We evaluated the safety and efficacy of total knee replacement in patients receiving continuous warfarin therapy.

We identified 24 consecutive patients receiving long-term warfarin therapy who underwent total knee replacement between 2006 and 2008 and compared them with a group of age- and gender-matched patients not on long-term anticoagulation. Primary observations were changes in haemoglobin, transfusion rates and complications. Secondary observations were fluctuations in the international normalised ratio (INR) and post-operative range of movement.

There was no significant difference between the two groups in pre- or post-operative haemoglobin, incidence of transfusion or incidence of post-operative complications. There were no surgical delays due to a high INR level. The mean change in INR during the peri-operative phase was minimal (mean 0.4; sd 0.7). There was no significant difference in the range of movement between the two groups after day two post-operatively.

Current American College of Chest Physicians guidelines recommend bridging therapy for high-risk patients receiving oral anticoagulation and undergoing major orthopaedic procedures. We have shown that a safe alternative is to continue the steady-state warfarin peri-operatively in patients on long-term anticoagulation requiring total knee replacement.

This study evaluated the long term outcome of isolated posterior cruciate ligament (PCL) reconstruction. Thirty patients underwent surgery with hamstring tendon autograft after failing conservative management. At 10 years after surgery patients were assessed with radiographs, full IKDC examination and KT1000 instrumented testing. The mean IKDC subjective knee score was 87 out of a possible 100. Regular participation in moderate to strenuous activities improved from 26% preoperatively to 88% of patients. At 10 years endoscopic reconstruction of the PCL with hamstring tendon autograft is effective in reducing knee symptoms. Patients can expect to continue participating in moderate to strenuous activties over the long term. Osteoarthritis is observed in some patients with 18% showing some loss of joint space which compares favorably with non-operatively managed PCL injuries. This is a successful procedure for symptomatic patients with PCL laxity who have failed conservative management.

This longitudinal prospective study reports the 10-year results of arthroscopic, anterior cruciate ligament (ACL) reviewed. Four (4%) menisectomies were performed, 6 graft (7%) ruptures and 18 (20%) contralateral ACL ruptures occurred in the follow-up period. Ninety-seven percent of patients graded their knee function as normal or nearly normal and the median Lysholm knee score was 95 at 10-years. The proportion of patients participating in IKDC level I and II sports fell from 85% at 2-years to 45% at 10 years, 12% attributing the decrease to their knee. On laxity testing 85% and 93% had grade 0 on Lachman and pivot shift testing, respectively and 77% had < 3mm of anterior tibial displacement at 10 years. Kneeling pain increased to 58% of patients. 59% had no pain on strenuous activity with 33% of patients having a fixed flexion deformity at 10 years. Radiological examination at 10 years demonstrated osteoarthritic changes in 48% of patients. Factors predictive for the development of radiograhic osteoarthritis were increased age at operation and increased ligamentous laxity at 2 years as measured clinically and by KT 1000. As such, arthroscopic ACL reconstruction, employing patellar tendon, is not preventative of the development of osteoarthritis even when the confounding factors of meniscal, chondral and other ligamentous injury are excluded.

Introduction and Aims: This longitudinal prospective study reports the 10-year results of anterior cruciate ligament (ACL) reconstruction in 90 patients with isolated ACL rupture.

Method: Three hundred and thirty-three patients undergoing endoscopic ACL reconstruction over a 15-month period using patellar tendon autograft and interference screw fixation were evaluated prospectively. Those patients with an associated ligament injury, chondral damage, previous meniscectomy, excision > 1/3 of one meniscus, an abnormal radiograph or contra-lateral knee, or a compensable injury were excluded. This left 90 patients in the study group. Evaluation was conducted annually for five years, then at seven and 10 years after surgery and included the IKDC Standard Evaluation, Lysholm knee score, kneeling pain, KT1000 testing and weight-bearing radiographs at two, five, seven and 10 years.

Results: Repeat ACL injury occurred in a total of 23 patients (26%). There were six cases of graft rupture (7%) and 18 cases of contralateral ACL injury (20%). One patient suffered both a contralateral and graft ACL rupture. Eight patients (9%) underwent surgery for meniscal or chondral symptoms during the 10-year period. Of the 84 patients with intact grafts at 10 years, 75 (89%) were reviewed. On radiological examination at 10 years, 47% displayed mild to moderate evidence of osteoarthritis. The median Lysholm knee score was 95. Ninety-six percent felt their knee was normal or nearly normal. Forty-seven percent were still participating in moderate to strenuous activity after 10 years. Eighty-seven percent reported that their knee did not affect their activity level. Ninety-seven percent had grade 0–1 on Lachman and pivot shift testing. On instrumented testing 81% had < 3mm of anterior tibial displacement. Twenty-five percent displayed loss of extension range when compared to the contralateral limb, however this was < 5 degrees in 20% of patients. Pain on kneeling was present in 56%. On overall IKDC assessment, 77% were normal or nearly normal.

