We describe 129 patients with disabling instability of the knee due to deficiency of the anterior cruciate ligament. They were treated by replacement of the ligament with a Leeds-Keio prosthesis supplemented by an extra-articular MacIntosh lateral substitution reconstruction. After an average period of 71 months a satisfactory outcome was found in only 60% of knees. Nine had required revision because of recurrent instability and the pivot-shift sign had become positive in 40% of patients. In our opinion the long-term results are unsatisfactory when compared with those obtained using a graft from the medial third of the patellar tendon supplemented with a MacIntosh extra-articular tenodesis.

We studied changes in patellar tendon length after reconstruction of the anterior cruciate ligament using either the medial third of the patellar tendon as a graft (n = 40) or a Leeds-Keio artificial ligament (n = 40). Both types of ligament replacement had been supplemented with a MacIntosh extra-articular lateral substitution. The mean change in length in the tendon graft group was 6% (SD 5.39); in the Leeds-Keio group it was 2.4% (SD 4.93). The change in length was significant in both groups, but shortening was more frequent and more severe in the tendon graft group. There was shortening of 10% or more in 25% of knees after patellar tendon graft and 7.5% after use of a Leeds-Keio prosthesis.

We measured on the radiographs of 100 knees the length of the patellar ligament and the anterior cruciate ligament, and the distance between the tibial tubercle and the femoral insertion of the anterior cruciate. The length of the patellar ligament was always greater than that of the anterior cruciate ligament, but shorter than the distance between the tibial tubercle and the femoral insertion of the anterior cruciate by a mean of 14.2 mm (3 to 22). We conclude that anatomical, isometric replacement of the anterior cruciate is possible using a free graft, but not by the technique of retaining the tibial attachment originally described by Jones (1970).

We describe 74 patients with disabling instability of the knee due to isolated anterior cruciate deficiency. None responded to conservative measures or correction of internal derangements. All patients were treated by replacement of the anterior cruciate ligament with the medial third of the patellar tendon as a free graft, supplemented by an extra-articular MacIntosh lateral reconstruction. A satisfactory outcome was found in 93% of knees after an average of 70 months follow-up. Cast immobilisation after operation, the interval between injury and reconstruction, the age of the patient and the severity of symptoms before reconstruction had no significant effect on the final outcome.

Nine pedunculated benign synoviomata causing mechanical symptoms similar to those of a torn meniscus are described. The average age of the patients was 34.4 years. During the period of study, 2254 meniscal lesions causing mechanical symptoms were identified, giving an incidence of one benign synovioma for every 250 meniscal lesions. All the lesions were removed arthroscopically with relief of symptoms.

The anatomy of 1000 symptomatic meniscus lesions is described and related to the age of the patients. All symptomatic lesions found during the study period were treated by arthroscopic surgery. Meniscal lesions were commoner in the right knee (56.5%) and 81% of the patients were men. Of the medial meniscus tears, 75% were vertical and 23% horizontal. Vertical tears of the medial meniscus occurred most often in the fourth decade and horizontal tears in the fifth. There were 22% type I, 37% type II and 31% type III vertical tears; 62% of type I tears and 23% of type II tears had locked fragments. Superior flaps were six times more common than inferior flaps. Of all medial meniscus fragments, 6% were inverted; 51% of these were flaps and the rest ruptured bucket-handle fragments. Of the lateral meniscus lesions 54% were vertical tears, 15% oblique, 15% myxoid, 4% were inverted and 5% were lesions of discoid menisci. The commonest pattern of tear in the lateral compartment (27%) was a vertical tear involving half the length and half the width of the meniscus.

We report the arthroscopic drilling of classical lesions of osteochondritis dissecans in 11 knees in 10 children with at least six months history and no sign of clinical or radiological improvement. There were eight boys and two girls and the average age at operation was 12 years 11 months. Relief of pain was noticed within days of operation; radiological healing occurred within 12 months in nine of the 11 knees.

We report the results of arthroscopic removal of loose bodies and abnormal synovium from 18 knees with primary synovial chondromatosis. After a mean of three years, six months (range one to 10 years), 14 knees were either symptom-free or had only minor symptoms. Three of these had required two arthroscopic operations. Three patients were improved but not cured and there was one failure. The results were better than the published results of open operation for this condition. Three patterns of macroscopic appearances were noted: four knees had large lesions covered by normal synovium, 10 had small fragments of cartilage lying in or on the synovium and four had only free fragments of cartilage in the joint cavity but none in, on, or under, the synovium. These three appearances may represent three different disease processes.

We reviewed lesions of the femoral condyles seen in 5,000 knee arthroscopies, recording the findings and the age and sex of the patients. We were able to distinguish the characteristics of developing and late osteochondritis dissecans, acute and old osteochondral fractures, chondral separations, chondral flaps and idiopathic osteonecrosis, and suggest that these are separate distinct conditions. Haemarthrosis was associated only with acute osteochondral fractures. The characteristic feature of osteochondritis dissecans was an expanding concentric lesion at the 'classical' site on the medial femoral condyle which appeared during the second decade of life and progressed to a concave steep-sided defect in the mature skeleton. Caffey's (1958) classification of epiphyseal dysplasias could not be applied to osteochondritis dissecans, which appeared to have a gradual onset without acute trauma. Much of the controversy about the cause of osteochondritis dissecans is the result of imprecise nomenclature.

