B R I T I S H ASSOCIATION F O R S U R G E R Y O F T H E K N E E

006 Meeting - 23rd & 24th Ma

• •smith&nephew GLIDEr Articular Cartilage Probe

Sometimes less is more Ihe GLIDER Articular Cartilage Probe is an early intervention tool for treatment of chondromatacia. With its pivoting head and low surface area electrode, the GLIDER Probe enables surgeons to debride and smooth diseased tissue with minimal cell death.

Through controlled application of RF energy, the GLIDER Probe restores a smooth, gliding cartilage surface while preserving the maximum amount of healthy tissue.

Endoscopy T 978 7491000 US "Trademark of Smith & Nephew Smith & Nephew, Inc . ©2005 Smith & Nephew, Inc. All rights reserved 150 Minuteman Road W W W . S m i t r i - n e p n e W . C O m Printed in USA 8/05 1876 Andover. AAA 01810 USA

BRITISH ASSOCIATON FOR SURGERY OF THE K N E E

Would like to thank Smith & Nephew for their generous contribution regarding the publication of both programmes for this meeting and the Annual Dinner.

Plus Orthopedics for generously sponsoring the coach transfers for both the meeting and the annual dinner.

PLUS ORTHOPEDICS

Stryker for sponsoring and supplying the delegate bags

Thank you to the following companies for their continued support and contri­butions in accepting the invitation to exhibit.

A r t h r ^ r ^ '^^rthroCarer A S T K a I ^ iHHHI ASTRA TECH ^ ^ A .

BIBRAUN cz i cD i imr SHARING EXPERTISE • • • • • • UK Ltd

C N R M e d i c a l

Biosurgery K A R L S T O R Z — E N D O S K O P E

genzyme Biosurgery

'ONMED' m a t h y s tPePuv I I N V A T E C af<A»<«.p»««»„p.„,

t u r o p e a n O r t h o p a e r i i r s

oRTHODYNAMics/ ^ITRB CHEMEDICA (UK) LID S O L U T I O N S I N O R T H O P A E D I C S r ^ L I V I U U I V H \ X/ Ul U

N / V R I G I - n : ( ^ z i m m e r Confidence in your tiands

Heraeus O B

iii

F O R E W O R D

Welcome to the BASK Annual Meeting.

We have had over 200 abstracts submitted. We have been able to accept 54 Podium presentations and 35 posters. There is an instructional session on soft tissue allo­grafts and a debate on bilateral Knee replacement, simultaneous or staged? Professor George Bentley is giving a lecture on contemporary management of osteochondral defects of the knee and Graham Deane on the early history of TKR. Geoffrey Glazer, Chairman of the Federation of Independent Practitioner Organisations (FIPO) wi l l be coming to the A G M to discuss current issues in pri­vate practice.

Twenty seven companies wi l l be exhibiting.

I do hope that you all have an enjoyable meeting.

Kind regards

Robin Allum FRCS President of BASK

iv

BASK - ANNUAL GENERAL MEETING BAYLIS HOUSE, SLOUGH, IS'" March 2006 - 4.30 pm

AGENDA

1. Apologies

2. Minutes of BASK AGM 18*" March 2005

3. Matters arising

4. Editor of The Knee Journal report

5. Knee Tutor's report

6. Private Practice Committee report with guest Geoffrey Glazer, Chairman FIPO

7. Secretary's Report

8. Treasurer's report

9. President's Report

10. Election of Officers

11. Applications for Membership

12. Fellowships: 1. DePuy 2. Endo 3. Smith and Nephew

13. Forthcoming Meetings: 1. ESSKA Innsbruck, May 2006 2. BASK Spring Meeting Belfast, March 2007 3. ISAKOS Florence, May, 2007

4. BASK Spring Meeting, Bournemouth 2008

14. National Joint Registry

15. Website

16. Any Other Business 17. Date of next meeting

APPLICATION FOR BASK MEMBERSHIP - AGM 2006, BAYLIS HOUSE, SLOUGH, BERKSHIRE

FULL MEMBERSHIP (16 )

Name Grade Hospital Proposed Seconded Tanweer Ashraf Consultant- University Hospital Birmingham Mr D Learmonth Mr K Baloch William Bradley Consultant Royal Surrey County Hospital Mr C Coates Galium Clark Consultant HeathenA/ood & Wexham Park NHS Trust Mr R Allum Mr R Dega Douglas Dunlop Consultant Southampton University Hospitals NHS Trust Mr P Chapman-Smith Mr D Barret Keith Eyres Consultant Royal Devon & Exeter Hospital Mr P Schranz Mr N Giles John Gallagher Consultant Nuffield Orthopaedic Centre, Oxfordshire Mr C Dodd Mr H Pandit Adrian Harvey Consultant Royal Bournemouth Hospital Mr N Fiddian Mr C Blakeway Rakesh Kucheria Consultant Heatherwood & Wexham Park NHS Trust Mr R Allum Mr R Dega Krishnachandra Mehta Consultant London Knee Clinic, London Bridge Hospital Mr A Strover Mr A Kumar Sathya Murthy Consultant QEQM Hospital, Margate, Kent Mr P Schranz Mr D Barret Barry O'Brien Consultant Sunderland Royal Hospital Mr R Gregory Mr D Weir Pankaj Pathak Ass Specialist University Hospital of Leicester Mr S Godsiff Mr C Esler Kasetti Ravikumar Consultant Maidstone Hospital Mr J Fleetcroft Mr S Rao Stuart Roy Consultant Royal Glamorgan Hospital Mr D Pemberton Mr C Wilson Binod Singh Consultant City Hospital NHS Trust Mr D Learmonth Andrew Toms Consultant Princess Elizabeth Orthopaedic Centre Mr P Schranz Mr K Eyres

ASSOCIATE MEMBERSHIP ( 5 )

Name Grade Hospital Proposed Seconded Emyr Chowdhury SpR Mr M Porter Mr R Parkinson Alister Hart SpR Harrow Hospital, NE Thames Rotation Mr P Allen Mr G Dowd Vikas Khanduja SpR Royal National Orthopaedic Hospital, Middx Mr G Dowd Mr J Skinner Ramakrishnan Venkatesh SpR Royal Bournemouth Hospital Mr C Blakeway Mr N Fiddian Jonathan Waite SpR Great Western Hospital Mr S Deo Mr V Satish

10 CME Points have been accredited to this meeting

BASK SPRING MEETING BAYLIS HOUSE, SLOUGH, BERKSHIRE

Thursday 23rd March 2006

09.30 am

09.50 am

Moderators Session I 10.00 Phil Hirst & Richard Parkinson

10.06

10.12

10.18

10.24

Session II 10.35 Phil Hirst & Richard Parkinson

10.41

10.47

10.53

REGISTRATION & GOFFEE

INTRODUGTION - Robin Allum, President

Free Papers - Patient issues in TKR

MAGNETIC RESONANCE DETERMINATION OF ANTHROPOMETRIC KNEE LANDMARKS FOR USE IN REVISION KNEE SURGERY L A Crawford, R Mehan, D Q Donaldson, G J Shepard Royal Bolton Hospital, England

RELATIONSHIP OF BODY MASS INDEX TO EARLY COMPLICATIONS IN KNEE REPLACEMENT SURGERY. MAlbrizio, A D Patel Hinchingbrooke Hospital, Cambridgeshire, Huntingdon, UK

CHANGES IN BODY WEIGHT FOLLOWING LOWER LIMB ARTHROPLASTY E Mughal, *P Desai, * F Ashraf, Y Khan, D Dunlop, R Treacy, A Thomas Royal Orthopaedic Hospital, Birmingham / ^University of Birmingham The Woodlands, Bristol Road South, Northfield, Birmingham

PROSPECTIVE RANDOMISED CONTROLLED TRIAL ON THE ROLE OF PATIENT INFORMATION LEAFLETS IN OBTAINING INFORMED CONSENT V Khanduja, S Ashraff, G Malawa, T Dolan.

Department of Trauma and Orthopaedics, Newham University Hospital

Discussion

Free Papers - Primary T K R decisions

A COMPARATIVE STUDY OF THE MIDVASTUS AND MEDIAL PARAPATELLAR APPROACHES FOR TOTAL KNEE ARTHROPLASTY IN THE EARLY POSTOPERATIVE PERIOD M Maru, V Kumar, G Akra, A Port The James Cook University Hospital, Middlesbrough

SHOULD WE RECONSIDER ALL-POLYETHYLENE TIBIAL IMPLANTS IN TOTAL KNEE ARTHROPLASTY? SD Muller, D.I Deehan. JP Holland, LM Kirk, S Outerside, PJ Gregg, AW McCaskie. Department of Orthopaedics, Freeman Hospital, Newcastle upon Tyne

LONG TERM FOLLOW-UP COMPARISON OF NEW JERSEY LCS MENISCAL-BEARING AND ROTATING-PLATFORM TOTAL KNEE REPLACEMENT / R Gill, P D Hamilton, S J Pearce, G Marsh Orthopaedic department, Mayday University Hospital Croydon

Discussion

3

Session III 11.02 Phil Hirst & Richard Parkinson

11.08

11.14

11.20

11.30

11.50

12.00

12.20

12.30

12.50

1.00 pm

Session IV 2.00 Roger Smith & Derek Bickerstajf

2.06

2.12

Free Papers - Perioperative T K R Techniques

THE BLOOD SAVING EFFECT OF IMMEDIATE KNEE FLEXION FOLLOWING TOTAL KNEE ARTHROPLASTY J McConway, R K Wilson, D O Molloy, L Ogonda, D E Beverland Departments of Orthopaedics' Musgrave Park Hospital, Belfast

COMPARISON OF TRANEXAMIC ACID AND TOPICAL FIBRIN SPRAY ON BLOOD LOSS FOLLOWING TOTAL KNEE ARTHROPLASTY - A RANDOMISED CONTROLLED TRIAL D O Molloy, J McConway, HA P Archbold, L Ogonda, Mr D E Beverland Orthopaedic Outcomes Department, Musgrave Park Hospital, Belfast

ASSESSMENT OF THE TIBIAL CEMENT MANTLE IN TOTAL KNEE REPLACEMENT - A PROSPECTIVE, CONTROLLED, COMPARATIVE STUDY OF TWO CEMENTING TECHNIQUES AM Perera, N Gogi, Bathla S, Dutta A, BK Singh. City Hospital, Birmingham

Discussion

Allograft Symposium: Chairman - Robin Allum

Guest Lecturer: Professor John Kearney 'Overview of Tissue Banking in the National Blood Service'

Discussion

Guest Lecturer: Professor David Pegg 'What Does Cryobiology have to offer Knee Surgeons and their patients?'

Discussion

Keynote Lecturer: Chairman Robin Allum Professor George Bentley 'Contemporary management of osteochondral defects of the knee'

Discussion

LUNCH

Free Paper Session - ACL Pre-op evaluation

MCMURRAY^S TEST REVISITED: EVALUATION OF VARIOUS METHODS OF PERFORMING MCMURRAYS TEST H Nalwad, MAgarwal, B N Muddu, M Smith, Mr. J K Borill Tameside General Hospital, Ashton-under-Lyne; South Manchester University Hospital, Wythenshawe.

IDIOPATHIC ANTERIOR KNEE PAIN: WHAT IS THE ELECTROPHYSIOLOGICAL EVIDENCE? S Patil, V Kumar, V Kamath, L White, J Dixon, A Hut Department of Orthopaedics, James Cook University Hospital, Middlesbrough

BELIEFS AND ATTITUDES OF MEMBERS OF THE BRITISH ASSOCIATION FOR SURGERY OF THE KNEE REGARDING THE TREATMENT OF ANTERIOR CRUCIATE LIGAMENT INJURY. M Goddard, A J Rees Rotherham District General Hospital

2.18 Discussion

4

Session V 2.26

Roger Smith & Derek Bickerstajf

2.32

2.38

2.44

Free Paper Session - ACL Injury and Reconstruction

COMPLETE TRANSPHYSEAL ACL RECONSTRUCTION IN SKELETALLY IMMATURE PATIENTS MM Utukuri, HS Somayaji, GSEDowd, DMHunt St Mary's Hospital, London; Royal Free Hospital, London; The Wellington Hospital, London

ANTERIOR CRUCIATE LIGAMENT INJURY - A QUIET EPIDEMIC REVISITED V T Veysi, S R Bollen Bradford Royal Infirmary

DAY SURGERY ARTHROSCOPIC ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: A PROSPECTIVE STUDY. S A Jain, J Rollo, A L Pimpalnerkar Royal Centre for Defence Medicine & Good Hope Hospital NHS Trust, Birmingham

PATIENT SATISFACTION FOLLOWING DAY CASE ARTHROSCOPIC ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION. H Deo, R Sharma, M Wilkinson King's College Hospital, London

2.50 THE CONTROL OF THE KNEE KINEMATICS ACHIEVED BY SINGLE VERSES DOUBLE-BUNDLE ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: INTRA-OPERATIVE MEASUREMENT USING SURGICAL NAVIGATION. J R Robinson, L Carat, C Granchi, P Colombet Centre de Chirurgie Orthopedique et Sportive, Bordeaux-Merignac, France

2.56 Discussion

Session VI 3.10 Roger Smith & Derek Bickerstaff

3.16

3.24

3.30

Free Paper Session - PCL and PLC Reconstruction

A STUDY OF FUNCTIONAL DISABILITY LOWER LIMB ELECTOMYOGRAPHY AND GAIT IN RECREATIONAL SPORTSMEN WITH POSTERIOR CRUCIATE AND POSTEROLATERAL LIGAMENT DEFICIENCY OF THE KNEE F Muir, S H Palmer, D Hollinghurst, T Theologis Nuffield Orthopaedic Centre, Oxford and Worthing and Southlands Hospitals, West Sussex

COMBINED RECONSTRUCTION OF CHRONIC POSTERIOR CRUCIATE LIGAMENT AND POSTEROLATERAL CORNER DEFICIENCY: A 2-9 YEAR FOLLOW UP STUDY

V Khanduja, H S Somayaji, M Utukuri, G Dowd.

Royal Free Hospital, London

KINEMATICS OF POSTERIOR CRUCIATE LIGAMENT (PCL) AND POSTEROLATERAL CORNER (PLC) DEFICIENT HUMAN CADAVER KNEE RECONSTRUCTED WITH TWO DIFFERENT TECHNIQUES OF POSTEROLATERAL CORNER RECONSTRUCTIONS.

T Nguyen, S Apsingi, AMJ Bull, A Unwin, DJ Deehan, AA Amis. Imperial College London

KINEMATICS OF POSTERIOR CRUCIATE LIGAMENT (PCL) AND POSTEROLATERAL CORNER (PLC) DEFICIENT HUMAN CADAVER KNEE RECONSTRUCTED WITH SINGLE OR DOUBLE BUNDLE POSTERIOR CRUCIATE LIGAMENT S Apsingi, T Nguyen, AMJ Bull, DJ Deehan, A Unwin, AA Amis. Imperial College, London.

3.36 Discussion

5

3.45 pm Tea

4.10 pm Graham Deane - Consultant Orthopaedic Surgeon, Somerton, Somerset 'TOTAL KNEE REPLACEMENT - Why are we where we are now?'

4.30 pm AGM Attending by invitation: Mr Geoffrey Glazer, Chairman of FIPO 'Private Practice: Facing the Abyss?'

7.45 pm for 8.15 pm Annual Association Dinner - Stoke Park Club, Buckinghamshire

6

BASK SPRING MEETING BAYLIS HOUSE, SLOUGH, BERKSHIRE

Friday 24th March 2006 08.30 am

Moderators Session VII 09.00 am John Newman & Colin Esler

09.06

09.12

09.18

Session VIII 09.27 John Newman & Colin Esler

09.33

09.39

09.45

Session IX 09.54 John Newman & Colin Esler

10.00

Coffee

Free Paper Session - Patello-femoral ligament reconstruction

MEDIAL PATELLO-FEMORAL LIGAMENT RECONSTRUCTION. THE DERBY EXPERIENCE. MA Yaqoob, D Baiju, R Chauhan, G Geutjens. Derbyshire Royal Infirmary.

THE OUTCOME OF ARTHROSCOPIC REPAIR OF TRAUMATIC PATELLO FEMORAL INSTABILITY (TPFI) S Shakkor, A Aldairy, KAdra Sports injury department, Hamish hospital, Damascus, Syria

MEDIAL PATELLO-FEMORAL LIGAMENT RECONSTRUCTION WITH SEMITENDINOSUS RE-ROUTING FOR THE TREATMENT OF TRAUMATIC PATELLA DISLOCATION V. Kumar, A Panagopoulos, J K Triantafyllopoulos, L van Niekerk Centre for Sports Injury Surgery, Friarge & Duchess of Kent Military Hospitals, Northallerton, North Yorkshire

Discussion

Free Paper Session - Fractures around the knee

MANAGEMENT OF PERIPROSTHETIC SUPRACONDYLAR FEMORAL FRACTURES WITH NEW TECHNIQUE V Ramasamy, S C Haider Calderdale Royal Hospital, Halifax, Southwest Yorkshire, UK

A BIOMECHANICAL STUDY COMPARING 6.5MM CANCELLOUS SCREWS AND 3.5MM CORTICAL SCREWS FOR DEPRESSED TIBIAL PLATEAU FRACTURES S Patil, A Mahon, I. McMurtry, S. Green, A. Port James Cook University Hospital, Middlesbrough

BIOMECHANICAL ASSESSMENT OF FORCES ACTING ACROSS THE PATELLA TO DETERMINE THE OPTIMAL TREATMENT OF PATELLA FRACTURES WS Khan, R Jones, L Nokes, DS Johnson Gait Analysis Laboratory, Centre for Rehabilitation and Human Performance Research, Salford University, Manchester

Discussion

Free Paper Session - Cartilage repair

THE SEQUENTIAL IMPROVEMENT IN CLINICAL OUTCOME FOLLOWING AUTOLOGOUS CHONDROCYTE IMPLANTATION - A 7 YEAR FOLLOW UP BA Rogers, Mr Carrington, Mr Skinner, Prof Bentley & TWR Briggs The Royal National Orthopaedic Hospital, Stanmore, UK.

DURABILITY OF CARTILAGE REPAIR- DOES HISTOLOGY MATTER? SP Krishnan, J A Skinner, J Jagiello, RWJ Carrington, AM Flanagan, TWR Briggs, G. Bentley. Royal National Orthopaedic Hospital Stanmore.

7

10.06

10.12

TWO STAGE AUTOLOGOUS CHONDROCYTE IMPLANTATION FOR LARGE FULL THICKNESS CARTILAGE DEFECTS IN HIGH DEMAND PATIENTS: RESULTS A F T E R 2 Y E A R S FOLLOW-UP V Kumar, A Panagoupolous, J K Triantafyllopoulos, Lvan Niekerk Centre for Sports Injury Surgery, Friarage and Duchess of Kent Military Hospitals, North Yorkshire

THE ROLE OF FIBROBLAST GROWTH FACTOR-2 IN THE PROLIFERATION AND CHONDROGENIC POTENTIAL OF INFRAPATELLAR FAT PAD DERIVED STEM CELLS WS Khan, DS Johnson, JG Andrew, TE Hardingham United Kingdom Centre for Tissue Engineering, University of Manchester

10.18

10.30

Discussion

Coffee

Session X 11.00 Simon Donell & Robin Allum

11.06

11.12

Free Paper Session - UKA

SURVIVORSHIP OF 203 FIXED BEARING UNICOMPARTMENTAL KNEE REPLACEMENTS DURING THE SECOND DECADE R G Steele, J H Newman. S Hutabarat, R Evans, C E Ackroyd Avon Orthopaedic Centre, Southmead Hospital, Bristol, U.K.

A PROSPECTIVE RANDOMISED TRIAL COMPARING MINIMAL INVASIVE AND STANDARD PARAPATELLAR APPROACHES FOR UNICOMPARTMENTAL ARTHROPLASTY MP Jackson, H Cottam, A Butler-Manuel, H Apthorp The Conquest Hospital, Hastings, East Sussex Hospitals NHS Trust

LATERAL UNICOMPARTMENTAL KNEE REPLACEMENT: FIXED OR MOBILE BEARING? MC Forster, A Bauze & G Keene Sportsmed SA, Adelaide, Australia.

11.18 Discussion

Session XI 11.27 Simon Donell & Robin Allum

11.33

11.39

Free Paper Session - PFJ Replacement

FIVE TO EIGHT YEAR RESULTS OF THE AVON PATELLOFEMORAL ARTHROPLASTY C E Ackroyd, J H Newman, R Evans, C C Joslin Avon Orthopaedic Centre, Southmead Hospital, Bristol

EARLY RESULTS IN 110 CASES OF PATELLO-FEMORAL REPLACEMENT I N PATIENTS UNDER 55 YEARS OF AGE T D Clare, J H Newman, Avon Orthopaedic Centre, Bristol

Discussion

Session XI1 11.45 Simon Donell & Robin Allum

11.51

Free Paper Session - Troclilear pathology

CLINICAL PRESENTATIONS OF TROCHLEAR DYSPLASIA M M Kulkarni, J D Eldridge, J H Newman Avon Orthopaedic Center, Bristol

FEMORAL TROCHLEOPLASTY FOR PATELLAR INSTABILITY; A NEW OPERATIVE TECHNIQUE S H Zaki, I Rafiq, P J Rae Wrightington Hospital for Joint Diseases, Lancashire.

11.57 Discussion

8

Session XI11 12.03 Simon Donell & Robin Allum

12.09

12.15

12.21

12.27

12.30

Free Paper Session - Patellar problems at TKR

PATELLO-FEMORAL TRACKING IN FIXED AND MOBILE KNEE DESIGNS. P J James', PA May', W Gerard Tarpey', M Blyth' and IG Stother" Nottingham City Hospital^ and Glasgow Royal Infirmary^

PSEUDO-PATELLA BAJA FOLLOWING SOFT TISSUE BALANCING IN TOTAL KNEE ARTHROPLASTY P. Thornton-Bott, L . Unitt, D.J. Johnstone, A. Sambatakakis and the Balancer Study Group. Stoke Mandeville Hospital, Solihull Hospital, RNOH Stanmore, Northwick Park Hospital Kings Mill Hospital.

