A reduced range of movement post total knee replacement (TKR) surgery is a well recognised problem. Manipulation under anaesthesia (MUA) is a commonly performed procedure in the stiff post operative TKR. Long term results have been variable in the literature.

We prospectively followed up 48 patients since 1996 from one centre, over an average of 7.5 years, (range 1 to 10 years) and report on the long term results.

The mean time to MUA post TKR was 12.3 weeks (range 3 to 48). Pre MUA, the mean flexion was 53°. The mean immediate passive flexion post MUA was 97°, an improvement of 44° (Range 10° to 90°, CI < 0.05). By one year, the mean flexion was 87°, improvement of 34°, (range −15° to 70°, CI< 0.05). At ten years the mean flexion was 86°.

We found no difference between those knees manipulated before or after 12 weeks. In addition there was no difference found in those knees which had a pre TKR flexion of greater or less than 90°. There were no complications as a result of MUA. However, one patient was eventually revised at two years secondary to low grade infection.

Our findings show that MUA is safe and effective method at improving the range of motion in a stiff post operative TKR. The improvement is maintained in the long term irrespective of time to MUA and range of motion pre TKR

Aims: Replacing human cadaveric specimens with fresh frozen animal tissue in biomechanical studies has become increasingly more popular due to the scarcity of young human tissue. The aims of this study were to characterise and compare the biomechanical parameters of tailored strips of equine extensor tendon, with 4 strand young human semitendinosus and gracilis (STG) tendons as an alternative tendon model for testing anterior cruciate ligament (ACL) graft reconstruction techniques using the Soffix Polyester ACL fixation device.

Method: Common digital extensor tendons were harvested from normal equine forelimbs and tailored into 5 mm wide, 2 strand equine tendon strips. The doubled equine tendons were overlapped and braided around the buttonholes of a Soffix fixation device and secured with No 2 Ethibond sutures (Johnson & Johnson Ltd). The Soffix-4-strand young human STG tendon complex was prepared in an identical manner. Mechanical testing was performed measuring ultimate tensile load (UTL) and elongation to failure (EF), structural stiffness (SS) was calculated from load extension curves.

Results: The Soffix-STG and the equine tendon complexes produced a mean UTL of 1186 N +/− 113.89 and 1116 N +/− 208.5 respectively showing no statistically significant difference.

Conclusions: We conclude that a tailored 5mm wide 2-strand equine extensor tendon strip provides a comparable alternative for in vitro testing of young human four strand STG tendon graft using a Soffix polyester fixation device.

The most common indication for knee arthrodesis is pain and instability in an unreconstructable knee following an infected knee arthroplasty. In this study, we compare the use of the Mayday arthrodesis nail (Ortho-dynamics, Christchurch, UK) versus external fixation, Orthofix (Berkshire UK) and Stryker Hoffman II (County Cork, Ireland).

All patients in this study underwent arthrodesis between 1995 and 2006 at Conquest Hospital, Hastings. In group A, 11 patients underwent arthrodesis with a Mayday nail. In all cases, the indications were infected total knee replacements (TKR). Three of these patients previously had failed attempts at arthrodesis with external fixation devices. In group B, seven patients underwent arthrodesis using external fixation. In six patients, the indication was infected TKRs. Results were reviewed retrospectively, with union assessed both clinically and radiologically.

The mean inpatient stay for the Mayday nail group was 23 days (range 8 – 45 days) compared with 76 days (range 34 – 122) for the external fixation group (p< 0.01, CI 95). Ten patients in group A went on to confirmed primary arthrodesis. One patient underwent revision arthrodesis with a Mayday nail and subsequently united. In group B only two patients achieved union. The rate of union was significantly greater in the Mayday nail group than the external fixation group (91% vs 29%, p< 0.01). Of those patients that achieved union, there was no difference in the time to fusion between groups.

Our study supported the existing literature and found that the Mayday nail appeared more effective than monoaxial external fixators for arthrodesis in the management of infected total knee replacements.

Aims: The aims of this study were to evaluate the biomechanical properties and mode of failure of a technique of anterior cruciate ligament (ACL) reconstruction using the Soffix polyester fixation device. A 2-strand equine extensor tendon graft model was used because a previous study has shown it to have equivalent bio-mechanical properties to that of 4-strand human semitendinosus and gracilis tendon grafts.

Method: Ten stifle joints were obtained from 5 skeletally mature pigs, the soft tissues were removed and the ACL and PCL were sacrificed. Tibial tunnel preparation was standardised using the Mayday rhino horn jig to accurately position a guide wire over which an 8mm tunnel was drilled. A 2-strand equine tendon-Soffix graft was used to reconstruct the ACL of the porcine knee using over the top femoral placement with bicortical screw fixation. Mechanical testing of 10 specimens was performed.

