Pigmented villonodular synovitis is a monoarticular proliferative process most commonly involving the synovium of the knee joint. There is considerable debate with regards to diagnosis and effective treatment.

We present our experience of managing PVNS of the knee joint over a 12 year period. Twenty-eight patients were reviewed. MRI was used to establish recurrence in symptomatic patients rather than routine screening and to identify posterior disease prior to surgery.

Eight patients had localised disease and were all treated with open synovectomy and excision of the lesion, with no evidence of recurrence. Twenty patients had diffuse disease, eight treated arthroscopically and twelve with open total synovectomy. Nineteen patients (95%) had recurrence on MRI, however, only five (25%) had evidence of clinical recurrence.

There were no significant complications following arthroscopic synovectomy. Open synovectomy, in contrast, was associated with three wound infections and two thrombo-embolisms. Three patients had Complex regional pain syndrome.

We believe diffuse disease should be treated with arthroscopic synovectomy which is associated with minimal morbidity and can be repeated to maintain disease control. Radiotherapy is helpful in very aggressive cases. TKR was used when there was associated articular erosion.

Background

Frozen Shoulder is a common condition which causes significant morbidity in people of working age. The 2 most popular forms of surgical treatment for this condition are Manipulation under Anaesthesia (MUA) or MUA plus Arthroscopic Capsular Release (ACR). Both treatment modalities are known to give good results, but no-one has compared the two to see which is better.

The results of a multi-surgeon, multi-implant series of patellofemoral joint arthroplasty performed over a ten year period are presented. All patellofemoral joint arthroplasty performed from the years 1996 to 2006 were retrospectively reviewed using case notes, radiographs and clinic appointments until their latest follow-up period.

101 arthroplasties in 91 patients were followed up for average period of 48 months (range 6–96 months). The average age was 57 years with female patients thrice as common as male patients. There were 5 (5%) complications with 1 deep infection and 4 stiff knees. 35 subsequent procedures were performed in 28 patients including arthroscopic debridement in 18, arthroscopic lateral retinacular release in 8, tibial tuberosity transfer in 3, manipulation for stiffness in 2, and revision to total knee arthroplasty in 4 patients (3 for progression of tib-iofemoral osteoarthritis and 1 for infection).

The necessity of further surgeries in one third of the study group suggests that close follow-up of these patients is needed to address any concerns that can be easily resolved.

Purpose: Isolated patellofemoral joint (PFJ) osteoarthritis has long been a common observation as an important source of knee pain. Once non-operative treatment modalities have been exhausted, the surgical options available are transposition/elevation of tibial tubercle, drilling, realignment procedures, patellectomy, patellar resurfacing, patellofemoral arthroplasty (PFA) and total knee arthroplasty (TKA). Among these, PFA is an established treatment of isolated PFJ osteoarthritis. We present our multi-surgeon, multi-implant series of patellofemoral joint arthroplasty performed over a 10 year period.

Method: This study was a retrospective review of all PFA performed in the Knee Arthroplasty Unit at our hospital over a ten year period from 1997 to 2006. The unit comprises seven specialist surgeons, each with considerable experience in knee arthroplasty and numerous trainee surgeons. One hundred and one PFA performed in 91 patients were identified from the theatre records. Three different implant models were used: the Lubinus implant (Waldemar Link), the FPV system (Wright Medical) and the Avon system (Stryker Howmedica Osteonics).

Results: 101 arthroplasties in 91 patients were followed up for average period of 48.8 months (6–96 months). Of these, none were lost to follow up. The average age was 57 years with female patients thrice as common as male patients. Concomitant procedures in the form of 23 lateral retinacular release or 6 osteochondral autograft transfer system (OATS) were performed. There were 6 complications with 2 infections and 4 stiff knees. 31 arthroplasties had subsequent procedures including arthroscopic debridement (18), arthroscopic lateral retinacular release (8), tibial tuberosity transfer (3) and manipulation for stiffness (2). A total of 4 arthroplasties underwent revision to total knee arthroplasty, 2 for infection and 2 for progression of tibiofemoral osteoarthritis.