Discussion

SIMULTANEOUS VERSUS STAGED KNEE ARTHROPLASTY; A COMPARISON OF OUTCOMES IN 116 PATIENTS S Dawson-Bowling, K Chettiar, R Hussein, D East, K Miles, H Apthorp, PA Butler-Manuel

Orthopaedic Dept., Conquest Hospital, Hastings

Discussion

DEBATE: Chairman - Nick Fiddian 'Bilateral TKR: Simultaneous or Staged? For Simultaneous - Mr Paul Allen vs For Staged - Mr Jonathan Noble

1.15

2.10

Session IV 2.15 Tim Wilton & Andy Williams

LUNCH

Prize awarded for the Best Poster Presentation

Free Paper Session - TKR Peri-operative complications

EFFECTIVENESS OF NAVIGATION-BASED TOTAL KNEE REPLACEMENT IN ENHANCING THE MECHANICAL PERFORMANCE OF KNEE SYSTEM COMPONENTS. MC Norris, D Beaver, W. Schmidt, M Kester, SK Chauhan Stryker Orthopaedics, Mahwah, NJ, USA; Royal Perth Hospital, Australia; Brighton and Sussex University Hospitals

2.21

2.26

Session XV 2.33 Tim Wilton & Andy Williams

2.36

2.42

THE EFFECT OF A THROMBOPROPHYLAXIS PROTOCOL ON THE INCIDENCE OF VENOUS THROMBOEMBOLISM AFTER TOTAL KNEE REPLACEMENT RAE Clayton, C R Howie, P Gaston, A C Watts Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh

Discussion

Free paper Session - Revision TKR Technique

IS LONGSTEM IMPLANT IMPERATIVE IN REVISION KNEE REPLACEMENT. S Hakkaiamani, V Prasanna, A Acharya, R Finley, RW Parkinson. Arrowe Park Hospital, Upton, UK.

THE USE OF CT IN PRE-OPERATIVE ASSESSMENT OF FAILED TOTAL KNEE REPLEACEMENT PRIOR TO REVISION SURGERY M. Norris, MAther, S Chauhan Brighton and Sussex University Hospitals

Discussion

9

Session XVI 2.47 Tim Wilton & Andy Williams

2.53

2.59

3.05

Free Paper Session - Infected TKR

THE ECONOMIC CONSEQUENCES OF INFECTED KNEE ARTHROPLASTY. E Robinson, PF Partington Wansbeck General Hospital, Ashington

MEASUREMENT OF IN VIVO INTRA-ARTICULAR GENTAMICIN LEVELS FROM ANTIBIOTIC LOADED ARTICULATING SPACERS / Mutimer, G Gillespie, A Lovering, A Porteous Avon Orthopaedic Centre, Southmead, North Bristol NHS Trust

SURGICAL SITE INFECTION (SSI) FOLLOWING TOTAL KNEE REPLACEMENT (TKR): A PROSPECTIVE STUDY M Venkatesan, SN Sambandam, R Barman, S Maxfield, RC McGivney, B Ilango Fairfield General Hospital, Bury

Discussion

Session XVI1 3.10 Tim Wilton & Andy Williams KNEE DESIGNS.

3.16

3.22

3.28

3.34

3.40

Free Paper Session - Clinical Outcomes

A COMPARISON OF RANGE OF MOTION AND OUTCOME IN FIXED AND MOBILE

P J James', P A May', W Gerard Tarpey', M Blyth' and IG Stother' Nottingham City Hospitah and Glasgow Royal Infirmary'

PREOPERATIVE KNEE FUNCTION PREDICTS THE SEQUENTIAL IMPROVEMENT IN CLINICAL & FUNCTIONAL OUTCOMES FOLLOWING TOTAL KNEE ARTHROPLASTY

BA Rogers, L Unitt, SR Cannon, TWR Briggs Royal Surrey County Hospital, Guildford; Royal National Orthopaedic Hospital, Stanmore

RANDOMIZED CONTROLLED TRIAL COMPARING FUNCTIONAL OUTCOME FOR FIXED AND MOBILE BEARING IN TOTAL KNEE ARTHROPLASTY B C Hanusch, S Patil, A Hui, P Gregg James Cook University Hospital, South Tees NHS Trust, Middlesbrough

THE ROLE OF PAIN AND PSYCHOSOCIAL FACTORS ON FUNCTIONAL RANGE OF KNEE MOTION IN PATIENTS WITH OSTEOARTHRITIS AWAITING TOTAL KNEE ARTHROPLASTY ML van der Linden', PJ Rowe', PA Roche', P Gaston', RW Nutton' 'School of Health Sciences, Queen Margaret University College, Edinburgh 'Bioengineering Unit, University of Strathclyde, Glasgow 'Orthopaedic department. New Royal Infirmary Edinburgh

FUNCTIONAL OUTCOME OF KNEE ARTHROPLASTY SURGERY IN OSTEOARTHRITIC PATIENTS 55 YEARS OLD OR YOUNGER: RESULTS FROM A REGIONAL JOINT MR Acharya, CNA Esler, WMHarper University Hospitals Leicester NHS Trust

Discussion

4.00 pm Close of Meeting

10

Session I Free Papers - Patient issues in T K R

M A G N E T I C R E S O N A N C E D E T E R M I N A T I O N O F A N T H R O P O M E T R I C K N E E L A N D M A R K S F O R USE IN R E V I S I O N K N E E S U R G E R Y

L A Crawford, R Mehan, D Q Donaldson, G J Shepard Royal Bolton Hospital, England

Aims: To determine the anthropometric measurements of bony landmarks in the knee using MR scans and so assist revision knee surgeons in prostheses place­ment. Methods: We analysed 100 MR scans of patients aged 16-50 (50 male, 50 female) which were performed for meniscal pathology, patellar dislocation and ACL injury. Those over the age of 50 or with symptoms suggestive of general osteoarthritis, or where the epiphyses had not yet fused were excluded. A l l measure­ments recorded were to the level of joint line and are shown below. Results: Table 1: Anatomical measurements

From To Sex (mean)

Distance mm Deviation

Range mm Standard

Tibial tubercle Joint Line Males 26 15-33 3.6 Females 24 17-32 3.0

Fibular head Joint Line Males 18 8-24 3.5 Females 15 7-23 3.6

Medial epicondyle Joint Line Males 28 21-38 3.4 Females 24 17-33 2.5

Lateral epicondyle Joint Line Males 22 14-35 4.0 Females 20 13-30 3.0

Table 2: Percentage of patients whose measurements are within 5mm of the recorded mean values for each measurement

Tibial tubercle Fibular head Medial epicondyle Lateral epicondyle M A L E 87% 88% 88% 84% F E M A L E 897f 84% 96% 94%

Conclusions: To ensure near normal knee mechanics are achieved during revision knee surgery the joint line should be within 5mm of the original. Our study provides mean values for the distance from various bony landmarks to the joint line in non-arthritic knees on MR scan. The use of the medial epicondyle value as a sole reference wil l place the joint line within 5mm in 88% of males and 96% of females. Use of multiple landmarks further increases accuracy. The final position of the joint wi l l depend on trialling prostheses.

R E L A T I O N S H I P O F BODY MASS I N D E X T O E A R L Y C O M P L I C A T I O N S IN K N E E R E P L A C E M E N T S U R G E R Y .

M Albrizio, A D Patel Hinchingbwoke Hospital, Cambridgeshire, Huntingdon, UK

Background: The purpose of this study was to evaluate the relationship between body mass index and early complications following total knee joint replace­ment surgery. Methods: 527 patients who underwent a primary knee replacement were included in this study. A l l these patients were subjected to a pre-operative assessment and then followed up at six weeks and one year following surgery. Any complication that occurred during this period was recorded. Complications were grouped into systemic and local, each group being subdivided into minor and major. Collected data were analysed by the SPSS version 12. Chi-square tests, t-test analy­sis, univariate logistic regression studies and multivariate analysis were performed. Results: 64 patients (12,1%) were found to have an early complication following knee replacement surgery. 36 patients (6.8%) were found to have a major local complication. Overall B M I did not seem to influence the rate of complication. After stratification of patients per B M I , there appeared to be a weak corre­lation between B M I and early complications but this was not statistically significant. A stronger correlation was found between the surgeon and presence of complication. Conclusions: B M I has a weak correlation to early complications following joint replacement surgery. The operating surgeon seems to have a stronger correla­tion to early complications as compared to B M I .

C H A N G E S IN BODY W E I G H T F O L L O W I N G L O W E R L I M B A R T H R O P L A S T Y .

E Mughal, *P Desai, * F Ashraf, Y Khan, D Dunlop, R Treacy, A Thomas Royal Orthopaedic Hospital, Birmingham / *University of Birmingham The Woodlands, Bristol Road South, Northfield, Birmingham

Weight gain is often reported by patients who succumb to impaired activity as a result of progressive osteoarthritis of the hip or knee. Optimistic views of weight loss after joint replacement are often held by patients. We studied the affect of lower limb arthroplasty on body weight. We reviewed 144 patients having undergone hip and knee arthroplasty and were functionally well. Infected cases were excluded. Average age was 65 years and average follow up was 27 months. The Body Mass Index (BMI) was prospectively measured at follow up and compared to immediate pre-operative B M I . Our findings demonstrated an average rise in BMI post-operatively which was staUstically significant. A rise in post operative BMI was seen in patients who were obese to start with or those who had undergone a total hip replacement (statistically significant). Moderate rises were seen in patients who had underwent hip resurfacing procedures or those who were overweight preoperatively (p=0.()6). These findings are useful in informing patients of achievable expectations following joint replacement surgery and preoperative overweightness should be treat­ed as a separate entity unrelated to co-existing joint degeneration.

11

P R O S P E C T I V E RANDOMISED C O N T R O L L E D T R I A L ON T H E R O L E O F PATIENT INFORMATION L E A F L E T S IN OBTAINING I N F O R M E D CONSENT

V Khanduja, S Ashraff, G Malawa, T Dolan. Department of Trauma and Orthopaedics, Newham University Hospita

Objective: To determine whether patient information leaflets improve patient recall during the process of informed consent. Design: Prospective randomised controlled trial which compared a group of patients who were posted a patient information leaflet with those given verbal con­sent only. Setting: Orthopaedic Unit of a District General Hospital Patients: 110 patients were selected, of which 57 were randomly allocated to receive patient information leaflets through the post and 53 were given verbal consent only. Outcome Measure: The recall of information given to the pauent. This was tested using a questionnaire on admission. Each patient was allocated a score out of ten. Results: There was a significant difference between the group who received patient information leaflets compared to those who did not (P<0.0001, CI 2.0 to 3.1). Conclusion: Patient information leaflets are a useful tool for the surgeon to improve the recall of the information given to the patient, in order to facilitate informed consent.

12

Session II Free Papers - Primary T K R decisions

A C O M P A R A T I V E STUDY O F T H E MIDVASTUS AND M E D I A L P A R A P A T E L L A R APPROACHES F O R T O T A L K N E E A R T H R O P L A S T Y IN T H E E A R L Y P O S T O P E R A T I V E P E R I O D

M Maru, V Kumar, G Akra, A Port The James Cook University Hospital, Middlesbrough

Introduction: The commonest surgical approach for total knee arthroplasty is medial parapatellar approach. This involves splitting the quadriceps tendon, potentially destabilising the extensor mechanism. The midvastus approach involves splitting the vastus medialis muscle instead of entering the quadriceps ten­don, therefore, minimising interruption of the extensor mechanism without compromising the exposure of the knee. Objective: To compare clinical parameters associated with medial parapatellar and midvastus approaches for total knee arthroplasty in the early postoperative period. Methods and results: We present a prospective observational study of 88 patients undergoing primary total knee arthroplasty using medial parapatellar or mid­vastus approach (44 in each group). The prosthetic design and physical intervention was standardised in all the patents. The Oxford Knee Score, pain scale, knee flexion, unassisted straight leg raise, standing and walking were compared at 3''' , 5th and 7 * day postoperatively, then at 6 weeks and at 3 months. The patients and physiotherapist were blinded to the type of approach used. The average age was 67 years (range 42 to 88). There were 49 women and 39 men. The average hospital stay was 7 days (range 2 to 15). There was statistically significant difference in duration of hospital stay, unassisted straight leg raise and standing at 3 days (p=0.001) and pain scale at 5 days, all in favour of midvastus approach. There was no statistically significant difference in Oxford Knee Scores and dura­tion to achieving full flexion and walking. The average duration to achieving straight leg raise for the midvastus group was 5 days and for the medial parap­atellar approach group was 8 days Conclusion: The study shows that total knee arthroplasty performed through the midvastus approach resulted in less postoperative pain, earlier unassisted straight leg raise and ambulation, therefore, shorter hospital stay as compared to medial parapatellar approach. This may be of benefit to the patients due to less discomfort after surgery, and to the healthcare system due to shorter hospital stay for patients.

SHOULD W E R E C O N S I D E R A L L - P O L Y E T H Y L E N E T I B I A L I M P L A N T S IN T O T A L K N E E A R T H R O P L A S T Y ?

SD Muller, DJ Deehan. JP Holland, LM Kirk, S Outerside, PJ Gregg, AW McCaskie. Department of Orthopaedics, Freeman Hospital, Newcastle upon Tyne

We report the results of a prospective randomised controlled clinical trial assessing the radiosterophotogrametric analysis (RSA), clinical and radiological per­formance of a metal backed and an all-polyethylene tibial cruciate retaining, condylar design, PFC-S TKA up to twenty four months. 65 patients were recruited, of which 41 patients were randomised. There were 20 metal backed and 21 all-polyethylene. None were lost to follow-up. There were no significant inter-group demographic differences. We found a significant increase in SF-12 and Oxford knee scores after surgery in both groups. No sig­nificant difference was found between the groups in the RSA, SF-12, Oxford Knee score, radiological alignment and range of movement at 6, 12 or 24 months. At 2 years one metal backed implant showed translational migration > lmm. No all polyethylene implant migrated > lmm. Further analysis identified possible progressive subsidence of the metal backed implants compared to all-polyethylene implants, although the magnitude of this difference was very small. We conclude that in the uncomplicated primary total knee arthroplasty, all polyethylene PFC-S tibial prostheses had equivalent performance to the metal backed counterpart, using RSA as the primary assessment instrument at 24 months. We found no differences between the two designs as assessed by the secondary instruments: SF-12, Oxford knee score, alignment and range of movement at 24 months. Should half of all primary total knee replacements performed in the UK receive an all-polyethylene tibial implant, the estimated annual cost saving would be 21 million pounds per annum.

L O N G T E R M F O L L O W - U P COMPARISON O F NEW J E R S E Y L C S M E N I S C A L - B E A R I N G AND R O T A T I N G - P L A T F O R M T O T A L K N E E R E P L A C E M E N T

/ R Gill, P D Hamilton, S J Pearce, G Marsh Orthopaedic department, Mayday University Hospital Croydon

This is a prospective study of 74 consecutive LCS total knee replacements of which 34 were meniscal-bearing and 40 rotating-platform total knee arthroplas­ties comparing functional and radiological outcome measures of the New Jersey total knee replacement. The study is based on a cohort of 96 patients who were followed up over a period of 8.6 to 15.6 years (mean 11.8 years). 49 patients (64 knees) were living and 5 patients were lost to follow-up. At time of follow-up 37 patients were dead. The patients were aged 23 to 81 (mean 64.5) at the time of surgery. The methods used include a pre- and post-operative New Jersey Orthopaedic Hospital Scoring Scale (NJOHSS). In addition the cohort were assessed post-oper­atively using the Knee Society Score (KSS) and the Knee Society Radiological Evaluation Form (KSREF). The results of the study showed that there was a significant overall improvement in the NJOHSS (mean improvement = 22.4 points) with 81% of the cohort scoring 'good to excellent' post-operatively. When the two types of arthroplasty were compared there was no significant difference in improvement in the NJOHSS. However, both the 'Post-op' and 'Function' components of the post-operative KSS were greater in the rotating-platform total knee replacement. The comparison of the post-operative KSREF did not show any significant differences between the two types of arthroplasty. Revision procedures were carried out in 3 patients with meniscal-bearing arthroplasty and 2 patients with rotating-platform arthroplasty. Of the Meniscal-bear­ing group two were for sepsis and one required liner exchange. Both of rotating-platform group were revised for aseptic loosening. We therefore conclude that there was excellent long-term survival of the LCS knee arthroplasty in this cohort and there was no significant difference in func­tional outcomes for either knee replacement. We also note that there have been no revisions for aseptic loosening in the meniscal-bearing group to date.

13

Session III Free Papers - Perioperative T K R Tehniques

T H E B L O O D SAVING E F F E C T O F I M M E D I A T E K N E E F L E X I O N F O L L O W I N G T O T A L K N E E A R T H R O P L A S T Y

J McConway, R K Wilson, D O Molloy, L Ogonda, D E Beverland Departments of Orthopaedies' Musgrave Park Hospital, Belfast

Introduction: Blood loss is a major concern following total knee arthroplasty (TKA) frequently resulting in blood transfusions postoperatively. Various strate­gies exist to reduce blood loss and allogenic transfusion requirements. This study investigates the effect of immediate postoperative flexion on blood loss and transfusion requirements following TKA. Methods: 180 consented patients undergoing primary TKA by a single surgeon were enrolled into a prospective randomised controlled study. 90 patients were randomised to have the operated knee nursed in extension postoperatively, and 90 patients to have the knee nursed in flexion for six hours postoperatively. Both groups followed a strict transfusion protocol. Data collected included calculated pre- and postoperative haemoglobin and haematocrit which was used to calcu­late total blood loss. Units transfused and postoperative complication rates were also recorded. Results: There was no significant difference in demographics or factors predisposing to bleeding between the groups. The mean total blood loss was 1841mls for those in the extension group compared with 1587mls in the flexion group (p=0.02). The mean number of units transfused in the extension group was 0.78 units/patient compared with 0.36 units/patient in the flexion group (p=0.004). There was no significant difference in pain scores between the groups (p= 0.62). Conclusion: This study shows that the use of immediate postoperative flexion significantly reduces calculated total blood loss and transfusion rates following TKA.

COMPARISON O F T R A N E X A M I C A C I D AND T O P I C A L F I B R I N SPRAY ON B L O O D LOSS F O L L O W I N G T O T A L K N E E A R T H R O P L A S T Y - A RANDOMISED C O N T R O L L E D T R I A L

D O Molloy, J McConwav. HA PArchbold, L Ogonda,, Mr D E Beverland Orthopaedic Outcomes Department, Musgrave Park Hospital, Belfast

Patients and Methods: One hundred and fifty patients with pre-operafive haemoglobin levels of 13.0g/dl or less were enrolled into a randomised controlled trial comparing the blood saving effect of intravenous tranexamic acid and topical fibrin spray on blood loss following primary total knee arthroplasty. Those randomly assigned to the Tranexamic Acid group received 500mg intravenously five minutes prior to tourniquet deflation and a repeat dose three hours later. Those assigned to the Topical Fibrin Spray group received lOmls of the combined product intra-operatively. Those in the control group received no phar­macological intervention. Results: There was a significant saving in total calculated blood loss for those in the topical fibrin spray group (p=0.016) and the tranexamic acid group (0.041) compared with the control group with losses of 1190mls, 1225mls and 1415mls respectively. The increased reduction in blood loss in the topical fibrin spray group was not significantiy different to that in the tranexamic acid group (p=0.72).

ASSESSMENT O F T H E T I B I A L C E M E N T M A N T L E IN T O T A L K N E E R E P L A C E M E N T - A P R O S P E C T I V E , C O N T R O L L E D , C O M P A R A T I V E STUDY O F T W O C E M E N T I N G T E C H N I Q U E S

AM Perera, N Gogi, Bathla S, Dutta A, BK Singh. City Hospital, Birmingham

Background Aseptic loosening of the tibial component is the one of the commonest cause of failure following a TKR. Good cement penetration into bone can reduce this and this has led to the development of new devices and techniques to improve the pressurisation during the cementing process. We have conducted a case controlled study on a novel cementing technique and compared the results with published optimum levels. Methods 104 patients that underwent TKR at our institution were studied. Half of these were cemented using a double mix of cement inserted under pressure via an inex­pensive alternative to the cement gun. The data was collected prospectively and included patient information, knee outcome scores and radiological assessment and there was a minimum 4 years follow-up. Results We found a significant difference in the number of early lucent lines as well as the size of the cement mantle particularly in the most important Zones. Despite pressurisation 1 of the 14 zones did not improve and we have examined the reasons for this. In order to achieve optimum cement penetration we recommend that attention is paid to good pressurization and cement penetration and describe our technique for doing this.

14

Session IV Free Papers - A C L Pre-op evaluation

M C M U R R A V S T E S T R E V I S I T E D : EVALUATION O F VARIOUS M E T H O D S O F P E R F O R M I N G M C M U R R A Y S T E S T

H Nalwad, MAgarwal, B N Muddu, M Smith, Mr. J K Borill Tameside General Hospital, Ashton-under-Lyne; South Manchester University Hospital, Wythenshawe.

Aim: To evaluate and assess the validity and accuracy of various described ways of performing the McMurray's test in the diagnosis of meniscal tears. Material & Methods: Prospective study with patients divided into seven groups based on seven described ways of performing McMurray's lest. Twenty-five patients in each group, aged between 15 to 60 years-undergoing arthroscopy of knee for clinically suspected meniscal tear. Exclusion criteria were ACL tear on arthroscopy, radiological or arthroscopic evidence of osteoarthritis and patients within six weeks of injury. A l l patients were assessed preoperatively with knee examined in one of seen different methods. EUA followed by arthroscopy. Clinical and arthroscopic find­ings were correlated and sensitivity and specificity were determined.

The study is ongoing with following results Methods Accuracy Apley 75% Hamilton Bailey 60% Monks 50% McRae 69% Reider 100% Cambell 67%

Conclusion: Accuracy of McMurrays test ranged between 0 to 95% in various studies. Factors determining outcome include patient selection difference in applying test and interpretation of results. McMurrays original description included no varus or valgus stress and a click a was positive test. Other descriptions include varus or valgus stress and apart from click pain is also considered a positive test. Comparisons among results in literature are difficult with confusing results. Our study s incomplete but trends suggest Reider" s method may be the most accurate.

IDIOPATHIC A N T E R I O R K N E E PAIN: WHAT IS T H E E L E C T R O P H Y S I O L O G I C A L E V I D E N C E ?

