Purpose: To report on our early experience with a synthetic meniscal substitute inserted for symptomatic post meniscectomy medial or lateral knee pain.

Methods and results: Six patients underwent underwent insertion of a collagen meniscal implant (Menaflex, Hospital Innovations, UK). These were inserted onto a trephinated rim of vascular meniscus to permit the structural incorporation of healing tissue. Specific rehabilitation included 8 weeks on crutches and restricted activity for 6 months. Patients were prospectively analysed documenting KOOS, IKDC, Lysholm and SF36 outcome scores.

All patients were male, 4 patients had deficiencies in the right knee, 2 the left knee and the mean patient age was 28.8years (range 17–45). Four CMI were inserted for lateral meniscal deficiencies, two medial. The mean length of implant sutured in place was 41mm (range 35–55). Median pre op scores were KOOS P/S/ADL/QOL 53/100, 54/100, 66/100, 25/100, 44/100, IKDC 49.43%, Tegner 3, SF-36 35.38 PCS and 27.48 MCS and Lysholm 87/100. The mean elapsed time post meniscectomy was 20 months (range 2–51). All but one of the implants used were 9.5mm in width and sizes ranged 35–45mm.

At early follow up there have been no complications and background pain has improved in all 6. MIR imaging has shown that none have separated. Post operative follow up suggest improved outcome.

Conclusion: Though this is very early data, close scuritny of new treatment options is essential. So far the clinical outcome is favourable and we believe that CMI may be beneficial in reducing post menisectomy pain. Hopefully, in the future CMI may become a means of preventing post meniscectomy osteoarthrtitis.

Purpose: To investigate the validity of previous observations that meniscal repair has a better success rate when associated with ACL reconstruction.

Methods and Results: The case notes of 170 patients who underwent meniscal repair between May 1999 and May 2007 were analysed for causes of re-operation and relation to status of the ACL. Mean age at the time of surgery was 28 years.

41 patients underwent re-operation at a mean time interval of 21 months (range 2 weeks - 87 months). 79 patients (Group A) had isolated meniscal tears. 44 patients (Group B) had meniscal repair at the same time as elective ACL reconstruction and underwent brace-free, accelerated rehabilitation. 47 patients (Group C) had meniscal repair in association with ACL disruption and underwent staged ligament reconstruction.

In Group A, 23 patients underwent re-operation (Indications; meniscal symptoms 21, stiffness 1, infection 1). Nineteen repairs (23.8%) were found to have failed. In Group B, 15 patients underwent re-operation (Indications; meniscal symptoms 12, stiffness 1, revision ACL 2). Twelve (27.2%) repairs were found to have failed. In Group C, Nine (19.6%) repairs were found to have failed. 6 at the time of staged ACL reconstruction and 3 subsequently, at further arthroscopy. There was no statistical difference between the groups with respect to the incidence of failed meniscal repairs.

Analysis of possible predictive factors including age, gender, location of lesion and the type of repair did not show statistical significance.

Conclusions: Reoperation rate following meniscal repair is high. Meniscal repair for tears associated with ACL disruption in this group did not appear to have a higher success rate compared to isolated tears. This raises questions regarding the current practice of ignoring meniscal repair and instituting brace-free, early, aggressive rehabilitation following concomitant ACL reconstruction.

Aim: To relate clinical progress following cartilage repair using TruFit plugs with appearance on MRI imaging with a view to determining safe healing in order for patients to return to activity, without needing invasive assessment.

Methods: 26 active sporting patients underwent cartilage repair using TruFit CB plugs (Smith & Nephew) for symptomatic chondral defects in the knee between February 2006 and September 2008. The plugs are a biphasic synthetic implant designed to reform both bone and articular cartilage. As part of this prospective series patients underwent MRI at post op time-points of 6, 12, 18 and 24 months. MRI was performed using a 1.5 Tesla scanner and later using a 3T scanner. We report the results of both including T2 cartilage mapping.

