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

DuPuy is pleased to support the 2007 BASK Spring Meeting

Intelligent Knee Surgery a ^oWnt-^ofcHMm, company

BRITISH ASSOCIATON FOR SURGERY OF THE KNEE

BASK & the Belfast Meeting Committee (Mr Ian Corry, Mr Joe McClelland, Mr Richard Nicholas, Mr Chris Connolly, Mr David Warnock and Mr David Beverland)

Would like to thank DePuy Johnson & Johnson for their generous contribution regarding the publication of both programmes for this meeting

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Smtih & Nephew Healthcare for sponsoring the 'Lorden Trickey Lecture' Dr Leo Pinczewski and their generous contribution regarding the Annual Dinner.

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PEI for sponsoring the 'Invited Lecturer' David Beverland.

A Partnership for Better Healthcare

Stryker UK for their generous contribution regarding the delegate coach transfers for both the meeting and the annual dinner.

DePuy Mitek for sponsoring and supplying the delegate bags.

DeRjymitGh a ^/ohtumJ^okwitni company

iii

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

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M A T H Y S ^ K A R L S T O R Z E N D O S K O P E u r o p e a n Orthopaedy

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

F O R E W O R D

Welcome to the 2007 annual meeting of BASK. The Belfast knee surgeons admirably lead by Ian Corry and assisted by Hazel have worked extremely hard to organise what promises to be a very stimulating and entertaining meeting.

As ever we were inundated with abstracts and many perfectly good papers had to be rejected. We have an excellent balance of papers on knee replacement, soft tissue recon­struction and the patello-femoral joint and two excellent guest lecturers in David Beverland and Leo Pinczewski who w i l l give the inaugural Lorden Trickey lecture.

Our difficulties in accepting more abstracts perhaps merits some discussion. Should the meeting run for two whole days or are we now getting big enough to run concurrent ses­sions on knee replacement and soft tissue reconstruction? Please give us your views dur­ing the course of the meeting.

Once again we have had excellent support from the companies who have come along to exhibit and to sponsor aspects of the meeting. The companies very much prefer the for­mat of BASK meetings to the bigger venues at the BOA so please take the opportunity to visit as many exhibitors as possible.

In future the BOA congress w i l l be divided up into speciality days and BASK wi l l have it's first such speciality day at this year's congress in Manchester on Friday, 28th September. Next year the annual meeting of BASK w i l l take place in Bournemouth on 17th and 18th Apr i l and in September or October we are hoping to organise a combined meeting with the Australian, New Zealand and hopefully South African knee surgeons in Queensland. In 2009 we have two interesting meetings in the autumn. Firstly BASK have been invited to join the American Knee Society for their annual meeting in Boston on October 9th and 10th and in early December the French Arthroscopy Society have invit­ed BASK to join them at their meeting in Deauville.

For the present, on behalf of BASK and our Belfast hosts, I hope that you wi l l find this meeting interesting, stimulating and fun!

Nick Fiddian President, BASK

1

BASK Annual General Meeting, Belfast Friday 23rd March 2007 - 4.50pm

(W5 Lecture Theatre - Level 4)

A G E N D A

L Apologies

2. a) Minutes of BASK AGM 23rd March 2006 b) Matters arising

3. Report from Private Practice Committee plus report from Mr R AUum re FIPO

4. President's Report

5. Report from the Knee Tutor

6. Treasurer's Report

7. Election of Officers - BASK Website Controller

8. Secretary's items/ NJR Report:

9. Knee Joumal Report

10. BASK Fellowships

11. Forthcoming Meetings:

ISAKOS Florence May 2007 BASK Spring Meeting Bournemouth 2008 Joint meeting with Australian Knee Society Joint meeting with N American Knee Society 2009

12. Any Other Business?

2

9 CME Points have been accredited to this meeting

BASK SPRING MEETING 2007 W5 at ODYSSEY, BELFAST

FRIDAY 23'» M A R C H

08.30 am

09.05 Moderators Session I 09.15 Tim Wilton & David Beverland

09.20

09.25

Moderators Session 11 09.33 Tim Wilton & David Beverland

09.39

09.45

09.51

REGISTRATION & C O F F E E

INTRODUCTION - Nick Fiddian, President & Ian Corry, Belfast Host

Free Paper Session - T K R operative teclinique

THE EFFECT OF POSTERIOR TIBIAL SLOPE ON CORONAL ALIGNMENT IN TOTAL KNEE ARTHROPLASTY Morris SAC, Round J, Edwards D, Walker N, Stapley SA, Langdown AJ

THE ANTERIOR FEMORAL CORTICAL LINE: A NEW TECHNIQUE FOR ASSESSMENT OF INTRA-OPERATIVE FEMORAL COMPONENT ROTATION IN TOTAL KNEE REPLACEMENT JRD Murray, M Sherlock, N Hogan, C Servant, S Palmer, MJ Cross Australian Institute of Musculo Skeletal Research, 286 Pacific Highway, Crows Nest NSW Australia 2065

Discussion

Free Paper Session - T K R general

A PROSPECTIVE STUDY OF PREDICTORS OF TRANSFUSION IN TOTAL KNEE REPLACEMENT. G Rainey, I Brenkel, S Gilani, R Elton. Victoria Hospital, Kirkcaldy

CRUCIATE RETAINING VERSUS CRUCIATE SUBSTITUTING KNEE REPLACEMENT WITH THE PCL CUT; A PROSPECTIVE, RANDOMIZED CONTROLLED TRIAL DT Loveday, ST Donell Norfolk and Norwich University Hospital NHS Trust, Norwich, England

RESULTS OF LOCAL FLAP SURGERY FOR SOFT TISSUE DEFECTS AFTER TOTAL KNEE ARTHROPLASTY SK Godey, JS Watson Wythenshawe Hospital, South Manchester University Hospitals NHS Trust

LESIONS OF THE SAPHENOUS NERVE AND ITS INFRAPATELLAR BRANCH AS A CAUSE OF PERSISTENT KNEE PAIN L . Beaton, J. Mitchell, A. Ehrenraich, J. Lavelle, A. Williams Chelsea and Westminster Hospital, London

09.51 Discussion

3

Moderators Session III 10.10 Tim Wilton & David Beverland

10.16

Free Paper Session - T K R complications

COMPARISON OF EMBOLIC PHENOMENA DURING COMPUTER-ASSISTED AND CONVENTIONAL TOTAL KNEE REPLACEMENT. A PROSPECTIVE, DOUBLE-BLIND, RANDOMISED, CONTROLLED TRIAL. J S Church, J Scadden, R Gupta, C Cokis, K Williams, G C Janes Perth Orthopaedic & Sports Medicine Centre, Western Australia

THE CASE FOR ADOPTING A UNIFIED SYSTEM FOR STRATIFYING COMPLEXITY OF PATIENTS UNDERGOING PRIMARY TOTAL KNEE REPLACEMENT Deo S D, Al-Arabi YB. S Vargas-Prada The Great Western Hospital, Swindon & Marlborough NHS Trust

Discussion

10.30 Coffee - Level 4, Exhibition Hall

Moderators Session IV 11.00 Colin Esler & Joe McClelland

11.06

11.12

Free Paper Session - Revision T K R complications

REPORT OF TKAR COMPLICATIONS UP TO 1-YEAR POSTOPERATIVELY: WHAT ARE THE ISSUES OF MOST CONCERN? IJGargan, KMulhall Mater Misericordiae Hospital, Dublin, Ireland

COMPARISON OF KNEE ARTHRODESIS TECHNIQUES BETWEEN A CUSTOM MADE INTRAMEDULLARY COUPLED DEVICE AND EXTERNAL FIXATION P Macnamara,C Jack, K.James, A Butler Manuel Conquest Orthopaedic Research Unit, Hastings, UK

OUTCOME FOLLOWING ARTHRODESIS OF THE KNEE USING A CUSTOM-MADE INTRAMEDULLARY COUPLED DEVICE. TM Barton, SP White, AJ Porteous, W Mintowt-Czyz, JH Newman Avon Orthopaedic Centre, Southmead Hospital, Bristol

11.18 Discussion

Moderators Session V 11.27 Colin Esler & Joe McClelland

11.33

11.39

Free Paper Session - Revision T K R results

CORRECTING BONE LOSS IN REVISION KNEE ARTHROPLASTY: USING A N UNCEMENTED PROSTHESIS & BONE GRAFTING. WJS Aston, N DeRoeck and D P Powles. The Lister Hospital Stevenage

SALVAGE REVISION TKR FOR INFECTION - A 10 YEAR REVIEW OF A 2 STAGE RE-IMPLANTATION TECHNIQUE N Briffa, P Mitchell, S Bridle Department of Trauma and Orthopaedic, St. George's Hospital, Blackshaw Road, Tooting

CO-ORDINATE PROSTHESIS FOR REVISION KNEE ARTHROPLASTY: RESULTS OF 9-12 YEAR FOLLOW-UP S Hakkalamani, PKR Mereddy, RW Parkinson Wirral Hospitals NHS Trust, UK.

11.45 Discussion

4

12.00

12.30

13.25

13.30

Moderators Session VI 14.10 Richard Parkinson & Richard Nicholas

14.16

14.22

14.28

Moderators Session VII 14.38 Richard Parkinson & Richard Nicholas

14.44

14.50 Moderators Session V I I I 14.57 Richard Parkinson & Richard Nicholas

15.03

15.09

INVITED L E C T U R E R : David Beverland MD PRCS - 'Knee Arthroplasty - 15 years of research' Consultant Orthopaedic Surgeon, Belfast

(PEI / A Partnership for Better Healthcare have kindly sponsored this lecture)

L U N C H - Level 4, Exhibition Hall P R E S I D E N T I A L M E D A L - Awarded by Robin Allum, President 2004 - 2006 to the author of the 'Best Podium Presentation' presented at the meeting in Newcastle 2005 or Slough 2006.

L O R D E N T R I C K E Y L E C T U R E : Dr Leo Pinczewski FRACS - 'Knee Ligament Reconstruction - 15 years of research' North Sydney Orthopaedic & Sports Medicine Centre, Sydney, AustraUa (Smith & Nephew have kindly sponsored this Lecturer)

Free Paper Session - Patello-femoral instability

THE A X I A L PATELLAR TENDON ANGLE - A SIMPLE NEW MRI MEASUREMENT IN PATELLAR INSTABILITY BJA Lankester, AJ Harnett, JDJ Eldridge, CJ Wakeley Bristol Royal Infirmary, Bristol

EARLY RESULTS OF TROCHLEOPLASTY FOR PATIENTS WITH DYSPLASIA AND SYMPTOMATIC RECURRENT PATELLOFEMORAL INSTABILITY. / S Mulford, MR Uttim. JDJ Eldridge. Avon Orthopaedic Centre, Bristol, United Kingdom

MEDIAL PATELLOFEMORAL LIGAMENT RECONSTRUCTION USING SINGLE HAMSTRING TENDON M Rathinam*, PJM Thompson, R B Brink. Geelong Private Hospital, Australia

Discussion

Free Paper Session - Patello-femoral replacement

INTERMEDIATE RESULTS OF AVON PATELLOFEMORAL ARTHROPLASTY FOR ISOLATED PATELLOFEMORAL ARTHRITIS- A 5 YEAR FOLLOW UP M Divekar, A Lee. Royal Cornwall Hospital, Truro, UK

A REVIEW OF REVISION PATELLOFEMORAL ARTHROPLASTY PATIENTS. A J Porteous, J S Mulford, J H Newman, C E Ackroyd. Avon Orthopaedic Centre, Bristol, United Kingdom

Discussion

Free Paper Session - Quads mechanism

IS IMPLANT REMOVAL NECESSARY FOLLOWING SURGICAL STABILISATION OF PATELLA FRACTURE? PKR Mereddy, G Kumar, HL George, S Hakkalamani, H Malik, NJ Donnachie. Arrowe Park Hospital, Wirral, Merseyside

A BIOMECHANICAL STUDY COMPARING DIFFERENT METHODS FOR REPAIR OF PATELLAR TENDON RUPTURE M D Waites, M D Chodos, I Wing, E Hoefnagels and S M Belkoff International Centre for Orthopaedic Advancement, Johns Hopkins Hospital, Baltimore, Maryland, USA.

Discussion

5

15.15 Tea - Level 5, Poster Presentation area

Moderators Session IX 15.35 Andy Williams & Ian Corry

15.41

15.47

Free Paper Session - Arthroscopy

IS PNEUMATIC TOURNIQUET NECESSARY IN KNEE ARTHROSCOPY? HL George, G Kumar, PKR Mereddy, R A Harvey. Arrowe Park Hospital, Liverpool, UK.

ARTHROSCOPY OF THE KNEE UNDER LOCAL ANAESTHESIA: IS IT SAFE AND PRACTICAL? Mr A Phadnis* ,DrA Khanna*, ,Dr D Griffths~, MrAP Chandratreya* Princess of Wales Hospital, Bridgend & Nottingham City Hospital, Nottingham. * Dept of Orthopaedics, -Dept of Anaesthesia.

CAN ARTHROSCOPIC SIMULATOR TRAINING IMPROVE OPERATIVE PERFORMANCE IN BASIC SURGICAL TRAINEES? N R Howells, A J Carr, A Price, J L Rees Nuffield Department of Orthopaedic Surgery, University of Oxford.

15.53 Discussion

Moderators Session X 16.03 Andy Williams & Ian Corry

16.09

16.15

Free Paper Session - A C L Technique

2-BUNDLE ACL RECONSTRUCTION IMPROVES CONTROL OF THE PIVOT SHIFT IN-VIVO J R Robinson, P D Colombet Centre de Chirurgie Orthopedique et Sportif, Bordeaux-Merignac, France.

ON THE RELATIVE CONTRIBUTION OF THE TWO MAIN ANTERIOR CRUCIATE LIGAMENT FUNCTIONAL BUNDLES TO INTACT KNEE KINEMATICS P. Cuomo, R. Boddu Siva Rama, A.M.J. Bull, A.A. Amis Imperial College London

THE FATE OF THE GRAFT IN ACL RECONSTRUCTION IN THE SKELETALLY IMMATURE F Pease, A Ehrenraich, J. Skinner, A Williams, S Bollen Chelsea & Westminster Hospital and The Yorkshire Clinic

16.21 Discussion

Moderators Session XI 16.30 Andy Williams & Ian Corry

16.36

Free Paper Session - A C L Ten Year Results

ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION USING PATELLAR TENDON AUTOGRAFT. 13 YEAR OUTCOME James RD Murray, Niall A Hogan, Allister Trezies, James Hutchinson, Erin Parish, John W Read, Mervyn J Cross Australian Institute of Musculoskeletal (AIMS) Research, Sydney, Australia

LONG TERM RESULTS OF ARTHROSCOPIC RECONSTRUCTION OF THE ANTERIOR CRUCIATE LIGAMENT WITH IPSILATERAL PATELLAR TENDON GRAFT. A PROSPECTIVE LONGITUDINAL TEN-YEAR STUDY Chris Connolly, Vivianne Russell, Lucy Salmon, Justin Roe, Craig Harris, Leo Pinczewski

16.42

16.50

Discussion

AGM

19.45 for 20.15 BASK Annual Dinner, Belfast City Hall, Host Joe McClelland Principal dinner guest - Lord Major of Belfast

6

SATURDAY 24''MARCH

08.15 am Moderators Session XII Phil Hirst & Chris Connolly

08.45

08.51

08.57

09.03

Moderators Session Xm 09.12 Phil Hirst & Chris Connolly

09.18

09.24

Moderators Session XIV 09.30 Phil Hirst & Chris Connolly

09.36

09.39

Coffee and registration

Free Paper Session - Anatomy and early OA

MEDIAL TIBIAL PLATEAU ANATOMY IN NORMAL AND EARLY ANTEROMEDIAL OA KNEES BJA Lankester, HL Cottam, V Pinskerova, JDJ Eldridge, MAR Freeman Bristol Royal Infirmary and Charles University, Prague

GENETIC INFLUENCES IN THE AETIOLOGY OF ANTEROMEDIAL OSTEOARTHRITIS OF THE KNEE. SM McDonnell, JS Sinsheimer, CAE Dodd, DW Murray, AJ Carr, AJ Price. Nuffield Department of Orthopaedic Surgery, University of Oxford, UK

WEAR PATTERNS IN ANTEROMEDIAL OSTEOARTHRITIS OF THE KNEE HAVE A CORROLATION WITH ACL STATUS. SM McDonnell, R Rout, CAE Dodd, DW Murray, AJ Price Nuffield Department of Orthopaedic Surgery, Nuffield Orthopaedic Centre, Oxford

Discussion

Free Paper Session - Visco-supplementation

A PROSPECTIVE RANDOMISED CONTROLLED TRIAL TO COMPARE SAFETY AND EFFICACY OF INTRA ARTICULAR SYNTHETIC AND AVIN HYALURONIC ACID INJECTIONS. VS Dachepalli, SA All, MV Prabhakar, DN Teanby Department of Trauma and Orthopaedics, Whiston Hospital, Prescot-L355DR

THE EFFICACY OF HYLAN G-F 20 AND SODIUM HYALURONATE IN THE TREATMENT OF OSTEOARTHRITIS OF THE KNEE - A PROSPECTIVE RANDOMIZED CLINICAL TRIAL R Raman, A Dutta, N Day, CJ Shaw, GV Johnson Department of Orthopaedics, Hull Royal Infirmary, United Kingdom

Discussion

Free Paper Session - ACI

IS AUTOLOGOUS CHONDROCYTE IMPLANTATION EFFECTIVE IN OVERWEIGHT PATIENTS? PK Jaiswal, M .lameson-Evans. J Jagiello, RWJ Carrington, J A Skinner, TWR Briggs, G Bentley. Joint Reconstruction Unit, Royal National Orthopaedic Hospital, Stanmore, United Kingdom

DOES AUTOLOGOUS CHONDROCYTE IMPLANTATION ALLOW RETURN TO PHYSICAL ACTIVITY AND WORK? M Jameson-Evans, P K Jaiswal, D H Park, RWJ Carrington, J A Skinner, TWR Briggs, G Bentley Joint Reconstruction Unit, Royal National Orthopaedic Hospital, Stanmore, UK

ISOLATION OF VIABLE HUMAN CHONDROCYTES FOLLOWING RTICULAR CARTILAGE CRYOPROSERVATION AJ Price, Z Xia, PA Hulley, DW Murray, JT Triffitt, Botnar Research Centre, Institute of Musculoskeletal Sciences, the University of Oxford, Oxford, 0X3 7LD UK.

