Introduction

Recurrent patellar dislocation is often reported in bilateral knees in young active individuals. The medial patellofemoral ligament (MPFL) tear is the attributable cause behind many of them and warrants reconstruction of the ligament to stabilize the patellofemoral joint. Besides, trochleoplasty and Fulkerson's osteotomy are some other procedures that are performed to treat this problem. This study aimed to compare the clinical and functional outcomes in a cohort of patients with single-stage bilateral realignment procedures vs staged procedures.

Glutamate is a neurotransmitter that transmits mechanical signals in bone (1) and activates glutamate receptors and transporters, in bone, cartilage, meniscus and synovium (2). Glutamate receptor activation influences inflammatory, degenerative and nociceptive pathways in arthritic joints (2). Thus glutamate signalling is a mechanism whereby mechanical load can directly influence joint pathology and pain. We have investigated components of glutamate signalling in the subchondral bone of patients with osteoarthritis to determine which are expressed and whether this varies in anatomical regions subject to different loads. Subchondral bone was sampled from tibial cuts derived from total knee arthroplasty (n=2, TKR, Kellgren Lawrence grade 3) and from tibial drill hole sites from high tibial osteotomy (n=5, HTO, KL grades 2 and 3) for osteoarthritis. RNA was extracted, reverse transcribed and RT-PCR performed for a housekeeping gene GAPDH, a glutamate transporters (EAAT-1, EAAT1ex9skip), glutamate receptors (NR2A and KA1), a bone matrix protein, osteocalcin, and signaling molecules (osteoprotegerin [OPG], RANKL). We found differential mRNA expression in different regions of subchondral bone. In one TKR patient, EAAT-1 expression was significantly reduced in the anterior zone versus the middle or posterior zones of the tibial plateau (ANOVA, p<0.001). HTO bone cores were subdivided medial/lateral and anterior/posterior. Good quality RNA was obtained from bone cores removed from drill holes during HTO surgery, with GAPDH, osteocalcin, EAAT-1, EAAT1ex9skip, NR2A, KA1, OPG and RANKL mRNA expression detected. In one patient, comparison of gene expression in bone cores obtained pre and post HTO revealed that EAAT1ex9skip was rarely detected in post-op bone whereas KA1 was rare in pre-op bone. This differential mRNA expression may be due to the altered loading through the joint caused by the osteotomy, although these on/off differences need to be quantified to confirm this.

We have shown that glutamate transporters and receptors are expressed in human subchondral bone. Activation of these receptors and transporters by the increased synovial fluid concentrations of glutamate released in arthritis will influence pathological changes and nociception. In some patients, glutamate transporter mRNA expression appears to vary with anatomical location in bone, or after HTO surgery, consistent with our original discovery of this transporter as mechanically-regulated in bone (1). If glutamatergic signaling is mechanically regulated in the human knee, this will vary during arthritic disease progression and after joint realignment, providing a direct mechanism linking mechanical loading through the joint to pathology and pain in arthritis.

Purpose: Since the neurotransmitter glutamate mediates nociceptive and pathological processes in arthritis, we have investigated how glutamate receptor and transporter expression varies with anatomical site or disease severity in subchondral bone of patients with osteoarthritis.

Methods and Results: Subchondral bone was sampled from tibial cuts derived from total knee arthroplasty (n=2, TKR, Kellgren Lawrence[KL] grade 3) and from tibial drill hole sites from high tibial osteotomy (n=2, HTO, KL grades 2 and 3) for osteoarthritis. RNA was extracted, reverse transcribed and RT-PCR performed for the housekeeping gene GAPDH, the glutamate transporter EAAT-1, and glutamate receptors (NR2A and KA1). Quantitative RT-PCR assessed differences in the expression of EAAT-1, a dominant negative splice variant called EAAT-1ex9skip and osteocalcin after normalisation to GAPDH.

Good quality RNA was obtained from bone cores removed from drill holes during HTO surgery, with GAPDH, EAAT-1, NR2A and KA1 expression detected. Osteocalcin expression was high indicating RNA was derived from osteoblasts and osteocytes, but did not vary with anatomical site or disease status. End-stage RT-PCR indicated differential expression of EAAT-1 between medial and lateral bone samples in total knee arthroplasty, however these differences were not significant by quantitative RT-PCR. In one patient, EAAT-1 expression was significantly reduced in the anterior zone versus the middle or posterior zones (ANOVA, p< 0.001). EAAT-1ex9skip represented a significant proportion of the total EAAT-1 mRNA expression in bone from TKR patients, but appeared less abundant in HTO samples.

Conclusion: We have shown for the first time that glutamate transporters and receptors are highly expressed in subchondral bone of patients with osteoarthritis and that EAAT-1 expression may vary with anatomical location and pathology. Activation of these receptors and transporters by the increased synovial fluid concentrations of glutamate that occur in arthritis may contribute to pathological changes and nociception.

Purpose of the study: The purpose of this study is to present our initial experience of single stage revision surgery for infected total knee arthroplasty (TKA).

