The management of disabling osteoarthritis of the knee following ipsilateral femoral fracture malunion can be difficult. This study presents the results of seven such patients treated by femoral shaft osteotomy in the fracture region and with locked intramedullary nail fixation.

Seven patients with malunited femoral shaft fractures presenting with knee symptoms between 1992 and 1999 were treated by femoral shaft osteotomy. The presenting knee symptoms and function were graded from 0–4. All patients underwent open femoral shaft osteotomy at the apex of the deformity and fixation was by locked intramedullary nailing. The patients were followed up until osteotomy union and reviewed clinically and radiologically with particular emphasis on knee symptoms and function.

There were six males and one female. The mean age at presentation was 48 years and the mean time from fracture 28 years. (Range 13–37 years). The mean knee alignment angle preoperatively was 5 degrees varus (range 0–12). The mean time to osteotomy union was 28 months. The mean knee alignment angle postoperatively was 2 degrees valgus. (range 5 degrees varus-5 degrees valgus). Five of the seven patients reported excellent pain relief and functional improvement. One patient had serious vascular complication and now has a stiff but pain free knee. One patient who presented with very advanced OA has since undergone an uncomplicated total knee arthroplasty after osteotomy union and nail removal.

These patients presenting with severe disability at an age that would be too young for total knee replacement are difficult to manage. Five out seven patients in these series are symptomatically improved to return to their old occupation. The knee replacement has been delayed in these by a mean of five years. Their eventual knee replacement is likely to have been made less difficult as a result of alignment correction.

Purpose: To compare the radiographic tibial tunnel enlargement at one year post operatively following anterior cruciate ligament reconstruction in two patient groups one operated on soon after an acute injury and the other for chronic instability. Also, to correlate the radiographic findings with the clinical results.

Patients and Methods: The study group was of 42 patients who underwent isolated central anterior cruciate ligament reconstruction with a four thickness hamstring tendon technique. 20 of these were consecutive patients with a mean injury to operation delay of 4.5 weeks. Twenty two were consecutive patients with chronic instability and a mean injury to reconstruction interval of 29 months. All patients were reviewed at year post-operatively, their assessment including clinical examination, Lachman and Jerk Tests, arthrometer testing, Tegner activity level recording and weight bearing AP and lateral radiographs.

Tibial tunnel diameters were measured by two independent observers at two points. The proximal measurement was made 5 mm from the tibial articular surface and the distal, 5 mm from the lower end of the tunnel. The tunnel enlargement was calculated from the known drill size after correction for magnification.

Tunnel enlargement was compared between the two groups, was correlated with the clinical findings and the results were analysed statistically.

Results: Tibial tunnel enlargement was seen in both groups (p< .001). The enlargement was significantly greater at the proximal end of the tunnel (34%) than at the distal end (25%) (p< .05). In the acute group the mean increase in the tunnel diameter at the proximal end was 31%. In the chronic group it was 36%. This difference however was not statistically significant. (P> .05). At the distal end the mean tunnel enlargement in acute and chronic groups was 24% and 27% respectively. (P> .05).

Tunnel enlargement was significantly higher in patients with persistent effusion at one year. (40%:31%) p< .05. We did not find any correlation between tunnel enlargement and clinical outcome.

Conclusion: Anterior cruciate reconstruction by an isolated central hamstring tendon technique, carried out sub-acutely following injury, does not significantly reduce the incidence of tibial tunnel enlargement as compared with knees operated on by the same technique for chronic instability. There was a significant association between tunnel enlargement and the persistence of effusion.

Purpose: To study the clinical and radiological results and survival of hydroxyapatite coated femoral components in total knee arthroplasty at a mean follow-up of eight years.

Materials and Methods: Between 1991and 1992 36 consecutive knees with disabling arthritis were replaced with Freeman Samuelson Total knee prostheses with hydroxyapatite coated femoral components. These patients were prospectively followed up according to a standardised protocol for a mean period of 8 years. (Range 7–9 years). Clinical and radiological examination was done at each follow up. 1 knee was lost to follow up at 7 years. 4 patients (6 knees) died at 4 years (1), 7 years(2), 8 years (2), 9 years (l). None had been revised at the time of death. The radiographs were studied for signs of loosening and presence of lucencies.

Survival analysis was done using Kaplan and Meir’s method and with revision as the criterion for failure.

Results: There were 15 males and 14 females. The average age at operation was 63 years. Two knees (1 patient) were revised due to aseptic loosening, in both, of the femoral component. The alignment of the component in these was poor with an oblique joint line. The tibial component of one other knee was revised due to osteolysis in the medial tibial condyle. In the remaining knees there was no radiological evidence of loosening.

The survival of the femoral component at a mean follow-up of 7 years was 94% when 31.5 knees were at risk, with revision for femoral aseptic loosening as the end point.

91 percent of patients were pain free and 96% had an uninterrupted walking distance more than 10 minutes. The average alignment was 7.20 valgus (range 00–100 valgus).

Conclusion: The results of total knee arthroplasty with hydroxyapatite coated femoral components are encouraging in the medium term although not as good as those with cemented fixation.

