Introduction:

Wear debris from articulating joint implants is inevitable. Small debris particles are phagocytosed by macrophages. Larger particles initiate the fusion of many macrophages into multi-nucleated giant cells for particle encasement. Macrophages are recruited into inflamed tissues from the circulating monocyte population. Approximately 10% of white blood cells are monocytes which after release from the bone marrow circulate for 2–3 days, before being recruited into tissues as inflammatory macrophages or undergoing apoptosis. Circulating MRP8/14 (S100A8/A9) is a measure of monocyte recruitment, part of the monocyte-endothelial docking complex, and shed during monocyte transmigration across the endothelium. The higher the S100A8/A9 the more monocytes being recruited giving an indirect measure of debris production.

Introduction:

The risk factors for degenerative joint disease are well established: increasing age, obesity, joint abnormalities, trauma and overuse, together with female gender, ethnic and genetic factors. That obesity is a significant risk factor for developing osteoarthritis in non-weight-bearing as well as weight-bearing and joints was one of the first indications that the risk was nor purely that of aberrant biomechanical loading. Low grade chronic systemic inflammation is a component of each of ageing and obesity, atherosclerosis and diabetes, culminating in Metabolic Syndrome. In our study of 1684 patients with joint degeneration 85% were overweight or obese and 65% older than 65 years with 62% being both, 73% of patients were taking medications for serious, ‘non-orthopaedic’ health problems such as cardiovascular or respiratory disease, obesity or NIDDM. Monocytes are a major component of chronic inflammation, approximately 10% of white blood cells are monocytes which circulate for 2–3 days, before being recruited into tissues as inflammatory macrophages or undergoing apoptosis. Circulating S100A8/A9 (MRP8/14) is a measure of monocyte recruitment being shed during monocyte transmigration across the endothelium. The higher the S100A8/A9 the more monocytes being recruited giving an indirect measure of chronic inflammatory status.

We continued a prospective longitudinal follow-up study of 53 remaining patients who underwent open total meniscectomy as adolescents and who at that time had no other intra-articular pathology of the knee. Their clinical, radiological and patient-reported outcomes are described at a mean follow-up of 40 years (33 to 50). The cohort of patients who had undergone radiological evaluation previously after 30 years were invited for clinical examination, radiological evaluation and review using two patient-reported outcome measures.

A total of seven patients (13.2%) had already undergone total knee replacement at the time of follow-up. A significant difference was observed between the operated and non-operated knee in terms of range of movement and osteoarthritis of the tibiofemoral joint, indicating a greater than fourfold relative risk of osteoarthritis at 40 years post-operatively. All patients were symptomatic as defined by the Knee Injury and Osteoarthritis Outcome Score.

This study represents the longest follow-up to date and it can be concluded that meniscectomy leads to symptomatic osteoarthritis of the knee later in life, with a resultant 132-fold increase in the rate of total knee replacement in comparison to their geographical and age-matched peers.

This prospective case-controlled study evaluates the outcome of chronic combined anterior cruciate ligament (ACL) & posterolateral corner (PLC) knee reconstruction.

Twenty-six patients (23 male) underwent combined ACL & PLC reconstruction between October 2001 and October 2006 (Group ACL/PLC). Mean age 30.2 years (range 17–44). Mean follow-up 51 months (range 27–109). The commonest mode of injury was football. Seven patients had concomitant lateral, and 9 medial meniscal procedures, 1 osteochondral defect was micro-fractured. All procedures were performed at the same operation. Prospective scoring was done pre-operatively and 3,6,12, and 24 months post-op using Lysholm, IKDC 2000 and KOOS scoring systems. These scores were compared to an age, sex and injury matched control group of patients who also underwent ACL reconstruction without posterolateral corners injury (Group ACL).

Functional scores showed a significant improvement in all patients in both ACL/PLC and ACL groups postop (p< 0.05). Pre-op scores for Lysholm (p=0.005), IKDC (p=0.03), KOOS sports (p=0.03) and quality of life (QOL) (p=0.03) were significantly lower in Group ACL/PLC compared to Group ACL. Other significantly reduced KOOS scores were - sports 12 (p=0.04) & 24 months (p=0.004); and QOL 12 (p=0.01) & 24 months (p=0.006).

Conclusions: Injury to the posterolateral stabilizing structures of the knee usually occurs in association with other ligamentous injuries. The recognition and adequate management of this injury is crucial. Knees with combined ACL & PLC injuries have reduced function compared to ACL injuries alone. Patients undergoing combined ACL & PLC reconstruction should be made aware that the nature of their injury is such that postoperatively they may have ongoing functional limitations with respect to return to sport and quality of life.

