1. Thirty-nine patients with rheumatoid arthritis who had had a MacIntosh tibial plateau hemiarthroplasty are reviewed. 2. From the clinical findings it is possible to suggest a basis for the selection of suitable patients for the procedure. 3. Eighty-five per cent of the patients obtained relief of pain with good function of the knee. 4. The complications were infection and instability of the prosthesis

Two cases of laterally open knee joints with surrounding skin defects are reported. The joints were closed by muscle flaps fashioned from the lateral belly of the gastrocnemius, which was detached distally and folded upwards and forwards to cover the defect. The transposed muscle and the remainder of the wound were covered by free skin grafts. Results were satisfactory

1. Fifty knees affected by rheumatoid arthritis were studied in detail at synovectomy. 2. The destructive lesions found were relatively constant and are described in detail. 3. Cartilage lesions were much more common than was expected radiologically. 4. The pattern described suggests that articular cartilage is destroyed by contact with diseased synovial membrane but protected by contact with another cartilaginous surface

We describe a new method of reconstruction after resection of tumours of the proximal tibia by grafting and arthrodesis of the knee. Two separate vascularised bone grafts from the ipsilateral limb were used, one a gastrocnemius-pedicled femoral graft and the other a pedicled fibular graft. An anatomical study of the gastrocnemius-pedicled femoral graft was made. The method was shown to be practical and reproducible. One patient with osteosarcoma has a successful result with no recurrence at two-and-a-half years

Forty-five patients with fractures of the tibial spine were reviewed 3 to 10 years after injury in order to determine the degree of residual laxity of the cruciate or collateral ligaments. After fractures which had been partially or completely displaced, some anterior cruciate laxity was evident, even if patients were asymptomatic. It was also found that an anatomical reduction did not prevent either laxity or some loss of full extension of the knee

We studied 19 videotaped knee arthroscopies in 19 patients with mild to moderate osteoarthritis (OA) of the knee in order to compare the intraobserver and interobserver reliability and the patterns of disagreement between four orthopaedic surgeons. The classifications of OA of Collins, Outerbridge and the French Society of Arthroscopy were used. Intraobserver and interobserver agreements using kappa measures were 0.42 to 0.66 and 0.43 to 0.49, respectively. Only 6% to 8% of paired intraobserver classifications differed by more than one category. Observer-specific disagreement was evident both within and between observers. A small, but significant, occasional variation was also seen. Although reliability may improve by an analysis of disagreement, it appears that the arthroscopic grading of early osteoarthritic lesions is inexact

We evaluated the accuracy of six clinical tests for posterior instability in 24 knees with acute surgically-proven posterior cruciate ligament injuries and intact anterior cruciate ligaments. We also performed stress radiography under anaesthesia. The gravity sign and the posterior drawer test in near extension and its passive reduction were diagnostic in 20 of the 24 knees, and the active reduction of posterior subluxation was diagnostic in 18. The reversed pivot shift sign helped to diagnose severe posterior and posterolateral subluxations, but the external rotation recurvatum test was negative in all 24 knees. Stress radiography in near extension revealed a highly significant increase in posterior tibial subluxation in the injured knees

1. In sixty mature rabbits osteochondral fractures of various types were made in the medial femoral condyle. 2. The fractures or fragments which remained stable united but those in which movement occurred progressed to non-union. 3. An ununited osteochondral fragment resembled osteochondritis dissecans in the human both radiologically and histologically. 4. Experiments in the cadaveric knee show that the patella articulates with the classical site on the intercondylar aspect of the medial femoral condyle in full flexion of the joint and here an osteochondral fracture could be sustained. 5. It is concluded that the fragment in osteochondritis dissecans follows an osteochondral fracture which remains ununited

