Pseudo-patella baja (PPB) describes narrowing of the distance between the patella and the tibia without shortening of the PT and occurs following Total Knee Arthroplasty (TKA), where the tibial prosthesis plus insert are thicker than the resected tibia. Soft tissue balancing is an important factor in the success of TKA, but if extensive may necessitate the use of thicker tibial inserts with the risk of creating a PPB. Patients who undergo extensive soft tissue releases during TKA, with resultant use of thicker tibial inserts will develop a PPB, with increased risk of patella pathology.

506 patients aged 40-90 years underwent 526 Kinemax TKAs, performed by 7 surgeons in 5 centres between 1999 and 2002. The extent of soft tissue releases and the thickness of tibial inserts were recorded. Pre- and post-operative lateral radiographs were measured by an independent observer, using the Caton-Deshamps method to assess patella position. The patients were assessed using the Oxford Knee Score and the American Knee Society Clinical Rating System, with a minimum follow-up of 12 months.

1. TKA surgery creates a Pseudo-Patella Baja. Excluding patients with a pre-operative patella baja, PPB was introduced into 26.7% of patients. (p=0.000). 2. The incidence of pseudo-patella baja increased with the extent of soft tissue release; Minimal, Moderate or Extensive. (p=0.000). 3. The incidence of pseudo-patella-baja increased with increases in insert thickness. Three groups were identified: Inserts 8 mm, inserts 10-12mm, and inserts 15-22 mm. (p=0.035). There was no correlation between the incidence of PPB and changes in clinical or functional outcome, as measured using the OKS and AKSS.

Pseudo-patella baja occurs in 26% of all patients following TKA, and in 46% of patients in whom extensive soft tissue releases have been performed and/or large tibial inserts have been used. At 12 months, no detrimental outcomes were attributable to the incidence of pseudo-patella baja.

Indications for Total Knee Arthroplasty (TKA) include pain and disability. Correction of instability is essential to post operative outcome as instability is often a component of pre-operative functional disability, particularly in patients with valgus deformity. Soft tissue balancing is essential to the success of TKA. Anecdotally, patients with valgus deformity seemed to complain more of instability than pain. The aim of this study was to identify the role and significance of instability and determine whether patients with instability benefit more from TKA as it is useful to determine which patient characteristics will predict success in TKA.

Five hundred and two patients aged 45–90 years underwent 522 Kinemax TKAs, performed by seven surgeons in five centres between October 1999 and December 2002. Soft tissue releases were recorded and objective soft tissue balance recorded using a ‘balancer’ device. Independent observers assessed patients using 3 outcome measures including the American Knee Society Score (AKSS) for a minimum of 12 months. Pre-operative alignment was divided into 6 groups according to the degree of varus or valgus deformity (mild, moderate, severe varus or valgus). Specific components of the AKSS including pain scores, knee scores and medio-lateral stability scores were specifically analyzed.

There is a significant difference in the improvement of the knee scores between the severely valgus knees and all varus knees (ANOVA p=0.000). Significant differences were found between pre-operative pain scores, knee scores and medio-lateral stability between severely varus and severely valgus knees (ANOVA p=0.029, p=0.000 & p=0.000 respectively).

Knees with severe valgus deformities have significantly worse pre operative scores and show greater improvement with equivocal post-operative outcome, when compared to those with severe varus deformity. We believe that this significant improvement is due to the fact that both key issues in the severely deformed valgus knee, namely pain and instability, have been addressed.

Soft tissue balance is known to be an important factor for the success of Total Knee Arthroplasty (TKA). This is of particular relevance in the surgical management of a valgus knee which has both bony and soft tissue abnormalities which need addressing. The correction of instability, particularly in severely valgus knees is essential to post operative outcome as instability is often a component of pre-operative functional disability. Traditional surgical techniques involve soft tissue releases and bony cuts to achieve the correct balance. Evaluation of balance is currently based on subjective intra-operative clinical assessment, or the feel of the knee. More recently, an instrument to objectively measure soft tissue balance following bony cuts has been developed. Soft tissue releases using this instrument may be extensive.

502 patients aged 45–90 years underwent 522 Kine-max TKAs, performed by seven surgeons in five centres between October 1999 and December 2002. Soft tissue releases were recorded and objective soft tissue balance recorded using a balancer device. Independent observers assessed patients using 3 outcome measures for a minimum of 12 months. Pre-operative alignment was divided into 6 groups according to the degree of varus or valgus deformity (mild, moderate, severe varus or valgus).

There is a significant difference in the improvement of the knee scores between the severely valgus knees and all varus knees (ANOVA p=0.000). Significant differences were found between pre-operative pain scores, knee scores and medio-lateral stability between severely varus and severely valgus knees (ANOVA p=0.029, p=0.000 & p=0.000 respectively).