5 Patil, V Kumar, V Kamath, L White, J Dixon, A Hui Department of Orthopaedics, James Cook University Hospital, Middlesbrough

Introduction: Poor proprioception and imbalance between quadriceps and hamstrings have been suggested as causes for anterior knee pain. The aim of our study was to compare the proprioception of patients with anterior knee pain to a normal population and to compare the activity of quadriceps and hamstrings using electromyography (EMG) in the 2 groups. Methods: Patients and controls between the ages 11-25 yrs were recruited into the study. The proprioception (stability index) of the patients and controls was tested using the Biodex stability system. This computerised system tests the ability of a person to balance his/her own body on a platform that moves in vari­ous directions. An EMG tracing from the quadriceps and hamstrings was also recorded simultaneously. Results: 22 patients and 16 controls were recruited. So far we have found a significant difference in the stability index between the cases and controls (p=0.048), indicafing thereby that controls had better propri­oception than the patients. We have not found a significant difference in the EMG recordings of the quadriceps and hamstrings in the 2 groups (p=0.41). This study is to be completed by the end of December. Conclusion: Poor proprioception is associated with anterior knee pain. Whether it is the cause or effect requires further assessment

B E L I E F S AND A T T I T U D E S O F M E M B E R S O F T H E B R I T I S H ASSOCIATION F O R S U R G E R Y O F T H E K N E E R E G A R D I N G T H E T R E A T ­MENT O F A N T E R I O R C R U C I A T E L I G A M E N T INJURY.

M Goddard, A J Rees Rotherham District General Hospital

Purpose: To quantify the amount of agreement among UK orthopaedic surgeons regarding the natural history and treatment including surgery and rehabilita­tion of the ACL deficient knee. Methods: Following from Marx et al (Arthroscopy. 2003 Sep;19(7):762-70) a surgeon mail survey was performed to 360 members of the British Association for Surgery of the Knee. Surgeons who had treated ACL deficient patients in the last year were asked to complete the survey. Thirty questions were included to determine the surgeons' opinions regarding the natural history of the ACL deficient knee, indications for surgery and patient selection, surgical treatment and rehabilitation. Clinical agreement was present when 80% or more agreed on the same response option. Results: 150 surgeons in total responded to the survey; 121 had treated ACL deficient patients in the past year. The mean age was 48.9 years and 83% consid­ered their practice to be a subspecialty in knee surgery. The mean number of ACL reconstructions performed in the past year was 41 (range 1-210). Clinical agreement was present for 12 (40%) of the 30 questions; surgeons disagreed on 18 (60%) of the questions. Conclusions: Similar significant variation regarding the management of ACL injuries is seen among members of BASK as among members of the American Academy of Orthopaedic Surgeons (AAOS). Clinical disagreement included whether ACL deficient patients can participate in all recreational sporting activi­ties, that ACL reconstruction reduces the rate of arthrosis in the ACL deficient knee, and the use of bracing in non-surgically treated ACL deficient knees. Surgeons also disagreed about age. open growth plates, radiographic evidence of osteoarthrosis, pain, and, repairable and unrepairable meniscal tears in ACL deficient patients.

15

Session V Free Papers - A C L Injury and Reconstruction

C O M P L E T E T R A N S P H Y S E A L A C L R E C O N S T R U C T I O N IN S K E L E T A L L Y I M M A T U R E PATIENTS

M M Utukuri, H S Somayaji, GSE Dowd, D M Hunt Sr Mary's Hospital, London: Royal Free Hospital, London: The Wellington Hospital, London

Aim: This is a report on outcome of Complete Transphyseal ACL reconstruction in a group of 24 children with open physes of whom 6 were under 12 years (Prepubertal). Materials & Methods: A group of twenty-four children with an average age of 13 years were reviewed. Six children were aged 12 or under at the time of oper­ation. There were 21 boys and 3 girls. The follow-up ranged from 12 to 72 months (mean 37.8 months). ACL Reconstruction was done by a standard 4-strand hamstring technique using an endobutton proximally and a spiked washer and screw distally in the tibia. The IKDC, Lysholm and Tegner scores were used to assess the knees pre and post-operatively. Stability was measured using the KT-1000 arthrometer. Results: Common modes of injury were football, rugby, skiing and squash. The left side was involved in 13 patients, and the right side in 11 patients. Interval between injury and surgery ranged from 3 to 22 months with an average of 8 months. Meniscal repair was carried out in 9 out of 14 patients with meniscal tears. The average Tegner score before injury was 7.7, before operation was 4 and at the last follow-up was 7.6.The average pre-operative Lysholm score was 54.6 compared to the post-operative score of 93. There was no incidence of angular deformity or a limb length discrepancy. There has been 1 re-rupture in a child aged 11 years 11 months at operation but no meniscal injuries. The outcome in the 5 other children aged 12 or less at the time of operation has been as good as the older children. Conclusion: Reconstruction of the anterior cruciate ligament using a trans-physeal technique gives good results in pre-pubertal children and in adolescents.

A N T E R I O R C R U C I A T E L I G A M E N T INJURY - A Q U I E T E P I D E M I C R E V I S I T E D

V T Veysi, S R Bollen Bradford Royal Infirmary

Purpose: The aim of the study was to evaluate whether the recognition rates of ACL injuries had improved in the decade following the original paper published by the senior author. Methods: Prospective data collection using a standard questionnaire on all patients presenting to a dedicated soft tissue knee injury clinic. There were 103 patients with a median age of 31. Results: 94 out of the 103 patients gave a typical history of an ACL injury. The mean time to referral to this specialist clinic was 92 weeks. The commonest mechanism of ACL injuries was sports (88/103), with soccer making up the vast majority. The correct diagnosis was made by 13% of A & E staff, 30% of CPs and 57% of Orthopaedic surgeons. Of the 11 patients who had an arthroscopy, 4 were told that they had an ACL injury. None of the 15 who had an MRI scan were told that they had an ACL injury. Conclusion: Despite the increasing incidence and changes in management, there appears to have been very little improvement in the detection of the ACL injured knee in the last 10 years.

DAY S U R G E R Y A R T H R O S C O P I C A N T E R I O R C R U C I A T E L I G A M E N T R E C O N S T R U C T I O N : A P R O S P E C T I V E STUDY.

S A Jain, J Rollo, A L Pimpalnerkar Royal Centre for Defence Medicine & Good Hope Hospital NHS Trust. Birmingham

A review of the outcome, safety, practicality and cost effectiveness of day surgery anterior cruciate ligament (ACL) reconstruction was studied in the British set-up. From January 2003 to May 2005, 75 patients who underwent day ca.se arthroscopic ACL reconstruction without the use of tourniquet or nerve blocks, but using a pump-regulated saline-epinephrine irrigation system were studied prospectively. 68 patients had a hamstring tendon graft and 7 patients had patellar tendon graft reconstruction. None of the patients required overnight stay. Mean immediate postoperative Visual Analogue Score (VAS) for pain was 2.5 (rangel-8) and 0.5 (range 0-3) at 6 weeks indicating excellent pain control. The mean follow-up was 14 months (range 6-30 months). We had no early or late complications in this .series. ACL specific Mohtadi Quality of Life Index improved from pre-operative score of 20 (15-40) to 93 (80-100) at 9 months after surgery. The mean Modified Lysholm Knee Score was 93.9 points, (range 80-100) at the 9 months follow-up examination. On Tegner activity score, 68 patients returned to the same level of sporting activity at 8 months and the rest 7 patients dropped 1 level. The average saving per patient was in the range of 50-60% when compared to inpatient ACL reconstruction. In conclusion, day case ACL reconstruction using a pump-regulated saline-epinephrine irrigation system is safe, cost-effective and is the patient's choice.

Fig.l Mohtadi QOL assessment index. Fig.2 Pain scores with only oral analgesia.

Pain. Max, Ave and Min over 6 weeks

Min Ave Max

4 H3 BTB H3 BTB : l-G

Immediate

h BTB

2 weeks 6weeks

16

PATIENT SATISFACTION F O L L O W I N G DAY C A S E A R T H R O S C O P I C A N T E R I O R C R U C I A T E L I G A M E N T R E C O N S T R U C T I O N .

H Deo, R Sharma, M Wilkinson King's College Hospital, London

A i m : To assess pain control, functional outcome and patient satisfaction following day surgery ACL reconstruction. We report the results of 60 consecutive primary anterior cruciate ligament (ACL) reconstructions performed by a single operator at King's College Hospital Day surgery unit. A "3 in 1" nerve block was used after general anaesthesia. Semitendinosis and gracilis were harvested from the ipsilateral side, doubled and implanted arthroscopically. Patients were discharged the same day with oral analgesia. The mean age was 34.7 years old (range 18-58). Mean period between injury and reconstruction was 26.9 months (range 6-63 months). Mean follow-up was 38 months (range 7-86 months). Average post operative pain score was 3.86 with an average analgesic requirement of 11.2 days (range 0-50 days) Mean Modified Lysholm score was 85.63 (range 31-100) and mean IKDC score was 79.83 (range 37-100). In conclusion we found that following day surgery ACL reconstruction, pain relief was adequate in most cases, functional outcome was rated good or excellent by 78% of patients and 91 % were satisfied with the overall service.

17

Session VI Free Papers - P C L and P L C Reconstruction

T H E CONTROL OF T H E KNEE KINEMATICS ACHIEVED BY SINGLE VERSES DOUBLE-BUNDLE ANTERIOR CRUCIATE L I G A M E N T RECONSTRUCTION: INTRA-OPERATIVE MEASUREMENT USING SURGICAL NAVIGATION.

J R Robinson, L Carat, C Granchi, P Colombet

Centre de Chirurgie Orthopedique et Sportive, Bordeaux-Merignac, France

Cadaveric experiments using Icnee testing machines have suggested that anatomical ACL reconstruction, replacing both antero-medial (AM) and postero-later-al (PL) bundles, restores knee rotation kinematics more effectively than does a single-bundle. The aim of this study was to measure intra-operatively the con­trol of the translation and coupled rotations that occur with standard clinical laxity tests (anterior drawer, Lachman and pivot shift). The knee kinematics of 10 patients were measured using a surgical navigation system and described in terms of tibial axial rotation and antero-posterior trans­lation. In the ACL deficient knee, the average maximum tibial rotation during the pivot shift test was 29.0° and the mean maximum translation 17.0 mm. Reconstruction of the A M bundle (which behaves in a biomechanically similar way to a single-bundle reconstruction) reduced the rotational component to 16.4° (p<0.000l) and translation to 6 mm (p = 0.0002). Addition of the PL bundle further reduced rotation to 12.6° (p = 0.0007) but had no significant effect on trans­lation. Addition of the PL bundle also significantly reduced coupled tibial internal rotation during the Lachman and Anterior draw tests. The pivot shift test simulates the instability suffered by patients with ACL deficiency and this study suggests that its rotational component is better restrained by anatomical, 2 bundle ACL reconstruction.

A STUDY OF FUNCTIONAL DISABILITY, LOWER L I M B ELECTOMYOGRAPHY AND G A I T I N RECREATIONAL SPORTSMEN W I T H POSTERIOR CRUCIATE A N D POSTEROLATERAL L I G A M E N T DEFICIENCY OF T H E KNEE

F Muir, S H Palmer, D Hollinghurst, T Theologis

Nujfield Orthopaedic Centre, Oxford and Worthing and Southlands Hospitals, West Sussex

Purpose of Study: 1. To describe the degree and type of disability experience by patients with combined postero-lateral comer and posterior cruciate ligament knee injuries 2. To document any dynamic abnormalities of the lower limbs through the gait cycle using kinematic and kinetic gait analysis 3. To identify abnormal electromyographic signals of the quadriceps, hamstring and gastrocnemius muscles through normal gait. Methods and Results: After rigorous exclusion criteria were instituted twelve patients were identified as having the required combined knee ligament injuries. These patients under­went functional assessment, clinic examination and gait analysis at the Oxford Gait Laboratory. Significant functional disability was noted in all patients. Characteristic gait abnormalities identified included hyperextension and dynamic varus deformity with a corresponding increase in the internal valgus knee moment. Electromyographic data revealed early and prolonged contraction of the medial hamstrings and gastrocnemius muscles. Conclusion: These results suggest the presence of compensatory mechanisms of the musculature around the knee and suggest direction in rehabilitation programs in patients with combined injuries to the posterior cruciate ligament and posterolateral corner of the knee. The results also provide baseline data that wil l be useful when evaluating the post-operative outcomes in patients undergoing knee ligament reconstruction in the future.

COMBINED RECONSTRUCTION OF CHRONIC POSTERIOR CRUCIATE L I G A M E N T AND POSTEROLATERAL CORNER DEFICIENCY: A 2-9 YEAR F O L L O W UP STUDY

V Khanduja, H S Somayaji, M Utukuri, G Dowd. Royal Free Hospital, London

Objective: The aim of this study was to assess the results of combined arthroscopically assisted posterior cruciate ligament reconstruction and open recon­struction of the posterolateral corner in patients with chronic (3 months or more) symptomatic instability and pain. Patients & Methods: A retrospective analysis of all the patients who had a combined reconstruction of the posterior cruciate ligament and the posterolateral comer between 1996 and 2003 was carried out. Nineteen patients who had the combined reconstruction were identified from the database. Al l the patients were assessed pre and post-operatively by physical examination and three different ligament rating scores. A l l the patients also had weight bearing radiographs, MRI scans and an examination under anaesthesia and arthroscopy pre-operatively. The PCL reconstruction was performed using an arthroscopically assisted single anterolateral bundle technique and the posterolateral comer structures were reconstmcted using an open Larson type of tenodesis. Results: Pre-operatively all the patients had a grade I I I posterior sag and demonstrated more than 20 degrees of external rotation as compared to the opposite normal knee on the Dial test. The average follow up was 66.8 months (range 24 -108). Post-operatively 7 patients had no residual posterior sag, 11 patients had a grade I posterior sag and 1 patient had a grade I I posterior sag. Five of the 19 patients demonstrated minimal residual posterolateral laxity. The Lysholm score improved from a mean of 41.2 to 76.5 (P=0.0001) and the Tegner score from a mean of 2.6 to 6.4 (p=0.0001). Conclusions: We conclude that while a combined reconstruction of chronic posterior cruciate ligament and posterolateral corner instability does not restore complete anatomical stability, improvement in symptoms and function demonstrate its value in these difficult injuries.

KINEMATICS OF POSTERIOR CRUCIATE L I G A M E N T (PCL) A N D POSTEROLATERAL CORNER (PLC) DEFICIENT H U M A N CADAVER KNEE RECONSTRUCTED W I T H T W O DIFFERENT TECHNIQUES OF POSTEROLATERAL CORNER RECONSTRUCTIONS.

r Nguyen, S Apsingi, AMJ Bull, A Unwin, DJ Deehan, AA Amis. Imperial College Ltmdon.

A i m : To compare the ability of two different PLC reconstmction techniques to restore the kinematics of a PCL & PLC deficient knee to PCL deficient condi-fion. Methods: 8 fresh frozen cadaver knees were used. A custom rig with electromagnetic tracking system measured knee kinematics. Each knee was tested with posterior & anterior drawer forces of 80N, external rotation moment of 5Nm & varus moment of 5Nm when intact, after dividing PCL, PLC (lateral collater­al ligament & popliteus tendon), after PLC reconstruction type 1 (1 PLC) & PLC reconstmction type 2 (2PLC). 1 PLC was modification of Larson's technique with semitendinosus graft. 2PLC was performed with semitendinosus graft to reconstruct the lateral collateral ligament & the popliteofibular ligament, gracil-lis used to reconstruct popliteus tendon. Results: The one-tailed paired student's t test with Bonferroni correction was used to analyse the data. Only in deep flexion 2PLC reconstruction was signifi­cantly better than the 1 PLC reconstruction in restoring the posterior laxity to PCL deficient condition (p=0.02). (Figure 1) In deep flexion 1 PLC could not restore the rotational laxity to PCL deficient condition (p=0.02). In mid flexion the 2PLC was unable to restore the rotational laxity to PCL deficient condition (p=0.048) (Figure 2).

18

Conclusion: The 2PLC reconstruction was better than the IPCL in controlling the posterior drawer. The IPLC technique though not significant tended to over constrain the external & varus rotations.

K I N E M A T I C S O F P O S T E R I O R C R U C I A T E L I G A M E N T (PCL) AND P O S T E R O L A T E R A L C O R N E R (PLC) D E F I C I E N T HUMAN CADAVER K N E E R E C O N S T R U C T E D W I T H S I N G L E OR D O U B L E B U N D L E P O S T E R I O R C R U C I A T E L I G A M E N T

S Apsingi, T Nguyen , AMJ Bull, DJ Deehan, A Unwin, AA Amis. Imperial College, London.

Aim: To analyse the posterior and external rotational laxities in single bundle PCL (sPCL) and double bundle PCL reconstruction (dPCL) in a PCL and PLC deficient knee. Methods: Ten fresh frozen were used. A custom made wooden rig with electromagnetic tracking was used to measured knee kinematics. Each knee was tested with posterior and anterior drawer forces of SON and an external rotation moment of 5Nm when intact, after PCL resection, after dividing the PLC and after performing dPCL and sPCL reconstructions with a bone patellar tendon bone allograft and tibial inlay technique. Results: The one-tailed paired Student's t test with Bonferroni correction was used. There was a significant difference between the ability of the dPCL and sPCL reconstruction to correct the posterior drawer in extension (p=0.002). There was no difference between the dPCL reconstruction and the intact condition of the knee near extension (p=0.142, Fig 1). There was no significant difference between the intact condition and both sPCL (p=0.26) and dPCL (p=0.20) recon-strucdons in flexion in restoring posterior laxity. Neither of the reconstructions could restore the rotational laxity (Fig 3). Conclusion: In a combined PCL and PLC deficient knee the posterior laxity can be controlled by both the sPCL as well as the dPCL reconstructions except near extension where the dPCL reconstrucdon was better.

Figure 1, Posterior position with p o s t e r i o r d r a w e r

0 20 40 60 80 100

Figure 3. Rotation Vv'ith externa! torque 40

1 10 " • PCL cut LU PCL & PLC cut

5 SB PCL DB PCL Knee Joint Flexion (1

Q 0 20 40 60 80 100

19

Session VII Free Papers - Patello-femoral ligament

M E D I A L P A T E L L O - F E M O R A L L I G A M E R N T R E C O N S T R U C T I O N . T H E D E R B Y E X P E R I E N C E .

MA Yaqoob, D Baiju, R Chauhan, G Geutjens. Derbyshire Royal Infirmary.

The aim of this study was to evaluate the functional and clinical outcome following medial patello-femoral ligament reconstruction using autogenous hamstring tendon grafts for patellar instability. Over a 4 year period the senior author operated on 35 patients for lateral instability of the patella. The predominant initiating event was a sporting injury. Patients were evaluated clinically and functionally. The Fulkerson score was utilised pre and post operatively. The minimum follow up was 6 months, the mean follow up was 20 months. There were 18 males and 17 females. The mean age was 24.6 years. The mean pre-operative Fulkerson score was 59.3(range 6-100). The mean post operative Fulkerson score was 83.6(range 25-100), the mean improvement was 24.3. 24 patients returned to sporting activities The main complications was one patient with a patella fracture that was stabilised with internal fixation, one patient requiring exploration and reinforcing the ligament which had attenuated. Both patients finally had a good clinical outcome. Our study has shown that symptomatic lateral instability of the patella can be effectively treated with a medial patello-femoral ligament reconstruction and result in overall good clinical and functional outcome. We would recommend this technique

T H E O U T C O M E O F A R T H R O S C O P I C R E P A I R O F T R A U M A T I C P A T E L L O F E M O R A L I N S T A B I L I T Y (TPFI)

S Shakkor, A Aldairy, KAdra Sports injury department, Hamish hospital, Damascus, Syria

Purpose: the purpose of this study was to evaluate the outcome of arthroscopic repair of the medial patello femoral joint capsule (MPFJC) and its supporting structures in traumatic patello femoral instability (TPFI). Type of study: prospective case series. Material and methods: 24 patients 15 male and 9 female with traumatic patello femoral instability (TPFI) were treated with arthroscopic repair of the medial patello femoral joint capsule regardless of the injury chronology using 2/0 vicryle stitches by outside-in technique lateral release were not required, average age at the operation was 23,2 years (range 20-26) with 1 patient was 33, average time from injury to operation 3mounths (range 1-8 months) with 1 patient had the injury for 3 years. The patients evaluated at 10 days, 3 weeks, 6 weeks, 3 months and every 3 months afterward up to 1 year. Average follow up was 9,3 months (range 3-12mounths). Subjective data were calculated using the IKDC system, objective data included a comprehensive knee examination and evaluation and comparing it with nor­mal side, which was used as a reference. Results: at the final review all patients were satisfied with their knees, the IKDC final score improves from 54pre op to 93. There has been no recurrence of the instability or tenderness around the knee, nil infection rate, normal side-to-side movement of the patella comparing with normal side, full range of motion, and normal quadriceps belly and strength. The patient returned to light sports activities at 6 weeks, and to their pre injury level of sport at 3 months. Conclusion: we feel that our approach to treat TPFI is a reliable, safe, and cost effective. Our results are encouraging, although we feel that longer follow up might be required.