09.45 Discussion

7

Moderators Session XV 9.54 Phil Hirst & Chris Connolly

10.00

10.18

10.24

10.30

11.00

Moderators Session XVI 11.15 Nick Fiddian & David Warnock

11.21

11.27

11.33

Moderators Session XVn 11.47 Nick Fiddian & David Warnock

11.53

11.59

Free Paper Session - UNI and Bilateral T K R

HIGHER EARLY RE-OPERATION RATE WITH THE PROFIX MOBILE BEARING COMPARED TO FIXED BEARING TOTAL KNEE REPLACEMENT Andrew P Davies BSc MD FRCS(Orth), Michael J Gillespie MB BS FRACS, Peter H Morris MB BS FRACS. Calvary Hospital, Canberra, Australia

TWENTY-YEAR SURVIVAL AND 10-YEAR CLINICAL RESULTS OF THE MEDIAL OXFORD UNICOMPARTMENTAL KNEE ARTHROPLASTY. A Price, UlfSvard Skaraborgs Sjukhus Kdrnsjukhuset, Skovde, Sweden Nuffield Orthopaedic Centre, Oxford, UK

BILATERAL TOTAL KNEE REPLACEMENTS STAGED ONE WEEK APART: A GOOD COMPROMISE? MC Forster, AJ Bauze, AG Bailie, MS Falworth, RD Oakeshott

SPORTSMED SA, Adelaide, Australia

Discussion

Coffee - Level 4, Exhibition Hall

PRESENTATION - Prize awarded for the 'Best 2007 Poster Presentation'

Free Paper Session - Postop pain in T K R

A RANDOMISED BLINDED CLINICAL TRIAL ASSESSING EFFICACY OF PERI­ARTICULAR INJECTION USING MULTIMODAL ANALGESIA IN TOTAL KNEE REPLACEMENT Constant A Busch*; Benjamin J Shore, Rakesh Bhandari,Su Ganapathy, Steven J MacDonald; Robert B. Bourne; Cecil H Rorabeck,; Richard W McCalden, Division of Orthopaedic Surgery, London Health Sciences Centre, University Campus, 339 Windermere Road, London, Ontario, N6A 5A5,Canada* Consultant rthopaedic Surgeon, The Rowley Bristow Unit, Ashford and St Peters NHS Trust, Guildford Road, Chertsey, Surrey, KT16 0PZ

DO MOBILE BEARING KNEE REPLACEMENTS CAUSE MORE PAIN? Gardner ROE, Newman JH Avon Orthopaedic Centre, Bristol, England

THE ROLE OF PAIN AND FUNCTION IN DETERMINING PATIENT SATISFACTION FOLLOWING TOTAL KNEE ARTHROPLASTY: ANALYSIS OF DATA FROM THE NATIONAL JOINT REGISTRY (NJR). P N Baker, J Van Der Meulen, J Lewsey, P J Gregg Clinical Effectiveness Unit, Royal College of Surgeons of England 35-43 Lincoln's Inn Fields, London WC2A 3PN

Discussion

Free Paper Session - Post T K R kneeling ability

FORCE PLATE ANALYSIS OF KNEELING ABILITY AFTER KNEE ARTHROPLASTY Hassaballa MA, Bevan D C^ Porteous A J Avon Orthopaedic Centre, Southmead Hospital, Westbury-on-Trym, Bristol, BSIO

DO MOBILE BEARINGS IMPROVE KNEELING ABILITY? M Hassaballa, A Porteous, J H Newman Avon Orthopaedic Centre, Bristol, UK

Discussion

8

Moderators Session XVIII 12.05 Nick Fiddian & David Warnock

12.11

12.17

Moderators Session XIX 12.23 Nick Fiddian & David Warnock

12.29

12.35

12.45

13.00

Free Paper Session - Cement / No cement

A RANDOMISED, CONTROLLED TRIAL OF CEMENTED VERSUS CEMENTLESS PRESS-FIT CONDYLAR KNEE REPLACEMENT: FIFTEEN YEAR SURVIVAL ANALYSIS. P N Baker, F M Khaw, LMG Kirk, R W Morris, P J Gregg Glenfield Hospital. Leicester, England.

5 TO 8 YEAR RESULTS OF THE UNCEMENTED DURACON TOTAL KNEE ARTHROPLASTY SYSTEM R Ghana*, Y Shenava, PW Skinner, PA Gibb. Department of Orthopaedics, Kent and Sussex Hospital, Mount Ephraim Road, Royal Tunbridge Wells, TN4 SAT

Discussion

Free Paper Session - T K R results

DOES A MANUFACTURER'S CHANGE IN DESIGN INFLUENCE THE OUTCOME IN TOTAL KNEE ARTHROPLASTY? B G Bolton-Maggs & L McGonagle St. Helens & Knowsley NHS Trust Hospitals

FIFTEEN YEAR FOLLOW-UP OF PRIMARY TOTAL KNEE REPLACEMENTS IN THE TRENT REGION VI Roberts, CN Esler, WM Harper Trent Regional Arthroplasty Study (TRAS), based at Glenfield General Hospital NHS Trust, Leicester

Discussion

Closing Remarks

L U N C H

9

Moderators - Tim Wilton & David Beverland Session I - T K R Operative Technique

T H E E F F E C T O F P O S T E R I O R T I B I A L S L O P E ON C O R O N A L A L I G N M E N T IN T O T A L K N E E A R T H R O P L A S T Y

Morris SAC, Round J, Edwards D, Walker N, Stapley SA & Langdown AJ

Background:Coronal alignment is important in long-term survival of TKA. Many systems are available; most aim to produce a posterior slope on the tibial component in order to reproduce the 7"̂ seen in the normal tibia. Some are designed to produce a bone cut with 7̂ ^ of slope whereas others combine the slope of the bone cut with an in-built slope on the polyethylene insert. We have investigated the theory that resecting the tibial plateau with a posterior slope can intro­duce error in coronal plane alignment in TKA. Methods: We used a standard saw-bones model in conjunction with a computer navigation system that is available for use in TKA (Stryker Orthopaedics). The normal protocol for preliminary referencing was followed; care was taken to identify tibial landmarks (tibial plateau reference point, true sagittal plane and trans-malleolar axis). We then used a standard extramedullary alignment j ig (Scorpio TKR System, Stryker Orthopaedics) with cutting blocks designed to give 0, 3, 5 and 7 degrees of posterior slope and varied the position of the alignment j ig . Variations included:

1. Medial rotation of the cutting block 2. Medialisation of the plateau reference point 3. Medio-lateral translation of the distal j ig 4. External rotation of the distal j ig

Results: In all experiments, there was a greater deviation from ideal coronal alignment as the slope on the tibial cut was increased. The greatest influence was from external rotation of the distal part of the j ig which produced 3° of varus at only 15° of external rotation with a 7° slope. Medialisation of the proximal ref­erence point worsened this to 4.5° of varus. Conclusions: We have quantified the degree of coronal malalignment that can occur for different posterior slopes during tibial resection for TKA. We recom­mend either using a minimal slope or navigation to ensure correct implant positioning.

T H E A N T E R I O R F E M O R A L C O R T I C A L L I N E :

A NEW T E C H N I Q U E F O R ASSESSMENT O F I N T R A - O P E R A T I V E F E M O R A L COMPONENT ROTATION IN T O T A L K N E E R E P L A C E M E N T

JRD Murray, M Sherlock, N Hogan, C Servant, S Palmer, MJ Cross

Australian Institute of Musculo Skeletal Research, 286 Pacific Highway, Crows Nest, NSW Australia 2065 Purpose: To assess the anterior femoral cortical line (AFCL) as an additional anatomical landmark for determining intraoperative femoral component rotation in total knee arthroplasty. The anterior femoral cortical line (AFCL) is an anatomical landmark which has been used by the senior author for 20 years to assess femoral rotation in over 4000 TKRs. The AFCL describes the alignment of the anterior cortex of the distal femur proximal to the trochlear articular cartilage. Methods: The AFCL was compared with the surgical epicondylar axis (SEA), anteroposterior axis (Whiteside's line) and posterior condylar (PC) axis using 50 dry-bone cadaveric femora, 16 wet cadaveric specimens, 50 axial MRI scans and 58 TKR patients intra-operatively. Results: In the dry-bone and cadaveric femora (measuring relative to the SEA) the AFCL and Whiteside's AP axis were 1° externally rotated and the PC axis was 1° internally rotated. With MRI (relative to the SEA) the AFCL was 8° internally rotated, Whiteside's was 2° externally rotated and the PC axis was 3° internally rotated. In the clinical study (measuring relative to a perpendicular to Whiteside's line alone) the AFCL was 4° degrees internally rotated, which equates to 2-3° of internal rotation relative to the SEA. Conclusion The AFCL is another axis, completing the 'compass points' around the knee. It may prove particularly useful when one or all of the other reference axes are disturbed such as in revision TKR, lateral condylar hypoplasia or where there has been previous epicondylar trauma. We suggest building in 5° exter­nal rotation with respect to the anterior femoral cortical line when judging femoral component rotation.

Session I I - T K R General A PROSPECTIVE STUDY OF PREDICTORS OF TRANSFUSION I N TOTAL KNEE REPLACEMENT.

G Rainey, I Brenkel, S Gilani, R Elton. Victoria Hospital, Kirkcaldy

As blood transfusion is associated with various risks, a prospective study was carried out to see i f it was possible to predict patients more likely to require trans­fusion following TKR. Data was collected prospectively on 1532 patients undergoing primary TKR between 1998 and 2006. This was collected at a preadmission clinic and various demographics were measured including haemoglobin, B M I , and a knee score. A l l patients had a tourniquet and the same approach. A l l received a L M W H until discharge. Patients with a post op haemoglobin less than 8.5 g/dl were transfused as were those less than 10 g/dl who were symptomatic as per unit protocol. Each of the predictive factors was tested for significance using t-tests and chi-squared tests as appropriate. Multiple logistic regression was used to test for the independent predictive of factors after adjusting for one another Results show transfusion is more likely i f the patient was older, female, short light or thin. Also those undergoing a lateral release or a bilateral procedure, hav­ing a low pre-op haemoglobin or a large post-op drop were more likely to be transfused. There was also a 2 fold difference between surgeons. After regression analysis 4 important factors were identified. These were a bilateral procedure, low pre-op haemoglobin, a low B M I or having a post-op drop greater than 3g/dl. Following this all patients with pre-op haemoglobin less than 1 Ig/dl are postponed and investigated and treated as required. For those with the above predictive factors, measures can be taken to try and reduce the rate of transfusion such as pre-donation, cell salvage or transexamic acid.

10

C R U C I A T E RETAINING V E R S U S C R U C I A T E S U B S T I T U T I N G K N E E R E P L A C E M E N T W I T H T H E P C L CUT; A P R O S P E C T I V E , 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

DT Loveday, ST Donell Norfolk and Norwich University Hospital NHS Trust, Norwich, England

This study was performed to compare the clinical outcomes and radiographic changes between patients with cruciate retaining (CR) and cruciate substituting (CS) total knee replacements (TKR) where the PCL was cut in both groups. From 1997 to 2001, 114 patients (79 females and 35 males) were enrolled in this study. Patients were blindly randomized into two groups, group 1 having a CR TKR and group 2 having a CS TKR. After surgery patients were followed up at six weeks, one year and at five years. The evaluation parameters at the 5 year assessment included the Oxford Knee Questionnaire, American Knee Society scoring system, SF-12 questionnaire and weight bearing radiographs of the knee, with anteroposterior and lateral views. There were 80 patients at the time of five year follow up. Of the other pafients, 26 had died and 10 were either too i l l to attend or did not respond to a follow up request. The average patient follow up was for 77 months (ranging from 51 to 96 months). There was no statistical difference between the two groups in the Oxford Knee Questionnaire, American Knee Society scoring system or the SF-12. Radiological assessment showed no statistical difference in radiolucent lines in either group. At five year follow up, one knee in the CS group had been revised for deep infection. The patient required a two stage revision procedure. Our study has shown no statistical difference in the five year results for a CR TKR or CS TKR. This suggests that a non-functioning PCL does not affect the performance of a CR TKR.

R E S U L T S O F L O C A L F L A P S U R G E R Y F O R S O F T T I S S U E D E F E C T S 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

SK Godey, JS Watson

Wythenshawe Hospital, South Manchester University Hospitals NHS Trust

Introduction and aims Soft tissue defects after total knee arthroplasty (TKA) are difficult problems to treat. Flap surgery has been successful in salvaging the prostheses. We present results of flap surgery for exposed TKAs over a 10 year period performed by single surgeon. Material and Methods Between 1996 and 2005, 31 patients (32 knees) underwent flap surgeries for TKAs. Four of these procedures were done prophylactically in patients with pre­vious knee surgeries. Gastrocnemius, medial fasciocutaneous and anterior compartment flaps were used either solely or in combination based on the size of the defect. The data was collected retrospectively from case-notes and correspondence from the B-eating orthopaedic surgeons. Results The patients were aged between 50 and 94 years. Indication for primary TKA was osteoarthritis in 25 patients and rheumatoid arthritis in 5. Coagulase nega­tive Staph.aureus was the most commonly isolated organism. In patients using steroids, 4 of 6 (71.4%) knees had good or satisfactory outcome compared to 22 of 24 (91.7%) knees in patients not on steroids. Smoking did not influence the outcome of flap surgery .The average duration between the TKA and flap sur­gery was 11 weeks (range 1 - 52). Successful soft tissue cover was achieved in 30 of 32 knees (94%), Overall, TKA was salvaged in 20 of 28 knees (71.4%) knees, 3 knees (9.7%) underwent arthrodesis and above knee amputation was performed in 4 (12.4%). The information gathered from case notes and orthopaedic surgeons was insufficient to use a knee score for evaluating the functional outcome of the procedure. Conclusion Local flap surgery for providing soft tissue cover for exposed TKA is a viable and successful procedure with good results.

L E S I O N S O F T H E SAPHENOUS N E R V E AND ITS I N F R A P A T E L L A R B R A N C H AS A C A U S E O F P E R S I S T E N T K N E E PAIN

L . Beaton, J. Mitchell, A. Ehrenraich, J. Lavelle, A. Williams Chelsea and Westminster Hospital, London

Purpose of Study: To further study a group of patients with characteristic features presenting with significant, perisistent, and seemingly hard to diagnose and so treat, knee pain. Methods / Results: 16 cases were collected. The was no association with age. 8 cases were sent as a second opinion. Causation- 7 cases:direct trauma [5: associated with MCL tears (1 chronic overload from triple-jump), l:a blow to front of knee, lichronic from kneeling]

4 cases: Knee replacement- related [irritation from osteophyte 1; implant-related 3] 3 cases: irritation from medial meniscal sutures [2: Fast-Fix; 1: in:out] 1 case: surgery induced neuroma in arthrotomy wound 1 case: irritation by an enlarging cyst

In all cases the time to make the diagnosis was prolonged. A l l had pain, which on close questioning was 'neuritic' [burning] in approximately 2/3. It was exceed­ingly well localized in all. Altered sensation in the appropriate distribution was noted by the patient in 3 cases, but shown in 5 cases on examination. A positive Tinel test was present in all cases. In approximately half of cases ultrasound plus diagnostic injection of local anaesthetic [+/- steroid] was useful. However 15 of the 16 came to surgery in which a neurolysis or removal of neuroma, in 3 cases, [all confirmed on histology] was undertaken plus the underlying causative factor dealt with eg excision of osteo­phyte or scar. One case settled 190% better according to patient] after ultrasound-guided injection of a prepatellar bursa which was irritating the infrapatellar branch of the nerve. Of the 15 who had had surgery 12 had complete resolution of symptoms. Conclusion: Although a relatively uncommon this scenario is worth considering as a cause of significant morbidity, with a good outcome from treatment in most cases. The presentation is of persistent very well localized troubling pain with marked tenderness, and a positive Tinel test.

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Session II I - T K R Complications

COMPARISON O F E M B O L I C PHENOMENA DURING C O M P U T E R - A S S I S T E D AND C O N V E N T I O N A L 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 , D O U B L E - B L I N D , RANDOMISED, C O N T R O L L E D T R I A L .

J S Church, J Scadden, R Gupta, C Cokis, K Williams, G C Janes Perth Orthopaedic & Sports Medicine Centre, Western Australia

Systemic embolic phenomena are well recognised during total knee replacement (TKR) and are widely believed to be the cause of intra-operative hypotension and reduced cardiac output, which may lead to circulatory collapse and sudden death. We undertook a prospective, double-blind, randomised study comparing the cardiac embolic load during computer-assisted and conventional (intramedullary-aligned) TKR, as measured by transoesophageal echocardiography. 26 consecutive procedures were performed by a single surgeon at a single site. Embolic load was scored using the modified Mayo grading system for echogenic emboli. Patients undergoing conventional TKR (n=12) had a mean embolic score of 6.15 (SD 0.83) on release of the tourniquet. Those undergoing computer-assisted TKR (n=14) had a mean embolic score of 4.89 (SD 1.10). Comparison of the groups using a two-tailed t-test confirmed a highly significant reduction (p=0.004) in embolic load when performing computer-assisted TKR. The groups were otherwise well matched and there were no complications. In conclusion, this study demonstrates that computer-assisted TKR results in the release of significantiy fewer systemic emboli than conventional TKR using intramedullary alignment. There is evidence that this should reduce perioperative morbidity and neurological dysfunction. This would appear to add to the ever­growing list of arguments in favour of computer-assisted total knee replacement.

T H E C A S E F O R ADOPTING A U N I F I E D S Y S T E M F O R S T R A T I F Y I N G C O M P L E X I T Y O F PATIENTS U N D E R G O I N G P R I M A R Y TOTAL K N E E R E P L A C E M E N T

Deo S D. Al-Arabi YB. S Vargas-Prada The Great Western Hospital, Swindon & Marlborough NHS Trust

We have previously noted that patients undergoing primary knee arthroplasty can be broadly divided into standard and complex. Complexity can be further sub­divided into local site of surgery issues, general co-morbidity problems or both. On this basis, we devised a simple to apply four-part classification system for patients undergoing primary total knee replacecments (PTKR) to facilitate cumu­lative risk estimation:

Complex 0 (CO): "Standard" knee replacement in a fit patient with a simple pattern of arthritis. Complex I (CI): A fit patient with a locally complex arthritis pattern. Complex I I (CII): Medically unfit patient with a simple pattern of arthritis.

• Complex I I I (CIII): Medically unfit patient with a complex arthritis pattern. When a series of consecutive PTKR's performed by the senior author was grouped according to our classification, all eariy postoperative complications and length of stay were evaluated and compared. Compared to "standard CO PTKR patients, we found a 3-fold increase in the cumulative complication risk in the CII group (p<0.001), a 4-fold increase in the CIII group (p<0.001) and an increased length of stay in the CII I group (p<0.001). There were similar trends between CO and other groups. Further local studies to quantify the cost differentials of treating complex patients and their longer term outcomes and satisfaction are underway. The senior author would like to discuss with the attending members of this BASK meeting the desirability of adopting such a system regionally or nationally, with the potential benefits for individual patients, surgeons, departments. Trusts and the healthcare system as a whole, and whether minor changes could and should be made to the National Joint Registry forms to accommodate this.

Moderators - Colin Esler & Joe McClelland Session IV - Revision T K R Complications

R E P O R T O F T K A R C O M P L I C A T I O N S UP T O 1-YEAR P O S T O P E R A T I V E L Y : WHAT A R E T H E ISSUES O F MOST C O N C E R N ?

IJGargan, KMulhall Mater Misericordiae Hospital, Dublin, Ireland

Total knee arthroplasty revisions (TKAR) are increasing in incidence. These complex and demanding procedures are typically associated with a higher com­plication rate than primaries. We report on the actual complications encountered in a prospective study of TKAR patients to determine the current nature and incidence of these problems. 230 consecutive patients undergoing TKAR were enrolled to our database and had information on demographics, comorbidities, outcomes (WOMAC and SF-36) and complications recorded. Baseline information and data from 2 month, 6 month and 1 year follow up was collated. Mean patient age was 68.0 and clinical outcomes scores showed significant improvements for function, stiffness and pain at all points of follow-up. The total number of complications was 131 in 97 (42.2%) patients (48 by 2 months, 46 at 6 months and 32 at 1 year). Systemic complications comprised 41 of these, many being relatively minor There were no deaths, 4 deep vein thromboses and 3 myocardial infarctions. The majority of complications (90) were local, includ­ing 2 patellar dislocations, 3 periprosthetic fractures, 3 peroneal nerve injuries, 2 'late' patellar tendon ruptures and 1 patellar avascular necrosis, 9 wound hematomas, and a substantial rate of 21 superficial or deep wound infections. Although patients experience significant improvement in function, activity and pain following TKAR, there is a considerable incidence of complications up to 1 year following TKAR. This is important in terms of resources, patient counseling and also in identifying and instituting preventive measures where possible in order to improve outcomes for these patients.

