With the advent of digital radiography, classical templating of implants for total knee replacement is no longer possible. Computer based programmes to size implants are available and should improve pre-operative planning. Two papers described experience of this and showed that traditional and digital templating were equally effective. There remained a poor correlation to the final implant inserted at surgery.
The early results of a pragmatic multi-centre randomised trail of total knee replacements were reported (the KAT trial). Further follow-up is required beyond the 2 years so far, but there appears to be no difference in complications, clinical outcome, functional status or quality of life measures whether the patella was resurfaced or not, if a mobile bearing was used or if the tibial tray was metal backed.
Knee replacement in younger patients is becoming more common, but do they last? A study of patients under 60 at the time of operation showed a significant fall in function and increase in pain in the second decade after surgery and 17% had required revision surgery by 15 years. Another paper reported the results of knee replacement in active golfers. The ability to play improved, but there was no reported improvement in handicap. There was a higher risk of failure of the left knee in right-handed golfers.
A paper discussed the vexed issue of steroid injections and knee replacements. It has been suggested that injections prior to surgery increase the risks of infection and poor wound healing. The paper showed no difference in the risk of these complications but a poll of the audience suggested that the great majority of experienced knee surgeons would defer such knee surgery for at least 6 months after a steroid injection.
Many patients say they cannot kneel after a knee replacement, but the reason is often down to poor advice and misunderstanding. Kneeling is not harmful to a knee replacement, and patients who were shown how to kneel at 6 weeks after surgery were much more able to kneel and stand up again.
Osteoarthritis localised to the patello-femoral joint is often treated with the Avon patello-femoral replacement. The originator of the operation described his experience of 21 patients referred to him where the operation had failed to improve pain. The majority were due to technical error rather than progression of arthritis and the study reinforced that this type of surgery should be performed by experienced surgeons avoiding incorrect positioning and sizing of the implants.
A report on the changing demographics of anterior cruciate ligment rupture confirmed the observation that these injuries are being seen more often in older age groups, women and skiers.
Graft choice for anterior cruciate ligament reconstruction remains controversial, but a study measuring stretching of the graft and slippage of fixation showed both were greater in hamstrings grafts rather than patellar tendon grafts. This needs to be interpreted with the knowledge that clinical studies have failed to show any significant difference in the functional outcome of the two techniques.