Background

The anatomy of the human body has been studied for centuries. Despite this, recent articles have announced the presence of a new knee ligament- the anterolateral ligament. It has been the subject of much discussion and media commentary. Previous anatomical studies indicate its presence, and describe its location, origin, course and insertion. Magnetic resonance imaging (MRI) is the best and most commonly used investigation to assess the ligamentous structure of the knee. To date, most MRI knee reports make no mention of the anterolateral ligament. The aim of this study was to assess for the presence of the anterolateral ligament using MRI, and to describe the structure if visualised.

Background

Proximal phalangeal fractures are caused by an injury to the dorsum of the hand. This usually causes volar angulation which is unstable when reduced. K-wiring or external fixation can damage the soft tissue envelope, can introduce infection and can loosen or displace. Traction splinting is not well described for these fractures.

Introduction: There is concern that cobalt and chromium ions released from metal on metal (MOM) bearing surfaces may have an adverse effect on renal function over time.

Aim: The aim of this study was to assess renal function in patients who have had MOM hip resurfacing at between two and seven years follow up.

Methods and Materials: Seventy seven patients had MOM hip resurfacing performed in our unit between 1st March 2001 and 28th February 2006. All patients were invited to present for an up to date renal profile. Of these, 59 patients volunteered a sample (76%). Forty-eight were male and eleven were female. Ages ranged from 33 to 63 years (mean 59 years). Nine patients had hypertension pre-operatively. No other risk factors for renal dysfunction were present in our patient population.

Results: Pre-operative urea and creatinine levels ranged from 2.9 to 10.6mmol/L (mean 6.4mmol/L) and 50 umol/L to 121umol/L (mean 77.2umol/L) respectively. Post-operative urea and creatinine levels ranged from 5.3mmol/L to 6.3mmol/L (mean 5.3mmol/L) and 62umol/L to 75umol/L (mean 67umol/L) respectively. Two patients who had normal serum creatinine profiles pre-operatively showed mildly elevated serum creatinine levels at most recent follow up.

Conclusion: Medium term follow up of patients following MOM hip resurfacing does not suggest evidence for the development of renal impairment in this patient population.

A new apparatus and technique of syndesmosis fixation is tested in a prospective clinical study. Buttons on both sides of the ankle anchor a strong suture under tension following syndesmosis reduction. This syndesmosis suture acts like a tightrope when under tension. Implantation is simple with a minimally invasive technique, as the medial side is not opened. It allows physiological micromotion whilst resisting diastasis, does not require routine removal, and allows patients to weight-bear earlier.

Sixteen patients with Weber C ankle fractures with a syndesmosis diastasis underwent suture-button fixation and the results compared to 16 consecutive patients with syndesmosis screw fixation. Patients were, in effect, quasi-randomised according to surgeon preference. Mean A,O,F,A,S, ankle scores were significantly better in the suture-button group at three months post-op (91 vs 80, p=0.01, unpaired t-test) and at twelve months (93 vs 83, p=0.04, unpaired t-test). Return to work was also significantly faster (2.6 months vs 4.6 months, p=0.02, unpaired t-test). No suture-buttons required implant removal. Axial CT scanning at three months showed implants to be intact with maintenance of reduction, as compared to the uninjured contralateral side.

Suture-button syndesmosis fixation is simple, safe and effective. It has shown improved outcomes and faster rehabilitation, without needing routine removal. Although the apparatus design may undergo further refinement, we believe this technique will become the treatment of choice in Weber C ankle fractures with a syndesmosis injury.

Introduction: Total knee replacement (TKR) is an established and successful treatment option for symptomatic osteoarthritis of the knee. Arthroplasty surgeons, however, continue to debate the merits of posterior cruciate ligament (PCL) preservation or resection. Published literature on this subject has not demonstrated a significant clinical difference in outcome in matched subjects. Deliberate PCL resection during non-posterior stabilised TKR has also been shown to have similar outcomes.

