Aims. Our primary aim was to establish the proportion of female orthopaedic consultants who perform arthroplasty via cases submitted to the National Joint Registry (NJR), which covers England, Wales, Northern Ireland, the Isle of Man, and Guernsey. Secondary aims included comparing time since specialist registration, private practice participation, and number of hospitals worked in between male and female surgeons. Methods. Publicly available data from the NJR was extracted on the types of arthroplasty performed by each surgeon, and the number of procedures of each type undertaken. Each surgeon was cross-referenced with the General Medical Council (GMC) website, using GMC number to extract surgeon demographic data. These included sex, region of practice, and dates of full and specialist registration. Results. Of 2,895 surgeons contributing to the NJR in 2023, 102 (4%) were female. The highest proportions of female surgeons were among those who performed elbow (n = 25; 5%), shoulder (n = 24; 4%), and ankle (n = 8; 4%) arthroplasty. Hip (n = 66; 3%) and knee arthroplasty (n = 39; 2%) had the lowest female representation. Female surgeons had been practising for a median of 10.4 years since specialist registration compared to 13.7 years for males (p < 0.001). Northern Ireland was the region with the highest proportion of female arthroplasty surgeons (8%). A greater proportion of male surgeons worked in private practice (63% vs 24%; p < 0.001) and in multiple hospitals (74% vs 40%; p < 0.001). Conclusion. Only 4% of surgeons currently contributing cases to the NJR are female, with the highest proportion performing elbow arthroplasty (5%). Female orthopaedic surgeons in the NJR are earlier in their careers than male surgeons, and are less involved in private practice. There is a wide geographical variation in the proportion of female arthroplasty surgeons. Cite this article: Bone Jt Open 2024;5(8):637–643

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To systematically review the predominant complication rates and changes to patient-reported outcome measures (PROMs) following osteochondral allograft (OCA) transplantation for shoulder instability.

Aims

Paediatric fractures are highly prevalent and are most often treated with plaster. The application and removal of plaster is often an anxiety-inducing experience for children. Decreasing the anxiety level may improve the patients’ satisfaction and the quality of healthcare. Virtual reality (VR) has proven to effectively distract children and reduce their anxiety in other clinical settings, and it seems to have a similar effect during plaster treatment. This study aims to further investigate the effect of VR on the anxiety level of children with fractures who undergo plaster removal or replacement in the plaster room.

Background. Studies have compared open reduction internal fixation (ORIF) with fibular nail fixation (FNF) and shown reduced wound complications with minimal difference to PROMS in the short term. Our aim is to compare long-term outcomes for unstable ankle fractures at 10 year follow up. Methods. Patients from a previously conducted RCT were contacted at a minimum of 10 years post intervention at a single study centre. Case notes were reviewed, and patient reported outcome measures acquired at 10 years. Results. Ninety-nine patients were included (48 FNF and 51 ORIF). After 10 years 75% (33/44) of patients in the FNF group required no further follow up versus 81% (39/48) in the ORIF group. Radiographically at 2 years post-injury, there was no statistically significant difference between groups for development of osteoarthritis (p=0.851). There was one tibio-talar fusion in each group secondary to osteoarthritis, but no statistically significant difference in overall re-operation rate (p=0.518). Fifty-one percent (n=50) of patients have so far returned patient reported outcome measures at a minimum of 10 years (Fibular nail n=23, plate fixation n=27). No significant difference was found between groups for the mean scores of Olerud and Molander Ankle Score (FNF 84.78 vs ORIF 84.07; p=0.883), the Manchester-Oxford Foot Questionnaire (MOXFQ) (FNF 89.54 vs ORIF 96.47; p=0.112), Euroqol-5D Index (FNF 0.88 vs ORIF 0.87; p=0.701) and Euroqol-5D Visual Analogue Score (FNF 77.30 vs ORIF 77.52; p=0.859). Conclusion. The current study illustrates that both methods of treatment result in a satisfactory long-term outcome with no difference in late complications or PROM scores at up to 10 years in patients under 65 years old, although the study is currently under powered

