Aims

To explore key stakeholder views around feasibility and acceptability of trials seeking to prevent post-traumatic osteoarthritis (PTOA) following knee injury, and provide guidance for next steps in PTOA trial design.

Abstract

The objectives of the study were to investigate demographic, injury and surgery/treatment-associated factors that could influence clinical outcome, following Autologous Chondrocyte Implantation (ACI) in a large, “real-world”, 20 year longitudinally collected clinical data set.

Multilevel modelling was conducted using R and 363 ACI procedures were suitable for model inclusion. All longitudinal post-operative Lysholm scores collected after ACI treatment and before a second procedure (such as knee arthroplasty but excluding minor procedures such as arthroscopy) were included. Any patients requiring a bone graft at the time of ACI were excluded. Potential predictors of ACI outcome explored were age at the time of ACI, gender, smoker status, pre-operative Lysholm score, time from surgery, defect location, number of defects, patch type, previous operations, undergoing parallel procedure(s) at the time of ACI, cell count prior to implantation and cell passage number.

The best fit model demonstrated that for every yearly increase in age at the time of surgery, Lysholm scores decreased by 0.2 at 1-year post-surgery. Additionally, for every point increase in pre-operative Lysholm score, post-operative Lysholm score at 1 year increased by 0.5. The number of cells implanted also impacted on Lysholm score at 1-year post-op with every point increase in log cell number resulting in a 5.3 lower score. In addition, those patients with a defect on the lateral femoral condyle (LFC), had on average Lysholm scores that were 6.3 points higher one year after surgery compared to medial femoral condyle (MFC) defects. Defect grade and location was shown to affect long term Lysholm scores, those with grade 3 and patella defects having on average higher scores compared to patients with grade 4 or trochlea defects.

Some of the predictors identified agree with previous reports, particularly that increased age, poorer pre-operative function and worse defect grades predicted poorer outcomes. Other findings were more novel, such as that a lower cell number implanted and that LFC defects were predicted to have higher Lysholm scores at 1 year and that patella lesions are associated with improved long-term outcomes cf. trochlea lesions.

Summary

The findings demonstrate that culture expanded human mesenchymal stem cells (MSCs) incorporated and proliferated in clinically relevant cell scaffolds better than freshly isolated bone marrow mononucleated cells (MNCs); in fact, only in MSC cultures were cells present for longer term chondrogenic inductions.

Introduction

Patellofemoral pain and instability can be quantified by using the tibial tuberosity to trochlea groove (TT-TG) distance with more than or equal to 20mm considered pathological requiring surgical correction. Aim of this study is to determine if knee joint rotation angle is predictive of a pathological TT-TG.

Aims

To determine whether a correlation exists between the clinical symptoms and signs of impingement, and the severity of the lesions seen at bursoscopy.

Aims

To describe the distribution and clinical presentation of SLAP tears in rugby players, and time taken for return to sport.

Introduction

We present an all arthroscopic technique for modified Weaver Dunn reconstruction of symptomatic chronic type III acromioclavicular joint injuries.

Purpose: To report the 2–5 year results of ACL reconstruction with doubled Tibialis anterior allograft.

Method: Seventy-three patients who underwent primary ACL reconstruction with doubled tibialis anterior allografts with minimum 2 year follow-up were included in the study. Patients were assessed via telephone interview using the Lysholm knee score, Tegner activity score, and the subjective International Knee Documentation Committee rating. In addition, they were asked if they had failure of the ACL requiring revision or any other procedures such as repeat arthroscopy for meniscal surgery/articular cartilage. Statistical analysis using levene’s test and the T-test was used to assess outcomes of patients according to age and sex.

Results: Sixty-four (88%) patients were available for follow-up. The mean age was 28.94 years (16–55). There were 33 males (51.6%) and 31 females (48.4%). The mean follow-up was 41.6 months (range 24–55 months). There were 2 (3%) complications, 1 patient suffered a DVT with subsequent PE, and 1 patient suffered a hardware problem. Four patients (6.3%) had failure of their graft and 6 patients (9%) required repeat arthroscopy. The mean Lysholm score was 91.75 (SD+/− 8.2), and the mean Tegner activity score was 5.4 (range 1–10). The mean IDKC was 88.94 (SD+/− 8.33). According to the IDKC score 58% of patients were rated as excellent, 27% as good, and 13% as fair and 2% as poor. There was no difference in outcome in patients under 30 compared to over 30 years. Males performed statistically better on the Lysholm and the IKDC scores (p 0.005 and 0.038 respectively) when compared to women.

