Osteochondritis dissecans of the knee. A long-term study.

Twenty-two knees with osteochondritis dissecans diagnosed before skeletal maturity were followed prospectively into middle age: 32% had radiographic evidence of moderate or severe osteoarthritis at an average follow-up of 33.6 years; only half had a good or excellent functional result. We found that osteoarthritis was more likely to occur if the defect was large or affected the lateral femoral condyle.

The natural history and treatment of rupture of the anterior cruciate ligament in children and adolescents. A prospective review.

A total of 60 children and adolescents with rupture of the anterior cruciate ligament (ACL) was seen between 1980 and 1990. Observation of the 23 patients who were treated conservatively revealed that the natural history of the injury resulted in severe instability and poor function of the knee. Associated meniscal tears were present in 15 knees. Three osteochondral fractures occurred and osteoarthritic changes developed in ten knees. In 1990 therefore we introduced reconstruction of the ACL with a four-strand hamstring graft using an anatomical placement with transphyseal tunnels and anchorage well away from the growth plate. Over a period of nine years, 47 knees underwent reconstruction. The mean follow-up was 49 months (12 to 96). No child suffered physeal damage or leg-length discrepancy. The results were satisfactory in 77% and there was little difference between patients treated before the adolescent growth spurt and those treated during or after this time. These results, however, were not as good as those seen in adults during the same period.

Congenital absence of the anterior cruciate ligament. A common component of knee dysplasia.

The clinical and radiological features of 12 knees (10 patients) with congenital absence of the anterior cruciate ligament are presented. The high frequency of this condition in association with other more easily recognised congenital abnormalities of the knee is discussed. It is concluded that congenital absence of the anterior cruciate ligament is more common than generally suspected and is associated with other developmental abnormalities of both bone and soft tissue in the lower limb, particularly around the knee joint.

Congenital discoid lateral meniscus in children. A follow-up study and evolution of management.

Fifty-two children with 62 discoid lateral menisci were reviewed at an average follow-up of 5.5 years. Their average age at operation was 10.5 years and the mean delay in diagnosis was 24 months. Most of the children had vague and intermittent symptoms and the classical clunk was demonstrable in only 39% of the knees. An associated osteochondritis dissecans of the lateral femoral condyle was seen in seven knees. Forty-eight knees with symptomatic torn discoid menisci underwent open total lateral meniscectomy, six had arthroscopic partial meniscectomy and eight knees with intact discoid menisci, were left alone. Based on Ikeuchi's grading (Ikeuchi 1982), 37% of the knees had an excellent result, 47% had a good result and 16% had a fair result: none was poor. Arthroscopic partial meniscectomy is recommended only when the posterior attachment of the discoid meniscus is stable. A total meniscectomy is indicated for the Wrisberg-ligament type of discoid meniscus with posterior instability.

Open and closed meniscectomy. A comparative analysis.

We reviewed 230 patients an average of 34 months after they had undergone partial or total meniscectomy by surgeons of different experience in a busy unit. Open and arthroscopic meniscectomies were compared. Arthroscopic partial meniscectomy resulted in a significant reduction of inpatient stay and earlier return to work and sport. Analysis of the type of meniscal damage showed that arthroscopic removal of "bucket handles" achieved better results than open techniques. Comparatively poor results were found for lateral meniscectomy.

Bone-marrow transplantation in Hurler's syndrome. Effect on skeletal development.

Between 1980 and 1988, displacement bone-marrow transplantation was performed on 25 children with Hurler's syndrome (type-1 mucopolysaccharidosis). We describe the musculoskeletal development of 11 of the 12 surviving children and the orthopaedic procedures undertaken to treat progressive thoracolumbar kyphosis, hip subluxation and carpal tunnel syndrome. We found abnormal bone modelling, focal failures of ossification and an avascular disorder of the femoral head in every patient and offer an explanation for these phenomena. Increasing valgus deformity of the knees and progressive generalised myopathy caused loss of mobility as the children entered adolescence. The benefit of bone-marrow transplantation as a treatment for the skeletal disorders of Hurler's syndrome is limited by the poor penetration of the musculoskeletal tissues by the enzyme derived from the leucocytes.