Knees with severe valgus deformities have significantly worse pre operative scores and show greater improvement with equivocal post-operative outcome, when compared to those with severe varus deformity. In addition to pain relief, is the correction of instability the key to this improvement in this group of patients?

Introduction: Patella baja is the distal positioning of the patella in relation to the femoral condyles in the sagittal plane. True patella baja is due to shortening of the patella tendon (PT), as measured by the Insall-Salvati method, and narrowing of the distance between the patella and the proximal tibia. Pseudo-patella baja describes narrowing of the distance between the patella and the proximal tibia without shortening of the PT and occurs following Total Knee Arthroplasty (TKA), where the tibial prosthesis plus insert are thicker than the resected tibia. Both may cause patella pathology, pain and a reduced range of motion. Pseudo-patella baja can be detected using the Caton-Deschamps method.

Soft tissue balancing is an important factor in the success outcome of TKA, but if extensive can necessitate the use of thicker tibial inserts. This may alter the position of the patella in relation to the tibia and increases the risk of creating a pseudo-patella baja.

Hypothesis: Patients who undergo extensive soft tissue releases during TKA, with the resultant use of thicker tibial inserts will develop a pseudo-patella baja, and will have a poorer outcome and reduced range of motion.

Method: In this prospective study, 506 patients aged 40–90 years underwent 526 Kinemax TKAs, performed by 7 surgeons in 5 centers between October 1999 and December 2002. The extent of soft tissue releases and the size of tibial inserts were recorded. Independent observers used the Caton-Deshamps method to assess patella position measured Pre and post-operative lateral radiographs. The patients were also assessed using the Oxford Knee Score and the American Knee Society Clinical Rating System, with a minimum follow-up of 12 months.

Results:

TKA surgery creates a Pseudo-Patella Baja. Excluding patients with a pre-operative patella baja, pseudo patella baja was introduced into 25.6% of patients. (p=0.00).

Conclusion: Pseudo patella baja occurs in 25% of all patients following TKA, and in over 40% of patients in whom extensive soft tissue releases have been performed and/or large tibial inserts have been used. At 12 months, no detrimental outcomes were attributable to the incidence of pseudo patella baja.

Introduction: Soft tissue balancing is an important factor in the success of TKA, but if extensive may necessitate the use of thicker tibial inserts with the risk of creating a Pseudo-patella baja (PPB), which describes narrowing between the patella and the tibia without shortening of the PT, and occurs when the tibial prosthesis plus insert are thicker than the resected tibia.

Hypothesis: Patients who undergo extensive soft tissue releases during TKA, with resultant use of thicker tibial inserts will develop a PPB, with increased risk of patella pathology.

Method: 506 patients aged 40–90 years underwent 526 Kinemax TKAs, between 1999 and 2002. The extent of soft tissue releases and thickness of tibial inserts were recorded. Patella height was measured on pre and postoperative radiographs by an independent observer. Outcome was assessed using the Oxford Knee Score and the American Knee Society Clinical Rating System, with a minimum follow-up of 12 months.

Results:

TKA surgery creates a Pseudo-Patella Baja. PPB was introduced into 26.7% of patients. (p=0.000).

There was no correlation between the incidence of PPB and changes in outcome, as measured using the OKS and AKSS.

Conclusion: Pseudo patella baja occurs in 26% of all patients following TKA, and in 46% of patients in whom extensive soft tissue releases have been performed and/or large tibial inserts have been used. AT 12 months, no detrimental outcomes were attributable to the incidence of pseudo patella baja.

We studied the influence of soft-tissue releases and soft-tissue balance on the outcome of 526 total knee replacements one year after operation. The surgery had been performed by seven surgeons in five centres in the United Kingdom between October 1999 and December 2002. Balancing was carried out by five surgeons using spacers and trials and by two surgeons using a ‘balancer’ instrument. All the surgeons assessed the adequacy of their releases by taking measurements with the balancer after soft-tissue release before implanting the components. Independent observers collected the Oxford knee scores and applied the American Knee Society functional and knee scores as well as recording the range of movement of the replaced knee. These were compared with the pre-operative scores and the extent of the releases.

We found differences in outcomes between minimal and extensive releases and between balanced and imbalanced knees.

Knees requiring extensive soft-tissue releases showed greater change in the short-term clinical outcome without increased complications and achieved similar results at one year compared with those with less deformity pre-operatively which had required less soft-tissue release. Balancing an imbalanced knee improved the short-term knee outcome.

