This study investigated the effects of arthroscopic release for the treatment of stiffness in total knee replacement (TKR) to compare the outcomes against the reported outcomes for more invasive procedures such as open release and revision. We prospectively followed all patients undergoing TKR between 1998 and 2008 at the lead author's institution where stiffness other than that for mechanical or infective reasons was treated arthroscopically. Nineteen knees from the author's series of 572 knee replacements and three knees from other units were treated and outcomes were recorded in terms of pre-operative and post-operative Oxford knee scores and range of motion. At arthroscopy each of the 22 knees displayed extensive scarring (particularly in the suprapatella pouch) that was debrided. The mean follow-up was 40 months (range 5 months to 10.5 years). The Oxford knee score improved from 42.6 (±7.5) prior to TKR to 36.3 (±8.5) after TKR and to 29.3 (±9.0) after arthroscopic arthrolysis. The mean maximum flexion declined from 107° prior to TKR to 64°. Arthroscopic arthrolysis improved mean maximum flexion to 105° on table and 93° at most recent follow-up.

We recommend this technique as a reasonable option for the treatment of stiffness after knee replacement as it compares well with more invasive surgical options.

Purpose: To investigate the validity of previous observations that meniscal repair has a better success rate when associated with ACL reconstruction.

Methods and Results: The case notes of 170 patients who underwent meniscal repair between May 1999 and May 2007 were analysed for causes of re-operation and relation to status of the ACL. Mean age at the time of surgery was 28 years.

41 patients underwent re-operation at a mean time interval of 21 months (range 2 weeks - 87 months). 79 patients (Group A) had isolated meniscal tears. 44 patients (Group B) had meniscal repair at the same time as elective ACL reconstruction and underwent brace-free, accelerated rehabilitation. 47 patients (Group C) had meniscal repair in association with ACL disruption and underwent staged ligament reconstruction.

In Group A, 23 patients underwent re-operation (Indications; meniscal symptoms 21, stiffness 1, infection 1). Nineteen repairs (23.8%) were found to have failed. In Group B, 15 patients underwent re-operation (Indications; meniscal symptoms 12, stiffness 1, revision ACL 2). Twelve (27.2%) repairs were found to have failed. In Group C, Nine (19.6%) repairs were found to have failed. 6 at the time of staged ACL reconstruction and 3 subsequently, at further arthroscopy. There was no statistical difference between the groups with respect to the incidence of failed meniscal repairs.

Analysis of possible predictive factors including age, gender, location of lesion and the type of repair did not show statistical significance.

Conclusions: Reoperation rate following meniscal repair is high. Meniscal repair for tears associated with ACL disruption in this group did not appear to have a higher success rate compared to isolated tears. This raises questions regarding the current practice of ignoring meniscal repair and instituting brace-free, early, aggressive rehabilitation following concomitant ACL reconstruction.

We prospectively assessed a consecutive series of patients undergoing MTPJ arthroplasty with the MOJE prosthesis. All patients entered into the study were assessed preoperatively with the AOFAS 100-point Hallux Meta-tarsophalangeal-Interphalangeal Joint Scale and the range of motion was recorded. Patients were assessed on table postoperatively for range of motion (ROM) and then at 3, 12 and 24 months with AOFAS scores and ROM.

Forty-two toes (40 patients) were recruited into the study. There were 24 women and 16 men. The mean patient age on the day of surgery was 59 (range 37 to 73). 18 operations were carried out on the left hallux and 24 on the right. All operations were carried out for a diagnosis of hallux rigidus (although one patient also had hallux valgus, with an intermetatarsal angle of 24° and a hallux valgus angle of 40°).

The mean pre-op AOFAS score increased from 36.0 to 82.2 at 3 months (p< 0.001) and was 87.0 at 12 months and 84.2 at 24 months. There was no significant change in scores from 3 months onwards. Only 2 patients had a follow-up of 36 months; both of them had AOFAS scores of 95.

The mean arc of motion reduced from 70.8° on-table to 33.3° by 24 months (p< 0.001). The difference in arc of motion from 3 months to 12 months was a decrease from 45.6 to 40.0 which was borderline significant.

