The surgical care of extra-articular distal tibial fractures remains controversial. This study looks at the radiological outcomes of distal tibial fractures treated with either a direct medial or anterolateral plate, with or without plating of the fibula, to assess the outcome and complications associated with these 2 approaches. This is a retrospective review of 80 patients with distal tibial extra-articular fractures, treated with an open reduction and plating, between 2008 and 2019 at Glasgow Royal Infirmary. Case notes and x-rays were reviewed. Of those tibial fractures fixed with only a medial plate, 78% united (28/36), 5% (2/36) had a non-union and 17% (6/36) a malunion. In the group treated with a combination of medial tibial and fibular plating, the figures were; 71% (15/21), 19% (4/21) and 10% (2/21). However, in the group treated with anterolateral plating of the tibia alone, only 53% (8/15) united, with a 20% (3/15) non-union and 13% (2/15) malunion rate. Additionally in this group, there were 2 patients (13%) with loss of fracture reduction within the first two months of fracture fixation, requiring revision surgery. Interestingly, of the 8 patients treated with anterolateral tibial and fibular plating, 88% (7/8) showed full union and only one (12%) had a non-union, with no malunions is this group. It would appear that medial tibial and a combination of medial tibial and fibular plating, have superior outcomes compared to anterolateral plating. Results suggest, if anterolateral plating is done, this should be augmented by fixation of the fibular fracture as well

Abstract. Introduction. The aim of this study was to determine if elite athletes could return to professional sport after MCL or PLC reconstruction using LARS ligaments and to demonstrate the safety and efficacy of LARS by reporting sport longevity, subsequent surgeries and complications. Methods. A retrospective review of all extra-articular knee ligament reconstructions in elite athletes utilising LARS ligaments by 3 knee surgeons between January 2013 and October 2020 was undertaken. Return to play (RTP) was defined as competing at professional level or national/ international level in amateur sport. Results. Sixty-four (84.2%) MCL and 12 (15.8%) PLC reconstructions utilising LARS in elite athletes were included. 52 (68.4%) underwent concomitant cruciate(s) reconstruction. The mean age was 25.1 years (SD +/− 4.50. Most were football (35, 46.1%) or rugby players (35, 46.1%). Sixty-seven athletes (88.2%) RTP with 65 (97.0%) of these playing at the same or higher Tegner level. 56 (83.6%) and 20 (57.1%) were still playing at 2 and 5 years post-surgery. Six (7.9%) players (5 of whom RTP) required further surgery relating to the LARS / metalwork and there was one case of adverse local inflammatory reaction to the synthetic material. There was one MCL re-rupture, sustained 4 years after RTP. Conclusion. Utilising LARS in extra-articular knee ligament reconstructions allows 88.2% of athletes, with a variety of knee ligament injuries, to return to elite sport. The low morbidity rates coupled with 57% of athletes still playing 5 years post-surgery suggests the LARS is safe and effective in these cases

Introduction. To determine if elite athletes can return to professional sport after MCL or posterolateral (PLC) reconstruction using LARS ligaments. The secondary aims are to demonstrate the safety and efficacy of LARS by reporting sport longevity, subsequent surgeries, and complications. Methods. A retrospective review of all extra-articular knee ligament reconstructions, utilising a LARS synthetic ligament, by 3 sports knee surgeons between 2013 and 2020 was undertaken. All elite athletes aged over 16 years and a minimum of 2 years post reconstruction were included. No LARS were used for ACL reconstructions, and they were excluded if a LARS ligament was used for a PCL reconstruction. Return to play (RTP) was defined as competing at professional level or national/ international level in amateur sport. Results. Sixty-four (84.2%) MCL reconstructions and 12 (15.8%) PLC reconstructions were included. 52 (68.4%) underwent concomitant autograft cruciate(s) reconstruction including 6 (7.8%) bicruciate reconstructions. The mean age was 25.1 years (SD +/− 4.50). 35 (46.1%) were footballers and 35 (46.1%) were rugby players. Sixty-seven athletes (88.2%) returned to elite sport, 7 (9.2%) did not RTP and RTP status was unknown for 2 (2.6%) (Figure 1). 65 out of 67 (97.0%) RTP at the same/higher Tegner level. 56 (83.6%) and 20 (57.1%) were still playing at 2- and 5-years post-surgery Six (7.9%) players required further surgery due to irritation from the metal fixation implants. One had an inflammation adjacent to the synthetic material at the femoral end and the other cases involved the tibial staples. All six cases were able to RTP. One athlete, following bicruciate /MCL surgery had the LARS removed due to laxity. There was one MCL re-rupture, sustained while jumping, 4 years after returning to football. Conclusions. Utilising LARS in extra-articular knee ligament reconstructions allows 88.2% of athletes with a variety of knee ligament injuries to return to elite sport. The results compare well regarding RTP, complication, and revision rates with the published evidence for other types of MCL and PLC grafts. This, coupled with 57% of athletes still playing 5 years post-surgery suggests the LARS is safe and effective in these cases. For any figures or tables, please contact authors directly