The aims of this study were to map the tibial PCL footplate using MRI in patients undergoing TKR and more importantly, to document the percentage disruption of this footplate as a result of the tibial cut.

Patients and Methods: Patients awaiting TKR were prospectively enrolled into this study. Plain radiographs and an MRI scan of the knee were performed. Using coronal and sagittal images and the available software, the cross sectional area of the tibial PCL footplate was determined along with its location relative to the tip of the fibular head. Plain x-rays of the knee were performed postoperatively. Using a number of pre-determined markers we estimated the impact of the operative tibial cut on the PCL footplate.

Results: Twenty-five patients were enrolled into this study. There were 7 male and 18 female patients, mean age: 69 years. The vast majority of implants were AMK (80%), with a mean posterior slope cut of 3.6 degrees (range 0–7) and mean spacer height 11.4 mm (range 8–16).

From MRI analysis, the tibial PCL footplate had a mean surface area of 83 mm² (range: 49 – 142), and there was a significant difference between male and female patients [Male: 104 mm²versus Females: 75 mm²; t-test, p < 0.005]. The inferior most aspect of the PCL footplate was located on average 1 mm above the superior most aspect of the fibular head (range: 10 mm below to 7 mm above).

Analysis of post-operative radiographs showed that the average tibial cut extended to 4 mm above the tip of the fibular head (range 2 mm below to 14 mm above). Over one third of patients had tibial cuts extending below the inferior most aspect of their PCL footplate (complete removal) and a further one third had cuts which extended into their PCL footplate (partial removal).

Conclusions We have found a wide variation in the size and location of the tibial PCL footplate when referenced against the fibular head.

Proximal tibial cuts using conventional jigs resulted in the removal of a significant portion if not all of the PCL footplate in the majority of patients.

Our findings suggest that when performing PCL retaining TKR’s, we commonly do not actually preserve the PCL.

Introduction: The goals of TKR are restoration of the mechanical axis, joint line and Q –angle. Reproduction of the offset of the extensor mechanism during arthroplasty is less well understood. The lever arm of the extensor mechanism is primarily affected by femoral component position, patella tracking and overall patellar thickness. Changing this lever arm alters quadriceps muscle and patellofemoral joint reaction force. Some TKR designs purposefully aim to increase this offset in order to reduce PFJ contact pressures. Overstuffing the PFJ will however adversely affect outcome.

The aims of this study were to measure and compare the pre and postoperative quadriceps lever arm and its effect on function in a consecutive series of patients undergoing TKR.

Methods: Fifty consecutive patients who had an LCS TKR without patellar resurfacing by a single surgeon were reviewed. Patient demographics were recorded. We measured the pre and post-operative quadriceps lever arm using comparable lateral radiographs and digital imaging software. Functional outcome in these patients was determined using the American Knee Society Score pre and 6-months post-operatively. Patients were specifically questioned regarding the presence or absence of anterior knee pain

Results: Quadriceps lever arm was on average 6 mm greater post-operatively than pre-op but this difference was not significant [t-test]. The functional outcome in these patients was independent of any change in quadriceps lever arm.

Conclusions Reproduction of normal biomechanics is essential in order to optimise outcome from TKR.

Using the LCS system, there is a small but insignificant increase in the quadriceps moment arm. We have not found that this has any bearing on functional outcome in these patients.

Introduction: Urinary retention is a significant complication following hip and knee arthroplasty. Published literature has shown that the insertion of a catheter post-op is associated with an increased incidence of deep joint sepsis, however, pre-operative catheterisation has not.

The International Prostate Symptom Score (IPSS) is an internationally validated scoring system used by Urologists to assess the severity of obstructive urinary symptoms and response to treatment.

The purpose of this study was to quantify the incidence of urinary retention following major joint arthroplasty in an elective orthopaedic unit and to investigate whether a patient’s pre-operative IPSS score could be used to predict the likelihood of post-operative urinary retention.

