Aims. Compartment syndrome results from increased intra-compartmental pressure (ICP) causing local tissue ischaemia and cell death, but the systemic effects are not well described. We hypothesised that compartment syndrome would have a profound effect not only on the affected limb, but also on remote organs. Methods. Using a rat model of compartment syndrome, its systemic effects on the viability of hepatocytes and on inflammation and circulation were directly visualised using intravital video microscopy. Results. We found that hepatocellular injury was significantly higher in the compartment syndrome group (192 PI-labelled cells/10. -1 . mm. 3. , standard error of the mean (. sem. ) 51) compared with controls (30 PI-labelled cells/10. -1 . mm. 3. , . sem . 12, p < 0.01). The number of adherent venular white blood cells was significantly higher for the compartment syndrome group (5 leukocytes/30s/10 000 μm. 2. , . sem 1. ) than controls (0.2 leukocytes/30 s/10 000 μm. 2. , . sem . 0.2, p < 0.01). Volumetric blood flow was not significantly different between the two groups, although there was an increase in the heterogeneity of perfusion. Conclusions. Compartment syndrome can be accompanied by severe systemic inflammation and end organ damage. This study provides evidence of the relationship between compartment syndrome in a limb and systemic inflammation and dysfunction in a remote organ. Cite this article: Bone Joint J 2016; 98-B:1132–7

Compartment syndrome, a devastating consequence of limb trauma, is characterised by severe tissue injury and microvascular perfusion deficits. We hypothesised that leucopenia might provide significant protection against microvascular dysfunction and preserve tissue viability. Using our clinically relevant rat model of compartment syndrome, microvascular perfusion and tissue injury were directly visualised by intravital video microscopy in leucopenic animals. We found that while the tissue perfusion was similar in both groups (38.8% (standard error of the mean (. sem). 7.1). , 36.4. % (. sem. 5.7), 32.0% (. sem. 1.7), and 30.5% (. sem. 5.35) continuously-perfused capillaries at 45, 90, 120 and 180 minutes compartment syndrome, respectively versus 39.2% (. sem. 8.6), 43.5% (. sem. 8.5). , . 36.6% (. sem. 1.4) and 50.8% (. sem. 4.8) at 45, 90, 120 and 180 minutes compartment syndrome, respectively in leucopenia), compartment syndrome-associated muscle injury was significantly decreased in leucopenic animals (7.0% (. sem. 2.0), 7.0%, (. sem. 1.0), 9.0% (. sem. 1.0) and 5.0% (. sem. 2.0) at 45, 90, 120 and 180 minutes of compartment syndrome, respectively in leucopenia group versus 18.0% (. sem. 4.0), 23.0% (. sem. 4.0), 32.0% (. sem. 7.0), and 20.0% (. sem. 5.0) at 45, 90, 120 and 180 minutes of compartment syndrome in control, p = 0.0005). This study demonstrates that the inflammatory process should be considered central to the understanding of the pathogenesis of cellular injury in compartment syndrome. Cite this article: Bone Joint J 2015;97-B:539–43

We have analysed associated factors in 164 patients with acute compartment syndrome whom we treated over an eight-year period. In 69% there was an associated fracture, about half of which were of the tibial shaft. Most patients were men, usually under 35 years of age. Acute compartment syndrome of the forearm, with associated fracture of the distal end of the radius, was again seen most commonly in young men. Injury to soft tissues, without fracture, was the second most common cause of the syndrome and one-tenth of the patients had a bleeding disorder or were taking anticoagulant drugs. We found that young patients, especially men, were at risk of acute compartment syndrome after injury. When treating such injured patients, the diagnosis should be made early, utilising measurements of tissue pressure

