Aims. Post-traumatic periprosthetic acetabular fractures are rare but serious. Few studies carried out on small cohorts have reported them in the literature. The aim of this work is to describe the specific characteristics of post-traumatic periprosthetic acetabular fractures, and the outcome of their surgical treatment in terms of function and complications. Methods. Patients with this type of fracture were identified retrospectively over a period of six years (January 2016 to December 2021). The following data were collected: demographic characteristics, date of insertion of the prosthesis, details of the intervention, date of the trauma, characteristics of the fracture, and type of treatment. Functional results were assessed with the Harris Hip Score (HHS). Data concerning complications of treatment were collected. Results. Our series included 20 patients, with a mean age of 77 years (46 to 90). All the patients had at least one comorbid condition. Radiographs showed that 75% of the fractures were pure transverse fractures, and a transverse component was present in 90% of patients. All our patients underwent surgical treatment: open reduction and internal fixation, revision of the acetabular component, or both. Mean follow-up was 24 months, and HHS at last follow-up was 75.5 (42 to 95). The principal complications observed were dislocations of the prosthesis (30%) and infections (20%). A need for revision surgery was noted in 30% of patients. No dislocation occurred in patients undergoing osteosynthesis with acetabular reconstruction. We did not note either mechanical loosening of the acetabular component nor thromboembolic complications. In all, 30% of patients presented acute anemia requiring transfusion, and one death was reported. Conclusion. Post-traumatic periprosthetic acetabular fractures frequently have a transverse component that can destabilize the acetabular implant. The frequency of complications, principally dislocations, led to a high rate of revision surgery. Improvements in preoperative planning should make it possible to codify management to reduce this high rate of complications. The best results were obtained when the surgical strategy combined osteosynthesis with acetabular reconstruction. Cite this article: Bone Jt Open 2024;5(1):28–36

Post-traumatic elbow stiffness is a disabling condition that remains challenging for upper limb surgeons. Open elbow arthrolysis is commonly used for the treatment of stiff elbow when conservative therapy has failed. Multiple questions commonly arise from surgeons who deal with this disease. These include whether the patient has post-traumatic stiff elbow, how to evaluate the problem, when surgery is appropriate, how to perform an excellent arthrolysis, what the optimal postoperative rehabilitation is, and how to prevent or reduce the incidence of complications. Following these questions, this review provides an update and overview of post-traumatic elbow stiffness with respect to the diagnosis, preoperative evaluation, arthrolysis strategies, postoperative rehabilitation, and prevention of complications, aiming to provide a complete diagnosis and treatment path. Cite this article: Bone Joint Open 2020;1-9:576–584

The optimal treatment strategy for post-traumatic long bone non-unions is subject of an ongoing discussion. At the Maastricht University Medical Center (MUMC+) the induced membrane technique is used to treat post-traumatic long bone non-unions. This technique uses a multimodal treatment algorithm involving bone marrow aspirate concentrate (BMAC), the reamer-irrigator-aspirator (RIA) and P-15 bioactive peptide (iFactor, Cerapedics). Bioactive glass (S53P4 BAG, Bonalive) is added when infection is suspected. This study aims to objectify the effect of this treatment algorithm on the health-related quality of life (HRQoL) of patients with post-traumatic long bone non-unions. We hypothesized that HRQoL would improve after treatment. From January 2020 to March 2023, consecutive patients who were referred to a multidisciplinary (trauma, orthopaedic and plastic surgery) non-union clinic at the MUMC+, The Netherlands, were evaluated using the Non-Union Scoring System (NUSS). The EQ-5D-5L questionnaire and the Lower Extremity Functional Scale (LEFS) were employed to obtain HRQoL outcomes both prior to and subsequent to surgery, with a follow-up at 6, 18 and 35 weeks. Seventy-six patients were assessed at baseline (T0), with a mean NUSS of 40 (± 13 SD). Thirty-eight patients had their first follow-up, six weeks after surgery (T1). Thirty-one patients had a second follow-up at 18 weeks (T2), and twenty patients had the third follow-up at 35 weeks (T3). The EQ-5D index mean at baseline was 0.480, followed by an index of 0.618 at T1, 0.636 at T2, and 0.702 at T3. A significant difference was found in the HRQoL score between T0 and T1, as well as T2 and T3 (p<0.001; p=0.011). The mean LEFS significantly increased from 26 before intervention to 34, 39, and 43 after treatment (p<0.001; p=0.033; p=0.016). This study demonstrated a significant improvement in the health-related quality of life of patients with post-traumatic long bone non-unions after the standardized treatment algorithm following the induced membrane technique