M E D I A L P A T E L L O - F E M O R A L L I G A M E N T R E C O N S T R U C T I O N W I T H SEMITENDINOSUS R E - R O U T I N G F O R T H E T R E A T M E N T O F T R A U M A T I C P A T E L L A D I S L O C A T I O N

V. Kumar, A Panagopoulos, J K Triantafyllopoulos, L van Niekerk Centre for Sports Injury Surgery, Friarge & Duchess of Kent Military Hospitals, Northallerton, North Yorkshire

Background: The medial patellofemoral ligament (MPFL) is the principle medial stabilizer of the patella. It is damaged after traumatic patella dislocation. We describe a reproducible technique for MPFL reconstruction and our preliminary results at 12 months. Material-methods: 25 patients (19 men, 6 women; average age 26.9 years-old) with post-traumatic patellar instability underwent MPFL reconstruction at a mean post-injury interval of 22.3 months. Five patients had evidence of generalized laxity, 3 had trochlear dysplasia and 16 (64%) more than two episodes of dislocation. Arthroscopic assessment revealed associated chondral lesions in 88% and marked lateralization. The reconstruction was performed using ipsilater­al semitendinosus tendon. With the distal attachment preserved, the proximal end is passed through the medial intermuscular membrane and secured to the medi­al border of the patella. Clinical pre- and post-operative assessments included IKDC, Tegner, Lysholm and Kujala scores. ICRS documentation recorded the contribution of articular cartilage damage, whereas Merchant views and MRI scans documented the abnormal radiological parameters and the damaged struc­tures of the medial retinaculum respectively. Results: At a mean follow up period of 12 months (8-18 months) no cases of re-dislocation were recorded. The Tegner and IKDC scores averaged 4.2 and 46.9 pre-injury. Postoperatively they had improved to 7.7 and 86.5. The average postoperative Lyshom- and Kujala scores were 87 and 89 respectively. Re-operation was required in one patient after patellar fracture 8 weeks post reconstruction. Conclusion: Our preliminary results suggest surgical reconstruction of the MPFL provide a favorable early outcome for the treatment of post-traumatic patellofemoral instability and wil l form the basis for longer follow up in a larger cohort.

20

Session VIII Free Papers - Fractures around the Knee

MANAGEMENT O F P E R I P R O S T H E T I C S U P R A C O N D Y L A R F E M O R A L F R A C T U R E S W I T H NEW T E C H N I Q U E

V Ramasamy, S C Haider Calderdale Royal Hospital, Halifax, Southwest Yorkshire, UK

Periprosthetic fractures around Total Knee Arthroplasty are potentially devastating complication to both the patients and the surgeons. The reported prevalence of supracondylar femoral fractures following Total Knee Replacement has ranged from 0.3 to 2.5 percent. The complication rates of various treatment modali­ties reported in literature varies from 25 to 70 percent. Aim: The purpose of this study is to evaluate the outcome of Antegrade Nailing and Wire fixation in Supracondylar femoral periprosthetic fractures. Material & Methods: Seven patients who sustained complex distal femoral fractures above Total Knee Arthroplasty all treated by New technique of Antegrade intramedullary Nailing and intramedullary bi-wire fixation through greater trochanteric approach without opening the distal femur were retrospecdvely evalu­ated. Results: A l l the patients demonstrated uncomplicated postoperative follow-ups and returned to weight bearing between 2 and 3 months. The average age of patient was 70 ( 55-90) years. A l l fractures healed in a satisfactory alignment in average duration of 12.6 weeks. There was no wound infection, loss of reduc­tion or implant failure. The average range of movement of knee was 86 degrees. Conclusion: The Antegrade Nail with Wires is a simple & effective method of treating displaced periprosthetic fractures proximal to Total Knee Arthroplasy. This involves less soft tissue dissection, less operative time and satisfactory bony healing even in poor quality bones while maintaining adequate range of move­ments of the knee.

A B I O M E C H A N I C A L STUDY COMPARING 6.5MM C A N C E L L O U S S C R E W S AND 3.5MM C O R T I C A L S C R E W S F O R D E P R E S S E D T I B I A L P L A T E A U F R A C T U R E S

S Patil, A Mahon, I. McMurtry, S. Green, A. Port James Cook University Hospital, Middlesbrough

Introduction: There is a recent trend of using a raft of small diameter 3.5 mm cortical screws instead of the large diameter 6.5mm screws in depressed dbial plateau fractures. Our aim was to compare the biomechanical properties of these two constructs in the normal and osteoporotic synthetic bone model. Methods: 20 rigid polyurethane foam blocks with a density simulating osteoporotic bone and normal bone were obtained. A Schatzker type 3 fracture was cre­ated in each block. The fracture fragments were then elevated and supported using 2, 6.5mm cancellous screws or 4, 3.5mm cortical screws. The fractures were loaded using a Lloyd's machine and a load displacement curve was plotted. Results: Osteoporotic model. The mean force needed to produce a depression of 5mm was 700.8N with the 4-screw construct and 512.4N with the 2 screw con­struct (p=0.007). Non-osteoporotic model. The mean force requires to produce the same depression was 1878.2N with the 2-screw construct and 1938.2N with the 4 screw con­struct (p=0.42). An increased fragmentation of the synthetic bone fragments was noticed with the 2-screw construct but not with the 4-screw construct. Conclusion: A raft of 4, 3.5 mm cortical screws is biomechanically stronger than two, 6.5mm cancellous screws in resisting axial compression in osteoporotic bone.

B I O M E C H A N I C A L ASSESSMENT O F F O R C E S A C T I N G ACROSS T H E P A T E L L A T O D E T E R M I N E T H E O P T I M A L T R E A T M E N T O F P A T E L L A F R A C T U R E S

WS Khan, R Jones, L Nokes, DS Johnson Gait Analysis Laboratory, Centre for Rehabilitation and Human Performance Research, Salford University, Manchester

Introduction: In this study the optimal angle of fixation or splintage for partially weight bearing fractures of the patella was determined by a gait analysis meas­urement system. Subjects and Methods: A knee brace was applied to eight subjects and locked at 0, 10, 20 and 30 degrees. Measurements were also taken for an unlocked brace and in the absence of a brace. The subjects were instructed on partial weight bearing mobilisation. Three dimensional motion analyses were performed using an infrared 8-camera system. The ground reaction force was recorded by two 3-dimensional force plates embedded in the walkway. Kinematic and kinetic data was collected and the data was transferred to a computer programme for further analysis and the forces acting on the patella were calculated. Results: The results showed that the forces acting on the patella were directly proportional to the knee flexion angle. The results also showed that the knee flex­ion angle does not always correspond with the angle set at the knee brace; however they did exhibit a direct relationship. Conclusion: Our findings show that, for partially weight bearing patella fractures, the optimum form of splintage corresponds with a low knee flexion angle.

21

Session VIII Free Papers - Cartilage Repair

T H E S E Q U E N T I A L I M P R O V E M E N T IN C L I N I C A L O U T C O M E F O L L O W I N G A U T O L O G O U S C H O N D R O C Y T E IMPLANTATION - A 7 Y E A R F O L L O W UP

BA Rogers, Mr Carrington, Mr Skinner, Prof Bentley & TWR Briggs The Royal National Orthopaedic Hospital, Stanmore. UK

Introduction: The treatment of distal femoral cartilage defects using autologous chondrocyte implantation (ACI) and matrix-guided autologous chondrocyte implantation (MACl) is become increasing ly common. This prospective 7-year study reviews and compares the clinical outcome of ACI and MACl . Methods: We present the clinical outcomes of 159 knees (156 patients) that have undergone autologous chondrocyte implantation from July 1998. One sur­geon performed all operations with patients subsequently assessed on a yearly basis using 7 independent validated clinical, functional & satisfaction rating scores. Results: Modified Cincinnati, Patient Functional Outcome and Lysholm & Gilchrist clinical rating scores all showed significant improvements compared to pre­operative levels (p<0.0001). Although ACI .scores are superior at one year (p<0.05) there is no significant difference between ACI and M A C l at 2 years. Visual Analogue Score and Bentley Functional rating score showed significant improvements compared to pre-operative levels (p<0.0001) with ongoing year­ly sequential improvement. Patient Rating and Brittberg scores, both subjective patient scores, similarly showed continuing improvements in the years following surgery. Discussion: ACI and M A C l produce significant improvements in knee function when compared to pre-operative levels with continued sequential improve­ment in outcomes for up to seven years. The initial data suggests a superior rate of clinical improvement using the M A C l technique

D U R A B I L I T Y O F C A R T I L A G E R E P A I R - D O E S H I S T O L O G Y M A T T E R ?

SP Krishnan, JA Skinner, J Jagiello, RWJ Carrington, AM Flanagan, TWR Briggs, G. Bentley. Royal National Orthopaedic Hospital Stcmmore.

Aim: The aim of this study was to correlate the histology of cartilage repair site with long term clinical function. Materials and methods: We have analyzed the clinical results of a cohort of patients who had collagen-covered autologous chondrocyte implantations per­formed since 1998. Our hypothesis was that the hyaline cartilage repair does influence the clinical outcome. The modified Cincinnati scores (MCRS) of eighty-six patients were evaluated prospectively at one year and at the latest follow-up following ACl-C (mean fol-low-up= 4.7 years. Range= 4 to 7 years). A l l these patients underwent biopsies of their cartilage repair site performed at variable periods between six months and five years following ACl-C (mean=22.2 months ). The neo-cartilage was graded as hyaline (n=32), mixed fibrohyaline (n=19), fibrocartilagenous (n=35) and fibrous (n=0). Results: The clinical results showed that at one year, the percentage of patients with excellent and good results was 84.4, 89.5 and 74.3 respectively for those with hyaline, mixed fibro-hyaline and fibro-cartilagenous histology respectively. Their mean MCRS were 70.8, 72.4 and 66.2 respectively. This difference was not statistically significant (p=0.34). However, their clinical scores at the latest follow-up demonstrated a significantly superior result for those with hyaline repair tissue when compared to those with mixed fibro-hyaline and fibro-cartilagenous repair tissue (p=0.05). The percentage of patients with excellent and good results for those with hyaline, mixed fibro-hyaline and fibro-cartilagenous repair was 75, 42 and 68.6 respectively. Their mean MCRS were 70.6, 56.8 and 63.9 respectively. Conclusion: This study demonstrates that any form of cartilage repair would give good clinical outcome at one year. At four years and beyond, it appears that patients with hyaline repair tissue tend to show a more favourable clinical outcome whereas those who demonstrated mixed fibrohyaline and fibrocartilagenous repair would show less favourable clinical results.

T W O S T A G E A U T O L O G O U S C H O N D R O C Y T E IMPLANTATION F O R L A R G E F U L L T H I C K N E S S C A R T I L A G E D E F E C T S IN H I G H DEMAND PATIENTS: R E S U L T S A F T E R 2 Y E A R S F O L L O W - U P

V Kumar, A Panagoupolous, J K Triantafyllopoulos, L van Niekerk Centre for Sports Injury Surgery, Friarage and Duchess of Kent Military Hospitals, North Yorkshire

Background & Aim: Recent studies have claimed good results after ACI in athletes. Our aim was to evaluate the early functional outcome and activity level after 2-stage ACI in professional athletes and soldiers. Methods: Thirteen soldiers and five professional athletes (14 men and 4 women; average age 31 years), with 21 full thickness cartilage defects (ICRS grade-IV) of the knee were treated with 2-stage ACI. Mean interval between injury and surgery was 43.8 months. Average defect size was 6.03 cm^ and was located to the MFC in 7 cases, LFC in 7 cases and the femoral trochlea in one case. The functional outcome was evaluated with ICRS form. Tegner activity rating scale and Lysholm score after a mean follow up period of 23.4 (18-32) months. Results: The ICRS and Lysholm scores were improved from 42.7 and 47.6 pre-operatively to 63.1 and 69.9 respectively. The average Tegner scale was 8.8 pre-injury, 3.7 prior to surgery and 6.4 at the final follow up. Nine patients (50%) underwent second-look arthroscopy for persistent mechanical symptoms. Periosteal flap overgrowth was identified in 6 cases with adequate graft integration while partial failure of the graft was noted in one case and was treated with microfrac­ture. Conclusions: The early results of ACI in high-performance athletes and professional soldiers are not as good as other studies suggest. Returning to pre-injury performance levels for athletes and military people is by no means assured in the first 24 months after ACI.

T H E R O L E O F F I B R O B L A S T G R O W T H FACTOR-2 IN T H E P R O L I F E R A T I O N AND C H O N D R O G E N I C P O T E N T I A L O F I N F R A P A T E L L A R FAT PAD D E R I V E D S T E M C E L L S

WS Khan, DS Johnson, JG Andrew, TE Hardingham United Kingdom Centre for Tissue Engineering, University of Manchester

Introduction: In this study infrapatellar fat pad (IPFP) derived stem cells were expanded with and without Fibroblast Growth Factor-2 (FGF-2) supplementa­tion and were compared with regards to their ability to proliferate and differentiate into chondrocytes. Materials and Methods: Cells were isolated from the IPFP tissue and expanded in monolayer culture with and without rhFGF-2 supplementation (final con­centration lOng/ml). Cell aggregates were placed in chondrogenic media for two weeks. Gene expression studies were carried out using quantitative real time PCR. Immunohistochemical labelling was performed with antibody localisation determined by an immunoperoxidase procedure. The pellets were also weighed and digested in papain for DNA and glycosoaminoglycan (GAG) analysis. Results: Cells expanded in FGF-2 supplemented media were smaller and proliferated more rapidly. The FGF-2 supplemented cell aggregates also showed 100 times higher expression of collagen type 11 (COL2A1). Immunohistochemical studies showed that pellets made from FGF-2 treated cells stained more strong­ly for collagen I I and more weakly for collagen I . Pellets made with FGF-2 treated cells were larger, continued with enhanced proliferation and contained more proteoglycan. Conclusion: Our findings show enhanced proliferation and chondrogenic differentiation in IPFP derived stem cells expanded in FGF-2 supplemented media.

22

Session X Free Papers - UKA

SURVIVORSHIP O F 203 F I X E D B E A R I N G UNICOMPARTMENTAL K N E E R E P L A C E M E N T S DURING T H E S E C O N D D E C A D E

R G Steele, J H Newman. S Hutabarat, R Evans, C E Ackroyd Avon Orthopaedic Centre, Southmead Hospital, Bristol, U.K.

Purpose of Study: Fixed bearing unicompartmental knee replacement (UKR) has become popular since several series have shown good 10 year survivorship and excellent function. However little is known about survival during the second decade. Method: From the Bristol database of over 4000 knee replacements 203 St. George Sled UKR's which had already survived 10 years were idendfied. The mean age at surgery was 67 years (48-85), with 64% being female. This cohort has been further reviewed at an average of 14.8 years (10-30) from surgery to deter­mine survivorship and function. Results: Survivorship during the second decade was 87.5%. 58 patients (69 knees) had deceased with implant in situ, only 2 after revision. A further 15 UKR's have been revised at an average of 13 years post op; 7 for progression of disease, 4 for tibial loosening, 3 for polyethylene wear, 2 for femoral component frac­ture and 2 for infection. 99 knees were followed for 15 years and 21 knees for 20 years. The average Bristol knee score of the surviving knees fell from 86 to 79 during the second decade. A previous study showed an 89% 10 year survivorship and this is now extended to 82% at 15 years and 76.5% at 20 years. Conclusion: Satisfactory survival of fixed bearing UKR can be achieved in the second decade suggesting that the indications for mobile bearings require care­ful definition since there is a higher incidence of complications in many people's hands.

A P R O S P E C T I V E RANDOMISED T R I A L COMPARING M I N I M A L INVASIVE AND STANDARD P A R A P A T E L L A R APPROACHES F O R UNICOMPARTMENTAL A R T H R O P L A S T Y

MP Jackson, H Cottam, A Butler-Manuel, H Apthorp The Conquest Hospital, Hastings, East Sussex Hospitals NHS Trust

AIMS: To compare a randomised group of patients undergoing UKA to investigate the advantages of the minimal invasive approach in the early post-operative stage. M E T H O D S & R E S U L T S : 100 patients on the waiting list for UKA were recruited into the trial. Patients were randomised into 2 groups: Group 1 - longitu­dinal skin incision with dislocation of the patella. Group 2 - the minimally invasive approach. Standard milestones were recorded post-operatively: time to achieve IRQ, independent stair climbing and to discharge. Additionally, patients were scored with the. AKSS and Oxford knee questionnaire pre-operatively, at 6 weeks, 6 months and 1 year. No significant differences were found between the 2 groups in the measured parameters. C O N C L U S I O N : To our knowledge, there has been no previous randomised trial to investigate the results of less invasive surgery for UKA. We have been unable to demonstrate a significant advantage of this approach. With the continued drive for early return to function, some centres incorporate a 24hr acceler­ated discharge protocol. The less invasive approach may make this more achievable. We recommend however that the surgical procedure and implant position must not be compromised for the benefit of rapid discharge to the deficit of long term results.

L A T E R A L UNICOMPARTMENTAL K N E E R E P L A C E M E N T : F I X E D OR M O B I L E B E A R I N G ?

MC Forster, A Bauze & G Keene Sportsmed SA, Adelaide, Australia.

The aim of this prospective cohort study is to compare the early results in a single surgeon series of the mobile and fixed bearing versions of the Preservation UKR for lateral OA. Lateral UKRs were only considered for patients with isolated lateral compartment osteoarthritis with a functioning anterior cruciate liga­ment. Mi ld patellofemoral osteoarthritis was not considered a contraindication. I f there was any doubt over the condition of the medial compartment or patellofemoral joint, single photon emission computed tomography was performed. Significant uptake it the medial or patellofemoral joint was considered a contraindication. Patients were assessed preoperatively and at 1 and 2 years postoperatively with the American Knee Society Score (AKSS), Oxford Knee Score (OKS) and with anteroposterior, lateral and Rosenberg radiographs. Between 29* May 2001 and 15'^ May 2003, the senior author (GK) performed 233 consecutive Preservation UKRs. Of these, 30 were lateral UKRs (13%) performed in 12 men and 16 women (2 bilateral cases) with a mean age of 67 years (range 36 to 93 years). A metal-backed mobile bearing tibial component was used in 13 knees and an all-polyethylene fixed bearing tibial component in 17 knees. Patients in the mobile bearing group were significantly younger (t test; p<0.0001) and had better AKSS knee (Mann-Whitney U test; p=0.05) and AKSS function scores (Mann-Whitney U test; p=0.005). The patients were reviewed after a minimum of 2 years (range 2 to 3.4 years). There was no significant difference between the 2 groups. There had been 3 revisions in the mobile bearing group for tibial loosening and none in the fixed bearing group (chi squared test; not significant). There was 1 tibial periprosthetic fracture in the fixed bearing group. This study shows that the choice of bearing type makes little difference in clinical outcome or range of motion over the first 2 years when using the Preservation Knee. A similar good functional result was obtained with a fixed bearing despite the mobile bearing group being younger and having significant­ly better preoperative AKS knee and function scores. The 3 revisions for tibial loosening in the mobile bearing group are a concern. However, these results are short-term and there may be improved implant longevity in the long-term with mobile bearing tibial components due to reduced polyethylene wear.

23

Session XI Free Papers - PFJ Replacement

F I V E T O E I G H T Y E A R R E S U L T S O F T H E AVON P A T E L L O F E M O R A L A R T H R O P L A S T Y

CE Ackroyd; J H Newman; R Evans; C C Joslin Avon Orthopaedic Centre, Southmead Hospital, Bristol.

Objective: To review the results of the Avon patellofemoral arthroplasty at 5 to 8 years. Methods: The Avon patellofemoral arthroplasty was introduced in clinical practice in September 1996. We present a prospective cohort review of all patients treated in the first three years. Patients were evaluated using the Bristol knee score (BSK), the Melbourne patella score (MPS) and the Oxford knee score (OKS). Results: 109 patellofemoral arthroplasties were performed in 92 pauents between September 1996 and November 1999. The median age was 68 years (range 46 to 86 years). Nine patients (12 knees) died and two patients (two knees) were unfit for follow-up. Ten knees in 9 patients were lost to follow-up giving a follow-up rate of 89%. The mean period of follow-up was 5.6 years. The median pain score rose from 15/40 pre-operatively to 40 points at eight years. The median (MPS) rose from 10/30 points pre-operatively to 25 points at eight years. The median (OKS) rose from 18/48 pre-operatively to 38 at eight years. 87% of knees had mild or no pain at eight years. There were no cases of failure of the prosthesis itself. All 15 revisions resulted from progression of arthrititis in the tibio-femoral joint. The five-year survival rate for all causes with 86 cases at risk was 96%. Conclusions: The results show that this type of arthroplasty can give predictable pain relief and excellent functional improvement in patients with isolated patellofemoral arthritis. Disease progression is the main reason for revision to total knee replacement and great care is required in assessing the indicaUons for this procedure.

E A R L Y R E S U L T S IN 110 C A S E S O F P A T E L L O - F E M O R A L R E P L A C E M E N T IN PATIENTS UNDER 55 Y E A R S O F A G E

T D Clare, J H Newman, Avon Orthopaedic Centre, Bristol

Introduction: Following previously gratifying results in older patients the study aims to quantify the outcomes and identify any contraindications in patient selection for patello-femoral replacements using the Avon prosthesis in patients under 55 years old. Method: We present early outcome results for a prospective cohort study of patients under 55 years of age. 110 knees in 86 patients (median age 47years, range 25-54) have been treated with Avon patello-femoral replacement (88 in females and 22 in males). Diagnoses included lateral facet OA (59 knees), patella dis­location (36 knees), trochlear dysplasia (39 knees) and post patellectomy instability (7 knees). 108 knees had undergone previous surgery. 14 knees required additional intra-operative procedures (including 11 lateral releases and 2 patella realignments). A l l patients were assessed pre-operatively using the Oxford, Bristol and WOMAC scores. Results: No knees have been lost to follow-up. 82 knees have post operative scores available (mean follow-up 27 months). 8 have been revised (6 due to pro­gression of OA). The mean Oxford, Bristol and WOMAC scores all improved: 18 to 32, 56 to 83 and 39 to 25 respectively. Asymptomatic deterioration of the tibio femoral joint is seen in some cases of primary OA but not with trochlear dysplasia. 21 knees required post-operative additional procedures including 6 lat­eral releases, 3 patella realignments and 5 revisions. Equally good results were seen when comparing patients with the 3 main diagnoses. Trochlear dysplasia is strongly predicted by young age at onset of symptoms and patellar dislocation. Conclusion: Many of this type of patient, with disabling symptoms, wish to "live now". The short-term improvements are frequently dramatic. Comparison of underlying pathologies has not identified groups that are performing less well to suggest restricting current indications. As yet there is no suggestion of pros­thetic failure. Revision has presented little difficulty since minimal bone is resected primarily.