Conclusion: ACL reconstruction with Allograft Tibialis anterior tendon provided good functional results with a low failure rate at 2–5 years. There was no statistical difference in outcome between Patients under 30 years and those above 30 years. Males performed better on the Lysholm and the IDKC questionnaires.

Introduction: Recent data suggests that Double Bundle ACL reconstruction is bio-mechanically and potentially clinically superior. The success of Doudle bundle ACL reconstruction is dependent on tunnel placement. Of clinical concern is the increased technical difficulty and the potential for complications. The aim of our study was to determine how big the learning curve was for a high volume ACL Surgeon.

Methods: Ten Double bundle ACL reconstruction procedures were carried out on suitable individuals. Following the procedure all patients underwent a CT scan of the relevant knee. Femoral tunnel placement was measured according to the quadrant technique described by Bernard and Hertel. The ideal tunnel locations used for analysis were those described by Zantop et al. On the tibial side, the radiographic measurements were performed according to Staubli and Rauschning. The centres of the AM and PL bundles were expressed as percentages of the maximum tibial sagittal diameter. The tibial ACL attachment at the centre of the AM bundle was taken to be 30% of the maximal tibial diameter and the centre of the PL bundle was located at 44%.

The tunnel positions were measured for each patient.

Results: Good tunnel placement was achieved in the majority of patients. There was an initial learning curve with improvement in tunnel placement as experience increased. Femoral tunnel positions had the greatest variation. There were no complications. The technical challenges are discussed.

Conclusion: We have shown that it is possible for a high volume ACL surgeon to convert from a single bundle reconstruction technique to a double bundle reconstruction with relative accuracy.

Introduction: Significant internal rotation limitation is thought to be due to posterior capsular thickening and therefore adding a posterior release to the anterior and inferior releases seems sensible. However, this is technically more difficult.

Aims: To assess the overall outcome of arthroscopic capsular release and to establish whether inclusion of a posterior capsular release has an additional beneficial.

Methods: 48 patients with primary or secondary frozen shoulder in whom conservative physiotherapy had failed were included. 27 had an anterior and inferior release only, whilst the 21 included a posterior release. All data was collected prospectively.

Results: Aetiology of the frozen shoulder was primary (22), diabetic (7), post-traumatic (7) and post-operative (11). There a highly significant improvement in Constant score (P < 0.001) and range of motion (P< 0.001) by 5 months in both groups. The mean satisfaction score (minimum 1 and maximum 10) was 7 post-operatively. There was no significant difference in Constant Score between the two groups (P = 0.56) and no significant difference in the improvement of the range of motion, in particular internal rotation (P=0.35).

Conclusion: There was an overall rapid significant improvement following arthroscopic capsular release, but no significant difference in the overall outcome with the addition of a posterior release.

Clinical relevance: Adding a posterior release to an arthroscopic capsulectomy does not seem to add any significant benefit to the outcome.

Aims To describe the distribution, clinical presentation of SLAP tears in rugby players, and time taken for return to sport.

Method A retrospective review of 51 shoulder arthroscopies performed on professional rugby players over a 35 month period was carried out. All patients diagnosed with a SLAP lesion at arthroscopy were identified. Each patient’s records were reviewed to record age, injury side, mechanism of injury, clinical diagnosis, investigations and results, management, and return to play.

Results The incidence of SLAP tears was 35%. All 18 patients were male with an average age of 27yrs. There were 11 isolated SLAP tears (61%), 3 SLAP tears associated with a Bankart lesion (17%), 2 SLAP tears associated with a posterior labral lesion (11%) and 2 SLAP tears associated with an anterior and posterior labral injury (11%). Of the 18 SLAP tears, 14 (78%) were Type 2, 3(17%) were Type 3 and 1(5%) was Type 4. All patients recalled a specific heavy tackle with fall onto the lateral aspect of shoulder. No patient sustained a complete dislocation. None of the patients presented with symptoms of instability. MR Arthrograms were performed in 17 of the 18 patients. SLAP tears were detected in 13 patients (76%). All patients underwent arthroscopic reconstruction within 6 months post injury. At Arthroscopy 7 patients (39%) were found to have associated injuries. Preoperatively 11% of patients were satisfied with their shoulder. By 6 months post surgery 89% of patients were satisfied and 95% were back to their previous activity level. Patients with isolated SLAP tears returned to sports at an average of 2.6 months post surgery.

Conclusion SLAP tears are a common injury in rugby players with shoulder pain following injury. These can often be diagnosed with MR arthrography. Arthroscopic repair is associated with excellent results and early return to sports.

