Standardising the clinical assessment of coronal knee laxity

Clinical laxity tests are used for assessing knee ligament injuries and for soft tissue balancing in total knee arthroplasty. This study reports the development and validation of a quantitative technique of assessing collateral knee laxity through accurate measurement of potential variables during routine clinical examination. The hypothesis was that standardisation of a clinical stress test would result in a repeatable range of laxity measurements.Non- invasive infrared tracking technology with kinematic registration of joint centres gave real-time measurement of both coronal and sagittal mechanical tibiofemoral alignment. Knee flexion, moment arm and magnitude of the applied force were all measured and standardised. Three clinicians then performed six knee laxity examinations on a single volunteer using a target moment of 18Nm. Standardised laxity measurements had small standard deviations (within 1.1°) for each clinician and similar mean values between clinicians, with the valgus laxity assessment (mean of 3°) being slightly more consistent than varus (means of 4° or 5°).The manual technique of coronal knee laxity assessment was successfully quantified and standardised, leading to a narrow range of measurements (within the accuracy of the measurement system). Minimising the subjective variables of clinical examination could improve current knowledge of soft tissue knee behaviour

Non-invasive computer-assisted measurement of knee alignment

The quantification of knee alignment is a routine part of orthopaedic practice and is important for monitoring disease progression, planning interventional strategies, and follow-up of patients. Currently available technologies such as radiographic measurements have a number of drawbacks. The aim of this study was to validate a potentially improved technique for measuring knee alignment under different conditions. An image-free navigation system was adapted for non-invasive use through the development of external infrared tracker mountings. Stability was assessed by comparing the variance (F-test) of repeated mechanical femoro-tibial (MFT) angle measurements for a volunteer and a leg model. MFT angles were then measured supine, standing and with varus-valgus stress in asymptomatic volunteers who each underwent two separate registrations and repeated measurements for each condition. The mean difference and 95% limits of agreement were used to assess intra-registration and inter-registration repeatability. For multiple registrations the range of measurements for the external mountings was 1° larger than for the rigid model with statistically similar variance (p=0.34). Thirty volunteers were assessed (19 males, 11 females) with a mean age of 41 years (range: 20-65) and a mean BMI of 26 (range: 19-34). For intra-registration repeatability, consecutive coronal alignment readings agreed to almost ±1°, with up to ±0.5° loss of repeatability for coronal alignment measured before and after stress maneuvers, and a ±0.2° loss following stance trials. Sagittal alignment measurements were less repeatable overall by an approximate factor of two. Inter-registration agreement limits for coronal and sagittal supine MFT angles were ±1.6° and ±2.3°, respectively. Varus and valgus stress measurements agreed to within ±1.3° and ±1.1°, respectively. Agreement limits for standing MFT angles were ±2.9° (coronal) and ±5.0° (sagittal), which may have reflected a variation in stance between measurements. The system provided repeatable, real-time measurements of coronal and sagittal knee alignment under a number of dynamic, real-time conditions, offering a potential alternative to radiographs

Femoral Stem Displacement in a Patient Suffering Recurrent Dislocations After Hip Hemiarthroplasty: Case Report

Displacement of the femoral component during attempt to closed reduction of a dislocated hip arthroplasty is an exceptionally rare, catastrophic event, which renders operative management obligatory. We report the proximal migration of a femoral stem during attempt to closed reduction in a patient with recurrent postoperative dislocations after hip hemiarthroplasty, and describe successful management by conversion to a standard total hip arthroplasty, retaining the same stem in the existing cement mantle. This illustrative case is reported not only as an extremely rare event, but also to highlight and discuss pitfalls and efficient measures in the management of this complex issue

Custom-designed orthopedic implants evaluated using finite element analysis of patient-specific computed tomography data: femoral-component case study