24

Session XII Free Papers - Trochlear Pathology

C L I N I C A L PRESENTATIONS O F T R O C H L E A R DYSPLASIA

M M Kulkarni, J D Eldridge, J H Newman Avon Orthopaedic Center, Bristol

Introduction: Anterior Knee pain is a very common presentation in Orthopaedic out patient clinics. However, Trochlear Dysplasia as a condition is still not very well understood. Materials and Methods: Operative findings in patients undergoing Trochleaplasty and in young patients undergoing Patella-femoral arthroplasty were studied. Patients having trochlear dysplasia were identified. A l l these patients were sent a questionnaire to explore the variety of symptoms they experienced. 87 patients were identified for the study. 71(82%) patients responded to the quesfionnaire. Results: Two subgroups were identified, one with dislocation of patella and the other without dislocation of the patella. Patients in patella dislocation group were younger (12 years vs 24) than those who presented without dislocation of patella. Patella dislocation group had more patients with anterior knee pain (71 % vs 52%) as teenagers as compared to the group without dislocations. Symptoms such as giving way, lack of trust and unable to participate in sports were more commonly seen in the group with patella dislocation whereas, limited walking distance and difficulty with climbing the stairs were more commonly seen in the group without dislocation. Symptoms such as pain, catching and locking were seen equally amongst the two groups. Conclusion: We believe that the patients with trochlear dysplasia have a bimodal presentation. Patients with dislocation of patella present earlier than those without patella dislocation. These two groups also have different symptoms at presentation. It is important to identify these subgroups correctly for appropriate management.

F E M O R A L T R O C H L E O P L A S T Y F O R P A T E L L A R INSTABILITY; A NEW O P E R A T I V E T E C H N I Q U E

S H Zaki, I Rafiq, P J Rae Wrightington Hospital for Joint Diseases, Lancashire.

Purpose Of The Study: Description of a new operative technique of trochleoplasty for patellar instability and its short-term results.

Method: we report a new technique of trochleoplasty for Trochlear dysplasia, using Mitek anchor sutures. The purpose of the procedure is to remove the ante­rior femoral boss associated with Femoral Trochlear dysplasia and make the floor of the trochlea level with the anterior femoral cortex. The operation entails undermining of the trochlear and lateral condylar articular cartilage to a new corrected level where it is held with the use of No 2 Ethibond Mitek anchor sutures. These anchors are placed in the subchondral bone, suture needle passed through the articular cartilage and the sutures tied over it. Approximately 4 -5 anchor sutures are placed to hold the trochlear cartilage down to the new corrected level. This procedure can be combined with proximal and distal patellar realign­ment.

So far, using this technique, we have operated on six patients with trochlear dysplasia and chronic patellar instability. The patients include 4 females and 2 male with an average age of 33 yrs (range 29 - 40). Average follow up is 16 months (range 8 - 24 months). There has not been any recurrence of patellar instabili­ty in the operated patients. Conclusion: Short-term follow up of a new operative technique of troachleoplasty for patellar instability shows promising results.

25

Session XII I Free Papers - Patella Problems at T K R

P A T E L L O - F E M O R A L T R A C K I N G IN F I X E D AND M O B I L E K N E E DESIGNS.

P J James', P A May' W Gerard Tarpey', M Blyth' and I G Stother' Nottingham City Hospital' and Glasgow Royal Infirmary^

Aim: The aim of the study was to assess the impact of a self aligning unidirectional mobile bearing TKR on lateral patella release rates within a knee system using a common femoral component for both the fixed and mobile variants. Methods and Results: A total of 357 patients undergoing TKR were randomly allocated to receive either a Mobile Bearing (181 knees) or a Fixed Bearing (176 knees) PSTKR. Further sub-randomisation into patella resurfacing or retention was performed for both designs. The need for lateral patella release was assessed during surgery. The lateral release rate was similar for fixed bearing (9%) and mobile bearing (9%) implants (p=0.95). Patella resurfacing resulted in lower lateral release rates when compared to patella retention (5.5% vs 13.5%; p=0.012). This difference was most marked in the mobile bearing group where the lateral release rate was 16% with patella retention compared to 3% with patella resurfacing (p=0.009). Conclusion: The addition of a rotating platform tibial component has had no impact on the lateral release rate in this study. Optimising patella geometry by patella resurfacing appears more important than dbial bearing deisgn per se. The combination of a mobile bearing design and patella resurfacing appears the optimise patello-femoral tracking.

P S E U D O - P A T E L L A BAJA F O L L O W I N G S O F T T I S S U E B A L A N C I N G IN T O T A L K N E E A R T H R O P L A S T Y

P. Thornton-Bott, L . Unitt, D.J. Johnstone, A. Sambatakakis and the Balancer Study Group. Stoke Mandeville Hospital, Solihull Hospital, RNOH Stanmore, Northwick Park Hospital Kings Mill Hospital.

Introduction: Soft dssue balancing is an important factor in the success of TKA, but i f extensive may necessitate the use of thicker tibial inserts with the risk of creating a Pseudo-patella baja (PPB), which describes narrowing between the patella and the tibia without shortening of the PT, and occurs when the tibial prosthesis plus insert are thicker than the resected tibia. Hypothesis: Patients who undergo extensive soft tissue releases during TKA, with resultant use of thicker tibial inserts wil l develop a PPB, with increased risk of patella pathology. Method: 506 patients aged 40-90 years underwent 526 Kinemax TKAs, between 1999 and 2002. The extent of soft tissue releases and thickness of tibial inserts were recorded. Patella height was measured on pre and post-operative radiographs by an independent observer. Outcome was assessed using the Oxford Knee Score and the American Knee Society Clinical Rating System, with a minimum follow-up of 12 months. Results: 1. TKA surgery creates a Pseudo-Patella Baja. PPB was introduced into 26.7%) of patients. (p=0.000). 2. The incidence of pseudo patella baja increased with the extent of soft tissue release. (p=0.000). 3. The incidence of pseudo-patella-baja increased with increases in insert thickness. (p=0.035). There was no correlation between the incidence of PPB and changes in outcome, as measured using the OKS and AKSS. Conclusion: Pseudo patella baja occurs in 26% of all patients following TKA, and in 46% of patients in whom extensive soft tissue releases have been per­formed and/or large tibial inserts have been used. AT 12 months, no detrimental outcomes were attributable to the incidence of pseudo patella baja.

SIMULTANEOUS V E R S U S STAGED K N E E A R T H R O P L A S T Y ; A COMPARISON O F O U T C O M E S IN 116 PATIENTS

S Dawson-Bowling, K Chettiar, R Hussein, D East, K Miles, H Apthorp, PA Butler-Manuel Orthopaedic Dept., Conquest Hospital, Hastings

Introduction: Debate continues regarding the optimal timing of surgery for patients requiring bilateral knee arthroplasty; we reviewed the costs, clinical and functional outcomes of 116 patients undergoing simultaneous or staged bilateral surgery using 3 different prostheses. Method: Data were retrospectively collected from 116 consecutive patients undergoing 232 knee replacements over 10 years, either simultaneously or over 2 hospital admissions (staged). Post-operative complication rate, total cost of treatment (calculated from prostheses, theatre time, days in hospital and number of clinic attendances) and functional (HSS) score at 1 year were the outcome measures. Results: 54 patients underwent Oxford unicondylar knee replacements, 41 simultaneously, 13 staged; respective mean total costs were £9890 and £13,553 (p<0.001). 42 patients were treated with AGC prostheses; 14 simultaneously, 28 staged, with respective total costs of £12,187 and £16,920 (p<0.001). 10 T M K patients had simultaneous surgery (mean total cost £14,812), 10 were staged (£20,191); p<0.001. For all 3 prostheses, there was no significant difference in complication rate or 1 year functional outcome between simultaneous and staged groups. Discussion: Some authors advocate replacing both knees simultaneously as safe and cost-effective; others report significant increases in medical and surgical morbidity. Our series shows significant cost savings with no increase in complication rate.

26

Session XIV Free Papers - T K R Peri-operative

E F F E C T I V E N E S S O F NAVIGATION-BASED T O T A L K N E E R E P L A C E M E N T IN ENHANCING T H E M E C H A N I C A L P E R F O R M A N C E O F K N E E S Y S T E M COMPONENTS.

MC Norris, D Beaver, W. Schmidt, M Kester, SK Chauhan Strylier Orthopaedics, Mahwah, NJ, USA; Roval Perth Hospital, Australia; Brightoti and Sussex University Hospitals

Introduction: Contact stresses, derived from navigation system and conventional TKR alignments, are compared to ideally aligned component stresses. Methods: This study builds upon the work of previous studies, in which post-operative CT scans from 7 0 patients were utilized to extract knee component angu­lar alignments from patients undergoing both navigation based and conventional TKR. Knee component (Stryker Orthopaedics Duracon'Xc Condylar) FE mod­els were oriented into specific alignment positions. Tibial insert contact stresses were computed under physiologically relevant loads at various flexion angles. FEA was also performed on ideally aligned cases for comparison purposes. Results: At full extension, the median alignment of conventional TKR induces contact stresses 1 7 . 8 % above ideal alignment conditions. Navigation based TKR alignment induces stresses . 3 . 5 % above ideal alignment conditions. At 4 5 - 9 0 o o flexion, conventional TKR alignment induces stresses 2 . 7 % above ideal align­ment conditions, while comparable navigation based TKR alignment induces stresses that match ideal alignment conditions. Conclusion: Navigation based TKR procedures improve knee component alignment, which decreases contact stresses in UHMWPE tibial inserts. The result is a reduction in abnormal wear patterns and expected wear rates, with an increase in the structural longevity of knee system components.

T H E E F F E C T O F A T H R O M B O P R O P H Y L A X I S P R O T O C O L ON T H E I N C I D E N C E O F VENOUS T H R O M B O E M B O L I S M A F T E R T O T A L K N E E R E P L A C E M E N T

RAE Clayton, C R Howie, P Gaston, A C Watts Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh

Aim: To investigate the incidence and type of venous thromboembolic event (VTE) diagnosed in patients undergoing total knee arthroplasty (TKA) and the trends over time following the introduction of a rigorously enforced thromboprophylaxis protocol. Methods: Data from all 3 2 6 0 TKAs performed in our unit between April 1 9 9 6 and March 2 0 0 3 were prospecUvely collected by the Scottish Arthroplasty Project (SAP). The SAP data identified 8 4 of these patients as having being admitted with or died from a VTE episode. A unified thromboprophylaxis protocol was introduced in 1 9 9 9 , from 2 0 0 1 it was included as part of the integrated care pathway. We retrospectively reviewed all available casenotes of these patients to identify the assessment and thromboprophylaxis given, the precise diagnosis of VTE, the treatment and adverse outcomes. Results: Of the 8 4 VTEs identified, 2 9 had pulmonary emboli (PE), 12 had above knee deep vein thrombosis (DVT), 2 4 had calf DVT and 10 had no evidence of VTE though were coded as such (but not treated) by physicians elsewhere. Data were unavailable for the remaining 9 but these were assumed to have had VTE for the purposes of this study. Of the 2 4 patients with calf only DVT, 16 were given therapeutic andcoagulation of whom five developed haemorrhagic complications. From 2 0 0 1 the thromboprophylaxis protocol was followed in 1 0 0 % of patients. The rate of VTE in our unit has fallen steadily from 2 . 2 6 % in 1 9 9 6 - 7 to 1 . 0 5 % in 2 0 0 2 - 3 .

Conclusions: There has been a steady decline in the rate of venous thromboembolism in our unit over the seven years of the study. A thromboprophylaxis pro­tocol has been successfully introduced in our unit and consistently applied since 2 0 0 1 . There is considerable overdiagnosis and treatment of calf DVT with sig­nificant resultant morbidity.

We are grateful for the help of the SAP in collecting these data.

Annual rate of venous th romboembo l i sm in Royal Inf i rmary of Edinburgh post TKR

2,50% -I

2.00%

1.50%

1,00%

0,50%

000% 1996 - 7 1997 - 8 1998 - 9 1999 - 2000 2000-1 2001 -2 2002 -3

27

Session XV Free Papers - Revision T K R Technique

IS L O N G S T E M IMPLANT I M P E R A T I V E IN R E V I S I O N K N E E R E P L A C E M E N T .

S Hakkaiamani, V Prasanna, A Acharya, R Finley, RW Parkinson. Arrowe Park Hospital, Upton, UK.

Stem dissociation in modular revision knee replacement due to failure of the frictional lock of the Morse taper has been reported in the literature. However, the medium and long-term implications of stem dissociation are unknown, as clinical outcomes have not been reported. We report a series of 10 cases in which there was intra-operative dissociation of the tibial stem. Between 1994 and 1999, 98 patients underwent revision total knee replacement for aseptic loosening at our institution. Ten of these patients were noted to have tibial stem dissociation, apparent on the immediate post-operative radiographs. The senior author (RWP) performed all procedures and used a standardized oper­ative technique. The Co-ordinate modular knee revision system was used in all cases. The quality of the bone was noted in all the cases intra-operatively; and was graded as 1) sound bone, 2) soft but intact, 3) soft and fractured cortex. Our study demonstrates that the tibial stem dissociation did not cause any significant detriment to the clinical outcome on minimum follow-up of six years in nine cases where the tibial metaphyseal cortical rim was intact. In one case, where the medial tibial plateau had a cortical defect, the prosthesis drifted into varus mal-alignment and the patient required a further revision for aseptic loosening. We therefore question whether long canal filling tibial stems are necessary in all revision total knee replacements particularly when the cortical rim is intact and a non-constrained polyethylene insert is used.

T H E U S E O F C T IN P R E - O P E R A T I V E ASSESSMENT O F F A I L E D T O T A L K N E E R E P L E A C E M E N T P R I O R T O R E V I S I O N S U R G E R Y

M. Norris, M Alher, S Chauhan Brighton and Susse.x University Hospitals

Introduction: We investigated the routine use of CT scans in identifying alignment causes for failure as well as in the pre operative planning of the procedure. Methods: Twenty poorly functioning total knee arthroplasties were analysed using the Perth CT protocol. A l l patients were awaiting revision total knee arthro­plasty and were scanned using a GE multislice CT scanner. The measurements were performed using standard CT software. Knee society scores were obtained pre- and post-operative. Results: The mean coronal position of the components was 3 degrees of valgus for the femoral component and 2.5 degrees of varus for the tibial component. Fourteen knees had errors of femoral component rotation, which ranged from 1 degree of external rotation to 9 degrees of internal rotation. Nine knees had errors of tibial baseplate rotation with all being internally rotated relative to the PCL/Tibial tuberosity axis from 3 to 12 degrees. The cumulative error of implantation ranged from 6- 24 degrees in all 7 planes. Knee society scores improved post-operatively from a mean of 52 pre-operatively to 83 at one year. Compound error also improved to a range of 6 to 10 in all 7 planes. Conclusions: Revision total knee arthroplasty remains a difficult procedure but is increasing in frequency. The use of a CT protocol allows all coronal, sagittal and rotational errors of a previous implant to be accurately identified prior to surgery. We believe that all knee revision operations should have a CT scan as part of the pre operative planning. Also CT scans may be useful in investigating painful total knee replacements. Total knee replacement failure in some cases maybe explained by a cumulative error in alignment when no other obvious cause is found.

28

Session X V I Free Papers - Infected T K R

T H E E C O N O M I C C O N S E Q U E N C E S O F I N F E C T E D K N E E A R T H R O P L A S T Y .

E Robinson, PF Partington Wansheck General Hospital, Ashington.

Purpose: to quantify tlie cost of liospitalisation and theatre time in the treatment of infected primary total knee replacements. Materials and Methods: hospital approval was obtained for the study. Inclusion criteria were defined as: patients requiring surgery for deep or superficial infection of a primary total knee replacement (TKR) with subsequent positive bacteriological cultures. Clinical coding provided a list of patients with the ICD 10 code T845 (infection or inflammatory reaction due to an internal joint replacement) over a 2 year period and notes of patients were obtained to confirm the inclusion criteria were met. The theatre procedures performed and numbers of days in hospital for all admissions related to joint infection were recorded. The cost of a day in hospital and the cost of each procedure by time in minutes were obtained from the hospital finance department hence the overall cost of hospi­talisation and theatre per patient estimated. Results: 15 patients were identified as having undergone surgery for an infected primary TKR. Prolonged hospital stay, predominantly for administration of antibiotics claimed the largest proportion of expenditure in our patient group. An average of 64 excess days per patient were spent in hospital (range 13 to 218). The cost of an overnight hospital stay is £180, therefore the cost per patient was £11544. Seven day procedures at a cost of £473 each were also carried out. Each patient underwent an average of 4.7 theatre procedures (range 1 to 12). The most common surgical procedures were joint washout / debridement for early infection, joint aspiration, first and second stage revision. The cost of a minute of theatre time is £12.97, hence the cost of theatre time per patient was £4959. The overall estimated cost per patient for treatment of an infected primary total knee replacement is £16503 (exclusive of implant and antibiotic costs). Conclusion: the cost of an infected TKR is a substantial financial burden for trusts as well as a catastrophic complication for patients. Methods of reducing expenditure include reduction in hospital stay by administradon of antibiotics by district nurses or trained family members, rapid management of early joint infection by washout and debridement with the possibility of avoiding revision surgery and explantation of components upon diagnosis of bone/cement inter­face infection hence avoiding futile operations.

M E A S U R E M E N T O F IN V I V O I N T R A - A R T I C U L A R G E N T A M I C I N L E V E L S F R O M A N T I B I O T I C L O A D E D A R T I C U L A T I N G SPACERS

J Mutimer, G Gillespie, A Lovering, A Porteous Avon Orthopaedic Centre, Southmead, North Bristol NHS Trust

The aim of this study was to measure intra-articular gentamicin levels at the 2"' ' stage revision following the use of an antibiotic impregnated articulating spac­er. Infected total knee replacements are a cause of considerable morbidity often requiring revision in two stages. Rings of bone cement, cement moulds and spac­er devices are available for use following the initial debridement and removal of infected metalwork. The availability of antibiotic impregnated articulating spac­ers are potentially attractive to achieve a high local dose of antibiotic and to maintain a good range of movement. Seven patients underwent a two stage revision of their total knee replacements. Following the initial debridement an antibiotic impregnated articulating spacer was cemented in place. At the 2"' ' stage revision a perioperative joint aspirate and blood sample was taken and gentamicin levels measured. The range of move­ment was assessed. The average gentamicin levels were 0.72mg/l (0.24 - 2.36mg/l). A good range of movement was maintained in all cases. At these levels the gentamicin would be therapeutic. Antibiotic impregnated articulating spacers possess several potential advantages to the revision knee surgeon by helping maintain the range of movement and provide local release of antibiotics. Their use should be considered in such cases.

S U R G I C A L S I T E I N F E C T I O N (SSI) F O L L O W I N G T O T A L K N E E R E P L A C E M E N T ( T K R ) : A P R O S P E C T I V E STUDY

M Venkatesan, SN Sambandam, R Burman, S Maxfield, RC McGivney, B Ilango Fairfield General Hospital, Bury

Introduction: Infection following TKR is a catastrophic complication. Few authors have highlighted the need for screening of patients (nose, axilla and groin) before TKR. Despite the fact that some of the centers in UK now routinely perform preoperative screening for TKR patients the overall incidence of surgical site infection in the year 2004 was 2.9%. Methods and Materials: We introduced a new admission policy and SSI surveillance protocol for TKR patients in the year 2004 at our center. According to the new admission policy all TKR patients who were preoperatively screened were admitted into a clean elective ward. Care was taken not to admit anybody with positive infection screening in that ward, irrespective of the diagnosis. Further we also introduced a new policy of SSI surveillance according toNINSS pro­tocol carried out by dedicated trained nurses. Results and conclusions: Following the introduction of these policies our surgical site infection has come down to 0% in the year 2004-5 in contrast to 1.7% in the year 2002-3. These results showed that simple measures like having dedicated infection free clean wards and dedicated trained surveillance nurses can significantiy reduce the infection rate following TKR

29

Session X V I I Free Papers - Clinical Outcomes

A COMPARISON O F R A N G E O F MOTION AND O U T C O M E IN F I X E D AND M O B I L E K N E E DESIGNS.

P J James', PA May', V/ Gerard Tarpey', M Blyth' and I G Stother' Nottingham City Hospital' and Glasgow Royal Infirmuiy'

Aim: This study aims to establish whether or not mobile bearing TKR delivers the often stated benefits improved function and range of motion when compared to its fixed bearing equivalent. Methods and Results: A total of 357 patients undergoing TKR were randomly allocated to receive either a Mobile Bearing (181 knees) or a Fixed Bearing (176 knees) PSTKR. Further sub-randomisation into patella resurfacing or retention was performed for both designs. Al l knees were scored using stan­dard tools (Oxford, AKSS and SF12) preoperatively and at intervals postoperatively by independent observers. The range of motion increased from an average of 96 deg. (pre-op) to an average of 109 deg. at 1 year post-op for both the fixed and mobile bearing design. The management of the patella had no effect in either group. The knee society and knee function scores increased equally for both the fixed bearing and mobile bearing knees with no differences noted. Conclusion: There were no measurable differences in range of motion and clinical outcome scores at 1 year post-op for a mobile bearing design over its fixed bearing equivalent. It is likely that any potential advantages of a mobile bearing design will manifest in longevity rather than function.

P R E O P E R A T I V E K N E E F U N C T I O N P R E D I C T S T H E S E Q U E N T I A L I M P R O V E M E N T IN C L I N I C A L & F U N C T I O N A L O U T C O M E S F O L ­L O W I N G T O T A L K N E E A R T H R O P L A S T Y

BA Rogers, L Unitt, SR Cannon, TWR Briggs Royal Surrey County Hospital, Guildford: Royal National Orthopaedic Hospital, Stanmore

Introduction: Predicting outcomes in the heterogenous population undergoing Total Knee Arthroplasty (TKA) is difficult. This prospective multi-centre study details the relationship between preoperative knee function and the sequential clinical and functional outcome progression of TKA. Methods:Annual clinical and functional outcome scores (Oxford Knee Score & Knee Society Score) from 526 primary cemented Kinemax TKA implanted into 506 patients over a period of 3 years were assessed. Depending on preoperative knee function, patients were grouped into 3 cohorts: mild, moderate and severe. Results: At one year there was a significantly (p<0.05) greater improvement in Oxford Knee Score, Knee Society Score and range of movement in patients with severe preoperative knee function in comparison to the mild cohort. However, a significantly greater improvement (p<0.05) in functional outcome was shown in patients with mild preoperative knee function. Only patients with severe preoperative knee function showed deterioration in outcome measures from three years, all other patients maintained improvements. Discussion: Severe, in comparison to mild, preoperative knee function predicts greater clinical but inferior functional improvement at one year, with deterio­ration in all outcome measures commencing from three years. Mi ld to moderate preoperative knee function affords ongoing sequential improvement in clini­cal and functional outcomes.