Introduction: The treatment of femoral nonunions remains challenging despite modern surgical techniques and adjuncts to fracture healing. We present a series of 14 patients in whom a bifocal treatment technique has been used in order to achieve bony union and correct limb length.

Methods: Patients were identified from theatre records and their hospital notes and x-rays were retrospectively reviewed. All patients underwent bifocal treatment for femoral nonunions – debridement and internal fixation (single or double plating) of the nonunion and lengthening at the opposite end of the bone to correct limb length discrepancy. Initially the procedures were staged, with treatment of the non-union then subsequent lengthening. However, our technique has evolved to perform all procedures in a single stage. All lengthening procedures were done with a monolateral (Orthofix LRS) fixator.

Results: 11 patients had distal and 3 proximal femoral nonunions. 13 patients were male and 1 female. The non-union united with the index procedure in 13 patients, 1 is still undergoing treatment. Limb length discrepancy range 2–5 cm was fully corrected in all patients with no axial deviation of the regenerate. There were no pin site problems.

Discussion: Femoral nonunions are challenging due to multiple previous procedures, insecure grip on the smaller fragment and bone loss. Successful union can be achieved by ORIF with bone grafting, but this does not restore length. Treatment by the Ilizarov method alone is associated with significant morbidity, particularly knee stiffness. A bifocal strategy provides stable internal fixation of the non-union to allow bone healing, and any consequent loss of length is safely restored. We believe this to be a safe and effective technique to treat femoral nonunions.

Introduction: The subtrochanteric area of the femur is subject to large tensile and compressive forces. The rate of nonunion following operative fixation of such fractures is about 7–20%. Revision surgery to obtain union is difficult because of the small size of the proximal fragment, muscle forces acting in 2 planes, and bone loss.

We present the results of a series of 9 consecutive patients with subtrochanteric non-unions treated by double plates.

Methods: Retrospective analysis of 9 consecutive subtrochanteric nonunions treated with double plates and additional osteoinduction (bone graft, or BG+BMP-7).

Results: There were 5 male and 4 female patients, with ages from 50–82 years (mean 65). All were treated in a single-stage procedure by implant removal, a lateral plate and a separate anterior plate. One patient had had a previous unsuccessful revision procedure with an intra-medullary device.

One patient with liver cirrhosis died 5 days postoperatively. Two patients are currently 8 weeks post surgery. All the others healed in a mean of 5.1 months (range 4–6 months).

Two patients underwent distal femoral lengthening to compensate for bone loss.

Discussion: The high muscle forces around the proximal femur require a sound mechanical environment for bone healing to occur. This is particularly marked in nonunions. The small size of the proximal fragment can result in suboptimal fixation. The addition of the anterior plate provides better fixation and also neutralizes the sagittal forces.

We believe that double plating neutralizes all the forces around the proximal femur, providing the best mechanical environment. Given the limits of the small numbers and the retrospective nature of the study, we believe that this method of treatment offers a sound surgical strategy, reflected by our success rate.

The purpose of this study was to evaluate the outcome of posterior cruciate ligament (PCL) reconstruction with a double tunnel technique, using prospective pre & post-operative functional scoring and clinical evaluation.

We reviewed those patients who underwent PCL reconstruction between October 2001 and October 2006. 24 patients were identified, 23 male and 1 female. Mean age 30.1 years (range 17–43). Mean follow up 56 months (range 29–86). The commonest mode of injury was football. 3 patients had isolated PCL injuries, 21 had concomitant knee ligament injuries which were treated surgically at the same operation. Patients were prospectively scored pre-operatively and at 3, 6, 12 & 24 months post-op using the Lysholm, IKDC 2000 & KOOS scoring systems. These scores were compared to an injury matched control group who underwent comparable knee ligament reconstructions, but who had intact PCL’s.

The knee scores showed a significant improvement in all PCL reconstructed patients post-op (p< 0.05). However, significant differences were found between the PCL reconstructed and PCL intact groups. Both groups had high return to employment and return to sports rates. We describe our method of double tunnel reconstruction.

Conclusions: PCL injury is usually associated with concomitant soft tissue knee injuries. PCL deficiency contributes significantly to the morbidity of the multiple ligament injured knee. Reconstruction with the double tunnel technique described gives excellent functional improvement and high rates of return to employment and sports.