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Introduction A significant percentage of patients require re-revision surgery regardless of the demonstrated durable short- and mid-term clinical results using metaphyseal sleeves in revision total knee arthroplasty (TKA). The aim of this study was to identify the association between sleeve alignment and contact zones, with loosening in patients with revision TKA. Materials & Methods Of a series of 103 patients who underwent revision TKA, at a mean follow-up of eight years, six patients were re-revised for tibial loosening. These patients were compared with 19 unrevised control subjects in a 1:3 ratio. We calculated and compared the cumulative number of contact zones between the porous-coated part of the sleeve and bone on immediate postoperative X-rays between re-revised and unrevised patients. The main hypothesis was that neutral positioning and absolute circumferential contact between trabecular metaphyseal bone and porous-coated part of the sleeve would lead to a better outcome. Results The use of a conservative (nonparametric) approach indeed revealed better circumferential contact between trabecular metaphyseal bone and porous-coated part of the sleeve among the survivors, i.e., survivors: median (interquartile range [IQR]): 3 (2-4); failures: 3 (1-3), p = 0.003 (Mann-Whitney [MW] test). The difference was borderline significant for coronal alignment, i.e., survivors: median (IQR): -1 (-4 to 2); failures: 0 (-1 to 3), p = 0.0569 (MW test). Conclusion A circumferential bony contact of the metaphyseal sleeve would lead to better survival of the revision implant, whereas the degree of varus fixation did not seem to influence the longevity of the implant.

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PURPOSE: The relationship between instrumented knee measurements and patient-reported outcome measures is a newer field that continues to evolve. The aim of this study was to evaluate long-term quality of life (QoL) post-total knee arthroplasty (TKA) surgery correlating validated self-reported questionnaires, clinical examination and instrumented analysis, using baropodometry and accelerometry. METHODS: Thirty-six patients who underwent primary unilateral TKA between 1999 and 2006 were evaluated at 11.3 ± 2.3 years following surgery. Clinical examination included range of motion (ROM) and instrumented knee laxity measurements with the Rolimeter device. The visual analogue scale (VAS) for pain was also recorded. The utilised subjective outcome scores were the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the short form of World Health Organisation Quality of Life (WHOQOL-BREF). Instrumented analysis was performed with baropodometry and accelerometry. QoL was assessed correlating clinical, subjective and instrumented results. Univariate analysis included the Spearman's Rho correlation coefficient and Mann-Whitney tests. RESULTS: At the long-term follow-up all patients had relatively high quality of life measurements, as well as functional scores, except for the Sport/Rec dimension of the KOOS score. Only cadence (p = 0.008) and velocity (p = 0.026) affected the WHOQOL psychology domain no matter the age, follow-up and gender of the patients. The domain was unaffected by VAS and Rolimeter measurements. WHOQOL Social domain was unaffected by all instrumentation measurements except for stance phase (p = 0.025), VAS (p = 0.005) and ROM (p = 0.028). KOOS physical domain was not affected by any parameter. KOOS pain was reversely affected by VAS (p = 0.004), KOOS symptom by ROM (p = 0.000 and median maximum pressure (p = 0.033). CONCLUSION: Quality of life for the TKA patient can be correlated and assessed reliably with instrumented analysis using pedobarography and accelerometry, at the long-term follow-up. LEVEL OF EVIDENCE: III.

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AIMS: Trochlear dysplasia is a significant risk factor for patellofemoral instability. The Dejour classification is currently considered the standard for classifying trochlear dysplasia, but numerous studies have reported poor reliability on both plain radiography and MRI. The severity of trochlear dysplasia is important to establish in order to guide surgical management. We have developed an MRI-specific classification system to assess the severity of trochlear dysplasia, the Oswestry-Bristol Classification (OBC). This is a four-part classification system comprising normal, mild, moderate, and severe to represent a normal, shallow, flat, and convex trochlear, respectively. The purpose of this study was to assess the inter- and intraobserver reliability of the OBC and compare it with that of the Dejour classification. METHODS: Four observers (two senior and two junior orthopaedic surgeons) independently assessed 32 CT and axial MRI scans for trochlear dysplasia and classified each according to the OBC and the Dejour classification systems. Assessments were repeated following a four-week interval. The inter- and intraobserver agreement was determined by using Fleiss' generalization of Cohen's kappa statistic and S-statistic nominal and linear weights. RESULTS: The OBC showed fair-to-good interobserver agreement and good-to-excellent intraobserver agreement (mean kappa 0.68). The Dejour classification showed poor interobserver agreement and fair-to-good intraobserver agreement (mean kappa 0.52). CONCLUSION: The OBC can be used to assess the severity of trochlear dysplasia. It can be applied in clinical practice to simplify and standardize surgical decision-making in patients with recurrent patella instability. Cite this article: Bone Joint J 2020;102-B(1):102-107.

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The main aim of this case report is to thoroughly describe the steps of diagnosis and treatment in the rare incidence of patellar tendon gouty tophus. The case of a 53-year-old man manual worker who was treated with open excision of the lesion, following failure of extended medical treatment with rheumatological input, is presented. Surgical treatment led to full restoration of the patient's knee function. Open or arthroscopic surgery is a viable option for the unusual case of intratendinous patellar gouty deposition if the patient fails medical management. Medical treatment should still be the mainstay.

