Objective

The aim of this study was to assess the results of combined arthroscopically assisted posterior cruciate ligament reconstruction and open reconstruction of the posterolateral corner in patients with chronic (3 months or more) symptomatic instability and pain.

Early stabilisation after an anterior cruciate ligament (ACL) rupture reduces future meniscal injury. We may therefore expect protection of articular cartilage from ACL reconstruction, but this has yet to be shown.

Our aim wasto determine the effect of meniscal injury on the long term risk of osteoarthritis (OA) following ACL reconstruction using Single Photon Emission Computed Tomography (SPECT, a 3 dimensional radionuclide scan).

We studied a prospective series of 31 patients (mean age at injury of 29 years) who had bone-patellar tendon-bone ACL reconstruction for unstable, ACL deficient knees. Mean follow-up was 10 years (range 9-13). Patients were separated into two groups according to the status of their menisci at the time of ACL reconstruction, those with intact menisci in group 1 (n=15) and those who required partial meniscectomy in group 2 (n=16). The contra-lateral normal knee was used as a control.

All knees were clinically stable with high clinical scores (mean Lysholm score 93 and mean Tegner activity score 6). In group 1 (intact menisci) only one patient (7%) had clinical symptoms of OA and was the only patient with increased uptake on SPECT compatible with early OA. In group 2 (partial meniscectomy), two had clinical symptoms of osteoarthritis, and five patients (32%) had increased uptake on SPECT compatible with early OA. None of the control knees had early OA on SPECT.

The prevalence of OA 10 years post ACL reconstruction, using the most sensitive investigation available, is very low in patients who had intact menisci (7%), but increases 5 fold (32%) if a meniscal tear was present. We recommend early ACL reconstruction to preserve the menisci to minimise the long term risk of OA.

Purpose: To determine if Cobalt-Chrome (CoCr) femoral components of knee replacement components roughen significantly, and when significant roughening may start.

Methods:

Retrieval study:

14 knee replacement components were retrieved after revision procedures. The average surface roughness (Ra) of the articulating regions of each condyle was measured by surface profilometry and compared to Ra of non-articulating regions, which acted as controls on each implant.

In vitro testing:

Pin-on-plate testing of 6 paired CoCr pins and vacuum γ-irradiated UHMWPE discs was carried out under a force of 2.3kN at 1Hz to investigate how the articular Ra of CoCr pins varied with increasing number of cycles. Ra was measured at 0, 10, 100 and 1000 cycles using surface profilometry.

Results:

Retrieval analysis:

Average medial femoral condyle Ra was significantly greater than control Ra (p=0.040). Average lateral femoral condyle Ra was not significantly greater than control Ra (p=0.158). Significantly higher average Ra was seen on the medial condyles when compared with the lateral condyles (p < 0.05). 8/14 retrieved femoral components had ≥1 significantly roughened condyle (p< 0.05).

In vitro testing:

At 100 and 1000 cycles the Ra of the CoCr pins was significantly greater than Ra at 0 cycles (p< 0.05).

Conclusion: A large proportion of femoral components of knee replacement implants roughen significantly in vivo, a finding supported by our in vitro testing which indicates that roughening may begin very early on. This may have important implications for aseptic loosening of knee replacement components. However, the average Ra of those CoCr surfaces significantly (p< 0.05) roughened was within acceptable limits for orthopaedic implants (0.050μm).

Objective: The aim of this study was to assess the results of combined arthroscopically assisted posterior cruciate ligament reconstruction and open reconstruction of the posterolateral corner in patients with chronic (3 months or more) symptomatic instability and pain.

Patients & Methods: A retrospective analysis of all the patients who had a combined reconstruction of the posterior cruciate ligament and the posterolateral corner between 1996 and 2003 was carried out. Nineteen patients who had the combined reconstruction were identified from the database. All the patients were assessed pre and post-operatively by physical examination and three different ligament rating scores. All the patients also had weight bearing radiographs, MRI scans and an examination under anaesthesia and arthroscopy pre-operatively. The PCL reconstruction was performed using an arthroscopically assisted single anterolateral bundle technique and the posterolateral corner structures were reconstructed using an open Larson type of tenodesis.

Results: Pre-operatively all the patients had a grade III posterior sag and demonstrated more than 20 degrees of external rotation as compared to the opposite normal knee on the Dial test. The average follow up was 66.8 months (range 24–108). Post-operatively 7 patients had no residual posterior sag, 11 patients had a grade I posterior sag and 1 patient had a grade II posterior sag. Five of the 19 patients demonstrated minimal residual posterolateral laxity. The Lysholm score improved from a mean of 41.2 to 76.5 (P=0.0001) and the Tegner score from a mean of 2.6 to 6.4 (p=0.0001).

Conclusions: We conclude that while a combined reconstruction of chronic posterior cruciate ligament and pos-terolateral corner instability does not restore complete anatomical stability, improvement in symptoms and function demonstrate its value in these difficult injuries.

Introduction: The place of Anterior Cruciate Ligament (ACL) reconstruction in skeletally immature patients is now well established, but in reported series the numbers are few and the follow-ups short. Also, the majority of children are aged between 14 and 16 years and the results are as good as in adults. This report includes a number of ACL reconstructions in children aged less than 12 years.

