Introduction: Fifty thousand knee replacements are performed annually in the UK at an estimated cost of £150 million. However, there is uncertainty as to the best surgical approach to the knee joint for knee arthroplasty. We undertook a randomised controlled trial to compare a standard medial parapatellar arthrotomy with sub-vastus arthrotomy for patients undergoing primary total knee arthroplasty in terms of short and long term knee function.

Methods: Two-hundred and thirty-one patients undergoing primary total knee arthroplasty during 2001–2003 were recruited into the study. Patients were randomised into subvastus (116) or medial parapatellar (115) approaches to knee arthroplasty. The primary outcome measures were the American Knee Society and WOMAC Scores. The secondary outcome measures were patient based measures of EuroQol and SF-36. All outcomes were measured pre-operatively, 1, 6, 12 and 52 weeks post-operatively. We also looked at a pain diary, analgesia diary, ease of surgical exposure, and complications.

Results: Pain as measured by WOMAC was significantly less in the subvastus group but only at 52 weeks. The Knee Society Score showed some early benefit at one week to the subvastus group. There was no difference between the two groups in relation to the knee function score, EuroQol, SF-36, pain diary, analgesia usage and length of hospital stay.

Conclusion: There is some benefit to patients receiving sub-vastus arthrotomy relative to medial para-patellar. Although the results show some statistical significance in using the sub-vastus approach the clinical importance of these findings and the costs of the various procedures involved remain to be ascertained.

Introduction: Fifty thousand knee replacements are performed annually in the UK at an estimated cost of £150 million. However, there is uncertainty as to the best surgical approach to the knee joint for knee arthroplasty. We undertook a randomised controlled trial to compare a standard medial parapatellar arthrotomy with sub-vastus arthrotomy for patients undergoing primary total knee arthroplasty in terms of short and long term knee function.

Methods: Two-hundred and thirty-one patients undergoing primary total knee arthroplasty during 2001–2003 were recruited into the study. Patients were randomised into subvastus (116) or medial parapatellar (115) approaches to knee arthroplasty. The primary outcome measures were the American Knee Society and WOMAC Scores. The secondary outcome measures were patient based measures of EuroQol and SF-36. All outcomes were measured pre-operatively, 1, 6, 12 and 52 weeks post-operatively. We also looked at a pain diary, analgesia diary, ease of surgical exposure, and complications.

Results: Pain as measured by WOMAC was significantly less in the subvastus group but only at 52 weeks. The Knee Society Score showed some early benefit at one week to the subvastus group. There was no difference between the two groups in relation to the knee function score, EuroQol, SF-36, pain diary, analgesia usage and length of hospital stay

Conclusion: There is some benefit to patients receiving sub-vastus arthrotomy relative to medial para-patellar. Although the results show some statistical significance in using the sub-vastus approach the clinical importance of these findings and the costs of the various procedures involved remain to be ascertained.

Introduction: Tendon tissue engineering entails the generation of a highly ordered collagen matrix with several organization scales that confer the tendon its mechanical functionality. Endogenous production of proteoglycans account for the typical microscopic organization in bundles of the tendon extracellular matrix, as they prevent lateral fusion of collagen fibril by binding the shaft of the fibres and promoting tip to tip fusion. The approach developed in this study is to rely on this molecular endogenous production and to induce a supramolecular uniaxial alignment of collagen fibres bundles with the help of specially designed scaffolds under continuous fluid shear stress.

Methods: Microchannel chitosan scaffolds were produced by casting 2% chitosan gel on a mould equipped with stainless steel needles array that was imaged by optical coherence tomography with a resolution at ~10microns. From OCT measurements, regularly spaced microchannels with clearly delimited boundaries are obtained inside a microporous core of chitosan. By varying the number and the diameter of needles (from 250 μm (microns)to 500 μm (microns)) different types of microstructure have been produced. Microchannels scaffolds were seeded with primary tenocytes explanted from pig tendons and cultured in static culture, as nonstimulated group, and in a perfusion bioreactor.

Results: There was a general increase in the channels occupation ratio for the group stimulated by perfusion, and inversely proportional to the microchannel diameter. Tenocytes were able to proliferate and to produce collagen extracellular matrix from the inner surface of the microchannel up to the whole channel volume.