Abstract. Introduction. Anterolateral procedures can reduce the risk of re-rupture after ACL reconstruction in high risk patients however, this effectiveness has never been evaluated in elite athletes. The purpose of this study was to evaluate the effectiveness of lateral extra-articular tenodesis in reducing revision rates in ACL reconstructions in elite athletes. Methodology. A consecutive cohort of elite athletes between 2005 and 2018 undergoing ACLR reconstruction with or without modified Lemaire lateral extra-articular tenodesis were analysed. A minimum of 2 years of follow-up was required. The association between the use of LET and ACL graft failure was evaluated with univariate and multivariate logistic regression models. Results. 455 elite athletes (83% male; 22.5±4.7 years) underwent primary ACL reconstruction with (n=117) or without (n=338) a LET procedure. Overall, 36 athletes (7.9%) experienced ACL graft failure including 32 (9.5%) reconstructions without a LET and 4 (3.4%) with a LET. Utilization of LET during primary ACL reconstruction reduced the risk of graft failure by 2.8 times with 16.5 athletes needing to be treated with LET to prevent a single ACL graft failure. Multivariate models showed that LET significantly reduced the risk of graft rupture (RR=0.325; p=.029) as compared to ACL reconstruction alone after controlling for age at ACL reconstruction and gender. Including graft type in the model did not significantly change the risk profile. Conclusion. The addition of LET in elite athletes undergoing primary ACL reconstruction reduced the risk of undergoing revision by 2.8 times

Abstract. Background. Performing lateral extra-articular tenodesis (LET) with ACL reconstruction may conflict with the ACLR femoral tunnel. Methods. 12 fresh-frozen cadaveric knees were used: at 120 flexion, an 8mm ACLR femoral tunnel was drilled in the anteromedial bundle position via the anteromedial portal. A modified Lemaire LET was performed using a 1 cm-wide iliotibial band strip left attached to Gerdy's tubercle. The LET femoral fixation point was identified 10mm proximal / 5 mm posterior to the LCL femoral attachment, and a 2.4-mm guide wire was drilled, aiming at 0, 10, 20, or 30 degrees anteriorly in the axial plane, and at 0, 10, or 20 degrees proximally in the coronal plane. The relationship between the LET drilling guide wire and the ACLR femoral tunnel reamer was recorded for each combination. When collision with the femoral tunnel was recorded, the LET wire depth was measured. Results. Tunnel conflict occurred at a mean LET wire depth of 23.6 mm (15–33 mm). No correlation existed between LET wire depth and LET drilling orientation (r=0.066; p=0.67). Drilling angle in the axial plane was significantly associated with the occurrence of tunnel conflict (P < .001). However, no such association was detected when comparing the drilling angle in the coronal plane (P=0.267). Conclusion. Conflict occurred at as little as 15 mm depth. When longer implants are used, the orientation should be at least 30 degrees anterior in the axial plane. Clinical Relevance. This study provides important information for surgeons performing LET in combination with ACLR

