Abstract

Conventional proximal tibial osteotomy is a widely successful joint-preserving treatment for osteoarthritis; however, conventional procedures do not adequately control the posterior tibial slope (PTS). Alterations to PTS can affect knee instability, ligament tensioning, knee kinematics, muscle and joint contact forces as well as range of motion.

This study primarily aimed to provide a comprehensive investigation of the variables influencing PTS during high tibial osteotomy using a 3D surgical simulation approach. Secondly, it aimed to provide a simple means of implementing the findings in future 3D pre-operative planning and /or clinically.

The influence of two key variables: the gap opening angle and the hinge axis orientation on PTS was investigated using three independent approaches: (1) 3D computational simulation using CAD software to perform virtual osteotomy surgery and simulate the post-operative outcome. (2) Derivation of a closed-form mathematical solution using a generalised vector rotation approach (3) Clinical assessment of synthetically generated x-rays of osteoarthritis patients (n=28; REC reference: 17/HRA/0033, RD&E NHS, UK) for comparison against the theoretical/computational approaches.

The results from the computational and analytical assessments agreed precisely. For three different opening angles (6°, 9° and 12°) and 7 different hinge axis orientations (from −30° to 30°), the results obtained were identical. A simple analytical solution for the change in PTS, ΔP_s, based on the hinge axis angle, α, and the osteotomy opening angle, θ, was derived:

ΔP_s=sin^-1(sin α sin θ)

The clinical assessment demonstrated that the absolute values of PTS, and changes resulting from various osteotomies, matched the results from the two relative prediction methods.

This study has demonstrated that PTS is impacted by the hinge axis angle and the extent of the osteotomy opening angle and provided computational evidence and analytical formula for general use.

High tibial osteotomy (HTO) is an effective surgical treatment for isolated medial compartment knee osteoarthritis; however, widespread adoption is limited due to difficulty in achieving the planned correction, and patient dissatisfaction due to soft tissue irritation. A new HTO system – Tailored Osteotomy Knee Alignment (TOKA®, 3D Metal Printing Ltd, Bath, UK) could potentially address these barriers having a custom titanium plate and titanium surgical guides featuring a unique mechanism for precise osteotomy opening as well as saw cutting and drilling guides. The aim of this study was to assess the accuracy of this novel HTO system using cadaveric specimens; a preclinical testing stage ahead of first-in-human surgery according to the ‘IDEAL-D’ framework for device innovation.

Local ethics committee approval was obtained. The novel opening wedge HTO procedure was performed on eight cadaver leg specimens. Whole lower limb CT scans pre- and post-operatively provided geometrical assessment quantifying the discrepancy between pre-planned and post-operative measurements for key variables: the gap opening angle and the patient specific surgical instrumentation positioning and rotation - assessed using the implanted plate.

The average discrepancy between the pre-operative plan and the post-operative osteotomy correction angle was: 0.0 ± 0.2°. The R2 value for the regression correlation was 0.95.

The average error in implant positioning was −0.4 ± 4.3 mm, −2.6 ± 3.4 mm and 3.1 ± 1.7° vertically, horizontally, and rotationally respectively.

This novel HTO surgery has greater accuracy and smaller variability in correction angle achieved compared to that reported for conventional or other patient specific methods with published data available. This system could potentially improve the accuracy and reliability of osteotomy correction angles achieved surgically.

Abstract

Abstract

The radiographic or bony landmark techniques are the two most common methods to determine Medial patellofemoral ligament (MPFL) femoral tunnel placement. Their intra/inter-observer reliability is widely debated. The palpation technique relies on identifying the medial epicondyle (ME) and adductor Tubercle (AT). The central longitudinal artery and associated vessels (CLV) are consistently seen in the surgical dissection during MPFL reconstruction. The aim of this study was to investigate the anatomic relationship of CLV to ME-AT and thereby use CLV as an important vascular landmark during MPFL reconstruction.

