Increasing emphasis is placed on outcomes research. In this community study knee outcomes scores were evaluated in a ‘normal’ elderly population

The American knee society (AKS), Oxford, and Bristol knee scores were recorded in 100 elderly people without a history of lower limb disorder. The mean age of subjects was 72 years. Mean normalised scores were 90%, 91% and 94% for AKS, Oxford and Bristol knee scores respectively. There were significant negative correlations between knee score and advanced age (p< 0.001) and knee score and co-existent major medical disorders (p< 0.001). The function component was the score component most senitive to these variables (p< 0.001)

Control studies are necessary if knee scores are to be taken as accurate measures of outcome. Comparison of outcome after knee replacement on the basis of knee scores should take account of demographic variables. Scores with a large ‘function’ component appear to be more susceptible to demographic variation.

Aim of the study: To determine the optimum hydroxy-apatite-coating pattern of the femoral component in cementless hip arthroplasty.

Methods: Between January 1996 and May 1997, the first 65 patients (73 hips) of a single center prospective trial were randomised to receive a proximally coated Osteonics or a fully coated JRI Furlong stem. 30 Osteonics and 43 JRI stems were implanted. Clinical assessment was carried out using the modified Merle D’Aubigne and Postel (MDP) scoring system and the visual analogue scale (VAS). Radiological evaluation included measurement of subsidence, bone resorbtion, pedestal formation and implant-bone interface assessment. All live patients were reviewed. The average follow up was 50.3 months in the JRI group and 51.8 months in the Osteonics group.

Results: There were eight intra-operative femoral and one medial acetabullar wall fractures in the JRI group. In the Osteonics group there was one intra operative femoral fracture. There was one cup revision in both groups for aseptic loosening and one excision arthroplasty in the JRI group for sepsis. Clinical evaluation revealed a mean MDP of 16.3 (8–18) and a mean VAS of 0.55 (0–7) for the JRI group. The mean MDP for the Osteonics group was 16.31 (8–18) and the mean VAS 0.62 (0–4). Radiological evaluation revealed resorbtion in zone 7A in 16 of the JRI hips and 5 of the Osteonics. There was a reactive line around the distal part of the Osteonics stem in 17 patients, which was not correlated with symptoms. Subsidence rates were limited and comparable.

Conclusion: Both hips performed well. There was no difference in revision rate for loosening (p> 0.84). Clinical evaluation showed no significant difference in outcome between the prostheses (p> 0.83 for MDP & VAS). Radiology revealed different patterns, which did not represent a clinical importance at this stage.

Aim: To accurately identify the meniscofemoral ligaments in cadaveric human specimens, and to determine anatomical variations in the posterior cruciate ligament that may lead to mis-identification of these structures.

Methods: A total of 79 fresh frozen knees were examined from 45 cadavers Combined anterior and posterior approaches were used to inspect the vicinity of the posterior cruciate ligament (PCL) for the presence of the anterior and posterior meniscofemoral ligaments. The anterior approach utilised a medial parapatellar incision followed by division of the anterior cruciate ligament, whilst a midline posterior arthrotomy was used for the posterior approach. Further dissection facilitated inspection of the meniscal and femoral attachments of the MFLs, and measurement of their lengths. Videos of MFL and PCL motion during passive flexion of the cadaveric were also performed.

Results: In total, 74 (94%) of the 79 specimens contained at least one meniscofemoral ligament. The posterior meniscofemoral ligament (pMFL) was present in 56 (71%) specimens, whilst the anterior meniscofemoral ligament (aMFL) was present in 58 specimens (73%). Both ligaments coexisted in 40 (51%) of knees. In 15 specimens the PCL was seen to have oblique fibres, which attached proximal to the tibial attachment of the main part of the PCL. We termed this “the false pMFL”, as it could be easily mis-identified as the posterior meniscofemoral ligament. Several other anatomical variations were also identified. The mean length of the aMFL was 20.7±3.9mm, whilst that of the pMFL was 23±4.2mm. Although the lengths of the MFLs were relatively constant, there was a wide variation in thickness.

Discussion: This study confirms the high incidence of at least one MFL in humans, which suggests a functional role for these structures. The oblique fibres of the PCL can be readily mis-identfied as the pMFL. These caveats should be borne in mind, during both arthroscopic examination and in the interpretation of magnetic resonance imaging (MRI) scans of the knee. Although some variations of the MFLs have been reported on MRI imaging2, there has been no note of the oblique fibres of the PCL reported in the present study. As this variation was present in almost one in five of our specimens, its appearance on MRI scanning requires investigation.

The function of the meniscofemoral ligaments is undetermined, although many hypotheses comment on a role in guiding the motion of the lateral meniscus during knee flexion. Other possibilities include a function as a secondary restraint supplementing the posterior cruciate ligament.

Our objectives were to establish the envelope of passive movement and to demonstrate the kinematic behaviour of the knee during standard clinical tests before and after reconstruction of the anterior cruciate ligament (ACL). An electromagnetic device was used to measure movement of the joint during surgery.

Reconstruction of the ACL significantly reduced the overall envelope of tibial rotation (10° to 90° flexion), moved this envelope into external rotation from 0° to 20° flexion, and reduced the anterior position of the tibial plateau (5° to 30° flexion) (p < 0.05 for all). During the pivot-shift test in early flexion there was progressive anterior tibial subluxation with internal rotation. These subluxations reversed suddenly around a mean position of 36 ± 9° of flexion of the knee and consisted of an external tibial rotation of 13 ± 8° combined with a posterior tibial translation of 12 ± 8 mm. This abnormal movement was abolished after reconstruction of the ACL.

