Long-term clinical review (10-20 years) after reconstruction of the anterior cruciate ligament using the Leeds-Keio synthetic ligament.

Prosthetic ligament use for anterior cruciate ligament (ACL) reconstruction was popular in the 1980s and 1990s. Information from published studies regarding the long-term outcomes of this surgery is limited. This paper presents the long-term results of stabilization of the ACL deficient knee using the Leeds-Keio synthetic ligament formed from woven polyester. Fifty patients were seen in clinic at a mean follow-up of 11.9 years (range 8.7-19.7 years). The mean ages were: at injury 26.8 years (range 16-47 years), at surgery 29.9 years (range 18-47 years), and at review 42 years (30-56 years). Of the 50 patients included, 86% were male and 14% were female. The main causes of injury were football (42%), rugby (25%), and skiing (8%). The mean time from injury to surgery was 37.6 months (range 0-324 months). All patients received intra-articular (IA) ligaments placed in the anatomical position of the natural ACL. In addition, approximately 75% also had an extra-articular ligament placed so that it ran parallel to the IA component on the lateral aspect of the knee. At review, patients were thoroughly assessed with history, examination, and IKDC criteria. IKDC scores were excellent or good in 92% of patients seen while combined IKDC and thorough clinical history findings were good or excellent in 84% of patients seen. Patient satisfaction was high with 90% of patients being satisfied or very satisfied with the outcome of surgery. Activity levels were also high according to IKDC criteria. At one year postoperatively, approximately 66% of patients had returned to their preinjury level of activity. At review, almost half of all patients still maintained this level. Of those patients who did not, only 6% attributed this to knee instability. Furthermore, the vast majority of patients (92%) still had activity levels superior to that of postinjury/preoperatively. Rupture of the intra-articular component was confirmed in six cases (12%) and three of these patients continued to experience functional knee instability. These results demonstrate that synthetic ligament can provide long-term functional stability in the knee following a loss of the ACL.

Comparison of autologous transfusion drains versus no drain in total knee arthroplasty.

Primary total knee arthroplasty is associated with blood loss both during surgery and in the immediate postoperative period, that may require allogenic blood transfusion. In view of the risks and financial implications of using allogenic blood, an accepted solution has been to utilise autotransfusion drains in the postoperative period thus allowing re-infusion of a patient's own blood. A number of studies have compared retransfusion techniques with standard drain use, but few report comparison with no drain use at all. We analysed data from patients undergoing primary total knee arthroplasty within our unit over an 18-month period. A total of 121 patients were included in the study: 53 received retransfusion drains whilst the remaining 68 received no drain at all. The mean postoperative haemoglobin drop was not significantly different between the two groups (p > 0.05). In the retransfusion group only one patient (2%) required allogenic blood transfusion postoperatively, whilst 4 of the 68 (6%) did so in the control group. This difference was not statistically significant either. This study showed a low rate of allogenic blood use postoperatively (< 5%) where either a retransfusion drain or no drain was used at all. However because there was no measurable difference between the two, we conclude that using a retransfusion technique does not appear to be of significant financial or clinical benefit with regards to allogenic blood transfusions compared with using no drain.

A novel external fixator used to treat open comminuted fractures of the middle and distal phalanges with concomitant FDP avulsion injury.

The use of external fixators for treating comminuted hand fractures has become popular with commercially available or handmade fixators assembled in the operating theater. We present a case of a Zone I flexor digitorum profundus (FDP) avulsion fracture that was complicated by the presence of open, comminuted fractures of the distal and middle phalanges. The injury was treated using an external fixator constructed in the operating theater from readily available materials and with a 4-strand pullout suture technique tied over a button to repair the FDP avulsion. This technique facilitated treatment of the comminuted and contaminated fractures while allowing reconstruction of the Zone I FDP injury and allowing relatively early mobilization of the FDP repair.

An electromyographic exploratory study comparing the difference in the onset of hamstring and quadriceps contraction in patients with anterior knee pain.

Idiopathic anterior knee pain in teenagers and young adults is a common condition. Patellar maltracking has been considered as a causative factor. The aim of our study was to investigate whether there was a difference in the timing of electromyographic (EMG) activity in the medial and lateral hamstring and quadriceps muscles of patients with anterior knee pain compared to asymptomatic control participants. This was a cross sectional observational study measuring EMG activation patterns. Two groups of participants were tested, one patient (mean age 15 years, n = 20) and one asymptomatic control (mean age 16 years, n = 17). Surface EMG (sampling rate 1000 Hz) was recorded from vastus medialis obliqus, vastus lateralis, and the medial and lateral hamstrings during three repetitions of maximal voluntary isometric contractions. The relative timing of the medial and lateral quadriceps and hamstrings was evaluated. The mean (95% confidence interval) difference between the groups in the lateral-medial hamstring onset timing was 53.8(1.9 to 105.6)ms during the maximal contraction. An independent t test showed that this difference was statistically significant (p = 0.043). The differences between the groups in the relative VMO to VL onset did not reach statistical significance. The results of this study suggest that the lateral hamstrings contract significantly earlier in patients with AKP compared to healthy controls for this small cohort. This altered activation pattern could produce external rotation of the tibia on the femur and cause lateral patella tracking.

A minimally invasive surgical technique for augmented reconstruction of the lateral ankle ligaments with woven polyester tape.

Although stabilization of the lateral ankle ligament complex (LALC) with augmented techniques is known to be successful, it is associated with a number of complications. We hypothesize that successful stabilization of LALC can be achieved with a woven polyester tape implant via a minimally invasive procedure, as an alternative to tenodesis. Four men with chronic instability of the ankle underwent a minimally invasive surgical stabilization of LALC with a woven polyester tape. This tape was passed through the distal fibula to the base of the fifth metatarsal and then back to the fibula once more before being tied. The foot was immobilized in a neutral position for 2 weeks. Partial weightbearing with a walking stick began on the same day, and physiotherapy began for 10 weeks. Evaluation was performed at a mean follow-up of 24.5 months postoperatively. Preoperatively, all patients had a chronically unstable index ankle both functionally and clinically. At a mean of 24.5 months postoperatively, functional stability for all patients was normal (Sefton grade 1). Subjective ankle performance grades were normal in all cases, and all patients felt the outcome was excellent. Objective measurement with clinical stress testing showed anterior drawer and inversion tests to be the same as the contralateral ankle in all patients. However, each displayed limited inversion of the ankle. No complications such as wound dehiscence, infection, pain, or nerve injury were observed after the procedure. All were able to return to their preinjury activity level within 3 months. Stabilization of LALC may be simply and successfully achieved with a woven polyester graft as an alternative to tenodesis.