Background. Total Ankle Replacement (TAR) is an established treatment option for end-stage ankle arthritis. We analysed at minimum, 10-year patient-reported and clinical outcomes of 156 TARs from a single centre. We specifically compared outcomes between patients under 60 and over 60 at time of surgery. Methods. Data was collected retrospectively from our departmental patient database. It included all patients who underwent a TAR by a single surgeon between 2006 and 2010 and patients were divided into those under 60 and those over 60 at the time of surgery. Patient reported outcomes (PROMs), including WOMAC, SF-36 and patient satisfaction scores and complications were analysed preoperatively and at one, two, five and over 10 years postoperatively. Results. There were 156 patients included in this analysis, 61 were under 60 (mean age 50.29) and 95 were over 60 (mean age 69.12). A total of 12 patients had revision surgery, (nine in the under 60 group) and 52 patients were deceased at the time of analysis (10 in the under 60 group). At one year the over 60 group had less pain and better functional scores (p=0.02, p=0.017). At two, five and ten years there was no statistical difference in pain and function between groups. At two years the over 60s reported less stiffness and quicker return to activities of daily living (p=0.007, p=0.001). However, at five and 10 years there was no statistical difference in any domain. Conclusions. This study demonstrates that age does not correlate with a significant difference in pain or functional outcomes in patients who have TAR, at over 10 years follow up. The higher revision rates in the younger group may correlate with higher functional demand and lower mortality rate

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Current diagnostic tools are not always able to effectively identify periprosthetic joint infections (PJIs). Recent studies suggest that circulating microRNAs (miRNAs) undergo changes under pathological conditions such as infection. The aim of this study was to analyze miRNA expression in hip arthroplasty PJI patients.

Background. Open or arthroscopic ankle fusion (AAF) is a successful operative treatment for end-stage ankle arthritis. Evidence suggest that AAFs have better outcomes. In addition to the operative technique other patient-factors can influence outcomes. The most significant complication of ankle fusion is a non-union. To better understand the risk factors related to this we undertook a retrospective investigation of primary AAFs. Methods. We reviewed all AAFs conducted at our institution over a 10-year period. Patients excluded if they had simultaneous fusion of neighbouring joints or were lost to follow-up. The primary outcome variable was radiographic union. Other operative complications were analysed as secondary outcomes. Two hundred and eighty-four eligible AAFs in 271 patients were performed over the study period. Results. The overall non-union rate was 7.7 %. Univariate logistic regression analysis found that smoking (6.2% non-union in non-smokers vs 24% in smokers) and prior triple fusion (5.5% non-union in the absence of prior triple fusion vs 70% in the presence of a prior triple fusion) were independent risk factors for non-union. Multivariate analysis showed that only prior triple fusion was predictive (OR 40.0 [9.4,170.3], p < 0.0001). Increasing age, obesity (BMI >30), surgical grade (trainee vs consultant), diabetes or the degree of weightbearing status post-operatively were not significant risk factors of non-union. The leading cause of reoperation was the removal of metal (18%). There were 5 superficial (1.8%) and 4 deep (1.4%) infections. Kaplan-Meier survival analysis showed a 75% ‘survivorship’ of the subtalar joint at 10 years following an arthroscopic ankle fusion. Conclusion. This is the largest case series of AAFs in the literature and the first to demonstrate that patients who had an AAF performed after a previous triple fusion have unacceptably high non-union rates and may benefit from other surgical options. This study data could also useful for patient consenting purposes

