The management of disabling osteoarthritis of the knee following ipsilateral femoral fracture malunion can be difficult. This study presents the results of seven such patients treated by femoral shaft osteotomy in the fracture region and with locked intramedullary nail fixation.

Seven patients with malunited femoral shaft fractures presenting with knee symptoms between 1992 and 1999 were treated by femoral shaft osteotomy. The presenting knee symptoms and function were graded from 0–4. All patients underwent open femoral shaft osteotomy at the apex of the deformity and fixation was by locked intramedullary nailing. The patients were followed up until osteotomy union and reviewed clinically and radiologically with particular emphasis on knee symptoms and function.

There were six males and one female. The mean age at presentation was 48 years and the mean time from fracture 28 years. (Range 13–37 years). The mean knee alignment angle preoperatively was 5 degrees varus (range 0–12). The mean time to osteotomy union was 28 months. The mean knee alignment angle postoperatively was 2 degrees valgus. (range 5 degrees varus-5 degrees valgus). Five of the seven patients reported excellent pain relief and functional improvement. One patient had serious vascular complication and now has a stiff but pain free knee. One patient who presented with very advanced OA has since undergone an uncomplicated total knee arthroplasty after osteotomy union and nail removal.

These patients presenting with severe disability at an age that would be too young for total knee replacement are difficult to manage. Five out seven patients in these series are symptomatically improved to return to their old occupation. The knee replacement has been delayed in these by a mean of five years. Their eventual knee replacement is likely to have been made less difficult as a result of alignment correction.

Purpose: The management of disabling knee osteoarthritis of the knee following malunion of an ipsilateral femoral shaft fracture is difficult and controversial. The purpose of this study is to analyse the results of femoral shaft osteotomy at the level of the old fracture in seven such patients.

Materials and Methods: Seven patients with old malunited femoral shaft fractures presented with disabling knee osteoarthritis between 1992 and 1999. Knee symptoms and function were graded at presentation. All underwent open femoral shaft osteotomy at the apex of the deformity, with locked intramedullary nail fixation. The patients were followed up regularly until osteotomy union and reviewed clinically and radiologically with particular emphasis on knee symptoms and function.

Results: There were six males and one female. The mean age at presentation was 55 years and mean time from the fracture was 28 years (range 13–35 years). The mean preoperative knee alignment angle was 5.60 varus (range O′12′). The mean time to osteotomy union was 28 months. The mean postoperative knee alignment angle was 20 valgus (range 50 valgus -50 varus). All patients reported significant improvement in knee symptoms and function. One osteotomy was followed by a serious vascular complication and the patient now has a stiff but pain free knee. One patient with very advanced osteoarthritis underwent an uncomplicated total knee replacement after osteotomy union and nail removal.

Conclusion: These patients presenting with severe disability at an age which is worryingly young for total knee arthroplasty present a difficult management problem. Five out seven patients had excellent symptomatic and functional improvement following the femoral shaft osteotomy. The possible need for knee replacement was delayed by at least 5 years and the eventual arthroplasty is likely to have been made less technically difficult and more functionally satisfactory as a result of the alignment correction.

Purpose: The radiological appearances of tibial tunnel enlargement following anterior cruciate ligament reconstruction in the short and medium term have been described. This study compares the tibial tunnel appearances at 1 year and again at 8 years post-operatively in 44 patients, and correlates the findings with the longer term clinical outcome.

Patients and Methods: The study was conducted on 44 consecutive patients who had undergone isolated central anterior cruciate reconstruction using a four thickness hamstring technique. All patients were reviewed at one year postoperatively, the assessment including full clinical examination, arthrometer testing and weight bearing AP and lateral radiographs. They were reviewed again at a mean of 8 years (range 5–10 years) post reconstruction. At the 8 year review, full clinical examination, Arthrometer testing, Lysholm and IKDC scoring, Tegner activity level recording were done and standardised weight bearing AP and lateral radiographs were taken.

The Tibial tunnel diameters were measured by two independent observers on both one year and 8 year radiographs. The proximal tunnel measurement was made 5 mm from the tibial articular surface and the distal, 5mm from the lower end of the tunnel. Tunnel enlargement was calculated from the known drill size after correction for magnification. The tunnel enlargements were correlated with clinical outcome and the results were analysed statistically.

Results: There were 6 failures of stability for which an additional operative procedure had been undertaken. The remaining 38 knees were functionally stable. 28 (75%) had negative Lachman and jerk tests and 34 (90%) had a side to side arthrometer difference of less than or equal to 3mm.

The mean tibial tunnel enlargement at one year was 31% at the proximal and 23% at the distal end of the tunnel. At 8 years the enlargements were 20% at the proximal and 13 % at the distal end of the tunnel (p< .001).

There were 10 patients (26%) whose distal tunnel diameter at 8 years was less than the initial drill size. Only one of these had a positive Lachman test. This negative association was significant (p< .05). There was no significant correlation between enlargement at the proximal end of the tunnel, the Lysholm score or clinical stability at 8 years.

Conclusion: Cruciate ligament reconstruction persists at 8 years. However there was a previously unreported reduction in radiographic tunnel size at the 8 year review and this reduction was significant at the distal end of the tibial tunnel. There was no correlation between tunnel enlargement and functional outcome even at 8 year review.