Conclusion: The necessity of revision surgeries in one third of the cases suggests that close follow-up of the patients is needed to address any concerns that can be easily resolved. A majority of the patients in our study had very good outcomes and did not need subsequent procedures in the medium term. Our study reiterates the importance of proper patient selection, surgeon experience and correct surgical technique in successful outcomes from PFA.

Introduction: We have come across a subset of patients with advanced patellofemoral osteoarthritis who also had well defined full thickness cartilage loss lesions on the weight bearing femoral condyle. In these patients the findings or the symptoms are not severe enough to warrant a total knee replacement. In this select group of patients, a combination of patellofemoral arthroplasty (PFA) and Osteochondral Autograft Transfer System (OATS) can be performed to address this unique problem.

Method& Results: Out of 38 PFA procedures performed by the senior author, a concomitant OATS was performed in 6 knees in 5 patients. A retrospective analysis of these patients was carried out with the average follow up being 3.8 years (18 months to 84 months). The average age of the patients in our case study was 48.2 years (36 to 59 years) at the time of surgery. Four of the six knees are doing well in the medium term. One patient had progression of tibiofemoral arthritis and underwent a total knee replacement. The only poor result was a young male, who two years following the PFA, developed a deep infection of the knee. Except for this patient awaiting a second stage revision for an infected knee, all the others have achieved their desired level of activity.

Conclusion: The advantage of this combination is that, the donor tubes for the OATS can be harvested from the trochlea or just adjacent to it, which happens to be the bed for the trochlear implant. This area provides good quality thick donor articular cartilage. As the surgical exposure has already been done for the PFA, the operative time is extended by approximately ten minutes for the OATS procedure. This combination procedure offers an alternative to more invasive options such as total knee replacement in younger patients in whom it is preferable to delay such major surgery.

Background – Frozen Shoulder is a common condition which causes significant morbidity in people of working age. The 2 most popular forms of surgical treatment for this condition are Manipulation under Anaesthesia (MUA) or MUA plus Arthroscopic Capsular Release (ACR). Both treatment modalities are known to give good results, but no-one has compared the 2 to see which is better.

Aim – To compare the outcome in patients with primary frozen shoulder, who are treated by either MUA or MUA plus ACR.

Method – 61 patients with primary frozen shoulder were treated by either MUA or MUA plus ACR. Each patient had their American Shoulder and Elbow Score (ASES), and their Oxford Shoulder Score (OSS) measured pre and post-operatively.

Results – The patients who had MUA plus ACR had a mean ASES of 24.8 preoperatively, 64 at 4 months, and a mean of 75.4 at 12 months. The mean OSS was 32.5 pre-operatively, 48.5 at 4 months and 53.4 at 12months. The patients who had a MUA had a mean ASES of 28.7 pre-operatively, 60.9 at 4months and 69.6 at 12months. The mean OSS was 33 preoperatively, 46.5 at 4 months and 50.9 at 12 months.

Conclusions – Both treatments give good results. MUA plus ACR give superior numerical results at 6 to 12 months post-operatively, however, these figures did not reach statistical significance

The aim of this study was to review the results of surgery on patients who had recurrent instabilty of the shoulder associated with significant bone loss who were treated by autogenous iliac crest tricortical grafts. Ten consecutive patients were reviewed. All had significant loss of glenoid bone stock as assessed by CT scan. All were treated by use of tricortical bone graft harvested from the iliac crest and fashioned to reconstitute the anterior glenoid defect. This was fixed intra-articularly with cannulated screws. The antero-inferior capsule was then repaired to this new “glenoid rim”. All patients had a standard rehabilitation regime. All patients had an assessment of the Oxford Shoulder Instability Score (OIS) and the American Shoulder and Elbow Surgeons Score (ASES) before and after the operation. At an average follow-up of 26 months, the mean OIS had improved from 38.3 to 22.3 and the mean ASES had increased from 40.5 to 86.6. None had had a recurrent dislocation. The use of autogenous iliac crest bone graft to treat recurrent shoulder instability associated with significant glenoid bone loss is an effective treatment for this difficult condition.

