The study was established to assess the long-term results and differences between autogenous and synthetic anterior cruciate ligament (ACL) reconstruction. We randomised 50 patients into 2 groups: 26 (52%) underwent reconstruction with middle third patellar tendon graft (PTG) harvested using the ‘ Graftologer ‘ (Neoligaments), and 24 (48%) underwent reconstruction with the Leeds-Keio ligament (LK). Subjective knee function was assessed using the Lysholm score, Tegner activity score, IKDC grading, and clinical assessment of anterior knee pain. Laxity was tested clinically, including anterior draw at 20° (Lachman), pivot shift, and arthrometric measurements using the Stryker laxometer. At five years we have noted a slight reduction in Lysholm scoring in the LK group, as well as reduced Tegner activity level. Pivot shift and laxity were significantly greater in the LK group. Compared with earlier results, which showed little subjective difference between the groups, the autogenous PTG group show more sustainable long-term results than the synthetic (LK) group. There is no significant difference in anterior knee symptoms between the groups.
The aim of this prospective study is to investigate the effectiveness of a new method for arthroscopic all-inside meniscus repair (Clearfix meniscal screw system-Innovasive Devices Inc.).This system consists of delivery cannulae,screw implants and a screw driver.After tear debridement a screw is located on the driver and passed through the cannula to the insertion site, holding the two sides of the tear together under linear compression.In this study, 46 patients (48 repairs)are included, mean age 32,7 years,with a follow-up ranging from 6 to 48 months (average 18,8 months).Only longitudinal lesions in the red/red zone or red/white areas were repaired. Ligament stabilizing procedures were done in 39 patients (84,8%) who had ACL deficient knees,.Thirty-four (71%) injuries were considered chronic (injury to repair time more than 4 weeks) and 14 (29%) injuries were considered acute (injury to repair time less than 4 weeks).The evaluation of the results was based on the clinical examination,the “OAK ” knee evaluation scheme and the MRI.Criteria for clinical success included absence of joimt line tenderness, swelling and a negative Mc Murray test.Thirteen out of 48 repairs (27%) were considered as failures according to the above mentioned criteria.The average time for the procedure was 8 minutes.Postoperatively there were no complications directly associated with the device.Magnetic resonance imaging, however,showed a persisting grade III and IV lesion in 72,8% of the patients (n=35) according to Reicher classification. Though the system offers two main advantages,that is the absence of serious complications and the reduced operative time, the failure rate in this study is quite high. This clinical study is in agreement with the recent experimental studies referring to the limited pull-out strength of this device.
Removal of well-fixed, cementless, acetabular components during revision arthroplasty remains a challenging problem. Further damage to host bone may limit options for reconstruction and compromise the long-term result of the revision operation. We report the results of 31 hips with well-fixed, cementless sockets which were removed using a new cup extraction system. In all hips the socket was removed without difficulty and with minimal further bone loss.
There is a recognised incidence of anterior knee pain following Anterior Cruciate Ligament (ACL) reconstruction using a patella tendon autograft. This study examined two group of patients both pre ACL ligament reconstruction and post ACL reconstruction using patella tendon grafts to define if anterior knee pain is a result of patella tendon harvest or a primary consequence of an ACL injury. The two groups of patients were best matched for age, sex and physical activity. The pre-operative group of twenty-five patients had a confirmed ACL rupture and exhibited symptoms of instability requiring an ACL reconstruction. The operative group of twenty-five patients were a minimum of a year post operation. The graft was harvested by an open procedure and the graft bone blocks were secured with interference screws. The patients’ anterior knee pain score was assessed using the Shelbourne scoring system that evaluates knee function in relation to anterior knee pain using five parameters. The maximum score is 100. The scores were compared using the unpaired student test. There was no significant age difference between the two groups, preoperative group age 32. 2 years (range 22 to 46) and postoperative age 34. 8years (range 19 to 48). The mean anterior knee pain score for the preoperative group was 71. 6 (49 to 100), the postoperative group was 77. 7 (45 to 100), this was not significantly different. We found no significant difference in knee function due to anterior knee pain between the two groups. Studies have shown significant anterior knee pain following hamstring reconstruction (Spicer). This study shows anterior knee pain in the ACL deficient knee is present prior to surgery. We conclude that patella tendon autografts produce no significant incidence of anterior knee pain post surgery.
