Aims

The aim of this study was to estimate the incremental use of resources, costs, and quality of life outcomes associated with surgical reconstruction compared to rehabilitation for long-standing anterior cruciate ligament (ACL) injury in the NHS, and to estimate its cost-effectiveness.

Aims

To map the Oxford Knee Score (OKS) and High Activity Arthroplasty Score (HAAS) items to a common scale, and to investigate the psychometric properties of this new scale for the measurement of knee health.

Aims

To calculate how the likelihood of obtaining measurable benefit from hip or knee arthroplasty varies with preoperative patient-reported scores.

Aims

The aim of the British Association for Surgery of the Knee (BASK) Meniscal Consensus Project was to develop an evidence-based treatment guideline for patients with meniscal lesions of the knee.

Aims

The aims of this study were to compare the use of resources, costs, and quality of life outcomes associated with subacromial decompression, arthroscopy only (placebo surgery), and no treatment for subacromial pain in the United Kingdom National Health Service (NHS), and to estimate their cost-effectiveness.

Aims

The aim of this to study was to compare the previously unreported long-term survival outcome of the Oxford medial unicompartmental knee arthroplasty (UKA) performed by trainee surgeons and consultants.

Objective

The objective of this study was to explore dimensionality of the Oxford Hip Score (OHS) and examine whether self-reported pain and functioning can be distinguished in the form of subscales.

Aims

Femoroacetabular Junction Impingement (FAI) describes abnormalities in the shape of the femoral head–neck junction, or abnormalities in the orientation of the acetabulum. In the short term, FAI can give rise to pain and disability, and in the long-term it significantly increases the risk of developing osteoarthritis. The Femoroacetabular Impingement Trial (FAIT) aims to determine whether operative or non-operative intervention is more effective at improving symptoms and preventing the development and progression of osteoarthritis.

This protocol describes a pragmatic multicentre randomised controlled trial (RCT) to assess the clinical and cost effectiveness of arthroscopic and open surgery in the management of rotator cuff tears. This trial began in 2007 and was modified in 2010, with the removal of a non-operative arm due to high rates of early crossover to surgery.

Cite this article: Bone Joint Res 2014;3:155–60.

Introduction

A prospective study was done using Kirschner (K) wires to internally fix capitellum fractures and its results were analysed.

Objectives

The number of surgical procedures performed each year to treat femoroacetabular impingement (FAI) continues to rise. Although there is evidence that surgery can improve symptoms in the short-term, there is no evidence that it slows the development of osteoarthritis (OA). We performed a feasibility study to determine whether patient and surgeon opinion was permissive for a Randomised Controlled Trial (RCT) comparing operative with non-operative treatment for FAI.

Rheumatology and Musculoskeletal Sciences, NIHR Biomedical Research Unit, University of Oxford and the Nuffield Orthopaedic Hospital, Oxford

Femoral stem varus has been associated with poorer results. We report the incidence of varus/valgus malalignment of the Exeter polished, double taper design in a multicentre prospective study. The surgical outcomes at a minimum of five year and complication rates are also reported.

A multicentre prospective study of 987 total hip replacements was undertaken to investigate whether there is an association between surgical outcome and femoral stem malalignment. The primary outcome measure was the change in the Oxford hip score (OHS) at five years. Secondary outcomes included the rate of dislocation and revision.

The incidence of varus and valgus malignment were 7.1% and 2.6% respectively. There was no significant difference in OHS between neutral and malaligned femoral stems at 5 years (neutral, mean = 40.2; varus, mean 39.3, p = 0.465; valgus, mean = 40.9, p = 0.605). There was no significant difference in dislocation rate between the groups (p = 0.66). There was also no significant difference in revision rate (p = 0.34).

This study provides evidence that the Exeter stem is extremely tolerant of varus and valgus malalignment, both in terms of outcome and complication rate.

Introduction: Patellofemoral joint subluxation is associated with pain and dysfunction. The causes of patel-lofemoral subluxation are poorly understood and multi-factorial, arising from abnormalities of both bone and soft tissues. This study aims to identify which anatomical variables assessed on Magnetic Resonance (MR) images are most relevant to patellofemoral subluxation.

Method: A retrospective analysis of MR studies of 60 patients with suspected patellofemoral subluxation was performed. All patients were graded for the severity/ magnitude of radiological subluxation using a dynamic MR scan (Grade 0 [nil] to Grade 3 [subluxed]. The patient scans were assessed using a range of anatomical variables, these included:

Patella alta,

Results: The distance of the VMO from the patella (p < 0.001), TTD (p < 0.001) and Patella Engagement (p < 0.001) showed highly significant relationships with patellofemoral subluxation.