Purpose of Study Disruption of the coraco-clavicular ligaments may be associated with either dislocation of the Acromioclavicular joint or fracture of the distal clavicle. If sufficient displacement occurs functional disability results. Traditional techniques have required a bra-strap incision and often require late removal of the metalwork. The Tightrope syndesmosis repair system was adapted to be used arthroscopically to reduce and hold the clavicle enabling healing of the ligaments and any associated fracture using a minimally invasive technique but ensuring accurate reduction and secure stabilisation. Between December 2004 and September 2005 20 patients with injuries to the coraco-clavicular ligaments were treated using this system. As the system was in evolution a the majority were treated arthroscopically and a few using an “open” technique. All had either the acromio-clavicular joint reduced or a distal clavicle fracture reduced and stabilised using the Tightrope Syndesmosis Repair system. The system had been modified from that commercially available for use in the ankle with the consent of the manufacturer (Arthrex, Naples, Fla).

Results All patients were evaluated at a minimum of 6 months post operatively using the DASH, ASES and Constant scores The mean ASES score was 94, the mean Constant score was 90, the mean DASH score was 5 One patient had failure of the metalwork due to malposition, this was revised successfully using the Tightrope and one had a transient adhesive capsulitis. There were no other complications and no patient required removal of the metalwork.

Conclusions The authors conclude that this new technique is a safe, simple, cosmetically acceptable and reproducible method of reducing and stabilising the distal clavicle allowing for healing of either the coraco-clavicular ligaments or the distal clavicle.

Full-thickness chondral defects of weight-bearing articular surfaces of the knee are a difficult condition to treat. Our aim is to evaluate the mid- and long-term functional outcome of the treatment of osteochondral defects of the knee with autologous osteochondral transplantation with the OATS technique.

Thirty-six patients (37 procedures) were included in this study. Twenty-three patients were male and 13 female with a mean age of 31,9 years (range: 18 to 48 years). The cause of the defect was OCD in 10 cases, AVN in 2, lateral patellar maltracking in 7, while in the remaining 17 patients the defect was post-traumatic. The lesion was located on the femoral condyles in 26 cases and the patellofemoral joint in the remaining 11. The average area covered was 2,73cm2 (range: 0,8 to 12cm2) and patients were followed for an average of 36,9 months (range: 18–73 months).

The average score in their Tegner Activity Scale was 3,76 (range: 1–8), while their score in Activities of Daily Living Scale of the Knee Outcome Survey ranged from 18 to 98 with an average of 72,3. Thirty-two out of 37 patients (86,5%) reported improvement of their pre-operative symptoms. All but 5 patients returned to their previous occupation while 18 went back to sports. No correlation was found between patient age at operation, the size or site of the chondral lesion and the functional outcome.

We believe that autologous osteochondral grafting with the OATS technique is a safe and successful treatment option for focal osteochondral defects of the knee. It offers a very satisfactory functional outcome and does not compromise in any way patients’ future options.

Patellofemoral problems are probably the most common type of knee complaint in adolescents and adults. Our aim is to evaluate the mid- and long-term functional outcome, as well as to detect factors affecting it in patients who underwent a modified Elmslie-Trillat procedure.

Forty-two patients (49 procedures) were included in this study. Nine were male and the 33 female, with a mean age of 31,3 years (range: 19 to 56). The reason for operation was patellar instability (recurrent subluxation or dislocation) in 13 cases (26,5%), anterior knee pain with malalignment of the extensor mechanism in 17 cases (34,7%) and a combination of both in the remaining 19 cases (38,8%). Patients were followed for a minimum of 18 months and an average of 38,6 months (range: 18 to 130 months).

The functional outcome according to Cox’s criteria was excellent in 14 cases (28,6%), good in 20 cases (40,8%), fair in 9 cases (18,4%) and poor in the remaining 6 cases (12,2%). Patients scored an average of 3,57 (range: 2–8) in their Tegner Activity Scale, while their score in Activities of Daily Living Scale of the Knee Outcome Survey ranged from 43 to 98 (average: 75,8). Result analysis revealed that the functional outcome was better in the subgroup that had the procedure due to patellar instability. Furthermore, the outcome was significantly better in the absence of grade 3 or 4 chondral changes in the patellofemoral joint at the time of operation (t-test: p=0,0362).