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COMPARISON O F K N E E A R T H R O D E S I S T E C H N I Q U E S B E T W E E N A C U S T O M M A D E I N T R A M E D U L L A R Y C O U P L E D D E V I C E AND E X T E R N A L F I X A T I O N

P Macnamara,C Jack, K.James, A Butler Manuel Conquest Orthopaedic Research Unit, Hastings, UK

The aim of this study was to compare two types of knee arthrodesis. Fourteen patients underwent arthrodesis of the knee in a single institution. Seven had a customised coupled nail (the Mayday arthrodesis nail), and six had exter­nal fixation applied, one patient had both procedures undertaken. Twelve patients had infected knee arthroplasty, one had recurrent dislocation following arthro­plasty and one had an infected open meniscetomy. Comparison was made with the external fixation in which only two cases achieved bony union compared with all eight (100%) using the customised nail. Time to bony union was also considerably shorter in the later group, as was the length of hospital stay. We conclude that a customised intra-meduUary nail is a superior method of knee arthrodesis compared with external fixation.

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

TM Barton, SP White, AJ Porteous, W Mintowt-Czyz, JH Newman Avon Orthopaedic Centre, Southmead Hospital, Bristol

Purpose: To review long-term outcome following knee arthrodesis, and compare this with patient outcome following revision knee arthroplasty. Methods: Case notes and radiographs of patients who underwent arthrodesis using the Mayday nail were reviewed retrospectively for evidence of clinical and radiological union. Patients also completed an SF12 health survey and Oxford knee score in the form of postal questionnaires. Each patient was matched with patients who had undergone revision knee arthoplasty and the outcomes were compared. Results: 19 patients were reviewed who underwent knee arthrodesis using a Mayday nail in two centres between 1993 and 2004. 18 cases had united clinical­ly and radiologically with one case lost to follow-up. Mean SF12 scores of patients following knee arthrodesis indicated severe physical (28.8) but only mild mental (43.3) disabilities. The mean Oxford knee score in this group was 41.0. These results were comparable with matched patients following revision knee arthroplasty who scores 27.2 (physical) and 41.1 (mental) on the SF12, and a mean of 38.8 on the Oxford knee score. Conclusion: Outcome scores following knee arthrodesis were similar to those following revision knee arthroplasty making it an option worth considering in selected patients requiring revision surgery. Discussion: The Mayday nail provides a method of knee arthrodesis with a high union rate and an acceptable complication rate. Outcome scores following arthrodesis were not dissimilar to those following revision total knee replacement. These results suggest that knee arthrodesis may be considered as an accept­able alternative to complex knee revision surgery.

Session V - Revision T K R Results

C O R R E C T I N G BONE LOSS IN R E V I S I O N K N E E A R T H R O P L A S T Y : USING AN U N C E M E N T E D PROSTHESIS & BONE G R A F T I N G .

WJS Aston, N DeRoeck and D P Powles. The Lister Hospital Stevenage

Aim: To determine whether moderate bone loss in revision total knee arthroplasty can be corrected using an uncemented prosthesis combined with cancellous bone grafting. Methods and Patients: 40 revision total knee replacements were undertaken by the senior author between May 1999 and June 2004. 27 one stage revisions for aseptic loosening and 13 two stage revisions for infection. Al l cases involved bone loss of grades Fl /2 and or T l /2 according to the Anderson Orthopaedic Research Institute Classification (Engh 1998). Bone loss was treated with a mixture of morselized autograft, morselized allograft and bone reamings loosely packed into any contained or uncontained defects following the technique of Whiteside (1992). Uncemented prostheses with long contact bearing stems were then inserted. Patients were followed up prospectively with Oxford and HSS knee scores. Results: A l l 40 cases were able to partially weight bear immediately postoperatively, indicating satisfactory early press fit. No cases of loosening or cases sus­picious of loosening have been noted. Mean follow up of 37 months with no patients requiring re revision, no persistent stem pain and no infection in the one stage revisions. 2 cases of infection in the 2 stage group are discussed, neither have required implant removal. Intraoperative and postoperative complications are discussed as well as range of motion, pain and patient satisfaction.In 39/40 cases bone stock has been restored. In 1 case there was significant bone resorp­tion under the tibial base plate due to stress shielding. Conclusions: This technique is successful in building up moderate bone loss in revision total knee arthroplasty, therefore avoiding the need for excessive bone resection, large metal augments, mass allografts or custom made prostheses.

SALVAGE R E V I S I O N T K R F O R I N F E C T I O N - A 10 Y E A R R E V I E W O F A 2 S T A G E RE-IMPLANTATION T E C H N I Q U E

N Briffa. P Mitchell. S Bridle

Department of Trauma and Orthopaedic, St. George's Hospital, Blackshaw Road, Tooting, London

Introduction Infection post knee arthroplasty is a catastrophic surgical complication offering a major challenge to the orthopaedic surgeon. We present the outcome of a two-stage revision implantation technique utilizing a rotational hinge prosthesis with an antibiotic impregnated cement spacer in the interim period. Materials & Method Since 1995. 38 definitely infected knee replacements were revised. Al l were followed prospectively over a 10 year period. Initial treatment consisted of thor­ough debridement, removal of implants and a period of antibiotic administration. Vancomycin impregnated articulating cement spacer was inserted in the inter­im. C-reactive protein values were monitored periodically. At second stage all patients were clinically and biochemically free of infection. Results Second stage revision was performed at an average interval of 9 months (range 4 - 1 1 months). Average length of hospital stay post 2"' ' stage was 19.8 ± 8.2 days. At follow-up (3.5 ± 2.5 years) outcome was poor in 33 % (amputations, arthrodesis, re-infections), good in 49 % (decreased ROM, PFJ pain) and excel­lent in 13 %. 3, 5% of patients had died with their prostheses in situ. The average pre and post operative Oxford Knee Score were 47.0 ± 7.5 and 21.6 ± 4.3 respectively. Conclusion Two-stage re-implantation using a hinge knee prosthesis is a safe and acceptable way of dealing with infected TKRs, conferring a stable reconstruction whilst allowing a through debridement. Thus potentially decreasing failure rates due to recurrence of primary infection. In this challenging group, complication rates were high, but at mid- and long-term review, no prostheses had failed from an aseptic cause. Moreover, this salvage procedure allows a quick rehabilitation and is tolerated well by patients.

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CO-ORDINATE P R O S T H E S I S F O R R E V I S I O N K N E E A R T H R O P L A S T Y : R E S U L T S O F 9-12 Y E A R F O L L O W - U P

5 Hakkalamani, PKR Mereddy, RW Parkinson Wirral Hospitals NHS Trust, UK.

We reviewed the clinical and radiological outcome of 72 Co-ordinate prostheses (DePuy, Warsaw, Ind) used for revision knee arthroplasty performed by a sin­gle surgeon from May 1994 to December 1997. Twenty-three patients (25 knees) since died. Two were lost to follow-up. At a mean follow-up of 10 years (range 9-12years), 45 knees in 43 patients were available for review. There were 12 men and 31 women with a mean age of 71.34 years (range 43 to 87 years). The reason for revision was instability in 38 knees, infection in 5 knees and stiffness in 2 knees. There was a significant improvement in the SF-12 PCS and WOMAC pain and stiffness scores at the latest follow-up. Five of these knees had to have re-revi­sion surgery. One patient had a re-revision for aseptic loosening, one patient for recurrent dislocation of patella. Three patients underwent repeat procedures for infection. Radiological evaluation using the Knee Society system revealed well-fixed components in 35 knees (77.78%). The radiolucencies of varying degrees were pres­ent in 10 knees (22.22%). Eight had non-progressive radiolucencies and did not show any evidence of loosening. 25 (55.5%) knees had halo sign (radiopaque line) present around the prosthesis (7 were femoral side, 4 were tibial side and 14 around both the prosthesis). Using Kaplan Meier method the cumulative sur­vival rate was 88.87% at 12 years, removal of the prosthesis or re-revision were used as end points. An analysis of clinical and standard radiographic outcomes has revealed that the Co-ordinate revision knee system continues to function satisfactorily at a mean of 10 years.

Moderators - Richard Parliinson & Richard Nicholas Session VI - Patello-Femoral Instability

T H E A X I A L P A T E L L A R TENDON A N G L E - A S I M P L E NEW M R I M E A S U R E M E N T IN P A T E L L A R I N S T A B I L I T Y

BJA Lankester, AJ Barnett, JDJ Eldridge, CJ Wakeley Bristol Royal Infirmary, Bristol

Introduction Patello-femoral instability (PFI) and pain may be caused by anatomical abnormality. Many radiographic measurements have been used to describe the shape and position of the patella and femoral trochlea. This paper describes a simple new MRI measurement of the axial patellar tendon angle (APTA), and compares this angle in patients with and without patello­femoral instability. Method Axial MRI images of the knee of 20 patients with PFI and 20 normal knees (isolated acute ACL rupture) were used for measurement. The angle between the patellar tendon and the posterior femoral condylar line was assessed at three levels from the proximal tendon to its insertion. Results In normal knees, the APTA is 11 degrees of lateral tilt at all levels from the proximal tendon to its distal insertion. In PFI knees, the APTA is 33 degrees at the proximal tendon, 28 degrees at the joint line and 22 degrees at the distal insertion. The difference is significant (p< 0.001) at all levels. Discussion Measurement of the APTA is reproducible and is easier than many other indices of patello-femoral anatomy. In PFI, the APTA is increased by 21 degrees at the proximal tendon and by 11 degrees at its distal insertion. In PFI, the patella is commonly tilted laterally. This is matched by the orientation of the patellar tendon. The increased tilt of the tendon is only partially nor­malized at its distal insertion with an abnormal angle of tibial attachment. When performing distal realignment procedures, angular correction as well as dis­placement may be appropriate.

E A R L Y R E S U L T S O F T R O C H L E O P L A S T Y F O R PATIENTS W I T H DYSPLASIA AND S Y M P T O M A T I C R E C U R R E N T P A T E L L O F E M O R A L INSTABILITY.

J S Mulford, M Rutting. JDJ Eldridge. Avon Orthopaedic Centre, Bristol, United Kingdom

Purpose: Trochlea dysplasia is a developmental condition characterized by an abnormally flat or dome shaped trochlea. This predisposes to recurrent patella instability. This study prospectively reviews the early results of patients undergoing a trochleoplasty procedure which corrects the dysplastic anatomical abnor­mality. Patients and Methods: A l l patients were recruited from the senior author's (JDJE) specialist knee clinic following the standard patellofemoral assessment. Patients were seen pre-operatively to collect epidemiological data, ensure completion of patient reported assessment forms and document clinical examination findings and investigations. Duration of instability and previous procedures performed for patella instability were recorded. Multiple patient-reported outcome measures were recorded. Outcome score assessments and clinical examinations were repeated post-operatively, along with a patient satisfaction questionnaire. A l l operations were carried out by the senior author with supplementary procedures based on pre-operative assessment. Results: 22 patients had a minimum of 12 months follow-up. The average age was 21 years and the average duration of instability symptoms (pre-trochleo-plasty) was 7 years. There were 16 females and 6 males. Mean follow up was 18 months. Patients reported improvement in outcome when the pre and post­operative scores were compared (mean scores of Oxford 34 to 41, WOMAC 23 to 15, Kujula 62 to 79, IKDC 62 to 81, and Lysholm 57 to 77). The patient sat­isfaction questionnaire revealed just one patient not satisfied with the procedure despite good patient reported outcome scores. The majority of patients per­ceived improvement due to the surgery and agreed they would recommend the procedure to others despite some residual symptoms. Recurrent instability after trochleoplasty was rare (one subluxation) and range of movement was uniformly excellent. Conclusion: Early results of this trochleoplasty for patients with trochlea dysplasia and symptomatic recurrent patella instability are encouraging.

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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 USING S I N G L E H A M S T R I N G TENDON

M Rathinam*, PJM Thompson, R B Brinli. Geelong Private Hospital, Australia

Aims: Patellar instability and painful patellar mal-tracking are common challenging conditions faced by a knee surgeon. Our purpose was to describe an arthroscopy assisted method of medial patellofemoral ligament reconstruction to address these conditions present our results using this modified technique. Materials & Method: Between April 2001 and December 2003, 22 knees in 20 consecutive patients underwent arthroscopically assisted MPFL reconstruction using an autologous hamstring tendon. There were 12 female and 8 male patients passed with a mean age of 29.9 years. The knees were assessed using Fulkerson's and Kujala's scoring systems and the mean follow-up period was 20.8 months (range 12 - 35). The technique uses a single hamstring tendon with undisturbed biological distal attachment, where the free end is routed through a longitudinal tunnel in the dorso-medial aspect of the patella and fixed to an isometric point near the medial femoral epicondyle using an interference screw. The position of femoral attach­ment is the most important factor in achieving an isometric graft. Results: There was a significant increase (p=<0.0001) in mean Fulkerson score of 35.4 from a pre-operative value of 47.4 to a post-operative value of 82.9. Sixteen patients rated their knees as good or excellent and there was only one complication of complex regional pain syndrome. 11 of 13 patients who were keen on sports returned to their sports at a mean of 3.9 months (range 1-10) . Conclusion: We report good results with this technique of medial patello femoral ligament reconstruction and would advocate it as an effective surgical option for patients with recurrent lateral instability as well as those with painful lateral mal-tracking.

Session VII - Patello-Femoral Replacement

I N T E R M E D I A T E R E S U L T S O F 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 F O R I S O L A T E D P A T E L L O F E M O R A L A R T H R I T I S - A 5 Y E A R F O L L O W UP

M Divekar, A Lee. Royal Cornwall Hospital, Truro, UK

Isolated patellofemoral arthritis is a common, often debilitating, condition with a number of treatment options available. Avon patellofemoral arthroplasty has been practiced in our district general hospital setting with favourable results. Previous studies have been mainly from the pioneering Bristol centre. We present the findings of the intermediate results of Avon patellofemoral arthroplasty (PFA) used in the treatment of isolated patellofemoral arthritis. From 1999 until August 2006, 63 Avon PFA were carried out in 46 patients by a single surgeon. We analysed retrospectively the patient case records and col­lected data regarding clinical, radiological findings along with patient satisfaction scores using the Oxford knee questionnaire. 45/46 (98%) patients had primary patellofemoral (PF) arthritis. 17/46 (36%) patients suffered from bilateral PF arthritis. The average duration of follow up was 5 years (3 months to 7 years). There were 7 males and 39 females with a median age of 63 years. The average range of movement was 120° (90°- 140°). There was no observable radiological loosening. There was a reduction in the Oxford knee score from 33 (21 - 48) to 17 (1 - 44). Complications of the procedure included superficial infections (2/46), transient foot drop (1/46), and persistent pain (2/46). Further surgery requiring lateral release was carried out in 2/46 patients. To date, none of the cases have required revision due to progression of arthritis. Patients reported high level of satisfaction following the procedure. Avon PFA is an effective procedure for the treatment of isolated patellofemoral arthritis, with a low rate of complications and good functional results. To our knowledge, this is the first study in UK outside Bristol, presenting the findings of intermediate results of Avon PFA.

A R E V I E W O F R E V I S I O N 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 PATIENTS.

A J Porteous, J S Mulford, J H Newman, C E Ackroyd. Avon Orthopaedic Centre, Bristol, United Kingdom.

Purpose: Revision patellofemoral arthroplasty (PFA) is a relatively uncommon procedure, with no published reviews identified in the literature. Revision PFAs performed at our institution were reviewed to determine the reasons for PFA failure, the technical ease of revision and to document patient-reported outcomes after revision. Methods: A prospective review of a cohort of 411 Avon PFA patients identified 31 subsequent revision knee procedures in 27 patients. Data was collected from the institution's prospective data base, operative reports. X-rays and medical records. Post-operative knee scores (Oxford Knee Score, WOMAC Osteoarthritis Index, Bristol Knee Score) were available on 26 knees. Results: The commonest reason for revision was progression of osteoarthritis (18 cases) followed by undetermined pain (7 cases). Patients with undetermined pain were found to be revised sooner than patients with disease progression (33 months vs 63 months) and also reported poorer outcome scores at 2 years post revision than the disease progression group. Only two trochlea components were loose at the time of revision and one patella had a large amount of macroscopic wear. A l l other components were found to be well fixed with minimal wear at the time of revision. There were no difficulties in removing either component. No cases required augments or stemmed femoral components due to bone loss. Patients undergoing revision surgery did report improvement in their post revision outcome scores compared with their pre-operative scores. The average Oxford Knee Score improved from 17 to 23, Bristol Knee Pain Scores improved from 11 to 20 and Bristol Knee Functional Scores improved from 15 to 16. These results are poorer than those recorded by the overall cohort of primary PFA. Conclusion: PFA is easy to revise to a primary total knee. Results of revision knees are improved from preoperative scores but not as good as expected.

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Session VIII - Quads Mectianism IS IMPLANT R E M O V A L N E C E S S A R Y F O L L O W I N G S U R G I C A L STABILISATION O F P A T E L L A F R A C T U R E ?

PKR Mereddy, G Kumar, HL George, S Hakkalamani, H Malik, NJ Donnachie. Arrowe Park Hospital, Wirral, Merseyside.

To assess the outcome and implant removal rate following surgical stabilisation of patella fracture. Sixty-seven patients who underwent surgical stabilisation of patella fracture between January 1999 and December 2004 were retrospectively reviewed to deter­mine the adequacy of fracture stabilisation, fracture union and implant removal rate. Forty-three were men and 24 were women with a mean age of 49 years (ranged 14-90 years). Table below demonstrates the injury, fracture patterns and fixa­tion methods. There were 3 open fractures and associated injuries were noted in 22 patients. A l l fractures united even though the fixation was inadequate in 46 patients. Two superficial infections responded to oral antibiotics. One patient had revision surgery at 6 weeks. Twenty-two patients required implant removal between 2 and 20 months (average 11 months) for implant related symptoms. Of the 22 (32.8%) patients requiring implant removal, 16/40 (40%) were less than 60 years and 6/27 (22.2%) were over 60 years. Mean follow up in asymptomatic patients was 8 months (3 to 18 months) and in patients with implant related problems was 17 months (10 to 36 months). Four patients were lost to follow up. Surgical stabilisation by current techniques demonstrated satisfactory fracture union. However, one in three required second surgery for implant related symp­toms. In the under 60 years group, the implant removal rate increased to 40%. Newer techniques to avoid skin irritation need to be considered.

Mechanism of Injury Fracture Pattern Fixation Method

Simple fall: 32 Transverse: 32 TBW: 44

RTA: 15 Comminuted: 15 TBW-1-Circlage Wire: 13

Fall From Height: 12 Inferior Pole: 14 TBW + Screws: 4

Other: 8 Other: 6 Screws: 6

A B I O M E C H A N I C A L STUDY COMPARING D I F F E R E N T M E T H O D S F O R R E P A I R O F P A T E L L A R TENDON R U P T U R E

M D Waites, M D Chodos, I Wing, E Hoefnagels and S M Belkoff

International Centre for Orthopaedic Advancement, Johns Hopkins Hospital, Baltimore, Maryland, USA.

Objective

The aim of this study was to compare different patellar tendon repair constructs.

Materials and Methods Eight pairs of cadaveric legs were used to compare metal suture anchor repair with "standard" Krakow tendon suture through patella bone tunnels and steel box wire augmentation loop repair. Each leg was retested with box wire augmentation loop and simple 2/0 polyglactin suture repair. The repairs were tested by mounting the legs on a specially designed rig on a materials testing machine which allowed the leg to be cycled from 90° knee flex­ion to full extension. The specimens were cycled 1000 times at 0.25Hz or until the repair failed. Optical markers were attached to the leg which enabled the repair gap and knee angle to be monitored during testing (Smart Capture and Analyser Tracking system, Padua, Italy). Results Six out of eight suture anchor repairs failed, all suture bone tunnel repairs with augmentation loops completed 1000 cycles. One out of 16 augmentation loop with simple 2/0 suture repair failed. For all specimens regardless of repair type that completed 1000 cycles there was no significant difference in repair gap distance. Conclusion Suture anchors alone do not provide a strong enough construct for patellar tendon repair. The box wire augmentation loop is key to maintaining patellar tendon repair. Krakow tendon sutures secured through patellar bone tunnels do not provide additional benefit to a simple appositional suture and box wire augmentation loop.