The purpose of this retrospective study was to analyze the indications for spinal instrumentation, report the clinical features, operative details and outcome in 16 patients with active pyogenic spinal infection. Between January 1991 to October 1999, 81 patients with spontaneous pyogenic spinal infection were treated at the authors’ institution. Surgery (other than biopsy) was indicated in 24 patients for neurological deterioration, deformity or instability. Sixteen of these patients were treated with instrumentation in the presence of active spinal infection. Six patients underwent combined anterior and posterior procedures. 10 had a posterior procedure only. Outcomes assessed were control of infection, neurology, fusion, back pain and complications. At a mean follow up period of 26. 9 months, all surviving patients were free of clinical infection. None of the patients had neurological deterioration. All patients who had neurological deficit preoperatively improved by at least one Frankel grade. A solid fusion was achieved in 15 patients. 12/15 patients remained asymptomatic or had very little pain. The remaining 3 patients had mild to moderate back pain. The mean correction of the kyphotic deformity was 18. 92 degrees. Postoperative complications included bronchopneumonia, nonfatal pulmonary embolism and seizures in 3 patients. One patient developed progressive kyphosis despite instrumentation but eventually fused in kyphus. Given early recognition of pyogenic spinal infection, most cases can be managed non-operatively. Our results support that instrumented fusion with or without decompression may be used safely when indicated without the risk of recurrence of infection. Instrumentation facilitates nursing care and allows early mobilisation. For biomechanical reasons, a combined procedure is probably indicated for lesions above the conus. For lesions below the conus, we were able to achieve successful results with posterior approach only.
We have performed a study comparing the radiological results of Total hip replacements performed by a single, experienced specialist hip surgeon with those reported from the Trent Regional Arthroplasty Study (TRAS) [presented at BOA congress 2000]. Results from TRAS have revealed that inadequate cementation grades and a cement mantle width of <
2mm were the most significant associations predicting early aseptic loosening. Interestingly, their respective incidences were as large as 20% and 50% in a random sample of THRs from the TRAS register. Data is lacking as to whether poorer radiographic cementation grades have a trend towards individual surgeons or whether they are more evenly distributed amongst the surgical population including those adhering to modem techniques. Therefore, we have undertaken an independent review of A-P and lateral radiographs of 33 consecutive Charnley THRs performed by a specialist hip surgeon using carefully controlled modem cementing techniques and compared the results with the same random cohort of THRs from the TRAS. Our results show that the specialist surgeon achieved a significantly higher proportion (82%) of complete cement mantles (>
2mm in all zones) than those achieved by TRAS (50%) [Chi2=7. 79, p=0. 0052]. This suggests that improved cement mantles can be achieved by the adoption of carefully controlled modem cementing techniques. However, use of the Barrack system of grading was unable to detect differences in cementation quality between specialist (88%) and TRAS group (81%) [Chi2=0. 235; p=0. 631 suggesting less sensitivity in this technique for assessing cementation quality. These results are important for the following reasons. Achievement of adequate mantle (>
2mm) can be improved upon by adoption of carefully controlled modem cementing technique. However, regardless of the method of assessment of cementation quality, approximately 18% will appear ‘inadequate’ despite modern techniques suggesting that factors outside the surgeon’s control are involved in determining cementation grade. This has important medico-legal implication in the current climate in which surgeons are being criticised, in negligence cases arising out of the 3M Capital Hip experience, for achieving ‘inadequate’ cementation.
The corticosteriods in the treatment of Duchenne’s or Becker’s muscular dystrophies causes muscular weakness and osteoporosis characteristic of these patients and result in different fractures which are of difficult resolution because prolonged immobilization increases morbidity. How can this problem be solved in highly risk patients? The diverse models of external fixators have given us the possibility of treating them without immobilization and in consequence obtain a quicker return to previous functional status including gait . 4 patients with Duchenne’s and Becker’s muscular dystrophies were treated. 1 patient recovered its ambulatory ability and the rest maintain their gait. 1 of them still has an external fixator but he is able to walk. Patients presented a diaphyseal fracture of the femur, a proximal fracture of the tibia, an introchanteric fracture of the hip and a supracondylar fracture of the femur. We consider that external fixators open an endless range of options, not very much used until recently, that help our patients to extend their functional status and gait. Patients accept them easily because they give them independence and avoid the depression that stems from the loss of capabilities.
death data for further patients currently awaited from Cancer Registry.
However whilst function appears to be as good the less successful objective criteria do suggest reservations for the long term results of the Leeds-keio graft.
High stress, non- hydrostatic regions were consistently recorded in the concave annulus.
Post-tuberculous kyphosis in children is a ‘Dynamic deformity’ which changes till skeletal maturity. Children must not be discharged after disease cure and yearly follow up to monitor deformity is mandatory. Surgical intervention to prevent late profress will be needed in one third of children.