Methods and results: 12 patients underwent single stage revision for infected TKA. The average patient age was 72.5 years and M: F was 2:1. 5 of the 12 patients had frank infection with presence of discharging sinuses pre-operatively. The procedure involved explantation, debridement, subtotal synovectomy, use of high pressure carbon dioxide (Carbojet) and re-implantation using revision prosthesis and antibiotic laden cement. Utmost care was taken to restore the balance and stability of the revised knee. All the patients were given appropriate intravenous and oral antibiotics in the peri-operative period. Oxford knee scores (OKS) were obtained pre-operatively and at the latest follow-up. Patient satisfaction was also assessed.

At the latest follow-up, none of the patients had recurrence of the infection nor did they need any further surgical procedure. There was no radiographic evidence of loosening of the prosthesis. The OKS had improved from a mean of 17 pre-operative to 41 at the latest follow-up. All the patients were extremely satisfied with the outcome.

Conclusion: Knee function and patient satisfaction improved significantly after single stage revision for infected TKA. None of the patients needed further surgery in the short term. Early results are very encouraging and this change in practice may save on costs and patient morbidity associated with the second stage.

Purpose of the study: The aim of this study was to determine risk factors for clinically relevant pulmonary embolism (PE) in patients undergoing elective knee arthroplasty.

Methods and results: We performed a retrospective analysis of 956 total knee arthroplasties performed at our institution between June 2007 and May 2008 to identify patients with postoperative PE confirmed by computed tomography pulmonary angiogram (CTPA). All patients had received foot pumps, thromboembolism deterrent stockings and 75mg of Aspirin postoperatively. Patients with PE were matched for age, gender, surgeon, date and type of surgery with a control group of 32 patients. Patients case notes were reviewed to identify known risk factors for PE such as age, gender, ASA grade, BMI, medical comorbidities, pre-operative haemoglobin (Hb), postoperative Hb, drop in Hb, day mobilised postoperatively, tourniquet time and temperature in the postoperative period. Statistical analysis was performed using Statistical Package for the Social Sciences version 12.0 (SPSS Inc., Chicago, Illinos).

Twenty one (2.2 %) cases were identified with CTPA confirmed PE. Of the various risk factors studied, delay in postoperative mobilization was the only significant risk factor for PE (p=0.019). None of the other risk factors were significant for PE. Postoperative pain was the commonest reason for delayed mobilisation followed by lower limb paraesthesia from regional nerve blocks.

Conclusion: We found that a delay in postoperative mobilization was the most significant risk factor for clinically relevant PE in our patient population following knee arthroplasty. The use of chemical thromboprophylaxis for all patients undergoing elective knee arthroplasty is currently under debate. Not all patients are at equal risk, however, and chemical prophylaxis is not devoid of complications. Early postoperative mobilization of all patients may help prevent this potentially fatal complication.

Purpose of the study: Since the neurotransmitter glutamate mediates nociceptive and pathological processes in arthritis, we have investigated how glutamate receptor and transporter expression varies with anatomical site or disease severity in subchondral bone of patients with osteoarthritis.

Methods and results: Subchondral bone was sampled from tibial cuts derived from total knee arthroplasty (n=2, TKR, Kellgren Lawrence grade 3) and from tibial drill hole sites from high tibial osteotomy (n=2, HTO, KL grades 2 and 3) for osteoarthritis. RNA was extracted, reverse transcribed and RT-PCR performed for the housekeeping gene GAPDH, the glutamate transporter EAAT-1, and glutamate receptors (NR2A and KA1). Quantitative RT-PCR assessed differences in the expression of EAAT-1, a dominant negative splice variant called EAAT-1ex9skip and osteocalcin after nor-malisation to GAPDH.

Good quality RNA was obtained from bone cores removed from drill holes during HTO surgery, with GAPDH, EAAT-1, NR2A and KA1 expression detected. Osteocalcin expression was high indicating RNA was derived from osteoblasts and osteocytes, but did not vary with anatomical site or disease status. End-stage RT-PCR indicated differential expression of EAAT-1 between medial and lateral bone samples in total knee arthroplasty, however these differences were not significant by quantitative RT-PCR. In one patient, EAAT-1 expression was significantly reduced in the anterior zone versus the middle or posterior zones (ANOVA, p< 0.001). EAAT-1ex9skip represented a significant proportion of the total EAAT-1 mRNA expression in bone from TKR patients, but appeared less abundant in HTO samples.

Conclusion: We have shown for the first time that glutamate transporters and receptors are highly expressed in subchondral bone of patients with osteoarthritis and that EAAT-1 expression may vary with anatomical location and pathology. Activation of these receptors and transporters by the increased synovial fluid concentrations of glutamate that occur in arthritis may contribute to pathological changes and nociception.

Purpose of the study: We describe a new modified arthroscopic technique of surgically treating avulsion fractures of the tibial eminence using the Scorpion device (Arthrex, Naples, FL).

