We reviewed 87 patients who underwent revision anterior cruciate ligament (ACL) reconstruction. The incidence of meniscal tears and degenerative change was assessed and related to the timing from primary ACL graft failure to revision ACL reconstruction. Patients were divided into either an early group (revision surgery within 6 months of graft failure) or a delayed group. Degenerative change was scored using the French Society of Arthroscopy system. There was a significantly higher incidence of articular cartilage degeneration in the delayed group compared to the early group (53.2% vs 24%, p < 0.01, Mann- Whitney U test). No patients in the early group had advanced degenerative change (SFA grades 3 or 4), compared with 12.9% of patients in the delayed group. There was no significant difference in the incidence of meniscal tears between the two groups. In conclusion, the findings of the study support the view that patients with a failed ACL reconstruction and symptomatic instability should have an early revision reconstruction procedure carried out to minimise the risk of articular degenerative change.

Purpose: This study was performed to assess the incidence of generalized ligament laxity in patients undergoing revision ACL reconstruction.

Methods and Results: Prospective data was collected for 40 patients undergoing revision ACL reconstruction, between 2004 and 2009 under the care of a single orthopaedic consultant including demographic details, graft used during primary and revision ACL reconstruction and causes of graft failure.

Clinical examination was used to assess the ligament laxity using the Beighton score. Laxity is scored on a 0–9 scale. Scores of 4 or above are indicative of generalized ligament laxity. Brighton criteria is used to diagnose Benign Joint Hypermobility Syndrome (BJHS) and use signs and symptoms along with Beighton score.

The most common graft used was a quadruple hamstring in 23 patients (57%). The causes of graft failure were trauma in 22 patients (55%), biological in 17 patients (42%) and infection in 1 patient (2.5%).

The revision ACL graft was patella tendon in 23 patients (57%), allograft tendon was used in 11 patients (28%) and quadruple hamstring was used in 4 patients (10%).

The average Beighton score for these patients was 3 with a range from 0–9. 20 patients (50%) in this group had a Beighton score of 4 or more. Only 6 patients (15%) fulfilled the Brighton criteria for BJHS.

Conclusion: We found that there is a high incidence (50%) of generalized ligament laxity in patients undergoing revision ACL reconstruction. Biological failure is common (42%) in these patients after using autogenous tendons. We recommend the use of allograft for primary ACL reconstruction in patients with generalized ligament laxity.

Aims: The aims of this study were to define the incidence of knee stiffness following ACL reconstruction, to determine which patient factors were associated with this, and to assess how effective arthroscopic arthrolysis has been in treating the stiffness.

Methods: To define the incidence of stiffness, we reviewed the patient records of a consecutive cohort of 100 primary isolated ACL reconstructions using quadruple hamstring autografts (2004–2006). Stiffness was defined as any loss of motion as compared to the contra-lateral leg. The mean age at reconstruction was 30 years and the median delay between injury and operation was 15 months. To assess the effectiveness of arthroscopic arthrolysis, we then reviewed all the patients who had undergone this procedure following primary isolated ACL reconstruction (n=18: 1997–2008). The mean age at arthrolysis was 31 years and the median delay between reconstruction and arthrolysis was nine months.

Results: Following primary ACL reconstruction, the incidence of stiffness was 12% six months postoperatively. Poor compliance with physiotherapy (p< 0.005), previous knee surgery (p< 0.005), and anterior knee pain (p< 0.029) were significantly associated with stiffness. A binary logistic regression found both poor compliance with physiotherapy (Exp(B)=6.931; 95%CI, 1.609–29.859; p< 0.009) and previous knee surgery (Exp(B)=6.383; 95%CI, 1.548–26.322; p< 0.010) to be significant predictors of the stiffness. The rate of stiffness fell to 5% at 12 months, without operative intervention. Of the 18 patients who underwent arthroscopic arthrolysis, the mean extension loss improved from 7° to 1° and the mean flexion loss improved from 8° to 2°. Arthroscopic arthrolysis was significantly more effective in restoring extension loss (p< 0.029) if carried out within eight months of the primary reconstruction.

Conclusions: Knee stiffness remains a significant problem post ACL reconstruction. This can however be effectively improved by appropriately timed arthroscopic arthrolysis.

Introduction: We investigated the incidence, risk factors and outcome of acute renal dysfunction (ARD) in patients with a fractured neck of femur.

Methods: 170 consecutive patients were prospectively included in the Scottish hip fracture audit database and retrospectively analysed. Historically, lack of consensus definition hindered accurate reporting of ARD. We defined ARD using the ‘RIFLE’ criteria recently described by the Acute Dialysis Quality Initiative (ADQI) Group.