Conclusion: The proposed microstructure was appropriate for tendon engineering and its channel structure is adequate for direct OCT monitoring.

Background: The Achilles tendon is commonly operated on, but has associated wound complications, ranging from 7–14% in previously reported series larger than 100 cases.

Methods: A retrospective review of one surgeon’s practice was conducted to assess the prevalence of wound complications associated with acute and chronic rupture repair, peritenolysis, tenodesis, debridement, retrocalcaneal exostectomy/bursectomy, and management of calcific tendinopathy of the Achilles tendon. The study evaluated the incidence of infection, and other wound complications such as suture reactions, scar revision, hematoma, incisional neuromas and granuloma formation.

Results: A total of 219 surgical cases were available for review (140 males, 70 females; average age at the time of surgery: 46.5 ± 12.6 years, range 16–75). Seven patients experienced a wound infection, three had keloid formation, six had suture granulomas, and six had suture abscesses, with an overall complication rate of 22 of 219 surgeries (10.1%). There were no hematomas. Seven patients had additional surgery following their wound complications; some had simple granuloma excision, while one necessitated a flap.

Conclusion: Knowledge of suture materials, proper incision placement and possibly avoiding tourniquet usage can keep complications low when performing Achilles tendon surgery. Regardless, some complications with Achilles tendon surgery may be unavoidable.

Introduction: Repair of chronic Achilles tendon rupture is technically complex. Flexor Hallucis Longus (FHL) and Peroneus Brevis (PB) Tendon transfers have been described, but the mechanical properties of these tissues have not been well reported.

Methods: The FHL, PB and tendo Achilles (TA) tendons were harvested from 17 fresh frozen human cadavers free of gross pathology (mean age 69 years). Samples were tested in uniaxial tension at 100% per minute. Samples were secured using special jigs for the bony aspect or by freezing the tendons in cryogrips using liquid carbon dioxide. The peak load (N), linear stiffness (N/mm) and energy to peak load (N*mm) were determined. Mechanical data was analysed using one way analysis of variance (ANOVA) followed by a Games Howell multiple comparison post-hoc test.

Results: 51 tendons were harvested. Mechanical testing was successfully completed in all samples apart from one PB that slipped from the grips during testing (sample was omitted from the analysis). The mean ultimate loads differed for each group, with the TA tendons being the strongest (1724.5 N ± 514.3) followed by FHL (511.0 N ± 164.3) and PB (333.1 N ± 137.2) (P< 0.05). Similar results were found with respect to energy, with TA tendons absorbing the most energy followed by FHL and PB (P< 0.05). Stiffness for the TA tendons (175.5 N/mm ± 94.8) was greater than FHL (43.3 N/mm ± 14.1) and PB (43.6 N/mm ± 18.9), which did not differ from each other.

Conclusions: FHL is stronger than PB, but have similar stiffness. The mechanical properties of PB and FHL were both inferior to TA. Graft stiffness appears to be an important variable rather than ultimate load based on the clinical success of both techniques.

Introduction: Between 1 and 4 per 1000 births worldwide are affected by clubfoot. Clubfoot etiology is unclear, but both genetic and environmental factors are thought to be involved. Low folate status in pregnant women has been implicated in several congenital malformations and folate metabolism may be affected by polymorphisms in the MTHFR gene.

Methods: Using a case-parent triad design, we investigated whether the MTHFR C677T polymorphism, and maternal peri-conceptional folic acid supplement use, influenced risk of isolated clubfoot. 375 case-parent triads took part.

Results: Among children there was a significant trend of decreasing clubfoot risk with increasing number of Talleles: relative risk (RR ) CT vs CC=0.75 (95% CI: 0.57,0.97); RR TT vs CC=0.57 (95% CI: 0.37,0.91); p trend=0.006. This association was not modified by maternal folic acid use.

Conclusion: Maternal MTHFR genotype did not influence risk of clubfoot in the offspring overall, although a possible interaction with folic acid use was found. This is the first report of a specific genetic polymorphism associated with clubfoot. The direction of the association is intriguing and suggests DNA synthesis may be relevant in clubfoot development. However, clubfoot mechanisms are poorly understood and the folate metabolism pathway is complex. Further research is needed to elucidate these relationships.