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PURPOSE: The purpose of this study was to measure the improvement in quality of life (QoL) following isolated anatomical double-bundle medial patellofemoral ligament reconstruction. METHODS: This is a single-centre, prospective study of 56 consecutive patients (57 knees) who underwent isolated MPFL reconstruction between 2014 and 2017. Functional outcome and QoL were assessed with the Kujala score and the EQ-5D-3L questionnaire, respectively. Objective outcomes were obtained through clinical examination at the latest follow-up assessing redislocation rate, patella apprehension test, patellar tilt, pain and range of motion. RESULTS: The median Kujala score increased from 60 (range 31-96) to 92 (range 34-100) at latest follow-up (p < 0.001). The median EQ-5D index also increased, from 0.69 (range 0.10-1) at baseline to 1 (range 0.16-1) at latest follow-up (p < 0.001), as well as the median EQ-5D VAS from 75 (range 20-95) to 92 (range 40-100) (p < 0.001). Four dimensions of the EQ-5D were significantly improved except for the anxiety/depression scores. Female patients reported lower scores at baseline and at latest follow-up, for all three outcomes (Kujala, EQ-5D index, EQ-5D VAS), however there was no evidence that gender negatively impacted on the benefit of surgery. The re-dislocation rate was 0%. Apprehension and patellar tilt test were negative in all patients and no flexion deficit was identified at latest follow-up. Two patients had tenderness along the reconstruction requiring femoral screw removal in one of them. CONCLUSIONS: Isolated anatomical double-bundle aperture MPFL reconstruction, offered significantly improved short-term QoL along with excellent functional outcome. Female patients scored lower, but this did not affect the overall outcome. Including QoL tools in the assessment of ligament reconstruction operations, such as the MPFL, can provide more accurate understanding of the overall patient benefit. LEVEL OF EVIDENCE: II.

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PURPOSE AND HYPOTHESIS: The principal purpose of this paper was to identify whether femoral notch morphology was different in females without anterior cruciate ligament (ACL) injury from those with ACL injury. Magnetic resonance imaging (MRI) was used to assess the femoral notch type, notch width index and 'α angle' in female patients and measure these differences. METHODS: This is a retrospective case control study of 119 female patients, 58 with ACL injury and 61 patients without ACL injury who underwent knee MRI between March 2014 and April 2016. The morphometric measurements were taken by two independent observers. The femoral notch width index was calculated as the ratio between the central notch width and transcondylar or intercondylar width; values >0.27 were considered normal. The femoral notch shape was classified as Type A, Type U or Type W, with Type A describing a stenotic notch, Type U a notch with a wider contour and Type W a wider Type U with two apices apparent. The angle between the longitudinal femoral axis and the Blumensaat line was identified as the 'α angle'. The statistical analysis was performed with t tests, simple and multivariable logistic regression analysis to evaluate the strength of these specific femoral notch morphometric values as predictive factors to ACL rupture. RESULTS: Stenotic femoral notch Type A was identified as a high risk factor to ACL injury (odds ratio [OR] = 2.8; p = 0.03). There was no significant difference between the two groups for the notch width index (OR = 0.7; p = n.s.) and the 'α angle' (OR 1.02; p = n.s.). Significant association between NWI and stenotic notch was found (p < 0.01). CONCLUSIONS: This study showed that Type A stenotic femoral notch can be considered as a valuable predictive factor for ACL injury. Notch width index and 'α angle' are weak indicators in ACL injury prognosis. Ligament impingement may be inferred as an important mechanism in female ACL rupture. Injury prevention strategies, such as prehabilitation programmes, could be introduced in the benefit of young females with stenotic notch. LEVEL OF EVIDENCE: III.

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OBJECTIVE: To provide evidence-based data about the aetiology, incidence, diagnosis and treatment of isthmic lumbar spondylolysis and low-grade spondylolisthesis and return to athletic activities in fine athlete. DESIGN: This is a comprehensive literature review. A thorough MEDLINE search in the period from 1973 to 2014 with the keywords: athlete, spondylolysis, low-grade spondylolisthesis, treatment and return to athletic activities was conducted. RESULTS: A total of 228 articles were initially enrolled from the search, and 74 case series and reviews were finally included because they referred to incidence, diagnosis, treatment and return to play in fine athletes with symptomatic isthmic spondylolysis and low-grade (Meyerding I and II) spondylolisthesis. There were 13 studies reporting surgical treatment (194 patients of average age 19 years) and 14 studies with conservative treatment (589 patients of average age 15.7). The percentage of athletes who were successfully treated with conservative or operative treatment was 85 and 87.8%, respectively. CONCLUSION: Conservative treatment including physiotherapy and bracing is the mainstay in the treatment of symptomatic spondylolysis and low-grade isthmic spondylolisthesis in fine athletes. If consequent treatment fails, the operative treatment (pars repair and short fusion) is decided. Return to play following surgery varies from 6 to 12 months with prohibition in collision sports. Return to play is mostly depended on specific sport activity.

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