Extra-articular deformity may be present in patients requiring TKA. Underlying causes include trauma, metabolic bone disease, congenital deformity, or prior osteotomy. Patients with intra-articular deformity have a combination of intra-articular bone loss and concomitant ligament contraction which can be managed in the standard fashion. In these cases establishing appropriate limb alignment and management of bone loss coincide well with the standard ligament balancing employed to provide a stable knee. However, if extra-articular deformity is not corrected extra-articularly, it must be corrected by a compensatory distal femoral or proximal tibial resection to reproduce appropriate limb alignment. Complex instabilities may result from this type of wedge resection because it occurs between the proximal and distal attachments of the collateral ligaments and so produces asymmetrical ligament length alterations. Femoral compensatory wedge resection for extra-articular deformity produces extension instability without affecting the flexion gap and so femoral deformities are POTENTIALLY more difficult to correct than tibial deformities where the compensatory tibial cut influences flexion AND extension equally. Lack of access to the intramedullary canal (as well as increased complexity of producing appropriately placed bone cuts) may be managed with computer guidance or patient specific instruments. The closer a deformity is to the knee, the greater its importance and the effect on the surgical correction. This is a directly proportional relationship, so that as the apex of the deformity moves from juxta-articular to more distant, the amount of corrective wedge needed to re-align the limb decreases proportionally. Rotatory deformities most commonly effect extensor mechanism tracking. The effect is similar to any other deformity in that proximity to the knee and increases the likelihood that it will have a significant local effect. In general, these deformities may be clinically, and radiographically more subtle and so must be searched for. They should be managed by restoring normal rotational parameters of the bone or by appropriate compensation of component rotation relative to the bone. As the need for prosthetic constraint increases due to ligament imbalance or deficiency, intramedullary stems may be required. Their use may be compromised by the presence of the deformity. The younger the patient and the more severe the deformity the more likely I am to treat the deformity by correction at the site of the deformity rather than compensating with abnormal bone resections. The older the patient and the milder the deformity (or the amount of correction required) the more intra-articular correction +/− increased TKA constraint is feasible

Deformity can be associated with significant bone loss, ligament laxity, soft-tissue contractures, distortion of long bone morphology, and extra-articular deformity. Correction of varus, valgus, or flexion deformity requires soft tissue releases in conjunction with bone cuts perpendicular to the long axes of the femur and tibia. Cruciate-retaining or -substituting implants can be used based on surgeon preference if the ligaments are well balanced. However, in presence of severe deformity, additional measures may be warranted to achieve alignment and balance. TKA then becomes a more challenging proposition and may require the surgeon to perform extensive releases, adjunct osteotomies and deploy more constrained implants. Merely enhancing constraint in the implant, however, without attending to releases and extra-articular correction may not suffice. Pre-operative planning, i.e., whether intra-articular correction alone will suffice or extra-articular correction is required, will be highlighted. Surgical principles and methods of performing large releases, reduction osteotomy, lateral epicondylar sliding osteotomy, sliding medial condylar osteotomy, and closed wedge diaphyseal/metaphyseal osteotomy concomitantly with TKA will be illustrated with examples. Results of a large series of TKA with extra-articular deformity resulting from coronal bowing of femoral or tibial diaphysis, malunited fractures, prior osteotomies, and stress fractures will be presented. The techniques reported can successfully restore alignment, pain-free motion, and stability without necessarily using more constrained implants

Extra-articular deformity may be present in patients requiring TKA. Underlying causes include trauma, metabolic bone disease, congenital deformity, or prior osteotomy. Patients with intra-articular deformity can have a combination of intra-articular bone loss and concomitant ligament contraction which can be managed in the standard fashion. In these cases establishing appropriate limb alignment and management of bone loss coincide well with the standard ligament balancing employed to provide a stable knee. However, if extra-articular deformity is not corrected extra-articularly, it must be corrected by a compensatory distal femoral or proximal tibial resection to reproduce appropriate limb alignment. Complex instabilities may result from this type of wedge resection because it occurs between the proximal and distal attachments of the collateral ligaments and so produces asymmetrical ligament length alterations. Femoral compensatory wedge resection for extra-articular deformity produces extension instability without affecting the flexion gap and so femoral deformities are POTENTIALLY more difficult to correct than tibial deformities where the compensatory tibial cut influences flexion AND extension equally. Lack of access to the intramedullary canal (as well as increased complexity of producing appropriately placed bone cuts) may be managed with computer guidance or patient specific instruments. The closer a deformity is to the knee, the greater its importance and the effect on the surgical correction. This is a directly proportional relationship, so that as the apex of the deformity moves from juxta-articular to more distant, the amount of corrective wedge needed to re-align the limb decreases proportionally. Rotatory deformities are complex and most commonly effect extensor mechanism tracking. In general the effect is similar to any other deformity in that proximity to the knee increases the likelihood that it will have a significant local effect. In general, these deformities are clinically, and radiographically more subtle and so must be searched for. They should be managed by an attempt to restore normal rotational parameters of the bone itself or appropriate compensation of component rotation in relation to the bone. As prosthetic constraint increases one may need to use intramedullary stems. Their use may be compromised by the deformity. Finally, the younger the patient and the more severe the deformity the more likely I am to treat the deformity by correction at the site of the deformity rather than compensating with abnormal bone resections. The older the patient and the milder the deformity (or the amount of wedge correction required) the more likely I am to manage the deformity with intra-articular correction and increased TKA constraint