A retrospective review of MRI scans in skeletally mature patients presenting to a tertiary referral knee clinic was undertaken. Group-N consisted of any presentation without patellofemoral instability or malalignment (PFI). Group-P with PFI. MRI's were reviewed and measured by two Consultant Radiologists for the CLV-ME-AT anatomy and relationship.

Following exclusions 50 patients were identified in each group. The CLV passed anterior to the AT and ME in all patients. ME morphology did not differ greatly between the groups except in the tubercle height, where there was a statically but not clinically significant difference (larger in the non-PFI group, 2.95mm vs 2.52mm, p=0.002). The CLV to ME Tip distance was consistent between the groups (Group PFI group 3.8mm & ‘normal’ non-PFI Group 3.9mm).

The CLV-ME-AT relationship remained consistent despite patients presenting pathology. The CLV consistently courses anterior to ME and AT. The CLV could be used as a vascular landmark assisting femoral tunnel placement during MPFL reconstruction.

Abstract

Abstract

Recognized anatomic variations that lead to patella instability include patella alta and trochlea dysplasia. Lateralization of the extensor mechanism relative to the trochlea is often considered to be a contributing factor; however, controversy remains as to the degree this contributes to instability and how this should be measured. As the tibial tuberosity-trochlear groove (TT-TG) is one of most common imaging measurements to assess lateralization of the extensor mechanism, it is important to understand its strengths and weaknesses. Care needs to be taken while interpreting the TT-TG value as it is affected by many factors. Medializing tibial tubercle osteotomy is sometimes used to correct the TT-TG, but may not truly address the underlying anatomical problem. This review set out to determine whether the TT-TG distance sufficiently summarizes the pathoanatomy, and if this assists with planning of surgery in patellar instability.

Cite this article: Bone Jt Open 2022;3(3):268–274.

Abstract

Background

The meniscal deficient knee often exists in the setting of associated pathology including instability, malalignment and chondral injury. Meniscal allograft transplantation (MAT) is established to be a reliable option in restoring function and treating symptoms. The aim of this study was to establish the role of MAT as part of a staged approach to treatment of the previously menisectomised knee.

Patellar instability most frequently presents during adolescence. Congenital and infantile dislocation of the patella is a distinct entity from adolescent instability and measurable abnormalities may be present at birth. In the normal patellofemoral joint an increase in quadriceps angle and patellar height are matched by an increase in trochlear depth as the joint matures. Adolescent instability may herald a lifelong condition leading to chronic disability and arthritis.

Restoring normal anatomy by trochleoplasty, tibial tubercle transfer or medial patellofemoral ligament (MPFL) reconstruction in the young adult prevents further instability. Although these techniques are proven in the young adult, they may cause growth arrest and deformity where the physis is open. A vigorous non-operative strategy may permit delay of surgery until growth is complete. Where non-operative treatment has failed a modified MPFL reconstruction may be performed to maintain stability until physeal closure permits anatomical reconstruction. If significant growth remains an extraosseous reconstruction of the MPFL may impart the lowest risk to the physis. If minor growth remains image intensifier guided placement of femoral intraosseous fixation may impart a small, but acceptable, risk to the physis.

This paper presents and discusses the literature relating to adolescent instability and provides a framework for management of these patients.

Cite this article: Bone Joint J 2017;99-B:159–70.

Aim

This study aims to elucidate the effects of radiofrequency chondroplasty (RFC), a surgical technique for the treatment of damaged articular cartilage, at a microscopic scale. Here we report about two aspects of the study – a morphological analysis of the treated surface using nonlinear microscopy and Raman spectroscopy, and an investigation into changes in permeability to large and small molecules. Cartilage samples were obtained from