Moderators - Andy Williams & Ian Corry Session IX - Arthroscopy

IS PNEUMATIC T O U R N I Q U E T N E C E S S A R Y IN K N E E A R T H R O S C O P Y ?

HL George, G Kumar, PKR Mereddy, R A Harvey. Arrowe Park Hospital, Liverpool, U K.

Background: Tourniquet provides a blood less field for surgery, but it has few complications and contraindications. There are several studies identifying the tourniquet as a factor for increased risk of complications in knee arthroscopy, we reviewed 200 consecutive knee arthroscopies done in our hospital with out tourniquet to analyse the outcome. Aim: To analyse the out come of 200 knee arthroscopies done with out use of tourniquet; with respect to visualisation, time of surgery, bleeding, analgesia and post operative complications. Materials and methods: We retrospectively analysed 200 consecutive knee arthroscopies with out tourniquet done in our institute. Average age of these patients was 39 (21-81). A l l patients underwent soft tissue procedures under general anaesthesia, supine, with sole support, no antibiotics and were done by same sur­geon as day case. Same arthroscopic kit (Dyonics) with pump was used for all patients, using 2 litre saline bag and pump set at 65 mm Hg pressure. First few cases had tourniquet applied but not inflated, but later even this was avoided. Procedures included were diagnostic arthroscopies, arthroscopic debridements, meniscal repairs and partial or complete meniscal resections. Procedures like arthroscopic ACL reconstruction and other bony procedures were excluded. We looked at any visualisation problems, time of surgery, bleeding, analgesia and post operative complications. We also looked weather any of these patients visit­ed the consultant or GP for any wound related problem or pain before the usual review at 2 weeks. Results: There was no problem with visualisation noted in any of the cases, or any incidence where arthroscopy was unduly prolonged. There was no incidence of bleeding, stiffness or increased need for analgesia in any of these patients. None of the patients had any wound problem or haemathrosis requiring interven­tion. There was no record of any patients reattending the clinic or their GP for pain or bleeding. Conclusions: Many orthopaedic units continue to use a tourniquet routinely for soft tissue procedures in knee arthroscopy, probably in the belief that a clear operative view can only be achieved with one. However, the findings in our study indicate that knee arthroscopy for soft tissue procedures may be performed

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adequately without the use of a tourniquet provided a pump system is used and the pressure maintained above venous pressure. Therefore we recommend that its use for routine soft tissue arthroscopic procedures be discontinued.

A R T H R O S C O P Y O F T H E K N E E UNDER L O C A L A N A E S T H E S I A : IS I T S A F E AND P R A C T I C A L ?

Mr A Phadnis* ,DrA Khanna*, ,Dr D Griffths-, MrAP Chandratreya*

Princess of Wales Hospital, Bridgend & Nottingham City Hospital, Nottingham. * Dept of Orthopaedics, -Dept of Anaesthesia.

Introduction: Knee arthroscopy under LA, has been shown to be reliable and safe. However, this is not a widely practiced method for knee arthroscopy in the UK. A number of studies have compared various types of anaesthesia with a specific knee pathology. The aim of this study was to compare various anaesthesia techniques, and determine for LA cases the ease of the procedure, level of perioperative pain, patient satisfaction and outcome, in a non homogenous population. Materials and Methods: We prospectively studied a group of 116 consecutive patients undergoing knee arthroscopy. The choice of LA and GA was given to the patient, the decision for Spinal was made by the anesthetist. Time for each method, surgical access, peri-operative pain and patient satisfaction was smdied. Patients undergoing arthroscopy for suspected instability had GA. Results: 97 patients had the surgery performed under LA, 6 had SA and 19 had GA. Patients undergoing arthroscopy under LA understood the disease process better. 86/97 patients of the L A group did not complain of any pain/discomfort. 8 patients required further sedation for completion of the procedure. 2 patients had a possible vaso-vagal attack and needed monitoring. Surgical access was good in all patients with LA. A variety of procedures could be carried out including par­tial menisectomy, chondroplasty and microfracture in 2 patients. Immediate post-operative pain score: 0 in 92/97. Overall patient satisfaction: good in 89/ 97.There were more complications in the Spinal and GA group. Conclusion: Arthroscopy of the knee performed under local anesthesia is a safe, practical and, possibly economical alternative to conventional anesthesia. It can be done in most routine knee arthroscopic surgery.

C A N A R T H R O S C O P I C S I M U L A T O R TRAINING I M P R O V E O P E R A T I V E P E R F O R M A N C E IN BASIC S U R G I C A L T R A I N E E S ?

N R Howells, A J Carr, A Price, J L Rees Nuffield Department of Orthopaedic Surgery, University of Oxford.

Objective: To investigate the effect of lab based simulator training, on the ability of basic surgical trainees to perform diagnostic knee arthroscopy. Method: 20 orthopaedic SHO's with minimal arthroscopic experience were randomised to 2 groups. 10 received a fixed protocol of simulator based arthroscopic skills training. This consisted of 3 sessions of 6 simulated arthroscopies using a Sawbones bench-top knee model. Their learning curve was assessed objective­ly using motion analysis. Time taken, path length and number of movements were recorded. A l l 20 then spent an operating list with a blinded consultant train­er. They received instruction and demonstration of diagnostic knee arthroscopy before performing the procedure independently. Their performance was as.sessed using the intra- operative section of the Orthopaedic Competence Assessment Project (OCAP) procedure based assessment (PEA) protocol for diagnostic arthroscopy and further quantified with a global rating assessment scale. Results: In theatre, simulator-trained SHO's outscored all but one untrained SHO. The simulator trained group were scored as competent on more than 70% of occasions compared to less than 15% for the un-trained group (p<0.05). The mean global rating score of the trained group was 24.4 out of 45 compared with 12.4 for the untrained group (p<0.05). Motion analysis demonstrated objective and significant improvement in performance during simulator training. Conclusion: The use of lab based arthroscopic skills training leads to subsequent significant improvement in operating theatre performance. This may suggest that formalised lab based training should be a standardised part of future surgical curricula. OCAP PBA's appear to provide a useful framework for assessment however potential questions are raised about the ability of OCAP to truly distinguish levels of surgical competence.

Session X - A C L Technique

2-BUNDLE A C L R E C O N S T R U C T I O N I M P R O V E S C O N T R O L O F T H E PIVOT S H I F T IN-VIVO

J R Robinson, P D Colombet Centre de Chirurgie Orthopedique et Sportif, Bordeaux-Merignac, France.

Background: Studies have shown that normal tibio-femoral rotational kinematics is not regained following single-bundle ACL reconstruction and that 14-30% of patients may have a residual "pivot glide". It has been suggested that 2-bundle reconstruction could better control this laxity, but this not been demonstrat­ed conclusively in-vivo. This study tested the hypothesis that 2-bundle ACL reconstruction improves the control of the Pivot Shift. Methods: We measured the mean maximum tibial translation and coupled rotation occurring during the pivot shift (using a previously validated surgical navi­gation based methodology) in 35 consecutive patients undergoing hamstrings ACL reconstruction. 17 patients had a standard single-bundle reconstruction and 18 patients a 4-tunnel. 2-bundle reconstruction. 10 pivot shift tests were performed pre- and post operatively by a single operator and the differences compared. Results: The two groups were equally age and sex matched. There was no difference in pre-operative pivot shift measurements. 2-bundle reconstruction decreased the tibial rotation occurring with the pivot shift test more than single-bundle reconstruction (Table 1). There was no detectable difference in the con­trol of tibial translation. Conclusions: This study quantifies, in-vivo, the differences between single and 2-bundle ACL reconstruction in controlling pivot shift. It suggests that anatom­ic, 2-bundle ACL reconstructions could reduce pivot instability more effectively than a single-bundle. Whether the 10% additional control of the rotational com­ponent of the pivot improves functional stability or is necessary every patient and, in the longer term, limits the development of gonarthrosis secondary to abnor­mal motions, remains to be seen.

% reduction

Single-bundle ACL reconstruction (n=17) Translation 64 %

Rotation 49%

Two-bundle ACL reconstruction (n=18) Translation 67%^̂ ^

Rotation 59%*

Table 1. The percentage reduction of the mean maximum AP tibial translation and coupled tibial rotation occurring during the Pivot Shift manoeuvre with ACL reconstruction ( p=0.034, ''^= Not significant).

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ON T H E R E L A T I V E C O N T R I B U T I O N O F T H E T W O MAIN A N T E R I O R C R U C I A T E L I G A M E N T F U N C T I O N A L B U N D L E S T O INTACT K N E E K I N E M A T I C S

P. Cuomo, R. Boddu Siva Rama, A.M.J. Bull, A.A. Amis Imperial College London

Background and purpose of the study: the anteiior craciate Ugament (ACL) is a continuum of fibres which are differently recruited through range of motion. Two main functional bundles can be identified: the posterolateral bundle (PLB) which is taut exclusively towards extension and the anteromedial bundle (AMB) which is taut through full range of motion. The purpose of this investigation was to assess the relative contribution of the bundles to intact knee kinematics. Material and methods: fourteen intact cadaver knees were instrumented in a non-ferromagnetic rig and six degrees of freedom kinematics through flexion-extension was recorded with an electromagnetic device under the application of a 90N anterior force or a 5Nm internal rotation torque. The A M B and PLB were alternatively cut first in each knee and knee kinematics was recorded. The other bundle was then dissected and ACL deficient knee kinematics tested. Results: when the AMB was cut anterior tibial translation increased and no effects on rotations were recorded. When the PLB was first cut no significant effects on anterior laxity were observed. Different rotational responses were observed in different knees. After the section of both bundles a larger increase in anterior laxity was observed. The changes in rotation differed from knee to knee. Discussion: The AMB is a primary restraint against anterior tibial translation and has a small and variable effect on rotations. The PLB is a secondary restraint against anterior tibial translation in extension and maintains normal rotational laxity in AMB deficient knees. Therefore, reconstruction of both bundles is the­oretically advantageous to restore both intact knee anteroposterior and rotational laxity.

T H E FATE O F T H E G R A F T IN A C L R E C O N S T R U C T I O N IN T H E S K E L E T A L L Y I M M A T U R E

F Pease, A Ehrenraich, J. Skinner, A Williams, S Bollen Chelsea & Westminster Hospital and The Yorkshire Clinic

Purposes of Study: To establish what happens, over time, to an ACL graft which is implanted in the skeletally immature knee. Methods / Results: 5 cases of hamstring ACL reconstruction in prepubertal patients were available from the practices of 2 surgeons in which there were X-ray / MRI images taken over a period of an average of approximately 3 years from the operation. The changes in graft dimensions were measured from these images. No case of growth arrest was seen, nor of soft tissue contracture such as fixed flexion. A l l patients recovered to their same pre-injury level of activity, including elite level sport in 3 cases. Clinical laxity tests were always satisfactory but the senior authors have noticed that they tighten in time. The growth of the patients was an average 17cm. The graft diameters did not change despite large changes in graft length (average 145%). Most of the length gain was in the femur. Conclusion: Much has been written regarding potential harm to the growth plate in these patients but we are not aware of literature on the subject of the fate of the graft itself Considerable length changes in the grafts were evident. The biological phenomena taking place in the graft are unknown. We have clearly shown an increase in the size of graft tissue due to lengthening but no change in girth. Either the graft stretches or tissue neogenesis occurs, or both. I f it sim­ply stretched then the graft would be expected to become narrower, at least in places- it did not. Nevertheless the 'tightening' phenomenon reported anecdotal-ly could be due to the graft having to stretch but failing to keep up with growth. As the volume of graft increases so much then at least some neogenesis is high­ly likely.

Session XI - A C L Ten Year Results

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 USING P A T E L L A R TENDON A U T O G R A F T . 13 Y E A R O U T C O M E

James RD Murray, Niall A Hogan, Allister Trezies, James Hutchinson, Erin Parish, John W Read, Mervyn J Cross Australian Institute of Musculoskeletal (AIMS) Research, Sydney, Australia

Background: There is limited evidence on long-term outcome following ACL reconstruction. Concern has been raised that degenerative joint disease is common in the long-term and this may be associated with use of patellar tendon autograft. Methods: 162 patients underwent single-surgeon arthroscopic ACL reconstruction (1991-1993) were identified from our prospective database. Patient-centred outcome was by Lysholm and Subjective IKDC score, objective outcome measures were clinical examination, arthrometry and X-rays. Results: 13 year outcome (10-15 years) is known in 115/161 patients (71%). The median subjective scores were 94% (Lysholm) and 90% (IKDC). Ipsilateral graft rup­ture rate was 4%, with contralateral ACL injury in 8%. Mean manual maximum KT 1000 was 9mm in the grafted knee and 8mm in the contralateral knee. Clinical laxity scores of grade 0 or 1 were found in over 93% patients. Radiographically 66% were normal or near normal (Grade A or B). When compared to the contralateral uninjured knee we found no significant difference in the proportion of normal/near normal x-rays (grade A/B) versus abnormal/severe (grade C/D) for the medial, lateral nor patellofemoral compartments. There was no significant difference in the radiological IKDC grades in the medial compartment when compared to the contralateral uninjured knee, but there was a difference in the lateral and patellofemoral joints. Conclusions: At 13 years patellar tendon ACER provides excellent patient satisfaction, with clinically objective knee stability and low risk of re-rupture. Radiographically degenerative change was seen in 34%. There was no significant side to side difference to the uninjured contralateral medial knee joint, but there was a small but significant difference in the lateral and patellofemoral joints. The lateral joint differences may reflect underlying bone bruising at the time of injury. We do not believe that the patellar tendon autograft is the cause of arthrosis after BTB ACLR.

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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 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 W I T H I P S I L A T E R A L P A T E L L A R TENDON G R A F T . A P R O S P E C T I V E L O N G I T U D I N A L T E N - Y E A R STUDY

Chris Connolly, Vivianne Russell, Lucy Salmon, Justin Roe, Craig Harris, Leo Pinczewski

This longitudinal prospective study reports the 10-year results of arthroscopic, anterior cruciate ligament (ACL) reconstruction using patellar tendon autograft in 90 patients. The patients selected had no significant meniscal, chondral or concurrent ligamentous pathology at the time of reconstruction. Evaluation was conducted pre-operatively, 2, 5, 7, and 10 years after surgery and included the IKDC Standard Evaluation, Lysholm knee score, clinical and instrumented liga­ment evaluation and radiographs at 2, 5, 7 and 10 years. Seventy-four of the 84 patients (88%) with intact grafts at 10 years were reviewed. Four (4%) meni-sectomies were performed, 6 graft (7%) ruptures and 18 (20%) contralateral ACL ruptures occurred in the follow-up period. Ninety-seven percent of patients graded their knee function as normal or nearly normal and the median Lysholm knee score was 95 at 10-years. The proportion of patients participating in IKDC level I and I I sports fell from 85% at 2-years to 45% at 10 years, 12% attributing the decrease to their knee. On laxity testing 85% and 93% had grade 0 on Lachman and pivot shift testing, respectively and 77% had <3mm of anterior tibial displacement at 10 years. Kneeling pain increased to 58% of patients. 59% had no pain on strenuous activity with 33% of patients having a fixed flexion deformity at 10 years. Radiological examination at 10 years demonstrated osteoarthrific changes in 48% of pafients. Factors predictive for the development of radiograhic osteoarthrifis were increased age at operation and increased lig­amentous laxity at 2 years as measured clinically and by KT 1000. As such, arthroscopic ACL reconstruction, employing patellar tendon, is not preventative of the development of osteoarthritis even when the confounding factors of meniscal, chondral and other ligamentous injury are excluded.

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Moderators - Phil Hirst & Chris Connolly Session X I I - Anatomy and Early OA

M E D I A L T I B I A L P L A T E A U ANATOMY IN NORMAL AND E A R L Y A N T E R O M E D L V L OA K N E E S

BJA Lankester, HL Cottam, V Pinskerova, JDJ Eldridge, MAR Freeman Bristol Royal Infirmary and Charles University, Prague

Introduction The medial tibial plateau is composed of two relatively flat facets. An anterior upward sloping "extension facet" (EF) articulates with the medial femoral condyle from 0 to 20° - the stance phase of gait (in Man but not in other mammals). A horizontal "flexion facet" contacts the femur from 20° to full flexion. Anatomical variation in this area might be responsible for the initiation of antero-medial osteoarthritis (AMOA). This paper reports the angle between the EF and the horizontal (the extension facet angle - EFA) in normal knees and in knees with early AMOA. Method MRI reports were searched to identify patients with acute rupture of the ACL on the assumption that they had anatomically normal tibiae (46 males and 18 females) and patients with MRI evidence of early AMOA without bone loss (11 males and 9 females). A sagittal image at the midpoint of the femoral condyle was used to determine the EFA. Repeat measurements were taken by two observers. Results The EFA in normal tibiae is 14 +/- 5° (range 3 - 25°). The angle is unrelated to age. The EFA in individuals with early AMOA is 19 +/- 4° (range 13 - 26°). The difference is highly significant (p<0.001). Discussion There is a wide variation in the EFA in normal knees that is unrelated to age. There is an association between an increased EFA (ie a steeper EF) and MRI evidence of AMOA. Although a causal link is not proven, we speculate that a steeper angle increases the duration of loading on the EF in stance and tibio-femoral interface shear. This may initiate cartilage breakdown.

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

SM McDonnell, JS Sinsheimer,CAF Dodd, DW Murray, AJ Carr, AJ Price. Nuffield Department of Onhopaedic Surgery, University of Oxford, UK

A sibling risk study that shows a statistically significant increase in risk for anteromedial osteoarthritis of the knee. Anteromedial osteoarthritis is a distinct phenotype of osteoarthritis. Previous studies have shown a genetic aetiology to both hip and knee osteoarthritis. The aim of this study was to determine the sibling risk of anteromedial osteoarthritis of the knee. We conducted a retrospective cohort study of 132 probands with primary anteromedial osteoarthritis, who had undergone unicompartmental arthroplasty. Sibling were identified as having symptomatic knee problems by postal Oxford Knee Score (OKS). A positive OKS was defined as an OKS-I-/-2SD of the mean of the proband group. Sibling spouses were used as controls. Those siblings & spouses that were symptomatic from the OKS were invited to undergo Knee X-rays, to look for radiological signs of osteoarthritis. Osteoarthritis was diagnosed as greater than Grade I I on the Kellgren Lawrence classification. The pattern of disease was noted and it was considered i f the sibling were suitable for a unicompartmental knee arthroplasty. The prevalence and sibling risk of anterome­dial osteoarthritis was determined using a randomly selected single sibling per proband family. The prevalence was determined in the 103 single proband sib ling pairs. There was a statistically significant risk within the sibling group P= 0.024 using the Chi square test. The relative risk of anteromedial osteoarthritis was. 3.21(95% CI 1.08 to 9.17) Genetic factors play a major role in the development of anteromedial osteoarthritis.

WEAR PATTERNS IN A N T E R O M E D I A L O S T E O A R T H R I T I S O F T H E K N E E HAVE A C O R R O L A T I O N W I T H A C L STATUS.

SM McDonnell, R Rout, CAF Dodd, DW Murray, AJ Price Nuffield Department of Orthopaedic Surgery, Nuffield Orthopaedic Centre, Oxford

Anteromedial osteoarthritis is a distinct phenotype of osteoarthritis. The arthritic lesion on the tibia is localised to the anteromedial quadrant with an intact ACL. Deficiency of the ACL leads to a progression to tricompartmental disease. Within the spectrum of intact ACL a varying degree of ligament damage is seen. Our aim was to cortelate the progression of ACL damage to the geographical extent of disease and the degree of cartilage loss on the tibial plateau.

We systematically digitally mapped 50 tibial plateau resection specimens from clinical photographs of patients undergoing unicompartmental arthroplasty, addi­tionally the damage to their ACL was graded (O:normal, Lsynovium loss, 2:longitudinal splits) These images were imported into image analysis software. Accurate measurements were made of the dimensions of the specimen. Measurements included the AP distance to the anterior and posterior aspect of the lesion, and the distance to the start of the macroscopically non damaged cartilage. The areas of car­tilage damage and full thickness loss were also recorded. The results were represented as a % of total area to account for variation in size of the resection spec­imens. We compared % of full thickness loss in patients with normal to those with damaged, but functionally intact ligaments.