Aims. The aim of this meta-analysis was to compare the outcome of total elbow arthroplasty (TEA) undertaken for rheumatoid arthritis (RA) with TEA performed for post-traumatic conditions with regard to implant failure, functional outcome, and perioperative complications. Materials and Methods. We completed a comprehensive literature search on PubMed, Web of Science, Embase, and the Cochrane Library and conducted a systematic review and meta-analysis. Nine cohort studies investigated the outcome of TEA between RA and post-traumatic conditions. The preferred reporting items for systematic reviews and meta-analysis (Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)) guidelines and Newcastle-Ottawa scale were applied to assess the quality of the included studies. We assessed three major outcome domains: implant failures (including aseptic loosening, septic loosening, bushing wear, axle failure, component disassembly, or component fracture); functional outcomes (including arc of range of movement, Mayo Elbow Performance Score (MEPS), and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire), and perioperative complications (including deep infection, intraoperative fracture, postoperative fracture, and ulnar neuropathy). Results. This study included a total of 679 TEAs for RA (n = 482) or post-traumatic conditions (n = 197). After exclusion, all of the TEAs included in this meta-analysis were cemented with linked components. Our analysis demonstrated that the RA group was associated with a higher risk of septic loosening after TEA (odds ratio (OR) 3.96, 95% confidence interval (CI) 1.11 to 14.12), while there was an increased risk of bushing wear, axle failure, component disassembly, or component fracture in the post-traumatic group (OR 4.72, 95% CI 2.37 to 9.35). A higher MEPS (standardized mean difference 0.634, 95% CI 0.379 to 0.890) was found in the RA group. There were no significant differences in arc of range of movement, DASH questionnaire, and risk of aseptic loosening, deep infection, perioperative fracture, or ulnar neuropathy. Conclusion. The aetiology of TEA surgery appears to have an impact on the outcome in terms of specific modes of implant failures. RA patients might have a better functional outcome after TEA surgery. Cite this article: Bone Joint J 2019;101-B:1489–1497

Aims. Post-traumatic osteoarthritis (PTOA) is a subset of osteoarthritis (OA). The gut microbiome is shown to be involved in OA. However, the effect of exercise on gut microbiome in PTOA remains elusive. Methods. A total of 18 eight-week Sprague-Dawley rats were assigned into three groups: Sham/sedentary (Sham/Sed), PTOA/sedentary (PTOA/Sed), and PTOA/treadmill-walking (PTOA/TW). PTOA model was induced by transection of the anterior cruciate ligament (ACLT) and the destabilization of the medial meniscus (DMM). Treadmill-walking (15 m/min, 30 min/d, five days/week for eight weeks) was employed in the PTOA/TW group. The response of cartilage, subchondral bone, serology, and gut microbiome and their correlations were assessed. Results. Eight-week treadmill-walking was effective at maintaining the integrity of cartilage-subchondral bone unit and reducing the elevated systematic inflammation factors and microbiome-derived metabolites. Furthermore, 16S ribosomal ribonucleic acid (rRNA) sequencing showed disease-relevant microbial shifts in PTOA animals, characterized by the decreased abundance of phylum TM7 and the increase of phylum Fusobacteria. At the genus level, the abundance of Lactobacillus, Turicibacter, Adlercreutzia, and Cetobacterium were increased in the PTOA animals, while the increase of Adlercreutzia and Cetobacterium was weakened as a response to exercise. The correlation analysis showed that genus Lactobacillus and Adlercreutzia were correlated to the structural OA phenotypes, while phylum Fusobacteria and genus Cetobacterium may contribute to the effects of exercise on the diminishment of serological inflammatory factors. Conclusion. Exercise is effective at maintaining the integrity of cartilage-subchondral bone unit, and the exercise-induced modification of disease-relevant microbial shifts is potentially involved in the mechanisms of exercise-induced amelioration of PTOA. Cite this article: Bone Joint Res 2022;11(4):214–225

