Background

Anterior Cruciate Ligament Reconstruction is a commonly performed orthopaedic operation. The use of a four-strand semitendinosus and gracilis hamstring graft (STG) is a well established method of reconstruction to restore knee stability.

Anterior cruciate ligament (ACL) reconstruction is a commonly performed operation. A variety of graft options are used with the most popular being bone-patellar-tendon-bone and hamstring autograft. There has been an increase in the popularity of hamstring autograft over the past decade.

The aim of the study was to assess the ten year subjective knee function and activity level following four-strand semitendinosis and gracilis (STG) anterior cruciate ligament reconstruction.

86 patients underwent anterior cruciate reconstruction by two knee surgeons over a 12 month period (January 1999 to December 1999). 80 patients meet the inclusion criteria of arthroscopic ACL reconstruction. The same surgical technique was used by both surgeons involving four-strand STG autograft, single femoral and tibial tunnels and aperture graft fixation with the Round headed Cannulated Interference (RCI) screw. Patient evaluation was by completion of a Lysholm Knee Score and Tegner Activity Level Scale at a minimum of ten years from reconstructive surgery. This was by initial postal questionnaire and subsequent telephone follow-up.

80 patients underwent anterior cruciate reconstruction with average age 30.9 years (15 to 58 years). There was a 77.5% (62 patients) response at ten years to the questionnaire.

The median Lysholm Knee Score at ten years was 94 (52 to 100). The median activity level had decreased from 9 to 5 at ten years according to the Tegner Activity Scale. 73% of patients reported a good or excellent outcome on the Lysholm score. The group of patients was further divided into those that required meniscal surgery and those that did not. The patients that did not require meniscal surgery had a median Lysholm score of 94 and those that required meniscal surgery had a similar median Lysholm score of 92.5. However it was noted that 8 patients required medial and lateral partial menisectomies at the time of original reconstruction. This group of patients had a median Lysholm Knee Score of 83.5 and Tegner Activity Scale of 4 at ten years following reconstruction. 17 of the 62 patients (27.4%) required re-operation because of further knee symptoms, with 4 patients requiring revision of the anterior cruciate following re-rupture.

In conclusion anterior cruciate ligament reconstruction with four-strand STG hamstring autograft provides a reliable method of restoring knee function, with a 6% revision rate for re-rupture at ten years. Combined partial medial and lateral menisectomy at the time of the initial reconstruction is a poor prognostic indicator of function at ten years.

Purpose

To study the initial presentation and subsequent investigation and management of acute knee dislocations at a regional trauma centre.

Study Design: Retrospective case review.

Objective: To assess factors influencing functional outcome, recurrence and survival following surgery for intradural spinal tumours

Subjects: Between January 1994 and December 2001, 115 patients had surgery for intradural spinal tumours: 76 extramedullary (48 male, mean age 54 years): 39 intramedullary (22 male, mean age 44 years).

Outcome measures and analysis: Functional outcome: Frankel scale. Recurrence: new symptoms with tumour growth. Death: post-operative or disease progression. Univariate and multivariate analysis was performed to identify features predicting post-operative functionally useful Frankel scale (4–5), recurrence and survival.

Results: 64 extramedullary tumours were excised, 12 debulked. 21 intramedullary tumours were excised, 13 debulked, 5 biopsied. Commonest tumours: meningioma, schwannoma, ependymoma, astrocytoma. 14 intramedullary tumours received radiotherapy. Mean follow-up was 45 months (range 4–117 months). There were 12 recurrent tumours. There were 8 deaths (2 post-operative, 6 disease-progression). 23% had complications (CSF leak, meningitis, wound infection/dehiscence). Functionally 96% of extramedullary tumours were unchanged/improved, 82% of intramedullary tumours were unchanged/improved. Multivariate analysis demonstrated that recurrence (Odds Ratio 28.2; 95% Confidence Interval 2.3–342.4) was the only significant factor influencing survival for intramedullary tumours. No factors investigated predicted functional outcome or recurrence in intramedullary tumours. No factors predicted any outcome in extramedullary tumours.

Conclusions: Our results were comparable to other studies. The two cases of MRSA meningitis (one death, one paralysis) reflect the growing problem of MRSA in neurosurgical units. Recurrence predicted poor survival in intramedullary tumours.

This study investigated the rapid progression of osteoarthritis of the hip in elderly females, taking into account their symptoms, the clinical signs and the radiological, MRI and histological findings.

Early radiographs are often non-contributory, which can lead to inappropriate further investigations and treatment, such as lumbar spine imaging and surgery. MRI and histological findings lead me to believe that patients’ dramatic deterioration may be due to segmental avascular necrosis of the femoral head, with osteo-cartilaginous detachment.

When a patient with hip symptoms and signs has normal radiographs, one should be aware of this condition.

This study investigated the rapid progression of osteoarthritis of the hip in elderly females, taking into account their symptoms, the clinical signs and the radiological, MRI and histological findings.

Early radiographs are often non-contributory, which can lead to inappropriate further investigations and treatment, such as lumbar spine imaging and surgery. MRI and histological findings lead me to believe that patients’ dramatic deterioration may be due to segmental avascular necrosis of the femoral head, with osteo-cartilaginous detachment.

