Anterior knee symptoms after four-strand hamstring tendon anterior cruciate ligament reconstruction.

Proponents of hamstring anterior cruciate ligament (ACL) reconstruction suggest that anterior knee symptoms (AKS) may be less than following the use of bone-patella-bone autograft. Our aim was to assess the incidence of AKS in a cohort of patients who had undergone hamstring reconstructions. Forty-four of 50 consecutive patients who had undergone arthroscopically assisted four-strand gracilis/semitendinosus hamstring ACL reconstructions were reviewed at a minimum follow-up of 24 months. The frequency and severity of anterior knee pain experienced during activities of daily living, sports, prolonged sitting, stair-climbing and kneeling was recorded by means of the Shelboume and Trumper anterior knee pain questionnaire. The location of both pain and any perceived sensory change was recorded using patient-drawn diagrams. Although mild or moderate symptoms occurred in a proportion of patients, only 2% experienced significant symptoms that caused limitation with daily activity, 7% with strenuous work or sport, 12% with kneeling, 5% with stairs and none with prolonged sitting. The pain was not specifically related to the incision for tendon harvest and drilling of the tibial tunnel. Areas of sensory change over the front of the knee were identifiable in 50% of patients, and of these, 86% demonstrated sensory change in the distribution of the infragenicular branch of the saphenous nerve. Although rarely a cause of limitation of activity, AKS can be a problem after hamstring ACL reconstruction and patients should be counselled accordingly.

Sensory pathways in the spinal accessory nerve.

We obtained samples of spinal accessory nerve from patients undergoing radical surgery for tumours or nerve grafting in the neck. These were analysed by light and electron microscopy for the type of fibre. All contained fibres consistent with non-proprioceptive sensory function including pain.

Current UK opinion on thromboprophylaxis in orthopaedic surgery: its use in routine total hip and knee arthroplasty.

We surveyed all surgically qualified members of the British Orthopaedic Association as to their views on thromboprophylaxis in routine total hip and knee replacement. The response rate was 92%. In total hip replacement, 13-15% of surgeons used no method of prophylaxis at all, 18-22% did not use a mechanical method of prophylaxis, while 26% did not use a pharamacological agent; 36% believed low-dose anticoagulant thromboprophylaxis to be a medicolegal necessity while 47% disagreed with this. In total knee replacement, 18-33% of surgeons used no method of prophylaxis at all, 20-26% did not use a mechanical method of prophylaxis, while 54-58% did not use a pharmacological agent; 12 believed low-dose anticoagulant thromboprophylaxis to be a medicolegal necessity, while 64% disagreed with this. We conclude that mechanical methods remain a popular method of thromboprophylaxis and pharmacological methods, while commonly used, are not seen as a medicolegal requirement in lower limb arthroplasty and are used less often in total knee replacement.

Intra-operative monitoring of the common peroneal nerve during total knee replacement.

We present a method allowing intra-operative monitoring of the common peroneal nerve during total knee arthroplasty using a magnetic stimulator. Previous reports have shown no pre-operative method successful in selecting those patients prone to develop a post-operative palsy. The device, placed beneath the lumbar spine, stimulates the cauda equina; common peroneal nerve function is assessed via the response in extensor digitorum brevis. There is a loss of signal from the nerve with the use of a tourniquet 25 min following its application. The protocol therefore requires that a tourniquet is used at least only for fixation of the prosthetic components. The method is quick, safe, non-invasive and reproducible, and is of use both in at-risk patients and in research work.

Dislocation after hemiarthroplasty of the hip: a comparison of the dislocation rate after posterior and lateral approaches to the hip.

We compared the 3-month dislocation rate for hip hemiarthroplasties inserted via the posterior and direct lateral routes. In all, 2906 primary hemiarthroplasties, performed between 1986 and 1992 in four hospitals on a training hospital rotation, were analysed. The posterior approach was used in 1656 (57%) and the lateral in 1250 (43%). The groups were otherwise comparable. The overall dislocation rate for the posterior approach was 9.0% (149/1656), whereas that for the direct lateral approach was 3.3% (41/2150). The difference is statistically highly significant. In addition, we analysed the dislocation rate for each approach in the three broad groups of surgical trainee. For senior registrars, there was no statistical difference in the dislocation rate. However, for registrars and senior house officers, there were statistically highly significant differences in the dislocation rate for posterior and direct lateral approaches (8.4% vs 3.3% and 14.2% vs 3.6%, respectively). We conclude that, because of the high mortality associated with dislocation of a hemiarthroplasty, the posterior approach for this operation should now be abandoned, especially by surgical trainees early in their careers.

Early failure of titanium alloy femoral components: a quantitative radiological analysis of osteolytic and granulomatous change.

Shot blasted titanium alloy femoral components with a coarse finish were withdrawn from use in 1987 following reports of early component failure. We reviewed all coarse titanium femoral stems used in primary total hip arthroplasty in our institution between 1985 and 1987 and compared them to a similar stem made of vitallium which was also used over the same period. We found that, at an average of 5.2 years following implantation, over two-thirds of titanium components were associated with endosteal lysis. In many of the cases the early lytic changes were asymptomatic with significant bone loss occurring prior to presentation. We discuss our findings in relation to revision surgery. We advocate that all those with coarse stem titanium components should be positively reviewed to detect early lytic change before extensive bone destruction occurs.