Revision anterior cruciate ligament reconstruction: a midterm patient assessment.

Twenty patients who underwent revision anterior cruciate reconstruction were retrospectively reviewed. Before revision surgery all patients reported functional instability with daily and or sporting activities. The causes of primary graft failure have been identified. Four different types of graft were used for the revision reconstruction. A comprehensive knee analysis was used to assess the graft performance both subjectively and objectively at an arranged follow-up visit. In general our study shows that although there is residual antero-posterior laxity on clinical assessment and KT-1000 instrumentation after revision surgery, the majority of patients thought the results were subjectively good or excellent. The study highlights the well-recognised technical failures of primary anterior cruciate ligament reconstruction and confirms good subjective results. The poor correlation between the physical examination (objective) and the patient's perception (subjective) of the revision surgery is discussed.

Functional evaluation of the modified Elmslie-Trillat procedure for patello-femoral dysfunction.

A series of 28 knees in 27 patients were evaluated at an average of 36 months following surgical treatment for patella dislocation, patello-femoral pain, or a combination of both. All cases were treated by the modified Elmslie-Trillat procedure, which involves a lateral retinacular release and medialisation of the tibial tubercle on a distal pedicle. The evaluation included subjective, objective (Fulkerson and Kujala functional knee scores) and radiographic assessments. Subjectively, eight knees (28%) had excellent results, nine knees (33%) good results and seven knees (25%) fair results, accounting for an overall improvement of 86% over the preoperative status. All the knees in patients with a primary symptom of patella dislocation had an excellent or good subjective result, whilst only four knees (40%) in those patients with a primary symptom of pain and four knees (44%) in those with both pain and dislocation had a good or excellent result. The mean objective knee score was excellent for patients with dislocation only, and fair for those with only pain or both pain and dislocation. There have been no further episodes of dislocation in all patients. Six knees (21%) required later screw removal. The modified Elmslie-Trillat procedure produces a favourable outcome in patients with patella dislocation.

Osseous metaplasia as a cause of loss of extension after anterior cruciate ligament reconstruction.

We report a case of osseous metaplasia of an autologous anterior cruciate ligament (ACL) reconstruction that was implicated in blocking extension of the knee. Nonoperative treatment was unsuccessful. Arthroscopic excision of the ACL and osseous metaplasia abolished the fixed flexion deformity. The osseous metaplasia was an additional factor in causing the block to extension along with an anteriorly placed femoral tunnel, raising the question that nonisometry of the graft may be involved in the pathogenesis of the osseous metaplasia.

Day surgery anterior cruciate ligament reconstruction: Sheffield experiences.

A review of the safety, practicality and cost effectiveness of day surgery anterior cruciate ligament reconstruction was studied in the British set-up. We evaluated 20 patients prospectively who underwent ACL reconstruction as a day surgery procedure for pain control, recovery time, post-operative complications and cost effectiveness. All patients on a verbal response score (VRS) for pain expressed themselves as satisfied or very satisfied. All patients regained a range of movement of 0-90 degrees by 1 week and 0-130 degrees by 6 weeks post-operatively. None of the patients required hospitalisation, only two patients had superficial wound infections at the graft-harvesting site. Cost analysis showed that day surgery ACL reconstruction was cost effective. The average saving per patient was in the range of 20-25% when compared to inpatient ACL reconstruction.

How your "free" tail liability policy is funded.

The Extended Reporting Endorsements for Claims-made Professional Liability policies are provided to insured doctors in the event of death, disability, and retirement (DDR) with no additional premium charge if certain criteria are met. However, this "free tail" policy is actually pre-funded via a percentage loading applied to all insureds' ongoing premium. The amount of this loading is determined by continual monitoring of the demographics of the insured population. This article sheds light on the process used by professional liability companies to price "free tail" policies and reviews the key concepts involved.

Degradation of cartilage type II collagen precedes the onset of osteoarthritis following anterior cruciate ligament rupture.