Al l specimens had a similar macro.scopic appearance. A significant difference was seen with the progression of ACL damage and area of ebumation of bone. Using an unpaired t test, a significant difference in area of % full thickness cartilage loss (P=0.047) was seen between patients with a normal and longitudinal splits within their ACL. No correlation between the clinical status of the ACL and start or finish point of cartilage loss on the tib­ial plateau

We surmise that the progression from anteromedial to tricompartmental osteoarthritis of the knee may be related to the graduated damage of the ACL.

Full thickness cartilage loss of tibial plateau

o 01

A C L status

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Session XII I - Visco -Supplementation A PROSPECTIVE RANDOMISED CONTROLLED T R I A L TO COMPARE SAFETY A N D EFFICACY OF INTRA ARTICULAR SYNTHETIC AND NATURAL HYALURONIC ACID INJECTIONS.

VS Dachepalli, DN Teanby, M Prabhakar, MAli Department of Trauma and Orthopaedics, Whiston Hospital, Prescot-L355DR

Purpose of the study: To see i f there are any differences in pain relief and complications with intraarticular Knee injection of natural and synthetic Hyaluronic acid products. Summary: After following the inclusion and exclusion criteria, 130 patients were randomly allocated two groups, receiving either synthetic or natural Hyaluronic acid injections. Patients were explained about the study and consent was sought. They were given Western Ontario and McMaster University [WOMAC] questionnaires to be filled before, 48 hours, 6 weeks and 3 months after the injections. They were examined at 3 and 6 months post injections. 124 of these patients promptly responded. 68 patients had natural product and 56 patients had synthetic product. In the natural injection group of 68 patients, 57 had pain relief at 3 months and 20 of these continued to have relief at 6 months. In the synthetic injection group of 56 patients, 48 had pain relief at 3 months and 28 of these continued to have relief at 6 moths. No complications were noted in either of the groups. Using Chi square test and with 95% confidence interval, synthetic injection has significant pain relief at 6months with p value of 0.043, but no significance in pain relief at 3 months with p value of 0.5. Conclusion: Synthetic injections are safe, significantly more effective and economical than natural ones. So, using synthetic products would give better pain relief for patients and also decrease the financial burden on the organisation.

T H E EFFICACY OF H Y L A N G-F 20 AND SODIUM HYALURONATE I N T H E TREATMENT OF OSTEOARTHRITIS OF T H E KNEE - A PROSPECTIVE R A N D O M I Z E D C L I N I C A L T R I A L

R Raman, A Dutta, N Day, CJ Shaw, GV Johnson Department of Orthopaedics, Hull Royal Infirmary, United Kingdom

A i m : To compare the clinical effectiveness, functional outcome and patient satisfaction following intra articular injection with Hylan G-F-20 and Sodium Hyaluronate in patients with osteoarthritis (OA) of the knee. Methods: In this independent study, 382 consecutive patients with OA of the knee were prospectively randomized into two groups to receive Hylan G-F-20 -Synvisc (n=I96) or Sodium Hyaluronate -Hyalgan (n=186) and reviewed by blinded independent assessors at pre injection, 6 weeks, 3, 6, 12 months. Knee pain, patient satisfaction was measured on a VAS. Functional outcome was assessed using WOMAC, UCLA, Tegner, Oxford knee score and EuroQol- 5D scores. Mean follow up was 14 months. Results: Patients in both groups predominantly had grade I I I OA. Knee pain on VAS improved from 6.7 to 3.2 by 6 weeks (p=0.02) and was sustained until 12 months (3.7, p=0.04) with Synvisc. In the Hyalgan group, pain improved from 6.6 to 5.7 at 6 weeks (p>0.05) and to 4.1 at 3 months (p=0.04) but was sustained only until 6 months (5.9, p>0.05). Improvements in the WOMAC pain and physical activity subscales were significantly superior in the Synvisc group at 3 months (p=0.02), 6 months (p=0.01) and 12 months (p=0.02). General patient satisfaction was better in the Synvisc group at all times although statistically sig­nificant at 3 months (p=0.01) and 6 months (p=0.02). There was local increase in knee pain in one patient who received Synvisc, which settled by 4 weeks. Total treatment cost was 23% more in the Hyalgan group due to the two additional visits. Conclusion: Although both treatments offered significant pain reduction, it was achieved earlier and sustained for a longer period in patients with Synvisc with early increase in activity levels. However, a local reaction of pseudo sepsis was observed with Synvisc in one patient. The total treatment cost, both for the patient and the hospital are higher with Hyalgan. From this study, it appears that the clinical effectiveness and general patient satisfaction are better amongst patients who received Synvisc.

Session XIV - ACI IS AUTOLOGOUS CHONDROCYTE I M P L A N T A T I O N EFFECTIVE I N OVERWEIGHT PATIENTS?

PK Jaiswal, M Jameson-Evans. J Jagiello, RWJ Carrington, J A Skinner, TWR Briggs, G Bentley. Joint Reconstruction Unit, Royal National Orthopaedic Hospital, Stanmore, United Kingdom

Aims To compare the clinical and functional outcomes of autologous chondrocyte implantation for treatment of osteochondral defects of the knee performed in over­weight, obese and patients of 'ideal weight'as defined by their B M I . Methods We analysed the data on all our patients that have been followed up for a minimum of 2 years and had their height and weight recorded initially in our database. Functional assessment consisted of the Modified Cincinatti Scores (collected prospectively at 6 months, 1 year, 2 years and 3 years following surgery). Patients were placed into 3 groups according to their body mass index (BMI). Group A consisted of patients with B M I of 20 to 24.9, group B patients with B M I of 25 to 29.9 and Group C are patients with B M I of 30 to 39.9. Results There were 80 patients (41 males and 39 females) with a mean age of 35.4 (range 18 to 49). The mean B M I for the entire group was 26.6.The pre-operative, 6 month, 1 year, 2 year, and 3 year Modified Cincinatti Score in Group A (32 patients) was 54.4, 80.3, 82.7, 74.7 and 72.6. Similarly in Group B, the scores were 53, 41, 54, 56, 49.5 and in Group C the scores were 36.3, 36.3, 49.6, 36, and 35.7. The wound infection rate in Group A was 6.25%, in Group B wasl7.6% and Group C was 14.3%. Conclusions Initial results from this study suggest that BMI is an important predictor of outcome after chondrocyte implantation. The group of patients that would gain most benefit from ACI are patients that are not overweight (defined by B M I in the range of 20 to 24.9). Further work is being carried out to support the hypothesis that surgeons should strongly consider not operating on patients unless the B M I is less than 25.

2 1

DOES A U T O L O G O U S C H O N D R O C Y T E IMPLANTATION A L L O W R E T U R N T O P H Y S I C A L A C T I V I T Y AND W O R K ?

M .lameson-Evans. P K Jaiswal, D H Park, RWJ Carrington, J A Skinner, TWR Briggs, G Bentley Joint Reconstruction Unit, Royal National Orthopaedic Hospital, Stanmore, United Kingdom

Aims The purpose of this study was to determine whether autologous chondrocyte implantation (ACI) in patients with articular cartilage defects of the knee resulted in patients returning to pre-injury levels of work and physical activities. Methods 133 consecutive patients from January 2001 to December 2002 underwent ACI at our institution. A telephone and postal questionnaire was conducted to ascer­tain a detailed occupational and leisure activity profile in this cohort of patients. For each job held for at least 2 months, we asked whether an average working day had involved any of the ten specified physical activities. Similarly, for each sport that had been played more than 5 times a year, we asked the age the sport­ing activities had began and whether they were able to return to these sports after surgery. Occupation for each patient was given a 3 digit code according to the Standard Occupational Classification System 2000 and hence determined whether the work performed was manual or non-manual. Results 97 patients responded to the questionnaire. There were 53 females and 44 males and the mean age at the time of operation was 34.5 (range 14 to 49). Category 6 (Personal Services Occupations) was the most common occupation pre-operatively, whereas category 4 (Administrative and Secretarial Occupations) was the most common post-operatively. 7% of patients' work involved kneeling or squatting and this figure rose to 12%, 4 years following surgery. 42% of patients had to make some form of modification to their work (usually less physical or more office based). 47% of patients were able to return to at least one of the sports they played pre-injury. Conclusion This is the first study to demonstrate that patients are able to return to work and resume sporting activity following autologous chondrocyte implantation.

ISOLATION O F V I A B L E HUMAN C H O N D R O C Y T E S F O L L O W I N G A R T I C U L A R C A R T I L A G E CRYOPROSERVATION

AJ Price, Z Xia, PA Hulley, DW Murray, JT Triffitt,

Botnar Research Centre, Institute of Musculoskeletal Sciences, the University of Oxford, Oxford, 0X3 7LD UK.

Aim The aim of this study was to investigate whether viable chondrocytes can be isolated and subsequently expanded in culture, from cryopreserved intact human articular cartilage. Method Human articular cartilage samples, retrieved from patient undergoing total knee replacement, were cored as 5 mm diameter discs then minced to approximate­ly 0.1 mm' size pieces. Samples were cryopreserved at the following stages; intact cartilage discs, minced cartilage and chondrocytes immediately after enzy­matic isolation. After completing of isolation, cell viability was examined using LIVE/DEAD fluorescent staining. Isolated chondrocytes were then cultured and a cell proliferation assay was performed at day 4, 7, 14, 21 and 28 days. Results The results showed that the viability of isolated chondrocytes from control, cryopreserved intact AC discs, minced AC and isolated then frozen samples were 71.84 ± 2.63%, 25.61 ± 2.41%, 31.32 ± 2.47 % and 42.53 ± 4.66% respectively. Isolated chondrocytes from all groups were expanded by following degrees after 28 days of culture; Group A: 10 times. Group B: 18 times. Group C: 106 times, and Group D: 154 times. Conclusion We conclude that viable chondrocytes can be isolated from cryopreserved intact human AC and then cultured to expand their number. This method could be employed to patients benefit undergoing autologous chondrocyte implantation.

Session XV - UNI and Bilateral T K R H I G H E R E A R L Y R E - O P E R A T I O N R A T E W I T H T H E P R O F I X M O B I L E B E A R I N G C O M P A R E D T O F I X E D B E A R I N G T O T A L K N E E R E P L A C E M E N T

Andrew P Davies BSc MD FRCS(Orth), Michael J Gillespie MB BS FRACS, Peter H Morris MB BS FRACS. Calvary Hospital, Canberra, Australia

The Profix knee replacement arthroplasty manufactured by Smith and Nephew has been in use for the past five years however there are few published outcome data for this prosthesis. The purpose of this study was to provide clinical outcome data for a cohort of patients with a Profix TKR at a minimum 3 years follow up. There were 65 joint replacements in 58 patients all performed by or under the direct supervision of one of two senior consultant Orthopaedic surgeons. There were 34 right and 31 left knees replaced in 31 male and 27 female patients. Mean age of the patients was 69 years (51-84 years) and mean body mass 89Kg (45-140Kg). The femoral component was uncemented in 49 knees and cemented in 16 knees. The tibial component was cemented in all 65 cases. There were 53 mobile bear­ing polyethylene inserts and 12 fixed bearing knees. The patella was resurfaced primarily in 32 cases. Using the Oxford Knee score, the mean knee score was 20.7 (Range 12-42) where a perfect score is 12 and the worst possible score 60. Mean clinical range of movement was 111 degrees (Range 90-130 degrees). Of the 65 joints, 13 have required or are awaiting some form of re-operation. These included 3 for patellae that were not resurfaced at the index arthroplasty, 6 for secondary insertion or revision of mobile bearing locking-screws and one femoral revision for failure of on-growth of an uncemented femoral component. The finding of loosening of the mobile bearing locking screw in three well functioning knees highlights the importance of Xray follow-up of patients even if their knee scores are entirely satisfactory. Overall, the clinical results of this prosthesis are satisfactory, however these data would support routine patellar resurfacing and use of the cemented fixed bear­ing option for the Profix arthroplasty.

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T W E N T Y - Y E A R SURVIVAL AND 10-YEAR C L I N I C A L R E S U L T S O F T H E M E D I A L O X F O R D UNICOMPARTMENTAL K N E E A R T H R O P L A S T Y .

A Price, UlfSvard Skaraborgs Sjukhus Kdrnsjukhusel, Skovde, Sweden Nuffield Orthopaedic Centre, Oxford, UK

Aim This paper presents the 20-year survival and 10-year clinical follow-up results from the entire series of all medial Oxford meniscal bearing unicompartmental knee arthroplasties performed in a single centre in Sweden, between 1985 and 2004. Method Patients were contacted and information about the state of the knee collected. Revision surgery was used in the life-table survival analysis performed. For the entire cohort clinical follow up at 10-years is routinely performed, using the HSS knee score. Results The entire group comprised of 683 knees in 572 patients. The mean age at implantation was 69.7 (range 48-94).There had been 30 revision procedures: 8 for lateral arthrosis, 7 for component loosening, 3 for infection, 6 for bearing dislocation, 1 for bearing fracture and 5 for unexplained pain. The 10-year, 15-year and 20-year survival (all cause revision) were 94.1 % (CI 2.9, 237 at risk), 93.5% (CI 4.6, 101 at risk) and 92.3% (CI 15.1, 11 at risk) respectively. From the patients reviewed clinically the mean pre-operative HSS knee score was 57 (95% CI I ) , compared to 87 (95% CI I ) at 10-years. Using HSS criteria the results were: 68% excellent, 23% good, 6% moderate and 2% poor. Conclusion The results show that this mobile bearing unicompartmental prosthesis offers patients excellent clinical results during the first decade and is durable during the second decade after implantafion.

B I L A T E R A L T O T A L K N E E R E P L A C E M E N T S STAGED ONE W E E K APART: A G O O D C O M P R O M I S E ?

MC Forster, AJ Bauze, AG Bailie, MS Falworth, RD Oakeshott SPORTSMED SA, Adelaide, Australia

The aim of this study was to assess the results of bilateral total knee replacement (TKR) staged one week apart during one hospital admission and compare these results with those of bilateral sequential TKRs and bilateral TKRs performed in 2 separate admissions by a single surgeon using a single prosthesis. Between 5th November 1997 and 10th August 2004, 104 patients underwent bilateral LCS TKRs using the Anteroposterior glide (APG) tibial component. The patients were analysed in 3 groups. The patients in Group 1 underwent bilateral sequential TKR under the same anaesthetic. The patients in Group 2 underwent bilat­eral TKRs under 2 separate anaesthetics, 7 days apart, during the same admission. The patients in Group 3 underwent bilateral TKR under 2 separate admis­sions, essentially 2 unilateral TKRs. The patients in Group I had shorter operations (p<0.0001) and shorter hospital stays (p<0.0001). Patients in Group 2 had less blood loss (p=0.004) but were not transfused any less than the other groups. The complication rate was low and comparable in all groups. There were no in hospital or 30 day deaths in any of the groups. Those patients in Group 3 had worse AKS function scores (p=0.02) and those patients in Group 2 had a sig­nificantly better HSS score (p=0.02). There was no significant difference between the groups in terms of range of motion or the AKS Knee score. This study has confirmed a shorter operation and hospital stay when the bilateral TKRs are carried out under the same anaesthetic. These patients also bled the most post­operatively. There was littie difference in terms of complications and clinical outcome at a mean follow up of 4 years. With appropriate patient selection, both same anaesthetic and same admission bilateral TKR are safe methods to treat bilateral arthritis.

Moderators - Nick Fiddian & David Warnock Session X V I - Postop Pain in T K R

A RANDOMISED B L I N D E D C L I N I C A L T R I A L ASSESSING E F F I C A C Y O F P E R I - A R T I C U L A R I N J E C T I O N USING M U L T I M O D A L 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 .

Constant A Busch, FRCS(Tr and Ortho}*; Benjamin J Shore, MD; Rakesh Bhandari, MD; Su Ganapathy, FRCA; Steven J MacDonald, MD, FRCSC; Robert B. Bourne, MD, FRCSC; Cecil H Rorabeck, MD, FRCSC; Richard W McCalden, MD, FRCSC Division of Orthopaedic Surgery, London Health Sciences Centre, University Campus, 339 Windermere Road, London, Ontario, N6A 5A5, Canada * Consultant Orthopaedic Surgeon, The Rowley Bristow Unit, Ashford and St Peters NHS Trust, Guildford Road Chertsey, Surrey KT 16 0 PZ

Background: Post-operative analgesia using parenteral opioids or epidural analgesia can be associated with troublesome side effects. Locally administered pre-emptive analgesia is effective, reduces central hyper sensitisation and avoids systemic drug related side-effects and may be of benefit in total knee replacement. Materials and Methods: 64 patients undergoing total knee replacement were randomised to receive a periarticular intra-operative injection containing ropivacaine, ketorolac, epimorphine and epinephrine or nothing. A l l patients received patient controlled analgesia (PCA) for 24 hours post surgery, followed by standard analgesia. Visual Analogue Scale (VAS) pain scores during activity and at rest and patient satisfaction scores were recorded pre and post operatively and at 6 week follow up. PCA consumption and overall analgesic requirement were measured. Results: PCA use at 6,12 and over 24 hours post surgery was significantiy less in patients receiving the injection (P<0.01, P=0.016, P<0.01). Patient satisfaction in PACU and 4 hrs post operation was greater (P=0.016, P=0.013). VAS for pain during activity in PACU and at 4 hrs were significantly less (P= 0.04, P=0.007) in the injected group. The average ROM at 6 weeks was no different. Overall hospital stay and the incidence of wound complications was not different between the two groups. Conclusion: Peri-articular intra-operative multimodal analgesia significantiy reduces post-operative PCA requirement. Patient satisfaction was greater in the injection group.

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DO M O B I L E B E A R I N G K N E E R E P L A C E M E N T S C A U S E M O R E PAIN?

Gardner ROE, Newman JH Avon Orthopaedic Centre, Bristol, England

BACKGROUND: In the UK 80% unicompartmental knee replacements(UKRs) and 10% of total knee replacements(TKRs) use mobile bearings. It is suggested that mobile bear­ings are more physiological and wear less, however it is still unclear whether patients tolerate mobile bearing knee replacements as well. PATIENTS AND M E T H O D S : We report four prospective studies,. Two compared fixed with mobile bearings in TKR and two in UKR. The prostheses involved were fixed and mobile vari­ants of the Rotaglide (TKR), Kinemax (TKR) and UnigUde (UKR). In addition the Oxford and St. George Sled UKRs were compared. A l l except the Uniglide study were randomized prospective trials (RCTs) 611 patients were involved with a mean age of 68 years. Residual pain following surgery was assessed with either the Oxford Knee Score (OKS) or the WOMAC score. The patients were followed up at one and two years postoperatively by a Research nurse and the findings recorded prospectively on the Bristol Knee data­base.

R E S U L T S : Study 1: Rotaglide. Prospective RCT. 171 patients. Mean pain score (OKS) Fixed bearing 15.4 v Mobile bearing 13.2. P= 0.012. Fixed bearing prosthesis

caused significantly less pain.

Study 2: Kinemax. Prospective RCT. 198 patients. Mean pain score (WOMAC) Fixed bearing 8.9 v Mobile bearing 8.3. P = 0.443. Trend favouring fixed bearing.

Study 3: Uniglide Non-randomised trial. 184 patients. Mean pain score (WOMAC) Fixed bearing 7.6 v Mobile bearing 10.1. P <0.001. Fixed bearing caused significantiy less pain.

Study 4: St. George Sled v Oxford). Prospective RCT. 94 patients. Mean pain score (OKS) 15.8 v 13.9 . P= 0.058. Strong trend suggesting the Sled caused less pain.

C O N C L U S I O N Our data suggests that the fixed bearing knee replacements result in less residual pain than their mobile bearing counterparts, at least in the first two years fol­lowing surgery.