Introduction. Restoration of mechanical axis is one of the main aims during Total Knee Arthroplasty (TKA) surgery. Treatment of osteoarthritis (OA) of the knee with extra-articular deformity either in femur or in tibia poses a technical challenge in achieving this aim. Insufficient correction of axis is associated with poor clinical outcome of total knee arthroplasty (TKA). Extra-articular deformity can either be addressed with compensatory intra-articular bone resection at the time of TKA or correctional osteotomy prior to or at the time of TKA. Patients & Methods & Results. We present our experience of treating 7 patients with knee arthritis (9 knees) and significant extra-articular deformity. Two patients had OA knee with severe valgus deformity in tibia from recurrent stress fractures. One was treated with one-stage corrective osteotomy and long stem modular TKA. The other had deformity correction with two level tibial osteotomy with intramedullary nail and modular long stem TKA later. Both required tibial tubercle osteotomy during TKA. Two patients with bilateral OA knees and significant varus deformity had sequential deformity correction with Taylor Spatial Frame (TSF) followed by TKA on one side and a single stage intra-articular correction during TKA on the other. Three patients with knee OA and associated deformity (femoral - two pt., tibia one pt.) had symptom resolution with just correction of malaligment with Taylor Spatial Frame (TSF) and did not require TKA. Conclusion. Complex extra-articular femoral or tibial deformities may require proper limb realignment prior to TKA. Our series supports all three approaches to correcting significant extra-articular deformity with knee OA. Each case should be considered individually and planned accordingly

Introduction. Bone tumours rarely involve the joint surface as cartilage is thought to be a good barrier to tumour spread. When the tumour does cross the surface the surgeon is faced with the dilemma of whether to amputate the limb, resect it without reconstruction or reconstruct with an implant. This paper aims to investigate the oncological and functional outcomes of patients undergoing an extra-articular resection and reconstruction with an endoprosthesis. Method. 3100 patients have been seen in ROH with primary bone tumours. Patients were identified who had an extra-articular resection considered pre-operatively and the notes and imaging was reviewed. This group was subdivided into a group who did have an extra-articular resection (EAR) and those who either had an amputation or traditional through joint resection. The outcomes of the three groups (group 1 = no joint involvement, group 2 = EAR considered but not done and group 3 = EAR) were then compared in terms of oncological outcome, surgical margins and complications. Results. EAR was considered in 94 cases (3%) usually due to either obvious tumour or joint effusion on initial imaging. Of these 94 cases an EAR was undertaken in 66 cases and not in 28 cases. There was no difference in age, site distribution, diagnosis between the groups. The mean size of the tumour was smaller in the EAR group. The percentage of wide margins achieved was significantly smaller in the EAR group and risk of local recurrent disease was greater in the EAR group but mainly in patients with chondrosarcoma. There was no difference in patient survival between the groups. Conclusions. EAR gives acceptable oncological and functional results but has significantly higher rates of locally recurrent disease in patients with chondrosarcoma