Results: 27 patients (16%) developed ARD. Risk factors were male sex, vascular disease, hypertension, diabetes, chronic kidney disease and pre-morbid use of nephro-toxic medications (p< 0.01). Inpatient, 30 and 120 day mortality was higher in the ARD group 19%, 22% and 41% respectively, versus 0%, 4% and 13% in the non-ARD group (p< 0.01) Length of hospital stay was significantly longer in the ARD group; 20 days compared to 13 days for patients in the non-ARD group (p< 0.01). Pre and post-operative complications were 12 and 5 times more frequent respectively in the ARD group (p< 0.01).

Discussion: Acute renal dysfunction is an important adverse event in this population. Awareness of risk factors and serial measurements of renal function will enable early identification and focused monitoring of these patients.

Purpose: To determine the outcome following anterior tibial spine avulsion in skeletally mature patients.

Summary: The study group comprised 83 knees with anterior tibial spine avulsion. The mean age of patients at injury was 35. Twenty knees with displaced tibial spine fractures were treated with fixation of the tibial spine and 63 patients with undisplaced or minimally displaced fractures were treated non-operatively.

Twenty two percent of the non operatively managed knees developed symptomatic instability and 10% of knees treated with tibial spine fixation developed instability (p=0.22). Stiffness was more common in knees treated with tibial spine fixation than in knees managed nonoperatively (60% vs 19%, p < 0.0005). There was a tendency for increased stiffness in older patients treated with surgical fixation of the tibial spine.

Conclusion: Tibial spine fracture in skeletally mature patients is associated with significant risk of knee stiffness and instability.

Objectives: To investigate participant experience of exercise programs for non-specific chronic low back pain (NSCLBP) and factors perceived to be important for engagement and participation.

Methods: Qualitative methods with three focus groups facilitated by an independent, experienced facilitator.

Participants: Eighteen people (> 18 years) who could speak, read and understand English and who had participated in an exercise program for NSCLBP.

Design: Participants were guided with a set of pre-determined questions and encouraged to give personal opinions freely. Data were transcribed verbatim, read independently by 2 researchers and analysed thematically using grounded theory.

Results: All focus group results concurred. Enablers for exercise participation included shared decision-making and effective communication; a history of exercise or fitness experience; individualised and supervised programs in a preferred environment; family support; variety and fun; motivation strategies; education and explanation. Barriers included lack of time, cost, boredom, symptom aggravation, consequences of stigma and dissatisfaction with formal exercise and gym ‘culture’. Perceived benefits of exercise were improved general fitness, a sense of achievement and increased activity, participation and social engagement. These results have informed the development of a clinician checklist for exercise program design that includes shared decision-making. A draft questionnaire for participant exercise preferences is also proposed.

Conclusion: People are likely to prefer and participate in exercise programs that are designed with consideration of their preferences, circumstances and past experiences. A mechanism for systematically recruiting information about patient preferences has not previously been proposed. Items suitable for inclusion in such an instrument are presented.

Introduction Following any intraarticular fracture, joint range of movement and muscle strength recovery are vital factors in patient’s return to activities. Quadriceps weakness is a known complication of any injury affecting the knee. The purpose of this study was to investigate the recovery of knee ROM and quadriceps and hamstrings muscle strength in the first year after tibial plateau fracture and to assess factors that affect the recovery.

Method 63 patients were recruited over a 5-year period. Data regarding the age and sex of the patient, the mechanism of injury, the grade of the fracture according to Shatzker’s classification and the treatment received were recorded. All patients underwent a standard rehabilitation regime. At 3, 6 and 12 months after injury the patients were seen by a research physiotherapist. The range of movement was recorded. Thigh muscle peak torque was measured using isokinetic dynanmometry. The uninjured limb was used as the control – the peak torque in the injured limb was expressed as a percentage of the value in the uninjured limb to give the percentage recovery in the injured limb.

Results There was an initial extension deficit of 7° at 3 months, which improved to 3° at 12 months. Quadriceps strength recovery lagged behind that in the hamstrings at all times and only achieved only 77% at 12 months, compared to 90% in the hamstrings (p< 0.001). Patients under 40 outperformed those over 40 at each time point. At 12 months under 40s had achieved 85% recovery in their quadriceps, while over 40s only reached 74% (p< 0.01). Patient sex, mechanism of injury and grade of fracture had no effect on the level of recovery in this study.

Conclusion Patients who sustain a tibial plateau fracture have a residual small extension deficit and objective quadriceps weakness at 1 year post injury. Patient age has a significant effect on the level of quadriceps recovery. This information is useful when counselling patients who sustain these injuries.

Purpose: To document the recovery of knee function following Medial Collateral Ligament (MCL) injury of the knee.

