Purpose: Mal-tracking or dislocation of the patella is often the result of abnormal anatomy. Understanding the anatomy will clarify the treatment options available. The common anatomical causes of dislocation range from the valgus knee to patella alta and external tibial torsion. External tibial torsion results in symptoms ranging from patello-femoral pain to subluzation or dislocation. Many patients become symptomatic after an injury and recognition of the anatomical pathology helps in the treatment decision.

Method: A retrospective study was carried out on 232 rotational high tibial osteotomies in 221 patients operated on between 1990–2004. The pre-operative degree of external tibial torsion and ‘Q’ angle was noted. The extent of any patello-femoral pathology was documented, as well as the degree of correction. Assessment was carried out using the HSS score and the Lysholm score. Notation was made of prior surgery, including arthroscopy, patella tendon tarnsfer and patellectomy.

Results: Of the 232 cases, 80% showed good to excellent results with resolution of patello-femoral pain and instability. Ten percent had residual pain but no instability and 20 cases proceeded to total knee replacement. The best results were seen in cases of pain and instability with minimal patello-femoral arthritis. Some cases with end-stage patello-femoral arthritis were improved with the improvement in quadriceps function via reduction in the ‘Q’ angle.

Conclusion: Rotational osteotomy of the proximal tibia for symptomatic patella instability secondary to significant external tibial torsion results in good to excellent results in 80% of cases.

BACKGROUND: The purpose of this study was to evaluate the long term results of meniscal transplantation in a consecutive series of younger patients treated for pain in the tibiofemoral compartment following a previous meniscectomy.

METHODS: One hundred and thirty eight (138) menisci were implanted into one hundred and thirty-five (135) patients over a sixteen year period.

Seventy five (75) knees also had an associated osteotomy, and eleven (11) had a ligament reconstruction. The clinical outcome using pain and functional knee scores and failure rate of all transplants was evaluated at a mean 10.2 years (2–16 years) postoperatively.

RESULTS: One hundred and twenty (120) patients with one hundred and twenty three (123) meniscal grafts were available for final follow up. Fifteen (15) patients were lost to follow up. Seventy five percent (75%) of patients had an improvement in pain knee score and seventy one percent (71 %) of patients had an improvement in functional knee score.

Twenty patients (16.6%) underwent a total knee replacement at a mean interval of 9.3 years after the meniscal transplant.

Patients with isolated meniscal transplantation had the most improved clinical outcome.

Patients with concomitant knee osteotomy and knee ligament reconstruction procedures also had improved knee function without an increase the rate of complications.

CONCLUSIONS: The long-term results of meniscal transplantation are encouraging in terms of reducing knee pain and increasing function at a mean follow up of 10.2 years. Patients with isolated meniscal transplantation have improved outcomes.

Purpose: Patello-femoral arthritis presents a considerable challenge to the orthopaedic surgeon. Traditionally, surgical options have produced unsatifactory results. Arthroscopic debridement, patellectomy, isolated patellar resurfacing and grafting have a poor long term clinical outcome. Patello-femoral arthroplasty is an alternative to total knee arthroplasty and patellectomy for anterior compartment osteoarthritis. Patello-femoral arthroplasty provides a more conservative approach in younger and more active patients especially. Advances in component design and biomechanics have led to many new generation replacements. The aim of this study was to look at the long term functional outcome of patello-femoral arthroplasty.

Methods: From a prospective database 36 patients were identified having a patello-femoral arthroplasty between 1990 – 2000. Four patients were lost to followup. Eighteen patients (56%) underwent an additional procedure for patella re-alignment (patella tendon transfer or lateral release) at the time of the patello-femoral arthroplasty. Mean followup was 72 months (range 24 – 149 mo). Clinical data was collected from a personal questionnaire and physical examination. All data was processed and all patients were evaluated using the Hungerford-Kenna score and the modified Lysholm score. Radiographs were assessed pre-operatively and at the most recent follow up. Peri-operative documentation was evaluated for etiology, pre-operative functional and subjective impairment, intra-operative technical difficulties or complications, early and late post-operative complications and post-operative functional outcomes.

Results: At the time of the most recent follow up, 22 knees had good or excellent result, 4 had fair result and 4 had a poor result. The remaining 2 knees were revised to a total knee arthrplasty due to progression of osteoarthritis. No loosening of the components was observed. The mean Lysholm knee score improved from 35.4 (range 9–68) pre-operatively to 76.1(range 37–100) post-operatively and the mean Hungerford-Kenna knee score improved from 29.6(range 10–65) pre-operatively to 78.1(range 45–100) post-operatively.