Background: Congenital talipes equinovarus (CTEV) is a common developmental disorder of the foot, affecting between 1 and 4.5 babies per 1000 live births. The etiology is not well elucidated. While both genetic and environmental factors are implicated, no specific genes have been identified and little is known about environmental risk factors.

Methods: We conducted a case-control study of idiopathic congenital talipes equinovarus (ICTEV) in the United Kingdom. 194 cases and 60 controls were recruited. Pedigrees were obtained for 162 cases.

Results: The rank of the index pregnancy, maternal education and cesarean delivery were significantly associated with ICTEV risk in a multivariate model. There were suggestions that maternal use of folic acid supplements in the three months before the pregnancy decreased ICTEV risk, and that parental smoking during the pregnancy increased risk. One quarter of pedigrees showed a family history of CTEV, and autosomal dominant inheritance was suggested in some of these.

Conclusion: Uterine restriction did not appear to have a strong influence on ICTEV development in our study. Large population-based studies are needed to clarify the etiology of this common developmental disorder.

Introduction: Tendon ruptures are increasingly common, repair can be difficult and healing poorly understood. Tissue engineering approaches often require expansion of cell numbers to populate a construct, and maintenance of cell phenotoype is essential for tissue regeneration.

Methods: In this study we characterise the phenotype of human Achilles tenocytes and assess how this is affected by passaging. Tenocytes, isolated from tendon samples from 6 patients receiving surgery for rupture of the Achilles tendon, were passaged 8 times. Proliferation rates and cell morphology were recorded at passages 1, 4 and 8. Total collagen, the ratio of collagen types I and III and decorin were used as indicators of matrix formation and expression of the integrin ‘alpha’1 subunit as a marker of cell-matrix interactions.

Results: With increasing passage number, cells became more rounded, were more widely spaced at confluence and confluent cell density declined from 18700 /cm2 to 16100 /cm2 (P=0.009). No change to total cell layer collagen was observed but the ratio of type III to type I collagen increased from 0.60 at passage 1 to 0.89 at passage 8 (P< 0.001). Decorin expression significantly decreased with passage number, from 22.9 ± 3.1 ng/ng DNA at passage 1, to 9.1 ± 1.8 ng/ngDNA at passage 8 (P< 0.001). Integrin expression did not change.

Conclusion: We conclude that the phenotype of tenocytes in culture rapidly drifts with progressive passage.

There is a trend towards the use of double-bundle techniques for the reconstruction of the anterior cruciate ligament. This has not been substantiated scientifically. The functional outcome of these techniques is equivalent to that of single-bundle methods. The main advantage of a double-bundle rather than a single-bundle reconstruction should be a better rotational stability, but the validity and accuracy of systems for the measurement of rotational stability have not been confirmed.

Despite the enthusiasm of surgeons for the double-bundle technique, reconstruction with a single-bundle should remain the standard method for managing deficiency of the anterior cruciate ligament until strong evidence in favour of the use of the double-bundle method is available.

Background: Recurrent peroneal tendon subluxation is uncommon. We report the results of a delayed anatomic repair using suture anchors. Using a case series we tested the null hypothesis that there are no differences between pre- and post-operative status following anatomical repair of the superior peroneal retinaculum.

Methods: In the period 1996 to 2001, we operated on 14 patients (all males; average age 25.3 ± 6.3 years, range 18–37) with traumatic recurrent unilateral peroneal tendon subluxation, with a followed up of 38 ± 3 (range 22 to 47) months.

Results: No patient experienced a further episode of peroneal tendon subluxation, and all had returned to their normal activities. Maximum calf circumference, functional ability, peak torque, total work and average power of plantar flexion were always lower in the operated leg, but the differences did not reach statistical significance. The AOFAS Ankle-Hindfoot Scale increased significantly from 54.3 ± 11.4 to 94.5 ± 6.4 (p = 0.03), with five patients reporting a fully normal ankle.

