The influence of pre-operative Computed Tomography (CT) on surgical approach and fixation for fractures of the tibial plateau.

Background: It is well known that a computed tomography (CT) scan improves the classification of tibial plateau fractures (TPF) compared with radiographs. However, it is less clear how this translates into clinical practice. The aim of this study is to establish to what extent a pre-operative CT scan alters the approach, setup and fixation choice in TPF compared to radiographs. Methods: 50 consecutive TPF with a preoperative CT and radiographic imaging available, were assessed by 4 consultant surgeons. First, anonymised radiographs were classifying according to the column classification and the planned setup, approach, and fixation technique documented. At a 1-month interval, randomised matched CT scans were assessed and the same data collected. A tibial plateau disruption score (TPDS) was derived for all 4 quadrants (no injury = 0, split = 1, split/depression = 2 and depression = 3). Radiograph and CT TPDS were assessed using an unpaired T-test. Results: 26 female and 24 male patients, mean age 50.3, were included. Mean TPDS on radiographs and CT scans were 2.77 and 3.17 respectively. A significantly higher CT TPDS, of 0.4 (95%CI 0.10-0.71)[P = 0.0093] was observed, demonstrating that radiographs underestimate the extent of injury. The surgical approach changed in 28.5% of cases, thus influencing a change in the patient setup in theatre in 27% of cases. Identification of fractures within a column changed in 34% of cases. A high intra-observer reliability was observed when surgeons were asked to repeat their assessment in a third round at a further one month interval. Conclusion: A pre-operative CT scan has a significant effect on the approach required to fix TPF. This therefore influences the setup of the patient and can justifiably be requested as part of pre-operative planning.

Synovial hemangioma of the knee.

A 24-year-old woman was diagnosed with monoarticular spontaneous nontraumatic knee hemarthrosis at age 9 years. Following multiple scans and arthroscopies, a diagnosis of cavernous synovial hemangioma was made radiographically and histologically 15 years later. This was treated surgically with excellent results. Preoperative magnetic resonance imaging (MRI) and Doppler ultrasound are recommended for diagnosis and surgical planning, with the use of a dual coagulation shaver for definitive excision of the lesion. Follow-up should be conducted 6 and 12 months postoperatively with MRI and Doppler ultrasound to determine recurrence.

Reliability of clinical diagnosis in meniscal tears.

This retrospective study was conducted to analyse the reliability of clinical diagnosis in meniscal tear injuries. All patients attending our clinic with knee pain from January 2003 to December 2004 underwent systematic and thorough clinical assessment. One hundred and fifty patients were clinically diagnosed to have meniscal tears. All these patients underwent therapeutic arthroscopic knee surgery. The clinical diagnosis was confirmed during this procedure. The accuracy, sensitivity and specificity were calculated based on these arthroscopic findings. The accuracy of clinical diagnosis in our study was 88% for medial meniscal tears and 92% for lateral meniscal tears. The results of this study demonstrate that clinical diagnosis of meniscal tears is as reliable as the results published by other authors for magnetic resonance imaging (MRI) scan. We recommend the use of MRI for more doubtful, difficult and complex knee injuries.

Anterior cruciate ligament reconstruction in patients over the age of 50 years: 2- to 8-year follow-up.

We present medium-term results in 30 prospectively followed patients aged over 50 years at the time of ACL reconstruction (31 procedures); mean follow-up time was 46 months (range 24-95). Mean Lysholm score improved significantly from 63 pre-operatively to 93 at final review Cincinnati score from 49 to 89. In IKDC score 25 knees (81%) were considered normal or nearly normal and 6 abnormal; there were no severely abnormal results. Mean Tegner activity scores improved from pre-operatively from 3.7 to 5.2 at review. Mean side-to-side difference measured by the KT-1000 at maximal manual pressure was 2.7 mm; two knees had. a measured difference greater than 5 mm. The mean torque ratio for isokinetic flexion strength was 102% and for extension strength 94%. Poor results as determined by the three scoring systems were associated mainly with advanced articular degenerative changes (Outerbridge grade 3 or 4) seen at the time of reconstruction. Despite this all patients reported improvement in stability and overall function of the knee. Degenerative change itself was associated with increased time to surgery from injury. This study demonstrates that the ACL can be reliably reconstructed in patients over the age of 50 years with good symptomatic relief, restoration of function and return to sporting activity.