Methods and Results A cohort of 38 consecutive patients with MCL injuries were followed prospectively from the time of injury for a period of one year. There were 13 grade I MCL sprains and 25 grade II sprains. Twelve patients had a concomitant ACL tear. Patients were treated in a hinged knee brace with full extension and 90 degrees of knee flexion for 6 weeks from the date of injury. All patients had an identical rehabilitation programme. Clinical outcome was assessed using two standard functional knee scores (International Knee Documentation Committee (IKDC) score and Knee Outcome Orthopaedic Score (KOOS)). Quadriceps and hamstring muscle function was tested isokinetically using a dynamometer. Outcome assessments were carried out at 2 weeks, 6 weeks, 3 months, 6 months and 1 year.

At 2 weeks the average range of motion (ROM) difference from the normal side was 31%. Twenty-five patients (66%) restored a functional range of motion (5–120 degrees) by 6 weeks. Thirty-five patients (92%) had a normal ROM by 3 months. Peak torque, average power and total work of quadriceps and hamstring muscle groups were normal in 4 patients (11%) at 6 weeks. At 3 months 11 patients (29%) had restored normal muscle function. At 6 months 46% of patients had normal muscle function. At 1 year 11 patients (29%) still had abnormalities of muscle function on isokinetic testing.

Conclusions: Patients with MCL injuries can be advised that range of motion can be expected to return to normal in the majority of cases by 3 months but muscle function recovers more slowly over 12 months following injury.

Aims: The results of surgical repair and reconstruction of knee dislocations were reviewed at average follow-up of 32 months. Methods: Twenty-one patients with 22 knee dislocations presented between 1994 and 2001. There was one vascular and one common peroneal nerve injury. Eight (38%) patients were treated in the acute period (< 14 days), the remainder were late reconstructions. The patients were evaluated at mean follow-up of 32 months (11 to 77). This included ROM measurement, clinical and instrumented ligament laxity testing. Posterior stress view with 10kg weight was used to evaluate the PCL reconstruction. Function was evaluated using the IKDC chart, the Lysholm Score and the Tegner Activity Level. Results: The mean Lysholm score in the acute group was 87 (range 81 to 93) and in the delayed group 75 (range 53 to 100), the mean Tegner activity rating was 5 in the acute group and 4.4 in the delayed group. IKDC assessment revealed no differences between the two patient groups. Instrumented testing of knee stability indicated better results for ACL reconstructions performed in the acute phase but no difference in the outcome of PCL reconstruction. There was no difference in loss of knee movement between the two groups. Conclusions: Good function can be obtained in the operatively treated knee dislocations at 1–7 years. Although the differences were small, the outcome in terms of overall knee function, activity levels and anterior tibial translation were better in those knees reconstructed within two weeks of injury.

Traumatic knee dislocations are rare but devastating injuries. We have evaluated the clinical results of ligament repair and reconstruction. Knee dislocation was defined as an acute event that produced multidirectional instability with at least 2 of the 4 major ligaments disrupted.

Twenty-one patients with 22 knee dislocations presented between 1994 and 2001. There was one vascular and one common peroneal nerve injury. Eight (38%) patients were treated in the acute period (< 14 days), 5 (24%) had reconstructions within 1 year of injury. The remainder were late reconstructions. The patients were evaluated at mean follow-up of 32 months (11 to 77). This included ROM measurement, clinical and instrumented ligament laxity testing. Posterior stress view with 10kg weight was used to evaluate the PCL reconstruction. Function was evaluated using the IKDC chart, the Lysholm Score, the Tegner Activity Level, the Knee Outcome Survey and WOMAC.

The mean extension deficit was 6.8 degrees (0–25) and mean flexion deficit was 8.6 degrees (0–20). Of the ACL reconstructions, 4 knees had 0–3mm side-to-side difference, 15 knees had 3–5mm and 1 knee had 6–10mm. Of the PCL reconstructions, 2 were within 3–5mm of side-to-side difference, 9 knees were 6-10mm and 4 were more than 10mm. Posterolateral corner repair/reconstructions appeared durable. None of the knees were IKDC Grade A, 8 knees were Grade B, 9 were as Grade C and 5 were Grade D. The mean Lysholm Score was 81 (66–100) and the mean Tegner Activity Level was 4.9 (1–7). The mean Knee Outcome Survey score was 75 (41–99). Acutely treated knees had better scores than late reconstructions.

Our study has demonstrated good function in the operatively treated knee dislocations at 1–7 years. Nearly all had few problems with daily activities. The ability to return to high-demand sports and heavy manual labour was less predictable.