Conclusion: If an anatomic approach to treating the pathology is utilised, reattachment of the superior retinaculum is a most appropriate technique. It returns patients to a high level of physical activity, and gives high rate of satisfactory results both objectively and subjectively. Randomised control trials may be the way forward in determining the best surgical management method. However, the relative rarity of the condition and the large number of techniques make such a study difficult.

Background and objectives: Tenocytes change their structure, composition and mechanical properties to adapt to mechanical loading. Voltage gated and mecha-nosensitive ion channels may play a key role in human tenocytes to regulate some or all initial responses to mechanical stimulation. To date, there has been no direct investigation of ion channel expression by human tenocytes.

Methods: Human tenocytes were cultured from patellar tendon samples harvested from five patients undergoing routine total knee replacement surgery (mean age: 66 years; range 63-73 years). RT-PCR, Western Blotting and whole cell electrophysiological studies were performed to investigate the expression of different classes of ion channels within tenocytes.

Results: Human tenocytes express mRNA and protein encoding voltage operated calcium channel (VOCCs) sub-units (Ca alpha 1A, Ca alpha 1C, Ca alpha 1D, Ca alpha2 delta1) and the mechanosensitive tandem pore domain potassium channel (2PK+) TREK-1. They exhibit whole cell currents consistent with the functional expression of these channels. In addition, other ionic currents were detected within these tenocytes consistent with the expression of voltage gated potassium channels, voltage gated sodium channels, and other outwardly rectifying leak currents.

Discussion and conclusions: Human tendon cells show increased levels of intracellular calcium when stress is applied to them. One of the mechanisms by which this occurs is by the influx of extracellular calcium into the cell via ion channels. VOCCs and TREK channels have been implicated in mechanotransduction signalling pathways in numerous connective tissue cell types. This study suggests that these mechanisms may be present in human tenocytes. In addition, human tenocytes may express other channel currents. Ion channels may represent potential targets for the pharmacological management of chronic tendinopathies.

Introduction: We present here the clinical features and management strategies of patients with gluteus medius and minimus enthesopathy.

Methodology: We studied seven patients with lateral hip pain and tenderness on palpation, worse over the tip of the greater trochanter. All of them had a positive Trendelenburg’s sign, and a transient relief of pain on injecting local anaesthetic in the abductor mechanism. All of these patients were tertiary referrals from the rheumatologists, who had at least once injected them with corticosteroids.

Results: Four of these seven patients underwent exploration. An insertional tendinopathy of the abductors was noted in all the patients, and was debrided. Two of the patients had, in addition, a tear in the gluteus medius tendon, which was repaired. One patient had an injection of local anaesthetic and Aprotinin in the abductor mechanism with resolution of symptoms.

Discussion: Gluteus medius and minimus enthesopathy is a distinct clinical entity. Although the condition has been described in the radiological literature, we were unable to find any reference to the orthopaedic management of this condition. We observed only a small number of patients, and we are thus unable to provide definite answers. Patients presenting with the above clinical features warrant consideration of the diagnosis of abductor enthesopathy. Ultrasound scan or MRI scan helps in confirming the diagnosis. At present, our management protocol involves injecting a local anaesthetic / Aprotinin in the abductor mechanism. However, we are cautious in injecting more than once, as, at operation, we have observed necrosis of the abductor mechanism at its insertion in two patients, similar to that described for Achilles tendon. If this fails, we undetake surgical exploration. The exact surgical procedure is difficult to predict and may involve debridement and repair of the pathological tendon.

Introduction: Neglected Achilles tendon ruptures are a management challenge. Several surgical techniques have been described. A two centre, two surgeon, two year longitudinal study was undertaken to report the results of reconstruction of neglected Achilles tendon rupture using a free autologous gracilis tendon graft

Methods: Fourteen patients underwent surgery for a neglected rupture of the Achilles tendon occurring between 65 days and nine months before the operation. All were prospectively followed up for two years.

Results: No patients experienced any problems in the wound used to harvest the tendon of gracilis. Four patients were managed conservatively following a superficial infection of the achilles tendon surgical wound. No patients developed a deep vein thrombosis or sustained a re-rupture. All patients were able to walk on tiptoes, and no patient used a heel raise or walked with a visible limp. The maximum calf circumference remained significantly decreased in the operated leg at latest follow up. The operated limb was significantly less strong than the non-operated one.