Aims. The aims of this retrospective study were to determine the incidence of extra-articular deformities (EADs), and determine their effect on postoperative alignment in knees undergoing mobile-bearing, medial unicompartmental knee arthroplasty (UKA). Patients and Methods. Limb mechanical alignment (hip-knee-ankle angle), coronal bowing of the femoral shaft and proximal tibia vara or medial proximal tibial angle (MPTA) were measured on standing, full-length hip-to-ankle radiographs of 162 patients who underwent 200 mobile-bearing, medial UKAs. Results. Incidence of EAD was 7.5% for coronal femoral bowing of >5°, 67% for proximal tibia vara of >3° (MPTA<87°) and 24.5% for proximal tibia vara of >6° (MPTA<84°). Mean postoperative HKA angle achieved in knees with femoral bowing ≤5° was significantly greater when compared to knees with femoral bowing >5° (p=0.04); in knees with proximal tibia vara ≤3° was significantly greater when compared to knees with proximal tibia vara >3° (p=0.0001) and when compared to knees with proximal tibia vara >6° (p=0.0001). Conclusion. Extra-articular deformities are frequently seen in patients undergoing mobile-bearing medial UKAs, especially in knees with varus deformity>10°. Presence of an EAD significantly affects postoperative mechanical limb alignment achieved when compared to limbs without EAD and may increase the risk of limbs being placed in varus>3° postoperatively. Clinical Relevance. Since the presence of an EAD, especially in knees with varus deformity>10°, may increase the risk of limbs being placed in varus>3° postoperatively and may affect long-term clinical and implant survival outcomes, UKR in such knees should be performed with caution

The aim of this review is to evaluate the current available literature evidencing on peri-articular hip endoscopy (the third compartment). A comprehensive approach has been set on reports dealing with endoscopic surgery for recalcitrant trochanteric bursitis, snapping hip (or coxa-saltans; external and internal), gluteus medius and minimus tears and endoscopy (or arthroscopy) after total hip arthroplasty. This information can be used to trigger further research, innovation and education in extra-articular hip endoscopy

Total knee arthroplasty becomes more challenging when knee arthritis is associated with an extra-articular deformity of the femur or tibia. We evaluated the outcome of navigated total knee arthroplasty in a large series of arthritic knees with extra-articular deformity. We retrospectively reviewed the records of 950 patients who had undergone navigated TKA between January 2005 and February 2008. There were 40 extra-articular deformities in 34 patients, with bilateral involvement in 6 patients which were included in the study. Twenty-two limbs had deformity in the femur and the tibia had deformity in 18 limbs. There were 24 females and 10 males with a mean age of 63.1 years (range, 46–80 years). The etiologies included malunited fractures (13 patients), stress fractures (4 patients), post high tibial osteotomy (3 patients), and excessive coronal bowing (14 patients). The mean femoral extra-articular deformity in the coronal plane was 9.3° varus (range, 24° varus to 2.8° varus) and the mean tibial extra-articular deformity in the coronal plane was 6.3° varus (range, 20° varus to 8.5° valgus). Three limbs underwent simultaneous corrective osteotomy and the rest were treated with intra-articular correction during computer-assisted total knee arthroplasty. The limb alignment changed from a mean of 166.7° preoperatively to 179.1° postoperatively. At a mean follow-up of 26.4 months, the Knee Society knee score improved from a mean pre-operative score of 49.7 points to 90.4 points postoperatively; function score improved from 47.3 points to 84.9 points. The results of our study indicate that computer-assisted total knee arthroplasty is a useful alternative to conventional total knee arthroplasty for knee arthritis with extraarticular deformity where accurate restoration of limb alignment may be challenging due to the presence of a deformed tibia or femur or in the presence of hardware

The treatment of patients with osteoarthritis of the knee and associated extra-articular deformity of the leg is challenging. Current teaching recognises two possible approaches: (1) a total knee replacement (TKR) with intra-articular bone resections to correct the malalignment or (2) an extra-articular osteotomy to correct the malalignment together with a TKR (either simultaneously or staged). However, a number of these patients only have unicompartmental knee osteoarthritis and, in the absence of an extra-articular deformity would be ideal candidates for joint preserving surgery such as unicompartmental knee replacement (UKR) given its superior functional outcome and lower cost relative to a TKR [1). We report four cases of medial unicondylar knee replacement, with a simultaneous extra-articular osteotomy to correct deformity, using novel 3D printed patient-specific guides (Embody, UK) (see Figure 1). The procedure was successful in all four patients, and there were no complications. A mean increase in the Oxford knee score of 9.5, and in the EQ5D VAS of 15 was observed. To our knowledge this is the first report of combined osteotomy and unicompartmental knee replacement for the treatment of extra-articular deformity and knee osteoarthritis. This technically challenging procedure is made possible by a novel 3D printed patient-specific guide which controls osteotomy position, degree of deformity correction (multi-plane if required), and orientates the saw-cuts for the unicompartmental prosthesis according to the corrected leg alignment. Using 3D printed surgical guides to perform operations not previously possible represents a paradigm shift in knee surgery. We suggest that this joint preserving approach should be considered the preferred treatment option for suitable patients