Epiphyseal distraction monitored by strain gauges. Results in seven children.

Ten epiphyses in seven children underwent fixed-rate distraction of 0.25 mm twice daily in an attempt to achieve percutaneous leg lengthening by chondrodiatasis. The forces generated across the growth plate were recorded by means of strain gauges incorporated into the distractors. All epiphyses fractured before 33 days of lengthening. An average gain of 6.75 cm was achieved. Epiphyseal distraction at the lower femur produced many complications, but at the upper tibial epiphysis planned lengthening was achieved, with excellent bone production and few complications.

Anterior cruciate ligament.

Anterior cruciate ligament surgery is currently widely practiced. Nevertheless it is a surgery which is performed electively, mostly in young healthy adults who chose to continue in their sporting endeavours. We present a short account of the various aspects of this surgery as well as our preferred technique and results.

The fat pad. Clinical observations.

This article retrospectively reviews 53 patients with various knee joint conditions in which the fat pad was implicated. The patients were divided into four groups: patellar tendonitis, cruciate ligament surgery, meniscal surgery, and miscellaneous. Patient ages ranged from 17 to 67 years, and follow-up ranged from 4 weeks to 5 years. All of the patients presented with pain or stiffness that was related in part to the fat pad pathology. This finding was confirmed by an injection of local anesthetic and steroid into the fat pad itself, which was followed by transient although complete symptomatic relief. We conclude that fat pad pathology is usually secondary to other knee joint pathology, and its primary involvement is rare. The pain produced by the fat pad may have serious implications on knee joint function if not dealt with promptly. Appreciation of the source of pain in knee joint pathology will allow better management of the knee condition. The role of physical therapy and cooperation between the physical therapist and the surgeon is of paramount importance for the final outcome. More work is needed to correlate the relation of the anatomy of the fat pad to knee symptoms and function.

A prospective review of arthroscopic debridement for degenerative joint disease of the knee.

A prospective review of 254 patients with moderate or severe knee pain due to degenerative joint disease, treated by arthroscopic debridement of menisci, articular cartilage, osteophytes and loose bodies has been made 24 to 140 months (average of 44 months) after surgery. Patients ranged in age from 28 to 82 years with an average of 49 years. At review, 75% had minimal discomfort and improved function and 85% were satisfied with the treatment. Those with less radiographic arthritis, less severe involvement of articular cartilage at operation and of younger age had more worthwhile improvement. This procedure allows worthwhile relief of symptoms, and only 14% had a subsequent operation after an average period of four years.

Radiological study of alignment after total knee replacement. Short radiographs or long radiographs?

The axial alignment on short and long radiographs was measured in 50 knees in 34 patients who had undergone posteriorly stabilised (Insall-Burstein) condylar knee arthroplasty. A mean difference of 1.6 degrees was found when the tibiofemoral angles were compared on short and long radiographs. Short radiographs are probably adequate for routine assessment of knee replacements in a busy out-patient clinic, but for accurate scientific studies the long radiographs are preferable.

Posteriorly stabilised (Insall-Burstein) total condylar knee arthroplasty. A follow-up study of 157 knees.

We reviewed 157 knees in 118 patients who underwent posteriorly stabilised (Insall-Burstein) knee replacement arthroplasty. Their mean age at operation was 69 years (range 47 to 85 years) and the average follow-up was 3.5 years (range 2 to 7 years). The "BASK" knee function assessment chart was utilised to evaluate the functional and clinical results. One hundred and thirty-five knees (86%) had excellent or good results, 16 knees (10%) had fair results and six (4%) had poor results. The mean postoperative BASK score was 79 points and the average postoperative knee flexion was 95 degrees (range 65 degrees to 130 degrees). Two patients had a superficial infection, one deep sepsis requiring revision arthroplasty and two mechanical loosening. Patellar impingement symptoms were present in 8% of the knees, although they were troublesome in less than half. Varus alignment of the knee and a varus tilt of the tibial component of more than 2 degrees correlated with the incidence of radiolucent lines around the tibial prosthesis. 90% of the patients were pleased or satisfied with the functional result. The total condylar knee is a safe, reliable and versatile prosthesis.