Conclusions: The management of neglected subcutaneous tears of the Achilles tendon by free gracilis tendon grafting is safe but technically demanding. It affords good recovery, even in patients with a neglected rupture of nine months’ duration. These patients should be warned that they are at risk of post-operative complications, and that their ankle plantar flexion strength can remain reduced.

Objective: To report the outcome of surgery for chronic recalcitrant Achilles tendinopathy in sedentary and athletic subjects.

Design: Case control study

Participants: We matched each of the 61 non-athletic patients with a diagnosis of tendinopathy of the Achilles tendon with an athletic patient with tendinopathy of the main body of the Achilles tendon of the same sex who was within two years of age at the time of operation. A match according was possible for 56 patients (23 males and 33 females). 48 sedentary subjects and 45 athletic subjects agreed to participate.

Main Outcome Measure: Outcome of surgery, return to sport, complication rate.

Results: Non-athletic patients were shorter and heavier than athletic patients. They had greater BMI, calf circumference, side-to-side calf circumference differences, and subcutaneous body fat than athletic patients. Of the 48 sedentary patients, only 25 reported an excellent or good result. Of these, three had undergone a further exploration of the Achilles tendon. The remaining patients could not return to their normal levels of activity. In all of them, pain significantly interfered with daily activities.

Conclusions: Non-athletic subjects experience more prolonged recovery, more complications, and a greater risk of further surgery than athletic subjects with recalcitrant Achilles tendinopathy. Key words: Achilles tendinopathy, surgery.

Introduction: We reviewed the complications and recovery of patients treated for Achilles tendon rupture by percutaneous repair, open repair, and non-operative management in a tertiary referral centre between 2001 and 2003.

Materials and Methods: We identified patients who underwent Achilles tendon rupture repair by percutaneous or open methods from the logbooks of Consultants and the operating theatre register. We used plaster room records were also used to identify patients who received non-operative treatment. We collated demographic and management details, and compared them with published rates relating to average age range, demographic, and management details.

Results: In the 20 patients who underwent open repair, one (4.8%) patient sustained a re-rupture, four (19%) sustained minor complications, and one (4.8%) had a major complication. In the 31 patients who underwent percutaneous repair, one (3.2%) patient sustained a major complication, six (19.4%) patients experienced minor wound complications, and there were no re-ruptures. In the 12 patients who underwent conservative management, re-ruptures occurred in one patient (8.3%), minor complications occurred in five patients (41.7%), and there were no major complications. The median recovery time in the open, percutaneous and conservative groups was 25 weeks, 26 weeks and 18.5 weeks respectively.

Discussion and Conclusion: In our setting, percutaneous repair is the most successful management method, with no re-ruptures and very few complications. Although conservative management produced the highest rate of complications, each patient will have different needs due to their age, occupation or level of sporting activity. Ultimately, the decision of the management regime used probably lies with the patient.

Reduction and K-wiring is the most popular form of treating displaced supracondylar fractures of the humerus. Complications including redisplacement of the fracture, cubitus varus, iatrogenic nerve injuries and pin tract infection have been reported following surgery. For successful outcome with K-wiring of supracondylar fractures, strict adherence to protocols and surgical expertise are necessary. We have treated these fractures in straight arm traction since 1995, and the purpose of this study was to audit our practice.

Between January 1995 and December 2000, 112 children with a closed displaced supracondylar fracture of the humerus, without neurovascular deficit, were managed by straight arm traction for a mean duration of 22 days. Final outcome was assessed using clinical (flex-ion-extension arc, carrying angle and residual rotational deformity) and radiographical (metaphyseal-diaphyseal angle and Humero-Capitellar angle) criteria. Our outcomes were compared with those of the recent large studies reporting results of surgical treatment.

71 (63%) patients had excellent, 33 (29%) patients good, 5 (4.4%) patients fair, and 3 (2.6%) patients poor outcome. All patients with fair or poor outcomes were older than 10 years.