Aims. This study aims to assess the relationship between history of pseudotumour formation secondary to metal-on-metal (MoM) implants and periprosthetic joint infection (PJI) rate, as well as establish ESR and CRP thresholds that are suggestive of infection in these patients. We hypothesized that patients with a pseudotumour were at increased risk of infection. Methods. A total of 1,171 total hip arthroplasty (THA) patients with MoM articulations from August 2000 to March 2014 were retrospectively identified. Of those, 328 patients underwent metal artefact reduction sequence MRI and had minimum two years’ clinical follow-up, and met our inclusion criteria. Data collected included demographic details, surgical indication, laterality, implants used, history of pseudotumour, and their corresponding preoperative ESR (mm/hr) and CRP (mg/dl) levels. Multivariate logistic regression modelling was used to evaluate PJI and history of pseudotumour, and receiver operating characteristic curves were created to assess the diagnostic capabilities of ESR and CRP to determine the presence of infection in patients undergoing revision surgery. Results. The rate of PJI for all identified MoM THAs was 3.5% (41/1,171), with a mean follow-up of 10.9 years (2.0 to 20.4). Of the patients included in the final cohort, 8.2% (27/328) had PJI, with a mean follow-up of 12.2 years (2.3 to 20.4). Among this cohort, 31.1% (102/328) had a history of pseudotumour. The rate of PJI in these patients was 14.7% (15/102), which was greater than those without pseudotumour, 5.3% (12/226) (p = 0.008). Additionally, logistic regression analysis showed an association between history of pseudotumour and PJI (odds ratio 4.36 (95% confidence interval 1.77 to 11.3); p = 0.002). Optimal diagnostic cutoffs for PJI in patients with history of pseudotumour versus those without were 33.1 mm/hr and 24.5 mm/hr for ESR and 7.37 mg/dl and 1.88 mg/dl for CRP, respectively. Conclusion. Patients with history of pseudotumour secondary to MoM THA had a higher likelihood of infection than those without. While suspicion of infection should be high for these patients, ESR and CRP cutoffs published by the European Bone and Joint Infection Society may not be appropriate for patients with a history of pseudotumour, as ESR and CRP levels suggestive of PJI are likely to be higher than for those without a pseudotumour. Additional investigation, such as aspiration, is highly recommended for these patients unless clinical suspicion and laboratory markers are low. Cite this article: Bone Joint J 2024;106-B(6):555–564

Introduction. Acetabular component loosening with associated bone loss is a challenge in revision hip arthroplasty. Trabecular Metal (TM) by Zimmer Biomet has been shown to have greater implant survivorship for all-cause acetabular revision in small cohort retrospective studies. Our study aims to review outcomes of acetabular TM implants locally. Method. This is a retrospective observational study using data from Auckland City and North Shore Hospitals from 1st of January 2010 to 31st of December 2020. Primary outcome is implant survivorship (re-revision acetabular surgery for any cause) demonstrated using Kaplan-Meier analysis. Secondary outcome is indication for index revision and re-revision surgery. Multivariate analysis used to identify statistically significant factors for re-revision surgery. Results. 225 cases used acetabular TM implants (shells and/or augments) over 10 years. Indications include aseptic loosening (63%), instability (15%) and infection (13%). Of these, 12% (n=28) had further re-revision for infection (54%) and instability (21%). Median time to re-revision was 156 days (range 11 – 2022). No cases of re-revision were due to failure of bony ingrowth or acetabular component loosening. Ethnicity, smoking status, and age were not risk factors for re-revision procedures. Additionally, previous prosthetic joint infection, ethnicity, sex and age were not significant risk factors for re-revision due to infection. Implant survivorship was 80% at 1 year, 71% at 5 years and 64% at 10 years. Discussion. Main indications for re-revision were infection and instability. Demographic factors and co-morbidities did not correlate with increased re-revision risk. Survivorship is poorer compared to cumulative survivorship reported by the New Zealand Joint Registry (NZJR). Explanations are multifactorial and possibly contributed by underestimation of true revision rates by registry data. Conclusions. We need to identify alternate causes for poorer survivorship and review the role of TM implants in acetabular revision within our specified population

