Introduction: We studied prospectively two groups of patients treated operatively for acute achilles tendon rupture admitted in our institution in order to compare post operative morbidity, usage of hospital resources and immobilisation regimen involving immediate weight-bearing with traditional non-weight-bearing. The aim was to assess the benefit of instrument guided surgical method, which reduces hospitalisation cost, post operative wound care cost and reduce requirement of post-operative analgesics together with improved rehabilitation and return to normal activity for young patients [age below 45] with a rupture of the Achilles tendon.

Material and methods: 34 patients had repair of the tendon with an open method as an inpatient under instruction of the admitting consultant. Second group of 25 patients had repair as limited open technique with an Achillon instrument and immediate weight bearing.

Result: Opiates or opiate-based analgesia were used in the open repair group and in the minimally invasive group, patients reported no pain with paracetamol or ibuprofen. Two cases of severe wound infection leading to dehiscence requiring further surgery and 5 cases of minor surgical site infection leading to delayed wound healing were reported as wound complications in the open group. All the patients in the mini invasive group reported their satisfaction with wound healing and minimal scar at the incision site. Based on self-reports, the time taken to return to normal walking was median of 11 weeks in the achillon treatment group and 17 weeks for the open group. There was also an earlier return to normal stair climbing, with a median of 13 weeks [9–21 weeks] in the achillon treatment group and 19 weeks [13–27 weeks] for the opens technique.

Conclusion: This study has shown that mini invasive repair with Achillon instrument may allow us to perform surgery with less bed usage, less consumption of post operative analgesics and other associated indirect cost to the healthcare provider. It also allows faster rehabilitation. It provides further evidence that minimally invasive repair with early weight bearing rehabilitation has advantages over traditional open repair with delayed mobilisation for patients who have undergone surgery for ruptured Achilles tendon. The practical advantages for patients in early weight-bearing mobilisation were earlier return to normal walking and stair climbing than their open group counterparts. We would, therefore, advocate the use of minimally invasive procedure with early weight-bearing mobilisation for the rehabilitation of all patients with acute ruptures of the Achilles tendon.

To describe our experience with computer assisted combined anterior cruciate ligament (ACL) reconstruction and osteotomy. It may provide long-term symptom relief and improved function in patients with medial knee arthrosis and ACL-deficiency, while delaying or possibly eliminating the need for further surgical intervention such as arthroplasty.

Two patients who had medial unicompartmental arthrosis and chronic ACL-deficient knees underwent ACL reconstruction along with femoral osteotomy in one case and upper tibial osteotomy in the other. We used Orthopilot software to perform computer assisted combined anterior cruciate ligament (ACL) reconstruction and osteotomy.

Subjective evaluation at postoperatively indicated significant improvement compared to preoperative evaluation and better scores for patients who obtained normal knee range of motion. Objective evaluation by International Knee Documentation Committee showed improved score postoperatively. Both had minor complications occurred in the immediate postoperative period. The average correction angle of the osteotomy was 7 degrees (7–10).

Computer assisted ACL reconstruction and osteotomy may provide long-term symptomatic pain relief, increased activity and improved function. Only Anterior cruciate ligament reconstruction may not effectively provide pain relief to the ACL-deficient knee with degenerative medial arthrosis. The results of this study suggest that combined high tibial or femoral osteotomy and ACL reconstructions are effective in the surgical treatment of varus, ACL-deficient knees with symptomatic medial compartment arthritis. Computer aided surgery allows precise correction of the axial deformity and tunnel orientation intraoperatively.

This prospective study is designed to assess intra-operative trauma to soft tissue envelope around the knee joint especially quadriceps due to rigid body fixation on the femur and its influence on rehabilitation outcome obtained using a kinematic navigation system for TKR. We also evaluated the impact of the extra time needed to adopt this system on immediate post-operative rehabilitation.

One hundred and sixteen operations were performed with the aid of the kinematic navigation system. Results, including operation time, radiographic alignment of the prosthesis and complications, were compared with non-navigated group. Outcome measures included preoperative knee function, intra-operative factors, blood loss and postoperative rehabilitation.

The operation time (from skin to skin) in the navigation group was average 32 minutes longer compared historical controls. No major complications such as delayed wound healing, infection or pulmonary embolism occurred during this study. Mean blood loss in both the group showed no difference

A higher incidence and duration of early postoperative quadriceps dysfunction was not associated with computer-assisted TKA through the lateral Para patellar approach. No patient who received surgery had a lag of more than 20 degrees, at 48 hours postoperatively, regardless of the duration of intra-operative time used.

