Introduction

There are approximately 1.2 million patients using orthotics in the UK costing the NHS in excess of £100 million per annum. Despite this, there is little data available to determine efficacy and patient compliance. There have been a few reports on patient satisfaction, which indicate that between 13-50% of patients are dissatisfied with their orthotics. Our aim was to evaluate patient reported satisfaction with orthotics prescribed and to investigate the reasons behind patient dissatisfaction.

Introduction: Severe haemophilia affects 1 in 10,000 men. The ankle along with the hip and knee are commonly affected. Ankle fusion is the preferred surgery for end stage arthritis in the younger patient although debate exists as to the preferred technique. We conducted a retrospective review of the arthroscopic ankle fusions on haemophiliacs from Oxford and compared data with that of a specialist unit in London using an open technique.

Materials and Methods: We reviewed 22 ankles (22 patients) from Oxford and 10 ankles (8 patients) from London. 90% had Type A haemophilia with similar regular monthly Factor VIII usage: 17941 U/month (Oxford) compared with 17992 (London). 73% of patients in the Oxford Group and 100% of the London group had Hepatitis C and/or HIV.

Results: Union was achieved in all patients. The mean time to union in the open group was 9.1 weeks (Mode- 8 weeks, Range 7–14) compared to 12.2 weeks (Mode- 12 weeks, Range 8–24) in the arthroscopic group. Screw removal was required in 4 patients (3 arthroscopic v’s 1 open). 1 patient in the arthroscopic group suffered a pseudoaneurysm of the dorsalis pedis artery. The arthroscopic group spent less time in hospital- 5.7 days compared to 9.5. Factor VIII usage was less in the arthroscopic group- 32,882 Units compared to 40013.

Discussion: Patients of this nature should be managed in centres used to dealing with their complex needs. Arthroscopic ankle fusion in haemophiliacs is safe for these patients. Although arthroscopic fusion may take slightly longer to unite, there are benefits in terms of reduced patient stay and factor VIII requirement and therefore costs.

Autologous chondrocyte implantation (ACI) and mosaicplasty are both claimed to be successful for the repair of defects of the articular cartilage of the knee but there has been no comparative study of the two methods. A total of 100 patients with a mean age of 31.3 years (16 to 49) and with a symptomatic lesion of the articular cartilage in the knee which was suitable for cartilage repair was randomised to undergo either ACI or mosaicplasty; 58 patients had ACI and 42 mosaicplasty. Most lesions were post-traumatic and the mean size of the defect was 4.66 cm². The mean duration of symptoms was 7.2 years and the mean number of previous operations, excluding arthroscopy, was 1.5. The mean follow-up was 19 months (12 to 26).

Functional assessment using the modified Cincinatti and Stanmore scores and objective clinical assessment showed that 88% had excellent or good results after ACI compared with 69% after mosaicplasty. Arthroscopy at one year demonstrated excellent or good repairs in 82% after ACI and in 34% after mosaicplasty. All five patellar mosaicplasties failed.

Our prospective, randomised, clinical trial has shown significant superiority of ACI over mosaicplasty for the repair of articular defects in the knee. The results for ACI are comparable with those in other studies, but those for mosaicplasty suggest that its continued use is of dubious value.

Mosaicplasty¹ and Autologous Chondrocyte Implantation² (ACI) are both modern cartilage repair techniques used to repair symptomatic articular cartilage defects in the knee, based on small osteochondral grafts and cultured chondrocytes respectively. The aim is the restoration of articular cartilage, but until now there is no data comparing the two methods.

100 consecutive patients aged 15–45 with a symptomatic articular cartilage lesion in the knee suitable for cartilage repair were randomised at arthroscopic assessment to undergo either mosaicplasty or ACI. 42 patients underwent mosaicplasty, 58 had ACI. Mean age at time of surgery was 31 years and the average defect size 4. 66 cm².

46% of the defects were post-traumatic, 19% had osteochondritis dissecans, 14% had chondromalacia patella and 16% had lesions of unknown aetiology. 53% had a medial femoral condyle lesion, 25% patella, 18% lateral femoral condyle, 3% trochlea and there was one defect of the lateral tibial plateau.

The mean duration of symptoms was 7. 2 years and the average number of previous operations (excluding arthroscopies) was 1. 5. Only 6 patients had no prior surgical interventions to the affected knee. The mean follow-up was 1. 7 years.

Patients were evaluated using Modified Cincinnati and Stanmore Functional rating systems, visual analogue scores and clinical assessment. Arthroscopy and biopsy was performed at one year and repair assessed with the International Cartilage Repair Society grading system.

Clinical results at one year showed 70% of mosaic-plasty patients and 87% of ACI patients had a good or excellent result. Arthroscopy at one year demonstrated more complete healing in ACI patients. Eleven (26%) of the mosaicplasty group subsequently failed clinically and arthroscopically, with peak failure at 2 years.

At one year follow-up, both techniques of articular cartilage repair can be useful in selected patients. ACI is preferred for lesions of the patella. Long-term follow-up is needed to assess the durability of articular cartilage repair using these methods, in particular mosaicplasty which showed signs of progressive failure over 2 years.