Introduction. The purpose of this study was to compare implant survivorship and functional outcomes in patients undergoing reverse total shoulder arthroplasty (RTSA) for acute proximal humeral fracture (PHF) with those undergoing elective RTSA in a population-based cohort study. Methods. Prospectively collected data from the New Zealand Joint Registry from 1999 to 2021 and identified 7,277 patients who underwent RTSA. Patients were categorized by pre-operative indication, including acute PHF (10.1%), rotator cuff arthropathy (RCA) (41.9%), osteoarthritis (OA) (32.2%), rheumatoid arthritis (RA) (5.2%) and old traumatic sequelae (4.9%). The PHF group was compared with elective indications based on patient, implant, and operative characteristics, as well as post-operative outcomes (Oxford Shoulder Score [OSS], and revision rate) at 6 months, 5 and 10 years after surgery. Survival and functional outcome analyses were adjusted by age, sex, ASA class and surgeon experience. Results. Implant survivorship at 10 years for RTSA for PHF was 97.3%, compared to 96.1%, 93.7%, 92.8% and 91.3% for OA, RCA, RA and traumatic sequelae, respectively. When compared with RTSA for PHF, the adjusted risk of revision was higher for traumatic sequelae (hazard ratio = 2.29; 95% CI:1.12–4.68, p=0.02) but not for other elective indications. At 6 months post-surgery, OSS were significantly lower for the PHF group compared to RCA, OA and RA groups (31.1±0.5 vs. 35.6±0.22, 37.7±0.25, 36.5±0.6, respectively, p<0.01), but not traumatic sequelae (31.7±0.7, p=0.43). At 5 years, OSS were only significantly lower for PHF compared to OA (37.4±0.9 vs 41.0±0.5, p<0.01), and at 10 years, there were no differences between groups. Discussion and Conclusion. RTSA for PHF demonstrated reliable long-term survivorship and functional outcomes compared to other elective indications. Despite lower functional outcomes in the early post-operative period for the acute PHF group, implant survivorship rates were similar to patients undergoing elective RTSA

Introduction. The Oxford Unicompartmental Knee Replacement (OUKA) is the most popular unicompartmental knee replacement (UKR) in the New Zealand Joint Registry with the majority utilising cementless fixation. We report the 10-year radiological outcomes. Methods. This is a prospective observational study. All patients undergoing a cementless OUKA between May 2005 and April 2011 were enrolled. There were no exclusions due to age, gender, body mass index or reduced bone density. All knees underwent fluoroscopic screening achieving true anteroposterior (AP) and lateral images for radiographic assessment. AP assessment for the presence of radiolucent lines and coronal alignment of the tibial and femoral components used Inteliviewer radiographic software. The lateral view was assessed for lucencies as well as sagittal alignment. Results. 687 OUKAs were performed in 641 patients. Mean age at surgery was 66 years (39–90yrs), 382 in males and 194 right sided. 413 radiographs were available for analysis; 92 patients had died, 30 UKRs had been revised and 19 radiographs were too rotated to be analysed the remainder were lost to follow-up. Mean radiograph to surgery interval was 10.2 years (7.1–16.2yrs). RLLs were identified in zone 1 (3 knees), zone 2 (2 knees), zone 3 (3 knees), zone 5 (3 knees), zone 6 (2 knees) and zone 7 (42 knees). No RLL had progressed, and no case had any osteolysis or prosthesis subsidence. Alignment in the coronal plane: mean 2.90° varus (9.30° varus - 4.49° valgus) of the tibial component to the tibial anatomic axis and the femoral component in mean 4.57° varus (17.02° varus - 9.3° valgus). Sagittal plane posterior tibial slope was a mean 6.30° (0.44° -13.60° degrees) and mean femoral component flexion of 8.11° (23.70° flexion – 16.43° extension). Conclusion. The cementless OUKA demonstrates stable fixation with low revision rates at our centre supporting results earlier published by the design centre