Although the total surgical time was longer, it does not translated into increased postoperative morbidity. Use of a kinematic navigation system has a short learning curve, and requires an additional operation time of less than 32 minutes. We found no impact of patients’ perioperative times on short-term outcomes obtained during our learning curve and next two years. The mechanical axis of the leg was within 3 degrees of neutral alignment along with accurate component alignment. The Computer-assisted TKA through a lateral parapatellar approach was not associated with delayed recovery of the patients during early postoperative rehabilitation.

Purpose: The current clinical Study was compared with historical control in terms of level of pain perception, blood loss and post-operative mobility in patients undergoing arthroplasty of the hip with computer navigation. A secondary objective was to investigate the level of patient satisfaction with the procedure.

Methods: The prospective study was conducted over a 24 month period. 30 Patients were sequentially operated and contralateral hip operated by different surgeons previously compared as control group. Delayed mobility was observed in 6% of patients with managed with computer navigation only. 2 patients had dislocation in early post-operative period, which was relocated Significantly less patients managed with the computer assisted hip arthroplasty complained of pain around the wound site [p< .01]after 48 hours of index surgery. Mean Blood loss was less [725ml Vs 1230ml] and mean length of skin incision [10.8cm Vs 17.5 cm] is lesser than the conventional arthroplasty.

Patient satisfaction was higher in the navigated group and 86% of patients were able to fully mobilize within 72 hours of the index operation.

Conclusion: Soft tissue trauma during surgery is an important cause of post-operative morbidity. Surgical exposure and malposition of the acetabular cup may cause delayed post-operative mobility after conventional hip arthroplasty

Computer aided hip arthroplasty may influence postoperative outcome in otherwise uncomplicated surgery. Although the study was limited by non randomization and other variables, initial results are encouraging.

Objectives: to illustrate our clinical experience with the computer-integrated instrumentation system in knee arthroplasty.

Method: From August 2003 to April 2006, 71 patients with knee osteoarthritis underwent 71 primary TKR operations by the same surgical team. All these operations were performed with the aid of the CT-free kinematic navigation system, Results, including operation time, radiographic alignment of the prosthesis and complications were analysed.

Results: The average wound length was 11.2 centimeters. Patients in the kinematic navigation group achieved accurate alignment in the coronal plane in terms of postoperative mechanical axis (1.89 +/− 0.63 degrees. one perioperative fractures and mediolateral flexion laxity occurred both of which were attributed to patient factors as opposed to operation procedures. No major complications such as infection or pulmonary embolism occurred in this cohort.

Conclusions: The OrthoPilot system facilitates proper alignment of the component in knee arthroplasty. We found the OrthoPilot system is reliable and reproducible. The preliminary results justify continuing the use of this technologyto help the patients to provide the best possible care. Use of a kinematic navigation system in TKR is easy to use, and requires an additional operation time.

Increased emphasis has been placed on hospital length of stay and discharge planning after total joint arthroplasty. The purpose of this study was to identify patient characteristics and assistance of surgical innovation could reduce length of stay of an inpatient after TJA.

Method: We analysed demographic and Clinical data 92 consecutive patients who underwent primary TKR with computer assisted surgery [n=46] and compare with another group operated with manual technique[n=46].

Result: Average length of stay: 8.87days (+/− 5.16 SD) in the navigation group and 7.59days (+/− 3.82 SD) in the manual group. Older age, higher American Society of Anesthesiologists class, social circumstances, and female sex were all associated with a higher likelihood of discharge to an ECF.

Conclusion: No Significant differences in length of stay patterns were found in this cohort with respect to discharge disposition at home after knee joint replacement. We believe to reduce length of stay while maintaining quality of care, early discharge home with integrated community services or home care nursing and physiotherapy should be more important than surgical innovation in the NHS in U.K

Background: We aim to compare our final results of Autologous Chondrocyte Implantation in full thickness articular cartilage defects of the knee with the outcome as reported in the literature.

Material: 9 patients median age of 29 (range 24 to 42) were operated and assessed clinically with use of International Cartilage Repair Scoring (ICRS), VAS and oxford knee score pre operation and 3, 6, 12 months post operation. 66.6% of the patients had traumatic defect due to sport injury and was located on the medial femoral condyle.

Method: Arthroscopically slivers of cartilage (300 to 500 mg) were obtained from the upper minor load-bearing area of the medial femoral condyle of the injured knee for cell culture. Implantation was performed by open procedure following periosteal cover technique and use of fibrin glue as a bioscaffold 4 weeks after the biopsy.

All the patients started knee exercise with CPM from next day and allowed to bear partial weight on the operated knee for 8 weeks.

Result: 3 patients still had pain after one year follow-up. One case had mosaicoplasty after 8 months, which we consider as a failure and two of them had second Arthroscopy, trimming of part of repaired cartilage. 67.2% of the patients had a good or excellent result.