T H E R O L E O F PAIN AND F U N C T I O N IN D E T E R M I N I N G PATIENT SATISFACTION 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 : ANALYSIS O F DATA F R O M T H E NATIONAL JOINT R E G I S T R Y (NJR).

P N Baker, J Van Der Meulen, J Lewsey, P J Gregg Clinical Effectiveness Unit, Royal College of Surgeons of England 35-43 Lincoln's Inn Fields, London WC2A 3PN

Purpose: To examine how patients viewed the outcome of their joint replacement at least one year post surgery. Emphasis was placed on investigating the relative influ­ence of ongoing pain and functional limitation on patient satisfaction. Method: Questionnaire based assessment of the Oxford Knee Score (OKS), patient satisfaction, and need for reoperation in a group of 10,000 patients who had under­gone primary unilateral knee replacement between April and December 2003. Questionnaires were linked to the NJR database to provide data on background demographics, clinical parameters and intraoperative surgical information for each patient. Data was analysed to investigate the relationship between the OKS, satisfaction rate and the background factors. Multivariable logistic regression was performed to establish which factors influenced patient satisfaction. Results: 87.4% patients returned questionnaires. Overall 81.8% indicated they were satisfied with their knee replacement, with 7.0% unsatisfied and 11.2% unsure. The mean OKS varied dependent upon patients' satisfaction (satisfied=22.04 (S.D 7.87), unsatisfied=41.70 (S.D 8.32), unsure=35.17 (S.D 8.24)). These differences were statistically significant (p<0.001). Regression modelling showed that patients with higher scores relating to the pain and function elements of the OKS had lower levels of satisfaction (p<0.001) and that ongoing pain was a stronger predictor of lower levels of satisfaction. Other predictors of lower levels of satisfaction included female gender (p<0.05), a primary diagnosis of osteoarthritis (p=0.02) and unicondylar replacement (p=0.002). Differences in satisfaction rate were also observed dependent upon age and ASA grade 609 patients (7.4%) had undergone further surgery and 1476 patients (17.9%) indicated another procedure was planned. Both the OKS and satisfaction rates were significantly better in patients who had not suffered complications. Conclusion: This study highlights a number of clinically important factors that influence patient satisfaction following knee replacement. This information could be used when planning surgery to counsel patients and help form realistic expectations of the anticipated postoperative result.

Session X V I I - Post T K R Kneeling ability F O R C E P L A T E ANALYSIS O F K N E E L I N G A B I L I T Y A F T E R K N E E A R T H R O P L A S T Y

Hassaballa MA, Bevan D C, Porteous A J

Avon Orthopaedic Centre, Southmead Hospital, Westhury-on-Trym, Bristol, BSIO

Introduction Force plate analysis of contact areas and pressure has been used in the fields of podiatry and foot surgery. We used this tool in assessing normal subjects and knee replacement patients kneeling. Aim We analysed contact areas and pressures over the front of the knee during different kneeling positions. Methods Twenty three normal subjects and 33 knee replacement patients were included in this study. The patients were selected according to age and kneeling ability and the absence of involvement of other joints. They had unilateral or bilateral Total (TKR) or Unicompartmental knee replacements (UKR).

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Target points were identified on the plate and patients were asked to place their tibial tuberosity on the target sites. Patients and normal subjects' data of load, contact area and pressure were recorded with knee at 90 degrees. A second reading was taken with subjects kneel­ing in their maximum flexion comfortable position. Foot position during kneeling was recorded in each case. Results Average age was 48.3 years for the normal group and 65.5.2 for the replaced knee group. Average range of motion was 141 degrees for the normal group and 115 degrees for the replaced knees group. In the normal group, there was a significant positive correlation between body mass and kneeling load at both 90 degrees and maximum flexion. Kneeling pres­sure was never identical in both knees in all groups. There was no significant difference of peak pressures and contact areas between the normal and UKR group. The angle of flexion affected the contact pressures as going from 90 degrees to higher flexion with the body weight still actively supported increases contact pressure, which then dropped to lowest level in maximum flexion when the body weight was supported by the calf Peak loads were usually in the region of the tibial tuberosity. Conclusion Kneeling may be a sided activity with each individual having a dominant knee. The UKR group showed more normal kinematics in comparison with the TKR group. Maximum contact pressures decreased in knees able to achieve full flexion. As kneeling flexion angle increases, the contact area decreases and while the thigh is off the calf and the peak pressure increases. Contact pressure dropped to below 90 degrees level whenever full flexion was achieved.

DO M O B I L E B E A R I N G S I M P R O V E K N E E L I N G A B I L I T Y ?

M Hassaballa, A Porteous, .1H Newman Avon Orthopaedic Centre, Bristol, UK

Introduction: There is an impression among Orthopaedic surgeons that mobile bearing knee replacement has a better functional outcome than fixed bearing knee replacement. Since kneeling demands a high level of function after knee replacement this study was undertaken to see i f mobile bearings in either total or unicompartmental replacement conferred an advantage. Methods: A prospective randomised study of 207 TKR patients receiving the same prosthesis (Rotaglid , Corin, UK) was performed. Patients were randomised into a mobile bearing group {102 patients with a mean age of 53 years) and a fixed bearing group (105 patients with a mean age of 55 years). Data was also prospectively collected on 215 UKR patients who received the same Unicompartmental implant (AMC, Uniglide, Corin, UK). One hundred and thirty six patients (Mean age: 62 yrs) had a mobile insert and 79 (mean age: 65 yrs) a fixed insert. A l l patients completed the Oxford Knee Questionnaire preoperatively as well as at 1 and 2 years postoperatively. Their stated kneeling ability and total scores were analysed with a perfect score for kneeling ability being 4 and 48 the maximum total score. Results: In all groups both the kneeling ability and the total scores improved markedly from their preoperative state. At two years the total score for the fixed bearing devices was marginally better than for the mobile (Rotaglide 36;31 and Uniglide 37;33) There was a more striking difference with respect to kneeling ability with the fixed- bearing variants performing better, (Rotaglide 1.4; 0.9 and Uniglide 1.9; 1.4), However, the greatest difference was between the UKR and TKR groups (UKR 1.7; TKR 1.2). Pre-operatively less than 2% of TKR patients (7% of the UKR patients) could kneel. Post-operatively, the patients' kneeling ability improved with 21% for the mobile bearing, 32% of fixed bearing UKR patients. The TKR patients kneeling ability was 13% of the mobile, 26% of fixed bearing patients were able to kneel with little or no difficulty. In all groups the stated kneeling ability was poor with less than 50% of any group being able to kneel with ease or only minor difficulty. Conclusion: Those undergoing UKR appeared to perform better than those with a TKR. None of the forms of knee replacement used resulted in good kneel­ing ability, though this function was improved by arthroplasty in all groups. Mobile bearing inserts did not confer any advantage with respect to kneeling and in fact performed worse with regard to this particular knee function.

Session X V I I I - Cement / No Cement A RANDOMISED, C O N T R O L L E D T R I A L O F C E M E N T E D V E R S U S C E M E N T L E S S 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 : F I F ­T E E N Y E A R SURVIVAL ANALYSIS.

P N Baker, F M Khaw, LMG Kirk, R W Morris, P J Gregg Glenfield Hospital. Leicester, England.

Purpose: To compare the survivorship, at 15 years, of cemented versus cementless fixation of press-fit condylar primary total knee replacements. Methods: A prospective randomised consecutive series of 501 primary knee replacements received either cemented (219 patients, 277 implants) or cementless (177 patients, 224 implants) fixation. Al l operations were performed either by, or under the direct supervision o f a single surgeon (PJG). Patients were followed up to establish the rate of implant survival. No patients were lost to follow up. Revision was defined as further surgery, irrespective of indication, that involved replacement of any of the three original components. Life table analysis was used to assess survival. Cox's proportional hazards regression analysis was used to compare the cumulative survival rates for the two groups. Results: Altogether 44 patients underwent revision surgery (24 cemented vs. 20 cementless). 11 cases were revised secondary to infection, 26 were revised due to asep­tic loosening and 7 cases were revised for other reasons (instability, anterior knee pain, polyethylene wear, patellar malallignment). At time of analysis a further 7 had revision planned. For cemented knees 15-year survival=80.7% (95%CI, 71.5-87.4), 10-year survival=91.7 (95%CI, 87.1-94.8). For cementless knees 15-year survival=75.3% (95% CI, 63.5-84.3), 10-year survival=93.3% (95%CI, 88.4-96.2). There was no difference between these two groups. When comparing the covariates (operation, sex, age, diagnosis, side), there was no significant difference between operation type (Hazard ratio=0.83 (95%CI, 0.45-1.52) p=0.545), side of operation (HR=0.58 (95%CI, 0.32-1.05) p=0.072), age (HR=0.97 (95%CI, 0.93-1.01) p=0.097), diagnosis (OA vs. non OA, (HR=1.25 (95%CI,0.38-4.12) p=0.718). However, there was a significant gender difference (Males vs. Females (HR=2.48 (95%CI, 1.34-4.61) p=0.004). The worst case scenario was calculated to include those patients that have also been listed for revision. Cemented 15-yr survival = 78.3%, (95%CI, 68.9-85.4), cementless 15-yr survival = 72.0%, (95%CL 59.9-81.5). Conclusion: This single surgeon series, with no loss to follow up, provides reliable data of the revision rates of the most commonly used total knee replacement. The sur­vival of the press-fit condylar total knee replacement remains good at 15 years irrespective of the method of fixation. This information is useful for strategic health authorities when establishing future requirements for revision knee surgery.

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5 T O 8 Y E A R R E S U L T S O F T H E U N C E M E N T E D DURACON T O T A L K N E E A R T H R O P L A S T Y S Y S T E M

R Ghana*, Y Shenava, PW Skinner, PA Gibb. Department of Orthopaedics, Kent and Sussex Hospital, Mount Ephraim Road, Royal Tunbridge Wells, TN4 HAT

We report the chnical and radiographic outcome of a consecutive series of 219 hydroxyapatite-coated total knee replacements with a follow-up of 5 to 8 years Patients who fulfilled the entry criteria were included in a prospective study from early 1997 to late 1999. Regular clinical & functional assessment was subse quently performed using the Knee Society Score, WOMAC & SF-12 self-assessment questionnaires. Analysis of fluoroscopically controlled radiographs was performed using the American Knee Society Score. Al l living patients (186 knees) were followed-up. Exhaustive efforts were made to ensure that no patient was lost to follow-up. 28 patients (30 knees) were deceased. There have been 3 revisions. The mean pre-operative Knee Score of 43.8 increased to 77.1 and the mean pre-operative Function Score of 20.3 increased to 63.4 at 5 years. The WOMAC scores also showed marked improvement from pre-operative status after 5 years minimum follow-up: pain 250 pre-op to 157, stiffness 115 pre-op to 56 and function 910 pre-op to 588. There was no radiographic evidence of loosening or migraUon. The average American Knee Society Score for each component was 4. Small gaps between the bone-implant interface were observed to heal over the first year. A separate phenomenon of focal osteopenia is also described in a small number of well-fixed femoral components (12 of 219). To date, 3 prostheses have been revised, 2 due to deep infection and 1 due to tibial tray subsidence. A survivorship of 98.6% has been achieved at 8 years. We believe this to be the first medium term study for the Duracon HA coated knee arthroplasty system, showing excellent clinical and radiographic outcome,

with 100% follow-up at 5 to 8 years.

Session XIX - T K R Results DOES A M A N U F A C T U R E R ' S C H A N G E IN D E S I G N I N F L U E N C E T H E O U T C O M E IN T O T A L K N E E A R T H R O P L A S T Y ?

B G Bolton-Maggs & L McGonagle St. Helens & Knowsley NHS Trust Hospitals

In 2000 the Nuffield and Rotaglide Knee prostheses were combined into the Rotaglide-H system. This allowed a choice of either mobile or fixed meniscal bear­ing in the same prosthesis. Between 1988 and 2000 460 primary Nuffield knee prostheses were implanted and between September 2000 and September 2005 185 primary Rotaglide-i- pros­theses have been used. A Prospective review using a pain score, range of movement, time walked, and the American Knee Surgeons score was performed. The Rotaglide-h cases have been age, sex, and diagnosis matched with 185 Nuffield knees. A l l prostheses have been implanted by one surgical team, using the same technique and the same instruments. Al l are inserted cementless with patella replacement i f possible. Statistical analysis was performed on the first 5 years of follow-up for both sets of prostheses. (STATA) The Nuffield prostheses was significantly better at relieving pain in all years post-operatively. The Rotaglide-H has a slightly better range of flexion, but this is significant only at the 2nd year. There is no significant difference in the walking time, and the AKSS is significantly better for the Nuffield prosthesis only at the first year Statistical significance is difficult to obtain in years 4 and 5 due to the small numbers of Rotaglide-H prostheses that have reached this stage of review. Conclusion. A change in design has not improved the short term outcome of these prostheses, and may have worsened the results especially in terms of pain relief This could be due to the change in stem size and the tibial fins. It is recommended that all changes in prostheses should undergo a limited controlled clinical trial before being released onto the open market

F I F T E E N Y E A R F O L L O W - U P O F 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 S IN T H E T R E N T R E G I O N

VI Roberts, CN Esler, WM Harper

Trent Regional Arthroplasty Study (TRAS), based at Glenfield General Hospital NHS Trust, Leicester

PURPOSE: To evaluate the fifteen year survivorship of primary Total Knee Replacements in a single UK health region. METHODS: Since the beginning of 1990, and with the agreement of all consultant orthopaedic surgeons in the region, all primary total knee replacements (TKR) performed throughout Trent were recorded prospectively. At the time of operation the surgeon completes a questionnaire, which records demographic, medical and oper­ative details for each patient and implant. In this study we have traced all the patients, who had a primary total knee replacement between 1990 and 1992. We issued a validated, self administered ques­tionnaire to all surviving patients, at a mean of fifteen years post arthroplasty. This questionnaire examines the patient's level of expectation and satisfaction with their TKR, and also measures their quality of life (using EQ-5D and visual analogue score). Using a similar register, containing information of all revi­sion TKR in the region, we have measured the survivorship of these primary TKR at 10 and 15 years. R E S U L T S : 4,665 primary TKR were performed on 4,448 patients. At fifteen year follow-up 1,408 patients were alive. The questionnaire response rate was 57.1% (n=912). Of our responders, 87.8% were satisfied with the result of their TKR at 15 years post-arthroplasty, and 82% felt their TKR had met their expectations. Survivorship analysis revealed that 94.7% (-h/-0.4%) of implants survive to 10 years, and 92.7% (-h/-0.5%) to 15 years. Survivorship was significantly affected by gender of the patient, age at time of primary, and type of prosthesis used. Infection rate at 15 years was 0.9%. DISCUSSION: This is one of the first long term studies of primary TKR, which assesses survivorship of primary TKR beyond 10 years. This study shows that survivorship ai 5 and 10 years compares favourably to the results of similar studies from other countries.

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Poster Presentations Level 5 H I G H F A I L U R E R A T E F O R A M O B I L E B E A R I N G UNI­C O M P A R T M E N T A L K N E E R E P L A C E M E N T . R E S U L T S O F I N D E P E N D E N T P O S T - O P E R A T I V E X - R A Y A S S E S S M E N T .

Arastu MH', Vijayaraghavan J\ J-\ H', Hull JB', Newman J\ 'Frimley Park NHS Foundation Trust. Camberley; GU16 5UJ. •The Winford Unit. Avon Orthopaedic Centre Southmead Hospital, Westbury- on Trym, Bristol BSW 5NB. UK.

Background. We have noted a concerning number of early failures (as defined by revision) for Preservation medial mobile-bearing uni-compartmen-tal knee replacements (UKR's) implanted in our hospital. This study retrospectively reviewed the postoperative radiographs to see i f these were as a result of surgical technical failure. Methods. Between 200.^ and 2004. 43 medial mobile-bearing Preservation UKR's were implanted into 39 patients. The average age of the patients al the time of the index procedure was 61.4 years (range, 46-85). (20 males). The immediate post-operative radiographs were reviewed by 2 independent orthopaedic consultants and a registrar, who were blinded to the patient outcomes, using the radiographic criteria used for the Oxford UKR. We however, particularly tried to identify any medio-lateral offset between femoral and tibial compo­nents due to the constrained nature of the prosthesis. A compound error score for all other technical errors was also calculated for each patient. Results. Six (13.9^f) of 43 knees were revised (5 for persistent pain. I for tibial component subsidence). Technical errors were few and no cor­relation was found between post-operative radiographic appear­ances and the subsequent need for revision. The mean compound error score (maximum value 18) was 4.5 (range. 2-9) in the revision ca.ses and in the non revised cases 3.2 (range. 0-8). Conclusions. We believe this study gives credence to the opinion that the DePuy Preservation mobile-bearing implant has design faults and is over-constrained leading to early failures in some cases.

U N I C O M P A R T M E N T O R T O T A L K N E E R E P L A C E M E N T -E V I D E N C E B A S E D P R A C T I S E O R S U R G E O N ' S P R E F E R E N C E ?

N Briffa, S Sadiq, J Cobb Departmeni of Trauma and Orthopaedics, Hammersmith NHS Hospitals Trust. London

Introduction A subjective observation suggests that a significant percentage of patients offered a TKR could benefit from a relatively more conser­vative, less invasive unicompartmental knee arthroplasty. We set out to challenge this hypothesis. Materials & Methods 1147 TKRs were performed between 2002 and 2005 at Ravenscourt Park Hospital. 50 consecutive knee x-rays of patients who under­went a TKR were reviewed by three independent observers. Medial and lateral articular cartilage height, varus angulation, and femero-tibial anteroposterior and mediolateral translation were measured on aniero-posterior and lateral weight bearing radiographs. Skyline views were analysed for patellofemoral disease. The most appro­priate procedure according to local radiological criteria was record­ed for all three observers. Unicompartmental arthropla.sty was con­sidered when the following criteria was met 1) anteromedial disease with preservation of posterior slope. 2) preservation of the tibial spines, 3) no anteroposterior or mediolateral translation, 4) normal tibiofemoral alignment and 5) preservation of patellofemoral joint. Osteophytes were disregarded. Tricompartmental disease merited a TKR while isolated patellofemoral (PFJ) disease considered for PFJ replacement. Patients were not formally examined. Preoperative Knee Society Scores (KSS) and W O M A C scores were noted. Results The diree observers indicated that 26 (52%). 21 (42%) and 22 (44%) patients respectively could potentially benefit from a unicompart­mental arthroplasty given the right clinical setting. Consensus was reached for unicompartmental replacement in 16 (31.2%) and for TKR in 18 (36%) of cases. Tliere was no correlation between the operation performed and operation proposed {42% ± 8) suggesting that the surgeon's preference is a dominating factor. Interestingly within the proposed unicompartmental group Knee Society Scores were higher (100 + 22 vs 71 ± 26) giving an indication to the dis-ea-se severity. Conclusion The clinical benefit and economic value of opting for a unicondy­lar knee arthroplasty when indicated is considerable. None the less it was only considered by a minority of surgeons who undertake knee arthroplasty.

S H O U L D P O S T E R O M E D L 4 L AND P O S T E R O L A T E R A L C O M P A R T M E N T V I S U A L I S A T I O N B E A P A R T O F R O U T I N E K N E E A R T H R O S C O P Y ?