Patients and Methods: Over a 9 month period, 118 patients were enrolled prospectively into this study. 28 patients were admitted for knee replacement(TKR) and 90 patients for hip replacement (THR). All patients were asked to fill out an IPSS questionnaire form on admission. Demographics including age, mode of anaesthetic, intra-operative blood loss and operative time were recorded. Results: In our study group of 118 patients, 43(36.4%) developed urinary retention postoperatively. 29(32.2%) patients following THR developed urinary retention, whereas 14(50%) of the men who had a TKR developed urinary retention post-op. Of the 25 patients with a pre-operative IPSS score > /=10, 14(56%) went into retention. The mean pre-operative IPSS score was 7.74 for those who went into retention, compared to 5.0 for the other patients (p < 0.05). Type of anaesthesia, blood loss and operative time were non-contributory.

Conclusion: This study shows a high rate of post-operative urinary catheterisation in our patient group. Despite the mean IPSS score being higher in patients requiring catheterisation, our results did not show any conclusive evidence that this scoring system could be used to predict the development of post-operatively urinary retention in patients presenting for hip or knee arthroplasty.

We present a retrospective study on the outcome of Clayton’s forefoot arthroplasty in 23 patients with rheumatoid arthritis.

The average age at surgery was 51.2 years (range 26–88). Pre-operative symptoms were pain, deformity, and footwear problems. Hallux valgus, lesser toe deformities and callosities were the common signs. One surgeon performed all procedures. All patients were assessed radiologically and clinically using American Orthopaedic Foot and Ankle Society (AOFAS) rating system.

Thirteen patients had bilateral correction, and 10 had single foot surgery, providing a total of 36 feet for analysis. Complications included eight wound infections, two toe tip ulceration, two ischaemic toes and two painful feet.

The AOFAS average score was under 45 before surgery and it improved to 83 (range 47–100) for hallux and 79 (range 40–100) for the lesser toes. Overall 91% patients were pleased with the procedure. Our results suggest that Clayton’s forefoot arthroplasty is a procedure, which provides predictable comfort and immediate, functional improvement in advanced rheumatoid arthritis.

Introduction: Anterior knee pain is a commonly encountered orthopaedic symptom. Textbooks list a number of clinical symptoms and physical signs that are specific for the PF joint in the assessment of the patient with knee pain. Radiological evaluation of the PF joint is rarely helpful. The authors have investigated the value of these symptoms and signs in predicting the presence of PF pathology.

Patients and Methods: All patients presenting for diagnostic knee arthroscopy were enrolled prospectively. A detailed proforma was completed with each patient pre-operatively recording the presence or absence of specific PF symptoms and clinical signs. A blinded independent observer recorded the operative findings of the PF joint, the presence / absence of a plica and / or anterior synovitis. Chondromalacia (CM) was graded using the Outerbridge classification and grade 2 or greater was considered a positive finding.

Pre-operative symptoms and signs were correlated with arthroscopic findings and their positive predictive value (PPV) was determined.

Results: Thirty patients were enrolled over a 2-month period. Pure anterior knee pain was present in 10 patients. The remainder had medial (15), lateral (2) or generalised pain (3). 20 of the thirty patients had degenerative changes in the PF joint. One patient had a plica and no patients had significant anterior synovitis. 20 of the 30 patients had pathological findings elsewhere in their joint.

In the prediction of PF degenerative changes, the PPV of symptoms exacerbated by squatting was 0.53; stairs – 0.55; kneeling – 0.57; rising from low chair – 0.6 and night pain – 0.5.

Analysis of specific signs in predicting PF changes showed that the PPV of PF crepitus was 0.5; pain exacerbated by patellar compression 0.6; and patellar facet compression was 0.62.

Conclusion: Degenerative changes of the PF joint are common in our patient population. The value of knee arthroscopy in patients with isolated PF symptoms is questionable. Our assessment of these patients with specific questions and physical signs has been shown to have a low PPV in predicting ultimate arthroscopic findings in the PF joint.

