Proprioception After Multiligament Knee Injury: Does Ligament Repair Lead to Better Proprioceptive Acuity Than Ligament Reconstruction?

Introduction Multiligament knee injuries are uncommon but serious injuries. There is ongoing debate on the optimal treatment of these injuries. We designed a study to establish the effects of repair or reconstruction on proprioceptive outcomes following multiligament injury to the knee. Materials and Methods A total of 34 patients were analysed by independent researchers who had no conflict of interest in the cases (23 in the repair group and 11 in the reconstruction group). Proprioception of the knee was measured using a previously validated tool to assess the reproduction of passive positioning. Functional outcome was measured using the Lysholm score. Sub-group analysis was performed. The mean time from injury to review was 83 months (range: 25-193 months). Results There were no significant differences in proprioceptive acuity between the injured (5.9±4.2°; range: 1.0-18.3°) and uninjured contralateral (control) knees (5.2±3.8°; range: 1.0-15.0°; p=0.35). Similarly, there was no significant difference in proprioceptive acuity identified between the injured knees that underwent repair (6.0±4.3°; range: 1.0-18.3°) or reconstruction (5.0±3.6°; range: 1.3-14°; p=0.53). Overall knee outcomes were good; the mean Lysholm score at final follow-up was 75.5±16.8 (range: 36-100). No significant differences were identified in any of the sub-groups. Conclusions We were unable to identify any differences in knee proprioceptive acuity between injured knees and controls nor between the types of surgical treatment, demonstrating equivocal recovery for both methods of treatment.

Nontraumatic fracture of the femoral condylar prosthesis in a total knee arthroplasty leading to mechanical failure.

This paper reports a case of fatigue fracture of the femoral component in a cruciate-retaining cemented total knee arthroplasty (TKA). A 64-year-old man had undergone a primary TKA for osteoarthritis 10 years previously at another institution using the PFC-Sigma prosthesis. The patient recovered fully and was back to his regular activities. He presented with a history of sudden onset pain and locking of the left knee since the preceding three months. There was no history of trauma, and the patient was mobilizing with difficulty using crutches. Radiographs revealed fracture of the posterior condyle of the femoral prosthesis. Revision surgery was performed as an elective procedure revealing the broken prosthesis. The TC3RP-PFC revision prosthesis was used with a medial parapatellar approach. The patient recovered fully without any squeal. Mechanical failure of the knee arthroplasty prosthesis is rare, and nontraumatic fracture of the femoral metallic component has not been reported before.

Revision of failed unicompartmental knee replacement to total knee replacement.

Recent reports suggest good outcome results following unicompartmental knee replacement (UKR). However, a number of authors have commented on the problem of osseous defects requiring technically difficult revision surgery. We reviewed clinical outcomes following revision total knee replacement (TKR) for failed UKR and analysed the reasons for failure and the technical aspects of the revision surgery. Between 2001 and 2010 our institute performed 132 UKR's out of which 33 required revision to TKR during a period 6 years. Demographics, details and indications for primary and revision surgery, the revised prosthesis including augments, technical difficulties and complications were noted. Patient outcome assessment was based on the Oxford knee score (OKS). Survival analysis for the UKR prosthesis was calculated using Kaplan-Meier Survival curves. Reasons for revision included aseptic loosening, persistent pain, dislocated meniscus, mal-alignment and other compartment osteoarthritis. Median time to revision was 19 months (range 2-159). Using revision as the end-point the survival proportion at 5-years was 69%. 18 revisions required additional intra-operative constructs including stemmed implants, wedge augmentation or bone graft. The mean 1 year post-operative OKS was 29 compared to 39 for primary TKR during the same period (p<0.001). Aseptic loosening was the commonest mode of failure. UKR survivorship at a non-specialist institute is considerably lower than at originating centres. Two thirds of the revisions were technically difficult and required additional constructs. The clinical outcome after revision surgery was inferior to that of primary TKR. The role of UKR needs to be more clearly defined.

High tibial osteotomy in knee instability: the rationale of treatment and early results.

We treated 14 patients having knee instability and varus alignment with tibial osteotomy with or without ligament reconstruction. Five patients with varus angulated anterior cruciate deficiency (double varus) were treated with single-stage closed-wedge tibial osteotomy and anterior cruciate ligament reconstruction. The remaining nine patients had varying amount of posterior cruciate and postero-lateral corner ligament injuries with varus angulation (triple varus); six of these patients had a ligament reconstruction using the Ligament Advanced Reconstruction System ligament with tibial osteotomy (intra-articular--posterior cruciate ligament/extra-articular--postero-lateral corner reconstruction), while the remaining three had a tibial osteotomy without a ligament reconstruction. Four of the nine patients with triple varus had open-wedge tibial osteotomy, and the remaining five had closed-wedge tibial osteotomy. The mean time interval between injury and index surgery of an osteotomy and ligament surgery was 8.3 years (range 1-20 years). At a mean follow-up of 2.8 years after tibial osteotomy, 12 knees (86%) were stable and eliminated of giving way while the remaining 2 were unstable. In one of these patients the result was compromised with severe infection, while in another there was combined cruciate ligament deficiency with postero-lateral corner ligament deficiency. Thirteen (93%) of the patients were able to participate in light recreational activities. None of these patients could return to competitive sports. Five (35%) continued to have pain of varying degree. The mean Cincinnati Knee Score improved from a mean preoperative of 53 (range 40-58) to a mean postoperative of 74 (range 58-82). Accordingly, there were two poor, four fair and eight good results. In-patients with triple-varus, open-wedge tibial osteotomy had better scores than those with closed-wedge procedure. The results of this series are encouraging, and we recommend a high tibial osteotomy along with ligament reconstruction in these complex injuries with varus alignment.

The uncemented Bi-Contact total hip arthroplasty.

We reviewed a consecutive series of 153 uncemented Bi-Contact (Aesculap, Tuttlingen, Germany) total hip arthroplasties (THAs) in 138 patients who had been followed for at least 5 years (mean, 6.8 years; range, 5-9 years). The Bi-Contact uncemented THA consists of a straight femoral stem made of titanium alloy. The proximal portion of the stem is titanium plasma-sprayed. The cup is press-fit with or without hydroxyapatite coating with a facility for anchoring screws with a snap-fit polyethylene liner. The mean age of the patients was 70.8 years (range, 41-94 years). The mean preoperative Harris hip score of 41 (range, 20-80) improved postoperatively to a mean of 92 (range, 56-96). Three acetabular cups were revised for aseptic loosening, and 1 cup was revised for recurrent dislocation. To date, none of the stems have been revised for aseptic loosening. Radiographic evaluation of the remaining 149 hips revealed that the acetabular cup was stable in 146 hips and possibly unstable in the remaining 3 cases with nonprogressive osteolysis behind the cup. None of the stems showed any evidence of instability. Using the recommendation of revision as the endpoint, the cumulative survival for the prosthesis was 97.3% at a mean follow-up of 6.8 years (95% confidence interval, 95.9-99.4), with stem survival of 100%. In the medium-term, these results are comparable to cemented primary THA and justify the continued use of this prosthesis.