Patients with recurrent patella instability, who have an abnormal patellofemoral alignment (patella height or tibial tubercle-trochlear groove (TTTG) distance), benefit from tibial tubercle transfer along with medial patellofemoral ligament (MPFL) reconstruction. Between July 2008 and April 2013, 18 patients (21 knees) with recurrent patellar instability underwent combined MPFL reconstruction and tibial tubercle transfer. All patients had abnormal patellofemoral alignment in addition to MPFL insufficiency. 15 patients (16 knees) with a mean age of 24 years (16–41) had a mean follow up of 26 months (6–55). We assessed the outcome using KOOS, KUJALA, activity level and patient satisfaction scores. All patients had a stable patella. There was a significant improvement in outcome scores in 12 out of 15 patients. At final follow up KOOS score had improved from 68.25(44 to 93.9) to 77.05(48.8 to 96.4) and KUJALA score had improved from 63.3(41–88) to 78.06 (45 to 99). 9 patients showed excellent results and achieved at least a pre-injury level of activity. 4 of these had activity level better then preoperative level. 6 patients had a lower activity level than pre-injury (1 – ongoing physiotherapy, 1 – because of lack of confidence, and 4 – Life style modification). 14 patients were satisfied and happy to recommend this procedure. There were 3 postop complications, with 2 cases of stiffness and 1 case of non-union of the tibial tuberosity. Our prospective study has shown that restoration of tibial tubercle-trochlear groove index, Patella height and Medial Patellofemoral Ligament reconstruction yields good results in carefully selected patients.

Introduction

Anatomical reconstruction of the Anterior Cruciate Ligament (ACL) reconstruction has been shown to improve patient outcome. The posterior border of the anterior horn of the lateral meniscus (AHLM) is an easily identifiable landmark on MRI and arthroscopy, which could help plan tibial tunnel position in the sagittal plane and provide anatomical graft position intra-operatively.

The resection of distal femur and proximal tibia during TKR is 90° to mechanical axis but in a normal knee, the joint line is 3°varus. We measured various angles on long-leg alignment radiographs. The mean age was 58.7 years. The mean HKA axis was 4.3°± 0.5°, mPTA was 3.8°±0.5°, mLDFA was 3.6±0.5° and aLDFA was 8.6°±0.5°. The mean HKA & MPTA were approximately 4°varus, mLDFA 4° valgus & aLDFA 8°valgus. The alignment of the knee to its mechanical axis during TKR is therefore not anatomic. This raises a question whether the knee should be aligned to its kinematic axis instead of mechanical axis.

Kinematic alignment has increased in popularity over the last few years in an attempt to improve clinical outcomes following total knee arthroplasty (TKA).

In our unit kinematic alignment has been used with patient-specific cutting guides as part of on-going clinical trials. We performed a retrospective analysis on all the TKA which had been planned to be implanted outside of the mechanical axis (0° ± 3°) based on pre-operative MRI scans and looked at their radiographic and clinical outcomes.

We identified 21 knees which had been implanted as ‘planned outliers’. All had clinical and radiographic follow up to a mean 11.6 months post op. All had a standard long leg alignment radiograph performed at 6 weeks post op to confirm alignment.

All patients had a good improvement in their Oxford Knee Scores with mean improvement from 23 pre-op to 42 at 1 year. Of our patients none had a poor clinical outcome due to the alignment of their TKA, 1 patient had a poor outcome because of a quadriceps rupture which occurred 4 months post-op. There were no post-operative radiographic abnormalities.

In our unit kinematic alignment outside of the mechanical axis is not associated with an increased rate of short term complications.

Chondral damage within the knee commonly occurs during sport following direct trauma or following degeneration through overuse. Radio frequency energy chondroplasty (RFC) can be used as an alternative to mechanical chondroplasty in the arthroscopic treatment of chondral lesions. Current literature supports the theoretical advantage of RFC and purports to in vitro improvements in cartilage structure and function following RFC. We conducted a retrospective study of patients undergoing RFC for isolated chondral lesions in the knee and assessed the short term clinical benefits.

Retrospective analysis was completed of operative notes and arthroscopic images of all patients who underwent arthroscopic chondroplasty at the royal Devon and Exeter Hospital between January 2009 and June 2012. Inclusion criteria included 1 to 2 defined chondral lesions, less than 2cm2, of Outerbridge grade II-IV, treated via arthroscopic RFC. Exclusion criteria included diffuse articular cartilage damage, additional pathologies affecting the knee or subsequent further injuries or invasive procedures to the knee. Data was collected via a subjective and objective questionnaire assessing patient outcome.