Osteoarthritis is a slowly progressive disease which includes the intervention of several cytokines and macrophage metalleinoproteinases reaction, leading to the degradation of the local cartilage but also having an impact on the serum acute phase proteins (APPs). Subsequently, biomarkers seem to be essential to estimate its progression and the need for any surgical intervention such as total arthroplasty, but also can be used as therapeutic agents. Recently, among APPs, fetuin-A drew attention regarding its possible anti-inflammatory role in animal models but also as a therapeutic agent in the inflammatory joint disease in clinical trials. The purpose of this study is to investigate the possible attenuating role of the intra-articular administration of Fetuin-A in post-traumatic induced secondary osteoarthritis in rats, and also its effect on the systematic levels of IL-2,4,7, BMPs 2,4,7, CRP and Fetuin-A. 30 male Sprague Dawley rats were separated in two groups where post-traumatic osteoarthritis was induced surgically by Anterior Cruciate Ligament Transection and the transection of the Medial Collateral Ligament of the right knee. In the Control Group, only surgical intervention took place. In Fetuin Group, along with the induction of osteoarthritis, a single dose of bovine fetuin was administrated intra-articularly intra-operatively in 5 and 8 weeks of the experimental protocol. Both groups were examined for 8 weeks. The levels of interleukins, bone morphogenetic proteins, Fetuin-A and C-Reactive Protein were evaluated by ELISA of peripheral blood in three time periods: preoperatively, 5 and 8 weeks post-operatively. Knee osteoarthritic lesions were classified according to Osteoarthritis Research Society International Grading System and Modified Mankin Score, by histologic examination. IL-2 levels were significantly decreased in the Fetuin Group. No statistical difference was signed on the levels of IL-7, BMP-2,4,7 and Fetuin-A between the two groups. CRP levels were significantly increased in the Fetuin Group in 5 weeks of the experiment. Fetuin Group signed better scores according to the OARSI classification system and Modified Mankin Score, without any statistical significance. Intra-articular administration of Fetuin-A restrictively affected the progression of post-traumatic arthritis in rats, as only the levels of IL-2 were decreased as well as limited osteoarthritic lesions were observed on the Fetuin Group

Aims. To explore key stakeholder views around feasibility and acceptability of trials seeking to prevent post-traumatic osteoarthritis (PTOA) following knee injury, and provide guidance for next steps in PTOA trial design. Methods. Healthcare professionals, clinicians, and/or researchers (HCP/Rs) were surveyed, and the data were presented at a congress workshop. A second and related survey was then developed for people with joint damage caused by knee injury and/or osteoarthritis (PJDs), who were approached by a UK Charity newsletter or Oxford involvement registry. Anonymized data were collected and analyzed in Qualtrics. Results. Survey responses (n = 19 HCP/Rs, 39 PJDs) supported studies testing pharmacological agents preventing PTOA. All HCP/Rs and 30/31 (97%) PJDs supported the development of new treatments that improved or delayed knee symptoms and damage to knee structure. PJDs thought that improving structural knee damage was more important than knee symptoms. Both groups found studies more acceptable as expected future benefit and risk of PTOA increased. All drug delivery routes were acceptable. Workshop participants (around n = 60) reflected survey views. Discussions suggested that stratifying using molecular testing for likely drug response appeared to be more acceptable than using characteristics such as sex, age, and BMI. Conclusion. Our findings supported PTOA drug intervention studies, including situations where there is low risk of disease, no expected benefit of treatment, and frequent treatment administration. PJDs appeared less risk-averse than HCP/Rs. This work reinforces the benefits of consensus and involvement work in the co-creation of PTOA drug trial design. Involvement of key stakeholders, such as PJDs with different risks of OA and regulatory representatives, are critical for trial design success. Cite this article: Bone Joint Res 2024;13(9):513–524

