Background

Every trainee in Trauma and Orthopaedics (T&O) in the UK and Ireland records their operative experience via the Faculty of Health Informatics eLogbook. Since August 2009, all doctors were subject to the full European Working Time Directive (EWTD) restrictions of 48 hours of work per week. We have previously shown that the implementation of shift working patterns in some units in preparation for these restrictions reduced training opportunities by 50% (elective surgical exposure). We have now analysed the national data to establish whether operative experience has fallen since August 2009.

This prospective longitudinal study compared the results of isolated endoscopic ACL reconstruction utilising 4-strand hamstring tendon (HT) or patellar tendon (PT) autograft over 15-years with respect to reinjury, clinical outcomes and osteoarthritis.

Ninty consecutive patients with isolated ACL rupture were reconstructed with a PT autograft and 90 patients received HT autograft, with an identical surgical technique. Patients were assessed at 2, 5, 7, 10 and 15 years. Assessment included the IKDC Knee Ligament Evaluation, radiographic evaluation, KT1000, Lysholm Knee Score, kneeling pain, and clinical outcomes.

Subjects who received the PT graft had significantly worse outcomes compared to those who received the HT graft at 15 years for the variables of radiologically detectable osteoarthritis (p=0.03), motion loss (p=0.01), single leg hop test (p=0.002), participation in strenuous activity (p=0.05), and kneeling pain (p=0.04). There was no significant difference between the HT and PT groups in overall IKDC grade (p=0.31). ACL graft rupture occurred in 16% of HT group and 8% of the PT group (p=0.07). ACL graft rupture was associated with non-ideal tunnel position (odds ratio 5.0) and males (odds ratio 3.2). Contralateral ACL rupture occurred in significantly more PT patients (24%) than HT patients (12%) (p=0.03), and was associated with age < 18 years (odds ratio 4.1) and the patellar tendon graft (odds ratio 2.6). Radiologically detectable osteoarthritis at 15 years was associated with the PT graft (odds ratio 2.3).

Significant differences have developed in the groups at 15 years after surgery which were not seen at earlier reviews. Compared to the HT Group, the PT group had significantly worse outcomes with respect to radiological osteoarthritis, extension loss and functional tests but no significant difference in laxity was identified. There was a high incidence of ACL injury after reconstruction, to both the reconstructed and the contralateral knee.

Introduction

The management of degenerative arthritis of the knee in the younger, active patient presents a challenge to the orthopaedic surgeon. Surgical treatment options include: high tibial osteotomy (HTO), unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). The aim of this study was to examine the long-term survival of closing wedge HTO in a large series of patients up to 19 years after surgery.