Aims

The aim of this study was to examine the recent trend in delivery of arthroscopic subacromial decompression (ASD) in Scotland and to determine if this varies by geographical location.

The aim of this study was to investigate the function, limitations and disability of a large cohort of active golfers following total knee replacement (TKR). The study group comprised the membership of the New Knee Golf Society (NKGS) and 211 members were reviewed with a questionnaire which asked the patient’s experience & difficulties of playing golf before and after TKR.

The functional outcome was recorded using the Oxford knee score. A total of 299 knees (TKR only) in 209 patients were included in the final analysis. The mean age was 70 years. Majority of the prostheses were cemented (95%) and had patellar resurfacing (90%). The mean post-operative period was 5 years. We found 196 patients (94%) returned to playing golf after a mean of 4.6 months following the TKR; 184 (88%) continue to play at review; 93% claimed significant improvement in their capability to play golf following TKR. However, none claimed to have achieved a significant improvement in their handicap.

Seventeen knees (5.7%) underwent revision surgery. Six knees (2%) were revised for infection at mean 17.3 months and eleven (3.7%) for aseptic loosening or instability at mean 5 years. Seven left knees (lead knee) of eleven right-handed golfers required revision for aseptic loosening. Varus collapse of the tibial component in the lead knee was observed.

The main problems experienced after playing 18 holes were knee stiffness (47%) and swelling (18%). Oxford Knee Scores: 69% excellent; 27% moderate functional impairment; 4% poor outcomes.

Although the capability to play improved the handicap remained the same. We found that the left TKR in a right-handed active golfer is more likely to require revision, which may be due to the increased torque on the lead knee.

Introduction: The aim of this study was to investigate the function, limitations and disability of a large cohort of active golfers following total knee replacement (TKR).

Materials & Methods: The study group comprised the membership of the New Knee Golf Society (NKGS), UK. 211 members were reviewed with a questionnaire which asked the patient’s experience & difficulties of playing golf before and after TKR. The functional outcome was recorded using the Oxford knee score.

A total of 299 knees in 209 patients were included in the final analysis. The mean age was 69.6 years. Majority of the prostheses were cemented (95%) and had patellar resurfacing (89.6%). The mean post-operative period was 5.1 years.

Results: 196 patients (94%) returned to playing golf after a mean 4.6 months following the TKR. 184 (88%) continue to play at review. 92.8 % claimed significant improvement in their ability to play and enjoy golf following TKR citing reduction in pain and improved walking ability as the reasons. However, none claimed to have achieved a significant improvement in their handicap.

17 knees (5.7%) underwent revision surgery. 6 knees (2%) were revised for infection at mean 17.3 months & 11 (3.7%) for aseptic loosening or instability at mean 4.9 years. 7 left knees (lead knee) of 11 right-handed golfers required revision for aseptic loosening.

The main problems experienced after playing 18 holes were knee stiffness (47%) & swelling (18%).

Conclusion: Although the ability to play improved the handicap remained the same. The left TKR in a right-handed active golfer is more likely to require revision which may be due to the increased torque on the lead knee.

Introduction We describe an arthroscopic technique of excising a lesion from within the posterior septum of the knee. To our knowledge this has not been described in the literature.

Case History A 35-year old male taxi-driver presented with pain in the back of his right knee. Examination did not reveal any abnormality except pain on flexing the knee beyond 90-degrees. MRI showed a multiloculated ganglion in the posterior compartment of the knee. The ganglion was located within the posterior septum and successfully excised arthroscopically. 6-months postoperatively the patient is assyptomatic.

Anatomy of the posterior septum The posterior septum is located between the posterior cruciate ligament (PCL) and the posterior capsule dividing the posterior cavity of the knee into seperate posteromedial and posterolateral compartments. It is triangular in shape, formed by the reflections of the synovium from the PCL.

The Technique The posterior septum of the knee was approached through the intercondylar notch by the anterior portals. Slow and careful dissection was carried out in the V-shaped space between the anterior and the posterior cruciate ligaments. The synovium of the septum was resected and the space within the septum entered. The ganglion was successfully removed. There was no complication. The relatively central placement of the anterior portals is important to gain access to the posterior septum via the notch.