R A N D O M I Z E D C O N T R O L L E D T R I A L COMPARING F U N C T I O N A L O U T C O M E F O R F I X E D AND M O B I L E B E A R I N G IN T O T A L K N E E A R T H R O P L A S T Y

B C Hanusch, S Patil, A Hui, P Gregg James Cook University Hospital, South Tees NHS Trust, Middlesbrough

The aim of this study was to determine whether there is a difference in the functional outcome between fixed and mobile bearings in total knee arthroplasty. 120 patients were randomized (computer generated) to receive either a fixed or mobile bearing RFC. Sigma total knee replacement. 96 patients were needed to detect a 20° difference in range of motion (ROM) with a significance level of 0.05 and a test power of 0.97. Oxford knee score (OKS) and ROM were assessed independently before and one year after surgery. Mean ROM and Oxford knee score before and at one year after surgery for both groups are shown as preliminary results for 70 patients (follow-up expected to be completed by March 2006):

ROM before ROM at 1 year OKS before OKS at 1 year mobile bearing 97° (0=20.88°) 101°(o=12.12°) 40.4 (o=7.66) 20.5 (o=5.89) fixed bearing 97° (a= 11.24°) 100° (0=9.62°) 41.5 (o=7.61) 21.5 (o=7.58)

Table. 1: Functional scores before and at one year after surgery

There is no statistically significant difference in the mean ROM at one year and in change in ROM between the two groups (p=0.53 and p=0.21 respectively). The findings were similar for Oxford Knee Score at one year and change in Oxford Knee Score (p=0.45 and p=0.82). There was no early aseptic loosening in either group. The one year results suggest that there is no significant difference in functional outcome measured as ROM and Oxford Knee Score between the two types of bearing. Further follow-up wil l be carried out to detect any differences in the long term outcome.

T H E R O L E O F PAIN AND P S Y C H O S O C I A L FACTORS ON F U N C T I O N A L R A N G E O F K N E E MOTION IN PATIENTS W I T H O S T E O A R T H R I T I S AWAITING T O T A L K N E E A R T H R O P L A S T Y

ML van der Linden', PJ Rowe', PA Roche', P Gaston', RW Nutton' 'School of Health Sciences, Queen Margaret University College, Edinburgh 'Bioengineering Unit, University of Strathclyde, Glasgow 'Orthopaedic department. New Royal Infirmary Edinburgh

Purpose: This study aims to explore the role of pain, fear of movement and learned helplessness on functional knee range of motion and daily functioning in a patients awaiting total knee arthroplasty (TKA) Methods and results: Sixty-five patients (mean age 69 years old) with osteoarthritis were assessed an average of 37 days prior to TKA. Dynamic knee angle was measured during 11 functional activities including getting up from a chair and walking up and down a slope and stairs using flexible electrogoniometry. Function was assessed using the function components of the Knee Society Score (KSS) and the Western Ontario & McMaster University Osteoarthritis Index (WOMAC). Other self-report measures included the 8 item Tampa scale for kinesiophobia to assess 'activity avoidance' (TSK-AA), and the 5 item Helplessness

30

subscale of the rheumatology attitudes index. The pain component of the WOMAC was negatively associated with the knee angle during sitting down and getting up from a low chair and stepping in and out of a bath (r=0.40-0.45), but not with the peak knee angle during ascending and descending a slope or walking speed. Higher scores of the activity avoid­ance and the helplessness scales however, were associated with reduced knee angles during descending a slope and a slower walking speed (r=0.31-0.38). Both psychosocial scales were also associated with function (r=0.39-0.45). Another important finding was that activity avoidance was not associated with pain. Conclusions: Not only pain but also fear of movement and learned helplessness play a role on specific components of knee function in patients with final stage osteoarthritis of the knee. Further research into the impact of pain and psychosocial variables on functional outcome in ostearthrius is indicated.

F U N C T I O N A L O U T C O M E O F K N E E A R T H R O P L A S T Y S U R G E R Y IN O S T E O A R T H R I T I C PATIENTS 55 Y E A R S O L D OR Y O U N G E R : R E S U L T S F R O M A R E G I O N A L JOINT

MR Acharya, CNA Esler, WMHarper University Hospitals Leicester NHS Trust

Introduction: The functional outcome and survivorship of knee arthroplasty in young patients remains a concern. The aim of this study is to assess patient reported outcomes of knee arthroplasty surgery in osteoarthritic patients age 55 years old or younger in a generalist setting. Patients and methods: A l l patients 55 years old or younger at the time of index arthroplasty were identified from the Trent arthroplasty register. Demographic data was available for all patients. A self-administered questionnaire was mailed to patients. This questionnaire included an Oxford Knee Score along with ques­tions relating to employment, leisure activities and the patient expectations of their surgery. Results: 242 patients 55 years old or younger had a knee arthroplasty in the study period ( male:female 1:1). 208 patients had a total knee arthroplasty. The remaining had a unicompartmental knee replacement. Mean age of patients for the total knee arthroplasty group was 51 years (range 37-55) and that for the uni­compartmental group was 50 years (range 37-55). The average length of follow up for the total knee arthroplasty group was 33.3 months (range 12-57) and that for the unicompartmental group was 29.3 months (range 16-45). The average Oxford knee score at follow up was comparable between the two groups; 31.8 (range 12-57) for the total knee arthroplasty group and 32.0 (range 13-54) for the unicompartmental group. 77% of patients in the total knee arthroplasty group and 71% of patients in the unicompartmental group reported that the pain relief was better or just as they expected following the operation. Conclusion: Knee arthroplasty remains a satisfactory procedure in young patients under the age of 55 years. There is no significant difference in Oxford knee scores between patients that have total knee replacement or unicompartmental knee replacement. Pain relief is better or just as expected in the majority of patients in both groups.

31

Poster Presentations - Total Knee Replacement 1. U S E O F L O N G L E G F I L M S IN T O T A L K N E E

A R T H R O P L A S T Y . S Hakkaiamani, A Acharya, A Carroll, R Finley, NJ Donnachie. Anowe Park Hospital. Upton. UK.

The aim of this study was to evaluate whether using a predetermined entry point and standard value for valgus cut could restore normal mechanical axis of the T K A . The study included 125 consecutive patients, who underwent T K A under care of the senior author (NJD). Details o f height, weight, B M I were noted. A l l the radiographs were taken with the patient standing, with the knees in maximum extension, with the patella facing forward. The long leg radiographs were evaluated and the mechanical axis and anatomical axis were marked. The entry point (EP) and the angle between the anatomical and the mechanical axis o f the femur ware measured, which is valgus angle o f distal femoral cut (VA). Statistical analysis was done using SPSS (Table 1). Proportion of the cases with VA less than 6 degrees or more than 7 degrees were identified. Similarly cases with EP distance less than 0 and more than 5mms were also identified. Cases with VA o f 6-7 degrees and EP 0-5mms were identified as one group. Correlation was performed using nonparametric tests. The resuhs revealed the angle between the anatomical and the mechanical axis ranges from 4 to 9.5 degrees (mean 6.8 degree and standard deviation 1.11 degree). Only 53% had an angle o f between 6 and 7 degrees, with 7% of knees having an angle o f less than 5 degree or greater than 8 degrees. The site of entry o f the j i g showed variation from 30mms medial to the centre to 18mms lateral to the centre with the mean entry point o f 5.04mms medial to centre o f the notch, with a standard deviation of 8.5mms. Overall only 33% of the knees templated would have an optimal femoral j i g placement and distal femoral angle cut with an entry point in the centre o f the notch or up to 5mms medial to centre and a distal valgus cut o f between 6 and 7 degrees. The author feel this study gives evidence that i f the mechanical axis is to be restored then long leg pre-operative radiographs should be performed and used as a key component to the pre­operative plan.

Table 1. Spearman's rho correlations, between the valgus angle and entry point to the height, weight and B M I of the patients.

HEIGHT WEIGHT B M I A N G L E Correlation

Coefficient -.005 -.075 -.065 Sig. (2-tailed) 959 .403 .469 N 125 125 125

DISTANCE Correlation Coefficient .171 -.051 -.166 Sig. (2-tailed) 056 .571 .064 N 125 125 125

I N F E C T I O N I N K N E E A R T H R O P L A S T Y A F T E R PREVIOUS I N J E C T I O N O F I N T R A - A R T I C U L A R S T E R O I D A V Papavasiliou, D L Isaac, R Marimuthu, B .\'urboja, A Skyrme, A Armitage Eastbourne District General Hospital, Eastbourne, East Sussex. UK

Objective: To assess the possible effect o f intra-articular steroid injections to ftiture T K A . Materials-Method: We retrospectively studied all 231 patients who underwent AGC (Biomet) TKR in our hospital from February 2002 to October 2004. Twenty notes were not available in medical records and were excluded from the study. Other exclusion criteria were previous surgery (other than knee arthroscopy) on the affected site, a diagnosis of inflammatory arthritis, immunosupressed patients, a previous history o f infection around the knee, smoking, diabetic patients. Applying these criteria we excluded a further sixty-seven patients. The remaining 144 patients were separated in to two groups. Group I (n=54) consisted o f those patients that received one or more recorded I/A steroid injections in their operated knee in an orthopaedic clinic, rheumatology clinic or general practice setting prior to surgery. Group I I (n=90) consisted o f those patients with no record o f receiving an I/A steroid injection prior to surgery. Results: We found that all the deep infections (3) were from Group I and had received an I/A steroid injection up to 11 months prior to surgery. The incidence of superficial infection was not significantly different from the control group (Group II ) . In addition to those patients with confirmed deep infections, five patients underwent post-operative investigations for suspected deep infection, due to symptoms o f persistent swelling or pain. A l l had received an I /A steroid injection pre­operatively. The length of time between injection and subsequent post­operative infection leads us to speculate that the steroid agent might not fijUy dissolve, becoming trapped within Ihe soft tissues or cystic areas of degeneration in the knee joint. Such steroids may become re-activated during operation, leading to catastrophic results. Indeed, there is experimental evidence to suggest an increased risk of infection with the intra-operative administration o f steroids. Conclusion: We conclude that the decision to administer intra­articular steroids to a patient who may be a candidate for knee

replacement surgery should not be taken lightly because of a risk o f post operative deep infection.

3. STIFF T K R . IS T H E R E A T R E N D ? D S Damany, S Hull, M L Sutcliffe Peterborough Hospitals

Aim: To assess patient and surgery related factors to identify any trend leading to a sfiff TKR. We also looked at the efficacy of M U A in the treatment o f a stiff TKR. Material and Methods: Retrospective analysis o f TKRs which have undergone M U A during the period from 01/01/1999 to 25/06/2005 at Peterborough Hospitals. We included primary TKRs with a minimum post M U A follow-up of six months. Results: Out o f a total of 1809 T K R s , 42 T K R s (2.3%) in 38 patients required M U A . 26 (68%) were females with a median age o f 67 years and a median B M I of 30. 34 (81%) had varus knees. Median pre-operative flexion was 100 deg. Median follow-up was 12 months (6 - 45 months). Median pre M U A flexion was 70 deg (15 - 100 deg.). Median surgery to M U A interval was 12 weeks (range: 10 days to 104 wks). Median gain in flexion during M U A was 35 deg (0 • 90 deg). At final follow-up. 74% had lost flexion gained at M U A (median loss: 17.5 deg, mean loss: 20 deg). 7 1 % gained a median o f 20 deg flexion with M U A (Mean: 25 deg, range: 15 -85 deg). Median range of flexion at final follow-up was 90 deg (40 - 120 deg). Conclusion: We were unable to identify any distinct trends in relation to B M I , pre op flexion, other patient or surgical factors that would help predict occurrence of a stiff TKR. We advocate the use o f M U A for a sfiff TKR. 7 1 % patients gained 20 to 25 deg flexion with M U A . 74% pafients lost about 20 deg flexion gained at M U A . The average post M U A flexion at final follow up was 90 deg. This information is useful when counselling patients undergoing M U A . A protocol for management of stiff T K R is suggested.

A N A L G E S I A IN T O T A L K N E E R E P L A C E M E N T : A C O M P A R I S O N B E T W E E N F E M O R A L V E R S U S C O M B I N E D F E M O R A L A N D S C I A T I C N E R V E B L O C K S Hakkaiamani, FA Carroll, CFord, PMereddy, G Jefferies, R W Parkinson Arrowc Park Hospital, Upton Road, Wirrai

Background and objectives: Total knee replacement (TKR) produces severe postoperative pain. Peripheral nerve blocks can be used as analgesic adjuncts for TKR. but the efficacy o f a sciatic nerve block as an adjunct to a femoral nerve block is controversial. The aim o f this study was to compare femoral with femoral and sciatic nerve blocks in postoperative pain management of patients undergoing total knee arthroplasty ( T K A ) . Methods: 42 patients were involved in the study. 20 patients received only a femoral nerve block, consisting of 20ml o f 0.5% Chirocaine and 22 patients received femoral and sciatic nerve blocks, consisfing of 20ml o f 0.375% Chirocaine for the femoral nerve and 10ml o f 0.5% Chirocaine for the sciatic nerve. The primary outcome measures used were visual analogue scale (VAS) scores for pain al 24 hours. 48 hours and 72 hours after the surgery, opiates consumption post­operatively and PCA use. The secondary outcomes were post­operative nausea and vomiting, sensory deficit, quadriceps contraction, straight leg raise, knee flexion, independent mobility and discharge from the hospital. Results: The results showed no difference in opiate consumption, PCA use, independent mobility and time of discharge from the hospital between the two groups. Conclusion: The study shows that the addition o f a sciatic nerve block to the femoral nerve block does not provide additional benefits.

5. AN 8 T O 10 Y E A R R E V I E W O F T H E R O T A C L I D E T O T A L K N E E R E P L A C E M E N T . Honvitz MD, Awan S, Chatoo MB, Stott DJ, Powles DP Lister Hospital Stevenage. Hertfordshire

Background :Mobile bearing knee arthroplasty is an alternative to a fixed bearing knee arthroplasty, we present the results of a retrospective study o f a fully congruent, multi­directional mobile bearing knee with a tibial post: the Rotaglide Total Knee System. Methods: Patients were clinically and radiologically assessed at dedicated follow up clinics. The Hospital for Special Surgery (HSS) and Knee Society Score (KSS) systems were used to describe the clinical and radiological findings. The results were analysed by an independent statistician. Results: The study group included 88 knees. The Prosthesis had a survival rate of 93,5 % at nine years. It is associated with good rates o f patient sausfaction and high scores on the HSS and the KSS System. No knees were revised for aseptic loosening. Conclusions: This, fially congruent, multidirectional mobile bearing knee replacement has survival equivalent to other prosthesis. It is a safe, reliable prosthesis associated with good clinical outcome.

Table -Survival Probabilities Survival probabilities (si.error)

Follow-up Complete Complete plus failures Partial failures

5 years 0.963 (0.021) 0.951 (0.024) 9 years 0.935 (0.034) 0.897 (0.044)

6 D E L A Y E D ONSET DEEP I N F E C T I O N A F T E R T O T A L K N E E A R T H R O P L A S T Y : C O M P A R I S O N BASED ON T H E I N F E C T I N G O R G A N I S M S Joshy, B Thomas, N Gogi, A Mahale, B K Singh Department of Orthopaedics, City Hospital. Birmingham

The aim of our study is to identify the organisms causing delayed deep infections following primary total knee arthroplasty in the current situation. We also compared the differences in outcome based on the infecting organism. We undertook a retrospective study of all the patients who presented with delayed deep infection following primary total knee replacement during a six year period between Apr i l 1998 and March 2004. We analysed the infecting organism, sensitivity of the organism to antibiotics, number o f surgical procedure carried out and the outcome o f the infected arthroplasty based on the infecting organism. Statistical analysis was done using Fisher's Exact test for categorical data and Mann-Whitney U test for the non-parametric numeric data. The mean age at Ihe lime o f primary arthroplasty was 69.9 years (range 46 to 92 years. SD=10.8). The mean follow-up (time since the initial knee replacement) was 77.3 months (range 27-170 months,). The mean follow-up since the last surgical procedure to treat infection was 31 months (range 14-47 months). Organisms were isolated in 27 o f the 31 pauents who presented with delayed deep infection. Forty-four % o f the organisms isolated were multi-drug resistant with increasing incidence of Methicillin resistant Staphylococcus aureus and multi-drug resistant Staphylococcus epidermidis infections. Successful outcome fol lowing an infected total knee arthroplasty was lower compared to the previous studies where there were fewer multi-drug resistant organisms. The number o f patients with satisfactory outcome is significantly lower when the organism isolated is multi-drug resistant. Patients infected by multi-drug resistant organisms undergo higher number o f surgical procedures compared to patients where the organism is not multi-drug resistant. We conclude that deep infection with MRSA and Methicillin resistant Staphylococcus epidermidis are on the rise. Outcome is significantly better when the organism isolated is non resistant Staphylococcus aureus.

7. C O N T E M P O R A R Y CAUSES OF P R E M A T U R E F A I L U R E OF P R I M A R Y T O T A L K N E E R E P L A C E M E N T . C R Davis, J H Newman and A P Davies Southmead Hospital, Bristol

The purpose o f this study was to determine the incidence o f revision total knee replacement (TKR) within 5 years o f the index procedure at a large multi-surgeon unit using a single prosthesis and to determine the cause of failure o f those implants. This was a retrospective review o f all primary Kinemax Plus TKR performed at the Avon Orthopaedic Center between 1.1.1990 and 1.1.2000. Cases were idenfified that required revision arthroplasty in any form within 5 years o f the index procedure. Case notes and Xrays were reviewed to determine causes o f failure. There were 2826 primary Kinemax Plus TKR performed during the study period. O f these 20 were known to have required revision surgery within 5 years. 8 were revised for deep infection of the prosthesis and 12 for aseptic causes. The overall incidence of premature failure of the Kinemax Plus TKR at 5 years was 0.71%. The incidence of aseptic premature failure at 5 years was 0.42%. Detailed examination of the clinical records indicated that some form o f technical error at the time o f the index arthroplasty was responsible for the early failure of 6 prostheses. This equates to 0.21% o f the procedures performed. Aseptic loosening of the remaining 6 cases could not be attributed to a specific cause.

C O N T E M P O R A R Y CAUSES OF P R E M A T U R E F A I L U R E OF P R I M A R Y T O T A L K N E E R E P L A C E M E N T . C R Davis, J H Newman and A P Davies Southmead Hospital, Bri.'ilol

The purpose o f this study was to determine the incidence of revision total knee replacement (TKR) within 5 years of the index procedure at a large multi-surgeon unit using a single prosthesis and to determine the cause of failure o f those implants. This was a retrospective review of all primary Kinemax Plus TKR performed at the Avon Orthopaedic Center between 1.1.1990 and 1.1.2000. Cases were idenfified that reqmred revision arthroplasty in any form within 5 years o f the index procedure. Case notes and Xrays were reviewed to determine causes o f failure. There were 2826 primary Kinemax Plus TKR performed during the study period. O f these 20 were known to have required revision surgery within 5 years. 8 were revised for deep infection of the prosthesis and 12 for aseptic causes. The

32

overall incidence o f premature failure of the Kinemax Plus TKR at 5 years was 0.71%. The incidence o f aseptic premature failure at 5 years was 0.42%. Detailed examination of the clinical records indicated that some form o f technical error at the time of the index arthroplasty was responsible for the early failure o f 6 prostheses. This equates to 0.21% o f the procedures performed. Aseptic loosening o f the remaining 6 cases could not be attributed to a specific cause.

9. REINFUSION DRAINS REDUCE T H E POST­O P E R A T I V E H A E M O G L O B I N DROP I N PATIENTS U N D E R G O I N G T O T A L K N E E R E P L A C E M E N T N Ohly, K Rourke, P Gaston Department of Orthopaedic Surgery, Royal Infirmary of Edinburgh. Scotland

Study Purpose: To investigate whether the use o f reinfusion drains and post-operative autogenous blood transfusion reduces the rate o f allogeneic blood transfusion after primary total knee replacement in our unit. Methods: A prospective audit was carried out over a 14-week period. Patients received either a reinfusion drain, a suction drain or no drain according to surgeon preference. Post­operative allogeneic blood transfusion criteria were based on clinical indication rather than an absolute haemoglobin level. Re$ults:127 consecutive patients underwent total knee replacement during the study period. Patients were matched between the three groups for age, medical co-morbidity, D V T prophylaxis, and implant used. Results are summarised below:

TyjK of drain No. Average Mean post- •/.age Patients requiring pre iperalive opmtive Hb Hbdrop allogeneic Hb(sdL) (g/dL) transfusion

No drain 36 13.7 10.2 25.5% 0 (0%)

Suction 48 13.9 107 23.0% 3 (6.3%)

Reinfusion 43 12.3 97 21.1% 6 (14.0%)

Conclusion:The use of reinfusion drains did not significantly reduce the requirement for post-operative allogeneic blood transfusion. This directly contrasts much of the published literature.

10. T R E A T M E N T O F S U P R A C O N D Y L A R F E M O R A L F R A C T U R E S A R O U N D T O T A L K N E E R E P L A C E M E N T W I T H R E T R O G R A D E I N T R A M E D U L L A R Y N A I L I N G J. Brewin, K. Chettiar, D Dass, PA. Butler-Manuel

Introduction: Periprosthetic fractures are an infrequent but increasingly pre\t problem and can be technically difficult to manage. Various techniques have been described to manage periprosthetic supracondylar fractures around a Total Knee Replacement (TKR) including, immobilisation, plate fixation, rush rods, LISS (less invasive stabilisation system) and retrograde nailing. The aim o f this retrospective study was to evaluate the effectiveness of the retrograde intramedullary nail. Methods: We identified all patients who underwent retrograde inframedullary nail for the treatment o f periprosthetic femoral fractures between January 1999 and October 2005. Notes, x-rays and operation data were examined retrospectively. Outcomes were measured by radiological union, l imb alignment, return to function, pain and complications. Results: Of the 15 patients 2 died o f coexisting medical problems during the follow-up period, but both with good fracture alignment. 13 united between 1 2 - 2 4 weeks (mean 15 weeks), 11 regained pre-injury function with alignment good in 12. 12 were pain free at follow-up. 2 patients required non­steroidal analgesia intermittently. There was one delayed union (53 weeks). There was one post operative complication where a pafient with bilateral fractures required one night stay on I T U .

