The aim of this study was to compare the efficacy of a hyaluronic acid (HA) supplement and a local anaesthetic (Bupivacaine) at providing early and short-term post-operative anagesic control following knee arthroscopy.

Patients were randomised to receive either 10mls of 0.5% Bupivacaine or 10mls of HA into the joint immediately after completion of surgery. WOMAC and Tegner-Lysholm scores were obtained at baseline then at 1, 2, and 6-weeks post surgery. VAS pain scores were obtained at baseline; 1 and 24-hours; and 1, 2 and 6 weeks following surgery.

49 patients received intra-articular Bupivacaine and 49 HA. There was no statistical difference in any of the outcome measures (WOMAC, Tegner-Lysholm, VAS pain scores) at any time point between the groups overall. Patients with grade III-IV chondral defects that received HA reported significantly lower VAS pain scores at rest and movement at all time points.

Use of Bupivacaine and HA intra-articular injection results in equivalent analgesic control in the immediate post-operative period and first six-weeks following surgery when administered immediately at the end of knee arthroscopy. Utilizing HA following knee arthroscopy does not sacrifice analgesic control and minimises exposure to chondrotoxic agents. Selective use of HA may improve pain-control in those with advanced chondral defects.

We reviewed a single-surgeon series of 300 athletic patients who had undergone reconstruction of the anterior cruciate ligament in order to establish the relationship between the timing of the reconstruction and the incidence of meniscal and chondral pathology. The patients were divided into five groups according to the time from their injury to surgery as follows: less than two months, two to six months, six to 12 months, 12 to 18 months and more than 18 months. The presence of meniscal tears was recorded and chondral pathology was scored according to the system of the French Society of Arthroscopy.

There was a significantly higher chance of a medial meniscal tear occurring in patients undergoing reconstruction after one year from their injury (odds ratio (7.99, p = 0.004). The odds of having a lateral meniscal tear did not change significantly with an increasing interval to reconstruction. The chance of patients developing degenerative changes was found to be significantly higher in the groups operated on after six months from injury (odds ratio 4.04, p = 0.005).

We advocate that patients with deficiency of the anterior cruciate ligament should be counselled that there is a significant relationship between the duration of the instability of their knee and the subsequent incidence of both chondral changes and meniscal tears. In order to minimise these risks, we recommend that reconstruction be performed within the first year from injury.

Graft choices for revision anterior cruciate ligament (ACL) reconstruction and complex ligament reconstructions of the knee are controversial. The aim of our study was to analyze the biomechanical effect of harvesting bone plugs from both the distal and proximal poles of the patella, to simulate a simultaneous harvesting of a Bone – Patellar Tendon – Bone and Quadriceps Tendon – Bone grafts, in a transverse stress environment.

Sixty Bovine Patellae were analysed. They were divided into 4 groups – based on the residual bone bridge (percentage of total length of patella) remaining after bone plug resection. 0 – 10%, 11 – 20%, 21 – 30% and > 30%. All patellae were tested in a modified 4 – point bending environment, to a maximum load of 10,000N, in a customized designed jig. This method simulates the axial bending stress on the patella during knee flexion. All dimensions of the patellae were recorded including Depth of patella at bone resection and wall thickness adjacent to plug resection site.

All patellae with a 0% bone bridge fractured (Ultimate Tensile Strength/UTS) at a mean Tensile Force of 5863N (Range 3140 – 8730N). There was a subgroup of incomplete fractures – extra-articular fractures – which fractured at 6542N (Range 5085 – 9180N). The remaining specimens failed to fracture. Comparing the UTS and the patellar dimensions, using Weibull’s Statistical Analysis we demonstrated that less than 60% bone plug resection carried a very low probability of fracture.

This study demonstrates the safe criteria for bone – tendon graft harvesting from both the proximal and distal poles of the patella. With regards to a normal human patella, a 40% bone – bridge is approximately a 20mm bone – bridge. We conclude that the simultaneous harvesting of Bone – Patellar Tendon – Bone and Quadriceps Tendon – bone grafts from a patella has no significant increase in the fracture risk of the patella.