Discussion and conclusion Intra-articular ganglion cysts are uncommon. Reported prevalence ranges from 0.2% to 1.3%. Ganglion cysts arising from the anterior and the posterior cruciate ligaments have been well described. The ganglion cyst within the posterior septum has not been reported.

The anatomy of the posterior septum makes it inaccessible to routine arthroscopic examination. It has close proximity to the vascular structures. We approached the posterior septum from the anterior portals through the intercondylar notch. The ganglion was successfully excised.

Aim: This investigation compares the tibial tunnel appearances at 1 year and again at 8 years post-operatively in 49 patients and reports on the clinical significance of these appearances. Materials and Methods:49 consecutive patients who underwent isolated central anterior cruciate ligament reconstruction using a four stranded hamstring tendon technique comprised the study group. The patients were reviewed clinically and with weight bearing AP and Lateral radiographs at one year and eight years (range 5–9years) from reconstruction. Two blinded observers measured the tunnel diameters using a digital caliper on the 1year and 8 year radiographs. Tunnel enlargement was calculated from the known drill size with correction for magnification. The findings were correlated with clinical outcome and various associations were studied. Results: At one year postoperatively tunnels had increased in diameter by a mean of 26% at the proximal end, and by 19% at the distal end. By 8 years both measurements had reduced to 20% and to 13% respectively and this decrease in tunnel enlargement was significant (p< 0.05). Tunnel enlargement was significantly greater in those knees with persistent effusion at one year. (P< 0.05). 10 patients (26%) had distal tibial tunnel diameters which were less than the original drill size and of these ten patients only one had a positive Lachman (side to side difference> 3mm) compared to 9 in the rest. (P< 0.05). Conclusion: Tunnel enlargement that occurs at 1yr reduces by 8 years from reconstruction. Decrease in tunnel enlargement at the distal end is associated with an improved and lasting stability.

The management of disabling osteoarthritis of the knee following ipsilateral femoral fracture malunion can be difficult. This study presents the results of seven such patients treated by femoral shaft osteotomy in the fracture region and with locked intramedullary nail fixation.

Seven patients with malunited femoral shaft fractures presenting with knee symptoms between 1992 and 1999 were treated by femoral shaft osteotomy. The presenting knee symptoms and function were graded from 0–4. All patients underwent open femoral shaft osteotomy at the apex of the deformity and fixation was by locked intramedullary nailing. The patients were followed up until osteotomy union and reviewed clinically and radiologically with particular emphasis on knee symptoms and function.

There were six males and one female. The mean age at presentation was 48 years and the mean time from fracture 28 years. (Range 13–37 years). The mean knee alignment angle preoperatively was 5 degrees varus (range 0–12). The mean time to osteotomy union was 28 months. The mean knee alignment angle postoperatively was 2 degrees valgus. (range 5 degrees varus-5 degrees valgus). Five of the seven patients reported excellent pain relief and functional improvement. One patient had serious vascular complication and now has a stiff but pain free knee. One patient who presented with very advanced OA has since undergone an uncomplicated total knee arthroplasty after osteotomy union and nail removal.

These patients presenting with severe disability at an age that would be too young for total knee replacement are difficult to manage. Five out seven patients in these series are symptomatically improved to return to their old occupation. The knee replacement has been delayed in these by a mean of five years. Their eventual knee replacement is likely to have been made less difficult as a result of alignment correction.

Purpose: To compare the radiographic tibial tunnel enlargement at one year post operatively following anterior cruciate ligament reconstruction in two patient groups one operated on soon after an acute injury and the other for chronic instability. Also, to correlate the radiographic findings with the clinical results.

Patients and Methods: The study group was of 42 patients who underwent isolated central anterior cruciate ligament reconstruction with a four thickness hamstring tendon technique. 20 of these were consecutive patients with a mean injury to operation delay of 4.5 weeks. Twenty two were consecutive patients with chronic instability and a mean injury to reconstruction interval of 29 months. All patients were reviewed at year post-operatively, their assessment including clinical examination, Lachman and Jerk Tests, arthrometer testing, Tegner activity level recording and weight bearing AP and lateral radiographs.