35 patients met the inclusion criteria, 32 were successfully followed up. Male: female ratio was 16:16, with a mean age of 39.5 (range 19–60).

84% (n=27) of patients experienced a significant reduction in pain (mean reduction of 51%, p < 0.001) lasting until the time of study (median of 21 months, range 9 to 31 months). There was no correlation between change in symptoms and site and grade of chondral lesion. Pre-operative instability symptoms did not significantly improve following RFC. Satisfaction with treatment was in direct correlation with pain relief achieved.

Our study appears to support current literature by suggesting short term improvements to pain following the use of RFC on chondral lesions. Greater population size and longer follow-up are required to provide more significant conclusions.

Introduction

Anatomical reconstruction of the Anterior Cruciate Ligament (ACL) reconstruction has been shown to be desirable and improve patient outcome. The posterior border of the anterior horn of the lateral meniscus (AHLM) is an easily identifiable arthroscopic landmark, which could guide anatomic tibial tunnel position in the sagital plane. The aim of the study was to establish the relationship between the posterior border of AHLM and the centre of the ACL foot print to facilitate anatomical tibial tunnel placement.

We sought to validate a method of measuring the range of motion of knees on radiographs as part of a new system of “Virtual Knee Clinics”.

The range of motion of 52 knees in 45 patients were first obtained clinically with goniometers and compared to radiographs of these patients' knees in full active flexion and extension. Four methods of plotting the range of motion on the radiographs were compared.

The intra-class correlation coefficient (ICC) for inter-rater reliability using the goniometer was very high; ICC=0.90 in extension and 0.85 in flexion. The best ICC for radiographic measurement in extension was 0.86 indicating substantial agreement and best ICC in flexion was 0.95 (method 4). ICC for intra-rater reliability was 0.98 for extension and 0.99 for flexion on radiographic measurements.

Measuring range of motion of the knee has never previously been validated in the literature. This study has allowed us to set up a “Virtual Knee Clinic,” combining postal questionnaires and radiographic measurements as a surrogate for knee function. We aim to maintain high quality patient surveillance following knee arthroplasty, reduce our new to follow-up ratios in line with Department of Health guidelines and improve patient satisfaction through reduced travel to hospital outpatients.

The aim of this prospective study was to determine the prevalence of bone marrow oedema (BME) in asymptomatic knees of athletes and to investigate the factors associated with appearance of BME in this group.

A total of 25 asymptomatic athletes who competed at an international, national or county level during their most recent sport season were recruited in this study and had MRI scan of both knees (n=50). MRI scans were reported independently by two experienced musculoskeletal radiologists. Statistical analysis included Cohen's kappa test to identify inter-observer agreement for MRI diagnosis of bone marrow oedema and multiple logistic regression model to identify the factors associated with BME on MRI scan.

There was very good agreement between radiologists for diagnosis of BME (Kappa = 0.896). Seven participants (28%) were found to have BME. Six of the participants had BME in unilateral knees and one participant had BME in bilateral knees. The commonest location of BME was medial femoral condyle (62.5%) The amount of time spent in preseason training (34-38 weeks) was significantly associated with appearance of BME (P=0.048)

BME seems to be common in asymptomatic athletes and one should realize that this finding might not be related to the clinical complaints of the patients. The results of the present study show that there is a training effect associated with BME. Knowing what is a ‘normal’ or ‘abnormal’ scan is important for a competitive athlete, as erroneously diagnosing BME as the underlying cause of athletes' symptoms could lead to decreased playing time or inappropriate therapy.