The aim of this study was to document our experience of acute forearm compartment syndrome, and to determine the risk factors for requiring split skin grafting (SSG) and developing complications post fasciotomy. We identified from our trauma database all patients who underwent fasciotomy for an acute forearm compartment syndrome over a 22-year period. Diagnosis was made using clinical signs and/or compartment pressure monitoring. Demographic data, aetiology, management, wound closure, complications and subsequent surgeries were recorded. Outcome measures were the use of SSG and the development of complications following forearm fasciotomy. 90 patients were identified with a mean age of 33 yrs (range, 13–81 yrs) and a significant male predominance (n=82, p<0.001). A fracture of one or both of the forearm bones was seen in 62 (69%) patients, with soft tissue injuries causative in 28 (31%). The median time to fasciotomy was 12hrs (2–72). Delayed wound closure was achieved in 38 (42%) patients, with 52 (58%) undergoing SSG. Risk factors for requiring a SSG were younger age and a crush injury (both p<0.05). Complications occurred in 29 (32%) patients at mean follow-up of 11 (3–60) months. Risk factors for developing complications were a delay in fasciotomy of >6 hrs (p=0.018), with pre-operative motor symptoms approaching significance (p=0.068). Forearm compartment syndrome requiring fasciotomy predominantly affects males and can occur following either a fracture or soft tissue injury. Age is an important predictor of undergoing SSG for wound closure. Complications occur in a third of patients and are associated with an increasing delay in the time to fasciotomy

Aim. To review current military orthopaedic experience and establish if there exists a consensus of opinion in how and if to perform fasciotomy of the foot and to guide other clinicians. Method. A questionnaire was sent to 10 DMS orthopaedic consultants to identify their experience with foot compartment syndrome and performing fasciotomies. Results. 50% had performed a foot fasciotomy (average 2, range 1-6) over an average of 6.2 years as consultant and an average of 7.3 months deployed. Most commonly two dorsal and a medial incision were used to decompress the foot, while one advocated not decompressing and accepting the contractures, a view consistent with some civilian literature. Discussion. The debate surrounding decompression stems from the rarity of the condition, the lack of consensus regarding the anatomy of the foot compartments and whether to accept the inevitable contractures by not decompressing. Given that foot compartment syndrome may not be seen during civilian training, then there is a requirement for guidance for the deploying military surgeon. Conclusion. DMS clinicians need to remain vigilant to compartment syndrome of the foot and especially in cases of crush or blast injury or of multiple fractures. If diagnosed or even if an impending compartment syndrome is suspected then the foot should be decompressed and the deployed orthopaedic surgeon should be capable of performing it

Whilst emergency fasciotomy for acute compartment syndrome (ACS) of the leg is limb and potentially lifesaving, there remains a perception that such surgery may result in excessive morbidity, which may deter surgeons in providing expeditious care. There are limited long-term studies reporting on the morbidity associated with fasciotomy. A total of 559 patients with a tibial diaphyseal fracture were managed at our centre over a 7-year period (2009–2016). Of these patients, 41 (7.3%) underwent fasciotomies for the treatment of ACS. A matched cohort of 185 patients who did not develop ACS were used as controls. The primary short-term outcome measure was the development of any complication. The primary long-term outcome measure was the patient reported EQ-5D. There was no significant difference between fasciotomy and non-fasciotomy groups in the overall rate of infection (17% vs 9.2% respectively; p=0.138), deep infection (4.9% vs 3.8%; p=0.668) or non-union (4.9% vs 7.0%; p=1.000). There were 11 (26.8%) patients who required skin grafting of fasciotomy wounds. There were 206 patients (21 ACS) with long-term outcome data at a mean of 5 years (1–9). There was no significant difference between groups in terms of the EQ-5D (p=0.81), Oxford Knee Score (p=0.239) or the Manchester-Oxford Foot Questionnaire (p=0.629). Patient satisfaction on a linear analogue scale was reduced in patients who developed ACS (77 vs 88; p=0.039). These data suggest that when managed with urgent decompressive fasciotomies, ACS does not appear to have a significant impact on the long-term patient reported outcome, although overall patient satisfaction is reduced