Conclusions: The following three anatomical variables are associated with patellofemoral subluxation: the distance of the VMO muscle from the patella, TTD and Patella Engagement.

This is the first study to establish that patella engagement is related to PFJ subluxation showing that the lower the percentage engagement of the patella in the trochlea, the greater the severity/magnitude of patellofemoral subluxation. The finding provides greater insight into the aetiology and understanding of the mechanism of symptomatic PFJ subluxation.

Purpose: Varus deformity after total knee replacement (TKR) is associated with poor outcome. This aim of this study was to determine whether the same is true for medial unicompartmental arthroplasty (UKA).

Methods: 158 patients implanted with the Oxford UKA, using a minimally invasive approach, were studied prospectively for five years. Leg alignment was measured with a long-arm goniometer referenced from Anterior Superior Iliac Spine, centre of patella and centre of ankle. Patients were grouped according to the American Knee Society Score (AKSS). Group A: > 0° varus (n=13, 8.2%); Group B: 0 to 4° valgus (n=39, 24.7%); Group C: 5–10° valgus (normal alignment, n=106, 67.12%). Comparisons were made between the three groups in terms of the absolute and the change in Oxford Knee Score (OKS) and AKSS over the five year period, and the presence of radiolucency.

Results: There was no significant difference in any outcome measure except for Objective-AKSS (p< 0.001). The means and standard deviations of the ΔOKS for the groups were:

24 ± 5,

The frequency of five year radiolucency for the groups A, B, and C were 42%, 35%, and 45% respectively.

Conclusion: The aim of the Oxford UKA is to restore knee kinematics and thus knee alignment to the pre-disease state. Therefore, as demonstrated by this study, about 30% of patients have varus alignment. This study also demonstrates that post-operative varus alignment does not compromise the outcome. The only score which did show worse outcome was the Objective-AKSS. This is because 10 or 20 points are deducted for varus alignment, which is not appropriate following UKA. Therefore, AKSS in its present form is not a reliable tool for assessment of UKA.

Purpose: To evaluate the effects of underhanging/overhanging tibial components on clinical outcome following the Oxford unicompartmental knee arthroplasty (UKA), and to identify an acceptable sizing limit.

Method: One hundred and sixty-three knees which had undergone the Phase 3 medial Oxford UKA (Biomet, Swindon) were measured. Based on five-year post-operative radiographs, they were divided into groups with tibial component underhang (n=38), none or minimal overhang of less than three millimetres (n=121), and a group with overhang equal to or in excess of three millimetres (n=13). Clinical outcome was assessed by changes in the twelve-question Oxford Knee Score (ΔOKS) and pain score (ΔPS) component (questions 1,4,5,8,9) from pre-operative assessment to five years following surgery.

Results: At five years after surgery, ΔOKS was significantly worse in the overhang group compared to both the neutral and underhang groups (p=0.015, and p=0.028 respectively). ΔPS was also shown to be significantly worse between the overhang and the neutral group (p=0.026 respectively).

Conclusion: Appropriate sizing of the tibial component is essential to optimise load bearing in total knee arthroplasty. In UKA such sizing is critical due to halving of the bony support for the tibial component and the lack of room for a large stem. Excessive undersizing of the prosthesis may lead to subsidence and loosening, whilst excessive overhanging may cause local soft tissue irritation and pain.

This study demonstrates that medial overhang of less than three millimetres for the tibial component is acceptable in the Oxford UKA. Excessive overhang equal to this or more results in significantly worse ΔOKS and ΔPS. However, no difference in the five year ΔOKS and ΔPS was demonstrated between underhang and the other two groups in this study.

Purpose: To identify associative factors for radiolucency (RL) under the tibial component following the Oxford unicompartmental arthroplasty (UKA), and to evaluate its effect on clinical outcome scores.

Method: One hundred and sixty-one knees which had undergone primary Phase 3 medial Oxford UKA were included. Fluoroscopic radiography films were assessed at five years post-operatively for areas of tibial RL. The two groups of patients, with and without RL, were compared to

patients’ pre-operative demographics for age, weight, height, BMI,

Results: 101 (62%) knees were found to have tibial RL. All RL were categorised as physiological or they were < 1mm thick, with sclerotic margins and non-progressive. No statistical difference was found between knees with RL and those without, in terms of pre-operative demographics, intra- or post-operative factors, and clinical outcome scores (p> 0.1 in all variables).