Conclusion: With proper patient selection, patello-femoral arthroplasty is a reliable procedure for the treatment of the patello-femoral arthritis. This procedure delays the need for further surgical procedures such as total knee arthroplasty with good results.

The management of medial osteoarthritis of the knee with underlying anterior cruciate ligament deficiency is challenging. Stabilization of the ligament instability at the time of re-alignment osteotomy addresses both components of the disability.

We are reporting a retrospective study of thirty-two cases of combined osteotomy and ligament repair between 1995 and 2000.

Patients were assessed by questionnaire and clinical examination. Objective measures, using the modified Lystolm score, WOMAC index and SF36 were performed. Radiological examination as well as a survivor-ship analysis were performed.

The average age at operation was thirty-six with an average follow-up of five years. Surgery was performed in patients who had complaints of both pain and instability and also had objective findings of Uni-compartmental osteoarthritis and anterior cruciate deficiency.

Seventy five percent of patients were classed as good to excellent with only five percent of patients classed as poor.

Combined tibial osteotomy and anterior cruciate reconstruction is an effective means to deal with this complex problem.

Fifty-five patients were assessed with a minimum of five- year follow up. Patients in this study underwent initial conservative treatment consisting of twelve months of physio. Those patients who continued to have recurrent instability underwent surgery. Only patients without rotational abnormalities of the femur were included. Tibial rotational was assessed geriometrically, with the degree of external rotation corrected to 20 – 23°. Those patients with associated patella alta underwent a distal transfer of the patella tendon also. Assessment included range of motion, thigh girth, quads strength, effusion and a modified Lystrom knee score assessed function and pre and post-op radiographic assessment.

The purpose of this paper is to report on the results of rotational osteotomy of the proximal tibia to treat patella instability.

At a mean follow-up of seven years (range 5 – 8.2) 76% of knees treated for congenital dislocation of the patella with external tibial torsion, achieved good to excellent results.

External tibial torsion associated with an increased “Q” angle is an important factor in recurrent dislocation of the patella. It is surgically correctable with a rotational osteotomy of the proximal tibia above the patella tendon insertion. This technique “normalizes” the extensor mechanics and produces better results than patella tendon transfer.

Ninety percent of the patients were female with an average age of thirty (range fourteen to forty-five years). Prior unsuccessful surgical procedures included lateral release (sixteen) Maquet procedure (ten) Hauser (sixteen) medialization of the patella tendon (ten) semitendinosis tenodesis and patellectomy (two). Pre-operative external tibial torsion averaged 45° (range 40° – 65°) with an average rotational correction of 25°. The average pre-op “Q” angle was 27° and post-op 14°. Outcome assessment of the fifty-five knees showed twenty-six excellent, sixteen good and thirteen poor. Overall 76% were good to excellent.

Outcome assessment was performed using a modified Lysholm score and the Tegner activity scale. The average pre-op score was forty and post-op seventy. Patients with less painful symptoms pre-op had significantly better outcomes. Knees that had undergone multiple unsuccessful surgical procedures had poorer outcomes.

Purpose: Mal-tracking or dislocation of the patella is often the result of abnormal anatomy. Understanding the abnormal anatomy will clarify the treatment options available. The common anatomical causes of dislocation range from the valgus knee with an elevated ‘Q’ angle to patella alta with a hypo-plastic trochlea, to external tibial torsion, resulting in an excessive ‘Q’ angle. External tibial torsion results in symptoms ranging from patello-femoral pain to subluxation or dislocation. Many patients are asymptomatic prior to an injury. The decision to correct the underlying anatomical abnormality is often a difficult one.

Methods: A retrospective study of 232 rotational HTO’s in 221 patients operated on between 1990 and 2003 was conducted. The pre-operative degree of external tibial torsion and ‘Q’ angle was noted as well as the degree of rotation. The extent, if any patello-femoral pathology, was noted. Assessment was carried out using the HSS scoring system and Lysholm score.|Notation was made of prior surgery to the knee ranging from arthroscopy to patella tendon transfer to patellectomy.

Results: Of the 232 cases 80% were good to excellent with resolution of patello-femoral pain and instability. 10% had residual pain but no instability and 20 cases had to proceed to total knee replacement.|The best results were seen in cases with pain and instability but minimal patello-femoral pathology. Even cases with end-stage patello-femoral osteoarthritis were improved by maximizing the function of the extensor mechanism.

Conclusions: Rotational osteotomy of the proximal tibia for symptoms of patello-femoral instability secondary to significant external tibia torsion provided much better results than isolated patella tendon transfer.