We reviewed 25 patients with tibial diaphyseal fractures which had been complicated by an acute compartment syndrome. Thirteen had undergone continuous monitoring of the compartment pressure and the other 12 had not. The average delay from injury to fasciotomy in the monitored group was 16 hours and in the non-monitored group 32 hours (p < 0.05). Of the 12 surviving patients in the monitored group, none had any sequelae of acute compartment syndrome at final review at an average of 10.5 months. Of the 11 surviving patients in the non-monitored group, ten had definite sequelae with muscle weakness and contractures (p < 0.01). There was also a significant delay in tibial union in the non-monitored group (p < 0.05). We recommend that, when equipment is available, all patients with tibial fractures should have continuous compartment monitoring to minimise the incidence of acute compartment syndrome

Failure to treat acute compartment syndrome (ACS) early leads to significant morbidity. Current practice depends on using clinical signs and intracompartmental pressure (ICP) monitoring to diagnose the syndrome but there is still debate regarding their accuracy and interpretation. Patients admitted with injuries at risk of ACS underwent intramuscular (IM) pH and ICP monitoring combined with regular clinical assessment. Fasciotomies were performed on those with clinical and/or pressure based evidence of ACS. All patients were subsequently assessed for evidence of a missed ACS at at 6 & 12 months. Of the 62 patients, 51 completed the protocol and were included in the analysis. They were divided into 2 groups: those who had ACS, either initially (fasciotomies; 13), or diagnosed at follow up (no fasciotomies; 7), and those with no evidence of ACS (31). The sensitivity and specificity for the worst values for each variable were calculated and receiver operator characteristic (ROC) curves generated. The area under the curve for pH was 0.92, 0.73 for absolute pressure and 0.59 for delta pressure. To achieve a sensitivity of 95%, an absolute pressure of >30mmHg was 30% specific, a delta pressure of <33mmHg was 27%, while IM pH of 6.38 was 80% specific. This study highlights the issues concerning current diagnostic methods for ACS. By comparison, IM pH radically out performed both the highest ICP and the lowest delta pressure, identifying patients early and accurately

Introduction. Carpal tunnel syndrome is a common neuropathy of the median nerve. Occupation has been widely examined as a risk factor for the development of carpal tunnel syndrome. The aim of this study was to examine the validity of the United Kingdom (UK) NS-SEC (National Statistics Socioeconomic Classification) in the assessment of correlation between occupation and CTS. Methods. A prospective audit database was collected of patients diagnosed with CTS over a 6 year period. Occupation was assessed using the NS-SEC self coded method, where occupation is classified depending on the type of job and the size of the employer. UK Census data from 2001 was used to compare the occupation profile of the cohort with the regional population. Results. There were 1564 patients diagnosed with CTS over a 6 year period. There were fewer patients with CTS in managerial and professional occupations (OR 0.77 95% CI 0.66 to 0.9), lower supervisory and technical occupations (OR 0.33, 0.23 to 0.45), and semi-routine and routine occupations (OR 0.68, 95% CI 0.58 to 0.79). There was a higher proportion of patients who were self-employed (OR 4.60, 3.93 to 5.30). Discussion. The NS-SeC is superficially attractive to assess occupational differences between a general population and a study group due to the availability of census data. This study has shown a higher proportion of patients having CTS in the self-employed category than in the general population. Such occupational classifications that are based on economic inidicators may not be useful in assessing exposure to risk factors for musculoskeletal disorders. Caution should be exercised in their use and more accurate scores developed that address physical intensity of an occupation

