Introduction

The dysplastic trochlear is a developmental condition characterized by an abnormally flat or dome-shaped trochlea and it is recognized as a significant cause of patella instability. Surgical correction of the shape of the Trochlear Groove is frequently performed. The described methods in the literature involve open arthrotomy to normalize and maintain the trochlear morphology achieving normal alignment and tracking of the patella.

We continued a prospective longitudinal follow-up study of 53 remaining patients who underwent open total meniscectomy as adolescents and who at that time had no other intra-articular pathology of the knee. Their clinical, radiological and patient-reported outcomes are described at a mean follow-up of 40 years (33 to 50). The cohort of patients who had undergone radiological evaluation previously after 30 years were invited for clinical examination, radiological evaluation and review using two patient-reported outcome measures.

A total of seven patients (13.2%) had already undergone total knee replacement at the time of follow-up. A significant difference was observed between the operated and non-operated knee in terms of range of movement and osteoarthritis of the tibiofemoral joint, indicating a greater than fourfold relative risk of osteoarthritis at 40 years post-operatively. All patients were symptomatic as defined by the Knee Injury and Osteoarthritis Outcome Score.

This study represents the longest follow-up to date and it can be concluded that meniscectomy leads to symptomatic osteoarthritis of the knee later in life, with a resultant 132-fold increase in the rate of total knee replacement in comparison to their geographical and age-matched peers.

The dysplastic Trochlear is a developmental condition characterised by an abnormally flat or dome-shaped trochlea and it is recognised as a significant cause of patella instability, with the increased sulcus angle being is the most common finding. Surgical correction of the shape of the Trochlear Groove is frequently performed. The described methods in the literature involve open arthrotomy to normalise and maintain the trochlear morphology achieving normal alignment and tracking of the patella.

Open procedures carries a significant risk of arthrofibrosis. The technique was developed in human cadaveric knees at the Donjoy Clinical Education and Research Facility (CERF) in Vista California. We describe an arthroscopic procedure to create a neo-trochlea using gouges, spherical and conical hooded burrs. We studied prospectively a series of 4 consecutive patients with patello-femoral instability secondary to trochlear dysplasia, who were treated by an Arthroscopic trochleoplasty by a single surgeon between 2007 and 2008. Postoperatively the patients were rehabilitated in accordance with our routine Patello-Femoral microfracture Protocol, allowing weight bearing and ROM 0-20 degrees in a long lever brace for 6 weeks. CT scanning at one year showed a complete neo-cortex and cartilage sequenced MRI at 12 months showed complete fill with fibro cartilage.

Pre- and post-operative scores (KOOS, Kujala) were assessed by the patients and a satisfaction questionnaire was completed. The results showed a statistical improvement in the outcome at the 2 year follow up.

Overall, patients (100%) were satisfied with the outcome of their procedure and there have been no adverse events. To our knowledge this technique has not been described before in the English literature and the early results of arthroscopic trochleoplasty are encouraging and offer an alternative to open approaches. Larger numbers and longer follow ups are needed to confirm the long term benefit.

Aim: To report outcomes of high tibial osteotomies (HTO) in the treatment of patients with symptomatic varus-osteoarthritic knees.

Methods: Fourteen patients had a medial opening wedge HTO between 2001–2008. Twelve were male, mean age 42.2 years (range 33–49). Follow-up range 8–72 (mean 31 months). Six had simultaneous ACL reconstruction (one a revision another part of multiligament reconstruction). X-rays were taken at follow-up at 6, 12, 24, 36 and 52 weeks. Patients had pre- and post-operative KOOS assessment.

Results: All patients achieved a pain free leg with radiological evidence of union at mean 4.7 months (range 3–9). Two major complications occurred in one patient (PE and sensory neuropraxia). Minor complications in three patients: cellulitis, donor site infection, 1cm limb length discrepancy. Six patients required 7 further procedures: 2 arthroscopic chondral debridements, 2 microfractures and 3 arthroplasties. Tibial knee varus angles improved from mean 4.7° to 0.28°. KOOS scores improved in all domains: pain 28.5 to 52.8 (P< 0.01), symptoms 30.4 to 48.2 (P< 0.01), ADL 31.3 to 54.4 (P< 0.05), sport and recreation 2.5 to 7.5 P=0.125 and QOL 4.69 to 17.2 (P< 0.05). Kaplan-Meier survival analysis with failure defined as conversion to TKR shows a survivorship of 78.8% at 3 years.

Conclusions: Young patients with medial compartment osteoarthritis can have improved pain and function after HTO.

Better results are reported in the literature. However, some papers suggest osteotomies have been carried out in relatively asymptomatic patients and others accept significant pain in longer follow-up intervals without their patient cohorts having been offered alternative pain relieving strategies, such as chondral resurfacing or arthroplasty.

Patients require careful counselling that they will not achieve normal function and have a high incidence of need for further intervention.

Aim: To study the effect intra-operative image guidance has on the position of both femoral and tibial tunnel placement in primary anterior cruciate ligament reconstruction surgery

Methods: Prospective study of 2 consecutive series of 10 patients undergoing ACL reconstruction surgery all operated on by the same surgeon (the senior author). In the first group intra-operative image guidance in the form of a standard image intensifier was used to guide the surgeon in the positioning of the tibial and femoral tunnels. In the second group no image guidance was used. The position of the femoral and tibial tunnels were assessed on AP and lateral radiographs post operatively and recorded. The two groups were compared.

Conclusion: There was no significant difference in the position of the femoral tunnel position between the 2 groups (p=0.23). There was no significant difference in the position of the tibial tunnel between the 2 groups, in either the AP (p=0.37) or lateral (p=> 0.5) plane. There appears to be no benefit to using an image intensifier to aid in tunnel preparation in ACL reconstruction surgery.

We treated 21 patients with 22 dislocations of the knee by repair or reconstruction of all injured ligaments. Eight knees were treated in the acute phase (less than two weeks after injury); the remainder were treated more than six months after injury (6 to 72). Reconstructions were carried out with a combination of autograft and allograft tendons and by direct ligament repair where possible. At a mean follow-up of 32 months (11 to 77) the mean Lysholm score was 87 (81 to 91) in the acute group and 75 (53 to 100) in the delayed group. The mean Tegner activity rating was 5 in the acute group and 4.4 in the delayed group.

The International Knee Documentation Committee assessment revealed no differences between the two groups. Instrumented testing of knee stability indicated better results for anterior cruciate ligament reconstructions which had been undertaken in the acute phase, but no difference in the outcome of posterior cruciate ligament reconstructions. There was no difference in the loss of knee movement between the two groups. Although the differences were small, the outcome in terms of overall knee function, activity levels and anterior tibial translation were better in those knees which had been reconstructed within two weeks of injury.

We have carried out a prospective, longitudinal 30-year review of 95 adolescents who underwent total meniscectomy in one knee, and have compared the results with those observed 13 years earlier. All the medical records were scrutinised. Of the 63 patients reviewed clinically, 47 reported decreased sporting activity, although subjective satisfaction rose by 3% to 71%. The scores on the WOMAC osteoarthritis index differed significantly between patients grouped by subjective global assessment. Satisfactory function scores increased from 48% to 60%. In the 53 patients consenting to bilateral radiography of the knee, the incidence of narrowing of the articular cartilage in the operated knee increased significantly between the reviews (19% to 36%). Progression of degenerative change paralleled reduction in activity. Outcome measures were best after medial, intermediate after lateral and worst after double meniscectomy.