Purpose: This study documents the short term follow-up of a group of patients with unicompartmental osteoarthritis with associated collateral ligament laxity. there are currently few studies documenting the indication and results of open wedge high tibial osteotomy.

Methods: A retrospective assessment of 52 cases of open wedge high tibial osteotomy ws carried out of cases performed between 1999–2003. The average follow-up was 4.5 years and the mean age was 38 years. We selected cases with varus alignment and laxity of the medial collateral ligament. Clinical evaluation was carried out using the HSS knee rating score. Clinical laxity pre and post-op was noted, as well as range of motion, quads bulk and swelling. Pre and post-op 3 foot standing x-rays were carried out to assess alignment.|The Puddu open wedge osteotomy was used in all cases with autogenous bone from the iliac crest. Supplemental fixation of the opposite side of the tibia was used if there was any tendency to open.

Results: Open wedge high tibial osteotomy for unicompartmental osteoarthritis with ligament laxity treats both problems. The change in alignment deals with the arthritic symptoms and the opening wedge tensions the collateral ligament.|Of the 52 cases, 44 are good to excellent with 2 non-unions and 3 cases converted to total knee replacement.

Conclusions: Open wedge high tibial osteotomy can deal effectively with selected cases of unicompartmental osteoarthritis with secondary collateral ligament laxity.

One hundred and forty eight meniscus allografts transplanted in one hundred and forty patients between 1988 and 2000 were reviewed. The indication for surgery included disabling knee pain, refractory to conservative treatment, objective symptoms of compartmental crepitus, pain on valgus/varus stress and osteoarthritis documented on arthroscopy following prior total meniscectomy. Knee mal-alignment and instability were also documented. Patients with varus alignment and medial OA, as well as valgus alignment with lateral OA, underwent re-alignment to unload the compartment for allograft transplantation. Patients with anterior cruciate deficiency, underwent ACL reconstruction at the time of allograft transplantation.

The purpose of this paper is to show the benefit of meniscus transplantation in osteoarthritis of the knee.

At a mean follow-up of six years (range two to fourteen), one hundred and twenty-five out of one hundred and forty-eight knees received good to excellent results.

Meniscus allograft transplantation can restore function in patients with arthritis secondary to prior total meniscectomy. The transplantation of a biological load-bearing structure has given reliable long term results, when used in well selected cases.

Forty six patients received an isolated meniscus allograft with forty-one receiving good to excellent results. Eleven received a medial or lateral meniscus allograft with an ACL reconstruction and nine obtained good to excellent results. Seventy five knees received a meniscal allograft in combination with an osteotomy to correct for pre-operative deformity, with sixty-four attaining good to excellent results. The remaining twenty-two knees underwent valgus high tibial osteotomy, meniscus allograft and ACL repair, with nineteen achieving good to excellent results.

Outcome was assessed subjectively and functionally using a modified Lysholm socre and objectively by clinical examination. The Tegner activity scale was used to compare pre and post- operative function. Second look arthroscopy was performed on the first ten transplanted meniscus to assess healing and graft integrity.

We have assessed the clinical and radiological outcome of traumatic knee injuries resulting in open reconstruction of the posterior cruciate ligament using synthetic ligaments at the University of Toronto, Ontario. Pre and post-operative stress radiographs at 30 and 90 degrees were performed, along with IKDC, Lysholm and Tegner scoring.

Between 1995 and 2002, 11 patients were operated on. The average time to surgery was 42.3 months (range 1 to 252 months). The average age at time of surgery was 34.1 (26 – 48). The length of follow up ranged from 6 to 87 months.

IKDC scoring showed that no patient returned to normal. 5 were nearly normal, 4 abnormal and 2 severely abnormal. The average Lysholm score was 83 (58 – 95). 2 scored excellent, 6 good, 2 fair and 1 poor. The average Tegner score pre-injury was 6.3, prior to surgery 1.8 and post-operatively 3.9 (twice weekly jogging). Stress radiographs showed a decrease in antero-posterior laxity at 30 and 90 degrees although statistical significance was not achieved (p = 0.229 and 0.474 respectively).

We conclude that PCL reconstruction restores the normal biomechanics of the knee allowing a more normal function. The synthetic ligament allowed early weight bearing and range of movement mobilisation. The Tegner scores showed a considerable improvement from pre to post-operative values. The stress radiographs showed a decrease in the antero-posterior laxity. Although the IKDC scores did not show any normal knees post-operatively, this was expected due to the severity of the initial injuries.