Elmslie-Trillat procedure satisfactorily restores patellofemoral stability and offers a very good functional outcome, especially in the absence of significant chondral changes in the patellofemoral joint at the time of operation.

Aim: To survey how acute, traumatic, first-time anterior shoulder dislocation (AFSD) is managed amongst trauma clinicians in the current clinical setting in UK hospitals.

Design: Postal Questionnaire.

Method: 228 questionnaires were sent out to list of active consultant member of the British Trauma Society practising in various hospitals around United Kingdom. Questions were laid out in two workgroups. In work-group one, an assortment of questions were asked with the emphasis on management in AFSD from the point of entry in a casualty department to departure and after-care. In workgroup two, case scenarios were included to look in the ‘aftercare’ management in three distinct age groups; young (< 25 years old), middle age (30–65 years old) and elderly (> 65 years old).

Results: The response rate of the questionnaires was 51%. Twenty-two per cent of respondents have local protocol for managing AFSD. All respondents recommended pre-and post-reduction X-rays as standard practice. Most respondents favoured systemic analgesia with ‘airways monitoring’, as opposed to intra-articular anaesthesia (68 versus 9). Kocher and Hippocrates were the most popular methods of reduction. Eighty-four respondents advocated immobilisation in internal rotation compared to six in external rotation. Only a small number of respondents would perform an immediate arthroscopic stabilisation in young, fit patients presenting with this type of injury (16 of 84).

Conclusion: This survey revealed the current practice of trauma clinicians in managing AFSD on the ‘front-line’. We conclude that there is significant variation in response to the issues incorporated in this survey. There is a need to address the issues of intra-articular analgesia, immobilisation technique and management of AFSD amongst young patient with regards to immediate surgical intervention. We suggest that these issues be revised and clarified, ideally in a randomised controlled clinical trial prior to the introduction of a protocol for managing this problem.

Multiple ligament deficiency in knees is usually the aftermath of high velocity trauma and leads to complex multidirectional instability, that can in turn greatly compromise the patient’s functional level if left untreated. The aim of this study is to evaluate the mid- and long-term functional outcome of patients who underwent complex reconstruction for multiple ligament deficiency.

Twenty-nine patients (21 male and 8 female) with an average age of 35.54 years (range 17–60) underwent arthroscopic or arthroscopically assisted multiple ligament reconstruction at an average of 2.1 years following their initial knee injury. Thirteen of them sustained a multiple ligament injury following an RTA, 11 during sports and 5 following a fall from a height.

They were followed for a period of 13 to 108 months (average: 45.8) and functionally evaluated according to Clancy’s criteria. The functional outcome was excellent in five patients (17.2%), good in ten (34.5%), fair in twelve (41.4%), while two reconstructions resulted in a failure (6.9%). Eleven patients returned to sporting activities and all but three returned to work, although sometimes in lighter duties.

Arthroscopic multiple ligament reconstruction is a complex and technically demanding procedure that should be carried out in specialised units. Although it rarely results in a “normal” knee, it offers in most cases a stable as well as functional knee.

We report a case of a 20-year-old microcephalic patient who suffered from symptomatic patellar dislocation since his early days. His patella was laterally dislocated from full extension to 40° of flexion and would remain subluxated thereafter. His CT-scan revealed excessive ipsilateral femoral neck anteversion (45°) that resulted in substantial internal femoral torsion and subsequently led to patella dislocation.

He was treated in one stage with a stepwise procedure, that involved arthroscopic assessment of patellar tracking followed by derotational femoral shaft osteotomy. Tracking was reassessed arthroscopically and although improved was still suboptimal. Therefore an arthroscopic lateral release and an Elmslie-Trillat tibial tubercle transfer were undertaken. This led to very satisfactory patellar tracking.

