Patellar complications in single versus double tunnel medial patellofemoral ligament reconstruction

PURPOSE

Hamstring graft fixation on the patellar side during medial patellofemoral ligament (MPFL) reconstruction is usually with transosseous tunnels and can frequently lead to further problems. The aim of our study was to compare and analyse patellar complications in single patellar tunnel versus double tunnel hamstring graft fixation.

METHODS

Twenty-nine knees with MPFL reconstructions (group S) in which the hamstring tendon graft was transfixed using a suspensory fixation method in a single tunnel drilled across the patella were analysed in comparison with 29 knees (group D) with interference fixation of the graft through two tunnels drilled up to a predetermined depth in the patella. Primary outcome measured was any patellar complication like anterior knee pain and patella fracture. Secondary outcomes assessed were future functional instability and failure of reconstruction.

RESULTS

Anterior knee pain was noted in six patients in group S, of which three patients had removal of the irritating metalwork on the patella. In all, nine surgical interventions were needed in six patients in this group. Three patients in group D complained of knee pain, but no one in this group needed any further surgical interventions ( p value 0.02). Symptomatic instability requiring revision surgery or realignment surgery was required in two patients in the group S and none in group D. No patellar fractures were seen in either group.

CONCLUSION

Our study showed increasing problems with single tunnel patellar fixation, with more reoperation and failure rates compared to double tunnel fixation. The evidence supports the move towards anatomical double bundle MPFL reconstructions.

The effect of waiting times from general practitioner referral to MRI or orthopaedic consultation for the knee on patient-based outcomes

OBJECTIVES

The purpose of this study was to test for the effect of waiting time from general practitioner (GP) referral to MRI or to orthopaedic consultation on outcomes of patients with knee problems, and to test whether any characteristics of trial participants predicted waiting time to MRI or orthopaedics.

METHODS

We undertook secondary analyses of data on 553 participants from a randomised trial who were recruited from 163 general practices during November 2002 to October 2004.

RESULTS

Of the patients allocated to MRI, 263 (94%) had an MRI, and of those referred to orthopaedics, 236 (86%) had an orthopaedic consultation. The median (interquartile range) waiting time in days from randomisation to MRI was 41.0 (21.0-71.0) and to orthopaedic appointment was 78.5 (54.5-167.5). Waiting time was found to have no significant effect on patient outcome for both the Short Form 36-item (SF-36) physical functioning score (p=0.570) and the Knee Quality of Life 26-item (KQoL-26) physical functioning score (p=0.268). There was weak evidence that males waited less time for their MRI (p=0.049) and older patients waited longer for their orthopaedic referral (p=0.049). For patients who resided in the catchment areas of some centres there were significantly longer waiting times for both MRI and orthopaedic appointment.

CONCLUSION

Where patients reside is a strong predictor of waiting time for access to services such as MRI or orthopaedics. There is no evidence to suggest, however, that this has a significant effect on physical well-being in the short term for patients with knee problems.

Impingement fracture of the anteromedial tibial margin: a radiographic sign of combined posterolateral complex and posterior cruciate ligament disruption

Marginal fractures of the tibial plateau are associated with a high incidence of soft tissue injuries to the stabilising structures of the knee joint. Injuries to the anterior cruciate ligament are associated with the Segond fracture and impingement fractures of the posteromedial tibial plateau. Recognition of these fractures aids diagnosis of these injuries. Marginal fractures of the tibial plateau associated with posterior cruciate ligament injuries are less common, though recently a "reverse" Segond fracture has been recognised. We describe a fracture of the anteromedial tibial plateau associated with complete disruption of the posterior cruciate ligament and posterolateral complex.

Kneeling ability after total knee arthroplasty. Perception and reality

Kneeling as one of the knee's capabilities required for many activities of daily living has not been examined in detail after total knee replacement. The purpose of the present study was to question the patients' ability to kneel and their perception of factors affecting this ability after total knee arthroplasty, and to objectively assess their kneeling ability. Seventy patients with 100 total knee arthroplasties were asked to comment on their ability to kneel. Thirty-one patients with 44 knees said they could kneel easily, 29 patients with 41 knees said they were able to kneel but avoided doing so, and 10 patients with 15 knees said they were unable to kneel. Regarding observed kneeling ability, all patients were able to kneel under supervision: 56 patients with 82 knees knelt easily and got up easily from this position, 11 patients with 14 knees showed slight difficulties in kneeling or in getting up, and three patients with four knees had marked difficulties with kneeling. The patients' perceived ability to kneel after total knee arthroplasty was less than their observed ability. Fear of harming the prosthesis and lack of information prevented kneeling in 49% of the patients (27 of 56 knees) with perceived inability to kneel. Of those patients with observed difficulty in kneeling, scar pain and back related problems seemed to be major factors in limiting the kneeling ability. Kneeling, as an important function of the knee, should be given additional consideration in relation to the functional results of total knee arthroplasty. Patients should be counseled regarding factors affecting future ability to kneel.

Synovial cyst of the proximal tibiofibular joint with peroneal nerve compression after total knee arthroplasty

Synovial or ganglion cysts of the proximal tibiofibular joint are less common than synovial cysts of the knee joint but may present in a similar manner and may be difficult to diagnose clinically. Although synovial cysts arising from the knee joint after prosthetic arthroplasty have already been described, we report a case in which a lateral knee mass compressing the peroneal nerve was found to be a synovial cyst arising from the tibiofibular joint.

Horizontal pelvic osteotomies for bladder exstrophy. A preliminary report

We have treated 11 patients aged three days to 15 years with bladder exstrophy by horizontal osteotomies of the innominate bones. The operation was originally used for older patients with severe deformity or failed previous surgery but is now applied as a primary procedure in the first week of life. The osteotomies enable the complex malformations to be corrected in a single operation without turning the patient: the pubic bones can be brought together, the abdominal wall repaired and the bladder closed with reconstruction of the urethra and external genitalia. The early results have been very satisfactory in all cases with only minor complications; we felt that a preliminary report should be made, despite a mean follow-up of only seven months.

Seasonal variation in anthelmintic response by cattle to dermally applied levamisole

Four experiments in 1978-79, and 2 in 1982 designed to define the optimum dose rate of dermally applied formulations of levamisole are described. These experiments showed that the absorption of levamisole with resultant blood levels and anthelmintic activity is strongly influenced by temperature. In warm to hot conditions percutaneous absorption is rapid and high blood levels with high anthelmintic activity against Haemonchus placei, Ostertagi sp, Trichostrongylus sp, Cooperia sp, Oesophagostomum radiatum, O. venulosum and Dictyocaulus viviparus result from dose rates of 10 mg/kg or more. In cold weather the high efficacy against H. placei, Cooperia sp, and Oesophagostomum sp is unchanged, but efficacy against Ostertagia sp, T. axei and D. viviparus decreases to the extent that a mean dose rate of 20 mg/kg (range 15 to 25 mg/kg) is necessary if the anthelmintic activity of dermally applied levamisole is to match that of either parenterally or orally administered material. These anthelmintic data are supported by the levamisole blood profile which in winter months, peaks at a figure of one quarter or less of that obtained from a similar dose rate in warm conditions. The implications of this variability in action are discussed.