In 4 radiographs there was evidence of progressive loosening (figure 4). This was at 24 months in all 4 cases. For 3 of the patients the AOFAS score was 85. For the 4th patient the AOFAS score was 65

One patient had a spontaneous fusion of the toe. There were also three episodes of wound breakdown, one patient had intra-operative division of the EHL tendon that was repaired. We also noted post-operatively that: three feet developed Morton’s neuromata; one patient developed tarsometatarsal joint osteoarthritis of the great toe, one sesamoid osteoarthritis and one plantar fasciitis.

At the most recent follow-up appointment 33 out of 40 patients (82.5%) were satisfied with the results of their operation, 2 were dissatisfied (5%) and results regarding satisfaction were not available for 5 patients.

The results obtained in this paper demonstrate good, prospective, short-term results with the press-fit zirconium ceramic Moje implant. We believe that in the correct patient group good short term results can be achieved in the treatment of 1st MTPJ osteoarthritis as an alternative to fusion, particularly in those patients who are unwilling to have permanent stiffness in this joint for cosmetic or functional reasons

The purpose of this study was to investigate the safety and outcome of bilateral simultaneous ACL reconstruction. In patients presenting with an ACL-deficient knee, 2 – 4% have bilateral ACL deficiency. A staged or simultaneous approach can be adopted when the patient requires reconstructive surgery for both knees. We report a case series of 8 patients (6 male, 2 female, average age 30.4 years) who underwent bilateral simultaneous ACL reconstruction.

Simultaneous or bilateral ACL reconstruction using ipsilateral patella tendon graft has been reported as a safe procedure with outcome and complication rate no different to unilateral procedures. Considerable cost savings of simultaneous over staged procedures have also been described. There are no case series in the published literature that describe the use of hamstring tendon autograft for bilateral simultaneous ACL reconstruction.

We used two camera stack systems and instrument sets to allow for simultaneous bilateral surgery by two surgical teams. Quadrupled hamstring tendon graft was used in 4 patients although in one patient patella tendon graft was used on the second side due to poor quality of hamstring tendons. Patella tendon graft was also used in a further 4 patients. At two weeks all patients were able to discard crutches and were independent in mobility. There was no difference in outcome at one year between those patients undergoing bilateral simultaneous ACL reconstruction in comparison to the outcomes of unilateral ACL reconstruction with respect to Lysholm, Tegner and IKDC scores. The mean follow up period was 2.3 years.

Our results demonstrate that bilateral simultaneous ACL reconstruction is safe and cost effective. A simultaneous approach also has the benefit of reducing the overall period of rehabilitation required by the patient. We report good short-term functional outcome but no long-term data is yet available.

Introduction: The problem of ingrowing toenails is worldwide, affecting all age groups. The exact incidence in children is difficult to measure.

The aim of this study was to review the different surgical modalities for ingrown toenails in the paediatric age group in a hospital setting.

Methods: We reviewed case series of 66 children aged between 9 months and 16 yrs. In total there were 89 affected toes operated upon between 1995 and 2001. The patients were followed up for up to 18 months.

All procedures were carried out under general anaesthetic. The treatment methods practised were:

Nail avulsion with or without nail matrix ablation using phenol.

RESULTS: We performed statistical analysis using Fischer’s exact test with the level of significance at P value 0.05. We found the recurrence rate to be 3% for those treated with wedge excision alone compared to 30% when treated with wedge excision and phenol ablation (p=0.001).

We also applied the same Fischer’s exact test for rate of infection in all the groups.

DISCUSSION: Ingrown toenails go through three stages- inflammation, infection and granulation.

During the stage of inflammation, conservative measures in the past have been noted to be successful.

In a hospital setting, most patients present in the second stage (infection). Nail avulsion is still commonly practised as a first line treatment. It provides good symptomatic relief in this stage but has been reported to have high rates of recurrence. We noted similar results (recurrence rate: 55%) in our study.

Then patients present in the next stage with symptoms of chronic ingrowths i.e. previous infection and presence granulation tissue in the nail fold. The aim of treatment here is to remove the ingrown area along with the nail fold. Wedge excision with or without removal of nail matrix is a commonly performed procedure. There are various methods for removing the nail matrix namely surgical matrixectomy, chemical matrixectomy using phenol or sodium hydroxides, diathermic/electric cauterisation, laser. There are reports that show low recurrence rates with use of phenol. In this study we found recurrence and infection to be high when phenol was used as the ablative agent. We achieved cure rate of 97% when using wedge excision alone and 70% when phenol was used for nail matrix ablation.

