Coronal Knee Alignment 40 Years after Total Meniscectomy in Adolescents: A Prospective Cohort Study

Introduction:

Meniscectomies result in altered knee biomechanics and increase contact forces on the operated knee joint.

Methods:

We assessed coronal knee alignment in relation to radiological osteoarthritis grading, clinical range of movement and patient reported outcome measures 40 years after total open meniscectomies in adolescence. Thirty eight knees (30 patients) that underwent total open meniscectomy were assessed on standardised weight-bearing anteroposterior radiographs for deviation from ‘physiological valgus angle’ in either direction (magnitude of malalignment). These values were analysed as per site of meniscectomy for correlations with radiographic scoring systems, range of motion and patient reported outcome measures.

Results:

Tibiofemoral angle was significantly more varus, and the magnitude of malalignment was significantly higher for the medial meniscectomy patients. The range of flexion was lower for those patients who underwent medial and lateral meniscectomies of the same knee. The patients who underwent meniscectomies of both knees had worse scores for IKDC and KOOS quality of life. Tibiofemoral angle, magnitude of malalignment and range of flexion strongly correlated with Ahlback, and Kellgren and Laurence scores, but patient reported that outcome measures did not correlate.

Conclusion:

Meniscectomy induced malalignment corresponds to the site of meniscectomy and the radiographic degree of osteoarthritis. While malalignment and reduced range of movement correlate well with worsening radiographic signs of arthritis, patient reported outcome measures do not correlate.

Adult native knee extensor mechanism ruptures

Extensor mechanism rupture is a serious event requiring prompt diagnosis and treatment. Patella fractures are reportedly six times more frequent than soft tissue injuries such as quadriceps or patella tendon ruptures. Classically quadriceps and patella tendon ruptures are seen more in males, with those over 40 predominantly suffering from quadriceps tendon ruptures, often associated with an underlying condition, whereas patella tendon ruptures are mostly associated with sport injuries and are commonly seen in the under 40s. Almost all types of extensor mechanism ruptures benefit from early management which typically involves surgery. Diagnosis can be deemed easy to make by demonstrating inability to actively extend the knee, this however can be easily overlooked and missed in a busy emergency department leading to a late diagnosis and necessitating more complex surgery. Earlier surgical intervention and rehabilitation tend to produce improved outcomes.

Impact of Weekend Physiotherapy Service on the Cost Effectiveness of Elective Orthopaedic Hip and Knee Arthroplasty

We performed a prospective correlational study to evaluate the efficiency and cost effectiveness of weekend physiotherapy in accelerating rehabilitation, reducing hospital stay as well as hospital costs for joint arthroplasty patients in a busy Scottish district general hospital. Patients that underwent elective hip (470) and knee (321) arthroplasty were analysed over a 12 month period. A four month period with weekend physiotherapy provision was arranged to ascertain its effectiveness on the length of stay and the achievement of set physiotherapy milestones. Data collected included length of stay and progression in a defined set of physiotherapy milestones. The relationship between time to discharge, mobilisation with sticks, straight leg raise, 90º knee flexion and cost effectiveness of service were used to determine the correlation, and analysis of the interactions of these factors separately. Our Outcome data demonstrate a statistical significance for the time to mobilisation with two sticks for hip (p=0.0030) and knee (p= 0.0037) arthroplasty patients. There was a trend towards earlier discharge times for all patients receiving weekend physiotherapy, but this was not statistically significant. We conclude that the provision of a continuous programme of weekend physiotherapy for all arthroplasty patients has the potential benefit of a quicker rehabilitation that would results in a cost saving.

Surgical management of the forefoot in patients with rheumatoid arthritis - a review article

Foot and ankle pathologies cause a significant disease burden on rheumatoid patients. Forefoot pathologies causes pain, callosities and possibly ulceration, and can cause problems with footwear. Forefoot correction in rheumatoid patients has historically comprised of excision of diseased joints. While satisfaction was high with this procedure, complications, changing expectations and improvement in medical therapy have raised expectation of patients, physicians and surgeons alike. This review assesses the role of joint preserving osteotomies and arthrodesis, as well as associated complications. It also describes the role of the multidisciplinary team in the management of these patients.

Total meniscectomy in adolescents: a 40-year follow-up

We continued a prospective longitudinal follow-up study of 53 remaining patients who underwent open total meniscectomy as adolescents and who at that time had no other intra-articular pathology of the knee. Their clinical, radiological and patient-reported outcomes are described at a mean follow-up of 40 years (33 to 50). The cohort of patients who had undergone radiological evaluation previously after 30 years were invited for clinical examination, radiological evaluation and review using two patient-reported outcome measures. A total of seven patients (13.2%) had already undergone total knee replacement at the time of follow-up. A significant difference was observed between the operated and non-operated knee in terms of range of movement and osteoarthritis of the tibiofemoral joint, indicating a greater than fourfold relative risk of osteoarthritis at 40 years post-operatively. All patients were symptomatic as defined by the Knee Injury and Osteoarthritis Outcome Score. This study represents the longest follow-up to date and it can be concluded that meniscectomy leads to symptomatic osteoarthritis of the knee later in life, with a resultant 132-fold increase in the rate of total knee replacement in comparison to their geographical and age-matched peers.