Results: The mode of failure included 4 midsubstance tendon failures, 3 Soffix failures and 3 failures at the suture-Soffix interface. The mean ultimate tensile load for the ACL reconstruction was 1360 N (standard deviation (SD) =354), elongation to failure of 41 mm (SD=7.5) and a structural stiffness of 35 N/mm (SD=8.1).

Conclusion: This in vitro study has shown that the technique of ACL reconstruction using the Soffix soft tissue fixation device with a tendon graft placed in the over the top position is biomechanically strong, providing a sufficiently high UTL immediately following reconstruction, therefore allowing early weight bearing and rehabilitation.

Introduction: The aims of this study were to determine whether patients were transfused appropriately, after a Unilateral Cemented Primary Total Knee Replacement (TKR), and whether it would be cost effective to use autologous transfusion drains compared with standard group & save and cross match protocols.

Method: Retrospective study of the pre- and postoperative day 1 haemoglobin values of all patients who underwent unilateral primary cemented TKR between November 2004 – November 2005 at the Kent & Sussex Hospital, Tunbridge Wells. Haemoglobin data and length of stay was obtained from computerised records & transfusion data from the blood transfusion department.

Results: 150 patients were assessed: 97 (65%) female and 53 (35%) male. 20 (14.6%) patients required blood transfusion. The mean preoperative haemoglobin for non-transfused and transfused patient’s was 13.7 and 12.5g/dl respectively (P = 0.0029). The mean postoperative haemoglobin for non-transfused and transfused patient’s was 11.1 and 9.27g/dl respectively (P< 0.001). The mean blood loss for non-transfused and transfused patient’s was 2.64 and 3.26g/dl respectively (P< 0.001). There was no significant correlation between length of stay and either preoperative haemoglobin or blood loss after surgery; Spearman’s correlation coefficient was 0.0222 and 0.0036 respectively. The cost of a standard group & save and cross match, plus the 56 required units of blood in this study was £15,443.60. The theoretical cost of using a CellTrans Autologous Transfusion System on these 150 patients would be £14,355.00, a saving of only £1,088.60. However, by only using the autologous drains on patients with a preoperative haemoglobin ≤ 12.5g/dl, this saving could be increased to £4,131.20 per annum.

Conclusion: Using autologous transfusion drains on patients with a preoperative haemoglobin ≤ 12.5g/dl would save over £4,000 per annum at Maidstone & Tunbridge Wells Hospital Trust. There is no correlation between length of stay in hospital and either preoperative haemoglobin or blood loss after surgery. Patients transfused had significantly lower pre- and postoperative haemoglobins.

Aims: The aims of this study were to evaluate the biomechanical properties and mode of failure of 4 methods of fixation used for hamstring tendon ACL grafts. The fixation methods investigated included titanium round headed cannulated interference (RCI) screws, bioabsorbable RCI screws, Endobuttons and Bollard fixation. It has been previously shown that a 2 strand tailored equine tendon-Soffix graft has equivalent biomechanical properties to a 4 strand human hamstring tendon-Soffix graft [1,2], therefore this model was used for the graft in the study.

Materials and Method: 32 stifle joints were obtained from skeletally mature pigs, the soft tissues were removed and the ACL and PCL were sacrificed. Tibial tunnel preparation was standardised using the Mayday Rhino horn jig to accurately position a guide wire. An 8 mm cannulated reamer was then used over the guide wire to create the final tibial tunnel. A back radiusing device was then placed into the tibial tunnel to chamfer the posterior margin of the tunnel exit to prevent abrasion and fretting of the graft. A 2 strand equine tendon-Soffix graft was then introduced into the tibial tunnel and secured with one of the four fixation methods. The proximal part of the graft was attached to the cross head of the materials testing machine using the Soffix. Five of each method of fixation were tested mechanically to failure and three of each method were cyclically loaded for 1000 cycles between 5 to 150 N, followed by 2000 cycles at 50 to 450 N.

Results: The mean ultimate tensile loads (UTL) were: titanium RCI screw = 444 N, bioabsorbable RCI screw = 668 N, Endobutton = 999 N and Bollard = 1153 N. The mode of failure for all RCI screws involved tendon slippage past the screw. Two Endobutton failures were encountered and one Bollard pull out occurred. Under cyclic loading conditions the titanium and bioabsorbable RCI screws failed rapidly after several hundred 5 to 150 N cycles due to tendon graft damage and progressive slippage. Both the Bollards and Endobuttons survived 1500 cycles at 50 to 450 N, with less tendon slippage occurring.