Conclusion: Intramedullary nailing of periprosthetic fractures around a TKR gave excellent functional results and 100% union in this series.

11. E T H N I C D I F F E R E N C E S IN P R E O P E R A T I V E F U N C T I O N IN P A T I E N T S U N D E R G O I N G T O T A L K N E E A R T H R O P L A S T Y S Joshy, A Datta, A Perera, N Gogi, A Modi, BK Singh City Hospital Nhs Trust. Birmingham

Aims: To compare the preoperative knee function in patients o f Asian origin and Caucasians living in the same community. Background: The prevalence o f osteoarthritis is high in all ethnic and demographic groups. The timing o f surgery is important as poor preoperative functional status is related to poor postoperative function. Methods: Prospective study o f 63 Asian patients age and sex matched with Caucasian patients undergoing total knee arthroplasty. Pre operative Knee Society Clinical Rating System scores were recorded as a separate Knee Score and Knee Function. Results: The mean preoperative Knee Score in Asian patients was 37.6 in comparison to 41.5 in Caucasians (p<0.10) this difference was not statistically significant. The mean preoperative Knee Funcfion in Asian patients was 32.5 in comparison to 45.0 in Caucasians (p<0.0001) this difference was highly statistically significant. Conclusions:Paticnts o f Asian origin undergoing total knee

arthroplasty have lower preoperative knee function to Caucasians. Cultural beliefs and social support explain part o f this discrepancy but health care providers must also attempt to educate patients and close family members about the importance o f timing the surgery to obtain the optimum benefits of pain relief and function.

12 A S I M P L E R I S K C L A S S I F I C A T I O N S Y S T E M F O R P R I M A R Y K N E E A R T H R O P L A S T Y P A T I E N T S YAl-Arabi,S D Deo The Great Western Hospital. Swindon

We devised a four-part clinical risk classification system for patients undergoing primary total knee arthroplasty (PTKR) to facilitate risk estimation. We retrospectively reviewed a series of consecutive PTKRs performed by the senior author A classification system was devised to take account of principal risk factors in PTKR (Table 1). The patients were grouped accordingly, and the following were compared:

Length o f stay Postoperafive complications Early post discharge follow-up assessment

Multiple regression analysis was performed. This revealed: Similar complication rates in the NCP and CPI groups. 3-fold and 4-fold increase in the cumulative risk in the CPU, and CPIII groups respectively (p<0.001) Increased length o f stay in the CPIH group (p<O.OOI).

Conclusion: This classification correlates wel l wi th complication rates from surgery, and has a role in stratifying patients for preoperative planning and risk counselling. It is reproducible and can be used for larger patient groups via the National Joint Registry. Our findings also have implications for payment by results and fixed tariffs for PTKR.

Group Criteria

NCP NO Local or systemic complicating factors

C P I Locally complex: Severe or fixed deformity and/or bone loss, previous bony surgery or trauma, ligamentous instability.

C P U Systemic complicating factors: Medical co­morbidity. Steroid or immunosuppressant therapy. High B M I . Equivalent to ASA of I I I or more.

c p i n Combination o f local and systemic complicating factors (CPU + CPU)

N C P CPI CRM CPIII

13 P R E S S F I T C O N D Y L A R K N E E R E P L A C E M E N T : R E V I E W AT A M I N I M U M O F 10 Y E A R S . N C Carrington, V T Veysi, S Datir, G Pavhu and M H Stone. Department of Orthopaedic Surgery, Leeds General Infirmary

Purpose: We report the 10 to 13 year results of the PFC knee system al our institution. Method/Results: Between 1992 and 1995 97 PFC primary knee arthroplasties were performed consecutively in 82 patients. 32 pafients have subsequently died (37 knees) and four (4 knees) are lost to follow-up. Clinical and radiological review of 46 patients (56 knees) was performed at a mean of 11.1 years post-operatively. Outcome was assessed using the Chamley modification of the Merle D'Aubigne score, with a median o f 5 for pain and 4 for fiinction. Radiological failure was defined as progressive radiolucency (1 case), lysis (1 case) or subsidence (1 case). Polyethylene wear was detectable in 10 cases, with >50% in two. There was 100% survivorship with revision for aseptic loosening as an endpoint. There has been one revision for infection and one patella resurfacing, giving a 98% survivorship with no re-operation. In addition one peri­prosthetic fracture above a well fixed femoral component, required a supracondylar nail. Conclusions: The PFC gives excellent outcome and survivorship at 13 years, regardless o f the experience o f the operating surgeon. This demonstrates that with carefiil training the PFC is a reliable knee replacement in the long-term for trainers and trainees alike.

14. T H E ' O P E N B O O K A P P R O A C H T O D I F F I C U L T K N E E A R T H R O P L A S T Y S P Badhe, M Espag, T J Wilton Derbyshire Royal Infirmary

Purpose of study: To evaluate the 'Open book' technique (described below) for the extended approach in Total Knee arthroplasty with respect to its efficacy and outcome. Summary: Adequete exposure in revision knee arthroplasty can be technically very demanding. Various techniques have been described to aid in exposure. These include Tibial tubercle osteotomy, V-Y quadricepsplasty, rectus snip and Patellar turn­down approach. Since 1998 the senior author (TJW) occasionally has combined a Tibial crest osteotomy and Rectus Snip-'Open Book Approach- in revision Knee Arthroplasty where exposure was made difficult by scarring and fibrosis. The Tibial crest osteotomy is performed as described by Whiteside and this is combined with a 3 cm oblique Rectus snip proximally. This enables the surgeon to reflect the extensor mechanism as i f opening a book. This approach protects the patellar blood supply by minimising soft tissue retraction and by making the rectus snip proximal, the feeding vessels in the quadriceps are not distributed. Methods and Materials: Eight patients requiring Revision Knee arthroplasty in whom the "open book' technique for extended approach to the Knee were reviewed for an average o f 4.5 years. The patients were evaluated clinically and radiologically at final follow-up.

Results: A l l pafients made good recovery of range of motion with little evidence of an extensor lag. There was no incidence of refracture, slippage or non-union of the osteotomy. Conclusions: We concluded that, the 'Open-Book' technique is useful in the extended approach of Total Knee arthroplasty resulting in improved clinical outcome with no adverse effects.

15. P R E D I C T I O N O F WOUND H E A L I N G IN T O T A L K N E E R E P L A C E M E N T S U R G E R Y : T R A N S C U T A N E O U S O X Y G E N T E N S I O N IS M O R E A C C U R A T E T H A N D U P L E X U L T R A S O N O G R A P H Y . D J Martin, S Patil, D Byrne, W J Leach Western Infirmary, Glasgow

Aim: We have carried out a prospective study to compare duplex ultrasonography and transcutaneous oxygen tension as predictors of wound healing after knee arthroplasty. Methods and Materials;53 patients were included in the study. A l l underwent pre-operative duplex scans of their lower limbs. In addifion, transcutaneous oxygen tension measurements were made adjacent to the proposed incision pre-operatively and on days I , 3 and 7 post knee arthroplasty. Wound healing was assessed using the ASEPSIS wound score. Results.*4 wounds had evidence of delayed wound healing. Duplex ultrasonography was a poor predictor o f such problems; however there was a significant correlafion between pre-operative transcutaneous oxygen tension and post­operative wound scores. Conclusion: Pre-operative transcutaneous oxygen tension measurement is a better predictor o f wound healing after knee replacement surgery than duplex ultrasonograph, and may be a useful adjunct to the investigation of patients at risk o f wound problems post knee arthroplasty.

16. K N E E S K I N T E M P E R A T U R E F O L L O W I N G U N C O M P L I C A T E D T O T A L K N E E A R T H R O P L A S T Y SG Haidar, RM Charity, RS Bassi, P Nicolai, BK Singh City Hospital. Dudley Road, Birmingham

Purpose: The aim o f our study was to establish the pattern of knee skin temperature following uncomplicated T K A . Methods and Materials: It was a prospective smdy that was carried out between 2001 and 2004. A pocket digital surface thermometer was used. A preliminary sttidy established the site and time of temperature measurement.. Patients with an increased risk of infection and those with a contralateral knee pathology or a previous surgery were excluded. Forty-eight patients fulfilled the inclusion criteria and consented to participate; the skin temperature of operated and contralateral knees was measured preoperatively and daily during the first six weeks postoperatively. Measurements were also taken at 3, 6, 12 and 24 months following surgery. During the course o f the study, pafients developing complications o f the operated knee or any pathology of the contralateral knee were excluded. Results: Thirty-two patients completed the main study. Following surgery, systemic and both knees temperatures increased. Whereas systemic and contralateral knee temperature settled within one week, the operated knee temperature took a longer fime. The difference in temperature between the two knees had a mean value of +2.9°C at 7 days. This mean value decreased to +\.6°C at 6 weeks, +\.i°C at 3 months, +O.9OC at 6 months +0.3°C at 12 months and +0.04°C at 24 months.

Conclusion; Following uncomplicated T K A , the operated knee skin temperature increases compared to the contralateral knee. This increase diminishes slowly over several months; however, it remains statistically significant up to 6 months.

33

Poster Presentations - Sports Knee Papers A N E W T E C H N I Q U E F O R F E M O R A L AND T I B I A L T U N N E L B O N E G R A F T I N G USING T H E OATS H A R V E S T E R S IN R E V I S I O N A C L R E C O N S T R U C T I O N H G Said, K Baloch, MA Green Royal Orthopaedic Hospital. Birmingham

Revision ACL reconstruction is becoming more frequent especially in specialized centers, due to the large numbers of primary A C L procedures performed. In two stage revisions, bone grafting of the tunnels may be undertaken i f the primary position was inaccurate or i f osteolysis has caused widening of the tunnels. This w i l l allow the desired placement of the new tunnels without the risk of loss of structural integrity. It is technically difficult to deliver and impact bone graft into the femoral tunnel with the standard surgical and arthroscopic instruments. We describe a new technique for femoral and tibial tunnels impaction grafting in two stage A C L revisions, utilizing the OATS grafting instruments. The appropriately sized OATS harvester is chosen 1 mm larger than the tunnel size and is used to harvest bone graft from the iliac crest through a percutaneous approach. This provides a cylindrical graft, which is delivered to the femoral tunnel through the arthroscopic portal. The inside punch of the harvester is tapped, this allows delivery of the graft in a controlled manner, and allows impaction into the tunnel. The same is repeated for the tibial tunnel while providing support for the proximal end of the tunnel.

2 A N T E R I O R C R U C I A T E L I G A M E N T R E C O N S T R U C T I O N : A S T U D Y O F T H E E F F E C T O F R A D I O L O G I C A L I M A G E G U I D A N C E ON T U N N E L P L A C E M E N T . C Stables, M Rathiman, M J McNicholas North Cheshire NHS Trust. Warrington Hospital.

Aim: To study the effect intra-operalive image guidance has on the position of both femoral and tibial tunnel placement in primary' anterior cruciate ligament reconstruction surgery Methods: Prospective study of 2 consecutive series of 10 patients undergoing A C L reconstruction surgery all operated on by the same surgeon (the senior author). In the first group intra­operative image guidance in the form of a standard image intensifier was used to guide the surgeon in the positioning of the tibial and femoral tunnels. In the second group no image guidance was used. The position of the femoral and tibial tunnels were assessed on AP and lateral radiographs post operatively and recorded. The two groups were compared. Conclusion: There was no significant difference in the position of the femoral tunnel position between the 2 groups (p=0.2.S). There was no significant difference in the position of the tibial tunnel between the 2 groups, in either the AP (p=0.37) or lateral (p=>0.5) plane. There appears to be no benefit to using an image intensifier to aid in tunnel preparation in A C L reconstruction surgery.

3. S U B J E C T I V E E V A L U A T I O N O F A C L R E C O N S T R U C T I O N S - A P R O S P E C T I V E S T U D Y USING T H E W A R R I N G T O N K N E E I N J U R Y D A T A B A S E M Rathinam, I Pengas, G Stables, A Hatcher, M McNicholas Warrington General Hospital. Warrington. United Kingdom

Purpose: To subjectively assess and present the outcome after ACL reconstruction with minimum follow-up of 24 months. Methods: Our knee injury database was established in June 2001. Data were collected prospectively for all knee ligameni reconstructions carried out by a single surgeon. The database has a prospectively studied consecutive series where all the patients surveyed completed the Lysholm. KOOS and IKDC 2(X)0 questionnaires preoperatively and at 3, 6. 12 and 24 months postoperatively. Our knee injury database comprises of 163 patients who had A C L reconstruction in which Hamstrings were used in 120 cases and Bone Patella-Tendon Bone (BPTB) grafts in 43. This includes 27 complex reconstructions and 12 revisions (11 from other centres). Results: Fifty-six of the 79 patients (70.8%) who were al least 2 years post ACL reconstruction attended for their 2 year review. Majority were male patienls(90'/f) and both attendees and non- attendees were of a similar age (30.5 /30 respectively) and did not exhibit a statistically significant difference in their pre op or early post op scores. In the non-attendee group 2 were students, 1 emigrated, I registered as unemployed, 7 no employment status and 3 did not consent to such foUow-up. The mechanism of injury was, 62 as sporting injury (24 conlact/38 non-contact sport), 3 road traffic accidents and 8 activities of daily living and 2 not recorded. The mean scores were. IKDC - 77.14. Lysholm - 83.96 and KOOS symptom -8 1 . 6 . Conclusions: A l l subjective evaluation questionnaires (KOOS, Lysholm and IKDC) revealed a progressive trend in our patients. We found that in the KOOS. a multidimensional patient completed aggregated score, the Quality of Life (QoL) dimension exhibited results which were interestingly not correlating with the other dimensions of the quesiionnaire, with patients who scored <50'7c occupying manual or non-administrative positions at work

A R T H R O S C O P I C D O U B L E B U N D L E P C L R E C O N S T R U C T I O N : A P R O S P E C T I V E S T U D Y A' Davidson M Rathinam, IP Pengas, A Hatcher, MJ McNicholas Warrington General Ho.spital. Warrington

Introduction: This prospective study is designed to evaluate PCL reconstruction using the arthroscopic 'double bundle technique' in a consecutive series of patients with multiple ligament instability. Methods: 12 consecutive patients who underwent arthroscopic posterior cruciate ligament reconstruction at Warrington Hospital for a combined ligament injury with PCL tear between 2001 and 2004 were included in the study. The indication for surgery was functional disability of the knee due to pain and instabihty. A l l were male patients with an average age 33 years (range 18 to 44). Average time from injury to surgery was 31.5 months (range 1 day to 96 months). The evaluation parameters included functional assessment, clinical examination, and functional score. A l l data was collected prospectively. The average period of follow up was 23months (range 9 to 50 months) Results: Using the IKDC subjective assessment 63% of the patients had normal/near normal knee function (range 16 lo 94). On Lyshoim scoring 7 1 % reported good or excellent results. On objective examination 83% had abolition of reverse pivot with 91 % showing no evidence of PLC instability. Conclusions: Arthroscopic double bundle PCL reconstruction in this study produced a satisfactory clinical outcome in terms of return lo function objective assessment and symptom improvement. The technique has improved results in terms of outcome than previous reports in the literature would suggest.

5 T H E O X F O R D K N E E S C O R E IN S O F T T I S S U E K N E E P A T H O L O G Y YAI-Arabi, JRD Murray, Matthew Y/yatt, V Satish, SD Deo The Great Western Hospital. Swindon

Aim: To assess the Oxford Knee Score (OKS) for the assessment of soft tissue knee pathology? Method: In a prospective study, we compared the OKS against the International Knee Documentation Committee ( IKDC 2000) and the Lysholm Scores (Lys). We also asses.sed the OKS with retrograde and antegrade (as currently used in Oxford) numbering. A l l patients completed 3 questionnaires stating which was the simplest from iheir perspective. We recruited 73 patients from the orthopaedic and physiotherapy clinics, meeting the following criteria:

Inclusion; Exclusion: • Soft tissue knee derangement. • Degenerative/inflammatory (Ligamentous/Meniscal injury) arthritis.

• Age between 15 and 45. • Bony surgery or trauma.

Results: Linear regression analysis revealed no significant difference between all 3 scores (R'=0.7823, P<0.000l). The OKS correlated best with the IKDC (r=0.7483. F i g l ) . but less so with the Lys (r=0.3278. Fig2). The reversed OKS did not cortelate as well (R-= 0.2603) with either the IKDC (r= -0.2978) or the Lys (r= -0.2586). ANOVA showed Ihe OKS to be significantly easier than Lys to complete (p<0.0001), but not significantly easier than IKDC (p>0.05). Conclusion: The OKS is patient friendly and reliable in assessing soft tissue knee injury. This is particularly useful i f the OKS is already in use within a department for measurement of severity of degenerative di.sease.

= 0.7823

= 0.2603

6. C H A N G I N G D E M O G R A P H I C S IN A N T E R I O R C R U C I A T E I N J U R Y S R Bollen Bradford Royal Infirmary

Purpose:- to examine changing demographics in A C L Injury Methods:- the data from a cohort of 117 consecutive patients with ACL injury from a study performed in 1994 was compared with the data from a cohort of 103 consecutive patients with ACL injury collected in 1994/95. Results:- In 1994, 12% of the patient.s were female, in 2004 25%. In 1994. 62% of the injuries were sustained during soccer and rugby, in 2004 58%. In 1994, 9% of injuries were sustained during skiing, in 2004 28% - a 300% increase. In 1994 the average age was 26.5. in 2004 33. When this increase was examined in detail the average age of the skiers was 41 . the soccer players 31 and the rugby players 27. Clearly there has been a change in the demographics of ACL injury which may have a significant impact in providing NHS services for the ACL injured patient in the UK.

7. L O N G T E R M R E S U L T S O F A R T H R O S C O P I C P O S T E R I O R C R U C I A T E L I G A M E N T R E C O N S T R U C T I O N QQadri,MSAli Russells Hall Ho.spital. Dudley West Midlands

Object: We would like present the long term results of Posterior Cruciate Ligament Reconstruction, with mean follow up of 4 years (range 1-9 years). Material and method: Between 1995 and 2003. 15 patients with PCL deficiency were treated surgically by arthroscopic reconstrucUon using 4 strand hamstring graft. • The diagnosis was confirmed by history of instability,

positive posterior sag and posterior drawer test on clinical examinaUon and finally by MR scanning.

• Patients with injuries of postero-lateral comer, medial ligament rupture or grade I I I - IV OA were excluded. In two cases both ACL and PCL were reconstructed in the same sitting.

• All 15 patients were male with mean age of 25 (19-40). 13 were involved in contact sports (football, rugby) and 2 were motorbike injuries.

• A l l patients were operated by one surgeon (Senior author), by two tunnel arthroscopic technique.

• Twelve patients were reviewed in a clinic recently and 3 were lost to follow up after 12 months.

• The patients were asses,sed clinically with Lysholm Knee Scoring Scale. Tegner Activity Score. IKDC Knee Ligament Standard Evaluation form and KT2000 arthrometer assessment.

Results: • On Lysholm Score 90% were good or excellent • On IKDC evaluafion 92% achieved normal or near normal

result • On KT2000 arthrometer, 70% had 2 mm or less AP laxity

and 30% had between 3-5 mm of AP laxity. Conclusion: Arthroscopic PCL reconstruction using 4 strand hamstring graft gives good functional result in the long term.

R I G I D F I X B O T H E N D S : C L I N I C A L O U T C O M E O F A N T E R I O R C R U C I A T E L I G A M E N T R E C O N S T R U C T I O N W I T H Q U A D R U P L E D H A M S T R I N G T E N D O N G R A F T AND B I O A B S O R B A B L E R I G I D F I X A Bhatti, M Shah, J N Brown The Manor Hospital Walsall. Northern General Hospital Sheffield

Introduction: To report the results of quadrupled hamstring tendon autograft anterior cruciate ligament reconstruction with bioabsorbable Rigidfix fixation for both femoral and fibial tunnels. Methods: ninety one patients were retrospectively idenfified by notes review as having undergone quadrupled hamstring

34

tendon auto graft anterior cruciate ligament reconstruction with Bioabsorbable Rigidfix fixation with a minimum 1 year follow-up[range!2 to 34 months] To our knowledge there has been no published results with Rigidfix device used as a method of fixation at both femoral and tibial tunnels Results: Data were collected on 91 knees in 91 patients (100 %) at an average 13 months (range, l 2 t o 34) after surgeryThey were all asked to fill in a subjective quetionaire.Seventy eight patients returned for clinical evaluation (85.7 % return) and subjective questionnaire was comleled by 78 patients (85.7 % ) . The KT-20(X) Arlhrometer . mean side-to-side difference for manual maximum displacement was 1 mm (range. 0 to 3). Anterior compliance index mean side-to-side difference wasl (range -1 to 3). Quadriceps active displacement tests mean side-to-side difference was .5 [range -1 to 2].The mean Intemafional Knee Documentation Committee knee score was 89 (range. 33.3 to 100). Conclusions: Quadrupled hamstring tendon auto graft anterior cruciate ligament reconstruction with Bioabsorbable Rigidfix fixation is comparable with other methods of anterior cruciate ligament reconstruction in terms of patient satisfaction, knee stability, and function.