The Oxford mobile bearing unicompartmental knee replacement (UKR) is a validated, highly successful implant with an excellent ten-year survivorship. From November 2001 to September 2006 three hundred and eighty two patients who had a medial cemented Oxford Unicompartmental knee replacement (Biomet, Bridgend, UK) via a minimally invasive approach were prospectively entered into a database and followed up as per departmental policy in the specialist joint assessment clinic. We have noted a minority of patients have persistent postoperative pain and/or mechanical symptoms resistant to the standard postoperative therapies. We report the outcome of 22 patients who had an arthroscopy for persistent pain and/or mechanical symptoms a median of 15 months (range 4 months – 31 months) following medial unicompartmental knee replacement. The median follow up time following arthroplasty was 38 months (range 16 months – 63 months). Post arthroscopy we divided our study patients into two groups; those who had an improvement in symptoms and those who had none. These groups were then compared, with particular reference to demographics, check radiographs and arthroscopic findings. The results showed that patients with anterior or anteromedial symptoms in whom a medial rim of scar tissue was identified and debrided sixty seven percent had a significantly increased probability of symptomatic improvement (p<0.005). In addition men appeared to significantly improve more that women (p<0.043). When performed this therapeutic intervention many prevent or at least defer the need for early revision to total knee replacement in some cases and we have no complications as a result of the arthroscopic intervention. This observational study provides evidence for a role for arthroscopy in selected patients with pain following unicompartmental knee replacement.

Background

In suspected scaphoid fracture the initial scaphoid series plain radiographs are 84-94% sensitive for scaphoid fractures. Patients are immobilised awaiting diagnosis. Unnecessary lengthy immobilisation leads to lost productivity and may leave the wrist stiff. Early accurate diagnosis would improve patient management. Although Magnetic Resonance Imaging (MRI) has come to be regarded as the gold standard in identifying occult scaphoid injury, recent evidence suggests Computer Tomography (CT) to be more accurate in identifying scaphoid cortical fracture. Additionally CT and USS are frequently a more available resource than MRI.

We hypothesised that 16 slice CT is superior to high spatial resolution Ultrasonography (USS) in the diagnosis of radiograph negative suspected cortical scaphoid fracture and that a 5 point clinical examination will help to identify patients most likely to have sustained a fracture within this group.

A number of measurements of patella height exist all of which use a position on the tibia as a reference. The Patellotrochlear Index has recently been proposed as a more accurate reflection of the functional height of the patella and described in normal knees.

We aimed to compare patellar height measurements in patients with patellofemoral dysplasia.

In a retrospective analysis of the MRI scans of 33 knees in 29 patients with patellofemoral dysplasia we assessed the inter- and intraobserver reliability of four patellar height measurements: the Patellotrochlear Index (PTI), Insall-Salvati (IS), Blackburne-Peel (BP) and Caton-Deschamps (CD) ratios. We also assessed the correlation between the different measurements in predicting patella alta. Three blinded observers on two separate occasions performed the measurements.

There were 21 females and 8 males with a mean age of 21.4 years (13–33). Statistical analysis revealed good inter-observer reliability for all measurements (0.78 for PTI, 0.78 for IS, 0.73 for BP and 0.77 for CD). Intra-observer reliability was also good (0.80, 0.83, 0.75, 0.78 respectively). When comparing the different measurements for patella alta there was a weak correlation between the PTI and the others. There was a strong correlation between the CD and BP ratios (0.96) and a moderate correlation between IS and CD and IS and BP ratios (0.594 and 0.539 respectively).

All measurements are reproducible. The PTI however suggests patella alta exists in different patients to that suggested by the established measures. We propose the PTI as a more clinically relevant measure.

A number of measurements of patellar height are in clinical use all of which reference from the tibia. The patellotrochlear index has been proposed recently as a more accurate reflection of the functional height of the patella and described in normal knees.

We compared patellar height measurements in patients with patellofemoral dysplasia.

In a retrospective analysis of the MRI scans of 33 knees in 29 patients with patellofemoral dysplasia we assessed the inter- and intraobserver reliability of four patellar height measurements: the recently described Patellotrochlear Index (PTI), Insall-Salvati (IS), Blackburne-Peel (BP) and Caton-Deschamps (CD) ratios. We also assessed the correlation between the different measurements in predicting patella alta. Three blinded observers on two separate occasions performed the measurements.