To evaluate the therapeutic effect of Pulsed Electromagnetic Field (PEMF) in the treatment of meniscal tears in the avascular region. Seventy-two twelve-week-old male Sprague-Dawley rats with full-thickness longitudinal medial meniscal tears in the avascular region were divided into 3 groups: control group (G. con. ), treated with classic signal PEMF (G. classic. ), and high slew rate signal PEMF(G. HSR. ). The HSR signal has the same pulse and burst frequencies as the classic signal, but with a higher slew rate. Macroscopic observation and histological analysis of the meniscus and articular cartilage were performed to evaluate the meniscal healing and progressions of osteoarthritis. The synovium was harvested for histological and immunofluorescent analysis to assess the intra-articular inflammation. The meniscal healing, articular cartilage degeneration, and synovitis were quantitatively evaluated according to their respective scoring system. Dramatic degenerative changes of the meniscus and articular cartilage were noticed during gross observation and histological evaluation in the control group at 8 weeks. However, the menisci in the two treatment groups were restored to normal morphology with a smooth surface and shiny white color. Particularly, the HSR signal remarkably enhanced the fibrochondrogenesis and accelerated the remodeling process of the regenerated tissue. The meniscal healing scores of PEMF treatment groups were significantly higher than those in the control group at 8 weeks. Specifically, the HSR signal showed a significantly higher meniscal repair score than the classic signal at week 8 (P < .01). The degeneration score (G. con. versus G. classic. : P < .0001; Gcon versus G. HSR. : P < .0001) and synovitis score (G. con. versus Gclassic: P < .0001; G. con. versus G. HSR. : P = .0002) of the control groups were significantly higher than those in the two treatment groups. PEMF promoted the healing of meniscal tears in the avascular region and restored the injured meniscus to its structural integrity in a rat model. Compared to the classic signal, the HSR signal showed the increased capability to promote fibrocartilaginous tissue formation and modulate the inflammatory environment and therefore protected the knee joint from post-traumatic osteoarthritis development

Post-traumatic osteonecrosis of the femoral head (ONFH) is a major complication of femoral neck fractures that require numerous solutions. The purpose of the current study is to investigate the effects of platelet-rich plasma (PRP) incorporated autologous granular bones graft for the treatment of pre-collapse stages (ARCO stage II-III) of post-traumatic ONFH. A total of 46 patients were eligible and enrolled into the study. 24 patients were treated with core decompression and PRP incorporated autologous granular bones graft (treatment group: 9 females and 15 males, age range, 16–39 years), and 22 patients with core decompression and autologous granular bones graft (control group: 6 females and 16 males, age range, 18–42 years. During a minimum duration of follow-up of 36 months, multiple imaging techniques including X-ray and computed tomography (CT) scanning were used to evaluate the radiological results, and Harris hip score (HHS) and the visual analogue scale (VAS) were chosen to assess the clinical results. Both treatment group and control group had a significant improved HHS (P < 0.001). The minimum clinically important difference (MCID) for HHS was reached in 91.7% of treatment group and 68.2% of control group (P = 0.0449). HHS in treatment group was significantly higher than control group at the last follow-up (P = 0.0254). VAS score was significantly declined in treatment group when compared with control group (P = 0.0125). Successful clinical results were achieved in 21 of 24 patients (87.5%) in treatment group compared with 13 of 22 patients (59.1%) in control group (P = 0.0284). Successful radiological results were achieved in 19 of 24 patients (79.2%) in treatment group compared with 11 of 22 patients (50%) in control group (P = 0.0380). The survival rates using requirement for further hip surgery as an endpoint were higher in treatment group in comparison to control group (P = 0.0260). The PRP incorporated autologous granular bones graft is a safe and effective procedure for the treatment of pre-collapse stages (ARCO stage II-III) of post-traumatic ONFH