Introduction. Total ankle arthroplasty (TAA) is an increasingly popular treatment option for patients with end-stage ankle arthritis. However, for most implant systems, failure rates of 10–20% have been reported within the first 10 years after primary TAA. Pain is the primary symptom that indicates failure of TAA but cause of it can be difficult to establish. Methods. All patients who underwent a primary TAA at our center were included in the study. The clinical outcomes were studied for patients requiring a further revision procedure following primary TAA. The reasons for revision surgery and outcomes of surgery were analyzed using appropriate inferential statistical tests. Results. Between 2007 and 2018, 42 primary TAA required revisions in 40 patients. There were 25 men (59.5%) and 15 women (35.7%) with mean age of 57.5 years the time of primary TAA. All patients had undergone primary procedure at a mean duration of 3.5 years previously (range: 3 months to 10 years). Of the total revision procedures, 12/40 (30%) of revisions were carried out due to malalignment, 10/42 (23.8%) due to loosening of the implants or bone subsidence, 5/42 procedures (11.9%) following infection, 4/42 (9.5%) due to polyethylene migration, 1/42 (2.3%) due to fracture and 1/42 (2.3%) due to Charcot arthropathy. In 9/42 (21.4%) cases, imaging showed no objective reason for pain. 50% of patients who underwent revision TAA reported 78.5% satisfaction with results of surgery at 2 years follow up post-operatively. Conclusion. Major reasons for revising primary TAR at our centre are mal-alignment, implant loosening / bone subsidence and suspicion of infection and pain. In-spite of undergoing a complex revision surgery, patients report 78.5% satisfaction from outcomes of surgery

Introduction. Total ankle replacement as a valid treatment for end stage ankle arthritis, is gaining popularity and every year there is an increasing number of procedures. With revision rates as high as 21% at 5 years and 43% at 10 years there is a need for understanding and reporting the outcome of revision ankle replacement. Our aim was to study the patient reported outcomes following revision TAR with a minimum of 2 year follow up. Methods. All patients that underwent a revision total ankle replacement between 2012 and 2016 were included in the study. All patients received a post-operative questionnaire comprising of MOX-FQ score, EQ-5D (UK) and Foot and Ankle outcomes scores (FAOS) and patients satisfaction questionnaire with a minimum of 2 years follow up. Results. 33 patients had a revision total ankle replacement between 2012 and 2016. 2 patients were deceased therefore 31 patients were included in the study. 4 patients declined participation for completing questionnaires. We received 15/27 (55.5%) completed questionnaires. The mean MOX-FQ average domain score for pain was (50.6 ± 26.9), walking/standing (62.4 ± 36.5) and social function was (43.7± 31.0). The mean FAOS scores were (52.5 ± 30.6; pain), (54.5 ± 29.2; symptoms), (62.1 ± 30.5; ADL) and (35.5 ± 28.2; for quality of life). The mean overall health score today for EQ-5D was 73.9/100. 50% of patients were satisfied with the pain relief and return to sports and recreation obtained following the operation, 57% were satisfied with the improved in daily activities. 78.5% were overall satisfied with the results from surgery. Conclusion. Revision total ankle replacement gives overall satisfactory results demonstrated from patients reported outcomes at a minimum of 2 years following surgery

Total hip replacement (THR) is one of the most common and cost-effective elective surgical procedures. In the National Health Service (NHS) of England and Wales a myriad of implants for THR are offered at a variety of locally negotiated prices. This study aims to estimate the total burden of elective THR to the NHS, expenditure on implants, and different scenarios of cost changes if implant selection changed for different patient groups. Using National Joint Registry (NJR) data and NHS reference costs, we estimated the number and expenditure of NHS funded primary and revision THR in the 10-year period 2008–2017 and forecasted the number and expenditure on THR over the next decade. Using NJR average NHS Trust prices for the different implant combinations we estimated the average cost of implants used in THRs and estimated the budget impact on NHS providers from switching to alternative implants. The NHS spent over £4.76 billion performing 702,381 THRs between 2008–2017. The average cost of implants was £1,260 per surgery, almost a fifth of the cost of primary THR. Providing cemented implant combinations in primary elective THRs may potentially save up to £281 million over the next 10 years, whilst keeping 10-year revision risks low. The NHS is likely to spend over £5.6 billion providing primary elective THR over the next decade. There are efficiency savings to realise in the NHS by switching to more cost-effective implant combinations available for patients undergoing primary elective THR surgery, but these will need to be balanced against the risks inherent to a change in selection of implants and surgical practice. The HIPPY programme will be conducting practice surveys, discrete choice experiments and a large randomised controlled trial of cemented, uncemented and hybrid fixation in THR for patients under 70 to answer uncertainties

