The purpose of this study was to investigate the safety and outcome of bilateral simultaneous ACL reconstruction. In patients presenting with an ACL-deficient knee, 2 – 4% have bilateral ACL deficiency. A staged or simultaneous approach can be adopted when the patient requires reconstructive surgery for both knees. We report a case series of 8 patients (6 male, 2 female, average age 30.4 years) who underwent bilateral simultaneous ACL reconstruction.

Simultaneous or bilateral ACL reconstruction using ipsilateral patella tendon graft has been reported as a safe procedure with outcome and complication rate no different to unilateral procedures. Considerable cost savings of simultaneous over staged procedures have also been described. There are no case series in the published literature that describe the use of hamstring tendon autograft for bilateral simultaneous ACL reconstruction.

We used two camera stack systems and instrument sets to allow for simultaneous bilateral surgery by two surgical teams. Quadrupled hamstring tendon graft was used in 4 patients although in one patient patella tendon graft was used on the second side due to poor quality of hamstring tendons. Patella tendon graft was also used in a further 4 patients. At two weeks all patients were able to discard crutches and were independent in mobility. There was no difference in outcome at one year between those patients undergoing bilateral simultaneous ACL reconstruction in comparison to the outcomes of unilateral ACL reconstruction with respect to Lysholm, Tegner and IKDC scores. The mean follow up period was 2.3 years.

Our results demonstrate that bilateral simultaneous ACL reconstruction is safe and cost effective. A simultaneous approach also has the benefit of reducing the overall period of rehabilitation required by the patient. We report good short-term functional outcome but no long-term data is yet available.

Aim: To assess the results and complications of the opening wedge form of distal femoral varus osteotomy (DFVO) in treating valgus arthritis and ligament instability of the knee.

Methods: Patients undergoing DFVO were assessed prospectively using validated scoring systems and pre/post operative alignment radiographs. All had failed non operative and arthroscopic procedures and were keen to avoid arthroplasty. The lateral based opening wedge osteotomy aimed to correct the weight bearing line to position 50% medial to lateral and was held with either the Puddu femoral plate (Arthrex UK) or the Tomofix plate (Synthes UK).

Results: 26 distal femoral osteotomies were performed in 23 patients with a mean age of 34 (16 –58). The mean duration of follow up is 32.5 months (1–72). 8 were undertaken for primary valgus malalignment, and 15 for secondary valgus with OA due to previous lateral menisectomy. Simultaneous additional procedures included microfracture (3), MACI (1), meniscal transplantation (1), and MCL advancement (1). Mean hospital stay was 4 days (2–6). Post op alignment was out by greater than 10% of intended in 2/3. 3 early major complications required re-operation: 2 for plate and screw cut out and 1 for infection. 2 developed delayed union requiring bone grafting. Failure with conversion to arthroplasty has occurred in 2 (1 lateral UKA, 1 TKA), and 2 patients are awaiting either multi-ligament reconstruction or collagen meniscal implantation. The overall mean Tegner score is 4 (2–6), and 20 of the 23 patients feel satisfied with the outcome having avoided arthroplasty.

Conclusion: Opening wedge DFVO is a technically difficult procedure with significant complications, but in the right indication offers long lasting pain relief and joint preservation prior to arthroplasty. New techniques including accurate closing wedge fixation systems and computer guided operative planning and surgery may offer improvements to this vital surgical option.

Purpose: X-Ray analysis of a subset of TKR’s performed using the mini-incision technique has been undertaken to assess the accuracy of alignment, as TKR through limited exposure lends itself to a potential risk of mal-positioning of the components.

Methods and Results: The limited exposure afforded by the small skin incision and mid-vastus approach in the new technique of Mini Incision TKR, has a potential for increasing the risk of mal positioning components without the use of navigation systems. 128 mini-incision TKR’s have to date of submission, been undertaken in 125 patients (67F: 58M: mean age 72: mean BMI 29). A prospective assessment of these patients has been ongoing since its introduction in November 2003. The mean hospital stay is 5.5 days and mean range of flexion at six weeks is 106°. Two patients have required manipulation under anaesthetic for poor flexion at six weeks and blood transfusion has only been required in 4%. In patients with a minimum 6 months follow up, long leg alignment X-rays have shown the mechanical axis to be within 3° of normal in 4/5.

Conclusion: We believe that Mini Incision TKR is a safe reliable and reproducible technique offering substantial savings to the patient and health service without compromising accuracy.

Purpose To report on the results, surgical technique and issues with mini-incision total knee arthroplasty.

Methods and results The new technique of mini-incision total knee replacement entails the use of smaller cutting blocks and alignment jigs applied to the femur with minimal surgical exposure, achieved by subluxation of the patella laterally rather than full eversion of the extensor mechanism. The technique was carefully introduced in November 2003.

The results of the first 20 consecutive patients have been compared with 20 standard TKR procedures. The mean age of 73.5 and BMI of 29 was not significantly different to the standard Group. Mean hospital stay was approximately halved (5 days versus 9 days). 75% of patients were discharged on day 4 without needing extra home support. Mean incision length was 13.5cm and only one of 20 required blood transfusion. Mean operative time was 12 minutes longer and post-operative CT alignment showed no mal-position of the implants.

Conclusion Mini-incision TKR is a safe, reliable and reproducible method, allowing significant cost savings and benefits for the patients and hospital. Confidence needs to be gained in the reduced visibility of traditional landmarks and training of surgeons remains an issue.

Purpose To determine which patients respond best to viscosupplementation injections for osteoarthritis of the knee.

Methods and Results We undertook a prospective study of all patients undergoing Hylan G-F 20 injections in the knee recording the indication, severity of symptoms, baseline demographic details and the WOMAC score. Outcome data was collected at 3, 6 and 12 months at an independent telephone interview to determine if patients were improved, the same or worse, and by postal WOMAC score.

100 patients were studied. 3 records were excluded, as there was no follow-up recorded. The demographics on 97 were: mean age 67 (range 37–91), male 56%, mean duration of symptoms 8.8yrs and primary OA in 65%.

Overall 43% were improved at 3 months, 31% at 6 months and 29% at 12 months. When the results were analysed according to indication, patients with ‘moderate non-mechanical osteoarthritic symptoms after failed medical management and not severe enough for arthroplasty’ did best (49% at 3 months and 38% at 6 months). Patients with ‘persisting arthritic symptoms after attempted arthroscopic debridement for mechanical type knee symptoms’ had less predictable results (42% improved at 3 months and 23% at 6 months). Patients with ‘severe or deteriorating symptoms while awaiting knee replacement’ or who were ‘too medically ill for TKR’ had a low rate of improvement (18% at 3 months).

Conclusion Viscosupplementation is unreliable in patients with end stage OA awaiting TKR. This study allows for better targeting of this useful expensive treatment modality.

Purpose: To audit the quality of the still images and documentation of arthroscopic surgery of the knee and to provide guidelines to optimize photographic records.

Methods and Results: The study was conducted in 4 parts

Questionnaire of surgeons views on photographic records: This showed that less than 50% of surgeons felt they could interpret their own photographs and only 25% felt other surgeons records were useful. 80% felt that single image photographs gave clearer information than 4 small images per sheet.

Conclusion: Poor picture labelling, inadequate pictures and documentation were found in the majority of the cases. New formulated guidelines led to an improvement in the accuracy and usefulness of recorded images.

This may lead to a reduction in the need for repeat arthroscopy when patients are referred for second opinions to specialist knee surgeons, thereby reducing costs and morbidity.