Results: All 26 patients were improved at latest follow-up when compared to pre-operative scores (mean follow up 15 months (range 6–30 months)). MRI evaluation demonstrates oedema like signal surrounding the plugs at an early stage but by 6 months the oedema resolves and the subchondral lamina is seen to reform. By 12 months the bone part of the plug has similar appearance to host bone and the neo-cartilage shows similar signal to native cartilage on all MRI modalities (1.5T, 3T and T2 mapping). This suggests that the repair tissue contains a high percentage of hyaline like cartilage. In one patient slow clinical improvement was reflected in the MRI appearance.

Conclusion: MRI imaging appears to relate to clinical improvement according to KOOS, IKDC, Lysholm, Tegner and SF36 scores. This indicates that MRI is a useful imaging tool for assessing healing, and knowledge of the recovery pattern is important for quantifying healing and for better advising patients on when it may be safe to load repaired areas.

Aim: To assess the safety and clinical and radiological outcome of the TruFit CB porous, resorbable scaffold for symptomatic osteochondral and chondral articular defects in the knee.

Methods: 11 active sporting patients underwent cartilage repair using TruFit CB plugs (Smith & Nephew) for symptomatic defects on the medial or lateral femoral condyle. All had failed previous treatment (debridement/microfracture) and had persistent symptoms. Postoperatively patients were touch weight bearing for 2 weeks and partial until 4 weeks. Data was collected prospectively. The mean age was 34 (range 19 – 50) and 5 were male. Four lateral femoral condyle defects were treated, all associated with lateral meniscal tears. Four medial defects were associated with ACL injury (1), PCL injury (1) or isolated chondral injury (2). Single plugs were required in 5 (9mm in 3 and 7mm plugs in 2), 2 patients required 2 plugs (9mm and 7mm), and 2 required 3 (2×9mm + 1×7mm).

Results: All 11 patients were improved at a mean follow up of 14.5 months (3–21 months) with 4 currently back to full pre-injury level of sport. Subjective IKDC scores improved from 45 pre-op to 79 post-op (p< 0.05), Lysholm from 47 to 71 (p< 0.05), and latest Tegner activity score at 5. MRI evaluation including T2 mapping demonstrates reformation of the subchondral lamina and resorption of the graft. 2nd look arthroscopy was undertaken in 2 showing a well healed and well integrated surface.

Conclusion: These preliminary results indicate that TruFit CB plugs offer a potential solution for small focal chondral defects, offering an alternative to microfracture or osteochondral grafting with advantages of low morbidity and rapid recovery without the need for prolonged non-weight bearing.

The purpose of this study was to assess the accuracy of a modified version of the pivot shift test in detecting ruptures of the anterior cruciate (ACL) ligament.

Methods: Two groups of patients aged 18 to 50 years were recruited from operating theatre lists examined at a check and consent clinic. One of the groups had ACL deficient knees and the control group had intact ACL, later proven at arthroscopy. A total of 48 independent examinations, 26 with ACL rupture and 22 without, were undertaken by a consultant or registrar proficient in the modified version of the pivot shift test. At the start of the consultation the examiner, who was blinded to the operation that the patient was listed for and to the patient’s history, performed the modified pivot shift test only. The result of the test was reported as positive or negative for ACL rupture to the study co-ordinator before the examiner continued with the consultation.

Results: Of the 26 examinations of ACL deficient knees, 22 were reported as positive and four negative for ACL rupture using the pivot shift test only. Of the 22 examinations of ACL intact knees one was reported as positive for ACL rupture and 21 as negative. This gives a specificity and sensitivity of the modified version of the pivot shift test as 95.5% (95% CI 75.1–99.8%) and 84.6% (95%CI 64.3–95.0%) respectively.