Methods and results: A 57 year-old female who sustained a type II fracture of the tibial spine was treated with arthroscopic fracture fixation using the Scorpion device to place a whip stitch into the substance of the anterior cruciate ligament (ACL). Tibial tunnels were made on the anteromedial aspect of the tibia using the Acufex ACL guide (Smith and Nephew, Mansfield, MA) and the sutures were passed through these tunnels and tied over a bony bridge. At 6 months after surgery, the patient was asymptomatic and had returned to her daily activities. She had regained full range of movement and had a clinically stable knee, confirmed on KT 2000 arthrometer. Radiographs showed anatomic reduction and fracture union.

Conclusion: The Scorpion device which is commonly used in arthroscopic shoulder surgery provides significant advantages as it can be used arthroscopically to place a whip stitch in the substance of the ACL. The hook at its end can be used to retrieve suture loop from the joint, thus reducing instrumentation and operating time. It is a user friendly arthroscopic technique that restores the necessary tension in the ACL, provides stable fracture fixation, and also results in a cosmetic end result.

Purpose of the study: Since glutamate can activate both nociceptive and pathological processes, we have investigated glutamate signalling in patients with painful and asymptomatic meniscal tears to determine which components are expressed, whether this varies in different anatomical regions of the meniscus and whether it is influenced by pain or degeneration.

Methods and results: Meniscus samples were obtained from two patients undergoing arthroscopic partial meniscal resection for chronic degenerate painful meniscal tears, from one patient with a torn painless meniscus and from the less affected compartment of the knee joint of three patients undergoing total knee arthroplasty. Menisci were dissected into anatomical regions (anterior horn, body, posterior horn, inner vascular, outer avascular), cryosectioned and RNA extracted. RNA was reverse transcribed and PCR performed for the housekeeping gene GAPDH and glutamate receptor subunits (NR2A, AMPA GluR3, KA1). Absolute quantitative RT-PCR assessed mRNA expression of glutamate transporters (EAAT-1, EAAT-1ex9skip) and type I collagen after normalisation to GAPDH or total RNA.

Human meniscus expressed GAPDH, type 1 collagen, EAAT-1, EAAT-1ex9skip, NR2A, AMPA GluR3 and KA1 mRNAs. Levels of EAAT-1 expression, normalised to GAPDH, did not differ between the inner and outer halves, or in the anterior, middle or posterior regions of menisci from the less affected compartments of arthritic knees. EAAT-1 expression appeared greater in the 2 painful, compared with the single non-painful meniscus. Interestingly, EAAT-1ex9skip was significantly more common within the outer zones (ANOVA, P=0.040) and in the posterior horns of the menisci (ANOVA, p=0.038).

Conclusion: We have shown for the first time that glutamate receptors and transporters are expressed in human meniscus providing a potential mechanism underlying the pathophysiology of pain associated with a torn meniscus. Our preliminary data indicate that EAAT-1 and EAAT-1ex9skip expression may vary with extent of damage and anatomical location in the human meniscus.

Purpose of the study: We report an unusual complication of patella tendon rupture that occurred secondary to the use of static cement spacer blocks in a series of three patients undergoing staged revision total knee arthroplasty (TKA) for infection.

Methods and results: 3 male patients developed patella tendon injury secondary to anterior subluxation of static cement spacer blocks used at the first of a two-stage revision procedure for infected TKA. Average patient age was 70 years. The interval between the 1st and the 2nd stages varied between 3.5 to 24 months. At the second stage, it was observed that the patella tendon was completely severed and irreparable in one case, whereas it was partially injured and repairable in the other two cases. In the case with irreparable tendon injury, stable joint reconstruction could not be achieved at the second stage and ultimately resulted in knee arthrodesis. In the other two cases, 2nd stage revision was performed using hinged revision knee components and the tendon injury was repaired and protected with a circlage wire. None of the patients were satisfied with their outcome at the final review.

Conclusion: This is the first report in the literature reporting the complication of patella tendon rupture secondary to the use of static cement spacer blocks in staged revision knee arthroplasty. The injury can either be repairable or irreparable. The functional outcome and satisfaction is not good after the salvage procedures. Therefore, we recommend that these spacer blocks should not be used in revision knee arthroplasty.

We have studied the natural history of a first episode of dislocation after primary total hip replacement (THR) to clarify the incidence of recurrent dislocation, the need for subsequent revision and the quality of life of these patients.

Over a six-year period, 99 patients (101 hips) presented with a first dislocation of a primary THR. A total of 61 hips (60.4%) had dislocated more than once. After a minimum follow-up of one year, seven patients had died. Of the remaining 94 hips (92 patients), 47 underwent a revision for instability and one awaits operation (51% in total). Of these, seven re-dislocated and four needed further surgery. The quality of life of the patients was studied using the Oxford Hip Score and the EuroQol-5 Dimension (EQ-5D) questionnaire. A control group of patients who had not dislocated was also studied. At a mean follow-up of 4.5 years (1 to 20), the mean Oxford Hip Score was 26.7 (15 to 47) after one episode of dislocation, 27.2 (12 to 45) after recurrent dislocation, 34.5 (12 to 54) after successful revision surgery, 42 (29 to 55) after failed revision surgery and 17.4 (12 to 32) in the control group. The EuroQol-5 dimension questionnaire revealed more health problems in patients undergoing revision surgery.