Z Dannawi MRCS, V Khanduja MSc, PRCS (Tr & Orth), M El-Zebdeh FRCS

Newham University- Ho.'tpital. London. UK

Background

Arthroscopic visualisation of the posteromedial and posterolateral compartments of the knee through the intercondylar notch using the anterolateral and anteromedial portals respectively is not common­ly practiced. The purpose of this study was to prospectively evalu­

ate whether these views are useful either diagnostically. therapeuti­cally or both in a routine knee arthroscopy. Patients and Methods It is a prospective study of two hundred consecutive patients who underwent a routine knee arthroscopy in our unit using the standard portals following an appropriate clinical and radiological evalua­tion. Posteromedial and posterolateral compartment visualisation through die intercondylar notch was undertaken in all the patients. An evaluation of the ease of the technique, the usefulness of visual­isation and the morbidity associated with the procedure were recorded. Results The technique was deemed simple to perform in 9 1 % of the patients. It was found to be more difficult in knees with degenera­tive joint disea.se. Posteromedial and posterolateral compartment visualisation was found to be useful for diagnosis or treatment in 15%. and 6% of the diagnosed conditions respectively. The tech­nique was most useful for tears of the posterior horn of the medial meniscus, most of which were not detected by visualisation from the anteromedial compartment alone. Visualisation of the compart­ments was deemed adequate in 98% of the patients. There was no morbidity associated with this procedure. Conclusion We believe that visualisation of the posteromedial and posterolater­al compartment in a roufine knee arthroscopy is beneficial; and an easy and safe procedure to perform.

G R A D E I I I N J U R I E S 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 ( P L C ) O F T H E K N E E - T H E U N R E C O G N I S E D L A X I T Y

Jamie Flanagan Chelmsford Knee Clinic

Purpose The aim of this paper is to draw delegates' attention to the published evidence that exists about these injuries and to challenge the concept that these laxities can be ignored, especially when associated with injuries to the ACL and PCL. Background The common impres.sion that injuries to the P L C occur infrequent­ly, require major force and are be.st treated by early repair, is true for Grade I I I injuries. Grade I I injuries are more common, more diffi­cult to detect clinically and may develop insidiously. Even enhanced MR imaging cannot reliably assess grade I I injuries to the PLC. This can result in patients with lack of trust in the knee, pain on kneeling, difficulty with twisting, slopes and rough ground, being reassured by their surgeon that their knee is stable, when bodi know that this is not the case. Failure to detect a Grade I I injury to the PLC in association with an ACL or PCL tear may result in ongoing subtle symptoms of insta­bility, overloading and possible failure of a cruciate reconstrucfion. Methods A careful literature review was carried out with particular emphasis on the biomechanical studies which provide the scientific basis on which the common clinical tests are based. Results 1. Significant damage to the popliteus mechanism is required to

produce a clinically detectable increase in ER. 2. Grade I I lesions of the PLC may fail to reach that threshold. 3. Of the traditional tests, only the Dial test and electronic

Goniometer test can be easily used towards extension. The former is not very sensitive, the latter is time consuming.

4. Increased posterior tibial transladon (PTT) is a more reliable assessment of Grade II lesions and biomechanical studies sup­port the prominent role of the postero-lateral corner at 20" of knee flexion

5. Only two obscure clinical tests and the unpublished posterior Lachman test assess PTT below 30° of knee flexion

Conclusion Until surgeons specifically test for increased PTT at 10-20" of knee flexion. Grade I I lesions of the PLC wi l l largely go unrecognised.

B I L A T E R A L S I M U L T A N E O U S U N I C O M P A R T M E N T A L R E P L A C E M E N T

MC Forster, G Keene SPORTSMED SA, Adelaide. Au.malia

The aim of this study was to assess die perioperative complications a.ssociated with bilateral simultaneous UKR and compare them with tho.se of unilateral UKR and bilateral TKRs. Over a 2 year period, 40 patients underwent bilateral simultaneous Preservation unicom­partmental knee replacement UKR. They were compared to 40 matched unilateral UKRs and 28 bilateral simultaneous total knee replacement patients who had their operations during the same dme period by the senior author. There was no significant difference between the groups in terms of age, weight. ASA grade and throm­boprophylaxis received. There was no statistically significant differ­ence in the complication rates of all 3 groups. When compared to 2 unilateral UKRs. bilateral simultaneous UKR results in a reduced operative time, blood loss and hospital stay but more blood transfu­sion. When compared to bilateral TKRs. bilateral simultaneous UKR results in reduced blood loss, reduced blood transfusion and hospital stay but an increased operative time. Bilateral UKR is a useful option in selected patients with bilateral unicompartmental osteoarthritis.

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

C Gupte, CM Gupte, A Lim, RD Thomas, AMJ Bull, AA Amis Imperial College London

Purpose: To correlate arthroscopic appearances of the anterior and posterior meniscofemoral ligaments (aMFL and pMFL respective­ly) with their appearances on magnetic resonance imaging. Methods: 50 patients underwent M R I scanning of their knees for a variety of suspected pathologies. The radiological presence or absence of the MFLs was assessed by examination of sequential coronal and sagittal T2 weighted M R I scans. Arthroscopic exami­nation of the knees was subsequently performed, during which the MFLs were identified using several anatomical cues. These includ­ed their femoral and meniscal attachments, their obliquity relative to the PCL. and the meniscal "tug test". Identification was classed as "easy" or "hard" by the operating surgeon. Results: From 50 knees 44 (88%) aMFLs and 30 (60%) pMFLs were identified on MRI scanning, whilst 47 (94%) aMFLs and 5 (10%) pMFLs were identified arthroscopically. Identification of the presence or absence of the aMFL was classed as easy in 47 (94%), whilst the p M F L was easy to identify in only 5 (10%) of knees, of which 3 (6%) had a ruptured PCL. Using arthroscopy of the aMFL as the gold standard, the sensitivity and specificity of M R I in detect­ing the aMFL were 94% and 75% respectively. Equivalent values for the pMFL were not calculated due to the difficulty of identify­ing the pMFL arthroscopically. Thus, with the exception of PCL-deficient knees, it was felt that many pMFLs were missed due lo dif-ficuUies in identification through anterior portals. Conclusions: This is the first study correlating the M R I appear­ances of the MFLs with arthroscopic findings. M R I is relatively sensitive in identifying the aMFL. but its accuracy in identifying the pMFL remains undetermined. Accurate identification of the MFLs at M R I is of value when assessing the status of the PCL. as these l ig­aments may contribute to stabilising the PCL-deficient knee.

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

M.A. Hassaballa, M.J. Perry, A.J Porteous, LD. Learmonth University department of Orthopaedic surgery Winford Unit, Avon Orthopaedic Centre, Southniead Hospital, Bristol BS8 5NB. UK

Although kneeling is a crucial function of the knee, there is a lack of information on kneeling ability in the elderly. The kneeling ability in a group of individuals aged over 60 years (n=96) without any evidence of arthrifis was investigated. The range of motion of the knee joint and the ability to kneel in a chair at 90° and on the floor at 90° and 120° were assessed. Comparisons were made to values obtained from groups of patients who had undergone unicompartmental knee replacement (UKR; n=45). total knee replacement (TKR; n=36) or patellofemoral replacement (PFR; n=28). Normal individuals had an average range of modon of 135° which was significantly greater than UKR and PFR groups which were both 120". The TKR had the lowest range of motion with an aver­age of 102", significantly lower than all other groups. Although 9% and 17% of normal individuals were unable to kneel at 90" in a chair and on the floor respectively, the proportion able to do so in both cases was significantly greater than the PFR group. Around half or less of patients in the surgical groups were able to kneel on the floor at 120° which was significantly less than the 83% of normal indi­viduals able to do so. The data demonstrate a wide disparity between the kneeling ability of normal individuals and knee arthroplasty patients that wi l l need to be addres.sed as patients increasingly demand greater knee func­tion.

T H E G E O M E T R Y O F T H E P A T E L L O F E M O R A L J O I N T

Iranpour, F; Cobb, J; Amis, AA Imperial College London

We have used CT to describe the geometry of the patellofemoral joint and its relationship to the tibiofemoral joint.

33 CT scans of patients without patellofemoral disease were per­formed. 3D images were reconstructed and measured using com­puter software. The flexion axis of the tibiofemoral joint was found as the line connecting the centres of the spheres fitted to posterior femoral condyles. The deepest points on the trochlear groove can be fitted to a circle with radius of 23mm (stdev 4mm) and an rms of 0.3mm. This cen­tre is offset by 21nim (stdev 3mm) at an angle of 68" (stdev 8") from the line connecdng the midpoint between the centres of the femoral condyles and a point in the piriform fossa. On either side of this line, the articular surface of the trochlea can be fitted to spheres of radius 30mm (stdev 6mm) laterally and 27mm (stdev 5mm) and an rms of 0.4mm medially. The centres of the cir­cle and the two spheres fall on a line with an rms of 1.1mm. The anterior and proximal patellar planes could be described as flat surfaces (rms of 0.4 and 0.3mm). The median ridge could be described as a straight line (rms of 0.2mm). The angle between planes was 112° (stdev 5°); the average angle between the proximal plane and the line on the medial ridge was 62" (stdev4"). The length, width and thickness of die patellae were measured at

27

34.2nmi +/-4Tnm, 44.8mm +/- 4.8mm and 22.4 mm+/- 2.3 mm (table). This invesugation has allowed us to characterise the patello-femoral joint geometry which may help identify and explain the aedology of patello-femoral pathologies. It may have implications for the design of patello-femoral replacements and the rules governing their posi­tion.

NAVIGATION IN T O T A L K N E E A R T H R O P L A S T Y : D O E S I N A C C U R A C Y IN R E G I S T R A T I O N L E A D T O M A L A L I G M E N T ?

P K Jaiswal, A Bayan Joint Reconstruction Unit. Royal National Orthopaedic Hospital, Stanmore, United Kingdom

Aims Several studies have shown that alignment error of greater than 3 degrees resuUs in rapid failure and less satisfactory outcomes after total knee arthroplasty (TKA) . We sought to determine the effects of inaccurate registration of landmarks on the definitive cuts of the tibia and femur and overall mechanical alignment of the limb in a computer assisted total knee replacement model. Methods A knee model was constructed using a constrained hip articulation and a non-rotating hinged knee prosthesis. Correct registrafion points and vectors were marked by a single observer on 7 occasions to determine intra-observer error. Alterations in the registration points by 5mm and lOmm were then performed with respect to the centre of knee, AP axis, and the centre of the ankle. The effect of a single point error and addidve effects of multiple registration errors were then analysed. Results There was no significant intra-observer error in model registration (p = 0.035). The results are summarised in the table below.

Distal femoral Tibial cut cut effects effects

Centre of Knee

AP Axis Centre of Ankle

AP Axis

5 mm medial Translation

0.5° Varus

No effect 0.5° Varus

No effect

10mm medial Translation

r Varus

0.5° Valgus

1.5° Varus

0.5°

5mm lateral Transladon

0.5° Valgus

No effect

10mm lateral translation

1.5° valgus Error

In addition, a 5mm lateral iransladon in the centre of the knee as well the centre of the ankle resulted in I ° varus cut of the femur and a 0.5° varus tibial cut, with no effect on tibial slope.

Conclusions The results suggest small errors in regislradon (single or combined) do not have a significant effect with respect to alignment in com­puter assisted T K A and the computer safeguards against greater errors.

" I N F L U E N C E O F P A T E L L A R H E I G H T O N O U T C O M E A F T E R M E D I A L O P E N I N G W E D G E H I G H T I B I A L O S T E O T O M Y "

Jaiswal PK, Chhaya NC, Cannon SR, Briggs TWR, Carrington RWJ, Skinner JAM Joint Reconstruction Unit. Royal National Orthopaedic Hospital. Stanmore UK

A I M : To assess whether clinical and functional outcomes after opening wedge high nbial osteotomy (HTO) are affected by changes in patellar height rafio. I N T R O D U C T I O N : Isolated unicompartmental osteoarthritis of the medial tibio-femoral joint can be treated with opening wedge HTO. There is reported incidence of patellar baja as a result of this procedure and the impli­cations for long-term funcfional outcome remain unclear. M E T H O D : We have a single-institution cohort of patients who have undergone opening-wedge HTO for varus malalignment. We undertook a ret-rospecnve clinical and radiographic review. Patients had clinical assessment of functional outcome using validated scoring systems. Radiographs were evaluated using Blackbume-Peel (BP) and Insall-SalvaU (IS) indices. R E S U L T S : We reviewed 55 knees (51 patients: 34 men and 17 women; mean age, 44.2years; range 34-58years) followed up for a minimum 12 months (range, 12-62months). Modified Cincinnati scores were 94.5% excellent (52/55) and 5.5% good (3/55) at 1 year, whilst at last follow-up they were 87.2% excellent (48/55). 9 .1% good (5/55) and 3.6% fair (2/55). There was a significant improvement in mean American Knee Society score at 1 year and maintained at last fol­low-up (p<0.05). Radiographic assessment revealed a significant decrease in mean patellar height rado as reflected by the BP index (mean reduction 15.3%, range 7.4-28.2%). whilst the IS index did not alter significandy. C O N C L U S I O N : Medial opening wedge tibial osteotomy results in patellar infera, but successful clinical and functional outcomes have been demonstrat­ed. The fact there is inconsistency between the two indices assess­ing patellar height rado reflects the inherent variability in the tech­niques employed. Distalisadon of the tibial tubercle w i l l mean the IS raUo remains unaffected, whilst the BP index more accurately

demonstrates the lowering of patella reladve to the joint line. However there may be other factors which are not immediately appreciated, such as changes in the tibial inclination or antero-pos-terior transladon.

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

CAJakaraddi, S Metikala, J S Davidson, A JA Santini, Lower Limb Arthroplasty Unit Royal Liverpool and Broadgreen University Hospitals NHS Trust. Liverpool, UK.

A I M To assess the validity of International Prostate Symptom Score (IPSS) and incidence of catheterisation in patients undergoing joint replacements. M E T H O D S AND R E S U L T S We assessed 302 panents admitted for total hip or total knee replace­ments (THR or TKR) between October 2005 and March 2006. Pre-operatively, patients were scored by the IPSS (0-35) for severity of their urinary symptoms. Padents were categorised into three symp­tom groups (mild, moderate and severe based on scores of 0-7, 8-18 and >18 respectively) and four age groups (<50 years, 51-60 years, 61-70 years and > 70 years). A l l pafients with post-op urinary reten­tion were catheterised per urethra. R E S U L T S There were 172 female (THR-91, TKR-81) and 130 male padents (THR-60, TKR-70).The average IPSS for males and females in non-catheterised patients were 10 and 9.7 respectively whereas in catheterised padents were 21.8 and 20 respectively. 16 males and 10 females were catheterised post-operatively. 87.5% of calheterised males had IPSS >18 and 75% were over 70 with IPSS > 18. Ninety percent of calheterised females had IPSS > 18 and 50% were over 70 with IPSS >l8.There was stadstically significant associadon between high IPSS (>18) and catheterisation risk in both males and females (Chi square lest- p s 0.001 and ps 0.005 respectively) and between males over 70 years of age and catheterisation risk (psO.OOl). C O N C L U S I O N IPSS is a widely accepted, simple and easy lo use tool lo predict patients at risk of post-op catheterisation. It is a simple pre-assess-ment tool even in female patients. Pafients with IPSS >18 and males > 70 years are most at risk of post-op relendon.

IS C O M P U T E R A S S I S T E D N A V I G A T I O N I N K N E E R E P L A C E M E N T O F A D V A N T A G E IN O B E S E P A T I E N T S ?

Y Kamat, D Matthews, M Changulani, Y Kalairajah, R Field, A Adhikari. Orthopaedic. Research Unit. The South West London Elective Orthopaedic Centre, Epsom, Surrey. UK.

Introduction: Obesity [Body Mass Index (BMI) >30] is seen in a growing per­centage of patients seeking joint replacement surgery. Recent stud­ies have shown no clear influence of obesity on the five-year, cl ini­cal outcome of total knee replacement; except for the morbidly obese ( B M I > 40). Computer navigafion has shown improved con­sistency of prosthetic component alignment. However, this aid does significanfiy increase operation time. Aims: 1. To compare tourniquet times of standard and computer assist­

ed total knee arthroplasty in padents with B M I more than 30 2. To evaluate the change in this variable as a surgeon gained

experience over a three year period. Methods and Results: A retrospective analysis of 82, obese, total knee replacements per­formed by a single surgeon, at a dedicated arthroplasty centre, was undertaken. Convenrional knee replacement instrumentadon (Plus Orthopaedics, UK) was used in 42 cases and computer assisted nav­igation (Galileo- Plus Orthopaedics) in 39 cases. The pafients were divided into three equal sized groups ( 1 , 2 & 3), in chronological order. Each group comprised fourteen knees undertaken using stan­dard surgical technique and thirteen knees using computer assisted navigadon. Group I had average tourniquet dmes of 95.69 and 111.67 minutes in the standard and computer assisted groups respecdvely (p 0.01). Group 2 tourniquet times were 80.75 and 92.33 minutes (p 0.05). Group 3 tourniquet times were 84.5 and 87.5 minutes; these were nol significantly different. Conclusions: As the surgeon acquired experience of computer assisted naviga­tion, his tourniquet dmes decreased and by the end of our study period, there was no longer any difference between the tourniquet dmes for convendonal and computer assisted knee replacement in this subgroup of obese patients. We hypodiesise that in obese patients, computer assisted navigadon helps the surgeon to over­come j i g alignment uncertainty and thus improves accuracy of com­ponent alignment without any significant time penalty.

H O W A C C U R A T E A R E L O C K A B L E O R T H O T I C K N E E B R A C E S AND W H A T A R E T H E I M P L I C A T I O N S O F I N A C C U R A C I E S ? - AN O B J E C T I V E G A I T A N A L Y S I S S T U D Y

W S Khan, R K Jones, L Nokes, D S Johnson Centre for Rehabilitation and Human Performance Research, University of Salford, Manchester. M6 6PU

I N T R O D U C T I O N : There has been an increasing use of orthotic knee braces in the management of knee injuries. To ensure the bio­

mechanics of the knee are not adversely affected, it is important thai orthotic knee braces accurately provide the desired angle of immo­bilisation. The objective of our study was lo measure the actual knee flexion angles for a lockable orthotic knee brace, and measure the resuldng knee flexion moment. M A T E R I A L S - A N D M E T H O D S : Eight healthy male volunteers participated in the study looking at six different types of knee immo­bilisation: locked in 0, 10, 20, 30 degrees of knee flexion, with the brace unlocked, and without a brace. Force and 3-dimensional motion data were collected using a single Kistler force plate and an eight-camera Qualisys ProReflex motion analysis system. R E S U L T S : The kinematic knee flexion angles were significantly different when compared with the angles sel at the orthotic knee brace for 0 degrees (p^O.OOl) and 10 degrees (p=0.011). The kine-madc knee flexion angle when no brace was used was significantly different from die angle for the unlocked orthotic knee brace (p= 0.003). The knee flexion moment was direcdy proportional to the knee flexion angle. There was a statistically significant difference between the knee flexion moment for the six types of immobilisa­tion {p<0.001). D I S C U S S I O N : The knee flexion angles measured using the kine­matic data did not always correspond with the angle set at the orthodc knee brace. These findings highlight inadequacies in the design of lockable orthotic knee braces, especially at low flexion angles of 0 and 10 degrees. The resuUing higher actual knee flexion angles were associated with greater knee flexion moments and joint reaction forces at the tibiofemoral and patellofemoral joints. This can, at best result in increased energy expenditure and decreased agility, and at worse polendally augment injuries to the knee.

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

S.K. Pai, A.G. MacEachem South Devon Healthcare NHS Trust. Torquay.

Aim of Study: To assess the efficacy of Computerised Strain Gauge Plethysmography (CSGP) to screen for proximal Deep Venous Thrombosis (DVT) following Total Knee Replacement (TKR). Introduction : CSGP is a non invasive, bedside screening tool, used lo detect the presence of proximal lower limb DVT. CSGP uses a low pressure thigh cuff to first occlude venous outflow. When the cuff is released the device is used to measure changes in calf dimen­sions (by means of strain gauges tied around a standardised point of the calf of the patient's operated limb) thereby giving a measure of venous outflow. Obstrucdon to outflow (producing a posidve resuli with the device) is seen with occlusion of proximal veins. Patients & Methods : A retrospective analysis of 184 consecutive pafients who had undergone primary TKR was performed. Foot pumps were used for ihrombophytaxis during the erioperative peri­od. On the fifth post operative day all patients were screened for proximal DVT using CSGP. Those with a negadve result who were ambulating safely were discharged. Those with a positive test had further imaging to confirm or refute the diagnosis of proximal DVT in the operated limb. The patients' medical notes were scrufini.sed for evidence of re attendances and evidence of whether proximal D V T was diagnosed following discharge from the ward. Results : The negative predictive value of CSGP was found to be 99%. The sensitivity of CSGP for detecdng proximal DVT was 83 %. The specificity was found to be 69%. The false posidve rate was 92%.