Materials & Methods: A group of twenty patients with an average age of 13.5 years were reviewed. 7 children were aged 12 or under at the time of operation. There were 17 boys and 3 girls. The follow-up ranged from 12 to 72 months (mean 37.8 months).

Reconstruction was done by a standard 4-strand hamstring technique using an endobutton proximally and a spiked washer and screw distally in the tibia.

The IKDC, Lysholm and Tegner scores were used to assess the knees pre and post-operatively. Stability was measured using the KT-1000 arthrometer.

Results: Common modes of injury were football, rugby, skiing and squash. The left side was involved in 12 patients, and the right side in 8 patients. Interval between injury and surgery ranged from 3 to 22 months with an average of 8 months. Meniscal repair was carried out in 7 out of 12 patients. The average Tegner score before injury was 7.7, before operation was 4 and at the last follow-up was 7.6. The average pre-operative Lysholm score was 54.6 compared to the post-operative score of 93. There was no incidence of angular deformity or a limb length discrepancy. There has been 1 re-rupture in a child aged 11 years 11 months at operation but no meniscal injuries. The outcome in the 6 other children aged 12 or less at the time of operation has been as good as the older children.

Conclusion: Reconstruction of the anterior cruciate ligament using a trans-physeal technique gives good results in pre-pubertal children and in adolescents.

The incidence of osteoarthritis (OA) after an ACL reconstruction is not clear. Reports estimate between 12% and 61% at 8 years post ACL reconstruction. Single Photon emission Computed Tomography (SPECT) scanning (a 3 dimensional radionuclide bone scan) is a sensitive and quantitative method of assessing knee OA, with abnormalities appearing before plain xray and arthroscopic changes.

Aim: to objectively assess the long term result of ACL reconstruction using SPECT.

Method: we have prospectively studied a series of 31 patients (mean age at injury of 29 years) up to a mean follow up of 10 years after ACL reconstruction. None had chondral defects, 15 had meniscectomies at or before ACL reconstruction. Each patient was assessed at 8 – 13 years following ACL reconstruction with clinical examination, plain xrays (grading OA in 3 compartments as 0,1,2 according to Albach) and a SPECT scan (grading metabolic activity as in 3 compartments: 0 (normal); 1 (increased but not clinically significant); 2 (increased, clinically significant); 3 (marked increased activity). The other, normal knee was used as a control.

Results: 43% of those with intact menisci had bone scans suggestive of OA. The prevalence of OA was 87% if meniscectomy was performed. All had a negative pivot shift. The mean Lysholm score was 93 (maximum 100) and the mean Tegner activity score was 6. Only 13% of our patients had clinical symptoms of knee OA.

Conclusions: We found bone scan to be a very sensitive investigation for knee OA, picking up abnormalities suggestive of OA in 66% of patients, with only 13% having clinical symptoms. 10 years post ACL reconstruction with intact menisci, and good clinical results, OA is present on bone scanning in 43%. This doubles if meniscectomy was performed. We encourage other units to use SPECT radionuclide bone scanning as an objective test of the outcome of ACL reconstruction.

We reviewed 31 of 33 consecutive patients with intra-articular fractures of the knee at 6 to 22 years (average 14). Of these, 77% had excellent or good results; the others had various degrees of degenerative osteoarthritis. There was no significant difference between the results after surgical or conservative treatment. Secondary degeneration was not related to cause or type of fracture, but its incidence increased with the patient's age at the time of injury, though not with the length of follow-up. Early mobilisation appeared to be beneficial in preventing later degenerative changes.

Minor degrees of malalignment of the patella and anatomical abnormalities including a flattened sulcus angle and an increased ratio between patellar tendon length and patellar length (PT:P) have been suggested as predisposing factors in the causation of chondromalacia patellae, as well as patellar instability. In order to confirm or refute this hypothesis a prospective study has been performed comparing the congruence and sulcus angles and the PT:P ratio in a group of 35 patients with chondromalacia confirmed by arthroscopy and a group of 33 patients with instability, with those of a group of 50 knees in normal volunteers. While there was a statistically significant correlation between an increased sulcus and congruence angle and a high-riding patella in patients with instability, no correlation could be identified in patients with idiopathic chondromalacia.

The transcutaneous oxygen pressure (tcPO2) was measured by a polarographic technique in the legs of 161 volunteers and compared with the levels found in 62 patients with ischaemic skin due to peripheral vascular disease. The results show that the tcPO2 was related to the degree of ischaemia and, in many cases, was a more accurate guide to the viability of the skin than clinical assessment. Measurement of the transcutaneous oxygen pressure in the leg at the site of amputation in 24 patients with peripheral vascular disease showed that a preoperative level greater than 40 millimetres of mercury at an electrode temperature of 44 degrees Celsius was necessary for the skin of the stump to heal. The technique is simple, non-invasive and reliable. The tcPO2 accurately reflects the physiological and pathological changes in the circulation of the skin. It has potential in many fields of surgery where careful assessment of the viability of the skin is necessary.