Soft tissue balance is known to be an important factor for the success of Total Knee Arthroplasty (TKA). Traditional surgical techniques involve soft tissue releases and bony cuts to achieve the correct balance. Evaluation of balance is currently based on subjective intraoperative clinical assessment, or the “feel” of the knee. More recently, an instrument to objectively measure soft tissue balance following bony cuts has been developed. Soft tissues releases using this instrument may be extensive.

Hypothesis. The hypothesis is that patients who undergo more extensive releases will have poorer short-term outcome and increased complication rates compared to those who undergo less extensive releases.

Method: 506 patients aged 40–90 years underwent 526 Kinemax TKAs, performed by seven surgeons in five centres between October 1999 and December 2002. Five surgeons used traditional methods for soft tissue balancing and two were guided by the balancer instrument taking measurements pre- and post-releases. Patients were assessed by an independent observer using the Oxford Knee Score, the American Knee Society Score and radiographic evaluation, with a minimum follow-up of 12 months.

Results: Extensive soft tissue releasing procedures showed no significant difference in outcome in comparison with minimal releases. For the 2 surgeons using the ‘balancer’ technique, a significant difference was seen with the change in knee scores. The knees left imbalanced had substantially lower change scores and the imbalanced – balanced group showed the most improvement. There was no significant difference between surgical technique or range-of-movement with outcome. Complication rates were low, clinically representative and showed no significant difference between the groups.

Conclusions: Extensive soft tissue releases do not result in an increase in complication rate or a poorer short-term outcome. When comparing traditional and ‘balancer’ guided techniques there is no difference in outcomes. Balancing an imbalanced knee significantly improves knee outcome.

Soft tissue balance is known to be an important factor for the success of Total Knee Arthroplasty.Traditional surgical techniques involve soft tissue releases and bony cuts to achieve the correct balance. Evaluation of balance is currently based on subjective intra-operative clinical assessment, or the feel of the knee. More recently, an instrument to objectively measure soft tissue balance following bony cuts has been developed. Soft tissues releases using this instrument may be extensive.

Hypothesis. The hypothesis is that patients who undergo more extensive releases will have poorer short-term outcome and increased complication rates compared to those who undergo less extensive releases.

Method. 506 patients aged 40–90 years underwent 526 Kinemax TKAs, performed by seven surgeons in five centres between October 1999 and December 2002. Five surgeons used traditional methods for soft tissue balancing and only took balancer measurements pre-cementation. The other two were guided by the balancer instrument and took measurements pre- and post-releases, therefore quantifying how imbalanced the knees were at the beginning of the operation. Patients were assessed by an independent observer using the Oxford Knee Score, the American Knee Society Clinical Rating System and the Roentographic and Evaluation Scoring System, with a minimum follow-up of 12 months.

Results. Extensive soft tissue releasing procedures showed no significant difference in outcome in comparison with minimal releases. For the 2 surgeons using the balancer technique, a significant difference was seen with the change in knee scores. The knees left imbal-anced had substantially lower change scores and the imbalanced – balanced group showed the most improvement. Regarding surgical technique, there was no significant difference between the groups with the Oxford Knee Score or with the Clinical Rating System. Range of movement and outcome also showed no significant difference between any of the groups. Complication rates were low, clinically representative and showed no significant difference between the groups.

Conclusions. Extensive soft tissue releases do not result in an increase in complication rate or a poorer short-term outcome. When comparing traditional and balancer guided techniques there is no difference in outcomes. Balancing an imbalanced knee significantly improves knee outcome.

Decreasing proprioception of the knee is multifactorial and is a function of age and degenerative joint disease. Soft-tissue release during total knee replacement may have an influence. We have quantified soft-tissue imbalance at the time of knee replacement and attempted to eliminate it at full extension, using established methods.

We studied the influence of residual soft-tissue imbalance on postoperative proprioception, assessing this in 38 patients before total knee replacement and at three and six months postoperatively.

We found that proprioception improved in varus knees at three and six months after soft-tissue balancing procedures. Knees balanced in full extension and in flexion (< ±2°) showed a significant improvement in proprioception (p < 0.0005) whereas those which were not balanced in flexion but fully balanced in extension had no significant improvement. We conclude that soft-tissue balance in both flexion and extension is important to allow satisfactory postoperative proprioception of the knee.

We report on the radiological findings in a series of 871 consecutive primary condylar knee replacements followed up for an average of four years. A new radiological sign has been identified, consisting of a smoothly tapering wedge of cement visible beneath the horizontal portion of the tibial component on the anteroposterior radiograph. This was found in 25.4% of our cases and appears to indicate a persistent soft-tissue imbalance following condylar arthroplasty of the knee. The cement-wedge sign was associated with a highly significant increase in radiolucent lines at the tibial cement-bone interface.