There were 21 females and 8 males with a mean age of 21.4 years (13–33).

Statistical analysis revealed good inter-observer reliability for all measurements (0.78 for PTI, 0.78 for IS, 0.73 for BP and 0.77 for CD). Intra-observer reliability was also good (0.80, 0.83, 0.75, 0.78 respectively). There was weak correlation between the PTI and the other ratios for patella alta. There was a strong correlation between the CD and BP ratios (0.96) and a moderate correlation between IS and CD and IS and BP ratios (0.594 and 0.539 respectively).

We propose the PTI as a more clinically relevant measure.

Many radiographic techniques have been described for measuring patellar height. They can be divided into two groups: those that relate the position of the patella to the femur (direct) and those that relate it to the tibia (indirect). This article looks at the methods that have been described, the logic behind their conception and the critical analyses that have been performed to test them.

A number of measurements of patella height exist all of which use a position on the tibia as a reference. The Patellotrochlear Index has recently been proposed as a more accurate reflection of the functional height of the patella and described in normal knees.

Aim: A comparison of patellar height measurements in patients with patellofemoral dysplasia.

Method: A retrospective analysis of the MRI scans of 33 knees in 29 patients with patellofemoral dysplasia to assess the inter- and intraobserver reliability of four patellar height measurements: the Patellotrochlear Index (PTI), Insall-Salvati (IS), Blackburne-Peel (BP) and Caton-Deschamps (CD) ratios. We also assessed the correlation between the different measurements in predicting patella alta. Three blinded observers on two separate occasions performed the measurements.

Results: There were 21 females and 8 males with a mean age of 21.4 years (13–33).

Statistical analysis revealed good inter-observer reliability for all measurements (0.78 for PTI, 0.78 for IS, 0.73 for BP and 0.77 for CD). Intra-observer reliability was also good (0.80, 0.83, 0.75, 0.78 respectively). When comparing the different measurements for patella alta there was a weak correlation between the PTI and the others. There was a strong correlation between the CD and BP ratios (0.96) and a moderate correlation between IS and CD and IS and BP ratios (0.594 and 0.539 respectively).

Conclusion: All measurements are reproducible. The PTI however suggests patella alta exists in different patients to that suggested by the established measures. We propose the PTI as a more clinically relevant measure.

The aim of this study was to find out whether distal radius fractures treated by K wire fixation loose reduction after wire removal and analyze the variables may influence this. Patients who underwent K wire fixation for unstable fractures of distal radius over a period of 3 years were included in this retrospective study. Fractures were classified according to AO classification. Radiographs taken just prior to removal of K wires and radiographs taken at least 1 month after wire removal were analyzed to study three radiological parameters; Palmar or dorsal tilt, radial inclination and ulnar variance. Loss of these angles was analyzed statistically against variables like age, sex, AO classification, type of K wires used, delay in fixation and duration of fixation. 59 fractures were analyzed with mean age of 56 years and male to female ratio of 1:2. Average loss of radial tilt was 2.6 deg, loss of palmar tilt was 2.6 deg and loss of ulnar variance was 1.3 mm. We found that distal radius fractures treated by percutaneous K wire fixation, do not suffer significant loss of reduction of fracture position after removal of wires. This remains true regardless of age, sex, fracture type according to AO type, type of wires used, delay in fixation or duration of wire fixation.

Aims:

1) To determine the predictive value of a simple stability test in children’s wrist fractures treated with simple manipulation and plaster of Paris (PoP) cast immobilisation.

Methods: This is a prospective study of 57 children aged 4 to 15 with metaphyseal and Salter-Harris II wrist fractures treated with simple manipulation. Under fluoroscopic imaging, a simple stability test involving moving the hand at the wrist in the dorsopalmar, and radioulnar planes was performed following reduction, and x-ray images were saved. We recorded and compared the displacement and angulation on the initial x-rays, during the test, and at one-and 6-week follow-up. We also recorded the skin-cast distance (SCD), and the cast index (CI).