Discussion: Radiolucency (RL) under the tibial component is a common finding following the Oxford UKA. Many theories have been proposed to explain the cause of RL, such as poor cementing, osteonecrosis, micromotion, and thermal necrosis. However, the true aetiology and clinical significance remain unclear. We attempted to address this.

We found no significant relationship between physiological RL, pre-operative demographics, intra-operative variables and clinical outcome scores in this study. Tibial RL remains a common finding following the Oxford UKA yet we do not know why it occurs but in the medium term, clinical outcome is not influenced by RL. In particular, it is not a sign of loosening. Physiological RL can therefore be ignored even if associated with adverse symptoms following the Oxford UKA.

Introduction: A new procedure has been recently adopted to implant the Oxford medial unicompartmental arthroplasty (UCA). All cases are now implanted through a short incision without dislocation of the patella. The aims of this study were to assess the one-year results using this new technique and to determine if the outcome is dependent on surgical experience.

Method: The first 104 Oxford UCA’s (Phase 3) implanted by six surgeons under the care of two consultants were reviewed at one year. All operations were performed using the new technique. The average age at surgery was 68 years. All knees were scored pre-operatively and at review with the American Knee Society score. The cohort was divided into two groups; the first ten cases for each surgeon were included in a ‘learning’ group, whilst the remaining cases were included in an ‘experienced’ group.

Results: Overall the average ‘knee score’ improved from 37 points to 94 and the average ‘functional score’ from 50 points to 92. Average maximum flexion improved from 117° to 131°. The ‘knee score’ for the ‘learning’ group was 91 points. This was significantly less (p = 0.008) than the score of the ‘experienced’ group (96 points).

Conclusions: These results are significantly better than the best historical results of the Oxford (UCA), performed through an open approach with dislocation of the patella.

Despite impressive overall results at one year, lower knee scores were associated with a surgeons ‘learning curve’. After this ‘learning curve’, increased surgical experience led to further improvement with 90% achieving an excellent result, 8% a good, 2% a fair and 0% a poor result.

Introduction: In conjunction with a bilateral randomised control trial comparing the clinical outcome of two total knee arthroplasties (TKA), we carried out an in-vivo fluoroscopic analysis of both knees in the trial. Knee A, is a new mobile bearing posterior cruciate retaining TKA and Knee B, an established fixed bearing posterior cruciate retaining TKA.

Method: In an ethically approved study, video fluoroscopy was taken of both knees of seven patients performing three exercises; extension against gravity, flexion against gravity and a step up exercise. Ten images at ten-degree intervals over the flexion range were frame grabbed and digitised. The relationship of patella tendon angle (PTA) to knee flexion angle (KFA) was assessed using a newly developed computer system. Five normal knees in fit volunteers were also fluoroscoped and assessed.

Results: A similar pattern of results was obtai ed for all three exercises. Knee A behaved in a linear, more consistent fashion than Knee B, which behaved non-linearly. Analysis of variance showed this difference was significant for all three exercises (p < 0.039).

Conclusions: This bilateral study provides a powerful way of assessing the kinematics of two different knee implants. Knee A behaves in a linear predictable fashion that is nearer normal than Knee B. These results will be used in conjunction with a clinical outcome study and an RSA study to provide a complete assessment of a new TKA.

Introduction: The Oxford medial unicompartmental arthroplasty (UCA) is now routinely performed through a short incision without Dislocation of the patella. The aim of this study was to assess the one-year results of this new technique to determine whether it enhances the quality of outcome, as well as the speed of its achievement.

Method: The first 88 consecutive Oxford UCA’s (Phase 3) implanted into 75 patients by two consultant surgeons were scored pre-operatively and at review with the American Knee Society Score. The average age of the patients was 68.1 years; the male to female ratio was 0.9 to 1.

Results: At review, one patient (one knee) had died and one knee had been revised for infection. The other patients (86 knees) were examined at a mean of 1.3 years from surgery. The average ‘knee score’ improved from 37 points to 95 and the average ‘functional score’ from 51 points to 93. Average maximum flexion improved from 117° to 132°. The ‘knee score’ outcome categories at review were 87% excellent, 8% good, 2.5% fair and 2.5% poor.

Conclusions: Historical comparison of these results with the best results of the Oxford UCA, performed through an open approach with dislocation of the patella, suggest that the minimally invasive approach, in addition to faster recovery, improves the quality of outcome at one year.