Conclusion: The modified pivot shift test is an accurate test for the detection of ACL rupture. Our modified pivot shift test compares favourably with data from previous accuracy studies of previously described versions of the pivot shift test. We now plan to assess the accuracy of the modified pivot shift test when carried out by medical students and junior doctors.

The purpose of this study was to investigate the safety and outcome of bilateral simultaneous ACL reconstruction. In patients presenting with an ACL-deficient knee, 2 – 4% have bilateral ACL deficiency. A staged or simultaneous approach can be adopted when the patient requires reconstructive surgery for both knees. We report a case series of 8 patients (6 male, 2 female, average age 30.4 years) who underwent bilateral simultaneous ACL reconstruction.

Simultaneous or bilateral ACL reconstruction using ipsilateral patella tendon graft has been reported as a safe procedure with outcome and complication rate no different to unilateral procedures. Considerable cost savings of simultaneous over staged procedures have also been described. There are no case series in the published literature that describe the use of hamstring tendon autograft for bilateral simultaneous ACL reconstruction.

We used two camera stack systems and instrument sets to allow for simultaneous bilateral surgery by two surgical teams. Quadrupled hamstring tendon graft was used in 4 patients although in one patient patella tendon graft was used on the second side due to poor quality of hamstring tendons. Patella tendon graft was also used in a further 4 patients. At two weeks all patients were able to discard crutches and were independent in mobility. There was no difference in outcome at one year between those patients undergoing bilateral simultaneous ACL reconstruction in comparison to the outcomes of unilateral ACL reconstruction with respect to Lysholm, Tegner and IKDC scores. The mean follow up period was 2.3 years.

Our results demonstrate that bilateral simultaneous ACL reconstruction is safe and cost effective. A simultaneous approach also has the benefit of reducing the overall period of rehabilitation required by the patient. We report good short-term functional outcome but no long-term data is yet available.

Aim: To assess the results and complications of the opening wedge form of distal femoral varus osteotomy (DFVO) in treating valgus arthritis and ligament instability of the knee.

Methods: Patients undergoing DFVO were assessed prospectively using validated scoring systems and pre/post operative alignment radiographs. All had failed non operative and arthroscopic procedures and were keen to avoid arthroplasty. The lateral based opening wedge osteotomy aimed to correct the weight bearing line to position 50% medial to lateral and was held with either the Puddu femoral plate (Arthrex UK) or the Tomofix plate (Synthes UK).

Results: 26 distal femoral osteotomies were performed in 23 patients with a mean age of 34 (16 –58). The mean duration of follow up is 32.5 months (1–72). 8 were undertaken for primary valgus malalignment, and 15 for secondary valgus with OA due to previous lateral menisectomy. Simultaneous additional procedures included microfracture (3), MACI (1), meniscal transplantation (1), and MCL advancement (1). Mean hospital stay was 4 days (2–6). Post op alignment was out by greater than 10% of intended in 2/3. 3 early major complications required re-operation: 2 for plate and screw cut out and 1 for infection. 2 developed delayed union requiring bone grafting. Failure with conversion to arthroplasty has occurred in 2 (1 lateral UKA, 1 TKA), and 2 patients are awaiting either multi-ligament reconstruction or collagen meniscal implantation. The overall mean Tegner score is 4 (2–6), and 20 of the 23 patients feel satisfied with the outcome having avoided arthroplasty.

Conclusion: Opening wedge DFVO is a technically difficult procedure with significant complications, but in the right indication offers long lasting pain relief and joint preservation prior to arthroplasty. New techniques including accurate closing wedge fixation systems and computer guided operative planning and surgery may offer improvements to this vital surgical option.

Purpose: X-Ray analysis of a subset of TKR’s performed using the mini-incision technique has been undertaken to assess the accuracy of alignment, as TKR through limited exposure lends itself to a potential risk of mal-positioning of the components.