Conclusion: CSGP allows the safe and prompt discharge of TKR padents who testnegative with CSGP with some degree of confi­dence. Padents who test posidve with CSGP however require fur­ther imaging to select out those individuals who have cfinically sig­nificant proximal D V T meriting full anticoagulation post operative-

ly.

C U R R E N T A C L P R A C T I C E S IN T H E U K : A P O S T A L S U R V E Y O F B A S K M E M B E R S

N Patel, A Chandratreya, G Radcliffe, S Bollen Bradford Knee Unit, Bradford Royal Infirmary, Duckworth Lane. Bradford, West Yorkshire BD9 6RJ

Anterior Cruciate Ligament (ACL) reconstruction is performed widely across the United Kingdom by orthopaedic surgeons many of whom are members of the Bridsh Associadon for Surgery to the Knee (BASK), The choice of graft and fixadon devices varies, based on surgeon's preference, experience and patient needs. No data has been published with regards to choice of graft material or fixadon devices in primary ACL reconstruction within the United Kingdom (UK). To find out what current practice is, we undertook a postal ques-donnaire of BASK members. 62% responded. Of diese, 55% of sur­geons have been undertaking ACL reconstruction for more than 10 years. Only 39% are performing over 50 ACL reconstrucdons per year. 71 % of surgeons have read the Good Practice for A C L recon­strucdon booklet published by the British Orthopaedic Association (BOA). For the femur, the most popular devices used were metal screws (49%), rigidfix (17%), endobutton (14%), transfix (8%) and bio-screws (6%), For die dbia it was metal screws (57%), bioscrews (25%) and intrafix (14%) 16% use bone patellar tendon bone graft (BPTB), 18% use ham­strings, while 66% use either. Overall the most popular method seems to be the use of hamstrings or BPTB secured at both ends with metal interference screws without the use of a tensioner. Whether the variation alters clinical result is difficult to prove. With no nadonal registry, comparison of outcomes becomes impossible. Our survey should serve as a basefine for any future research in this area.

28

A N T E R I O R C R U C I A T E L I G A M E N T I N J U R Y - T H E PATHWAY F R O M I N J U R Y T O S U R G E R Y

A J Porteous, WMJ Kennel Avon Orthopaedic Centre, Bristol, UK

Background: 10 years ago Bollen reported that, in the UK, the diagnosis of A C L injury was made by the primary treating physician in only 9% of cases and that the mean delay from injury to diagnosis was 21 months. Aim: To assess i f accuracy and delay of diagnosis of ACL rupture, and delay to surgery, have improved with dme and with the implemen-tadon of local measures to address these issues. Methods: The records of 100 patients who had undergone A C L reconstruction by the senior author at a single NHS hospital, were reviewed to assess: date of injury, date of first presentation, initial physician's diagnosis, delay from initial presentation to correct diagnosis and date of surgery. Results: When an diagnosis was made by the primary treadng physician, it was correct in 43% of ca.ses. 19 patients had arthroscopies and 53 had M R I scans. Mean delay from injury to presentation was 3.2 months and from presentation to diagnosis wa.s 4.3 mondis (influ­enced by NHS M R I waiting times). Mean time from diagnosis to surgery was 11.3 months (reflecting the NHS waiting list during the study period). Mean time from injury to surgery was 17.3 months (range 2.3 lo 97 months). Patients referred elecdvely by their GP's had longer delays to cor­

rect diagnosis and to surgery. Patients attending A & E and referred to an Acute Knee Injury clinic were diagnosed more accurately and had shorter waits for diagnosis and surgery. Conclusion: Correct diagnosis rates and delays from injury to diagnosis have improved substantially (compared with Bollen 1996). Padenl awareness needs to be improved to decrease the delay to presenta­tion. Acute Knee Injury clinics improve speed and accuracy of diag­nosis. Decreasing NHS wails for M R I scans and surgery should fur­ther decrease delays from diagnosis to surgery in future.

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

R K Ranjith, I Seferiadis, I AC Lennox Basildon and Thurrock University Hospitals. Nethermayne. Basildon, Essex

Introduction There is little dispute that flexion and extension spaces should be rectangular and equal in a knee replacement and that rotation of the femoral component has a bearing on funcdon and outcome. However, there is dispute over what is the 'correct' rotation and how best to achieve it. Transepicondylar line, computer navigadon, 3 degrees external rotation have all been tried with a similar lack of reliability (Siston et al, JBJS A m , 2005 Oct; 87( 10):2276-80) Insall and Scuderi recommended placing a tensor in the knee in flexion and rotating the femoral cutting block so that its posterior edge is parallel to the top of the tibia (Scuderi et al, Orthop Clinc. North. America, 20:70-78. 1989) We feel the Equiflex instrumentation designed by M r Lennox w i l l reliably achieve Insall and Scuderi's recommendation and reduce the incidence of lateral relinacular release Purpose of Study: To evaluate early clinical results and lateral reti-nacular release rates using Equiflex instrumentation to do TKR Method We evaluated 209 consecudve knees done with this technique al Basildon from 4 Apr i l 0 5 - 1 9 September 06. Pre and postop American Knee Society and Oxford scores, deformity. ROM were recorded for the 152 cases with 6 week follow-up. Lateral retinacu-lar release rates and complications are presented for the entire cohort of 209 cases. Results Average inpatient stay -A.9 days (20% discharged in s3 days) i f we exclude complications. There were 31 Valgus knees, 178 varus knees with an average alignment of 5.95 (23 degree varus - 25 degree valgus). 38 uncemented knees. At 6 weeks. Knee score improved from 34.5 to 78.5, function score improved from 47.5 to 49.8, oxford score improved from 43.4 to 30.06. Average preop flexion was 105 degrees ( 65-130) and aver­age postop flexion was 98 ( 40-130) We could correct alignment and achieve our technical goals in 99% of cases A lateral rednacular release was required in only 5 out 31 valgus knees (16%) and 0 out of 178 varus knees (a total lateral release rate of 2.4%^) Complications Wound or ipsilateral skin problems - 10 (4,7%) all of which settled rapidly with antibiofics. Thromboembolic phenomena - 13 cases (6.2%) - 9DVTS. 5 PE. M U A - 3 (2.3%). Hairiine crack of tibial cortex in soft porotic bone- 3 (1.4 % ) . M l - 2 (1 postop. I at 4 weeks).CVA - 4 ( 1 postop. I at 6 weeks).Confusion - 2. GI bleed -2 .Bleeding PR, Ca Rectum - 1 . Discussion Perioperative complications probably underreported in studies widi> I year follow up. Callahan et al in their metaanalysis of liter­ature from 1966-1992 did not include delayed wound healing, wound drainage, haematoma, urinary retention etc. They found a weighted mean complication rate of 18.1 % with a mortality per year of followup of 1.5%. Studies which have specifically looked at complications have reported an average of 3.9% superficial infec-dons, 1.7% deep infections, 6.5% DVTs and 2 .1% peripheral nerve damage (9).

Our complication rates were well within published data and we could correct alignment and achieve our technical goals in 99% of cases. We required to do a lateral retinacular relea.se only in 5 val­gus knees with subluxed patellae and contracted lateral structures for an overall release rate of 2.4%.

Conclusions 1. This is a safe, effecdve and reproducible procedure with com-

plicadons comparable to published data 2. The equiflex instrumentadon does help in equalising die flex­

ion-extension gaps, improves patellar tracking and reduces the incidence of lateral retinacular relea.se

3. Design modification to include a calibrated quantifiable ten­sioner may be helpful

4. Further follow up of die same cohort would be desirable to get medium and long term results.

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

MRathinam*, A McGee, TJWSpalding. University Hospital. Coventry and Warn'ickshire NHS Trust, Coventry, UK

Aims: To assess the outcome of biological resurfacing combined with osteotomy for knee osteoarthritis (OA] in young individuals. Methods: Between January 2001 and March 2006, 25 active patients with unicompartmental OA were treated with a combina­tion of cartilage resurfacing and dbial or femoral osteotomy. The cartilage resurfacing procedure was microfracture on both surfaces in 20 patients. Matrix Autologous Chondrocyte Implantation in 3, Autologous Chondrocyte Transplantation in 1 and Meni.scal trans­plantation in 1. For limb realignment, an open wedge High Tibial Osteotomy was performed in 23 patients and Distal Femoral Osteotomy in 2 patients, using either the Puddu plate (Ardirex) or the Tomofix plate (Synthes). There were 23 male and 2 female padents with a mean age of 45 years (range 27 to 60). The median follow-up period was 22.5 months (range 6 to 60). At follow-up patients were a.ssessed radi­ographically and clinically using the knee society clinical score [KSS] and the Tegner activity scale. Results: The outcome was safisfactory in 20 patients who had improvement in pain and funcdon. The median Tegner acdvity level was 5.5 and the median KSS was 164. Poor results in five patients were due to delayed union in I . nonunion in 2 and persist­ent severe pain in 2 who subsequently underwent unicompartmen­tal or total knee replacement. Discussion and conclusion: Management of the young acdve indi­vidual with grade 4 bare bone arthritis in the knee is challenging, and arthroplasty may nol provide the ideal solution. Our series has shown that combining opening wedge osteotomy with cartilage repair results in improvement in a high proportion of padents. Such salvage surgery or "biological resurfacing' may therefore have a place in the management of active young patients with bare bone osteoarlhrids.

IS T H E Q U A D R I C E P S S P A R I N G A P P R O A C H P O S S I B L E IN A L L T O T A L K N E E A R T H R O P L A S T Y P A T I E N T S ?

VI Roberts, PKR Mereddy S Hakkalamani. NJ Donnachie Arrow Park Hospital. Wirral

I N T R O D U C T I O N The technique of quadriceps sparing knee arthroplasty involves a pure capsular incision, without violation of the extensor mecha­nism. This capsular incision should be placed distal to Vastus Medialis Obliquus (VMO) . It is well known that the termination of V M O is variable and may make the quadriceps sparing approach difficult. We initiated this study based on the hypothesis that the quadriceps sparing approach is not possible in all patients undergo­ing total knee arthroplasty. M E T H O D S We examined the axial M R I images of the knee joint performed over a period of 12 months at our in.stitute. A total of 198 M R I scans were analysed between two observers. To calculate the patellar height the apex of the patella was consid­ered as 'Reference Slice V. The consecutive slices were followed dislally lo the last slice in which the patella was visible. From 'Reference Slice 1' V M O muscle was followed distally to the slice in which the muscle was last visible. We calculated the patella height and V M O muscle length as the product of the number of M R I slices and M R I slice thickness. R E S U L T S Of the 134 patients aged less dian 50 years. 68 patients (50.7%) had a V M O that terminated in the proximal half of the patella. Out of 64 patients aged 50 years or older, 51 patients (79.7%) had a V M O that terminated in the proximal half of the patella. A statistically significant inverse relationship was noted between the level of insertion of V M O and the age of die padent. D I S C U S S I O N Our results wilt have an implication on the use of the quadriceps sparing approach, as they highlight another possible limitation of this approach. Padents need to be warned before the T K A that the quadriceps sparing approach may not be possible in all, especially i f they are younger

B I L A T E R A L S I M U L T A N E O U S T W O S U R G E O N K N E E R E P L A C E M E N T - E F F I C I E N T , S A F E AND E D U C A T I O N A L

J E Tomlinson, E Hannon, S W Sturdee, N J London Harrogate District Hospital NHS Foundation Trust. Lancaster Park

Road, Harrogate. North Yorkshire. HG2 7SX.

Aim: To assess the safety and efficiency of bilateral simultaneous total knee replacement surgery using a retrospective notes ba.sed review.

Mediods: We performed a retrospective case note review of a series of 112 bilateral simultaneous knee replacements performed over a five year period in a district general hospital. (224 joints - 142 total joints. 82 unicompartmental). The procedures were all performed by a consultant knee surgeon operadng alongside a knee fellow. Patients were only offered bilateral procedures i f in ASA class I / I I . (any borderline candidates were referred for anaesthetic assess­ment). Results were obtained for a number of parameters to assess the safety of this technique by measuring rates of both minor and major complications. Data was also gathered to as.sess the efficien­cy of the technique - measuring both tourniquet dmes and length of stay. Results: Over the period of five years there were no deaths or major complicadons reported. There were diree ca.ses of DVT (2.6%) and one case of PE (0.9%). There were three cases of superficial wound infection (2.6%), one of joint infection (0.9%) and one of aseptic loosening (0.9%). Average tourniquet time was 76 minutes with an average length of stay of 8,6 nights. Conclusion: Bilateral simultaneous knee replacement is a valuable technique which offers the patient a single operation and recovery period, and return to normal life. In addidon, the complication rates are acceptable, unlike several studies looking at bilateral procedures performed back to back. It also offers an excellent training opportu­nity for the 2"*^ surgeon to operate under close supervision. In an increasingly time pressured health service we believe this procedure is an efficient and safe technique when used in suitable patients.

P R E D I C T I N G A N T E R I O R C R U C U T E L I G A M E N T I N T E G R I T Y IN P A T I E N T S W I T H O S T E O A R T H R I T I S

AJ Trompeter, K Gill, R Mobasheri, SNAgarwala, MAC Appleton, SH Palmer Department of Trauma and Orthopaedic Surgery, Worthing Hospital, We.st Sussex.

Aims: To determine the difference between macroscopic and microscopic appearances of the anterior cruciate ligament (ACL) in patients with osteoarthritis undergoing total knee replacement. Methods: Patients admitted for routine total knee replacement (TKR) for osteoarthritis were assessed. The integrity of the ACL was noted as normal, moderately damaged (fissured) or complete rupture on a macroscopic level at the dme of surgery. The ACL was sacrificed as a normal step in the operadon and sent for histological analysis. The macroscopic and microscopic findings of ACL histology were com­pared using a common grading system (Grade 1 = normal. Grade 2 = moderately diseased. Grade 3 = severely diseased). Results: The sample contained 48 patients. 17 male and 31 female, age range 55-87 years (mean 73). After exclusions, at surgery 7 ACL ruptures and 8 moderately diseased ligaments (defined by the presence of visible Assuring) were found despite negadve pivot shift tests pre-operatively. Of the 30 ACL's that were found to be macroscopically normal, 22 of these (73%) were microscopically moderately or severely diseased. Conclusion: We have found that a macroscopically normal ACL does not neces­sarily equate to microscopic integrity in the presence of osteoarthri­tis. This is an important consideradon given the current trend towards unicompartmental knee replacement and highlights the possible need for invesdgafion with appropriate imaging (MRI) and arthroscopy prior to this specific surgery.

S O F T T I S S U E R E L E A S E AND R A N G E O F M O V E M E N T 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

S Yousufuddin, D Chesney, M Van Der Unden, R Nation. Royal Infirmary of Edinburgh. Little France, Edinburgh Scotland

Objective To evaluate the impact of soft dssue release on range of movement following total knee replacement. Methods Sixty four patients underwent next-gen (Zimmer) posterior stabilis­ing total knee replacement through a medial arthrotomy. Range of acdve movement was measured preoperadvely, and maximal flex­ion was measured after implantation, using the drop test while the patient was under anaesthetic. Soft tissue release was graded from 1 to 5. depending on the structures released. Range of movement (ROM) was correlated with extent of soft ds­sue release, to see i f release had any impact on increase in range of movement. Results A l l patients had an improvement in range of movement following surgery. Post operative range of movement correlated strongly with preoperative ROM. Patients requiring extensive releases tended to have less preopera­tive ROM, but the gain was independent of medial release. Those requiring extensive posterior release had poorer preoperadve move­ment, and significantly less improvement. In those requiring an extensive medial release, a posterior release improved gain in ROM. Conclusion Postoperative ROM following TKR is independent of extent of medial release. In pafients requiring extensive medial release, a pos­terior relea.se improves gain in movement.

29

BRIT ISH A S S O C I A T I O N F O R S U R G E R Y O F T H E K N E E at the Royal Col lege of S u r g e o n s

President: N J Fiddian FRCS Honorary Secretary: T J Wilton FRCS Treasurer: C N A Esler FRCS Secretariat: IVIrs Hazel Choules, Britisli Orthopaedic Association, Royal College of Surgeons

35-43 Lincoln's Inn Fields, London WC2A 3PN Tel: 020 7406 1763 Fax: 020 7831 2676 Website: www.baskonline.com

B A S K / D E P U Y F E L L O W S H I P A N N O U N C E M E N T

The British Association for Surgery of tine 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 2007.

B A S K / D E P U Y R E S E A R C H F E L L O W S H I P

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, Ml, 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 2007

30

m • BRITISH ASSOCIATION FOR SURGERY OF THE KNEE

at the Royal Col lege of S u r g e o n s

President:: N J Fiddian, FRCS Honorary Secretary: T J Wilton FRCS Treasurer: C N A Esler MA, FRCS

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 Website: www.baskonline.com

BASK/SMITH & N E P H E W T R A V E L L I N G F E L L O W S H I P

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 2007

31

Dear Colleague,

Re: The Journal of Bone and Joint Surgery

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

At the Joumal 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 Joumal.

In an age of specialisation, I appreciate the importance of speciality joumals. 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.

I f 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

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32

B A S K 2007 Annual Meeting Odyssey Arena W5 / Level 4 ^XSLAII^

Stand 01 - Elsevier Knee Joumal Stand 02 - T R B Chemedica UK Ltd Stand 03 - Wright Medical UK Ltd Stand 04 - Biomet Stand 05 - Conmed Linvatech UK Stand 06 - Finsbury Orthopaedics Ltd

Stand 07 - Exactech UK Ltd Stand 08 - Zimmer Ltd Stand 09 - Plus Orthopedics Stand 1 0 - B r a i n L A 8 U K L t d Stand 11 - Karl Storz Endoscopy (UK) Ltd Stand 12 - Genzyme Therapeutics

Stand 13-ArthrBxLtd Stand 14 - Stryker UK Stand 15 -Heraeus Medical Stand 16 - Mathys Orthopaedics Ltd Stand 17 - Ferring Pharmaceuticals Ltd Stand 18 - ArthoCare UK Ltd (Sports Medicine Division)

Stand 19 - Joint Replacement instrumentation Ltd Stand 20 - Smith & Nephew Stand 21 - DePuy UK & DePuy MItek

T e a , coffee and lunch will be served in the a rea marked by the black boxes

33

B A S K 2007 Annual Meeting Odyssey Arena Concourse Area Outside EXCLAIM Main Exhibition Hall W5 / Level 4 ™

n n n a r

LIFT a •

LIFT

Stand 22 - Ossur UK Ltd Stand 23 - Praxim Medivision Stand 24 - Corin Group PLC Stand 25 - neurotech® Stand 26 - Confonnis

Notes:

35

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

B A S K Executive Committee 2007

Mr Nick Fiddian - President

Mr Tim Wilton - Honorary Secretary

Mr Colin Esler - Honorary Treasurer

Mr Phil Hirst

Mr Simon Donell

Mr Andy Williams

Mr Richard Parkinson

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

Hazel Choules - Senior Administrator BOA Specialist Societies

Email: h.choules@boa.ac.uk

Telephone: 020 7406 1763

Website: www.baskonline.com

This programme has been sponsored by DePuy U K

• D e P U v a^ufcwn«*<^pfc»MeH company

This programme has been sponsored byi

t. ^uhv,wi'..<^-dv,'company

«h Association of Surgery of the Knee 2007 Spring Meeting