Corticosteroid use has been implicated in the development of osteonecrosis of the femoral head (ONFH). The exact mechanism and predisposing factors such as age, gender, dosage, type and combination of steroid treatment remain controversial. Between March and July 2003, a total of 539 patients with severe acute respiratory syndrome (SARS) were treated with five different types of steroid. There were 129 men (24%) and 410 women (76%) with a mean age of 33.7 years (21 to 59). Routine screening was undertaken with radiographs, MRI and/or CT to determine the incidence of ONFH. Of the 129 male patients with SARS, 51 (39.5%) were diagnosed as suffering from ONFH, compared with only 79 of 410 female patients (19.3%). The incidence of ONFH in the patients aged between 20 and 49 years was much higher than that of the group aged between 50 and 59 years (25.9% (127 of 491) versus 6.3% (3 of 48); p = 0.018). The incidence of ONFH in patients receiving one type of steroid was 12.5% (21 of 168), which was much lower than patients receiving two different types (28.6%; 96 of 336) or three different types of steroid (37.1%; 13 of 35). Cite this article: Bone Joint J 2014;96-B:259–62

There is much debate regarding the use of continuous-compartment-pressure-monitoring (CCM) in the diagnosis of acute compartment syndrome (ACS). We retrospectively reviewed the management of all patients (aged 15 and over) who were admitted with a fracture of the tibial diaphysis, across 3 centres, during 2013–2015. Patient demographics, pre-existing medical problems, initial treatment, subsequent complications, methods of compartment monitoring, and follow-up were all included in the data collection. We separated patients into monitored (MG) and non-monitored groups (NMG), and compared the outcomes of their treatment. Data analysis was performed using SPSS and statistical significance was set as p < 0.05. 287 patients were included in this study (116 NMG vs. 171 MG). There were no significant differences observed in age, sex, previous medical problems, length of stay, AO classification of fracture and post-operative complications between the groups. 21 patients were suspected to have developed ACS (n=8 NMG 6.9percnt;, n=13 MG 7.6percnt;) and were treated with acute decompression fasciotomies. The average time from admission to fasciotomy was 20.3 hours (21.25hrs NMG, 19.5hrs MG p=0.448). There was no significant difference in the average length of hospital stay and documentation of complications at follow up between the 2 groups. There were no reported cases of soft tissue infections associated with the use of CCM. This study illustrates that CCM does not increase the rate of fasciotomies in this patient group, or reduce the time to fasciotomy significantly. There was no evidence to suggest that use of CCM is associated with superficial or deep infection

Background. Overlooked compartment syndrome represents a devastating complication for the patient. Invasive compartment pressure measurement continues to be the gold standard. However, repeated measurements in uncertain cases may be difficult to achieve. We developed a new, noninvasive method to assess tissue firmness by pressure related ultrasound. Methods. Decreased tissue elasticity by means of rising compartment pressures was mimicked by infusion of saline directly into the anterior tibial compartment of 6 human specimens post mortem. A pressure transducer (Codman) monitored the pressure of the anterior tibial compartment. A second transducer was located in a saline filled ultrasound probe head to allow a simultaneous recording of the probe pressure provoked by the user. The ultrasound images were generated at 5 and 100mmHg probe pressures to detect the tissue deformity by B-mode ultrasound. The fascial displacement was measured before and after compression (d). Subsequently, increments of 5mmHg pressure increases were used to generate a standard curve (0–80mmHg), thus mimicking rising compartment pressures. The intra-observer reliability was tested using 10 subsequent measurements. A correlation was determined between d and the simulated intacompartmental pressure (ICP) in the compartment. The Pearson correlation coefficient (r) was calculated. The reliability determined by the kappa value and a regression analysis was performed. Results. With rising compartmental pressure, a concordant consistent correlation between d and ICP occurred. The Pearson coefficient was significant at r=0.979 and the intra-observer value kappa (k) showed a statistically good reliability (k10=0.73 and k70=0.79). Within a pressure ranging from 5–35mmHg there was an almost linear behavior, with decreasing elasticity and tissue movement in case of raising ICP. Conclusions. Pressure related ultrasound emphasized as a reliable tool to determine the correlation between the measured compartmental displacement and the raising intracompartmental pressures. This may help to improve the clinical assessment of the compartment elasticity by the physician. Further studies are required to investigate whether the good correlation also applies for the clinical scenario. However, this new method may be useful to monitor trends in the compartment pressures and may help to avoid delayed decision of fasciotomy

Aims

The aim of this study was to evaluate near-infrared spectroscopy (NIRS) as a continuous, non-invasive monitor for acute compartment syndrome (ACS).

