Aim

Computer assisted total knee arthroplasty may have advantages over conventional surgery with respect to component positioning. Femoral component mal-rotation has been shown to be associated with poor outcomes, and may be related to posterior referencing jigs. We aimed to determine the variation between the transepicondylar axis (TEA) and posterior condylar axis (PCA) in a series of knees undergoing navigated total knee arthroplasty (TKA), and to determine the correlation between final intra-operative and post-operative coronal alignment.

We reviewed 5086 patients with a mean age of 30 years (9 to 69) undergoing primary reconstruction of the anterior cruciate ligament (ACL) in order to determine the incidence of secondary pathology with respect to the time between injury and reconstruction. There was an increasing incidence of medial meniscal tears and chondral damage, but not lateral meniscal tears, with increasing intervals before surgery. The chances of requiring medial meniscal surgery was increased by a factor of two if ACL reconstruction was delayed more than five months, and increased by a factor of six if surgery was delayed by > 12 months. The effect of delaying surgery on medial meniscal injury was also pronounced in the patients aged < 17 years, where a delay of five to 12 months doubled the odds of medial meniscal surgery (odds ratio (OR) 2.0, p = 0.001) and a delay of > 12 months quadrupled the odds (OR 4.3, p = 0.001). Increasing age was associated with a greater odds of chondral damage (OR 4.6, p = 0.001) and medial meniscal injury (OR 2.9, p = 0.001), but not lateral meniscal injury. The gender split (3251 men, 1835 women) revealed that males had a greater incidence of both lateral (34% (n = 1114) vs 20% (n = 364), p = 0.001) and medial meniscal tears (28% (n = 924) vs 25% (n = 457), p = 0.006), but not chondral damage (35% (n = 1152) vs 36% (n = 665), p = 0.565). We conclude that ideally, and particularly in younger patients, ACL reconstruction should not be delayed more than five months from injury.

Cite this article: Bone Joint J 2013;95-B:59–64.

Bioabsorbable screws for anterior cruciate ligament reconstruction (ACLR) have been shown to be associated with femoral tunnel widening and cyst formation.

To compare a poly-L-lactide–hydroxyapatite screw (PLLA-HA) with a titanium screw with respect to clinical and radiological outcomes over a 5 year period.

40 patients were equally randomized into 2 groups (PLLA-HA vs titanium) and ACLR performed with a 4 strand hamstring graft with femoral tunnel drilling via the anteromedial portal. Evaluation at 2 and 5 years was performed using the International Knee Documentation Committee assessment (IKDC), Lysholm knee score, KT 1000 arthrometer, single-legged hop test. Magnetic resonance imaging was used to evaluate tunnel and screw volume, ossification around the screws, graft integration and cyst formation.

There was no difference in any clinical outcome measure at 2 or 5 years between the 2 groups. At 2 years, the PLLA-HA femoral tunnel was significantly smaller than the titanium screw tunnel (p=0.015) and at 5 years, there was no difference. At 2 years the femoral PLLA-HA screw was a mean 76% of its original volume and by 5 years, 36%. At 2 years the tibial PLLA-HA screw mean volume was 68% of its original volume and by 5 years, 46%. At 5 years, 88% of femoral tunnels and 56% of tibial tunnels demonstrated a significant ossification response. There was no increase in cyst formation in the PLLA-HA group and no screw breakages.

The PLLA-HA screw provides adequate aperture fixation in ACLR with excellent functional outcomes. It was not associated with femoral tunnel widening or increased cyst formation when compared with the titanium screw. The resorbtion characteristics appear favourable and the hydroxyapatite component of the screw may stimulate osteoconduction, contributing to these results. The PLLA-HA screw is a good alternative to a titanium screw in ACLR, which may aid revision procedures and allow for imaging without artifact.

Computer assisted total knee arthroplasty may have advantages over conventional surgery with respect to component positioning. Femoral component mal-rotation has been shown to be associated with poor outcomes, and may be related to posterior referencing jigs. We aimed to determine the variation between the transepicondylar axis (TEA) and posterior condylar axis (PCA) in a series of knees undergoing navigated total knee arthroplasty, and to determine the correlation between final intra-operative coronal alignment and post-operative radiographic functional alignment.

A review of 170 consecutive patients undergoing primary total knee arthroplasty between June 2007 and August 2010, using Precision navigation and Triathlon implants (Stryker). The difference between the TEA and PCA was measured as was the initial coronal alignment. Referencing of the TEA had been previously validated against computerised tomography in a previous study. During arthroplasty, neutral alignment was aimed for, and the final alignment after implant insertion was recorded. Pre- and 1 year post-operative flexion was measured. A standing four foot alignment radiograph was obtained 6 weeks after surgery to determine the weight-bearing mechanical axis.

