Aim: This is a report on outcome of Complete Trans-physeal ACL reconstruction in a group of 24 children with open physes of whom 6 were under 12 years (Pre-pubertal).

Materials & Methods: A group of twenty-four children with an average age of 13 years were reviewed. Six children were aged 12 or under at the time of operation. There were 21 boys and 3 girls. The follow-up ranged from 12 to 72 months (mean 37.8 months).

ACL 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 13 patients, and the right side in 11 patients. Interval between injury and surgery ranged from 3 to 22 months with an average of 8 months. Meniscal repair was carried out in 9 out of 14 patients with meniscal tears. 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 5 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.

Complex regional pain syndrome is characterised by an exaggerated response to injury in a limb with intense prolonged pain, vasomotor disturbance, delayed functional recovery and trophic changes. This review describes the current knowledge of the condition and outlines the methods of treatment available with particular emphasis on the knee.

We report a retrospective analysis of the results of combined arthroscopically-assisted posterior cruciate ligament reconstruction and open reconstruction of the posterolateral corner in 19 patients with chronic (three or more months) symptomatic instability and pain in the knee.

All the operations were performed between 1996 and 2003 and all the patients were assessed pre- and post-operatively by physical examination and by applying three different ligament rating scores. All also had weight-bearing radiographs, MR scans and an examination under anaesthesia and arthroscopy pre-operatively. The posterior cruciate ligament 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.

The mean follow up was 66.8 months (24 to 110). Pre-operatively, all the patients had a grade III posterior sag according to Clancy and demonstrated more than 20° of external rotation compared with the opposite normal knee on the Dial test. Post-operatively, seven patients (37%) had no residual posterior sag, 11 (58%) had a grade I posterior sag and one (5%) had a grade II posterior sag. In five patients (26%) there was persistent minimal posterolateral laxity. The Lysholm score improved from a mean of 41.2 (28 to 53) to 76.5 (57 to 100) (p = 0.0001) and the Tegner score from a mean of 2.6 (1 to 4) to 6.4 (4 to 9) (p = 0.0001).

We conclude that while a combined reconstruction of chronic posterior cruciate ligament and posterolateral corner instability improves the function of the knee, it does not restore complete stability.

We used single-photon emission computed tomography (SPECT) to determine the long-term risk of degenerative change after reconstruction of the anterior cruciate ligament (ACL). Our study population was a prospective series of 31 patients with a mean age at injury of 27.8 years (18 to 47) and a mean follow-up of ten years (9 to 13) after bone-patellar tendon-bone reconstruction of the ACL. The contralateral normal knee was used as a control. All knees were clinically stable with high clinical scores (mean Lysholm score, 93; mean Tegner activity score, 6). Fifteen patients had undergone a partial meniscectomy and ACL reconstruction at or before reconstruction of their ACL.

In the group with an intact meniscus, clinical symptoms of osteoarthritis (OA) were found in only one patient (7%), who was also the only patient with marked isotope uptake on the SPECT scan compatible with OA. In the group which underwent a partial meniscectomy, clinical symptoms of OA were found in two patients (13%), who were among five (31%) with isotope uptake compatible with OA. Only one patient (7%) in this group had evidence of advanced OA on plain radiographs.

The risk of developing OA after ACL reconstruction in this series is very low and lower than published figures for untreated ACL-deficient knees. There is a significant increase (p < 0.05) in degenerative change in patients who had a reconstruction of their ACL and a partial meniscectomy compared with those who had a reconstruction of their ACL alone.

Aim: To determine retrospectively the post-operative mortality and fatal pulmonary embolism (PE) rates in 936 consecutive primary total knee replacements (TKR) in the three month period after surgery where chemical thromboprophylaxis was not routinely used.

Methods: Operations were performed over a period of eleven years by eight different senior orthopaedic surgeons on 248 men and 525 women. One hundred and sixty three patients had bilateral TKRs and the mean age at the time of operation was similar (69.4 and 72.2 years respectively). Patients were traced by out-patient appointments, telephone and through their general practitioners (GPs). Post-mortem examinations were used to verify cause of death in all save three of the cases. All but one of the patients were followed up.

Results: There were no deaths from PE confirmed by post-mortem examinations. As three patients were certified dead without post-mortem examination and one patient could not be traced this meant that, at worst, our fatal PE rate was 0.43% (4/936; CI 0.14%–1.17%). The all-cause mortality rate was 0.64% (6/936; CI 0.26%–0.46%) (Table 1). The patient mortality was compared with the population mortality of England and Wales using standardised mortality ratios (SMRs). The SMR for both sexes combined was 0.74 (CI 0.29–1.52). We observed a lower mortality in females SMR = 0.67 and males SMR = 0.84 during the first three post-operative months than compared to the general population.

Conclusion: Fatal pulmonary embolism after total knee replacement without routine chemical thromboprophylaxis is uncommon. The overall death rate in this series of patients undergoing total knee replacement appears to be lower than that in the general population.

Objective: Many have advocated the importance of correcting posterolateral rotatory instability (PLRI) in injuries causing rupture of the posterior cruciate ligament and PLRI. However, there have been few studies comparing the results of reconstructing the posterior cruciate ligament (PCL) in isolation with PCL reconstruction combined with stabilisation of the posterolateral corner. We set up a retrospective study to directly compare the results of an isolated PCL reconstruction with a combined PCL reconstruction and Larsen tenodesis.

Methods: Seventeen consecutive patients with symptoms of instability and chronic rupture of the PCL and PLS were identified from our database. There were 1 1 men and 6 women. Ten patients were injured while playing sport, six in road traffic accidents, and one was a result of a fall. The mean age of the patients at the time of surgery was 31 (range 21–47), and the interval from injury to surgery was a mean of 23 months (months–10 years). The mean follow up was 35 months (14–74 months). All patients had unstable knees, with significant posterolateral rotatory instability. In 12 cases the PCL alone was reconstructed, in 5 cases a combined posterior cruciate ligament and posterolateral corner reconstruction was performed. Prior to surgery all patients underwent a physical examination of both knees. Posterior draw, posterior sag and reverse Lachman tests were used to assess PCL function. Posterolateral rotatory instability was assessed by the dial test. Plain radiographs and either an M [RI or arthroscopy of the affected knee were performed. At follow-up patients underwent examination of both their knees. A subjective assessments of function was made using the Tegner, and Lysholm scoring systems

Results: At a mean follow up of 35 months, both groups had significantly improved compared to their preoperative status, as measured by Lysholm and Tegner scores and posterior draw test (P< 0.01). The group in which only the PCL was reconstructed had significantly lower scores compared to those who had the additional posterolateral corner reconstruction (Tegner P< 0.04, Lysholm P< 0.02).

Conclusion: The results of PCL reconstruction were significantly improved when combined with a Larsen tenodesis in patients with severe posterolateral rotatory instability.