Recurrent haemarthrosis following total knee replacement.

Total knee replacement is a well-established treatment for osteoarthritis with increasing numbers performed each year. Recurrent haemarthrosis is a relatively rare complication following TKR being reported in up to 1.6% of patients. While some causes are related to direct trauma to blood vessels, others are more obscure and may be difficult to diagnose. The purpose of this review is to give an overview of this unusual complication and summarise the current methods of management.

Patient-based outcomes in patellofemoral arthroplasty.

This retrospective study evaluated the short-term functional outcome of patellofemoral arthroplasty using patient-based outcome measures. The study cohort included 17 patients who underwent patellofemoral arthroplasty (14 unilateral and 3 bilateral) between 1996 and 2005. Mean patient age was 56 years (range, 43-65 years), and mean follow-up was 52.5 months (range, 24-84 months). Clinical and radiographic assessment was performed using the Hospital for Special Surgery (HSS) knee score. Functional assessment was performed using the Short Form-36 (SF-36) and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Mean HSS knee score was 64 (range, 51-79) preoperatively and 90 (range, 71-100) postoperatively. Mean postoperative SF-36 scores were compared with normative data compiled by the British Omnibus Survey in 1992. Scores for physical and social functioning, role limitation due to physical and emotional problems, and pain were poorer compared with mental health and energy/vitality. Mean postoperative scores for the 5 KOOS subscales ranged from 51% to 72%. These findings indicate patient-based outcome measures should be used routinely for functional assessment of patients undergoing patellofemoral arthroplasty.

Knee arthrodesis--a review.

Knee arthrodesis as a primary treatment method for knee arthritis has re-emerged as a salvage procedure for failed knee arthroplasty. This article is an overview of indications, contraindications, principles, preoperative preparation and surgical techniques of knee arthrodesis. Their advantages and disadvantages are discussed together with results and complications. An attempt has also been made to incorporate technical considerations, the author's preferred surgical techniques and indications for the various methods of arthrodesis.

Complex regional pain syndrome with special emphasis on the knee.

Complex regional pain syndrome is characterised by an exaggerated response to injury in a limb with intense prolonged pain, vasomotor disturbance, delayed functional recovery and trophic changes. This review describes the current knowledge of the condition and outlines the methods of treatment available with particular emphasis on the knee.

Combined reconstruction of chronic posterior cruciate ligament and posterolateral corner deficiency. A two- to nine-year follow-up study.

We report a retrospective analysis of the results of combined arthroscopically-assisted posterior cruciate ligament reconstruction and open reconstruction of the posterolateral corner in 19 patients with chronic (three or more months) symptomatic instability and pain in the knee. All the operations were performed between 1996 and 2003 and all the patients were assessed pre- and post-operatively by physical examination and by applying three different ligament rating scores. All also had weight-bearing radiographs, MR scans and an examination under anaesthesia and arthroscopy pre-operatively. The posterior cruciate ligament reconstruction was performed using an arthroscopically-assisted single anterolateral bundle technique and the posterolateral corner structures were reconstructed using an open Larson type of tenodesis. The mean follow up was 66.8 months (24 to 110). Pre-operatively, all the patients had a grade III posterior sag according to Clancy and demonstrated more than 20 degrees of external rotation compared with the opposite normal knee on the Dial test. Post-operatively, seven patients (37%) had no residual posterior sag, 11 (58%) had a grade I posterior sag and one (5%) had a grade II posterior sag. In five patients (26%) there was persistent minimal posterolateral laxity. The Lysholm score improved from a mean of 41.2 (28 to 53) to 76.5 (57 to 100) (p = 0.0001) and the Tegner score from a mean of 2.6 (1 to 4) to 6.4 (4 to 9) (p = 0.0001). We conclude that while a combined reconstruction of chronic posterior cruciate ligament and posterolateral corner instability improves the function of the knee, it does not restore complete stability.

Update on paediatric ACL injuries.

In the last two decades there has been an increase in the incidence of anterior cruciate ligament (ACL) injuries in children. This may be due to increased awareness, more participation in high demand contact and non-contact sports at an earlier age and better diagnosis as a result of better imaging. A review of the literature suggests that the long-term results of non-operative treatment are poor. While the short to medium-term results of ACL reconstruction in children are encouraging, the long-term results are unknown. In this review, the current trends in the management of paediatric ACL injuries are discussed with particular emphasis on the natural history, surgical techniques, the effect of surgery on the growth plate and complications.

High tibial osteotomy for medial compartment osteoarthritis.

Unicompartmental osteoarthritis of the knee is often a difficult management problem in the younger age group. A high tibial osteotomy has been found to be quite an effective procedure for this condition in the past. A better understanding of the principles of this technique and innovations in the instrumentation has renewed interest in this procedure. This article provides an overview of the principles, biology, indications, contraindications, planning and execution, postoperative care, results and complications of high tibial osteotomy. An attempt has been made to incorporate important technical considerations, recent developments and other treatment options in this condition.

Injuries of the posterior cruciate ligament and posterolateral corner of the knee.