Results: 38 patients had isolated radius fractures and 19 had radius and ulna fractures. Four patients needed remanipulation with K-wire fixation. Multiple regression analysis revealed significant correlation between percentage loss of reduction on testing and subsequent re-displacement (relationship between the two sets of values r = 0.6167, (p< 0.001)). This indicates that instability on testing (seen as a significant percentage loss of reduction) is likely to be associated with some loss of reduction on follow-up. There was a significant relationship between the skin cast distance and the cast index, and loss of reduction on one week follow-up. (p=0.006). Isolated radius fractures had a higher risk of re-displacement than radius and ulna fractures (3.9% and 0.9% respectively; p< 0.05%)

Conclusion: Stable reduction on stability testing in wrist fractures in children immobilised in a good cast (reflected in a low SCD, and CI) is associated with a good outcome. Isolated radius and ulna fractures are more likely to re-displace than radius and ulna fractures. There is a relationship between instability and loss of position at the 1-week follow-up. Potentially unstable fractures can be prevented from slipping by a good cast. A stable fracture on our stability test rarely slips. We therefore feel that stability test is a useful adjunct in decision-making.

The management of patients with a painful total knee replacement requires careful assessment and a stepwise approach in order to diagnose the underlying pathology accurately. The management should include a multidisciplinary approach to the patient’s pain as well as addressing the underlying aetiology. Pain should be treated with appropriate analgesia, according to the analgesic ladder of the World Health Organisation. Special measures should be taken to identify and to treat any neuropathic pain. There are a number of intrinsic and extrinsic causes of a painful knee replacement which should be identified and treated early. Patients with unexplained pain and without any recognised pathology should be treated conservatively since they may improve over a period of time and rarely do so after a revision operation.

Evaluation of patients with painful total knee replacement requires a thorough clinical examination and relevant investigations in order to reach a diagnosis. Awareness of the common and uncommon problems leading to painful total knee replacement is useful in the diagnostic approach. This review article aims to act as a guide to the evaluation of patients with painful total knee replacement.

Aim: To identify the variables associated with poor radiological outcome in the distal radius fractures stabilized with K wires.

Materials & Methods: All the patients who underwent K wire fixation of distal radius fracture in last 3 years were included in this retrospective study. AO Classification was used to classify the fracture. Immediate post fixation radiographs and radiographs taken just prior to removal of K wires (5–6 weeks) were analyzed to study three radiological parameters (dorsal tilt, radial tilt, ulnar variance). Changes in these parameters were recorded. Results were graded as excellent, good, fair and poor according to the Stewart classification. The results were analyzed against variables like age, sex, AO classification, associated ulnar fracture, number of k wires used, delay in fixation and duration of fixation. Statistical tests were performed to find out variables associated with the poor radiological outcome.

Results: 113 distal radius fractures were analyzed in total. Average age of patients was 56.2 years (standard deviation-19.9) with male to female ratio of 1:2.1. Average loss of radial tilt was 4.12 deg, loss of dorsal tilt was 8.07 deg and change in the ulnar variance was 3.12 mm. We found excellent results in 23.9 %, good result in 56.6%, fair results in 15 % and poor results in 4.4 % of patients.

Age more than 65 years (p value 0.006), comminuted distal radius fracture [A3 or C3 in AO classification] (p value 0.049) and associated ulnar fracture (p value 0.013) were the variables found to have statistically significant correlation with poor radiological outcome.

Conclusion: Age more than 65, comminuted distal radius fracture and associated ulnar fracture are the variables associated with poor stability of K wire fixation in distal radius fracture. Alternative mode of stabilization should be considered to improve the stability of the fracture fixation in these patients.

Introduction and Aims: To study the natural history of the bone bruising of the knee and to identify the effect of weight-bearing and associated internal derangement on clinical improvement and radiological progress of the bone bruising of the knee.