Conclusion: Titanium and bioabsorbable RCI screws provide poor initial fixation of tendon grafts used for ACL reconstruction, having significantly lower UTL’s than both Endobutton and Bollard fixation. Under cyclic loading titanium and bioabsorbable RCI screws fail rapidly due to progressive tendon slippage, whereas Bollards and Endobuttons survive cyclic loading. Both Bollard fixation and Endobuttons provide sufficiently high UTL’s and survive cyclic loading to allow early postoperative mobilisation and rehabilitation. Caution must be used in the early postoperative period when using interference screws to secure a hamstring tendon graft because progressive tendon slippage may result in excessive graft elongation and early clinical failure.

Aims: The aims of this study were to evaluate the biomechanical properties and mode of failure of four methods of fixation of hamstring anterior cruciate ligament (ACL) grafts. A 2-strand equine extensor tendon graft model was used because a previous study has shown it to have equivalent biomechanical properties to that of 4-strand human semitendinosus and gracilis tendon grafts. Method: Twenty stifle joints were obtained from 10 skeletally mature pigs, the soft tissues were removed and the ACL and PCL were sacrificed. Tibial tunnel preparation was standardised using the Mayday rhino horn jig to accurately position a guide wire over which an 8mm tunnel was drilled. A 2-strand equine tendon graft was then introduced into the tibial tunnel and secured with either a titanium round headed cannulated interference (RCI) screw, a bioabsorbable RCI screw, an Endobutton or an expansile Bollard. Five of each method of fixation were tested mechanically to ultimate failure and under cyclical loading. Results: The mean ultimate tensile loads (UTL) were: titanium RCI screw = 444 N, bioabsorbable RCI screw = 668 N, Endobutton = 999 N and Bollard = 1153 N. Under cyclic loading conditions the titanium and bioabsorbable RCI screws rapidly failed after several hundred 5 to 150 N cycles due to tendon damage and slippage. Both the Bollards and Endobuttons survived 1500 cycles at 50-450N, with less tendon slippage. Conclusion: Titanium and bioabsorbale RCI screws provide poor initial fixation of tendon grafts and fail rapidly under cyclic loading. Both Bollards and Endobuttons provide sufficiently high UTL’s and survive cyclic loading to allow early postoperative rehabilitation.

Aim: The aim of our study was to evaluate the results of the Soffix Mark I and Mark II hamstring fixation devices, placed transtibially with an “over the top” femoral route when applied to revision anterior cruciate ligament (ACL) surgery secondary to synthetic ligament failure.

Patients and Methods: 29 ACL revisions performed between 1992 and 2000 were evaluated. Twenty six failed prosthetic ligaments, 2 failed semitendinosus/gracilis (STG) and one BTB autografts were revised using hamstring grafts in 26, quadriceps in 2, and patella bone tendon bone (BTB) in 1 patient. Mark I and II fixation devices were employed. Follow up included clinical examination, KT 2000 arthrometric assessment, Lysholm, Tegner and IKDC scoring. The average follow up time was 50 months ±22.4.

Results: Arthrometric examination showed a mean side to side difference (SSD) of 2.98 mm ±1.5. The mean Lysholm score was 86.5 ±10.5 and 21 patients had a B rating (nearly normal) on IKDC scoring, while 3 score A (normal). The mean Lysholm score was 86.5 ±10.5. The lowest clinical scores were noted in 4 multiply operated knees.

Conclusions: We concluded that a revision technique using the STG Soffix fixation device can restore stability with good functional outcomes following failed primary ACL reconstruction. Multiply re-operated knees had the worst functional results despite restoration of stability.

Aim. The purpose of this paper is to report on the results of ACL hamstring reconstruction using a novel fixation device.

Patients-Methods. We reviewed a total of 132 patients with anterior cruciate ligament reconstruction, operated between 1998 and 2002, with a mean follow up time of 51 ± 9 months. A uniform arthroscopically assisted surgical technique with an instrument guided impingement free tibial tunnel placement and “over the top” femoral routing was employed. An autologous four strand semitendinosus-gracilis tendon graft in combination with a polyester graft suspension tape and cortical fixation device was used. An accelerated rehabilitation was instructed. All patients were examined in a dedicated Research Clinic on a 6 month basis. IKDC, Lysholm and Tegner scoring were employed to validate the end results. Arthrometric evaluation was performed with the KT 2000 device.

Results. The over all analysis showed a mean side to side difference of 2.9 mm ± 1.8 and the International Knee Documentation Committee score rating was 91.6 % normal or nearly normal (121 patients). Complications included one graft rupture, one deep infection and 5 case of loosening.

Conclusion. These findings suggest that the described method of anterior cruciate ligament replacement produces good early functional results and restores knee stability.