One year postoperatively he had significant functional improvement, no further episodes of patellar dislocation and a ROM of 0–110°. His Lysholm score improved from 45 to 88, his Tegner activity scale from 2 to 4 and his Knee Outcome Score from 38/80 to 70/80.

This complex case highlights excessive femoral neck anteversion as a causative factor for patella dislocation. A combination of proximal and distal bony realignment procedures is proposed and the role of arthroscopy is emphasised.

Aim The aim of this study was to identify the presentation, management and outcomes this rare disease using the large series of patients treated at our unit

Material and Methods We reviewed the medical records and x-rays of all the patients who were referred – treated for PVNS around the knee joint between 1990 and 2002

Results 42 patients totally were treated or had second opinion for PVNS disease. 37 have been analysed in detail.

Their mean age was 33 years old and 11 patients were below 17 years of age. There was a predilection for females with 22 (59.5%) out of 37 patients.

There was average 3.3 years period of time with swelling/knee symptoms before diagnosis .

The MRI scan was the cornerstone for the patient’s assessment. It has proved useful in recurrent disease and posterior ”Bakers cyst” disease.

2 of the patients had been managed with arthroscopic synovectomy alone, 10 patients have undergone simultaneous arthroscopic synovectomy combined with open excision of any “Bakers cyst” disease.

10 had “open synovectomy”. 3 patients have had radiotherapy .3 patients have had TKR Complications included 3 superficial wound infections, 1 DVT, 1 PE, 1 stress fracture after radical bone curettage, common temporary/refractory stiffness (needing physio/ MUAs). Recurrence was high and managed with repeat arthroscopic synovectomy.

Conclusion PVNS is a rare disorder with typical mono-articular involvement affecting most commonly the knee joint. MRI and biopsy is the gold standard for the establishment of diagnosis and often needs a combined approach with arthroscopic and open posterior cyst excision. Radiotherapy is helpful in aggressive cases. TKR is suggested when there is associated articular erosion. The patient should be warned about the long course of treatment and often multiple procedures because of high recurrence rates.

Rotator cuff pathology is common in orthopaedic patients. However, there are still debates about the best way of treating those patients. We present the clinical experience from our Unit.

We present 85 patients who had arthroscopic or arthroscopically assisted shoulder surgery for full thickness rotator cuff tears between 1994 and 2001. Their medical records and radiological investigations were reviewed, and the management as well as the outcome of their treatment were recorded. The aim was to review those patients and determine if optimum assessment and management was implemented to them.

There were 47 male and 38 female patients with average age 58.8 years and weight 79.9 kg, 32 of the patients reported trauma prior to their symptoms. 63 patients had MRI scan and they had average 2.6 years of symptoms and 2.4 steroid injections before their operative management. 27 patients had arthroscopic and 58 mini open rotator cuff repair. From those with recorded pain management 32 patients had interscalene block and 21 infiltration with local anaesthetic. Their average hospital stay was 1.4 and 1.8 days for the arthroscopic and mini open repairs respectively. In 69 (77.7%) patients the result was considered overall satisfactory; 8 (9.4%) patients had temporary shoulder stiffness and/or pain, which were treated conservatively with steroid injections and physiotherapy. 11 (12.9%) of the patients required reoperation, 5 from which required cuff resuturing and 4 manipulations under anaesthetic for postoperative stiffness. 3 patients (3.5%) had other than shoulder complications including CVA, chest infection, and CTS.

Rotator cuff surgery remains a challenge where often the working surgical plan is altered intraoperatively and tissue quality is of major importance for the final outcome. Arthroscopy has reduced patient’s hospital stay and rehabilitation time. However, a not durable repair, or postoperative stiffness can be a potential risk complicating the surgical result.

In this study it is demonstrated that treatment of patients with rotator cuff disease is still a challenge, time in hospital is reduced with arthroscopic management, but the overall risk for reoperation/MUA either for not durable previous repair or postoperative stiffness was still quite high (12.9%).