OBJECTIVE: To determine if degradation of cartilage matrix in primary osteoarthritis (OA) or in OA secondary to rupture of the anterior cruciate ligament (ACL) is a gradual response to excessive loading or an early, initiating event in the disease process. METHODS: Biopsy samples were obtained from the low-weight-bearing articular cartilage of the intercondylar notch, in patients undergoing knee arthroscopy (ACL injury) or arthroplasty (late-stage primary OA) or in controls. In some cases, biopsy samples were also removed from the high-weight-bearing articular cartilage of the femoral condyles. Biopsy specimens were extracted and assayed for total and denatured type II collagen (CII) by inhibition enzyme-linked immunosorbent assay and for proteoglycan using a colorimetric method. All patients were assessed radiographically for cartilage erosion. In addition, the cartilage of patients with ACL injury was assessed at arthroscopy, and the knee function of patients with primary OA was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). RESULTS: Increased CII degradation was detected in the low- as well as the high-weight-bearing cartilage of patients with late-stage OA, and there was a positive correlation between the percentage denatured collagen and the WOMAC score. Most of the patients with ACL injury had no clinical signs of OA or macroscopic cartilage erosion. However, the low-weight-bearing articular cartilage from these patients showed a significant increase in CII degradation, similar to that observed in late-stage OA. The proteoglycan content of articular cartilage did not change significantly in patients with OA or ACL injury compared with controls. CONCLUSION: CII degradation is an early event following ACL injury and is unlikely to be a direct result of mechanical loading, since it was observed in cartilage obtained from a low-weight-bearing site.

The popliteofibular ligament. An anatomical study of the posterolateral corner of the knee.

We designed an experimental study to prove the existence of the popliteofibular ligament (PFL) and to define its role in providing static stability of the knee. We also examined the contribution of the lateral collateral ligament (LCL). We found this ligament to be present in all eight human cadaver knees examined. These specimens were mounted on a specially designed rig and subjected to posterior, varus and external rotational forces. We used the technique of selective sectioning of ligaments and measured the displacement with a constant force applied, before and after its division. We recorded the displacement in primary posterior translation, coupled external rotation, primary varus angulation and primary external rotation. Statistical analysis using the standard error of the mean by plotting 95% confidence intervals, was used to evaluate the results. The PFL had a significant role in preventing excessive posterior translation and varus angulation, and in restricting excessive primary and coupled external rotation. Isolated section of the belly of popliteus did not cause significant posterolateral instability of the knee. The LCL was also seen to act as a primary restraint against varus angulation and secondary restraint against external rotation and posterior displacement. Our findings showed that in knees with isolated disruption of the PFL stability was restored when it was reconstructed. However in knees in which the LCL was also disrupted, isolated reconstruction of the PFL did not restore stability.

Mucoid cystic degeneration of the cruciate ligament.

A 35-year-old man was seen with pain in the back of the knee. MRI showed a mass in the anterior cruciate ligament. Biopsy indicated mucoid degeneration. Arthroscopic resection of the ligament was carried out, with relief of symptoms.

Synovial osteochondromatosis of the cruciate ligament.

An unusual case of synovial chondromatosis of the cruciate ligaments is reported that resulted principally in a loss of function, secondary to a mechanical block to extension. Magnetic resonance imaging was useful in directing surgery, but not in making the formal diagnosis.

Posterior cruciate ligament injuries.

Until recently, the function of the posterior cruciate ligament has been poorly understood and the traditional wisdom is that injuries to this ligament do not result in any appreciable functional disability. There is increasing evidence, however, that the natural history may not be as benign as was originally assumed. This review seeks to analyse current knowledge concerning the function, diagnosis, natural history and treatment of this injury.

Mechanical properties of the human anterior cruciate ligament.

