Anterior cruciate ligament (ACL) rupture is one of the commonest knee sport injuries. The annual incidence of the ACL injury is between 100000-200000 in the United States. Worldwide around 400000 ACL reconstructions are performed in a year. The goal of ACL reconstruction is to restore the normal knee anatomy and kinesiology. The tibial and femoral tunnel placements are of primordial importance in achieving this outcome. Other factors that influence successful reconstruction are types of grafts, surgical techniques and rehabilitation programmes. A comprehensive understanding of ACL anatomy has led to the development of newer techniques supplemented by more robust biological and mechanical concepts. In this review we are mainly focussing on the evolution of tunnel placement in ACL reconstruction, focusing on three main categories, i.e., anatomical, biological and clinical outcomes. The importance of tunnel placement in the success of ACL reconstruction is well researched. Definite clinical and functional data is lacking to establish the superiority of the single or double bundle reconstruction technique. While there is a trend towards the use of anteromedial portals for femoral tunnel placement, their clinical superiority over trans-tibial tunnels is yet to be established.

Trapezium fractures are rare injuries which should not be missed. We report a case of a 27-year-old right hand dominant man who sustained a closed vertical trapezium fracture and first carpometacarpal joint dislocation which was treated with closed reduction and percutaneous Kirschner-wire fixation, a technique familiar to all orthopaedic surgeons. Satisfactory functional outcome was achieved at final follow-up.

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This study aimed to evaluate the effect of manipulation under anaesthesia (MUA) and Kirschner wire (K-wire) fixation of displaced, paediatric distal radius fractures on residual radiological angulation, displacement, and shortening, as well as functional outcomes, including complication rates. A retrospective review was conducted of all paediatric patients undergoing MUA and K-wire fixation for an extra-articular distal radius fracture over a period of 5 years. A total of 248 patients were included in the study with a mean age of 9.9 years (3-15). Mean follow-up was 6.6 weeks (4-156). There was a statistically significant increase in median dorsal angulation (p<0.0001) between initial post-operative and follow-up radiographs at the time of K-wire removal. The number of K-wires used did not have a significant effect on dorsal angulation (p=0.9015) at time of K-wire removal, nor did the use of an above or below elbow cast (p=0.3883). Seventeen patients required a further general anaesthetic (5 revision operations, 12 removal of migrated K-wires). Eighty-seven percentage of (215 patients) of patients had normal function at follow-up post-K-wire removal. Angulation at time of K-wire removal of more than 15° was significantly associated with reduced functional outcome (p=0.0377). A total of 41 patients (17%) had complications associated with K-wire use. We conclude that though K-wire fixation is an effective technique, it does not prevent re-angulation of the fracture and is associated with a significant complication rate. Given the remodelling potential and tolerance to deformity in children, surgeons should give careful thought before utilising this technique for all displaced or angulated paediatric distal radius fractures. If used, 1 K-wire with immobilisation in a below elbow cast is sufficient in most cases.

This study has demonstrated how simple, intensive educational sessions can lead to an improvement in discharge summaries and communication with primary care.

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In our series, the incidence of MSCC due to an unknown primary was 6 %. They had similar overall outcome (neurology post-operatively, complications and survival) to those patients with MSCC from a known primary. Our experience would suggest that we need to treat these patients expeditiously with thorough evaluation and urgent treatment.

Aims The aim of this study was to determine the trajectory of recovery following fixation of tibial plateau fractures up to five-year follow-up, including simple (Schatzker I-IV) versus complex (Schatzker V-VI) fractures. Patients and Methods Patients undergoing open reduction and internal fixation (ORIF) for tibial plateau fractures were enrolled into a prospective database. Functional outcome, using the 36-Item Short Form Health Survey Physical Component Summary (SF-36 PCS), was collected at baseline, six months, one year, and five years. The trajectory of recovery for complex fractures (Schatzker V and VI) was compared with simple fractures (Schatzker I to IV). Minimal clinically important difference (MCID) was calculated between timepoints. In all, 182 patients were enrolled: 136 (74.7%) in simple and 46 (25.3%) in complex. There were 103 female patients and 79 male patients with a mean age of 45.8 years (15 to 86). Results Mean SF-36 PCS improved significantly in both groups from six to 12 months (p < 0.001) and one to five years (simple, p = 0.008; complex, p = 0.007). In both groups, the baseline scores were not reached at five years. The SF-36 PCS was significantly higher in the simple group compared with the complex group at both six months (p = 0.007) and 12 months (p = 0.01), but not at five years (p = 0.17). Between each timepoint, approximately 50% or more of the patients in each group achieved an MCID in their score change, indicating a significant clinical change in condition. The complex group had a much larger drop off in the first six months, with comparable proportions achieving MCID at the subsequent time intervals. Conclusion Tibial plateau fracture recovery was characterized overall by an initial decline in functional outcome from baseline, followed by a steep improvement from six to 12 months, and ongoing recovery up to five years. In simple patterns, patients tended to achieve a higher functional score by six months compared with the complex patterns. However, comparable functional scores between the groups achieved only at the five-year point suggest later recovery in the complex group. Function does not improve to baseline by five years in either group. This information is useful in counselling patients about the course of prospective recovery. Cite this article: Bone Joint J 2019;101-B:1009–1014.