<p>Abstract</p> <p>Background</p> <p>Conventional knee and hip implant systems have been in use for many years with good success. However, the custom design of implant components based on patient-specific anatomy has been attempted to overcome existing shortcomings of current designs. The longevity of cementless implant components is highly dependent on the initial fit between the bone surface and the implant. The bone-implant interface design has historically been limited by the surgical tools and cutting guides available; and the cost of fabricating custom-designed implant components has been prohibitive.</p> <p>Methods</p> <p>This paper describes an approach where the custom design is based on a Computed Tomography scan of the patient's joint. The proposed design will customize both the articulating surface and the bone-implant interface to address the most common problems found with conventional knee-implant components. Finite Element Analysis is used to evaluate and compare the proposed design of a custom femoral component with a conventional design.</p> <p>Results</p> <p>The proposed design shows a more even stress distribution on the bone-implant interface surface, which will reduce the uneven bone remodeling that can lead to premature loosening.</p> <p>Conclusion</p> <p>The proposed custom femoral component design has the following advantages compared with a conventional femoral component. (i) Since the articulating surface closely mimics the shape of the distal femur, there is no need for resurfacing of the patella or gait change. (ii) Owing to the resulting stress distribution, bone remodeling is even and the risk of premature loosening might be reduced. (iii) Because the bone-implant interface can accommodate anatomical abnormalities at the distal femur, the need for surgical interventions and fitting of filler components is reduced. (iv) Given that the bone-implant interface is customized, about 40% less bone must be removed. The primary disadvantages are the time and cost required for the design and the possible need for a surgical robot to perform the bone resection. Some of these disadvantages may be eliminated by the use of rapid prototyping technologies, especially the use of Electron Beam Melting technology for quick and economical fabrication of custom implant components.</p

The Weaker Sex? The Propensity for Male-Biased Piglet Mortality

For the most part solutions to farm animal welfare issues, such as piglet mortality, are likely to lie within the scientific disciplines of environmental design and genetic selection, however understanding the ecological basis of some of the complex dynamics observed between parent and offspring could make a valuable contribution. One interesting, and often discussed, aspect of mortality is the propensity for it to be sex-biased. This study investigated whether known physiological and behavioural indicators of piglet survival differed between the sexes and whether life history strategies (often reported in wild or feral populations) relating to parental investment were being displayed in a domestic population of pigs. Sex ratio (proportion of males (males/males+females)) at birth was 0.54 and sex allocation (maternal investment measured as piglet birth weight/litter weight) was statistically significantly male-biased at 0.55 (t35 = 2.51 P = 0.017), suggesting that sows invested more in sons than daughters during gestation. Despite this investment in birth weight, a known survival indicator, total pre-weaning male mortality was statistically significantly higher than female mortality (12% vs. 7% respectively z = 2.06 P = 0.040). Males tended to suffer from crushing by the sow more than females and statistically significantly more males died from disease-related causes. Although males were born on average heavier, with higher body mass index and ponderal index, these differences were not sustained. In addition male piglets showed impaired thermoregulation compared to females. These results suggest male-biased mortality exists despite greater initial maternal investment, and therefore reflects the greater susceptibility of this sex to causal mortality factors. Life history strategies are being displayed by a domestic population of pigs with sows in this study displaying a form of parental optimism by allocating greater resources at birth to males and providing an over-supply of this more vulnerable sex in expectation of sex-biased mortality

The controversy of patellar resurfacing in total knee arthroplasty: Ibisne in medio tutissimus?

Early arthroplasty designs were associated with a high level of anterior knee pain as they failed to cater for the patello-femoral joint. Patellar resurfacing was heralded as the saviour safeguarding patient satisfaction and success but opinion on its necessity has since deeply divided the scientific community and has become synonymous to topics of religion or politics. Opponents of resurfacing contend that the native patella provides better patellar tracking, improved clinical function, and avoids implant-related complications, whilst proponents argue that patients have less pain, are overall more satisfied, and avert the need for secondary resurfacing. The question remains whether complications associated with patellar resurfacing including those arising from future component revision outweigh the somewhat increased incidence of anterior knee pain recorded in unresurfaced patients. The current scientific literature, which is often affected by methodological limitations and observer bias, remains confusing as it provides evidence in support of both sides of the argument, whilst blinded satisfaction studies comparing resurfaced and non-resurfaced knees generally reveal equivalent results. Even national arthroplasty register data show wide variations in the proportion of patellar resurfacing between countries that cannot be explained by cultural differences alone. Advocates who always resurface or never resurface indiscriminately expose the patella to a random choice. Selective resurfacing offers a compromise by providing a decision algorithm based on a propensity for improved clinical success, whilst avoiding potential complications associated with unnecessary resurfacing. Evidence regarding the validity of selection criteria, however, is missing, and the decision when to resurface is often based on intuitive reasoning. Our lack of understanding why, irrespective of pre-operative symptoms and patellar resurfacing, some patients may suffer pain following TKA and others may not have so far stifled our efforts to make the strategy of selective resurfacing succeed. We should hence devote our efforts in defining predictive criteria and indicators that will enable us to reliably identify those individuals who might benefit from a resurfacing procedure. Level of evidence V