Tibial tunnel diameters were measured by two independent observers at two points. The proximal measurement was made 5 mm from the tibial articular surface and the distal, 5 mm from the lower end of the tunnel. The tunnel enlargement was calculated from the known drill size after correction for magnification.

Tunnel enlargement was compared between the two groups, was correlated with the clinical findings and the results were analysed statistically.

Results: Tibial tunnel enlargement was seen in both groups (p< .001). The enlargement was significantly greater at the proximal end of the tunnel (34%) than at the distal end (25%) (p< .05). In the acute group the mean increase in the tunnel diameter at the proximal end was 31%. In the chronic group it was 36%. This difference however was not statistically significant. (P> .05). At the distal end the mean tunnel enlargement in acute and chronic groups was 24% and 27% respectively. (P> .05).

Tunnel enlargement was significantly higher in patients with persistent effusion at one year. (40%:31%) p< .05. We did not find any correlation between tunnel enlargement and clinical outcome.

Conclusion: Anterior cruciate reconstruction by an isolated central hamstring tendon technique, carried out sub-acutely following injury, does not significantly reduce the incidence of tibial tunnel enlargement as compared with knees operated on by the same technique for chronic instability. There was a significant association between tunnel enlargement and the persistence of effusion.

Purpose: The management of disabling knee osteoarthritis of the knee following malunion of an ipsilateral femoral shaft fracture is difficult and controversial. The purpose of this study is to analyse the results of femoral shaft osteotomy at the level of the old fracture in seven such patients.

Materials and Methods: Seven patients with old malunited femoral shaft fractures presented with disabling knee osteoarthritis between 1992 and 1999. Knee symptoms and function were graded at presentation. All underwent open femoral shaft osteotomy at the apex of the deformity, with locked intramedullary nail fixation. The patients were followed up regularly until osteotomy union and reviewed clinically and radiologically with particular emphasis on knee symptoms and function.

Results: There were six males and one female. The mean age at presentation was 55 years and mean time from the fracture was 28 years (range 13–35 years). The mean preoperative knee alignment angle was 5.60 varus (range O′12′). The mean time to osteotomy union was 28 months. The mean postoperative knee alignment angle was 20 valgus (range 50 valgus -50 varus). All patients reported significant improvement in knee symptoms and function. One osteotomy was followed by a serious vascular complication and the patient now has a stiff but pain free knee. One patient with very advanced osteoarthritis underwent an uncomplicated total knee replacement after osteotomy union and nail removal.

Conclusion: These patients presenting with severe disability at an age which is worryingly young for total knee arthroplasty present a difficult management problem. Five out seven patients had excellent symptomatic and functional improvement following the femoral shaft osteotomy. The possible need for knee replacement was delayed by at least 5 years and the eventual arthroplasty is likely to have been made less technically difficult and more functionally satisfactory as a result of the alignment correction.

Purpose: Localisation of the femoral head is essential during total knee arthroplasty for assessing the overall alignment of the leg. The purpose of this study is to describe and report the accuracy a clinical method of estimating the centre of the femoral head.

Method: A line is drawn joining the anterior superior iliac spine and the pubic tubercle on the patient lying supine on the operating table. The point where femoral artery crosses this line is estimated. The Femoral head centre is marked 1.5 cm lateral to this point. This point was marked with an ECG electrode which has a radiopaque and prominent centre that is easily felt through the drapes. A radiograph was then made with the tube at 1 metre from the plate and centred over the hip marker.

The error in the hip marker placement is measured as the transverse mm (corrected for magnification) of the marker from the centre of the head, which is located on the radiograph using a template of concentric. The potential angle of error in coronal alignment of the associated knee replacement is calculated trigonometrically from femoral and tibial lengths.

Patients: The study group was comprised of 73 consecutive patients (100 knees) who underwent primary Total knee replacement. There were 36 males and 37 females.

Results: The average error was 8 mm (Range 0–30 mm). It was lateral to the femoral head in 47 patients and medial in 53 patients. The error was significantly greater in female patients (7mm:10mm, p < .05). The calculated potential error in coronal alignment was < 20 in 84% of patients and < 30 in 99% of the knees.

