Jonathan Noble

Simultaneous Bilateral Total Knee Replacement: A persistent controversy

The benefits and risks of Simultaneous Bilateral Total Knee Replacement (SBTKR) remain controversial. A review of the English speaking literature was undertaken and found that many papers took staunch positions either for or against the procedure. It was also noted that earlier papers supporting SBTKR suggested cost benefits. There was a huge disparity in the incidence of mortality and morbidity and it was not possible to compare many papers, because in some medically frail patients were excluded from the SBTKR cohorts. In large published series the proportion of patients having a SBTKR varied between 3% and 70%. Many, but not all, series highlighted age and co-morbidity as risk factors. Overall there was no clear case for or against SBTKR. The evidence suggested that careful preoperative assessment and patient selection on a strict protocol were essential. The procedure should be confined to hospitals where high dependency nursing is readily available and the literature indicated that the risk is less in high through-put units. By refining preoperative assessment and preparation it can be a safe and effective procedure in an appropriate clinical setting for postoperative care.

Infected knee treated by total knee arthroplasty

The perceived wisdom in orthopaedics precludes insertion of implants in cases of post-recent active joint sepsis. However, revision knee surgery after infected arthroplasty has now been recognised to be safe and efficacious in specialised centres. We illustrate the concept of using principles of revision surgery to successfully treat knees destroyed by primary staphylococcal septic arthritis.

Should the patella be resurfaced at total knee replacement

Total knee replacement (TKR) presumably is replacement of the total knee articular surface. Sometimes it is and sometimes it is not. It is this authors firm conviction that the patella should be resurfaced in the vast majority of cases. Such advocacy must be critically justified and the potential drawbacks and alternatives examined.

Angiography in vascular problems with total knee replacement: a report of three cases

Abstract Vascular complications after total knee replacement are rare and the prognosis is usually poor. The true incidence is not available and only 44 cases are reported in the literature. We report three cases of vascular complications encountered by one of us (JN), in 20 years experience of 1000 total knee replacements. It includes an unusual complication of vascular spasm, which has not been reported before. These cases are presented with a commentary upon the lessons learned in their management.

Placement of a palpable marker adjacent to the mid-inguinal point: Assessment of a clinical method for detecting the femoral head centre during knee arthroplasty

Localization of the centre of the femoral head is vital when using extra-medullary femoral alignment systems in knee arthroplasty. This study investigated the accuracy of a palpable marker placed in the groin for detecting the centre of the femoral head. A table tennis ball, 38 mm in diameter, was taped 2.5 cm perpendicular to the mid-inguinal point in patients having a plain radiograph of the pelvis. The mean horizontal distance between the centre of the table tennis ball and a vertical line passing through the centre of the femoral head was 8.62 mm (range 0-28.6, SD 6.76). In 100% of cases the horizontal distance between the centre of the table tennis ball and a vertical line passing through the centre of the femoral head was less than one diameter of the table tennis ball. Using a theoretical mechanical axis model our clinical method would confer an error equal to or less than 2 degrees from the weight-bearing axis of the knee in up to 98% of cases. In conclusion, our results suggest that the clinical method reported here provides a simple and reliable way of localizing the centre of the femoral head in knee arthroplasty.

Localized pigmented villonodular synovitis presenting as a locked knee: a report of three cases and a review of the literature

Abstract We report three cases of pigmented villonodular synovitis (PVNS), which presented with a locked knee in the absence of significant trauma. After clinical examination all patients were strongly suspected to have a mechanical derangement of the knee. Two patients underwent arthroscopic resection of the mass which on histology proved to be PVNS, one patient needed a small arthrotomy to remove the PVNS mass.

The use of a spoon for meniscal suturing

Abstract Arthroscopic ‘inside-out’ meniscal suturing is now an established method of meniscal repair in the knee. Injury to the neurovascular structures around the knee may be a complication of this technique if due regard is not given to their protection. We describe the use of a household spoon to act as a retractor and to deflect the path of flexible needles used in meniscal suturing as they pass from inside to the outside of the knee joint, thereby protecting the neurovascular structures.