To investigate the incidence of PTS in patients with veno-graphically proven DVT following hip or knee replacement surgery, patients were derived from a randomised controlled trial of LMWH versus unfractionated heparin prophylaxis in 500 total hip or knee replacement patients. Surveillance venogram at 10 days detected DVT in 93 patients, and these were warfarinised for 3–6 months. At a minimum follow-up of 7 years, patients were assessed by clinical examination, questionnaire and application of two scoring systems; a modified PTS score based on the Browse score, and the clinical component of the International Consensus Committee on Chronic Venous Disease classification (ICC-CVD).

70 patients (21 deaths and 2 non-responders, follow-up rate 97%) with 32 THR and 38 TKR were studied. 63% patients were female, and average age was 74 years. Leg ache (46%) and swelling (42%) were the most common subjective complaints, but 40% patients had no complaints. Objectively, leg swelling was observed in 52% of patients, varicose veins in 26%, but ulceration was seen in only 3% of patients. The modified PTS score showed 14% patients had no symptoms, 64% mild symptoms, 19% moderate and 3% severe symptoms of PTS. The ICC-CVD score revealed 27% with no symptoms, 53% mild symptoms, 17% moderate and 3% severe symptoms of PTS. There was good correlation between the scoring systems for moderate and severe disease, but the modified PTS may have overestimated the incidence of mild PTS.

Severe symptomatic PTS is rare following early detection and treatment of DVT after total hip and knee replacement.

Autologous Chondrocyte Implantation’ (ACI) is a cartilage repair technique that involves implantation of cultured chondrocytes beneath a membrane of autologous periosteum. In this study a porcine biodegradable membrane was also used to assess its effectiveness. The aim is to restore articular cartilage to symptomatic defects, rather than initiating a fibrocartilagenous repair.

We undertook a prospective study of 125 consecutive patients who underwent ACI. Average age at the time of surgery was 30. 9 years (range 14 – 49), 55% of patients were male. The average size of the defect was 4. 35 cm².

44% of defects were attributable to known traumatic incidents, 2 1 % had osteochondritis dessicans, 18% chondromalacia patella, 12% had defects of unknown aetiology and 5% other.

The average duration of symptoms prior to this surgery was 7. 16 years. The mean number of previous operations (excluding arthroscopies) was 1. 6. Only 9 patients had no previous major surgery to the affected knee. 44% had defects of the medial femoral condyle, 31% patella, 20% lateral femoral condyle and 5% had a trochlea lesion. 26% of the defects were covered with periosteum and 74% with a porcine collagen membrane (chondrogide)

Minimum follow-up was six months, 70 patients had minimum follow-up of one year. Mean follow-up 18 months.

Patients were assessed using Modified Cincinnati and Stanmore Functional rating systems, visual analogue scores and clinical evaluation.

Arthroscopy and biopsy was performed at one year and the repair assessed using the International Cartilage Research Society grading system.

At one year follow-up overall 41 % patients had an excellent result, 48% good, 8% fair and 3% poor. For defects of the medial femoral condyle, 88% had a good or excellent result, 85% for the lateral femoral condyle and 80% for the patella.

61 patients were arthroscopically assessed at one year. 50/61 (82%) demonstrated ICRS grade 1 or 2 repair. Healing of the defect occurred with either a periosteum or chondrogide defect cover.

Results at one year suggest that ACI is a successful articular cartilage repair technique in selected patients. Long-term follow-up is required to assess the durability of the repair.

Many methods have been described over the past 5 years for repair of articular cartilage defects. The best reported results have been from the use of autologous chondrocyte transplantation (ACT)(1) and mosaicplasty.(2) There have, however, been no prospective clinical trials of these two methods. In this trial 70 patients were prospectively randomized to receive either autologous chondrocyte transplantation (37) or mosaicplasty (33) in the knee. 37 patients were female and 33 male. The average age was 32 years (16 – 44). The indications for surgery were persistent pain and mechanical symptoms in the knee with an isolated defect of the articular cartilage. 38 (56%) were post-traumatic, 12 (16%) due to osteochondritis dissecans, 10 (14%) due to previous meniscectomy, and 10 (14%) due to chondromalacia patellae. The size of the defects ranged from 2cm2 to 12cm2 (mean 4.8cm2). There were 35 defects on the medial femoral condyle, 13 on the lateral femoral condyle, 17 on the patella and 5 on the trochlear. 31 patients were undergoing primary surgery and 39 secondary surgery. All were independently reviewed using the Visual Analogue Pain Score, the Cincinatti Pain Score and the Stanmore Score. Patients were arthroscoped at one year with MRI scan and biopsies where possible.

Results: The visual analogue pain score improved overall from a mean of 5.4 (range 3.4 – 7.4) pre-operatively to 3.9 (1.8 – 5.1) at one year review. Similarly the Cincinatti pain score improved from 6.5 pre-operatively to 10.2 post-operatively and the Cincinatti function score improved from 46 to 62 at one year before sport commenced. Overall 71% (49) patients were excellent or good on the clinical scoring scales, 15% (11) were fair, and 14% (10) were poor. The 10 poor results were no different from the main group with regard to age, sex, pain level or site or size of lesion. However, 5 were secondary procedures, 2 had multiple lesions, and 3 had had previous ruptured anterior cruciate ligaments. Arthroscopy and biopsy of 21 lesions so far after one year has shown mature articular cartilage in 2, and immature cartilage in 19. In all cases there was bonding of the repair tissue to the underlying bone. This study is already clarifying the role of ACT and mosaicplasty in the management of cartilage defects in the knee and also the necessity for the use of periosteal covering membrane.