A carbonated apatite cement with a high compressive strength was used in the treatment of tibial plateau fractures. There were 41 patients (20 male; 21 female; mean age 59 years). All patients had isolated tibial plateau fractures.

There were 15 B2.2, 23 B3.1 and 3 B2.3 fractures. Fractures were fixed with limited internal fixation using a short anterior parapatellar incision. Reduction and fixation were initially achieved. Once this was carried out the void under the elevated plateau was filled using calcium phosphate cement. A buttress plate was used in one case, screws or K-wires in 33 cases and calcium phosphate cement alone in 7 cases. Patients were mobilised partially weight bearing in a hinged knee brace and allowed full weight bearing at 6 weeks.

Reductions were anatomic (< 2mm displacement in 32 (78%) cases, satisfactory (3-5mm displacement) in 7 (17%) cases and imperfect (> 5mm) in 2 (5%) patients. Extrusion of some calcium phosphate cement into surrounding soft tissue occurred in one case. This material resorbed with no adverse effects. Loss of reduction was observed in 6 (15%) cases. There were no other significant complications. Thirty-seven patients (90%) had more than 120 degrees of knee flexion at 6 months.

Calcium phosphate cement is an alternative to the use of bone grafting in any area of cancellous subject to compressive load. It is ideal for use in tibial plateau fractures with compressed subchondral bone after elevation. It obviates the need for buttress plating and bone grafting and there is no bone graft donor site morbidity. Patients are able to mobilise more rapidly and early discharge is facilitated.

Calcium phosphate cement is a promising development in the management of tibial plateau fractures and initial results suggest it may be more effective in maintaining reduction that standard methods of fixation and grafting.

Exchange nailing for failure of union after primary intramedullary nailing of the tibia is widely used but the indications and effectiveness have not been reported in detail. We have reviewed 33 cases of uninfected nonunion of the tibia treated by exchange nailing. This technique was successful without open bone grafting in all closed fractures and in open fractures of Gustilo types I, II and IIIa. The requirement for open bone grafting was reduced in type-IIIb fractures, but exchange nailing failed in type-IIIb fractures with significant bone loss. For these we recommend early open bone grafting. The most common complication was wound infection, seen more often than after primary nailing. We discuss our protocol for the use and timing of exchange nailing of all grades and types of tibial fracture.

We report the results of a three-year study of bifocal fractures of the tibia and fibula, excluding segmental shaft fractures. In our whole series, these formed 4.7% of all tibial diaphyseal fractures. We describe three groups: bifocal fractures of both the proximal and the distal joint surfaces, fractures of the shaft and tibial plateau, and fractures of the shaft and ankle. These groups of fractures had different characteristics and prognoses. We discuss treatment protocols for each of these three groups.

We reviewed a series of 79 distal radial fractures with volar displacement which had been fixed internally using a buttress plate. The fractures were classified using the Frykman and AO systems; 59% were intraarticular. Complications occurred in 40.5% of cases; malunion was most frequent (28%). Functional recovery in patients with malunion was significantly worse than in those with good anatomical restoration (p < 0.001). The AO and Frykman classifications and the degree of restoration of volar tilt were predictive of outcome.

We performed transoesophageal echocardiography on 24 patients during reamed intramedullary nailing of 17 tibial and seven femoral fractures. In 14 patients there was only minimal evidence of emboli passing through the heart, but in six copious showers of small emboli (< 10 mm maximum dimension) were observed. In four other patients, there were also multiple large emboli (> 10 mm maximum dimension). Three of these patients developed fat embolism syndrome postoperatively and one died. Earlier nailing was associated with smaller quantities of emboli.

We studied five cadaver shoulders to determine the strength relationship of the four rotator cuff muscles. The mean fibre length and volume of each muscle were measured, from which the physiological cross-sectional area was calculated. This value was used to estimate the force which each muscle was capable of generating. The lever arm of each muscle about the humeral head was then measured and the moment exerted was calculated. The strength ratios between the muscles were more or less constant in the five specimens. Subscapularis was the most powerful muscle and contributed 53% of the cuff moment; supraspinatus contributed 14%, infraspinatus 22% and teres minor 10%. The force-generating capacity of the subscapularis was equal to that of the other three muscles combined.

There is concern about the incidence and serious nature of infection after intramedullary nailing of the tibia, especially for open injuries. We have reviewed 459 patients with tibial fractures treated by primary reamed nailing. The incidence of infection was 1.8% in closed and Gustilo type I open fractures, 3.8% in type II, and 9.5% in type III fractures (5.5% in type IIIa, 12.5% in type IIIb). These incidences appear to be acceptable in comparison with other published results. We describe the different modes of presentation of infection in these cases, and suggest a protocol for its management, which has been generally successful in our series.