We present an all arthroscopic technique for modified Weaver Dunn reconstruction of symptomatic chronic type III ACJ joint injuries. Over a one year period we performed 12 all arthroscopic modified Weaver-Dunn procedures. All patients had failed non-operative management for at least 6 months. The technique involved excision of the lateral end of clavicle, stabilisation with a suture cerclage technique from 2 anchors placed in the base of the coracoid and coracoacromial ligament transfer from the acromion to lateral end of clavicle. Post-operatively the patients were immobilised for six weeks, followed by an active rehabilitation programme and return to work and sports at 3 months. We have currently performed this technique in 12 patients, all male. The average age at operation was 25.8yrs at a mean interval of 11 months post injury. The mean Constant score preoperatively was 49 (44–54). The mean 3 month postoperative Constant score was 88.6 (84–96). There have been no complications, and the 2 professional sportsmen within our cohort returned to full contact at 3 months. Due to an irreducible clavicle, one patient required an open excision of lateral clavicle, with the rest of the procedure performed arthroscopically. Arthroscopic Weaver-Dunn has a number of advantages over the corresponding open procedure. It avoids the detachment of deltoid needed to gain exposure and also the morbidity from the wound. From our experience is that it enables patients to regain their function more rapidly with an earlier return to sporting activities. The early results from our initial experience have been excellent, with no complications. With this technique an anatomic reconstruction can be achieved with excellent cosmesis, low morbidity and potentially accelerated rehabilitation.

There is a legal and ethical obligation to gain informed consent before treatment commences. A number of bodies have issued guidelines for obtaining consent and these include the Department of Health, the GMC, The Royal College Surgeons of England, and the B.O.A. For a patient to give their informed consent to surgery they must receive sufficient information about their illness, proposed treatment and its prognosis. There are no specific guidelines regarding joint replacement. With this in mind a retrospective case note study was undertaken involving 100 patients who had undergone a hip replacement. Noting the documented discussion at all stages of patient contact.Fifty percent of patients had been seen and listed in the Outpatients by a Consultant, 25% were discussed with the Consultant responsible and the remainder were listed without Consultant input. In only 33 % of cases were any specific risks recorded. This had fallen to 4% on their visit to pre operative assessment clinic. All the consent forms were completed at the time of admission for surgery. Forty percent of these on the day of surgery. The majority were completed by SHOs (58%), while only 4% were completed by consultants. None of the forms noted the lead surgeon. All the consent forms noted some frequently occurring risks. However there was a large variance in the details recorded. The study highlights that the majority of complications are only documented on the consent form, with little note of the dialogue leading up to it. It is also apparent that there is no agreement as to what represents a significant or frequent complication.

This review raises a number of important issues. There needs to be a national standardisation of the process of consent. We propose the introduction of a specific consent form for hip replacements that provide improved documentation of the standardised risks involved. This should also include guidelines regarding prosthesis choice, surgical approach and the extent of trainee involvement. In addition we would also suggest there is a need to improve sequential documented discussion up to the point of surgery and introduce specific training for juniors carrying out consent.

All patients over 65 yrs with an ISS greater than 15 attending Edinburgh Royal Infirmary between 1997 and 2000 were prospectively entered into the study. Patients were followed until death or discharge home. The patients were divided into, group 1 [patients who survived], and group 2 [those who died.]

A total of 72 patients were included in the study, 42 males and 31 females. 42 patients survived, and 31 died.

Group 1 consisted of 29 males and 15 females with an average age of 75.23yrs. Group 2 consisted of 13 males and 18 females with an average age of 78.05yrs. All incidents involved blunt trauma. The three main mechanisms of injury were RTA, Fall less than 2 meters, and Fall greater than 2 meters.

Five patients required intubation in group 1 and 12 patients in group 2.The average GCS was lower in group 1 compared to the group 2. All Injuries with AIS of greater than 3 were analysed. The total number of injuries was greater in the group 2. Group 1 required 214 days in HDU/ITU and a total of 943 in-patient days. Group 2 in comparison needed 62 HDU/ITU days and 169 in-patient days. The major cause of death was head and spinal injury 11 (35%), and Multiple injuries 9 (29%).

A total number of 1952 days were spent in rehabilitation prior to discharge, with an average of 46.48 days. Post trauma the level of independence was significantly reduced.

The injuries are exclusively blunt and in the majority of cases secondary to motor vehicle accidents. Predictors of mortality appear to include, intubation, head and neck injuries, GCS, and chest injuries. Current outcome scores correlate inaccurately. These patients require long hospital stays with a large amount of intensive care input. After discharge rehabilitation is universally required. These patients place a large demand on the NHS and social services; the total cost of their care was approximately £2,500,000.