The aim was to measure the stiffness and strength of the femur-anterior cruciate ligament-tibia complex tested in a physiological manner with a force exerted anteriorly on the tibia, at knee joint flexion angles of 0 degrees, 10 degrees and 30 degrees and at speeds of 50 and 500 mm/min. Ligaments were preconditioned by cycling five times, with data from the fifth cycle used to determine the stiffness of the ligament in a low-load range. The ligaments were then tested to failure with the knee at 30 degrees flexion. The specimens were divided into two groups, middle-aged (40-60) and old (>60). For each group no statistical difference was observed between stiffness of the ligament at different joint flexion angles or speeds. Seven of the 21 specimens in the older age group failed by avulsion at the bone-ligament interface. All the other specimens failed by tears in the substance of the ligament. Ultimate failure load was found to have a significant correlation with bodyweight. It was 1.6 and 1.3 times bodyweight for the middle-aged and older age groups respectively. This study has highlighted the importance of identifying different modes of failure, of making corrections for bodyweight and testing in a physiological manner. The results allow a better understanding of the mechanical behaviour of the anterior cruciate ligament and provide design data for anterior cruciate ligament grafts and prostheses. RELEVANCE:--Our clinical experience indicates that the anterior cruciate ligament is frequently ruptured during uncoordinated contraction of the quadriceps mechanism. The results of this study, in which the mechanical properties of the anterior cruciate ligament have been measured with force exerted anteriorly on the tibia, allow a more complete understanding of the mechanical behaviour of the anterior cruciate ligament and provide design data for anterior cruciate ligament grafts and prostheses.

Algodystrophy: an under-recognized complication of minor trauma.

Algodystrophy is a poorly recognized condition of uncertain aetiology which presents with pain and tenderness, vascular instability, swelling and stiffness of an affected limb. It is most commonly seen after trauma. In order to ascertain its incidence, natural history and the degree of morbidity induced we studied prospectively 274 patients with Colles' fracture. Algodystrophy, as judged by the presence of bone pain or tenderness, vasomotor symptoms, swelling and stiffness of the hand was noted in 28% of patients. There was a significant association between the presence of these features (P < 0.0001). The degree of trauma sustained was identified as a predisposing factor. Actuarial analysis showed a gradual resolution of symptoms. Six months after injury, the proportion of patients complaining of pain and swelling had fallen to 20-30%, vascular instability and tenderness to 50% and stiffness to 80%. Failure to improve was associated with a significant loss of hand function (P < 0.0001). By 1 yr, pain and tenderness, vascular instability and swelling had decreased still further but stiffness was still apparent in 50%. We believe that algodystrophy is a neglected disorder and is far more common than formerly appreciated. Although it often resolves spontaneously, it is associated with a significant increase in short-term morbidity in the majority of patients and persistent dysfunction in a minority.

Changes in cortical and trabecular bone in algodystrophy.

We studied the pattern of bone loss in the hand of 77 patients with Colles' fracture using metacarpal morphometry, single photon absorptiometry and a radiographic scoring system. Forty-four patients had post-traumatic algodystrophy and the remainder served as controls. Both groups were immobilized in the same manner and for the same period of time and both showed loss of bone during immobilization. The loss of bone 7 weeks after fracture was significantly greater in algodystrophy than in controls both at cortical (P < 0.05) and at trabecular sites (P < 0.001). Recovery of bone occurred in the control patients by 19 weeks after fracture at cortical sites and by 31 weeks in trabecular bone. In contrast, the bone loss seen in patients with algodystrophy persisted for the 6-month duration of the follow-up, and up to 1 year in all nine patients studied for longer. These findings indicate that post-traumatic algodystrophy is associated with regional skeletal losses greater than those following uncomplicated fracture and may result in irreversible changes in the structure and thus the strength of the bony architecture.

The use of nasal calcitonin in the treatment of post-traumatic algodystrophy.

Calcitonin is widely used in the treatment of algodystrophy but a major disadvantage is the need for its parenteral administration. For this reason, we evaluated the effect of 400 iu of nasal calcitonin in the treatment of post-traumatic algodystrophy in a prospective randomized double-blind study. We found no demonstrable effect on the clinical or skeletal progression of the disorder using sensitive methods of measuring the response to treatment. There was, however, a small but significant hypocalcaemic response in the treatment group despite no change in the other indices of bone turnover. Possible reasons for this lack of clinical and skeletal effect are discussed.

An investigation into the etiology of irritable hip.

A prospective review has been made of 111 children who presented with acute hip pain to determine it's etiology and assess the need for multiple investigations at presentation. There was no clinical hematological, serological or bacteriological evidence to identify positively patients with an irritable hip, neither was there good correlation with a history of infection. An effusion was diagnosed by ultrasound in 71% but there were no factors, either clinically or by investigation, to differentiate between patients with or without an effusion. We conclude that multiple investigations to find a source of infection in patients with irritable hip are not warranted as they are rarely positive, seldom affect management and are of no help in investigating the etiology of irritable hip.