The authors recommend the use of synthetic ligaments to reconstruct the PCL.

Introduction: Meniscus allograft transplantation can restore function in patients with arthritis secondary to prior total meniscectomy. The transplantation of a biological load-bearing structure in young patients has given reliable long-term results, when used in well-selected cases.

Method: One hundred and forty-eight meniscus allografts transplanted in l40 patients between 1988 and 2000 were reviewed. The indication for surgery included disabling knee pain, refractory to conservative treatment, objective symptoms of compartmental crepitus, pain on valgus/varus stress and osteoarthritis documented on arthroscopy following prior total meniscectomy. Knee mal-alignment and instability were also documented. Patients with varus alignment and medial OA, as well as valgus alignment with lateral OA, underwent re-alignment to unload the compartment for allograft transplantation. Patients with anterior cruciate deficiency, underwent ACL reconstruction at the time of allograft transplantation.

Results: At a mean follow-up of six years (range two to 14). One hundred and twenty-five received a good to excellent result. Forty-six patients received an isolated meniscus allograft, with 41 receiving good to excellent results. Eleven received a medial or lateral meniscus allograft with an ACL reconstruction and nine obtained good to excellent results. Seventy-five knees received a meniscal allograft in combination with either a valgus high tibial osteotomy, varus high tibial osteotomy or varus distal femoral osteotomy to correct for pre-operative deformity with l26 attaining good to excellent results. The remaining 22 knees underwent valgus high tibial osteotomy, meniscal allograft and ACL repair with 19 receiving good to excellent results.

Outcome was assessed subjectively and functionally using a modified Lysholm score and objectively by clinical examination of stress pain and joint crepitus. The Tegner activity scale comparing pre- and post-operative function was applied. Second-look arthroscopy was performed on the first l0 transplanted meniscii to assess healing and integrity of the transplantation graft.

The most frequent complication was a traumatic posterior horn tear in l3 knees.

Introduction and Aims: External tibial torsion associated with an increased ‘Q’ angle is an important factor in recurrent patella instability. It is surgically correctable with a rotational osteotomy of the proximal tibia above the patella tendon insertion. This technique ‘normalises’ the extensor mechanics and produces better results than patella tendon transfer.

Method: Fifty-five patients were assessed with a minimum of five-year follow-up. Patients in this study underwent initial conservative treatment consisting of l2 months of physio. Those patients who continued to have recurrent instability underwent surgery. Only patients without rotational abnormalities of the femur were included. Tibial rotation was assessed geriometrically, with the degree of external rotational corrected to 20–23 degrees. Those patients with associated patella alta, underwent a distal transfer of the patella tendon also. Assessment included range of motion, thigh girth, quads strength, effusion and a modified Lystrom knee score assessed function and pre- and post-op radiographic assessment.

Results: Ninety percent of the patients were female with an average of 30 (range 14–45). Prior unsuccessful surgical procedures included lateral release (l6) Maquet procedure (l0), Hauser procedure (l6) medialisation of patella tendon (l0), semitendinosis tenodesis and patellectomy (two). Post-operative follow-up average five to 8.2 years. Pre-operative external tibial torsion averaged 45 degrees (range 40–65 degrees) with an average rotational correction of 25 degrees. The average pre-op ‘Q’ angle was 27 degrees and post-op 14 degrees. Average pre-op functional score has 40 and post-op 70 degrees. Outcome assessment of the 55 knees showed 26 excellent, 16 good and 13 poor. Overall 76% of the knee were good – excellent. Of the 16 patients with associated anterior knee pain, 13 obtained good-excellent results. Patients with less painful symptoms pre-op, had significantly better outcomes. Knees that had undergone multiple unsuccessful surgical procedures, had significantly poorer outcomes. Uniplanar patella tendon transfer in these cases generally results in continued anterior knee pain.

Conclusions: Derotational osteotomy re-aligned the extensor mechanism in cases of recurrent dislocation of the patella secondary to external tibial torsion. All patients had some improvement with the surgery, but the patients with poor outcomes continued to have anterior knee pain.

Introduction: The relationship between the axial alignment of the knee and symptomatic instability of the collateral ligament is very important. This paper presents an approach to the management of chronic collateral ligament instability. Reconstruction of the MCL in the valgus knee and of the LCL in the varus knee is usually unsuccessful without re-alignment of the knee.

Method: The gait pattern of the patient with valgus alignment and MCL laxity demonstrates a medial thrust on weight-bearing. Laxity may involve the MCL alone, in combination with ACL laxity, or associated with LCL laxity. MCL laxity in the valgus knee is best managed with a varus distal femoral osteotomy. MCL laxity with medial osteoarthritis is best managed with an open wedge valgus tibial osteotomy.