Introduction A new technique of ankle syndesmosis fixation is proposed. Buttons are placed on both sides of the ankle, connected by a strong non-absorbable suture. The technique is simple and minimally invasive: a medial incision is not required. It resists diastasis whilst allowing physiological micromotion and does not require routine removal.

Methods The technique was tested on a cadaver model of a Maisonneuve injury under increasing torque loads. Sixteen embalmed cadaver legs were randomised to receive suture-button fixation or four-cortical 4.5 mm syndesmosis screw fixation. A prospective clinical study involving 16 patients with Weber C fractures and syndesmosis diastasis is presented. They underwent suture-button fixation and the results were compared to 16 consecutive patients with syndesmosis screw fixation.

Results In the cadaver study, both groups had similar rates of diastasis following torque loading. However, the suture-button did give a more consistent performance: standard deviations were significantly lower (p=0.001) than the screw group. In the clinical study, both groups were evenly matched as regards patient age, male: female ratio, and fracture patterns. Mean AOFAS ankle outcome scores at three months were significantly better in the suture-button group (91 versus 82, p=0.01). No suture-button patients required implant removal. They had a faster return to work compared to the screw group (three months versus five months). Axial CT scanning performed at three months post-op showed all implants to be intact with no loss of reduction.

Conclusions Suture-button syndesmosis fixation is simple, safe, effective and physiological. It has shown improved outcomes and faster rehabilitation, without needing routine removal. It may become the treatment of choice in Weber C ankle fractures with a syndesmosis diastasis.

In relation to the conduct of this study, one or more the authors have received, or are likely to receive direct material benefits.

Clinical and radiographic data on 47 hips in 45 patients with Developmental Hip Dysplasia who underwent either a Salters Innominate Osteotomy or a Femoral Derotation Varus Osteotomy by a single operator were reviewed. The average age of patients at the time of osteotomy was 21 months (range 12–108 months). Clinical evaluation was performed with use of the lowa hip rating score and the Harris hip score. Radiographs were evaluated pre=operatively, post-operatively and at final review.

The mean duration of follow-up was 15 years 9 months (range 10–21 years). Thirty-five patients had a Salter innominate osteotomy, 11 a derotation varus osteotomies and one a Klisic.

Al last follow-up examination the Iowa hip rating averaged 96.6 (range 62 to 100) and the modified Harris Hip Score averaged 96.8 (range 48 to 100). Forty seven percent of patients reported abductor fatigue after sport. Forty-one patients had excellent result with a Severin class I hip on radiographic evaluation. All of these patients had an Iowa index > 95 and a mean Centre-Edge angle of 35.5 (range 25–40).

Six patients had a poor radiological outcome with 5 Severin class IV hips and one class V. Clinical outcome scores did not correlate with poor radiological outcome; Iowa hip score 92 (range 62–100). One patient required a Ganz periactabular osteotomy. The age at which primary osteotomy was performed was significantly higher in the poor outcome group with a mean of 50.8 months.

When the anatomy of the hip is restored to normality at an early age with out the development of avascular necrosis excellent long-term results can be expected.

We have reviewed 59 patients with injury to the spinal cord to assess the predictive value of the sparing of sensation to pin prick in determining motor recovery in segments which initially had MRC grade-0 power.

There were 35 tetraplegics (18 complete, 17 incomplete) and 24 paraplegics (19 complete, 5 incomplete), and the mean follow-up was 29.6 months. A total of 114 motor segments initially had grade-0 power but sparing of sensation to pin prick in the corresponding dermatome. Of these, 97 (85%) had return of functional power (≥ grade 3) at follow-up. There were 479 motor segments with grade-0 power but no sparing of sensation to pin prick and of these only six (1.3%) had return of functional power. Both of the above associations were statistically significant (chi-squared test, p < 0.0001).

After injury to the spinal cord, the preservation of sensation to pin prick in a motor segment with grade-0 power indicated an 85% chance of motor recovery to at least grade 3.