When a patient with hip symptoms and signs has normal radiographs, one should be aware of this condition.

We retrospectively audited outcomes from 97 patients aged over 40 who had undergone arthroscopy in the last 4 years in this orthopaedic unit. The audit was carried out by way of questionnaires which were sent out to patients with the results inputted to a database combined with a review of patients charts, in particular the operative note from the arthroscopy. A standardised proforma was used to record both patient’s details and operative findings.

The questionnaires were sent out to 165 patients. Of that number 102 were returned, five of which were excluded due to inadequate information.

The average wait for surgery was 10 months and 6 patients noticed an improvement in symptoms while waiting for surgery. 80% of those waiting less than 1 year experienced an improvement compared to 73% of those waiting more than 1 year. The results showed that post-operative symptoms in 74 out of the 97 (77%) patients were improved, 12 (12%) remained unchanged with 11 (11%) experiencing a worsening in symptoms.

The age group 60+ had the best outcomes with 23 out of 26 (89%) experiencing some improvement in symptoms; males also experienced a better outcome with 51 out of 63 (81 %) achieving some improvement, compared to females where only 23 out of 34 (67%) showed improvement.

We did not have routine access to an MRI scanner so only 23 of the patients had a pre-operative scan. We have insufficient numbers to comment on the accuracy or otherwise of positive MRI findings.

Pre-operative symptoms of pain, swelling, locking and instability were recorded and their correlation to successful outcome analysed. This showed that the presence of these symptoms did not predict a post-operative improvement in symptoms as an equal number of those with any of these symptoms compared to those without derived benefit from the procedure. This finding is significant in that these symptoms are commonly used in clinical practice to predict the likely benefit from arthroscopy.

A pre-operative history of locking was a specific predictive symptom for meniscal injury in that 27 out of 33 (82%) patients with true locking as a symptom had a meniscal injury but only 27 out of 58 (47%) patients with a meniscal injury experienced locking as a symptom implying that it is not a sensitive indicator of meniscal damage.

We also enquired about the presence of a definite acute injury associated with the onset of symptoms. This also had no predictive value as to the potential benefit of surgery.

A significant negative from the study was the fact that a history of an acute injury gave no indication as to the presence of a meniscal injury and even if a meniscal injury was present the patient’s outcomes were not significantly better than if no injury was present.

In conclusion 77% of patients aged 40+ derived benefit from arthroscopy, possibly due to the effects of washing out the knee rather than any active intervention. A history of locking, pain swelling or an acute injury did not offer an accurate prediction of benefit from arthroscopy, therefore the elderly and those without a history of locking or acute injury should not be dissuaded from undergoing this procedure. This study is confined to those over 40 years of age and the findings are quite different to the findings in younger patients. These findings surprised the surgeons at our unit and therefore we feel may be an interesting and stimulating presentation at the B.A.S.K. meeting.

Combined bony and vascular injuries present challenging problems to orthopaedic and vascular surgeons. The use of temporary intraluminal vascular shunts produces significant reductions in ischaemia time and allows fracture stabilisation to be performed before definitive, delicate vascular repair. We report our management of a five-week-old infant who sustained a comminuted fracture of the femur with arterial and venous injuries in a shooting incident. Paediatric nasogastric feeding tubes were used as temporary vascular shunts to re-establish the distal circulation. Stabilisation of the fracture was then followed by vascular reconstruction and soft-tissue surgery, with a good result. We emphasise the need for skills from several surgical disciplines in the management of complex combined injuries.

We cultured human osteoblasts from trabecular bone explants and confirmed their phenotype by alkaline phosphatase assay, increased cyclic adenosine monophosphate production in response to prostaglandin E2 and radiographic micro-analysis of nodules of calcification. The osteoblasts were seeded on to demineralised human bone fragments and examined at ten-day intervals over a 50-day period by scanning electron microscopy. During this time the bank bone became progressively repopulated by the cultured osteoblasts. This system may offer a means of graft enhancement in elective orthopaedic and maxillofacial surgery by delivery of cultured autologous human osteoblasts to bone defects.

We performed 20 de la Caffiniere trapeziometacarpal arthroplasties for osteoarthritis occurring only at this joint and reviewed all patients after periods of up to ten years. Eighteen arthroplasties were satisfactory postoperatively, although all 20 patients had a satisfactory range of motion and only one experienced pain after surgery such that it impeded normal function. Failure occurred in two patients and was due to overreaming of the trapezium during surgery and a traumatic dislocation. A radiolucency between the prosthesis and bone was observed in one arthroplasty, although this patient was asymptomatic. We recommend arthroplasty using the de la Caffiniere prosthesis as a satisfactory method of treatment for the osteoarthritic trapeziometacarpal joint.

Augmentation of the acetabular component of total hip replacements is a method of increasing stability and preventing recurrent dislocation. We report a series of mechanical experiments designed to evaluate the turning moments and angles required to dislocate standard, long posterior wall and two different augmented prostheses.