The purpose of this study was to evaluate the results of subcutaneous ulnar nerve transposition in the treatment of Cubital Tunnel Syndrome (CTS) and the influence of prognostic factores such as preoperative McGowan stage, age and duration of symptoms. 36 patients (17 men and 19 women) with CTS who underwent subcutaneous ulnar nerve transposition between 2006 and 2009 were evaluated postoperatively, an average follow-up of 28 months. Sensory and motor recovery was evaluated clinically. The postoperative outcome was based on modified Bishop score, subjective assessment of function and on the degree of patient satisfaction. The dominant side was involved in 61% cases and the mean age was 51.2 years. There were 9 (25%) McGowan stage I, 18 (50%) stage II and 9 stage III patients. We used the Mann-Whitney and Kruskal-Wallis test to compare continuous variables and chi-square and Fisher Exact Test for categorical variables. There was a statistically significant improvement of sensory (p=0.02) and motor (p=0.02) deficits. We obtained 21 (58.3%) excellent results, seven (19.4%) fair, six (16.7%) satisfactory, and two bad ones (5.55%). There was a statistically significant improvement of function (p<0.001). There is controversy in the literature regarding the best surgical treatment for CTS. The duration and severity of symptoms and advanced age, more than the surgical technique, seem to influence prognosis. With the technique used, the satisfaction rate was 86% and 72% recovered their daily activities without limitations. 78% of patients with severe neuropathy improved after surgery. The rates of postoperative complications were comparable with those of other studies. The severity of neuropathy and duration of symptoms (>12months) pre-operatively, but not age, had a negative influence on the outcome. The results showed that the subcutaneous ulnar nerve transposition is safe and effective for postoperative clinical sensory and motor recovery for several degrees of severity in CTS. Given the major prognostic factors, surgical treatment should be advocated as soon as axonal loss has become clinically evident

Aims. The objective of our study is to identify the causes for recurrence and to evaluate the results of our technique. Material and Methods. We retrospectively analysed 18 patients (12 females; 6 males) who had both clinical and electrophysiological confirmation (7 focal entrapments; 11 severe entrapments) of recurrent carpal tunnel syndrome. In all the patients, after releasing the nerve a vascularised fat pad flap was mobilised from hypothenar region and sutured to the lateral cut end of flexor retinaculum. All the patients were assessed post-operatively for relief of pain, recovery of sensory and motor dysfunction. Results. The average age was 61 years and dominant hand was involved in 13/18. The average time between the first and second surgery was fifty-nine months. Intra-operatively ten had completely reformed retinaculum, two partially reformed (proximally) and five had scar tissue between the cut ends and one had scar tissue and fibrosis around the nerve. All patients had improvement of symptoms post-operatively. Ten had complete recovery immediately after surgery, the remaining patients had severe focal entrapment and had scar tissue intraoperatively. The patients with delayed recovery had high incidence of a) Early recuurence (average of nine months), b) Diabetes mellitus c) Obese/over-weight and d) cervical spine problems. Conclusions. The hypothenar fat pad transposition flap provides a reliable source of vascularised local tissue that prevents scar formation and helps nerve gliding. 80% of the patients in whom recurrence occurred within a year are associated with poor outcome/delayed recovery

CECS is an exercised induced condition that causes pain, typically in the lower limbs, and is relieved by rest. It is often seen in military personnel significantly restricting their duties. Conservative treatment is rarely successful and patients often require surgical decompression by fasciotomy or fasciectomy.

