, as opposed to intra-articular anaesthesia (68 versus 9). Eighty-four respondents advocated immobilisation in internal rotation compared to six in external rotation. Only 19% (16 of 84) of respondents would perform an immediate arthroscopic stabilisation in young, fit patients presenting with this type of injury. CONCLUSIONS: This survey revealed variations among trauma clinicians in managing AFSD on the 'front-line'. There is a need to address the issue of intra-articular analgesia, immobilisation technique and management of AFSD in the young patient with regards to immediate surgical intervention. We suggest that these issues be revised and clarified, ideally in a randomised, controlled, clinical trial prior to the introduction of a protocol for managing this problem.

Atraumatic haemarthrosis following total knee replacement treated with selective embolisation.

Spontaneous haemarthrosis in the absence of anticoagulant medication or a bleeding disorder is a very rare complication after total knee arthroplasty. A case of recurrent spontaneous haemarthrosis following total knee replacement in a 69-year-old patient is reported. Angiography was used to aid the diagnosis. It demonstrated an abnormal blush of vessels around the anterior aspect of the knee joint, that was fed by genicular branches and a recurrent branch of the anterior tibial artery. Selective embolisation of the bleeding vessels with coils led to immediate control of the bleeding. No further recurrence of haemarthrosis has been recorded.

Reamer breakage in the femoral medulla during total knee arthroplasty: should reamers have a finite life?

We present a case of intraoperative breakage of an intramedullary reamer in the femoral canal during a total knee arthroplasty (TKA). The reamer snapped at the junction of its distal and middle thirds leaving the distal fragment of the reamer at the level of the femoral isthmus. The broken part was in the middle third of the femoral medulla invisible from the lower part of the femur. That was removed using a Küntscher intramedullary nail inserted proximally through the piriformis fossa. After removing it from the knee joint, the TKA was performed as initially planned. Our case highlights the rare however potential complication of intraoperative instrumentation failure and raises requests of metal fatigue and failure with repeated use. Further to that a technical note is made describing how to remove the broken instrument from the femoral medulla and complete the planned TKA.

Bilateral patellar component dissociation in a patient with total knee arthroplasties.

We present a case of bilateral patellar component dissociation 6 years after bilateral total knee arthroplasty. The patient had undergone arthroscopic lateral releases bilaterally for patellar maltracking. After repetitive trauma, the patient experienced patellar component dissociation, which was treated arthroscopically by removing the patellar components and leaving the patellae unresurfaced. The patient's symptoms improved substantially. Our case highlights certain features of the etiology as well as the management of patellar component dissociation in the total knee arthroplasty, showing the important role of arthroscopy.

Natural progression of osteo-chondral defect in the femoral condyle.

We have tried to establish the course of an isolated osteochondral defect in a femoral condyle would take if it were not treated surgically. We studied 15 knees in 12 patients where a diagnosis of the condition had been made in the past and no surgical treatment instituted for it. Each patient was examined clinically and had an MRI scan. The average period of follow-up was 109 months, the range being 54-282 months. Six patients (seven knees) were under the age of 18 at the onset of symptoms. Of these, MRI of six knees showed either no abnormality or a healed lesion. Where the onset was after skeletal maturity, six of the eight knees showed features osteoarthritis on the MRI scan. Symptomatically, there was also a difference between the two groups.