The incidence of secondary pathology after anterior cruciate ligament rupture in 5086 patients requiring ligament reconstruction.

We reviewed 5086 patients with a mean age of 30 years (9 to 69) undergoing primary reconstruction of the anterior cruciate ligament (ACL) in order to determine the incidence of secondary pathology with respect to the time between injury and reconstruction. There was an increasing incidence of medial meniscal tears and chondral damage, but not lateral meniscal tears, with increasing intervals before surgery. The chances of requiring medial meniscal surgery was increased by a factor of two if ACL reconstruction was delayed more than five months, and increased by a factor of six if surgery was delayed by > 12 months. The effect of delaying surgery on medial meniscal injury was also pronounced in the patients aged < 17 years, where a delay of five to 12 months doubled the odds of medial meniscal surgery (odds ratio (OR) 2.0, p = 0.001) and a delay of > 12 months quadrupled the odds (OR 4.3, p = 0.001). Increasing age was associated with a greater odds of chondral damage (OR 4.6, p = 0.001) and medial meniscal injury (OR 2.9, p = 0.001), but not lateral meniscal injury. The gender split (3251 men, 1835 women) revealed that males had a greater incidence of both lateral (34% (n = 1114) vs 20% (n = 364), p = 0.001) and medial meniscal tears (28% (n = 924) vs 25% (n = 457), p = 0.006), but not chondral damage (35% (n = 1152) vs 36% (n = 665), p = 0.565). We conclude that ideally, and particularly in younger patients, ACL reconstruction should not be delayed more than five months from injury.

A new technique of endoprosthetic replacement for osteosarcoma of proximal femur with intra-articular extension.

INTRODUCTION: Osteosarcoma is the most common primary malignant tumour of bone and commonly involved sites are the distal femur, proximal tibia, and humerus. Osteosarcoma of proximal femur usually arises at the metaphysis and articular cartilage acts as a relative barrier to tumour spread, with extension into the hip joint being extremely rare. PRESENTATION OF CASE: A previously fit and well sixteen-year-old male presented with a 2month history of right hip pain and a limp. Plain radiographs and magnetic resonance imaging (MRI) showed an expansile lesion in the right femoral neck, extending 16cm distally from the proximal femoral articular surface through the intertrochanteric region into the upper right femoral shaft. There was also clear evidence of intra-articular extension into the acetabulum. DISCUSSION: Endoprosthetic replacement following resection is a good treatment option for proximal femoral tumours due to the low complication rate and achievement of good postoperative function. However, treatment of a proximal femoral lesion with intra-articular involvement by prosthetic reconstruction is challenging. We report a patient who presented with osteosarcoma of the proximal femur extending into the hip joint and describe the technique of en-bloc extra-articular resection of the acetabulum and proximal femur with reconstruction using a custom made prosthesis. CONCLUSION: We conclude that extra-articular resection and endoprosthetic reconstruction using a coned hemi-pelvic implant with fluted stem and a modular femoral implant is a useful treatment option in the management of a proximal femoral lesion involving the hip-joint. It allows adequate tumour clearance and stable reconstruction for rapid post-operative recovery with early mobilisation.

The outcome of extra-abdominal fibromatosis treated at a tertiary referral centre.

PURPOSE: To review the outcomes of patients with extra-abdominal fibromatosis treated at a tertiary referral centre. METHODS: A retrospective review of a series of 72 patients with fibromatosis treated at the Royal National Orthopaedic Hospital (RNOH) between 1980 and 2009, with a median follow up of 4 years (1-17 years). RESULTS: Forty patients were primary referrals, and 32 more had operations at the referring hospital. Five were treated non-operatively; 48 patients were treated by operation alone and 19 patients underwent surgery supplemented by adjuvant therapy. Recurrence was seen in 24 of the operation alone group and 10 in the operation and adjuvant therapy group. The rate of recurrence was lower with complete excision. However, complete excision was impossible in some cases because of extension into the chest or spinal canal, or involvement with the axial vessels and lumbosacral or brachial plexus. CONCLUSION: We suggest that operative excision should seek to preserve function and that supplementary adjuvant therapy may reduce the risk of recurrence, although excision margin appears to be the most important factor. The aggressive, infiltrative behaviour of deep fibromatoses and the associated genetic mutations identified, clearly distinguish them from the superficial fibromatoses and makes their treatment more difficult and dangerous, especially where vital structures are involved.

Variation of the distal metatarsal articular angle with axial rotation and inclination of the first metatarsal.

BACKGROUND: The distal metatarsal articular angle (DMAA) is a radiographic measure of the orientation of the first metatarsal articular surface. There is debate with regards to the accuracy, reproducibility, and validity of measurement of the DMAA in the literature. This study aimed to test the validity of the measurement of the DMAA from standard radiographs, to explore the trigonometric relationship of the first metatarsal rotation and the DMAA, and to assess interobserver reliability. METHODS: Thirty-four separate dry cadaver first metatarsal bones were mounted onto a customized light-box-protractor, allowing controlled incremental changes in rotation and inclination. A series of 39 digital photographs were taken of each metatarsal in 5-degree increments of rotation between 30 degrees supination and 30 degrees pronation at 10, 20 and 30 degrees of inclination. Three reviewers performed blinded DMAA measurements from each photographic image; the data were collated for statistical analysis. The data were analysed using a mixed effects linear model comparing the DMAA with rotation of the first metatarsal. RESULTS: A strong statistically significant trend of increasing score with increasing pronation of the metatarsal was observed, the relationship was approximately linear. There was a strong effect of inclination, but the strength of this varied with rotation and was amplified at higher inclinations. Interobserver error was noted in line with other studies, but even allowing for this interobserver error, the linear relationship was maintained. CONCLUSIONS: This study showed that the DMAA varies significantly in a linear pattern with axial rotation of the first metatarsal. Inclination of the first metatarsal also affects the magnitude of the angle. This study does not refute the DMAA as an entity but does confirm the inaccuracy of extrapolating the DMAA from plain anteroposterior radiographs.

Arthroscopic assessment of the syndesmosis following ankle fracture.

A Maisonneuve ankle fracture without convincing evidence of syndesmotic injury on plain radiographs is described. Stress views and computerised tomography (CT) were also negative. A high index of suspicion led to ankle arthroscopy, which revealed a diastasis, and also an osteochondral fragment. This was treated with two percutaneous diastasis screws and removal of the osteochondral fragment. This case suggests that ankle arthroscopy should be considered as part of the management of syndesmotic injury where conventional imaging techniques fail to show syndesmotic disruption.