All IMP (intramuscular pressure) tests (n=286) carried out between December 2007 and October 2010 on patients with suspected CECS in the anterior compartment of the lower leg were reviewed. The treatment and outcomes of those referred for surgery were analysed. Pre- and post-surgery military medical grading for leg function was extracted from the medical records system. Independent t-tests compared differences between patients that had surgery or did not. The Wilcoxon signed-rank test compared grades before and after surgery.

According to the diagnostic criterion, 80% of patients undergoing IMP testing had CECS. Of these, 179 (68%) patients underwent surgery, 17 (9%) of these were for recurrent symptoms. Almost all decompressions were bilateral (95%). The majority of operations (121) were fasciectomies of the anterior compartment only and were performed by 2 surgeons. The remaining operations (58) were performed by 6 surgeons and were fasciotomies of both anterior and lateral compartments. The mean time from testing to surgery was 24 (median 11) weeks. There were 23 (13%) complications other than recurrence including 16 wound infections, 6 seromas and 1 haematoma. Pre- and post-surgery grading was available for 67% of patients. These patients had significantly better leg function after surgery (Z=−3.67, p<0.001). Of these, 47% improved, 38% showed no improvement and 15% had a poorer outcome had. Those who had a fasciectomy were significantly more likely to improve than those who had a fasciotomy (p=0.023, rho=−1.96).

Our results demonstrate that patients generally improve lower limb function following surgical decompression. However, 53% showed no improvement or deteriorated in their medical grading. In addition, there is a high diagnosis rate for CECS following IMP measurement. This may reflect the poor validity of the diagnostic criterion or this could be due to good clinical selection for testing. Furthermore, fasciectomy shows a greater correlation with improved outcome than fasciotomy. There is a need to develop more accurate diagnostic criteria and to evaluate the benefits of standardising surgical technique.

We describe six patients aged from 10 to 15 years who, after injury to the distal tibial physis, presented with the following clinical findings: 1) severe pain and swelling of the ankle; 2) hypoaesthesia or anaesthesia in the web space of the great toe; 3) weakness of extensor hallucis longus and extensor digitorum communis; and 4) pain on passive flexion of the toes, especially the great toe.

In four patients, the fractures were not reduced for more than 24 hours. The intramuscular pressure beneath the superior extensor retinaculum of the ankle was greater than 40 mmHg in all cases (40 to 130 mmHg), and less than 20 mmHg in the anterior compartment. Treatment consisted of release of the superior extensor retinaculum and stabilisation of the fracture. All patients had prompt relief of pain and improved strength and sensation within 24 hours, although two had some residual numbness in the web space of the great toe.

Aims. The aim of this study was to investigate the association between additional rehabilitation at the weekend, and in-hospital mortality and complications in patients with hip fracture who underwent surgery. Methods. A retrospective cohort study was conducted in Japan using a nationwide multicentre database from April 2010 to March 2018, including 572,181 patients who had received hip fracture surgery. Propensity score matching was performed to compare patients who received additional weekend rehabilitation at the weekend in addition to rehabilitation on weekdays after the surgery (plus-weekends group), as well as those who did not receive additional rehabilitation at the weekend but did receive weekday rehabilitation (weekdays-only group). After the propensity score matching of 259,168 cases, in-hospital mortality as the primary outcome and systemic and surgical complications as the secondary outcomes were compared between the two groups. Results. The plus-weekends group was significantly associated with lower in-hospital mortality rates compared with the weekdays-only group (hazard ratio 0.86; 95% confidence interval 0.8 to 0.92; p < 0.001). Systemic complications such as acute coronary syndrome, heart failure, renal failure, and sepsis were significantly lower in the plus-weekends group, whereas urinary tract infection (UTI) and surgical complications such as surgical site infection and haematoma were significantly higher in the plus-weekends group. Conclusion. Additional weekend rehabilitation was significantly associated with lower in-hospital mortality, as well as acute coronary syndrome, heart failure, renal failure, and sepsis, but was also significantly associated with a higher risk of UTI and surgical complications. This result can facilitate the effective use of the limited rehabilitation resources at the weekend and improve the clinical awareness of specific complications. To establish more robust causal associations between additional rehabilitation over the weekend and clinical outcomes, further prospective studies or randomized controlled trials with larger sample sizes are warranted. Cite this article: Bone Joint J 2023;105-B(8):872–879