Method: Patients with an acute knee injury were prospectively subjected to clinical and MRI examination within 48 hours of injury. Patients with osteoarthritis, bleeding disorder and previous injury or surgery to the injured knee were excluded. Internal derangement of the knee joint was identified. Patients with bone bruising (study group) were randomised into weight-bearing and non weight-bearing groups and followed-up for clinical and MRI examination at six weeks, three months, six months and 12 months. At follow-up, bone bruising on MRI was classified as Progressive, Static, Resolving or Resolved. Patients without bone bruising (control group) were similarly followed up for clinical examination. Lyshom score was used for clinical assessment.

Results: 28 patients were available for the follow-up. Average age was 24. There were eight patients in control group and 10 patients each in weight-bearing and non weight-bearing group. Eleven patients had associated internal derangement of the knee joint.

Clinical improvement was better in the control group compared to the study group. Patients with isolated bone bruising were doing better than those with associated internal derangement.

On radiological examination there was tendency for the bone bruise to progress in the first six weeks but majority started resolving by three months time. All isolated BB were resolved by six months, but there was delayed resolution of BB associated with ID.

Weight-bearing status did not influence clinical or radiological course of bone bruising.

Conclusion: Weight bearing does not alter the course of the bone bruising. Internal derangement associated with bone bruising delayed radiological resolution and clinical improvement of the patient.

Aim To study the natural history of bone bruising of the knee and to identify the effect of weight bearing and associated internal derangement (ID) on clinico-radiololgical progress of bone bruising of the knee.

Method Patients with an acute knee injury were prospectively assessed by clinical and MRI examination within 48 hours of injury. Patients with fracture, osteoarthrosis, bleeding disorder and previous injury or surgery to the injured knee were excluded. Internal derangement (ID) of the knee joint was identified. Patients with bone bruising (study group) were randomised into weight bearing and non weight bearing groups and followed up for clinical and MRI examination at six weeks, three months, six months and twelve months. At follow up, bone bruising on MRI was classified as Progressive, Static, Resolving or Resolved. Patients without bone bruising (control group) were similarly followed up for clinical examination. This is an ongoing study

Results Twenty-eight patients were available for the follow up. There were 8 patients in the control group and 10 patients each in the weight bearing and non-weight bearing group. Eleven patients had associated internal derangement of the knee joint.

Clinical improvement was better in the control group compared to the study group. Patients with isolated bone bruising were doing better than those with associated ID.

Radiololgically there was a tendency for the bone bruise (BB) to progress in the first six weeks but the majority started resolving by three months time. All isolated BB were resolved by six months but there was delayed resolution of BB associated with internal derangement.

Weight bearing status did not influence clinical or radiological course of bone bruising.

Conclusion Weight bearing does not alter the course of the bone bruising. Internal derangement associated with bone bruising delayed radiological resolution and clinical improvement of the patient.

The aim of this study was to evaluate the analgesic effect of extracorporeal shock wave lithotripsy (ESWL) in patients with refractory tennis elbow, golfer’s elbow and plantar fasciitis.

Patients with tennis elbow (34), golfer’s elbow (11) and plantar fasciitis lesions (14) who had not responded to a minimum of six months’ conservative treatment were included in this three-year study of ESWL. Patients who were pregnant or had neurological problems, coagulation disorder and tumour in the area of treatment were excluded. Patients received 2 000 shock waves of 0.04 to 0.12 mj/mnf three times at monthly intervals. Patients were followed up for a minimum of six months and maximum of 36 months. The effectiveness of ESWL was assessed in terms of improvement in duration and severity of pain, functional disability, complication of treatment and recurrence. Good or excellent results were achieved in 67.65% of patients with tennis elbow, 45.45% with golfer’s elbow and 71.42% with plantar fasciitis.

ESWL seems a useful treatment option, as effective administered monthly as weekly. Its effectiveness in cases of golfer’s elbow in questionable.