We report two patients with permanent dislocation of the proximal tibiofibular joint and no history of trauma. Both needed operation, one for persistent pain and the other for common peroneal nerve involvement, and both had a good result.

We reviewed 41 knees after arthroscopic lateral release for recurrent dislocation of the patella at a mean follow-up of four years, and graded the results according to the criteria of Crosby and Insall (1976). There were no dislocations after operation in 28 knees (68%); the less satisfactory results were in patients with subluxation of the patella on extension of the knee and those with generalised ligamentous laxity. There were no complications. A characteristic and previously unreported lesion of the patellar surface was seen in eight of the 41 knees. The results of lateral release are better than those reported for other techniques. This treatment, by either open or arthroscopic methods, is recommended.

We examined the menisci in 47 patients at the time of anterior cruciate ligament reconstruction. Twenty-one patients had abnormal menisci at a mean of 34 months after injury, but there was no difference between the Lysholm scores of patients with intact or damaged menisci. Eleven patients had a new meniscal injury between reconstruction and review at a mean of six years later; only 15 patients had both menisci intact nine years after injury. If pivot shift had been cured, the incidence of meniscal injury was reduced, but remained higher than normal. If pivot shift returned after reconstruction there was a significantly higher incidence of meniscal injury. Meniscal lesions appear to be the result of instability and not the cause.

Forty-seven patients with disabling instability due to isolated anterior cruciate deficiency are described. None had responded to conservative measures or to attempted correction of internal derangements. Eighteen patients were treated by extra-articular MacIntosh lateral substitution alone, the other 29 were treated by the same procedure combined with carbon-fibre replacement of the anterior cruciate ligament. No statistically significant difference was found between the two groups at six years. A satisfactory outcome was found in 44% of the extra-articular group and 55% of the carbon-fibre group at last review; however, the latter group had more complications. There was a marked deterioration in the quality of results between three and six years in both groups.

Seventy-six knees with fracture-separations of articular cartilage are described. The lesion involved the full thickness of the articular surface with exposed subchondral bone in 28 knees and only part of the thickness in 48. The clinical features and distribution of the lesions within the knee are described.

The results of three different types of meniscectomy have been compared in 219 knees, 71 treated by arthroscopic partial meniscectomy, 45 treated by open partial meniscectomy, and 103 treated by open total meniscectomy, with a mean follow-up of 4.3 years. Knees which had undergone previous operations or had other simultaneous operative procedures or ligamentous damage were excluded. Knees with chondromalacia were included provided that this did not amount to frank osteoarthritis. Simple indicators were used for the rate of early recovery from the operation, and the Tapper and Hoover scale was used to record the symptomatic results in the longer term. It was found that knees treated by arthroscopic partial meniscectomy did considerably better than the others by all the criteria used. In most parts of the study there was a clear gradation between the results of the three types of treatment: arthroscopic techniques did better than open operations, and partial meniscectomy did better than total meniscectomy.

Thirty-nine patients underwent reconstruction of the anterior cruciate ligament with carbon-fibre and a MacIntosh repair; all had a negative pivot shift test after operation. Some patients had persistent pain, mild effusion and synovial thickening; in 10 of these patients the symptoms warranted arthroscopic examination and biopsy at a mean of 16.9 months after the repair. Arthroscopy revealed that the carbon-fibre had not induced the formation of a "new ligament" and that the repair was merely covered by a thin, fibrous sheath. Histological investigations confirmed this finding, with only a suggestion of a fibroblastic response to carbon-fibre found in two patients. Particles of carbon-fibre were found scattered through the knees. Synovitis and breakdown of the skin over subcutaneous carbon-fibre complicated treatment. Failure of the carbon-fibre to bond to bone was detected radiographically.

Twenty patients with an average age of eighteen and a half years sustained osteochondral fractures of the lateral femoral condyle as the result of a sudden twist and valgus strain to the straight or almost straight knee. All the patients felt sudden pain at the moment of injury, all had a haemarthrosis, and yet the fracture escaped early diagnosis in one-third of the cases. Internal fixation of the fragment with early mobilisation is recommended if the diagnosis is made within two weeks of injury, and excision of the fragment if it is only later identified.

Deep infection, the most serious local complication of total hip replacement, prompted a study of the records of 135 patients (137 hips) thus afflicted in a nationwide survey of Canada. Particular attention has been paid to the natural history of the infection, and the problems of diagnosis are described. Twenty-one patients died after the insertion, or removal, of the prosthesis, and of the survivors of the original 135 patients only eighteen have been able to retain the prosthesis without further problems with the wound. The remaining patients had the prosthesis removed, and most dry wounds. Certain suggestions are made on management. The advice that a second total hip prosthesis should be inserted after a deep infection of the first implant is not supported.