The anterolateral ligament of the knee: unwrapping the enigma. Anatomical study and comparison to previous reports.

BACKGROUND: It has been suggested that the anterolateral ligament (ALL) of the knee may have importance in limiting rotational instability, and reconstruction may prevent a continued pivot-shift following anterior cruciate ligament surgery. However, the anatomy of this ligament has not been consistently reported in recent publications. We describe our experience of cadaveric dissection with reference to other published work. MATERIALS AND METHODS: Eleven fresh-frozen cadaveric knees were dissected using a standard technique. The ALL tissue was identified with internal rotation of the tibia and varus stress. Measurements were made using a digital caliper and details of the origin and insertion were recorded. RESULTS: The ALL was identified in ten of the 11 cadavers. The only specimen in which it was not identified was found to also have an anterior cruciate ligament deficiency. The mean dimensions were: length 40.1 (± 5.53) mm, width 4.63 (± 1.39) mm, thickness 0.87 (± 0.18) mm. The femoral origin was posterior and proximal to the lateral collateral ligament attachment in six knees, anterior and distal in three knees, and at the same site in one knee. The tibial insertion was a mean 17.7 (± 2.95) mm from Gerdy's tubercle (GT) and 12.3 (± 3.55) mm from the fibula head (FH). This was 59.5 (± 5.44) % from GT to FH. CONCLUSIONS: This anatomical data adds to previous information about the ALL. Our results support the finding that the ALL is a capsular thickening with meniscal attachment. The findings will help to guide the further work required to define the indications for reconstruction and appropriate grafts.

Principles of surgical management of musculoskeletal conditions.

Practical procedures for treatment of fractures and dislocations have been used since the time of Hippocrates in fourth century BC. Orthopaedic surgery became a recognized part of surgical treatment since the mid-nineteenth century, but saw major developments with the invention of x-rays and antibiotics in the early part of the twentieth century. Though orthopaedic surgery had started with an interest in the correction of deformities in children, the major musculoskeletal problems facing orthopaedic surgery today relate to osteoarthritis, trauma (including sports injuries), and osteoporosis. The practice of orthopaedic surgery has evolved with technology: advances in engineering and material science and increasing expectations towards faster rehabilitation have moved orthopaedics into the era of joint replacements, arthroscopy, and less invasive surgical procedures. This chapter aims to provide an evidence-based condensed overview of the surgical management for a broad spectrum of musculoskeletal disorders encountered by primary-care clinicians and rheumatologists.

Periprosthetic femoral fractures around hip arthroplasty: current concepts in their management.

Peri-prosthetic fractures (PFF) are complex management problems in orthopaedic surgery. Their treatment has evolved with advances in principles of internal fixation and revision hip surgery. Current classification systems look at anatomical location, prosthesis stability and bone quality. Recent evidence highlights the importance of fracture stability in treatment planning, the weaknesses of single plating, the increasing role of long stem revision and also the importance of bone allografts. We present the principles of management of both intra and post-operative PFFs, including surgical techniques and published outcomes.

Wii knee.

We present the case of a 16-year-old boy who injured his knee whilst playing on the video games console Nintendo Wii. The patient presented with an acutely swollen and painful knee to the emergency department of our institution. Initial radiographs revealed an effusion and an osteochondral fracture. Further imaging with magnetic resonance imaging demonstrated evidence of lateral patella dislocation with medial patello-femoral ligamentous damage and a large femoral osteochondral fracture. The patient was successfully treated with surgical fixation of the osteochondral fragment and medial patello-femoral ligament repair. This case highlights the force that can be generated whilst using these new games consoles.

Methicillin resistant Staphylococcus aureus versus methicillin sensitive Staphylococcus aureus adult haematogenous septic arthritis.

INTRODUCTION: Septic arthritis is an orthopaedic emergency and Staphylococcus aureus (SA) is the number one cause. Methicillin resistant Staphylococcus aureus (MRSA) is increasing in incidence but how it differs from methicillin sensitive Staphylococcus aureus (MSSA) septic arthritis is unclear. Our aim was to delineate the differences in clinical features and outcomes between patients with MRSA and MSSA septic arthritis. MATERIALS AND METHODS: We performed a retrospective review of all adult patients presenting to our institute over a 5 year period from June 2000 to June 2005 with haematogenous septic arthritis. We identified 15 cases of MRSA and 43 cases of MSSA septic arthritis. Fisher's exact test and the Student's t-test were used in analysis. RESULTS: MRSA and MSSA predominantly affected males 60 versus 79%. MRSA cases were older with a mean age of 76 versus 44 years (P < 0.05), and had more comorbidities with a mean of 2.7 versus 1.35 (P < 0.05). In MRSA and MSSA cases the main sources of sepsis were unknown (20 vs. 47%), intravenous lines (47 vs. 2%), soft tissue infection (13 vs. 2%) and intravenous drug use (7 vs. 49%). MRSA was significantly more associated with intravenous line sepsis (P < 0.05), soft tissue infection (P = 0.05) and to be nosocomial (P < 0.05). MSSA was significantly more associated with IVDU (P < 0.05). Presentation was similar in both groups although MRSA patients were significantly more likely to be pyrexial (80 vs. 40%, P < 0.05) and to have glenohumeral involvement (P < 0.05) while MSSA was significantly more likely to affect the knee (P < 0.05). There were no significant differences between the total length of antimicrobial therapy in MRSA and MSSA patients (43 vs. 38 days, P > 0.2), or the number of surgical interventions required (1.8 vs. 1.6, P > 0.2). However MRSA patients were significantly more likely to be placed on inappropriate empirical antimicrobials pending sensitivities (93 vs. 0%, P < 0.05). Outcomes were similar in MRSA and MSSA patients with no significant differences in recurrences (0 vs. 10%, P > 0.2) or sepsis related mortality (13.3 vs. 6.9%, P > 0.2). MRSA, however, did show a strong towards a higher all cause 6 month mortality (26 vs. 7%, P = 0.07). CONCLUSION: MRSA septic arthritis tends to affect older patients with multiple comorbidities and has a tropism for the glenohumeral joint while MSSA has a tropism for the knee. We did not find a significant difference in required length of antimicrobials, number or requirement of operative interventions or outcomes in terms of number of recurrences or sepsis related mortality. However MRSA septic arthritis patients were found to have a strong trend towards an increased all cause 6 month mortality and were significantly more likely to receive inappropriate empirical antimicrobials.