The meniscofemoral ligaments were studied in 84 fresh-frozen knees from 49 cadavers. Combined anterior and posterior approaches were used to identify the ligaments. In total, 78 specimens (93%) contained at least one meniscofemoral ligament. The anterior meniscofemoral ligament (aMFL) was present in 62 specimens (74%), and the posterior meniscofemoral ligament (pMFL) in 58 (69%). The 42 specimens (50%) in which both ligaments were present were from a significantly younger population than that with one MFL or none (p < 0.05). Several anatomical variations were identified, including oblique fibres of the posterior cruciate ligament (PCL), which were seen in 16 specimens (19%). These were termed the ‘false pMFL’.

The high incidence of MFLs and their anatomical variations should be borne in mind during arthroscopic and radiological examination of the PCL. It is important to recognise the oblique fibres of the PCL on MRI in order to avoid wrongly identifying them as either a pMFL or a tear of the lateral meniscus. The increased incidence of MFLs in younger donors suggests that they degenerate with age.

Purpose of study: Sixty four patellofemoral (PF) arthroplasties in 48 patients were evaluated to assess the effectiveness of this procedure in patients with a preoperative diagnosis of patellofemoral osteoarthritis.

Methods: All patients who underwent patellofemoral arthroplasty for patellofemoral osteoarthritis between 1992 and 1998 in two district general hospitals were studied. Three authors not directly involved in the patients care assessed the patients by:

both a modified Hungerford and Kenna knee rating system and Insall and Crosby grading system, and

Results: Preoperative diagnosis included 53 patients with primary PF arthritis, 1 with post-traumatic arthritis and 1 with PF osteoarthritis secondary to recurrent subluxation. The average patient age at surgery was 73 (range 42–89) and the average length of follow-up was 41 months (range 6–90 months).

Preoperatively 17 knees had undergone arthroscopy. 36 Lubinus, 17 Cartier and 2 PFV prostheses were used. 5 patients died with 8 PF arthroplasties in situ, 1 patient lost to follow up (these patients are not included further in the analysis). 48 Patellofemoral arthroplasty knees were reviewed. 38 knees were classed as good or excellent, 10 had unsatisfactory results, and 7 were revised. 5 implants were revised to TKR and 2 were revised to PF arthroplasty (for maltracking). Subjectively 41 patients felt they were better, 5 unchanged and 2 worse.

Overall we had 69% good or excellent results, 18% poor, and 12% revised. There were no infections, no revision for loosening, and no documented difficulty in revisions. The worst results were obtained in patients with evidence of tiblo-femoral OA preoperatively and in patients with tracking problems.

Conclusion: PF arthroplasty is technically demanding. Nevertheless, providing one adheres to strict patient selection criteria, and the surgery is performed by a dedicated specialist knee surgeon, PF arthroplasty may be used to treat proven isolated patellofemoral arthritis.

Aim: To assess the efficiency of pre-emptive analgesia in a clinical setting as opposed to closely controlled animal models, looking at postoperative pain scores, total analgesia requirement and amount of general anaesthetic agent required during surgery.

Methods and Results. Subject to exclusions, 40 patients undergoing day-case arthroscopy of the knee (mean age 44 years, ASA grade 1–2) were randomized into two treatment groups. All patients had general anaesthesia. The trial group received an injection of 15mI 0.5% Bupivicaine / 1/200,000 adrenaline pre-emptively. After surgery a placebo injection was given of 15ml normal saline in an identical manner. The control group received the opposite order. Additional post-operative analgesia, if required, was administered in recovery. This was recorded, also total dose of propofol used, time to awakening, visual analogue pain score at 15 / 30 / 60 minutes, postoperative nausea and vomiting at 30 minutes and the number of delayed discharges. Although no difference was observed in postoperative pain scores at 15, 30 or 60 minutes, a trend for the trial group to require less analgesia in recovery was observed (Chi squared =9.74, p=0. 1) but this was not statistically significant.

There was no difference in mean dose of propofol used in either group, 15mg/kg/hr (sd=2.85) trial versus 14.6mg/kg/hr (sd=1.96) control.

Conclusion: Local anaesthetic given pre-emptively appears to be no more effective at controlling pain in the immediate postoperative period than the current standard practice of postoperative injection. It’s effect in clinical practice may be less dramatic than that observed in more controlled animal models and a larger study may be required to show a statistically significant difference.

We measured the driver reaction times of 40 patients before total knee replacement (TKR) and 4, 6, 8 and 10 weeks after operation. The ability to perform an emergency stop was assessed as the time taken to achieve a brake pressure of 100 N after a visual stimulus. There were 18 drivers and 11 non-drivers; the latter had longer reaction times. In drivers, the ability to transfer the right foot from accelerator to brake pedal did not recover to preoperative levels for eight weeks after right TKR and was unchanged after left TKR. Patients should be advised that they should not drive for at least eight weeks after right TKR.

Thirty-four patients with adolescent idiopathic scoliosis were assessed by radiography and the integrated shape imaging system (ISIS) both before and after spinal surgery. Twenty-seven patients underwent Harrington instrumentation, after which lateral indices of curvature were significantly improved, but changes in the transverse plane were less pronounced. Sublaminar wiring was carried out in two patients whose thoracic lordosis was corrected by the surgery. Five patients whose severe deformity had persisted after previous spinal surgery underwent costoplasty, which resulted in a significant improvement in back shape measurements. We conclude that the cosmetic deformity of the back in scoliosis is only partially corrected by operations on the spine itself, whilst costoplasty addresses the problem directly, and improves the surface shape.