CONCLUSION: We advocate wedge excision as primary treatment of ingrowing toenails in children. We did not note a statistical significance in giving postoperative antibiotics but this has to correlate with the clinical presentation. We would not recommend phenol ablation of the nail matrix in the younger patient as it increases both infection and recurrence rates. The results of nail bed ablation with diathermy appear promising.

Purpose: To assess the results of ACL reconstructions carried out at our institution in a non-elite cohort of patients with regards to return to active sports post reconstruction.

Materials & Methods: Seventy-five (71%) of 106 patients who underwent reconstruction of isolated ACL tears between June 2001 and August 2004 performed by the senior author completed a newly designed questionnaire (incorporating Cincinnati Sports Activity Scale [CSAS]) to help us fully assess their return to sports and to elucidate reasons if not returning to pre-injury level. 55 were completed at follow up, with objective clinical assessment and other subjective questionnaires [KOOS, IKDC and Lysholm] and 20 were done through telephone interview.

Results: All 75 patients were involved in sports at CSAS Levels 1 & 2 prior to their injury and 39 (52%) had to drop to level 4 after injury. Following reconstruction 61 patients (81.3%) returned to CSAS 1 & 2 levels. 28 of 30 patients (93.3%) operated within 2 years from injury achieved pre-injury CSAS levels compared to 33 of 45 (73.3%) with a longer interval. The mean Lysholm, IKDC and KOOS Sports scores at 12 to 24 months follow up revealed a progressive trend and were 84.9, 76.3 and 73.6 respectively.

One reason for not returning to pre–injury intensity of sports was that many (71.7%) expressed fears of instability though most (70%) had no instability on playing. 77.8% of non-returners who were more than 30 years age reasoned not wanting to risk re-injury compared to 36.8% in the under 30 group. More significantly, 44.4% of over 30s said they were planning to drop their sporting level anyway compared to 5.5% in the younger group.

Conclusion: ACL reconstruction is best done as early as possible after injury for persons intending to return to competitive sports. The results are even better after early intervention in younger patients. Psychosocial issues play a significant role in return to active sports.

Introduction: Instrumented arthrometry is a widely used technique for the quantification of cruciate ligament laxity. It is used both before and after surgery. The Rolimeter(Aircast, Europe) is used in such scenarios. It has several advantages over its cousins; it is more compact, lighter, less expensive and amenable to sterilization techniques. The other leading arthrometers have however had over 15 years of clinical use and their reliability has been thoroughly assessed. Muellner et al found no significant difference in the intra-tester and inter-tester results obtained on Rolimeter assessment of the knees of un-injured healthy subjects. Our study assessed the inter-tester and intra-tester variability when the Rolimeter is applied to patients with unilateral ACL-deficient knees. It also examines whether the level of experience of the examiner influences the results in this group of patients.

Materials and Methods: Six examiners each examined thirty-three subjects on two occasions. One examiner was medically qualified but had never performed a Lachman or anterior drawer test. Two examiners were qualified physiotherapists who routinely examined knees, but had never used a Rolimeter. One medically qualified examiner was considered to be of intermediate experience.Two examiners were regarded as expert Rolimeter users.For each examination a Rolimeter reading was taken three times with the knee at 30 degrees of flexion and three times at 90 degrees of flexion for both knees.The interval between examinations was at least thirty minutes. All the readings were acquired on the same day. The examiners were blinded to whether the subject was known to be ACL deficient or not. The results of the examinations were entered onto a data-base.Repeated measures analysis of variance was used to test for the effects of the following factors, difference between examiners, reproduction of results between examinations.

Results: There was no significant difference between each set of measures for each subject between examinations (p=0.767), indicating that the measurement procedure was reliable. Measurements were significantly higher in patients with ACL-deficient knees compared to the control group (p< 0.001) confirming the sensitivity of the Rolimeter to help diagnose ACL-deficient knees. The in-experienced examiner’s measurements were lowest and were more reliable. The examiner with the intermediate experience was the most un-reliable. Both experienced examiners were in close agreement.

Conclusion: We have demonstrated that the rolimeter is reliable in the assesment of ACL deficient patients regardless of the experience of the examiner.