We describe a new method for the reconstruction of ruptures of the patellar ligament or the quadriceps tendon, using the flexible open-weave polyester Leeds-Keio prosthetic ligament. Of 25 operations performed since 1985, we were able to review 18 patients (19 knees) with a mean follow-up of 3.5 years (3 to 6.5). No patient had required immobilisation of the knee after operation and the average period to return to normal activities without a walking aid was 10.5 weeks. The average range of motion was 146 degrees, and four patients could squat fully in the Japanese style. There was an extension lag (< 10 degrees) in only four patients; eight patients had some patellar crepitus which was mildly painful in three. There were no cases of infection, persistent joint effusion or rerupture of the extensor apparatus

The administration of intra-articular local anaesthetic is common following arthroscopy of the knee. However, recent evidence has suggested that bupivacaine may be harmful to articular cartilage. This study aimed to establish whether infiltration of bupivacaine around the portals is as effective as intra-articular injection. We randomised 137 patients to receive either 20 ml 0.5% bupivacaine introduced into the joint (group 1) or 20 ml 0.5% bupivacaine infiltrated only around the portals (group 2) following arthroscopy. A visual analogue scale was administered one hour post-operatively to assess pain relief. Both patients and observers were blinded to the treatment group. A power calculation was performed. The mean visual analogue score was 3.24 (. sd. 2.20) in group I and 3.04 (. sd. 2.31) in group 2. This difference was not statistically significant (p = 0.62). Infiltration of bupivacaine around the portals had an equivalent effect on pain scores at one hour, and we would therefore recommend this technique to avoid the possible chondrotoxic effect of intra-articular bupivacaine

Of 34 consecutive proximal tibial osteotomies for secondary degenerative arthritis in patients under 40 years of age, 33 were evaluated at least three years (mean 7.5 years) after operation. In all 73% were satisfactory, with four failures in 21 procedures in men and five failures in 12 procedures in women. The primary abnormalities were medial meniscectomy (11), medial and lateral meniscectomy (4), osteochondritis dissecans (3), osteochondritis dissecans with medial meniscectomy (4) and fracture (11). All four knees with both medial and lateral meniscectomy had unsatisfactory results despite obtaining anatomical alignment. Eight patients needed subsequent surgery; five of them had total knee replacement, four within four years of the osteotomy. Proximal tibial osteotomy in younger patients with secondary arthritis gives similar results to those for older patients with primary osteoarthritis. If it fails, this is generally within the first four years after the operation

We report a prospective study of gait and tibial component migration in 45 patients with osteoarthritis treated by total knee arthroplasty (TKA). Migration was measured over two years using roentgen stereophotogrammetry. We used the previously established threshold of 200 μm migration in the second postoperative year to distinguish two groups: a risk group of 15 patients and a stable group of 28 patients. We performed gait analysis before operation and at six months and at two years after TKA. On all three occasions we found significant differences between the two groups in the mean sagittal plane moments of the knee joint. The risk group walked with higher peak flexion moments than the stable group. The two groups were not discriminated by any clinical or radiological criteria or other gait characteristics. The relationship which we have found between gait with increased flexion moments and risk of tibial component loosening warrants further study as regards the aetiology of prosthetic loosening and possible methods of influencing its incidence

We report a prospective, randomised, controlled trial of the effect of either a non-steroidal anti-inflammatory drug (diclofenac sodium) or physiotherapy on the recovery of knee function after arthroscopy. At 42 days after surgery there was no significant benefit from either form of postoperative treatment compared with the control group. Complications attributable to the anti-inflammatory drug occurred in 9.6% of the patients so treated. Neither the routine administration of a non-steroidal anti-inflammatory agent nor routine physiotherapy is justified after arthroscopy of the knee