Methods and Results: The limited exposure afforded by the small skin incision and mid-vastus approach in the new technique of Mini Incision TKR, has a potential for increasing the risk of mal positioning components without the use of navigation systems. 128 mini-incision TKR’s have to date of submission, been undertaken in 125 patients (67F: 58M: mean age 72: mean BMI 29). A prospective assessment of these patients has been ongoing since its introduction in November 2003. The mean hospital stay is 5.5 days and mean range of flexion at six weeks is 106°. Two patients have required manipulation under anaesthetic for poor flexion at six weeks and blood transfusion has only been required in 4%. In patients with a minimum 6 months follow up, long leg alignment X-rays have shown the mechanical axis to be within 3° of normal in 4/5.

Conclusion: We believe that Mini Incision TKR is a safe reliable and reproducible technique offering substantial savings to the patient and health service without compromising accuracy.

Purpose To report on the results, surgical technique and issues with mini-incision total knee arthroplasty.

Methods and results The new technique of mini-incision total knee replacement entails the use of smaller cutting blocks and alignment jigs applied to the femur with minimal surgical exposure, achieved by subluxation of the patella laterally rather than full eversion of the extensor mechanism. The technique was carefully introduced in November 2003.

The results of the first 20 consecutive patients have been compared with 20 standard TKR procedures. The mean age of 73.5 and BMI of 29 was not significantly different to the standard Group. Mean hospital stay was approximately halved (5 days versus 9 days). 75% of patients were discharged on day 4 without needing extra home support. Mean incision length was 13.5cm and only one of 20 required blood transfusion. Mean operative time was 12 minutes longer and post-operative CT alignment showed no mal-position of the implants.

Conclusion Mini-incision TKR is a safe, reliable and reproducible method, allowing significant cost savings and benefits for the patients and hospital. Confidence needs to be gained in the reduced visibility of traditional landmarks and training of surgeons remains an issue.

Purpose: To audit the quality of the still images and documentation of arthroscopic surgery of the knee and to provide guidelines to optimize photographic records.

Methods and Results: The study was conducted in 4 parts

Questionnaire of surgeons views on photographic records: This showed that less than 50% of surgeons felt they could interpret their own photographs and only 25% felt other surgeons records were useful. 80% felt that single image photographs gave clearer information than 4 small images per sheet.

Conclusion: Poor picture labelling, inadequate pictures and documentation were found in the majority of the cases. New formulated guidelines led to an improvement in the accuracy and usefulness of recorded images.

This may lead to a reduction in the need for repeat arthroscopy when patients are referred for second opinions to specialist knee surgeons, thereby reducing costs and morbidity.

Purpose To determine which patients respond best to viscosupplementation injections for osteoarthritis of the knee.

Methods and Results We undertook a prospective study of all patients undergoing Hylan G-F 20 injections in the knee recording the indication, severity of symptoms, baseline demographic details and the WOMAC score. Outcome data was collected at 3, 6 and 12 months at an independent telephone interview to determine if patients were improved, the same or worse, and by postal WOMAC score.

100 patients were studied. 3 records were excluded, as there was no follow-up recorded. The demographics on 97 were: mean age 67 (range 37–91), male 56%, mean duration of symptoms 8.8yrs and primary OA in 65%.

Overall 43% were improved at 3 months, 31% at 6 months and 29% at 12 months. When the results were analysed according to indication, patients with ‘moderate non-mechanical osteoarthritic symptoms after failed medical management and not severe enough for arthroplasty’ did best (49% at 3 months and 38% at 6 months). Patients with ‘persisting arthritic symptoms after attempted arthroscopic debridement for mechanical type knee symptoms’ had less predictable results (42% improved at 3 months and 23% at 6 months). Patients with ‘severe or deteriorating symptoms while awaiting knee replacement’ or who were ‘too medically ill for TKR’ had a low rate of improvement (18% at 3 months).

Conclusion Viscosupplementation is unreliable in patients with end stage OA awaiting TKR. This study allows for better targeting of this useful expensive treatment modality.

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.