Introduction: Total knee replacement (TKR) is an established and successful treatment option for symptomatic osteoarthritis of the knee. Arthroplasty surgeons, however, continue to debate the merits of posterior cruciate ligament (PCL) preservation or resection. Published literature on this subject has not demonstrated a significant clinical difference in outcome in matched subjects. Deliberate PCL resection during non-posterior stabilised TKR has also been shown to have similar outcomes.

The aims of this study were to map the tibial PCL footplate using MRI in patients undergoing TKR and more importantly, to document the percentage disruption of this footplate as a result of the tibial cut.

Patients and Methods: Patients awaiting TKR were prospectively enrolled into this study. Plain radiographs and an MRI scan of the knee were performed. Using coronal and sagittal images and the available software, the cross sectional area of the tibial PCL footplate was determined along with its location relative to the tip of the fibular head. Plain x-rays of the knee were performed postoperatively. Using a number of pre-determined markers we estimated the impact of the operative tibial cut on the PCL footplate.

Results: Twenty-five patients were enrolled into this study. There were 7 male and 18 female patients, mean age: 69 years. The vast majority of implants were AMK (80%), with a mean posterior slope cut of 3.6 degrees (range 0–7) and mean spacer height 11.4 mm (range 8–16).

From MRI analysis, the tibial PCL footplate had a mean surface area of 83 mm² (range: 49 – 142), and there was a significant difference between male and female patients [Male: 104 mm²versus Females: 75 mm²; t-test, p < 0.005]. The inferior most aspect of the PCL footplate was located on average 1 mm above the superior most aspect of the fibular head (range: 10 mm below to 7 mm above).

Analysis of post-operative radiographs showed that the average tibial cut extended to 4 mm above the tip of the fibular head (range 2 mm below to 14 mm above). Over one third of patients had tibial cuts extending below the inferior most aspect of their PCL footplate (complete removal) and a further one third had cuts which extended into their PCL footplate (partial removal).

Conclusions We have found a wide variation in the size and location of the tibial PCL footplate when referenced against the fibular head.

Proximal tibial cuts using conventional jigs resulted in the removal of a significant portion if not all of the PCL footplate in the majority of patients.

Our findings suggest that when performing PCL retaining TKR’s, we commonly do not actually preserve the PCL.

Introduction: Urinary retention is a significant complication following hip and knee arthroplasty. Published literature has shown that the insertion of a catheter post-op is associated with an increased incidence of deep joint sepsis, however, pre-operative catheterisation has not.

The International Prostate Symptom Score (IPSS) is an internationally validated scoring system used by Urologists to assess the severity of obstructive urinary symptoms and response to treatment.

The purpose of this study was to quantify the incidence of urinary retention following major joint arthroplasty in an elective orthopaedic unit and to investigate whether a patient’s pre-operative IPSS score could be used to predict the likelihood of post-operative urinary retention.

Patients and Methods: Over a 9 month period, 118 patients were enrolled prospectively into this study. 28 patients were admitted for knee replacement(TKR) and 90 patients for hip replacement (THR). All patients were asked to fill out an IPSS questionnaire form on admission. Demographics including age, mode of anaesthetic, intra-operative blood loss and operative time were recorded. Results: In our study group of 118 patients, 43(36.4%) developed urinary retention postoperatively. 29(32.2%) patients following THR developed urinary retention, whereas 14(50%) of the men who had a TKR developed urinary retention post-op. Of the 25 patients with a pre-operative IPSS score > /=10, 14(56%) went into retention. The mean pre-operative IPSS score was 7.74 for those who went into retention, compared to 5.0 for the other patients (p < 0.05). Type of anaesthesia, blood loss and operative time were non-contributory.

Conclusion: This study shows a high rate of post-operative urinary catheterisation in our patient group. Despite the mean IPSS score being higher in patients requiring catheterisation, our results did not show any conclusive evidence that this scoring system could be used to predict the development of post-operatively urinary retention in patients presenting for hip or knee arthroplasty.

Introduction: Anterior knee pain is a commonly encountered orthopaedic symptom. Textbooks list a number of clinical symptoms and physical signs that are specific for the PF joint in the assessment of the patient with knee pain. Radiological evaluation of the PF joint is rarely helpful. The authors have investigated the value of these symptoms and signs in predicting the presence of PF pathology.

