Long-term results of the lateral resurfacing elbow arthroplasty.

Aims: The aim of this study was to report the long-term outcome and implant survival of the lateral resurfacing elbow (LRE) arthroplasty in the treatment of elbow arthritis. Patients and Methods: We reviewed a consecutive series of 27 patients (30 elbows) who underwent LRE arthroplasty between December 2005 and January 2008. There were 15 women and 12 men, with a mean age of 61 years (25 to 82). The diagnosis was primary hypotrophic osteoarthritis (OA) in 12 patients (14 elbows), post-traumatic osteoarthritis (PTOA) in five (five elbows) and rheumatoid arthritis (RA) in ten patients (11 elbows). The mean clinical outcome scores including the Mayo Elbow Performance Score (MEPS), the American Shoulder and Elbow Surgeons elbow score (ASES-e), the mean range of movement and the radiological outcome were recorded at three, six and 12 months and at a mean final follow-up of 8.3 years (7.3 to 9.4). A one sample t-test comparing pre and postoperative values, and survival analysis using the Kaplan-Meier method were undertaken. Results: A statistically significantly increased outcome score was noted for the whole group at each time interval. This was also significantly increased at each time in each of the subgroups (OA, RA, and PTOA). Implant survivorship was 100%. Conclusion: We found that the LRE arthroplasty, which was initially developed for younger patients with osteoarthritis, is an effective form of surgical treatment for a wider range of patients with more severe degenerative changes, irrespective of their cause. It is therefore a satisfactory alternative to total elbow arthroplasty (TEA) and has lower rates of complications in the subgroups of patients we have studied. It does not require activities to be restricted to the same extent as following TEA. Based on this experience, we now recommend LRE arthroplasty rather than TEA as the primary form of implant for the treatment of patients with OA of the elbow. Cite this article: Bone Joint J 2018;100-B:338-45.

Surgical accuracy in high tibial osteotomy: coronal equivalence of computer navigation and gap measurement.

PURPOSE: Medial opening wedge high tibial osteotomy (MOW HTO) is now a successful operation with a range of indications, requiring an individualised approach to the choice of intended correction. This manuscript introduces the concept of surgical accuracy as the absolute deviation of the achieved correction from the intended correction, where small values represent greater accuracy. Surgical accuracy is compared in a randomised controlled trial (RCT) between gap measurement and computer navigation groups. METHODS: This was a prospective RCT conducted over 3 years of 120 consecutive patients with varus malalignment and medial compartment osteoarthritis, who underwent MOW HTO. All procedures were planned with digital software. Patients were randomly assigned into gap measurement or computer navigation groups. Coronal plane alignment was judged using the mechanical tibiofemoral angle (mTFA), before and after surgery. Absolute (positive) values were calculated for surgical accuracy in each individual case. RESULTS: There was no significant difference in the mean intended correction between groups. The achieved mTFA revealed a small under-correction in both groups. This was attributed to a failure to account for saw blade thickness (gap measurement) and over-compensation for weight bearing (computer navigation). Surgical accuracy was 1.7° ± 1.2° (gap measurement) compared to 2.1° ± 1.4° (computer navigation) without statistical significance. The difference in tibial slope increases of 2.7° ± 3.9° (gap measurement) and 2.1° ± 3.9° (computer navigation) had statistical significance (P < 0.001) but magnitude (0.6°) without clinical relevance. CONCLUSION: Surgical accuracy as described here is a new way to judge achieved alignment following knee osteotomy for individual cases. This work is clinically relevant because coronal surgical accuracy was not superior in either group. Therefore, the increased expense and surgical time associated with navigated MOW HTO is not supported, because meticulously conducted gap measurement yields equivalent surgical accuracy. LEVEL OF EVIDENCE: I.

High reliability in digital planning of medial opening wedge high tibial osteotomy, using Miniaci's method.

PURPOSE: Pre-operative planning is essential in high tibial osteotomy (HTO). Miniaci's method employs Mikulicz's weight-bearing line and is advantageous because the point of mechanical loading is related to the known degenerative condition of the knee. Miniaci's geometrical method has been modified for an opening wedge and described for use with a digital picture archiving and communications system viewer. Reliability for this method was hypothesised to be equivalent to published reliability for landmark-based commercial software and independent of observer experience. METHODS: Twenty-four patients awaiting HTO had standardised long-leg radiographs. Mikulicz's weight-bearing line was projected through the lateral compartment of the knee at Fujisawa's point. The correction angle was generated at the hinge point subtending the current and proposed ankle centres. The opening wedge was plotted to measure an opening distance. Observations were recorded twice by three observers. Agreement was reported as intraclass correlation coefficients with 95 % confidence intervals. RESULTS: Intra-rater agreement was excellent for the correction angle (0.965-0.985) and opening distance (0.928-0.980). If no set hinge point was used, then the inter-rater reliability was 0.986 for the correction angle and 0.984 for the opening distance. There was no discernible pattern demonstrating improved reliability from the experienced observer. CONCLUSIONS: Reliability is comparable to commercially based landmark software and independent of observer experience. This makes such geometrical pre-operative planning accessible to surgeons who perform HTO with insufficient frequency to justify the investment in commercial software. LEVEL OF EVIDENCE: Diagnostic study, Level II.

Clinically insignificant association between anterior knee pain and patellofemoral lesions which are found incidentally.

BACKGROUND: Patellofemoral chondral lesions are frequently identified incidentally during the arthroscopic treatment of other knee pathologies. A role has been described for arthroscopic debridement when symptoms are known to originate from pathology of the patellofemoral joint. However, it remains unclear how to manage lesions which are found incidentally whilst tackling other pathologies. The purpose of this study was to establish the strength of association between anterior knee pain and patellofemoral lesions identified incidentally in a typical arthroscopic population. METHODS: A consecutive series of patients undergoing arthroscopy for a range of standard indications formed the basis of this cross section study. We excluded those with patellofemoral conditions in order to identify patellofemoral lesions which were solely incidental. Pre-operative assessments were performed on 64 patients, where anterior knee pain was sought by three methods: an annotated photographic knee pain map (PKPM), patient indication with one finger and by palpated tenderness. A single blinded surgeon, performed standard arthroscopies and recorded patellofemoral lesions. Statistical correlations were performed to identify the association magnitude. RESULTS: Associations were identified between incidental patellofemoral lesions and tenderness palpated on the medial patella (P = 0.007, χ(2) = 0.32) and the quadriceps tendon (P = 0.029, χ(2) = 0.26), but these associations were at best fair, which could be interpreted as clinically insignificant. CONCLUSION: Incidental patellofemoral lesions are not necessarily associated with anterior knee pain, we suggest that they could be left alone. This recommendation is only applicable to patellofemoral lesions which are found incidentally whilst addressing other pathology.

A conservative approach is feasible in unexplained pain after knee replacement: a selected cohort study.

Pain is the main indication for performing total knee replacement (TKR). In most patients after TKR there is an improvement, but a few continue to have pain. Generally, the cause of the pain can be addressed when it is identified. However, unexplained pain can be more difficult to manage because revision surgery is likely to be unrewarding in this group. In our study of 622 cemented TKRs in 512 patients with a mean age of 69 years (23 to 90) treated between January 1995 and August 1998, we identified 24 patients (knees) with unexplained pain at six months. This group was followed for five years (data was available for 18 knees in the study) [corrected] and ten patients (55.5%) went on to show an improvement without intervention. In the case of unexplained pain, management decisions must be carefully considered, but reassurance can be offered to patients that the pain will improve in more than half with time.