Introduction: Reconstruction of ruptured anterior cruciate ligament is a commonly performed orthopaedic procedure. There are many ways of reconstructing this ligament. One method of doing so is to harvest a tendon graft from the hamstring muscles and use it as part of the reconstruction. The tendon is usually harvested by passing a tendon stripper along the length of the tendon from an anterior knee incision. The semitendinosus and the gracilis are the hamstring muscles whose tendons are used for this. A recent case study reported injury to the sciatic nerve during the harvest of semitendinosus graft. Although morbidity arising from iatrogenic injury to nerves at the anterior aspect of the knee has been well documented, little has been written about the relationship of the sciatic nerve to the semitendinosus and gracilis in the posterior thigh. This study proposes to look at this anatomical relationship.

Method: 20 legs on ten cadavers underwent the same dissection to expose the semitendinosus tendon, gracilis tendon and the sciatic nerve while maintaining their anatomical relationships. In all cases the gracilis lay further away from the sciatic nerve than the semiten-dinosus tendon. As the semitendinosus tendon was in between the semitendinosus and the sciatic nerve in all instances it was decided not to measure the distance between gracilis and the sciatic nerve. The distance between the closest point of the sciatic nerve to the tendon of semitendinosus was measured at the joint line and at intervals of 20 mm from the joint line.

Results: In 45 % of the subjects the sciatic nerve and the semitendinosus tendon gradually moved further apart as the measurements were taken more proximally in the leg. In 10 % they consistently moved apart from 6 cm from the joint line onwards. In another 10% they moved consistently apart from the 8cm from the joint line measurement and in 15 % they moved apart consistently from 12 cm from the joint line. In the remaining 20 % the sciatic nerve and the semitendinosus tendon did not consistently move apart from each other until after 14 cm from the joint line. In one subject (a female of small stature) it was noted that the semitendinosus muscle lay almost directly upon the sciatic nerve. In 6 subjects the minimum distance between the sciatic nerve and the semitendinosus tendon was less than 18mm. In one subject the distance between the sciatic nerve and the semitendinosus tendon was found to be 10 mm at the closest point and remained in close proximity for a further 4 cm.

Conclusion: In 55 % of our patients the sciatic nerve did not consistently move further away from the semi-tendinosus tendon as it was measured more proximally. In some subjects the minimum distance between the nerve and the tendon was less than 2 cm. Both these facts would put the sciatic nerve at risk during tendon harvesting if the tendon stripper were to move outside of the tendon during the procedure.

Introduction: Anterior knee pain is a commonly encountered orthopaedic symptom. Textbooks list a number of clinical symptoms and physical signs that are specific for the PF joint in the assessment of the patient with knee pain. Radiological evaluation of the PF joint is rarely helpful. The authors have investigated the value of these symptoms and signs in predicting the presence of PF pathology.

Patients and Methods: All patients presenting for diagnostic knee arthroscopy were enrolled prospectively. A detailed proforma was completed with each patient pre-operatively recording the presence or absence of specific PF symptoms and clinical signs. A blinded independent observer recorded the operative findings of the PF joint, the presence / absence of a plica and / or anterior synovitis. Chondromalacia (CM) was graded using the Outerbridge classification and grade 2 or greater was considered a positive finding.

Pre-operative symptoms and signs were correlated with arthroscopic findings and their positive predictive value (PPV) was determined.

Results: Thirty patients were enrolled over a 2-month period. Pure anterior knee pain was present in 10 patients. The remainder had medial (15), lateral (2) or generalised pain (3). 20 of the thirty patients had degenerative changes in the PF joint. One patient had a plica and no patients had significant anterior synovitis. 20 of the 30 patients had pathological findings elsewhere in their joint.

In the prediction of PF degenerative changes, the PPV of symptoms exacerbated by squatting was 0.53; stairs – 0.55; kneeling – 0.57; rising from low chair – 0.6 and night pain – 0.5.

Analysis of specific signs in predicting PF changes showed that the PPV of PF crepitus was 0.5; pain exacerbated by patellar compression 0.6; and patellar facet compression was 0.62.

Conclusion: Degenerative changes of the PF joint are common in our patient population. The value of knee arthroscopy in patients with isolated PF symptoms is questionable. Our assessment of these patients with specific questions and physical signs has been shown to have a low PPV in predicting ultimate arthroscopic findings in the PF joint.