Elevated straight-arm traction is safe and effective in children younger than 10 years. It can be effectively used in an environment that has provision of paediatric medical care and general orthopaedic expertise with outcomes comparable to those fractures treated surgically in specialist centres.

Purpose of study: To study the effect of an additional locking screw on fracture strain and stability in tibias undergoing intramedullary nailing.

Methods: An additional locking hole was drilled into four tibial nails, 185 mm from the proximal end of the 8 mm x 315 mm solid tibial nails. The nails were locked proximally and distally into a triple strain-gauged sawbone. An osteotomy was created distal to the additional hole, and the construct loaded axially, in flexion and extension, and in torsion with and without the extra locking screw. With the additional locking screw in place, strain increased at the proximal strain gauge site during loading in neutral by 17% (139 mϵ, 91–198) (p=0.01) and flexion by 8% (65 mϵ, 60–73) (p< 0.005). Strain decreased on loading in extension by 10% (141 mϵ, 62–243) (p=0.0497). The extra locking screw decreased strain at the gauge closest to the osteotomy site in all loading positions. Strain showed an overall increase with axial loading of 14% (47 mϵ, 4–105) (p=0.16), an increase with loading in flexion of 2% (9 mϵ, −38 to 62) (p=0.75) but a decrease of 47% (254 mϵ, 6–549) (p=0.18) with loading in extension. A significant reduction in angular motion at the osteotomy site occurred with the addition of the extra locking screw (21° at 34.5 Nm without the screw, 13° at 34.5 Nm with the screw, p=0.001). Additional hole in the shaft of the nail lead to increase the stress from 29 – 48 mPa (29 – 48 N/mm2) but did not fail when vertically loaded with 450 Newtons applied at rate of 5Hz sinusoidal waves for 2 million cycles.

Conclusion: Nails with additional locking options, by altering strain and motion at the fracture site, may have the clinical potential to affect fracture healing with relatively low risk of implant failure.

Statement of Purpose: We tested the null hypothesis of no significant difference in arthroscopy rates for patients on a waiting list for arthroscopy in patients in which surgeons had a knee magnetic resonance imaging scan report prior to surgery, compared to those who did not have a report.

Methods and Results: This is a single-centre randomised controlled trial. 252 eligible patients consented and randomised. The two groups were similar with respect to a range of baseline factors. Very few arthroscopies were not performed −4.8% in the intervention arm and 5.5% in the control arm (χ²=0.06, df=1, p> 0.05). A longitudinal analysis of the secondary outcomes showed that there were no significant differences between the intervention and the control arms of the study.

Conclusion: Magnetic resonance imaging, prior to knee arthroscopy, does not lead to a reduction in the number of arthroscopies undertaken in the intervention group nor improve patient outcome in a range of secondary measures.

Aim: To investigate and compare the effects of two types of LCS total knee arthroplasty AP glide {(posterior cruciate is retained and the mobile bearing allows anteroposterior and well as rotational movement) and RP (in which posterior cruciate is sacrificed and the mobile bearing allows only rotational movement)} on joint proprioception and range of motion.

Methods: 30 patients scheduled to undergo mobile bearing total knee arthroplasty were randomised to receive either a LCS AP glide or Rotating platform prosthesis. Clinical scores (Oxford knee score, American knee society score (AKSS), EuroQol), range of motion and proprioception were assessed prior to and at three and six months after the operation. Proprioception was assessed in terms of absolute error angle (mean difference between the target angle and the response angle). Student’s t-test was used to compare the mean of two groups (with a level of significance of p < 0.05).

Results: Both groups were comparable in terms of pre-operative range of motion, oxford knee score, American knee society score, EuroQol score and proprioception. At 6 months there was significant improvement in the Oxford knee score, AKSS and EuroQol score in both groups (p< 0.001), but no difference was noted between the two groups with respect to these parameters. There was improvement in the proprioception (reduction in absolute error angle) in both groups though this was not significant statistically (p> 0.05). The mean active non-weight-bearing range of motion improved in both groups {AP glide group, (p< 0.05) and RP group, (p> 0.05)}

Conclusions: We did not find significant difference between AP glide and RP LCS knee arthroplasty in terms of improvement in proprioception and range of motion.