The April 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Ultrasonography or radiography for suspected paediatric distal forearm fractures?; Implant density in scoliosis: an important variable?; Gait after paediatric femoral shaft fracture treated with intramedullary nail fixation: a longitudinal prospective study; The opioid dilemma: navigating pain management for children’s bone fractures; 12- to 20-year follow-up of Dega acetabuloplasty in patients with developmental dysplasia of the hip; Physeal fractures of the distal ulna: incidence and risk factors for premature growth arrest; Analysis of growth after transphyseal anterior cruciate ligament reconstruction in children; Management of lateral condyle humeral fracture associated with elbow dislocation in children: a retrospective international multicentre cohort study.

Aims

Posterior malleolar (PM) fractures are commonly associated with ankle fractures, pilon fractures, and to a lesser extent tibial shaft fractures. The tibialis posterior (TP) tendon entrapment is a rare complication associated with PM fractures. If undiagnosed, TP entrapment is associated with complications, ranging from reduced range of ankle movement to instability and pes planus deformities, which require further surgeries including radical treatments such as arthrodesis.

Aims. The first aim of this study was to evaluate whether preoperative renal function is associated with postoperative changes in whole blood levels of metal ions in patients who have undergone a Birmingham Hip Resurfacing (BHR) arthroplasty with a metal-on-metal bearing. The second aim was to evaluate whether exposure to increased cobalt (Co) and chromium (Cr) levels for ten years adversely affected renal function. Methods. As part of a multicentre, prospective post-approval study, whole blood samples were sent to a single specialized laboratory to determine Co and Cr levels, and the estimated glomerular filtration rate (eGFR). The study included patients with 117 unrevised unilateral BHRs. There were 36 females (31%). The mean age of the patients at the time of surgery of 51.3 years (SD 6.5), and they all had preoperative one-, four-, five-, and ten-year laboratory data. The mean follow-up was 10.1 years (SD 0.2). Results. Median Co levels at one year postoperatively increased significantly compared with the preoperative values, by a factor of 9.7, from 0.13 to 1.26 ppb (p < 0.001), and the median Cr levels increased significantly by a factor of 2.5, from 0.60 to 1.50 ppb (p < 0.001). Lower preoperative eGFRs were associated with significantly larger increases in Co at one year compared with the preoperative levels (ρ = -0.26; p = 0.005), but there was no relationship between preoperative eGFRs and changes in Cr at one year (ρ = -0.13; p = 0.153). Metal levels remained relatively constant with the passage of time, with a median ten-year value of 1.12 ppb for Co and 1.29 ppb for Cr. There was no significant relationship between the Co and Cr levels at ten-year follow-up and the change in eGFR from the preoperative level to that at ten years (ρ = -0.02; p = 0.827 for Co; ρ = -0.008; p = 0.933 for Cr). Conclusion. Although patients with lower preoperative eGFRs tended to have larger increases in Co levels at one year, increased metal levels for patients who underwent unilateral BHR did not adversely affect renal function during the first ten postoperative years. Cite this article: Bone Joint J 2024;106-B(3 Supple A):44–50

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In metal-on-polyethylene (MoP) total hip arthroplasty (THA), large metal femoral heads have been used to increase stability and reduce the risk of dislocation. The increased size of the femoral head can, however, lead to increased taper corrosion, with the release of metal ions and adverse reactions. The aim of this study was to investigate the relationship between the size of the femoral head and the levels of metal ions in the blood in these patients.