9 C L I N I C A L R E S U L T S O F R E C O N S T R U C T I O N O F T H E P O S T E R O L A T E R A L C O R N E R O F T H E K N E E D Adams, D Houlihan-Burne, J Webb BUPA Hospital. Bristol

Statement : A prospective review of the clinical outcome following reconstruction of isolated posterolateral comer (PLC) injuries to the knee. Method : 10 patients underwent an isolated P L C reconstrucfion for symptomatic instability. A l l patients had preoperaUve and post operative clinical examination, and functional knee scores. Results : There were 9 males and 1 female, mean age of 35, with 100% follow up. Median length of follow up was 46 months (range 2 -69). At the latest follow up, the mean Lysholm scores were 89.9. with an average increase in Tegner scores of 3.3 (range 2-10). IKDC scores showed a median of 93 (66 - 100). A l l patients had <3 mm mean side to side difference using the KTIOOO arthrometer. and no increase in P L R I . There were no complications and no clinical failures requiring further surgery. A l l the patients said they would undergo the surgery again. Conclusion : In this series of pauents with symptomatic PLC injury, hamstring graft reconstrucUon has restored knee stability with good functional outcomes.

and recorded. The tunnel positions were compared to the recommended positions as established by literature review. Lateral radiographs displaying greater than 2mm of imperfect projection in relation to the femoral condyles were noted. Results: 108 radiographs were collected from 105 patients, 60 were right knees and 48 were left. There were 88 men and 17 women. When measured along Blumensaats line from the anterior condylar surface, the femoral tunnel in the saggital plane should be found at 75% of the total anteroposterior distance, the recorded figure in this audit was 74%. Measured from the anterior edge in the saggital plane, the tibial tunnel should be found at 44% of the total tibial depth, our measurements averaged 40%. The tibial tunnel in the coronal plane should be found at 45% of the total width from the medial edge, our measurements averaged 46%. 57 (53%) of the radiographs demonstrated imperfect lateral projection of greater than 2mm. Conclusion: The position of the tunnels analyzed in this audit compare favourably with the positions recommended in the available literature. Over 50% of the lateral radiographs displayed imperfect lateral projection greater than 2mm. Imperfect lateral film projection affects the apparent position of the tunnel. Any interpretation of position as it appears on a two-dimensional image must take into account possible errors in the image.

10 R E T U R N T O S P O R T S A F T E R R E C O N S T R U C T I O N O F I S O L A T E D A C L R U P T U R E S M Rathinam, IP Pengas, A Hatcher, JE Arbuthnot, MJ McNicholas Warrington General Hospital. Cheshire. UK

Purpose: To assess the results of ACL reconstmctions carried out at our institution in a non-elite cohort of patients with regards lo return to active sports post reconstrucfion. Materials & Methods: Seventy-five (71%) of 106 patients who underwent reconstmction 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 retum to sports and lo elucidate reasons i f not reluming to pre-injury level. 55 were completed at follow up, with objective clinical assessment and other subjective quesuonnaires |KOOS, IKDC and Lysholm] and 20 were done through telephone interview. Results: A l l 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 reconstmction 61 patients (81.3%) returned to CSAS i & 2 levels. 28 of 30 patients (93.3%) operated within 2 years from injury achieved preinjnry 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 respecfively. One reason for not returning to pre-injury intensity of sports was that many (71.7%) expres.sed fears of instability though most (70%) had no instability on playing. 77.8% of non-retumers 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: A C L reconstmction 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. Psycho-social issues play a significant role in retum to active sports.

11 AN A U D I T O F T U N N E L P O S I T I O N F O L L O W I N G R E C O N S T R U C T I O N O F T H E A N T E R I O R C R U C I A T E L I G A M E N T : T H E I M P O R T A N C E O F G O O D I M A G I N G A J Wilkinson, R M Nicholas Musgrave Park Hospital - Belfast

Purpose of the study: To audit the radiological position of the tunnels following reconstruction of the anterior cruciate ligament (ACL) . Methods: Postoperative radiographs were obtained on patients following A C L reconstmction in a single surgeon series. The positions of the tunnel in the femur and the tibia were measured

35

Poster Presentations - Miscellaneous 1 T E N S E G R I T Y O P E N I N G W E D G E O S T E O T O M Y

R H Banim, A B Putti, J-H Kuiper, J B Richardson Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry. Shropshire

The purpose of this study is to demonstrate proof o f principle o f a novel opening wedge osteotomy. *Tensegrity' is an engineering term, applied to a system in which structures stabilize themselves by balancing the counteracting forces o f compression and tension. The 'tensegrity' osteotomy is performed by exposing the pre­planned osteotomy site; drilling two holes in the osteotomy plane, and completing it with osteotomes and saw. Two threaded conical wedges are then inserted into the drill holes, and slowly inserted, opening the osteotomy to the pre­determined width. The osteotomy is then stabilized with a plate and screws, possibly augmented by a staple on the opposite side. Six patients have been operated using this technique, all wi th a diagnosis of unicompartmental osteoarthritis. There has been no loss o f correction o f the osteotomy, and no revision procedures. We believe the 'tensegrity' osteotomy gives additional support compared with traditional constructs, because the conical compression devices separate the forces of compression and tension, and by being positioned anterior and posterior to the tension plate, it gives a triangular construct with a broad base which is more stable than a linear model. We believe this is supported by clinical resuhs.

2. R E S U L T S O F A R T H R O S C O P I C R E S E C T I O N O F H O F F A ' S FAT PAD AT F I V E T O E I G H T Y E A R S M Bhatia, SAlam, J P Fleetcroft Medway Maritime Hospital. Gittingham, Kent

Purpose: The aim o f this study was to analyse the intermediate to long term results o f arthroscopic resection o f Hoffa's fat pad. Methods & Results: This is a retrospective study. A l l the patients who underwent arthroscopic resection o f the infrapatellar fat pad for anterior knee pain during 1997 to 2000 were included in this study. The patients who had another surgical procedure in addition to Hoffa's fat pad excision were excluded. A l l the patients had a BASK score and an M R I scan pre-operatively. A l l these patients had surgery by the senior author. They were reviewed by telephonic interview and postal survey. The BASK score and the patient satisfaction was recorded. Thirty patients were available for follow up at minimum follow-up period o f 5 years. The clinical diagnosis of Hoffa's disease was made pre­operatively in 12 cases whereas in 18 cases the arthroscopy revealed an inflammed Hoffa's pad. O f the thirty cases only in one case the M R I scan was reported as Hoffa's disease. The average follow up period was 76 months (60 - 186 moths). There were 20 males and 10 females. The average age was 36 years ( 1 3 - 6 2 years). The left side was involved in 19 patients and right in 9 patients. One patient had a bilateral involvement. The average pre operative BASK score was 60.5. This improved to 85.8 post-operatively (p<0.001). This improvement was statistically significant (p< 0.05) for all the components of BASK score. 23 patients (76.6 % ) rated their knee as excellent or good whereas five patients rated the improvement as fair. Two patients feh that there was no change following the operation. There was no significant post­operative complication. Conclusion: Hoffa's disease is an important cause o f anterior knee pain. M R I scan is not a sensitive tool for diagnosis o f this pathology. The diagnosis is essentially clinical and a high index o f suspicion is needed. At arthroscopy i f the knee is otherwise normal and Hoffa's pad is seen to be inflamed, we recommend the arihroscopic excision o f the Hoffa's pad. This study confirms resection o f the Hoffa Pad in chronic Hoffa's Disease produces long-term improvement in the symptoms.

3. S H O U L D O U R M A N A G E M E N T O F T H E A C U T E L Y L O C K E D K N E E C H A N G E ? V Beckles, P Rust, V Simms, D Splcer St, Mary s Hospital. London

Purposes Of Study: To review our management o f the acutely locked knee and the health economic implications o f a change in our protocol. Methods: Patients who underwent knee arthroscopy (£1602 per patient) for an acutely locked knee from October 1^^ 2003 to October 31^^ 2005 were identified. Using direct costs, an analysis was performed to assess the implications o f adding M R I (£240 per patient) to our protocol.

Results: Number of acutely locked knees which underwent arthroscopy 21

ACUTE LOCKED KNEE

CLASSICAL EW(McNally,2002)

Findings meniscal tear ligamentous injury bleed into fat pad no mechanical cause found

13 4 1 3

A R T H R O S C O P Y ( J / J

Physiotherapy pathology (4) meniscectomy (4)

other pathology (U)

M R i r : / )

Physiotherapy (4) ARTHROSCOPIC (4)

other meniscectomy (IS)

[£1602x21] =£33642 [£240x21] + [£1602x13] =£25866

per patient =£1602 per patient =£1232

Conclusion: In terms of direct costs, it would be £370 cheaper per patient to M R I our patients with acutely locked knees as 38% o f our cases did not require arthroscopic treatment. Based on this analysis we w i l l formally change our protocol for managing acutely locked knees.

4 C E N T R A L P A T E L L A W E A R AND R A D I O L O G I C A L U N D E R - D I A G N O S I S O F P A T E L L O - F E M O R A L O S T E O A R T H R I T I S DKA Smart, H Akrawi, Z Dehabreh, T K Bagga Diana Princess of Wales Hospital, Grimsby

Aim: To record and explain the incidence of an observed gross disparity between osteoarthritis grading pre-operatively on skyline patella radiographs and actual intra-operative findings. Methods: Ninety-six consecutive patients undergoing total knee arthroplasty had skyline patella radiographs pre­operatively. Osteoarthritis in the patello-femoral joint was graded according to Kellgren and Lawrence. At operation the true extent o f osteoarthrifis was observed and graded according to Outerbridge. Wear patterns were also recorded. These included; single and double facet, central and generalised. Results: The pre-operative and intra-operative osteoarthritis grades for each patient were compared. The Kellgren and Lawrence classification was accurate in 51 cases (53%). It underestimated the true extent of osteoarthritis by at least two grades in 37 cases (39%) and overestimated in eight cases (8%). The wear pattern was noted to be central in 27 o f the cases where osteoarthritis was underestimated. Seven of these had grade four, central osteoarthritis observed intra-operatively but normal skyline radiographs. Conclusions: Skyline knee radiographs can appear normal in the presence of severe, central, patello-femoral osteoarthritis.

T H E S U R G I C A L T R E A T M E N T O F P R O X I M A L T I B I O ­F I B U L A R G A N G L I O N S D Whitwell, PSteadman Nuffield Orthopaedic Centre. Oxford and the Wesley Hospital. Brisbane, Australia

Introduction and alms: The aim o f this study was to retrospectively assess the long term results o f the surgical excision o f a series o f proximal tibio-fibula joint ganglions. Method: They are uncommon tumours in this position (prevalence <1%) ' and mimic more sinister pathology creating diagnostic difficulty. They can expand between or within muscle and can lie close to or within the deep branch o f the common peroneal nerve. From the Queensland Orthopaedic Oncology Database, twelve patients were identified who had presented with proximal fibio-fibular joint cysts between 1991 and 2004 and proceeded to surgery. Pauents were reviewed at clinic or contacted by phone to assess confinued symptoms or recurrence. Results: There were 4 males and 8 females with an average age of 44 years (18-75). One patient had bilateral cysts but elected to only have one side resected. The side distribution was equal. A l l patients presented with a swelling and ten with pain. Two patients presented with a common peroneal nerve palsy. A l l patients obtained a marginal excision and histology confirmed a ganglion cyst. At mean long term follow up of 49 months (8-168). eight patients had had no recurrence. One patient postoperatively had a transient common peroneal nerve palsy. O f the four patients who had had a recurrence, one patient's surgery is planned and another patient at 5 months post surgery is symptom free following further resection. The two remaining patients have required re-resection but have presented with further recurrence within 1 year. The common peroneal nerve palsies resolved between 6-12 weeks post surgery. A number o f case reports record neurological involvement by direct epineurial involvement but this behaviour was not observed in our series. Review of the literature shows no larger series than ours ^. Conclusions: We conclude that ganglion cysts arising in this region commonly present with pain, swelling and neurology. Recurrence rate is high (33%) and fiirther marginal resecfion is often not curative. More aggressive surgery such as joint resection or arthrodesis may then be necessary.

1. Ilahi OA, Younas SA, Labbe MR, Edson SB. Prevalence o f ganglion cysts originating from the proximal tibiofibular joint: A magnetic resonance imaging study. Arthroscopy 2003;19-2:150-3. 2. Miskovsky S, Kaeding C, Weis L. Proximal tibiofibular joint ganglion cysts: excision, recurrence, and joint arthrodesis. Am J Sports Med 2004;32-4:1022-8.

6. A C O M P A R A T I V E S T U D Y O F B I O M E T R I C P A R A M E T E R S IN P A T I E N T S W I T H I D I O P A T H I C A N T E R I O R K N E E PAIN 5 PatiL V Kumar, V Kamath, L White, A Hui Department of Orthopaedics. James Cook University Hospital

Introduction: Our aim was to compare the biometric parameters of patients with idiopathic anterior knee pain ( lAKP) with age and sex matched normal population. We also wanted to assess the short-term outcomes of these patients. Methods: We prospectively recorded the Q angles, joint laxity (Beighton's index), A C L laxity (KT-1000), hamstring tighmess (popliteal angle), pain (visual analogue scale) and the general health status (SF-36 quesuonnaire) of paUents with idiopathic anterior knee pain between the ages of 11-25 years. These findings were compared with a control group. We also performed a radiological evaluation in all patients. Results: The visual analogue pain scores in 67 patients (40 bilateral) improved from a mean o f 40 at presentation to 25 at follow up. Patients with l A K P had significantly greater hamstring tightness than the conU-ol group (p=0.03). The median popliteal angles were 30 degrees and 20 degrees respectively in the patient and control groups. We did not find a statistically significant difference in the other biometric parameters. Conclusion: Idiopathic anterior knee pain is a self-limifing condition. Tightness of the hamstring muscles and an imbalance between the quadriceps and hamsmngs may be one of the aetiological factors, though further research is needed to prove the causauon.

7. T H E FLTNCTIONAL O U T C O M E O F A U T O L O G O U S C H O N D R O C Y T E I M P L A N T A T I O N IN D I S T A L F E M O R A L O S T E O A T H R I T I S BA Rogers, G Bentley, R Carrington, J Skinner, TWR Briggs Royal National Orthopaedic Hospital. Stanmore. Middlesex

Introduction: The treatment of distal femoral cartilage defects using autologous chondrocyte implantation (ACI) and matrix-guided autologous chondrocyte implantation ( M A C l ) is becoming increasingly common. This prospective study reviews and compares the clinical outcome o f A C I and M A C l used for the treatment of osteoarthritis (OA). Methods: We present the clinical outcomes of 23 knees that have undergone A C I or M A C l for OA from July 1998. A l l patients were subsequently assessed on a yeariy basis using 6 independent validated clinical, functional & satisfaction rating scores. Results: Modified CincinnaU, Bentley Functional Outcome and Lysholm & Gilchrist clinical rating scores all showed significant improvements compared to pre-operative levels (p<0.05). There was no significant difference between A C I and M A C L Patient Satisfaction and Brittberg Functional Rating Scores both showed sustained improvements. Benefits to both the physical and mental health components o f the SF-36 score were demonstrated. Discussion: This study suggests ACT and M A C l produce significant functional improvements in the ostcoarthritic knee compared to pre-operative levels.

8 T O P O G R A P H I C A L G L Y C O S A M I N O G L Y C A N V A R I A T I O N IN H U M A N A R T I C U L A R C A R T I L A G E BA Rogers', C Murphy, SR Cannon', TWR Briggs'

The Royal National Orthopaedic Hospital, Slanmore. UK. • The Kennedy Institute of Rheumatology, Imperial College. Hammersmith. UK.

Introduction: The load bearing status o f articular cartilage has been shown to affect its biochemical composition. This study investigates the topographical variation of glycosaminoglycan (GAG) relative to DNA content in human distal femoral articular cartilage. Methods: 26-paired specimens of distal femoral articular cartilage, from weight bearing and non-weight regions, were obtained from thirteen patients undergoing amputation. Following papain enzyme digestion, spectrophotometric (GAG) and fluorometric ( D N A ) assays assessed the biochemical composition o f the explants. Data was analysed using a paired T test. Results: Despite no significant differences in absolute D N A concentrations, weight-bearing regions of articular cartilage showed a significantly higher concentrafion of GAG relative to D N A compared with non-weight bearing areas (p=0.021). Discussion: This study suggests that chondrocytes in weight bearing regions of human articular cartilage produce a greater quantity o f GAG than those located in non-weight bearing areas. We conclude that mechanical loading is essential in maintaining the biochemical composition o f human articular cartilage.

36

BRITISH ASSOCIATION FOR SURGERY OF THE KNEE at the Royal College of Surgeons

President: R L Allum FRCS Honorary Secretary: T J Wilton FRCS Treasurer: C N A E s l e r F R C S Secretariat: Mrs Hazel Choules, British Orthopaedic Association, Royal College of Surgeons 35-43 Lincoln's Inn Fields, London WC2A 3PN Tel: 020 7406 1763 Fax: 020 7831 2676

BASK/DEPUY FELLOWSHIP ANNOUNCEMENT

The British Association for Surgery of the Knee is pleased to announce a Research Fellowship in knee surgery, generously sponsored by DePuy to the sum of £45,000 for one year. The Executive believe that the research should be undertaken in the UK and that the fellow should not undertake any routine clinical work. DePuy have made it clear that their support is totally without commercial restraints. A protocol for application is available. The applications will be judged by the President, Secretary and Education Secretary of BASK. A short list of applicants may be asked to attend for an interview. Applications should be submitted to the Honorary Secretary at the above address by 31st August 2006.

BASK/ DEPUY RESEARCH FELLOWSHIP

1. APPLICANTS These may be: a. A person in training with a project which will be supervised by a full Member of BASK and will be based in his/her

Department. Firm evidence must be presented that the applicant has the backing and use of facilities of that Department.

b. A full member or members of BASK with a project that will be undertaken within or from the Member's Department, either by himself or by a named individual who can be recruited after the grant is awarded. Priority will usually be given to applications in which the research worker is an orthopaedic trainee, although applications in which the work will be undertaken by others such as a scientist, therapist or statistician will be considered.

2. APPLICATIONS The application must consist of: a. A copy of the applicant's CV. Where the potential research worker is known, a copy of their CV should be

enclosed. b. An outline of the proposed research set out as follows:

i) . Summary in lay terms (maximum 250 words). ii) . Aims of study. iii) . Background to study. iv) . Methods. v) . Financial details including salary, Nl, additional costs. vi) . A brief statement as to the exact location or base for the work. vii) . If the application comes from 1(a) (see above) it should be accompanied by a brief report from the

Supervisor. c. Referees must be named. For option 1(a) they must take the form of conventional professional trainee

references. For option 1 (b) there should be a brief letter from two relevant BASK Members who have had the opportunity to scrutinise the application prior to submission.

3. Where the award is made to a BASK member, who subsequently recruits a research worker, no money will be paid until the selection committee is satisfied that the individual recruited is suitable for the task in hand. This may involve an interview.

Deadline for Entries: 31 August 2006

37

BRITISH ASSOCIATION FOR SURGERY OF THE KNEE at the Royal College of Surgeons

President: R L A l lum FRCS Honorary Secretary: T J Wi l ton FRCS Treasurer: C N A Esler IVIA, FRCS

Secretariat: Mrs Hazel Choules, British Orthopaedic Association, Royal College of Surgeons

35-43 Lincoln's Inn Fields, London WC2A3PN Tel: 020 7406 1763 Fax: 020 7831 2676

BASK/SMITH & NEPHEW TRAVELLING FELLOWSHIP

The British Association for Surgery of the Knee is pleased to announce a Travelling Fellowship in conjunction with Smith & Nephew to the value of £5000. Applications are invited from Specialist Registrars years 5 and 6 or Consultants in the first 5 years of appointment. Applications should include a CV, proposed itinerary and reasons for applying. The successful candidate will be required to submit a brief report to the BASK Executive after completion of his Fellowship and may also be required to present an account of some or all of his Fellowship either to a BASK meet­ing or The Knee Journal.

Applications should be submitted to: The Honorary Secretary at the above address by 31^* August 2006

38

Notes:

39

Dear Colleague,

Re: The .Tournal of Bone and .Toint Surgery

I am delighted to say that the British Volume of the Journal of Bone and Joint Surgery will continue to publish free the Abstracts of your Society's Meetings.

At the Journal of Bone and Joint Surgery, we believe it is very important to encourage all those involved in the practice of orthopaedic surgery to subscribe to the premier orthopaedic Journal.

In an age of specialisation, I appreciate the importance of speciality journals. Nonetheless, across the field of orthopaedics around the world many surgeons believe they should reserve their best work for submission to the JBJS. Within its pages, therefore, is the cream of world orthopaedic research.

If you do not subscribe, can I encourage you to do so. Note that there is a 50% discount for all orthopaedic Trainees. At the bottom of this letter the methods of subscribing are outlined.

I do hope you will join us i f you have not done so already.

Yours sincerely,

Chairman

ORDER F O R M FOR JBJS SUBSCRIPTION Print subscription rates for 2006 (Volume 88) Standard Trainee (Resident)*

Combined (American and British Volumes 24 issues) • £ 1 5 8 . 0 0 • £ 7 9 . 0 0

British Volume (12 issues + 3 supplements) • £76.00 • £38.00

American Volume International rate (12 issues) • £105.50 • £52.75

*Orders must be accompanied by a letter confirming your status, as a trainee, from your head of training programme.

METHOD OF PAYMENT I enclose my cheque for £ Al l cheques must be made payable to the Journal of Bone and Joint Surgery in pounds Sterling and drawn on a UK bank account. We are unable to accept Eurocheques.

Please debit my credit card account with £ ( Visa, MasterCard, Amex )

Credit card number: / Expiry date on the card _ _ / _ _

Signature

UK/EC Your VAT Registration No. (Our VAT No. GB 232423501)

D E L I V E R Y ADDRESS

Name Email

Address

Town Postcode Country

Please complete this form and return it to The Subscriptions Manager, 22 Buckingham Street, London WC2N 6ET, UK or fax it to the Subscriptions Department on +44 (0) 20 7782 0995. We do not sell names and addresses to third parties. Your details wil l only be used to keep you informed of products available through the BESBJS. • Please tick the box i f you wish to receive relevant information. NAPA04

40

BRITISH ASSOCIATION FOR SURGERY OF THE KNEE

BASK Executive Committee 2006

Mr Robin L Allum - President

Mr Nick J Fiddian - President Elect

Mr Timothy J Wilton - Honorary Secretary

Mr Colin E Esler - Honorary Treasurer

Mr Phil Hirst

Mr Andy Williams

Mr Simon Donnell

Mr Richard Parkinson

Contact Details: BASK Hazel Choules - BOA at the Royal College of Surgeons 35 - 43 Lincoln's Inn Fields London WC2A 3PE

To request a registration form please contact:

Hazel Choules Senior Administrator BOA -Specialist Societies Tel: 020 7406 1763 Fax: 020 7X31 2676

Email:- Societiessec@boa.ac.uk

This programine has been sponsored by Smith & Nephew Endoseopy

smith&nephew

British Association of Surgery of the Knee 2006 Spring Meeting