The mean difference between the TEA and PCA was 3.94 degrees (−2.80 to 11.59) and median difference was 3.6 degrees. (A positive value implies the PCA is internally rotated with respect to the TEA). The median pre-operative flexion was 120 degrees (80–130) and the median post-operative flexion was 125 (85–145). The mean change in flexion was −2.5 degrees (−40 to 40; p=0.001). The mean intra-operative alignment was 0.75 degrees (−3 to 6, SD 1.9) and the mean radiographic alignment was 1.24 degrees (−6.5 to 6.5, SD 1.6).

Taking −3 to +3 to be neutral, the outlier rate intra-operatively was 6.5% and radiographically was 16.5%. The intra-operative and radiographic alignment showed correlation (coefficient 0.289). There was poor correlation between pre-operative deformity and degree of difference between intra-operative and radiographic alignment (coefficient −0.1).

Conclusion: There is a wide variation in the difference between the TEA and PCA, and there is not a good relationship with coronal alignment. Although most valgus knees had a bigger difference, such a difference was also seen in many varus knees. This should alert the surgeon when using posterior referencing jigs when determining the femoral component size and rotation. Although these patients achieved good post-operative flexion, this was determined by the pre-operative range. There was reasonable correlation between the final intra-operative mechanical alignment and the weight-bearing alignment as determined by a standing radiograph.

To determine the relationship between advancing months from ACL rupture and the incidence of intra-articular meniscal and chondral damage.

From a prospectively collected database 5086 patients undergoing primary ACL reconstruction, using hamstring graft, carried out between January 2000 and August 2010 were identified. Data collected included the interval between injury and surgery, type and location of meniscal tears (requiring meniscectomy) and location and severity of chondral damage (ICRS grading system). Patients were grouped according to time interval and age.

The median time from ACL injury to ACL reconstruction was 3 months (range 0.25 to 480). Overall, an increasing incidence of medial meniscal injury and chondral damage occurred with advancing chronicity of ACL deficiency. The incidence of medial meniscal injury requiring meniscectomy increased from 18% of patients undergoing ACL reconstruction within 4 months of injury to 59% of patients if ACL reconstruction was delayed more than 12 months (p<0.001). The incidence of lateral meniscal tears did not increase significantly over time.

The increasing incidence of secondary pathology with advancing chronicity was more pronounced in the younger age groups. The risk of a medial meniscal tear requiring resection was significantly less if surgery was performed before 5 months in the <17 years group (Odds Ratio 2) and 17–30 years group (OR 1.9), but less so in the 31–50 years group (OR 1.5) and >50 years group (OR 1.5). Advancing age was associated with a greater incidence of chondral damage and medial meniscal injury, but not lateral meniscal injury. Males had a greater incidence of lateral meniscal tears (34% vs. 20%), but not medial (28% vs. 25%) or chondral damage (35% vs. 36%), compared to females.

The incidence of chondral damage and medial meniscal tears increases with advancing time after ACL injury. Particularly in younger patients, ACL reconstruction should be performed within 4 months of ACL injury in order to minimise the risk of irreversible damage to meniscal and chondral structures.

Objective: This study was performed to review the current treatment and outcome of extra abdominal fibromatosis in our hospital, supplemented by a current review of the literature.

Method: A retrospective study of 72 patients with fibromatosis seen at the Royal National Orthopaedic Hospital (RNOH) between 1980 and 2009 was performed. Patients were identified using the databases at the peripheral nerves injury (PNI) unit and the histopathology department. Medical and radiological records were reviewed.

Results: There were 72 patients treated at the Sarcoma and PNI units. 40 patients were primary referrals, and 32 more had operations at the referring hospital. An operation was not carried out in 5 patients. 48 patients were treated by operation alone and this was supplemented by adjuvant therapy in 19 patients. Recurrence was seen in 24 (50.0%) of the operation alone group and 10 (52.6%) in the operation and adjuvant therapy group. The rate of recurrence was lower with complete excision. However, complete excision was impossible in some cases because of extension into the chest or spinal canal, or involvement with the axial vessels and lumbosacral or brachial plexus.

Conclusion: We suggest that operative excision should seek to preserve function and that supplementary adjuvant therapy may reduce the risk of recurrence, although excision margin appears to be the most important factor. The aggressive, infiltrative behaviour of deep fibromatoses and the associated genetic mutations identified, clearly distinguish them from the superficial fibromatoses and makes their treatment more difficult and dangerous, especially where vital structures are involved. We agree with the recent recommendation that these lesions should be treated in regional soft tissue sarcoma units.