Conclusion: This is a clinically useful method of locating the centre of the femoral head for surgeons who find + 3 degrees of error in coronal alignment acceptable. For those striving for greater accuracy a preoperative hip marked radiograph may be more helpful.

Purpose: The radiological appearances of tibial tunnel enlargement following anterior cruciate ligament reconstruction in the short and medium term have been described. This study compares the tibial tunnel appearances at 1 year and again at 8 years post-operatively in 44 patients, and correlates the findings with the longer term clinical outcome.

Patients and Methods: The study was conducted on 44 consecutive patients who had undergone isolated central anterior cruciate reconstruction using a four thickness hamstring technique. All patients were reviewed at one year postoperatively, the assessment including full clinical examination, arthrometer testing and weight bearing AP and lateral radiographs. They were reviewed again at a mean of 8 years (range 5–10 years) post reconstruction. At the 8 year review, full clinical examination, Arthrometer testing, Lysholm and IKDC scoring, Tegner activity level recording were done and standardised weight bearing AP and lateral radiographs were taken.

The Tibial tunnel diameters were measured by two independent observers on both one year and 8 year radiographs. The proximal tunnel measurement was made 5 mm from the tibial articular surface and the distal, 5mm from the lower end of the tunnel. Tunnel enlargement was calculated from the known drill size after correction for magnification. The tunnel enlargements were correlated with clinical outcome and the results were analysed statistically.

Results: There were 6 failures of stability for which an additional operative procedure had been undertaken. The remaining 38 knees were functionally stable. 28 (75%) had negative Lachman and jerk tests and 34 (90%) had a side to side arthrometer difference of less than or equal to 3mm.

The mean tibial tunnel enlargement at one year was 31% at the proximal and 23% at the distal end of the tunnel. At 8 years the enlargements were 20% at the proximal and 13 % at the distal end of the tunnel (p< .001).

There were 10 patients (26%) whose distal tunnel diameter at 8 years was less than the initial drill size. Only one of these had a positive Lachman test. This negative association was significant (p< .05). There was no significant correlation between enlargement at the proximal end of the tunnel, the Lysholm score or clinical stability at 8 years.

Conclusion: Cruciate ligament reconstruction persists at 8 years. However there was a previously unreported reduction in radiographic tunnel size at the 8 year review and this reduction was significant at the distal end of the tibial tunnel. There was no correlation between tunnel enlargement and functional outcome even at 8 year review.

A simple technique for screw fixation of the carpal scaphoid in cases of delayed union and non-union is described. The results obtained in 32 patients treated by this method are reported. The average follow-up was three years ranging from 10 months to 12 years. Union was obtained in 28 patients. The causes of failure to unite are discussed and the advantages of the reported method over other techniques such as bone grafting are stressed.

Fifty patients who underwent a MacIntosh repair for anterolateral instability of the knee have been reviewed after a mean follow-up of two and a quarter years. The repair abolished a positive anterolateral jerk test in 42 out of 50 knees and at the time of review 37 patients (74 per cent) were involved in some form of active sport, having regained functional and clinical stability. The MacIntosh repair is described in detail and the importance of excluding meniscal lesions as the main cause of instability is emphasised.

A series of 135 knee arthroscopies has been reviewed to determine the accuracy of detection of meniscal lesions. Arthroscopy and double-contrast arthrography achieved similar accuracy (84 per cent and 86 per cent) in the diagnostically more difficult knees of the series. The combined accuracy of both examinations was 98 per cent. Arthroscopic difficulty in seeing the posterior third of the medial meniscus, and consequently tears in this region, is emphasised and discussed. Arthroscopy and arthrography are complementary in the diagnosis of difficult meniscal problems.

Intertrochanteric osteotomy gives compensatory correction for the severely slipped upper femoral epiphysis without endangering its blood supply. The results of thirty-five such osteotomies carried out over an eighteen-year period are reviewed. The indication for operation was a chronic slip of a third or more of the growth plate in the lateral radiograph. The mean age at operation was fourteen years and the mean follow-up period seven and a half years. The results showed that even a moderate correction of deformity as shown by the radiograph could produce a hip with a functionally satisfactory range of movement. Chondrolysis was the most serious complication and occurred in four hips. The radiological results are discussed in relation to details of operative technique and also to long-term prognosis.