Introduction. Arthritic knees requiring total knee replacement may present with additional deformities located along the femur or tibia away from the articular region. These deformities may be congenital, developmental, associated with metabolic bone disease, or acquired as a result of malunited fractures or previous advocated for arthritic knee with ipsilateral extra-articular deformity. Methods. We undertook retrospective study to evaluate the results of total knee arthroplasty in arthritic knee with extra-articular deformity in 26 knees (24 patients). Sixteen deformities were in tibia and ten deformities were in femur. All patients underwent total knee arthroplasty with intraarticular bone resection and soft tissue balancing. Results. Average period of follow up was 30 months. Average preoperative arc of motion was 57.5 degrees, which improved to 102.5 degrees. The average preoperative knee society knee score 23.5 points, which improved to an average of 91.3 points at the time of last follow up. The average functional score was 27.0 points, which improved to average of 88.0 points. There were no complications such as infection, ligament instability or component loosening. Conclusion. Intra-articular bone resection is an effective procedure for management of arthritic knees with extra-articular deformity

We treated 31 feet in 17 children with myelomeningocele by extra-articular subtalar arthrodesis. Two patients were lost to follow-up. In the rest, we assessed the correction of valgus deformity and the growth of the tarsal bones. At operation the mean age of the eight girls and nine boys was 6.3 years (3 to 9). At a mean follow-up period of 5.5 years (3 to 9) patients were evaluated clinically and radiologically. We assessed calcaneal growth by calculating the ratio of calcaneal and naviculo-metatarsal longitudinal length on the preoperative and follow-up lateral radiographs. Results of valgus correction were good in 19 feet. In eight they were unsatisfactory owing to progressive valgus of the ankle. Orthotic fitting was difficult and pressure sores over the medial malleolus often developed. Four of the patients underwent further correction by distal tibial osteotomy. The growth ratio was increased in 15 feet, remained the same in seven and decreased in five. Extra-articular subtalar arthrodesis produced satisfactory partial correction of a complex valgus deformity and stability of the hindfoot, and did not have a detrimental effect on the growth of the calcaneus

Aim: To analyse retrospectively patients after subtalar extra-articular arthrodesis in CP patients. Material and methods: The operation was designed to correct pronated valgus foot. Followed cohort involved 43 patients with 72 affected and operated feet. Subtalar arthrodesis was based on insertion of bicortical graft obtained from iliac wing in the corrected position of the foot. Immobilisation in POP cast continued for 6 weeks postoperatively. Patients were followed clinically and radiographically in standing position before the operation, and after that at regular intervals. Clinical examination involved estimation of heel valgus, foot-prints, videodocumentation. Lateral talo-calcaneal angle (TC) and calcaneal-bottom angle (CB) were measured on radiographs. Moreover qualitative-descriptive classification was used (good, fair, poor). Results: The median of preoperative TC angle was 44,5° at right foot and 48,0° at left foot. The median of postoperative angle changed to 29,5° at right foot and 29,0° at left foot. The difference in TC angles before and after operation was statistically significant. The median of preoperative CB angle was 7,5° at right foot and 7,0° at left foot. The median of postoperative CB angle was 10,5° at right foot and 7,5° at left foot. The difference in CB angles before and after operation was not statistically significant. Operation failed in two cases due to collapse or migration of the graft. Significant improvement in this study was found in 59 (82%) of cases. Discussion: Plenty of reports concerning the use of classical Grice-Green operation in different modifications were reported. This study is based on the use of bicortical cortico-cancellous graft, which provided good stability as well as a smooth incorporation to the neighbouring bones. The correction in TC angle dominated over change in CB angle. Conclusion: Subtalar extra-articular arthrodesis showed in mid-term follow up very good results

