The aim of this paper is to evaluate the Linvatec SE graft tensioner system in obtaining predictable initial tension during ACL reconstruction using hamstring grafts.

The gracilis and semitendinosus grafts were tensioned individually prior to fixation distally to a combined tension of 80N. The knees were then cycled through full range of motion and the tension recorded at 90 degrees and in full flexion and extension. Experience on the first 22 patients indicated that 41% required 10 cycles of the knee to remove pre-conditioning and equalise tension at 80N combined, while the remaining 50% required 15 cycles. 90% reached stable tension after 15 cycles. In 54% the tension increased at full extension and graft tension was adjusted to 80N in extension to avoid overconstraining the graft. Twenty-two patients studied following this initial protocol underwent outcome assessment after minimum 6 months. Mean KT1000 arthrometry manual maximum side to side difference was 1.5mm. Femoral fixation was achieved using the Endobutton (Smith and Nephew) and Tibial fixation using the Extralok bioabsorbable screw (Linvatec).

A subsequent shortened protocol of initial over-tensioning to 60N and 40N for the semitendinosus and gracilis double bundles respectively, followed by 15 cycles of the knee resulted in stable 80N combined tension with no further drop with more cycling.

We conclude that the new tensioner system allows for accurate and predictable initial tension of hamstring reconstructed ACL grafts and that its use can be simplified by using the second technique protocol.

Aims: To assess the outcome of biological resurfacing combined with osteotomy for knee osteoarthritis [OA] in young individuals.

Methods: Between January 2001 and March 2006, 25 active patients with unicompartmental OA were treated with a combination of cartilage resurfacing and tibial or femoral osteotomy. The cartilage resurfacing procedure was microfracture on both surfaces in 20 patients, Matrix Autologous Chondrocyte Implantation in 3, Autologous Chondrocyte Transplantation in 1 and Meniscal transplantation in 1. For limb realignment, an open wedge High Tibial Osteotomy was performed in 23 patients and Distal Femoral Osteotomy in 2 patients, using either the Puddu plate (Arthrex) or the Tomofix plate (Synthes).

There were 23 male and 2 female patients with a mean age of 45 years (range 27 to 60). The median follow-up period was 22.5 months (range 6 to 60). At follow-up patients were assessed radiographically and clinically using the knee society clinical score [KSS] and the Tegner activity scale.

Results: The outcome was satisfactory in 20 patients who had improvement in pain and function. The median Tegner activity level was 5.5 and the median KSS was 164. Poor results in five patients were due to delayed union in 1, nonunion in 2 and persistent severe pain in 2 who subsequently underwent unicompartmental or total knee replacement.

Discussion and conclusion: Management of the young active individual with grade 4 bare bone arthritis in the knee is challenging, and arthroplasty may not provide the ideal solution. Our series has shown that combining opening wedge osteotomy with cartilage repair results in improvement in a high proportion of patients. Such salvage surgery or ‘biological resurfacing’ may therefore have a place in the management of active young patients with bare bone osteoarthritis.

The clinical diagnosis of an acute compartment syndrome is most reliably based on increasing pain and pain on stretching the affected muscle groups. These signs cannot be elicited in the presence of epidural or regional blocks, or if the patient is unconscious. We present a national audit of consultant trauma and orthopaedic surgeons on the use of compartmental pressure monitoring in such patients. The postal questionnaire also asked whether a departmental protocol was in use and whether regional and epidural blocks were withheld in patients at risk of developing an acute compartment syndrome.

17% of consultants had such an agreed protocol, 53% did not have access to a continuous pressure monitoring device, 58% would request for an epidural/regional block to be withheld with only 2% routinely measuring compartment pressures in the presence of such a block.

This study highlights a major deficiency in the clinical approach to a relatively common condition that may result in limb and life threatening complications and supports the recommendation for compartmental monitoring equipment to be made available.