Patients and Methods: All patients presenting for diagnostic knee arthroscopy were enrolled prospectively. A detailed proforma was completed with each patient pre-operatively recording the presence or absence of specific PF symptoms and clinical signs. A blinded independent observer recorded the operative findings of the PF joint, the presence / absence of a plica and / or anterior synovitis. Chondromalacia (CM) was graded using the Outerbridge classification and grade 2 or greater was considered a positive finding.

Pre-operative symptoms and signs were correlated with arthroscopic findings and their positive predictive value (PPV) was determined.

Results: Thirty patients were enrolled over a 2-month period. Pure anterior knee pain was present in 10 patients. The remainder had medial (15), lateral (2) or generalised pain (3). 20 of the thirty patients had degenerative changes in the PF joint. One patient had a plica and no patients had significant anterior synovitis. 20 of the 30 patients had pathological findings elsewhere in their joint.

In the prediction of PF degenerative changes, the PPV of symptoms exacerbated by squatting was 0.53; stairs – 0.55; kneeling – 0.57; rising from low chair – 0.6 and night pain – 0.5.

Analysis of specific signs in predicting PF changes showed that the PPV of PF crepitus was 0.5; pain exacerbated by patellar compression 0.6; and patellar facet compression was 0.62.

Conclusion: Degenerative changes of the PF joint are common in our patient population. The value of knee arthroscopy in patients with isolated PF symptoms is questionable. Our assessment of these patients with specific questions and physical signs has been shown to have a low PPV in predicting ultimate arthroscopic findings in the PF joint.

Background: First Metatarsophalangeal joint (MTP) arthrodesis is commonly performed for hallux valgus with an arthritic joint, however previous studies have recommended that this should be combined with another procedure to correct the hallux valgus when the intermetatarsal angle is enlarged. We propose that an arthrodesis of the first MTP joint with a soft tissue release produces a significant correction of the intermetatarsal angle in such a group of patients avoiding the need for a concomitant procedure to change the intermetatatarsal angle.

Patients and Methods: The charts and radiographs of 20 patients who had an arthrodesis of the first MTP joint were retrospectively reviewed. All 20 patients were female with a mean age of 54.2 years (range 42–78 years). The intermetatarsal (IMT) angles were measured by two individuals independently. These were measured on a weight-bearing pre-operative film and a weight-bearing 6-week post-operative film. Fusions were performed using either the Hallu-S® plate or two crossed screws. A Student “t” test was performed on the change of the IMT angle and also on the inter-observer variations for the same.

Results: The mean pre-operative IMT angle was 16.85° (range 12–30°). The mean post-operative IMT angle was 10.6° (range 6–20°). The mean change in the IMT angle was 6.25° (range 2–12°). This change of the IMT angle was statistically significant – p< 0.0001 – Student “t” test. There was no significance in the inter-observer difference (p> 0.5) note in 6 radiographs with a mean of 1.3° (range 1–2°).

Conclusion: This is the first study to show that performing an arthrodesis of the first MTP joint with soft tissue release in patients with hallux valgus and degenerate first MTP joint will significantly correct the IM angle. Therefore, this alleviates the need for performing another procedure on these patients.

Aim When first metatarsophalangeal (MTP) joint fusion is performed in the presence of a high first intermeta-tarsal angle (IMA), an important question to arise is whether the first metatarsal varus will correct with MTP fusion alone or whether an additional basal osteotomy is necessary. We compared the pre-operative IMAs to the post-operative angles to answer this question.

Method Twenty patients had a first MTP fusion for severe hallux valgus deformity performed by the senior author over a 2-year period. All were female. Mean age was 54.2 years (range 42–78). Seven patients had rheumatoid arthritis. Their IMAs were retrospectively measured on weight bearing X-rays taken pre-operatively and 6 weeks post-operatively. They were recalled for an additional measurement at a mean of 13.72 months (range 6–30).

Results Pre-operatively the mean hallux valgus angle was 46.55 degrees and the mean IMA was 16.65 degrees (range 12–26). The mean 6 week post-operative IMA was 10.35 degrees (range 6–15) with a mean improvement of 6.3 degrees (range 0–12). The mean IMA at final follow-up was 8.67 degrees (range 5–12). The mean final improvement was 8.22 degrees (range 4–14). In eight patients with a pre-operative IMA of 15 degrees or less the mean improvement was 6.13 degrees. In 10 patients with an pre-operative IMA of 16 degrees or more, the mean improvement was 9.9 degrees.

Significance First MTP joint fusion in hallux valgus deformity permanently reduces the IMA. As the pre-operative IMA increases from moderate to severe, there is a significant increase in post-operative correction. An additional basal osteotomy is not indicated.