Purpose: The management of disabling knee osteoarthritis of the knee following malunion of an ipsilateral femoral shaft fracture is difficult and controversial. The purpose of this study is to analyse the results of femoral shaft osteotomy at the level of the old fracture in seven such patients.

Materials and Methods: Seven patients with old malunited femoral shaft fractures presented with disabling knee osteoarthritis between 1992 and 1999. Knee symptoms and function were graded at presentation. All underwent open femoral shaft osteotomy at the apex of the deformity, with locked intramedullary nail fixation. The patients were followed up regularly until osteotomy union and reviewed clinically and radiologically with particular emphasis on knee symptoms and function.

Results: There were six males and one female. The mean age at presentation was 55 years and mean time from the fracture was 28 years (range 13–35 years). The mean preoperative knee alignment angle was 5.60 varus (range O′12′). The mean time to osteotomy union was 28 months. The mean postoperative knee alignment angle was 20 valgus (range 50 valgus -50 varus). All patients reported significant improvement in knee symptoms and function. One osteotomy was followed by a serious vascular complication and the patient now has a stiff but pain free knee. One patient with very advanced osteoarthritis underwent an uncomplicated total knee replacement after osteotomy union and nail removal.

Conclusion: These patients presenting with severe disability at an age which is worryingly young for total knee arthroplasty present a difficult management problem. Five out seven patients had excellent symptomatic and functional improvement following the femoral shaft osteotomy. The possible need for knee replacement was delayed by at least 5 years and the eventual arthroplasty is likely to have been made less technically difficult and more functionally satisfactory as a result of the alignment correction.

Purpose: Localisation of the femoral head is essential during total knee arthroplasty for assessing the overall alignment of the leg. The purpose of this study is to describe and report the accuracy a clinical method of estimating the centre of the femoral head.

Method: A line is drawn joining the anterior superior iliac spine and the pubic tubercle on the patient lying supine on the operating table. The point where femoral artery crosses this line is estimated. The Femoral head centre is marked 1.5 cm lateral to this point. This point was marked with an ECG electrode which has a radiopaque and prominent centre that is easily felt through the drapes. A radiograph was then made with the tube at 1 metre from the plate and centred over the hip marker.

The error in the hip marker placement is measured as the transverse mm (corrected for magnification) of the marker from the centre of the head, which is located on the radiograph using a template of concentric. The potential angle of error in coronal alignment of the associated knee replacement is calculated trigonometrically from femoral and tibial lengths.

Patients: The study group was comprised of 73 consecutive patients (100 knees) who underwent primary Total knee replacement. There were 36 males and 37 females.

Results: The average error was 8 mm (Range 0–30 mm). It was lateral to the femoral head in 47 patients and medial in 53 patients. The error was significantly greater in female patients (7mm:10mm, p < .05). The calculated potential error in coronal alignment was < 20 in 84% of patients and < 30 in 99% of the knees.

Conclusion: This is a clinically useful method of locating the centre of the femoral head for surgeons who find + 3 degrees of error in coronal alignment acceptable. For those striving for greater accuracy a preoperative hip marked radiograph may be more helpful.

Purpose: The radiological appearances of tibial tunnel enlargement following anterior cruciate ligament reconstruction in the short and medium term have been described. This study compares the tibial tunnel appearances at 1 year and again at 8 years post-operatively in 44 patients, and correlates the findings with the longer term clinical outcome.

Patients and Methods: The study was conducted on 44 consecutive patients who had undergone isolated central anterior cruciate reconstruction using a four thickness hamstring technique. All patients were reviewed at one year postoperatively, the assessment including full clinical examination, arthrometer testing and weight bearing AP and lateral radiographs. They were reviewed again at a mean of 8 years (range 5–10 years) post reconstruction. At the 8 year review, full clinical examination, Arthrometer testing, Lysholm and IKDC scoring, Tegner activity level recording were done and standardised weight bearing AP and lateral radiographs were taken.

The Tibial tunnel diameters were measured by two independent observers on both one year and 8 year radiographs. The proximal tunnel measurement was made 5 mm from the tibial articular surface and the distal, 5mm from the lower end of the tunnel. Tunnel enlargement was calculated from the known drill size after correction for magnification. The tunnel enlargements were correlated with clinical outcome and the results were analysed statistically.

Results: There were 6 failures of stability for which an additional operative procedure had been undertaken. The remaining 38 knees were functionally stable. 28 (75%) had negative Lachman and jerk tests and 34 (90%) had a side to side arthrometer difference of less than or equal to 3mm.

The mean tibial tunnel enlargement at one year was 31% at the proximal and 23% at the distal end of the tunnel. At 8 years the enlargements were 20% at the proximal and 13 % at the distal end of the tunnel (p< .001).

There were 10 patients (26%) whose distal tunnel diameter at 8 years was less than the initial drill size. Only one of these had a positive Lachman test. This negative association was significant (p< .05). There was no significant correlation between enlargement at the proximal end of the tunnel, the Lysholm score or clinical stability at 8 years.

Conclusion: Cruciate ligament reconstruction persists at 8 years. However there was a previously unreported reduction in radiographic tunnel size at the 8 year review and this reduction was significant at the distal end of the tibial tunnel. There was no correlation between tunnel enlargement and functional outcome even at 8 year review.