LCL laxity in the varus knee responds well to valgus correction with a high tibial osteotomy. LCL laxity secondary to malunion of a lateral tibial plateau fracture can be managed with an open wedge varus high tibial osteotomy

Results: Fifty-two patients with chronic, symptomatic collateral ligament instability have been surgically reconstructed. Most cases involved multiple ligament injury and most were seen after the initial surgical procedure. Twenty-eight of 52 patients underwent two or more operative procedures before osteotomy. Twenty-one cases involved the MCL and 3l involved the LCL.

Varus distal femoral osteotomy was performed for isolated symptomatic MCL laxity. The average resultant anatomical axis was zero degrees. This resulted in loss of the medial thrust on weightbearing. Patients with injuries resulting in early medial OA with varus alignment and MCL laxity were treated with open wedge valgus high tibial osteotomy.

The majority of patients with LCL laxity and varus alignment responded to closing wedge valgus high tibial osteotomy. A smaller number (six) with depression of the lateral tibial plateau two degrees to fracture and associated LCL laxity responded to open wedge varus high tibial osteotomy.

ACL patients were followed for over two years (range two to four years) post-surgery. All patients were assessed clinically and radiographically. Clinical examinations included a Lysholm functional score and Tegner activity scale. Radiographic examination included pre- and post-operative three foot x-rays and pre-operation valgus, varus stem x-rays.

Introduction and Aims: To determine the efficacy of autologous chondrocyte implantation (ACI) in treating focal chondral defects of the knee, we reviewed the two-year treatment outcome of ACI in 53 patients through clinical evaluation, MRI, second-look arthroscopy and core biopsies obtained.

Method: From November 2000 to December 2003, 54 consecutive knees with 72 focal chondral defects (grade III or IV by modified Outerbridge) were treated with ACI using the Peterson periosteal patch technique. In this method, an initial arthroscopy was carried out to confirm the suitability for repair and when appropriate, cells were harvested either from the margins of the lesion, the intercondylar notch or both. The harvested cells were proliferated in vitro. Three to four weeks later, the cells were implanted in the defect with a medial or lateral parapatellar arthrotomy approach. A standardised post-operative rehabilitation protocol was carried out depending on the site of the lesion or lesions.

Results: Improvement in mean subjective score from pre-operative (37.6) to 12 months (56.4) and 24 (60.1) months post-ACI were observed. Knee function levels also improved (86% ICRS III/IV to 66.6% I/II) from pre-operative period to 24 months post-implantation. Objective IKDC score of A or B were observed in 88% pre-operatively. This decreased to 67.9% at three months before improving to 92.5% at 12 months and 94.4% at 24 months post-implantation. Transient deterioration in all these clinical scores was observed at three months before progressive improvement became evident. MRI studies demonstrated 75.3% with at least 50% defect fill, 46.3% with near normal signal, 68.1% with mild/no effusion and also 66.7% with mild/no underlying bone marrow edema at three months. These values improved to 94.2%, 86.9%, 91.3% and 88.4% respectively at 12 months. At 24 months, further improvement to 97%, 97%, 95.6% and 92.6% respectively were observed. Second-look arthroscopy carried out in 22 knees (32 lesions) demonstrated all grafts to be normal / nearly normal based on the International Cartilage Repair Society (ICRS) visual repair assessment while core biopsies from 20 lesions demonstrated 13 (65%) grafts to have hyaline / hyaline-like tissue.

Conclusion: Improvement in clinical and MRI findings obtained from second-look arthroscopy and core biopsies evaluated indicate that, at 24 months post-ACI, the resurfaced focal chondral defects of the knee remained intact and continued to function well.

The lateral substitution reconstruction operation described by MacIntosh has been evaluated in 27 patients with chronic anterior cruciate ligament deficiency of the knee. The results, at an average of 11.3 years after operation, have been assessed by a scoring system which allocates a maximum of 25 points each for function and for clinical evaluation. Emphasis was placed on subjective giving way and objective evidence of a positive anterior drawer sign and a positive lateral pivot shift test. A score of 46 to 50 was classified as excellent, 41 to 46 as fair, and less than 41 was a poor result: 52% scored excellent, 26% fair and 22% were poor. Most of those with poor results had had evidence of osteoarthritis at the time of operation. Despite the recorded scores, no less than 75% of the patients at long-term follow-up were subjectively improved, and able to maintain an active life style.