Injuries of the posterior cruciate ligament (PCL) and posterolateral corner (PLC) of the knee are less common than those of the anterior cruciate ligament (ACL) and their significance is often under-appreciated in the acute setting. Even when recognised, knowledge of the natural history and outcome of treatment has lagged behind that of the ACL and has led to confusion over the indications for operative treatment. Recent developments in the understanding of the anatomy and biomechanics of this area of the knee have led to improvements in management and a renewed interest in these potentially disabling injuries. The aim of this review is to bring the trauma generalist abreast of these recent developments and to improve diagnosis through a heightened index of suspicion and use of appropriate special investigations. The principles of management of both isolated and combined injuries to the PCL and PLC, in the acute and chronic settings, are described.

Assessment of osteoarthritis after reconstruction of the anterior cruciate ligament: a study using single-photon emission computed tomography at ten years.

We used single-photon emission computed tomography (SPECT) to determine the long-term risk of degenerative change after reconstruction of the anterior cruciate ligament (ACL). Our study population was a prospective series of 31 patients with a mean age at injury of 27.8 years (18 to 47) and a mean follow-up of ten years (9 to 13) after bone-patellar tendon-bone reconstruction of the ACL. The contralateral normal knee was used as a control. All knees were clinically stable with high clinical scores (mean Lysholm score, 93; mean Tegner activity score, 6). Fifteen patients had undergone a partial meniscectomy and ACL reconstruction at or before reconstruction of their ACL. In the group with an intact meniscus, clinical symptoms of osteoarthritis (OA) were found in only one patient (7%), who was also the only patient with marked isotope uptake on the SPECT scan compatible with OA. In the group which underwent a partial meniscectomy, clinical symptoms of OA were found in two patients (13%), who were among five (31%) with isotope uptake compatible with OA. Only one patient (7%) in this group had evidence of advanced OA on plain radiographs. The risk of developing OA after ACL reconstruction in this series is very low and lower than published figures for untreated ACL-deficient knees. There is a significant increase (p < 0.05) in degenerative change in patients who had a reconstruction of their ACL and a partial meniscectomy compared with those who had a reconstruction of their ACL alone.

Fixed flexion deformity of the knee following femoral physeal fracture: the Inverted Cyclops lesion.

An adolescent inter-condylar fracture of the distal femur was treated with percutaneous cancellous screws and an above-knee plaster. The subsequent fixed flexion deformity of the knee was initially considered to be due to soft tissue capsular scarring and adhesions but arthroscopic assessment of the joint identified an "Inverted Cyclops" lesion. This consisted of excess callus and fibrous tissue arising from the femoral notch. Arthroscopic excision of this tissue cured the deformity.

Medium term follow up of endoscopically assisted BPTB ACL reconstruction using a two-incision technique--return to sporting activity.

We report our findings of a prospective outcome study of a series of 50 patients with chronic ACL injury undergoing arthroscopically assisted bone-patellar-tendon-bone ACL reconstruction. Patients underwent reconstruction if they had instability precluding participation in sport at the desired level and were reviewed at a mean of 62 months. Clinical examination was carried out pre and post operatively. Assessment was augmented by KT 1000 measurement, Tegner activity score and Lysholm score. Surgery was considered a failure if the Pivot Shift test was 2+(jerk) or symptoms of instability persisted. By these criteria 48 patients were successfully treated. Our results show a good medium term outcome for this reconstructive method. We had a 94% return to sporting activity but at a lower than expected activity level. Clinical examination showed an improvement and we recorded excellent or good results on Lysholm score in all these patients.

Combined chronic posterior cruciate and posterolateral corner ligamentous injuries: a comparison of posterior cruciate ligament reconstruction with and without reconstruction of the posterolateral corner.

Many have advocated the importance of correcting posterolateral rotatory instability (PLRI) in injuries causing rupture of the posterior cruciate ligament (PCL) and posterolateral corner. However, there have been few studies directly comparing the results of reconstructing the PCL in isolation with PCL reconstruction combined with stabilisation of the posterolateral corner. We report on a retrospective study into 17 consecutive patients with chronic combined posterior cruciate and posterolateral corner ligamentous injuries. The mean follow-up was 35 months (range 14-74 months). All patients had unstable knees, with significant PLRI. In 12 cases the PCL alone was reconstructed, in 5 cases a combined PCL and posterolateral corner reconstruction was performed. At a mean follow-up of 35 months, both groups had significantly improved compared to their pre-operative status, as measured by Lysholm and Tegner scores and clinical examination (P<0.01). The group in which only the PCL was reconstructed had significantly lower scores compared to those who had the additional posterolateral corner reconstruction (Tegner P<0.04, Lysholm P<0.02).

Compartment syndrome following pelvic surgery in the lithotomy position.

We report the cases of two patients who developed compartment syndrome following pelvic surgery in the lithotomy position. These cases highlight this important and potentially devastating complication.

Fracture of the tibial tubercle following anterior cruciate ligament reconstruction.

A case is presented of a traumatic avulsion fracture of part of the tibial tubercle after harvesting of the central third of the patellar tendon, with bone blocks, for anterior cruciate ligament (ACL) reconstruction. The literature is reviewed. This injury has not been reported previously.