Primary synovial chondromatosis, defined by Jaffe (1951), is a rare, benign arthropathy, of unknown aetiology, distinguished by the chondroid metaplasia of the synovial membrane of the joint, bursa or tendon sheath, which leads to the formation of loose bodies, usually intra-articular. It is characteristically monoarticular and the knee, hip and elbow are the joints most commonly affected. The shoulder is a rare localisation and the extra-articular involvement even rarer, with only few cases presented in the literature. The diagnosis is possibilited by the clinical examination and by the confirmation of the presence of multiple intra-articular loose bodies by roentgenographic studies and magnetic resonance (MR). The treatment is always surgical. Malignant degeneration of synovial chondromatosis into chondrosarcoma is described, although rare. We report an exceptionally rare case of synovial osteochondromatosis of the shoulder with combined intra and extra-articular involvement in a 28 years old female patient, former athlete. She presented with a five-year history of shoulder pain and slight limitation of motion. Radiographic examination and magnetic resonance imaging led us to the diagnosis of synovial chondromatosis of the shoulder. The patient underwent arthroscopic removal of the intra-articular loose bodies and partial synovectomy. The subscapularis recess was then identified through an anterior deltopectoral incision and multiple loose bodies were removed from within. Primary synovial chondromatosis of the shoulder is rare (5% of the cases) and the involvement of the extra-articular shoulder site is even rarer. Bloom and colleagues reported ten cases involving the shoulder in a meta-analysis of 191 synovial chondromatosis cases. The arthroscopic removal of the loose bodies combined with the partial sinovectomy has demonstrated efficacy and low recurrence rates, allowing excellent visualization of the joint, decreased morbidity and early functional return. Nevertheless, we think that this approach may become insufficient when the extra-articular involvement is verified

Aims: The aim of this study is to compare open Bankart procedure and arthroscopic extra-articular stabilization of the shoulder in patients with anterior instability. Material and Methods: 236 patients with recurrent anterior shoulder instability were treated surgically between 1992 and 2002. Open Bankart procedure was performed in 177 patients, mean age 29 years (range 17–67), and arthroscopic extra-articular stabilization in 59 patients, mean age 27 years (range 14–45). Single surgeon was performed all surgery. Follow-up for open surgery was from 2 to10 years, and for arthroscopic stabilization from 12 to 60 months. Results: Constant score for Bankart procedure was 90 points and for arthroscopic stabilization was 96 points. Five patients (2.8%) had re-dislocation after open procedure and three patients (5,1%) after arthroscopic stabilization. Conclusion: Open Bankart is more reliable than arthroscopic stabilisation of the shoulder. However, arthroscopic stabilisation has more advantages; better ROM, better function and cosmesis, lesser morbidity and small violation of normal anatomy

Background: Extra-articular fractures of the distal radius in children are most often treated with closed reduction and cast immobilization. The purpose of this retrospective study was to evaluate long term (> 12 years follow-up) objective and subjective outcomes in a consecutive series of pediatric patients treated with closed reduction with standardized outcome instruments. We hypothesized that children treated with closed reduction and cast immobilization have little or no objective functional impairment in later life and therefore subjective factors are the strongest determinants of outcome. Methods: Twenty-seven patients with an average age at time of injury of 9 years (range, five to sixteen years) were evaluated at an average of twenty-one years (range, twelve to twenty seven years) after injury (patients aged 21 to 39) after closed reduction of an extra-articular distal radius fracture. Patients were evaluated using 2 physician-based evaluation instruments (modified Mayo wrist score; MMWS, and the Sarmiento modification of the Gartland and Werley score; MGWS) and an upper extremity-specific health status questionnaire (Disabilities of the Arm, Shoulder and Hand; DASH) questionnaire. Radiographic measurements were also made. Multivariable analysis of variance and multiple linear regression modelling were used to identify the degree to which various factors affect variability in the scores derived with these measures. Results: All fractures had healed without significant loss of alignment. Final functional results according to the MGWS were rated as excellent or good in all patients. The average MMWS score was 90 points, and the median DASH score was 0 points. Twenty patients (74%) considered themselves pain free. Bivariate analysis revealed pain -as rated according to scales used in the MMWS- and age at time of injury to be correlated with DASH scores, with pain as the only independent predictor of patient-based outcome in multivariable analysis. This explains almost three quarters of the variability in DASH scores. Pain, range of motion, and radiographic measurement of radial length correlated with the physician based scoring system MMWS;. Conclusions: Twenty-one years after injury 96% of patients have a satisfactory outcome according to physician-based MMWS categorical ratings and patient-based DASH scores. It is remarkable that pain explained 74% of the variation in DASH scores. Perhaps when there is very little impairment, subjective factors are more important determinants of disability