Rupture of a ligament usually occurs along a definite line, but is associated with considerable intrinsic damage to the remote parts of the ligament. In spite of this, healing occurs by regeneration of regular collagen to form a new ligament with good tensile strength, provided the ends of the torn ligament are in reasonable apposition, and provided the blood supply is adequate. When lateral instability of the knee after a recent injury suggests that a collateral ligament has been ruptured, wide displacement of the torn ends should be suspected. Accurate replacement can be guaranteed only by surgical intervention; operative repair therefore seems to be justifiable on anatomical grounds. If operation is contemplated it should be undertaken within the first week after injury when it is easy to achieve accurate repair, which later becomes impossible because of shrinkage and friability of the tissue. In order to preserve blood supply, the areolar covering should be disturbed as little as possible, and the least possible amount of fine suture material should be used to anchor the torn ends in position. Nevertheless when the tear involves the upper attachment, ischaemia of the damaged ligament may prevent normal healing, whatever the treatment adopted

A description is given of a direct approach to the lateral compartment of the knee with the joint fully flexed. This approach has been found useful for excision of cysts of the lateral cartilage, but is also applicable to excision of the lateral cartilage for tear

Twenty-one patients with leg-length inequality underwent femoral lengthening using the Wagner technique. When reviewed, seven were found to have varying degrees of posterior subluxation of the knee. Critical assessment demonstrated that each of these was associated with a hypoplastic femur. It is postulated that posterior displacement of the tibia on the femur occurred as a result of the distal femoral and intraarticular bony deficiencies

We have performed a prospective, single-surgeon study analysing the histological results of autologous chondrocyte implantation. Fourteen patients underwent autologous chondrocyte implantation of the knee and were evaluated at one year by clinical assessment and arthroscopy. Standard staining was used to examine the sections. In addition, in situ hybridisation was used to establish type-IIa and type-IIb collagen mRNA expression and immunolocalisation techniques demonstrated the positions of type-II and type-X collagen. Eight patients regenerated hyaline cartilage and also contained type-X collagen in the deepest layers and type-II collagen in the deep layers. Three demonstrated fibrocartilage and had type-II collagen in the deep layers. In situ hybridisation revealed that all 14 samples had the potential to express both type-IIa and type-IIb collagen. We have shown that one year after the initial implantation chondrocytes are capable of producing type-II collagen and that they continue to proliferate and mature

Subtotal synovectomy was performed in the knee joints of New Zealand white rabbits. The changes noted in the articular cartilage as manifest by decreased metachromatic staining of the matrix were considered to indicate matrix degradation caused by the altered joint environment. The documentation of the enzyme changes suggests that the histological alteration in the articular cartilage noted after synovectomy may be mediated through the activation of endogenous chondrocyte lysozomal enzymes, particularly cathepsin and acid hydrolases

We compared fibrin sealant, polydioxanone (PDS) pins and Kirschner wires in the fixation of osteochondral fractures in rabbit knees. Standardised osteochondral fractures of the right medial femoral condyle were made in 56 adult New Zealand white rabbits. There were equal groups of control knees, and those which had Kirschner-wire, fibrin-sealant or PDS-pin fixation. No external immobilisation was used. One animal from each group was killed at two, three and four weeks. The remaining rabbits were killed at six weeks. A fracture which healed with less than 1 mm of displacement was considered a success. There was successful healing in 29% of the control group, in all of the Kirschner-wire group, in 50% of the fibrin-sealant group, and in 86% of the PDS-pin group. The use of PDS pins appears to be a reliable alternative to the use of metal in the fixation of osteochondral fractures in rabbits

We carried out a prospective study in order to establish to what extent the intra-articular evaluation undertaken during arthroscopy of the knee differed between surgeons. Two senior specialist registrars and a consultant orthopaedic surgeon with a special interest in knee surgery were involved. A total of 78 knee arthroscopies (78 patients) was studied. Arthroscopy was first carried out by the trainee and then by the senior author (ACWH). The intra-articular evaluation during the arthroscopy was recorded independently by a third person in the operating theatre. Data were collected to record variations in examination under anaesthesia, the morphology and pathology of the menisci and anterior cruciate ligament and the state of the articular surfaces. The overall interobserver variation was 20% in all categories. We question the published results of intra-articular evaluation during knee arthroscopy when surgeons of different levels of experience are involved in a single study