Many factors have been demonstrated to influence the range of knee movement that an individual can achieve. The purpose of this study was to objectively demonstrate how range of knee movement is affected when the influence of pain is abolished. Sixty-eight patients with degenerative joint disease presenting for primary total knee arthroplasty were recruited. Using a digital camera, images were taken before and after the induction of anaesthesia with the lower limb in four positions- extension, forced extension, flexion and forced flexion. Camera set up was standard and the range of knee motion was measured from the digital images. Average arc of motion before anaesthesia was 96° (range, 41°–157°). After induction of anaesthesia, the arc of motion increased to 115° (range, 410–161°). Knee extension improved by an average of 5° (range, 0–15°) and flexion improved by an average of 16° (range, 0–65°). In conclusion, these results demonstrate that pain has a significant inhibitory effect on the measured range of knee movement before surgical intervention.
Dislocation of the polyethylene-rotating platform is a recognised complication of LCS knee arthroplasty. We report ten cases of rotating platform dislocation out of 2151 primary total knee arthroplasties (0.5%) performed to date in our unit. Of the ten cases (3 male: 7 female), six patients had a preoperative valgus deformity, two had a varus deformity and the remaining two patients were in neutral alignment, although the wear was predominantly within the lateral compartment. Two patients also had a previous patellectomy on the side of the platform spinout. Of the ten cases, six patients were symptomatic as a result of their platform dislocation. The remaining four patients were asymptomatic and mobilising without any difficulty. In these patients, the dislocated platform was diagnosed on x-ray at outpatient review. Time to detection of the platform dislocation ranged from six days to two years. Three patients required revision of their original insert to a larger, deeper dish insert. Three were managed by open reduction of the original insert. Of the remaining patients, one was managed successfully by closed reduction, one required an arthrodesis and one had the tibial insert cemented to the tibial tray. All patients at latest review have a functional and stable knee joint. In conclusion, we feel that surgical error was to blame for the majority of our ten cases. Furthermore, we emphasise the importance of producing equal and balanced flexion and extension gaps at the time of knee arthroplasty in order to prevent mobile bearing dislocation. A novel technique for reducing a dislocated rotating platform is also described.
The aim of this trial was to assess the clinical examination findings commonly used for the ACL deficient knee. For reliability testing and criterion validation 102 patients with ACL injuries were assessed by a single observer, 35 by a second observer and 47 again by the initial observer. For construct and criterion validation 30 patients were assessed pre-operatively and a mean of 1.7 years after ACL reconstruction. The Lysholm 11, Tegner and Cincinnati outcome measures were assessed along with instrumented knee laxity (Stryker test), the one hop test (OHT) and graded tests (including anterior draw, Lachman test, quality of end point, and pivot shift test). The outcome measures were found to be reliable except the Cincinnati system. All examination findings were of unsatisfactory reliability, with the exception of the OHT and the Stryker test. Construct validation revealed a significant improvement in all outcome measure scores and examination findings following ACL reconstruction. Criterion validation revealed that of the examination findings only the OHT had a satisfactory correlation with the symptom of giving way and the Lysholm/Tegner measures. Comparison of the difference between the desired and actual Tegner activity levels with the examination findings revealed an improvement in all levels of correlation. With the exception of the OHT, the clinical examination findings used for the ACL deficient knee are unreliable and correlate poorly with the functional outcome of the patient. They may, however, have some benefit in assessment of deficiency of the anatomical structures and the findings should be presented individually, rather than forming part of the functional assessment of the patient.
The aim of this randomised prospective study was to establish whether the use of knee splints following total knee replacement is necessary. The study included 81 patients undergoing total knee replacement who were randomised into a ‘splint’ and a ‘no splint’ group postoperatively. Patients in the ‘splint’ group had their knee splinted in extension in the early post-operative period but the splint was removed for the patients to do exercise. Splintage was completely removed when the patient could straight leg raise. Patients in the ‘no splint’ group had a wool and crepe bandage applied around their knee and allowed to fully mobilise from the first postoperative day. The following parameters were recorded: The range of movement preoperatively, 5 days post-operatively and 6 weeks postoperatively; the length of time to straight leg raise; the blood drained from the wound. and the amount of postoperative analgesia required. Using the unpaired 2 tailed t-test it was found that patients in the four ‘no splint’ group achieved significantly greater flexion at 5 days and 6 weeks post-operatively but drained significantly more blood from the wound. Transfusion requirements were similar in the two groups. There was no other significant difference in the parameters measured between the two groups. In conclusion we found no evidence to advocate the use of knee splints following total knee arthroplasty.