Conclusion: All patients showed improvement of clinical symptoms except one patient who failed at 8 months. We found our results are comparable as reported in the literature in this small cohort. This kind of surgery may be performed in a non referral hospital.

Background: Acute rupture of Tendo achillis can be treated by open, percutaneous surgery and minimally invasive technique. Open method reported to have high complication.

Objective: We report the outcome and length of hospital stay with minimally invasive technique with achillion

Design: Non randomised prospective observational study form October 2002 to December 2005

Materials and Methods: 9 male non professional athletes of mean age 38 years (range 23-73) presented with closed rupture were treated surgically using achillon technique were treated with same preoperative cast, post operative orthosis and rehabilitation protocol. All the patients had suture removed at 10 days after the surgery and followed up at 3 weeks, 8 weeks, 12 weeks and 6 months and yearly.

Results: The average operating time is 38 mins [range 27-58mins]. Mean length of incision is 3.4cm. No patient had clinical DVT, sural nerve disturbance and failure of repair and no bed stay.

Summary: Achillion Method helps to repair tendon under direct visualization, preserving its vascularity. We found no complication in wound healing. This surgical technique reduces financial burden in terms of bed use and wound care to the care provider. Randomised control studies may be necessary to highlight potential cost effectiveness

Massive disc herniations after surgical decompression develop secondary back pain due to important loss of nucleus material with instability. No earlier proposed method to restore disc function was biological.

Chondrocyte culturing allows living repair of lost disc tissue. The contained disc space appears particularly suitable for receiving those tissue cultures. Surprisingly disc replantations had not been attempted before.

In 1996 two women and one man (aged 38-55) underwent open resection of a massive disc herniation by hemi-laminotomy, twice at L5-S1, once at L4/5.

All the excised disc tissue was given to tissue culture in an identical protocol as in autologous chondrocyte transplantation (ACT) for articular cartilage repair. After sufficient cell multiplication (11.5-23 millions living cells in 750 μl) four weeks later the engineered autolo-gous disc tissue was injected in suspension through a contra-lateral puncture under local anaesthesia.

In prospective follow up a simplified Oswestry Disability Index was recorded and functional radiographs and NMR were taken after one, three, six and nine years.

All three patients remained freed from radicular pain and vertebral symptoms over the whole follow up period. Two patients never had functional restrictions nor loss of working capacity (Oswestry 1 and 6), one after retirement at 5 years developed rheumatoid disease but is still unchanged at the lumbar spine. The third patient partially recovered from preoperative radiculop-athy (slight loss of strength and sensitivity S1) but still works, with minor adaptations to his original professional activity (Oswestry 18).

Functional radiographs up to the last follow up didn’t show vertebral instability. In all cases the replanted intervertebral disc space remained unchanged with minimal widening in one case.

In NMR all three discs had partial signal recovery. Twice during the first year a new outgrowth of disc tissue was observed at the site of the primary disc herniation opposite to the replanting injection, without any clinical correlation.

Three cases with massive lumbar disc herniations showed good clinical and large anatomical recovery persisting nine years after reimplantation of engineered autologous disc tissue. The encouraging results of this small pilot study led to further closely monitored clinical applications before wider propagation of biological disc repair surgery.

Malpositioning of the component of a total knee implant and malalignment of the leg is one of the significant factors for the outcome after Total Knee Arthroplasty.

Previous studies have shown that the use of a navigation system can improve these. This article presents the initial results of a prospective and non-randomised study describing navigated implantation in TKA with special reference to soft tissue balancing in knees with posttraumatic deformity. The secondary objective is to found out reproducibility of the software.

Methods: Since January 2004, 15 patients with post-traumatic arthrosis of the knee and axial malalignment of more than 15 degrees, pre operative arc of motion 75 degrees admitted to our senior author for TKA have been followed up prospectively. The data were collected over a period of 25 months. Apart from the usual clinical evaluations, no patients had CT of the leg prior to the operation & postoperatively. Intra-operative and peri-operative morbidity data were collected and blood loss measured.

Results: A postoperative leg axis between 3 degrees varus and 3 degrees valgus was obtained in all of the navigated knees after soft tissue balancing. The alignment of the components using computer-assisted surgery in regard to femoral varus/valgus, femoral rotation, tibial varus/valgus, tibial posterior slope, tibial rotation are reproducible and consistent. Computer-assisted surgery took longer with a mean increase of 31 minutes for kinematic data acquition. Intraoperatively we achieved range of motion more than 120 degrees. No patient required manipulation postoperatively for improving range of motion

Conclusion: These results support that the precise surgical reconstruction of the mechanical axis of the knee and proper alignment of the component is achievable in patients who suffered posttraumatic deformities and secondary arthrosis by using an intraoperative navigation system.