Aims. The aim of this study was to assess whether it is possible to predict the mortality, and the extent and time of neurological recovery from the time of the onset of symptoms and MRI grade, in patients with the cerebral fat embolism syndrome (CFES). This has not previously been investigated. Methods. The study included 34 patients who were diagnosed with CFES following trauma between 2012 and 2018. The clinical diagnosis was confirmed and the severity graded by MRI. We investigated the rate of mortality, the time and extent of neurological recovery, the time between the injury and the onset of symptoms, the clinical severity of the condition, and the MRI grade. All patients were male with a mean age of 29.7 years (18 to 70). The mean follow-up was 4.15 years (2 to 8), with neurological recovery being assessed by the Glasgow Outcome Scale and the Mini-Mental State Examination. Results. In all, seven who had early-onset CFES (< 24 hours), and a severe Takahashi grade on MRI, died. There was a significant association between the time of onset of neurological signs and mortality (p = 0.035). Mortality was also significantly associated with a severe Takahashi grade (p < 0.001). Among the 27 surviving patients, 26 (96.3%) recovered completely. One (3.7%) had a cognitive deficit. The mean time to recovery was 4.7 weeks (2 to 13), with late recovery aftereight eight weeks being recorded in three patients. Conclusion. There was a significantly increased rate of mortality in patients with CFES who had an early onset of symptoms and a severe grade on MRI. Complete neurological recovery can be expected in most patients with CFES who survive. Cite this article: Bone Joint J 2022;104-B(1):142–149

Objectives. Congenital cruciate ligament deficiency is a rare condition that may occur in isolation or in association with longitudinal limb deficiencies such as fibular hemimelia or proximal femoral focal deficiency. Often anomalies of the menisci and their attachments can be very abnormal and impact on surgical management by standard techniques. Arthroscopic surgical knee reconstruction is undertaken to improve symptomatic instability and/or to stabilise and protect the knee for future planned limb lengthening surgery. The aim of this study is to evaluate the arthroscopic findings of patients undergoing surgery for congenital cruciate ligament deficiency, and specifically to determine the frequency and types of meniscal anatomical variations seen in these cases. Methods. Patients undergoing surgery for congenital cruciate ligament deficiency were identified from a prospectively collated database. Diagnosis was confirmed through review of the clinical notes and imaging. Operative notes and 4K saved arthroscopic images and video recordings for these cases were reviewed. Results. Over a six-year period (July 2017 – September 2023), 42 patients underwent surgery for congenital ligament deficiency and tibiofemoral instability (45 surgical episodes). Median age of patients at time of surgery was 10 years (range 4 – 17 years). The most frequent diagnosis was congenital longitudinal limb deficiency syndromes in 27 cases, with the most frequent being fibular hemimelia. Isolated congenital ligament deficiency without any other associated extra-articular manifestations occurred in 11 cases. Absence of meniscal root attachments or hypertrophy of meniscofemoral ligaments acting as ‘pseudo-cruciates’ were seen in over 25% of patients. In isolated ACL deficiency these were injured causing onset of instability symptoms and pain following trauma. Often these abnormal structures required addressing to allow surgical reconstruction. Conclusions. Our findings demonstrate that there are often meniscal variations seen in association with congenital absence or hypoplasia of the cruciate ligaments. In these patients hypertrophied meniscofemoral ligaments may act as cruciate-like structures and play a role in providing a degree of sagittal plane stability to the knee. However, when the knee becomes unstable to the point that cruciate ligament reconstruction is indicated, these meniscal variants may often require stabilisation using complex meniscal root repair techniques or variations to standard cruciate ligament reconstruction techniques to accommodate the variant anatomy