Rotator cuff or long head of biceps tendon tears are common in patients with degenerative shoulder rotator cuff disease. Most often they are investigated with an MRI scan. Diagnosis prior to surgery is useful for the appropriate surgical planning.

We present 63 consecutive patients who had arthroscopic shoulder surgery and prior to that had MRI investigation between 1994 and 2001. Their medical records were reviewed; arthroscopic operative findings as well as the report of the MRI scan were recorded and compared retrospectively. The aim of our study was to assess the accuracy of MRI findings comparing the arthroscopic ones regarding rotator cuff and biceps tendon pathology.

There were 63 patients with mean age 58 years. All of these had MRI scan investigation and the waiting time prior to surgery was 10 months. It was found that there were 6 false (−)ve, 1 false (+)ve and two cases with full thickness cuff tears which were reported as probable tears. Further to that, there were 11 frayed biceps tendons, 8 partially ruptured, 3 subluxed, 4 complete ruptures and 1 SLAP lesion. All biceps lesions were not commented in the MRI scan reports.

MRI scan is very sensitive detecting soft tissue pathology in shoulder investigation. However, even on that basis, rotator cuff and in particular biceps tendon pathology can be missed. The shoulder arthroscopy is the best method to accurately diagnose those lesions. However, it should be noted that often the surgeon has got to alter to working surgical plan in order to address the problem intraoperatively.

In this study it is demonstrated the MRI scan often misses rotator cuff or long head of biceps tendon pathology. The most sensitive method for the diagnosis of it is the shoulder arthroscopy, which address its treatment in the same time.

Full thickness defects of articular cartilage have a poor capacity for biological repair and often progress to osteoarthritis. Various surgical techniques have been developed to overcome the inability of chondrocytes to heal injured cartilage. Arthroscopic lavage and debridement offer temporary symptomatic relief whereas marrow-stimulating techniques like drilling, microfracture and abrasion arthroplasty yield poor quality fibro-cartilage that is incapable of withstanding the mechanical stresses to which healthy articular cartilage is subjected.

We present our experience using the osteochondral graft transfer technique in the treatment of isolated Outerbridge grade 4 lesions of the knee. The study includes nineteen patients with a mean age of 29 years (range 17 to 40) presenting with symptomatic lesions of the knee with a mean defect size of 2.4cm (0.8 to 6). At a mean follow-up of 20 months (6 to 40) our results showed a significant improvement in patient function by a mean of 46 points or a 23% mean improvement as assessed by the Knee Society Score (P< 0.0001; One sample t-test). Similarly there was significant improvement in the Brittberg scores with a mean improvement by 2 clinical grades (p< 0.0001; Wilcoxon Rank test). Quality of life scores as measured by the Short Form 36 were dramatically improved by a mean of 24 points (p< 0.0001; Wilcoxon Rank test). In addition, there was significant reduction in pain post-operatively (p< 0.0001; Wilcoxon Rank test) with patients describing a mean improvement of 6 points as measured on the visual analogue chart. A significant number of patients (84.2%) were able to return to active sporting levels by 6 months (p< 0.0001;McNemar Change test).

The results of the osteochondral graft transfer technique, at relatively short-term follow-up, are encouraging with a high percentage of subjective satisfaction. This procedure proved to be a reliable and valid solution for treating isolated osteochondral defects of the knee, providing functional and durable cartilage that is critical to joint function.

We treated 39 knees with chronic deficiency of the anterior cruciate ligament by reconstruction using the ABC carbon and polyester prosthetic ligament; 31 (79.5%) were reviewed at an average follow-up of 34 months. There had been four complete failures requiring revision. The remaining 27 were studied in detail. On the Lysholm rating, only 11 knees (41%) had good results with a score of over 76. The mean anterior drawer movement was reduced from 7.6 mm before operation to 5.8 mm at review. The mean difference from the opposite uninjured knee was 3.9 mm before operation, 1 mm (in 21 patients) at mean follow-up of 7.4 months and 2.5 mm (in 27 patients) at 34 months, indicating progressive loss of effect. In our opinion the results are unsatisfactory: we do not recommend the use of this prosthetic ligament.