Conclusion: Endoscopic ACL reconstruction using the PT autograft and interference screw fixation achieves and maintains excellent subjective results and objective stability. This combined with the low incidence of patients requiring subsequent meniscal or chondral surgery enforces the meniscoprotective function of ACL reconstruction. However, early signs of osteoarthritis are developing at 10 years, as displayed by radiological examination and early loss of extension.

The aim of this longitudinal study is to compare the clinical outcomes of endoscopic ACL reconstruction with either a 4-strand HT or PT autograft over a 5-year period.

90 patients with isolated ACL rupture received PT autograft and 90 received HT autograft were studied annually for 5 years. Assessment included the IKDC Knee Ligament Evaluation, KT1000, Lysholm Knee Score, thigh atrophy, kneeling pain, hamstring pain and radiographs.

The median Lysholm Knee Score was 96 for the PT group and 95 for the HT group. No significant difference was found for subjective knee function, overall IKDC assessment, Xray findings, manual ligament KT1000 instrumented testing, graft rupture or contralateral ACL rupture. There was an increasing incidence of fixed flex-ion deformity seen in the PT group. There was no difference in the requirement for subsequent surgery. The incidence of kneeling pain at 5 years was significantly higher in the PT group.

Endoscopic reconstruction of the ACL utilizing either autograft can restore knee stability and is menisco protective despite a high level of sporting activity. We did find a worrying trend towards an increasing incidence of fixed flexion deformity with time in the patellar tendon group. Kneeling pain also remains a persistent problem in this subgroup.

Aim: To determine if a side-to-side difference in laxity occurs with anterior cruciate ligament (ACL) reconstruction utilizing a hamstring tendon and standard RCI (Smith and Nephew) interference screw fixation, and if this can be affected by the use of a reverse thread RCI screw in right-sided knees.

Methods: This was a prospective study of 80 patients undergoing right-sided ACL reconstruction with hamstring tendon autograft. Females were excluded in case of there being a sex difference in postoperative laxity with HT graft. The study group comprised of 36 males utilising standard RCI screws (STD) and 44 males utilising reverse-thread RCI screws (REV). The same technique was used on all patients and all procedures were carried out by the same surgeon. The patients were evaluated at six and 12 months following the surgery with KT1000, IKDC assessment, and Lysholm Knee Score.

Results: At the follow-up after 12 months, the average side-to-side differences using KT1000 testing were 2.0 mm (STD) and 1.0 mm (REV) using manual maximum, and 1.7 (STD) and 1.0 (REV) using KT20. Both results were statistically significant. In addition, 33% of the STD group had a manual maximum of ≥3mm compared with 11% of the REV group (p< 0.01). Accordingly, there was a higher incidence of grade I instability (Lachman) in the STD group (23% of STD group; 8% of REV group, p=0.04).

Conclusion: The use of a reverse-thread interference (RCI) screw for femoral fixation in right-sided hamstring tendon ACL reconstructions in males significantly decreased side-to-side laxity at the 12 month review when compared with standard RCI fixation.

Aim: To determine the influence of concomitant partial meniscal resection on the medium-term clinical results after anterior cruciate ligament (ACL) reconstruction.

Method: Four hundred and sixty patients fulfilled the criteria for inclusion in this multi-center study. Four hundred and twelve of the 460 (90%) patients were re-examined by independent observers after a median 41 months (range: 24 months to 60 months). At the initial operation resection of a minimum of one third of the medial or lateral menisci was performed in 137 patients. The remaining 275 patients had stable, intact menisci. Patients who had undergone previous or subsequent meniscal surgery, a re-rupture of the ACL graft, or had an abnormal contralateral limb were excluded from the study.

Results: The patients who underwent concomitant meniscal resection at the ACL reconstruction had significantly more pain (p=0.012), a greater incidence of loss of motion (p=0.0006), increased laxity (p=0.001) and lower IKDC (p< 0.0001) and Lysholm (p< 0.0001) evaluation scores than patients who had intact menisci.

Conclusion: At the medium-term clinical follow-up the patients who underwent partial meniscal resection in conjunction with the ACL reconstruction revealed significantly worse subjective and objective measurements than the patients who had intact menisci. These findings demonstrated the effect of meniscectomy on the surgical outcome of ACL reconstruction and emphasised the importance of intact menisci for the function of the knee joint.