BACKGROUND. Theatre-listed trauma patients routinely require two ‘group and save’ blood-bank samples, in case they need perioperative transfusion. The Welsh Blood Service (WBS) need patients to have one recorded sample from any time in the last 10 years. A second sample, to permit cross-matching and blood issuing, must be within 7 days of transfusion (or within 48 hours if the patient is pregnant, or has been transfused within the last 3 months). The approximate cost of processing a sample is £15.00. AIM. To investigate whether routine pretransfusion blood sampling for trauma admissions exceeds requirements. METHODS. Electronic records were used to collect pretransfusion sampling data for all adult non-elective trauma patients listed for theatre under a trauma and orthopaedics consultant between 1/1/2023-31/1/2023. Data were collected on unnecessary samples, rejected samples and total excess samples. RESULTS. 113 patients (mean age[±SD] 64.09[±19.96]) underwent 132 procedures. On average, unnecessary sampling occurred at a rate of 0.48 samples per operation, equating to a cost of £945.00/month. Samples were rejected by the laboratory at a rate of 0.25 samples per operation. Common reasons for rejection were ‘patient date of birth discrepancy’ (between sample and request form), ‘patient address discrepancy’ and ‘signature discrepancy’. Overall, total excessive sampling occurred at a rate of 0.60 samples per operation. CONCLUSION. Nearly half of trauma patients undergo unnecessary blood testing in anticipation of potential perioperative transfusion. This has implications for sustainability, financial cost and patient welfare. This signals poor understanding of WBS requirements and is an area that requires improvement

Objectives. Congenital cruciate ligament deficiency is a rare condition that may occur in isolation or in association with longitudinal limb deficiencies such as fibular hemimelia or proximal femoral focal deficiency. Often anomalies of the menisci and their attachments can be very abnormal and impact on surgical management by standard techniques. Arthroscopic surgical knee reconstruction is undertaken to improve symptomatic instability and/or to stabilise and protect the knee for future planned limb lengthening surgery. The aim of this study is to evaluate the arthroscopic findings of patients undergoing surgery for congenital cruciate ligament deficiency, and specifically to determine the frequency and types of meniscal anatomical variations seen in these cases. Methods. Patients undergoing surgery for congenital cruciate ligament deficiency were identified from a prospectively collated database. Diagnosis was confirmed through review of the clinical notes and imaging. Operative notes and 4K saved arthroscopic images and video recordings for these cases were reviewed. Results. Over a six-year period (July 2017 – September 2023), 42 patients underwent surgery for congenital ligament deficiency and tibiofemoral instability (45 surgical episodes). Median age of patients at time of surgery was 10 years (range 4 – 17 years). The most frequent diagnosis was congenital longitudinal limb deficiency syndromes in 27 cases, with the most frequent being fibular hemimelia. Isolated congenital ligament deficiency without any other associated extra-articular manifestations occurred in 11 cases. Absence of meniscal root attachments or hypertrophy of meniscofemoral ligaments acting as ‘pseudo-cruciates’ were seen in over 25% of patients. In isolated ACL deficiency these were injured causing onset of instability symptoms and pain following trauma. Often these abnormal structures required addressing to allow surgical reconstruction. Conclusions. Our findings demonstrate that there are often meniscal variations seen in association with congenital absence or hypoplasia of the cruciate ligaments. In these patients hypertrophied meniscofemoral ligaments may act as cruciate-like structures and play a role in providing a degree of sagittal plane stability to the knee. However, when the knee becomes unstable to the point that cruciate ligament reconstruction is indicated, these meniscal variants may often require stabilisation using complex meniscal root repair techniques or variations to standard cruciate ligament reconstruction techniques to accommodate the variant anatomy