The posterior cruciate ligament: a review.

The posterior cruciate ligament (PCL) has acquired the attention given to the anterior cruciate ligament (ACL) 15 years ago. Although parallels can be drawn between the ACL and the PCL in general, PCL deficiency is generally more complex in its effect, evaluation, documentation, and treatment. While there has been a constant upgrading of the operative techniques, grafting tissue, and material, it is the correlation of anatomy and function that still lag behind. Conservative treatment, therefore, is the safe approach for a while but is not without limited function in many cases, leading to a decrease in activity level or preventing the patient from working. This article reviews PCL deficiency and presents our approach to this ligamentous deficiency.

The interposition of extensor digitorum brevis in the resection of calcaneonavicular bars.

In this series of 19 resected calcaneonavicular bars for peroneal spastic flatfoot (mean follow-up 3.4 years), we demonstrate that interposition of extensor digitorum brevis led to asymptomatic mobile feet without evidence of recurrence of the bar in 90% of the patients; this compares well with 43% recurrence rates of bars with associated pain and stiffness when extensor digitorum brevis is not interposed. We therefore recommend this method for prevention of the bar and their symptoms.

Surgical aspects of patellar tendonitis: technique and results.

Patellar tendonitis is a difficult clinical problem, and surgical treatment remains unclear in its indications, technique, and functional outcome. This article reviews 17 patients (18 knees) with either primary or secondary patellar tendonitis who required operative treatment. Twelve men and 5 women aged 19-50 years comprised the study population. The right knee was involved in 10 patients, and the left knee was involved in 8. Average time from injury to surgery was 24 months, and average postoperative follow-up was 12 months (range: 6-24 months). Criteria were developed for subjective, objective, functional, and overall evaluation. All knees that were operated on were rated as "very abnormal" preoperatively. Postoperatively, 16 (89%) knees were rated as normal or nearly normal, whereas 2 (11%) knees were rated as abnormal. A surgical technique is described, with emphasis on the rationale and technique, and reasons for initial surgical failure and poor functional outcomes are discussed.

A combined intra- and extra-articular reconstruction using a carbon-dacron composite prosthesis for chronic anterior cruciate instability. A two to six-year follow-up study.

Fifty patients with chronic symptomatic anterior cruciate insufficiency underwent ligamentous reconstruction using the "Westminster Composite Prosthesis" which consists of a central core of carbon fibre with an external weave of polyester. In 42 patients, the prosthesis was used as an augmentation within a tube of ilio-tibial tract, combined with a MacIntosh's extraarticular reconstruction. The prosthetic replacement alone was used in eight patients where there had been a previous extraarticular reconstruction and was associated with only fair results. The average age of the patients at operation was 28.5 years (range 18 to 50 years); instability of the knee had been present for a mean of 5.3 years and the average follow-up was 3.8 years (range 2 to 6 years). Assessment included subjective functional rating (Lysholm knee score) and clinical examination for instability. Thirty-seven patients (74%) had a good or excellent result, 11 (22%) had a fair result and two (4%) had a poor result. The Lachman test was grade I or less in 35 patients and the pivot shift sign was eliminated in 37 patients. Clinical signs of instability correlated well with the Lysholm knee score (p less than 0.001). Twenty-two unselected patients (44%) underwent an arthroscopic assessment and biopsy of the "neoligament" at an average of 10.4 months post-operatively. The prosthesis was found to be stable and well covered by a thick fibrous sheath ("neoligament") in 19 patients. The prosthesis was partially ruptured in two patients and completely disrupted in one. Thirty-two patients (64%) returned to their previous sports and 13 of them (26%) achieved their pre-injury level of performance.(ABSTRACT TRUNCATED AT 250 WORDS)