Aim: To compare, in a longitudinal study, the clinical outcomes of endoscopic anterior cruciate ligament (ACL) reconstruction with either a four-strand hamstring tendon (HT) or a patellar tendon (PT) autograft over a five-year period, when a similar operative procedure is followed for both groups.

Method: Ninety patients with isolated ACL ruptures who had received PT autografts and another 90 who had received HT autografts were studied annually for five years. Fifty patients were randomised as a subgroup. The assessments included the IKDC Knee Ligament Evaluation, KT1000, Lysholm Knee Score, thigh atrophy, kneeling pain, hamstring pain and radiographs.

Results: The median Lysholm Knee Score was 96 for the PT group and 95 for the HT group. No significant difference was found for subjective knee function, overall IKDC assessment, X-ray findings, manual ligament KT1000 instrumented testing, graft rupture or contra-lateral ACL rupture. There was an increasing incidence of fixed flexion deformity seen in the PT group. There was no difference in the requirement for subsequent surgery. The incidence of kneeling pain at five years was significantly higher in the PT group. The results of the randomised patients were identical to the sequential patients.

Conclusions: Endoscopic reconstruction of the ACL utilizing either type of autograft restored knee stability and was protective of the meniscus despite a high level of sporting activity. We found a worrying trend towards an increasing incidence of fixed flexion deformity with time in the PT group. Pain when kneeling also remained a persistent problem in this subgroup. PT grafts appeared tighter clinically and, with the KT 1000, when assessed up to three years post operatively, compared with HT grafts. Thereafter the results were similar.

Aim: To study the influence of anterior cruciate ligament (ACL) deficiency upon functional outcome after Coventry high tibial osteotomy, four to seven years after the surgery.

Method: One hundred and thirty-five patients (142 knees) each underwent a Coventry high-tibial osteotomy with staple fixation, performed by a single surgeon for medial arthrosis of the knee. During the study period, six patients (seven knees) proceeded to total knee arthroplasty and three patients died from unrelated causes. Nine patients were lost to follow-up. Comparisons were drawn between those patients with an intact ACL (ACLi) and those with ACL deficiency (ACLd).

Results: One hundred and seventeen patients (122 procedures) were available for review (100 males, median age 49 years, range: 29years to 70 years). The median follow up period was 64 months (range 37 to 80 months). The ACLd group was significantly younger (median age was 44 versus 51, p< 0.05) and reported significantly less pain and difficulty with stairs, shopping and rising to stand than the ACLi group. Seventy-eight percent of ACLd patients underwent previous surgical procedures on the affected knee. Ninety-six percent of the ACLd group and 89% of the ACLi group were either enthusiastic or satisfied with the outcome of the surgery. The mean Knee Society Score was 83 and 79 (respectively). All six revisions of the knee arthroplasties were in the ACLi group.

Conclusions: High tibial osteotomy was performed at a younger age for those patients with an absent anterior cruciate ligament. These patients had a subjectively better functional medium-term outcome, despite having had a greater number of surgical procedures prior to the osteotomy and having an ACL-deficient joint.

Aim: To confirm previous studies and reports of tunnel widening following anterior cruciate ligament (ACL) reconstruction. To report the medium term behaviour and the effect of tunnel widening on the clinical results.

Methods: A retrospective analysis of the ACL database comparing BPTB autograft versus HT autograft and interference screw fixation was carried out. All procedures were performed by the same surgeon using an identical endoscopic, single-incision, surgical technique and a single method of fixation (7 x 25mm Titanium RCI screws). Patients who had a radiographic series at two and five years were included in the study. All patients had an isolated ACL injury.

Patients underwent a continuous follow up evaluation including clinical examination IKDC, Lysholm knee score and KT-1000 man max testing. Tibial tunnel widening was calculated from lateral radiographs digitalised and corrected for magnification. The tunnel shape was classified according to Peyrache.

Results: The median HT tunnel area increased significantly for the first two years (p = 0.00) and was unchanged from two to five years. The median PT tunnel area decreased significantly during the first two years (p = 0.03), and decreased again from two to five years (p = 0.02). A significant difference in tunnel shape existed between HT and PT groups (p = 0.00).

Conclusion: Tibial tunnel widening was confirmed in 79% of HT and 24% of PT ACL reconstructions utilising a single Titanium RCI screw fixation in each. Graft choice was shown to influence tibial tunnel shape; 21% of HT developed a cavity shape and 29% of PT exhibited tunnel disappearance. All patients with a decrease in tunnel area had a negative pivot shift. This was significantly different from the tunnel-widening group.