It has been mentioned in the literature that minor deviations in the insertion point of Intramedullary instrumentation during TKA may result in malalign-ment of several degrees [Nuno-Siebrecht 2000], which can be avoided with these soft ware.

To illustrate our clinical experience of using a complete biological method of fixation in ACL surgery and correlate the histology at the graft and the host bone interface performed in an animal experiment.

Materials: 18 male patients of mean age were 31.2 years (range 18 to 50 years) were operated on. The autogenous graft prepared from lateral part of the quadriceps aponeurosis, part of the patella and ligament leaving distal tibial attachment, passed through the trans-osseous tunnel so that bony part of the graft stay within the femoral tunnel, remaining part was sutured with the iliotibial tract.

Patients began immediate knee exercises with continous-passive-motion devices in the recovery room. With 100 degrees of knee motion, they allowed to bear full weight on the operatively treated limb with knee in a brace in extension

Results: 3 patients had superficial wound infection and 2 had haemarthrosis. None had any laxity or flexion contracture, mean flexion arc was135 (130–145) degree.

Conclusion: Histology of the bone graft and host tunnel confirms full incorporation of the graft in experimental animals performed by our senior author. The procedure of biologic fixation method in ACL reconstruction surgery to preserve the biological integrity of the patellar ligament distally in the tibial end may avoid early failure in fixation method. The biological integration producing a bone block in the femoral tunnel may enable clinician to start early rehabilitation program.

Inappropriate use of surgical dressing cause blisters around the surgical wound and increase the incidence of peri-operative wound infection and patients dissatisfaction which influence the outcome of the surgery. It is more so when patients are being treated as a day case procedure. We have not found any study correlating with patient’s satisfaction and surgical dressing.

Objective: To evaluate patient’s preference of surgical dressing and analyse which type of dressing is associated with significant morbidity

Design: Prospective, Non randomised, Clinical study.

Materials and Methods: Two different dressings Opsite post op or Mepore were applied by a single surgeon on 100 patients (50 each group) undergoing same arthroscopic procedure of the knee under general anesthetic were included in this study. They were followed up to 10 days. An independent nurse practitioner evaluated the complication related to the dressing and assessed the satisfaction with the 5 item short questionnaires at outpatients clinic.

Results: Blisters developed in 6% of patients with Mepore dressing (p=0.24) and none with Opsite Post op. 14% Patients with Mepore dressing developed superficial inflammation and this is significantly greater (p< 0.001) than opsite. 86% patients with opsite dressing on were able to take bath and thereby reduce the chance of contamination from the skin flora. 90% patients with opsite rated the dressing as excellent compared to mepore 26%, (p< 0.001)

Conclusion: Patients preferred Opsite post op as the dressing of their choice. It is not associated with dressing related morbidity, may improve better post operative wound healing. It may help to prevent superficial wound infection by contamination. After this study, we have changed our policy.

Early mobilisation following Anterior Cruciate Ligament(ACL) reconstruction surgery is indicated for optimum results for accelerated rehabilitation. However, the graft used in reconstruction is at it’s weakest during the early post-operative period and can be prone to slipping.

Aim: This study compared two types of graft, bone-patellar tendon-bone (BPTB) and soft tissue tendon, with the hypothesis that BPTB grafts would lead to less slippage under cyclical loading conditi ons.

Materials & Method: A comparative biomechanical study was carried out using sixteen proximal tibiae of calves, aged 20–26 weeks and carrying out ACL reconstruction, 8 constructs with human Cadaveric BPTB and another 8 with calves’ extensor tendons. An interference screw measured 9 x 25mm was used to fix graft tissue in the transosseous tunnel. The specimens were tested in material-testing machine using Merlin software.

The constructs were subjected to cyclical loading. A load cycle of 0-150-0N was applied at a crosshead speed of 100mm/min, approximately 80 load cycles per minute simulating the forces applied in post-operative mobilisation. The crosshead position was noted at peak load at 1, 100, 300, and 1000 cycles.

Results: The value of the graft slippage found in the soft tissue tendon model was 1.83 ± 0.54 and that of bone tissue (BPTB) model was 0.76 ±0.29. Creep value showed no statistical significance. There was significantly less slippage when using BPTB-to-bone fixation than with soft tissue tendon-to bone fixation (p< 0.005).

Clinical relevance: BPTB grafts are more likely to resist the return of anterior-posterior laxity in the immediate post-operative period, prior to graft fixation by tissue healing. BPTB grafts should be used when accelerated rehabilitation is required.