Objectives. Induced membrane technique is a relatively new technique in the reconstruction of large bone defects. It involves the implantation of polymethylmethacrylate (PMMA) cement in the bone defects to induce the formation of membranes after radical debridement and reconstruction of bone defects using an autologous cancellous bone graft in a span of four to eight weeks. The purpose of this study was to explore the clinical outcomes of the induced membrane technique for the treatment of post-traumatic osteomyelitis in 32 patients. Methods. A total of 32 cases of post-traumatic osteomyelitis were admitted to our department between August 2011 and October 2012. This retrospective study included 22 men and ten women, with a mean age of 40 years (19 to 70). Within this group there were 20 tibias and 12 femurs with a mean defect of 5 cm (1.5 to 12.5). Antibiotic-loaded PMMA cement was inserted into the defects after radical debridement. After approximately eight weeks, the defects were implanted with bone graft. Results. The patients were followed for 27.5 months (24 to 32). Radiographic bone union occurred at six months for 26 cases (81%) and clinical healing occurred in 29 cases (90%) at ten months. A total of six cases had a second debridement before bone grafting because of recurrence of infection and one patient required a third debridement. No cases of osteomyelitis had recurred at the time of the last follow-up visit. Conclusion. The induced membrane technique for the treatment of post-traumatic osteomyelitis is a simple, reliable method, with good early results. However, there are many challenges in determining the scope of the debridement, type of limb fixation and source of bone graft to be used. Cite this article: Dr Z. Xie. Induced membrane technique for the treatment of bone defects due to post-traumatic osteomyelitis. Bone Joint Res 2016;5:101–105. DOI: 10.1302/2046-3758.53.2000487

Aim. Cyclooxygenase-2 (COX-2) enzyme is one of the major mediators during inflammation reactions, and COX-2 gene polymorphisms of rs20417 and rs689466 have been reported to be associated with several inflammatory diseases. However, potential links between the two polymorphisms and risk of developing post-traumatic osteomyelitis remain unclear. The present study aimed to investigate associations between the rs20417 and rs689466 polymorphisms and susceptibility to post-traumatic osteomyelitis in Chinese population. Methods. A total of 189 patients with definite diagnosis of post-traumatic osteomyelitis and 220 healthy controls were genotyped for rs20417 and rs689466 using the genotyping method*. Chi-square test was used to compare differences of genotype distributions as well as outcomes of five different genetic models between the two groups. Results. Significant association was found between rs689466 and post-traumatic osteomyelitis by recessive model (GG vs. AA + AG) (OR = 1.74, 95% CI: 1.098–2.755, P =0.018). Although no statistical differences were identified of rs689466 between the two groups by allele model (P = .098) or homozygous model (P = 0.084), outcomes revealed a tendency that allele G may be a risk factor and people of GG genotype may be in a higher risk to develop post-traumatic osteomyelitis in Chinese population. However, no significant link was found between rs20417 and susceptibility to post-traumatic osteomyelitis in this Chinese cohort. Conclusions. To our knowledge, we reported for the first time that COX-2 gene polymorphism rs689466 may contribute to the increased susceptibility to post-traumatic osteomyelitis in Chinese population. *SNaPshot®

Introduction and Objective. Evidence in literature is contradicting regarding outcomes of total knee arthroplasty (TKA) in post-traumatic osteoarthritis (PTOA) and whether they are inferior to TKA in primary osteoarthritis (OA). The aim of this review was to find out if any difference exists in the results of TKA between the two indications. Materials and Methods. The electronic databases MEDLINE, EMBASE, The Cochrane Collaboration, and PubMed were searched and screened in duplicate for relevant studies. The selected studies were further subjected to quality assessment using the modified Coleman method. The primary outcome measure was patient reported outcome, and secondary outcome measures were infection, revision, stiffness, and patella tendon rupture. Results. A total of 18 studies involved 1129 patients with a mean age of 60.6 years (range 45.7–69) and follow up of 6.3 years. The time interval from index injury to TKA was 9.1 years. Knee Society Score (KSS) in PTOA reported in 12/18 studies showed functional improvement from 42.5 to 70 post-TKA exceeding minimally clinically important difference. In TKA for primary OA vs PTOA, deep peri-prosthetic joint infection (PJI) was reported in 1.9% vs 5.4% of patients, whilst revision of prosthesis at an average of 6 years post-operatively was performed in 2.6 vs 9.7% of patients. Conclusions. TKA is a successful treatment option for PTOA. However, the risk of significant complications like PJI and implant failure requiring revision is higher than primary OA cases. Patients should be counselled about those risks. Further well-designed comparative cohort-matched studies are needed to compare outcomes between the two populations

Introduction and Objective. Traditionally, osteoarthritis (OA) has been associated mostly with degradation of cartilage only. More recently, it has been established that other joint tissues, in particular bone, are also centrally involved. However, the link between these two tissues remains unclear. This relationship is particularly evident in post-traumatic OA (PTOA), where bone marrow lesions (BMLs), as well as fluctuating levels of inflammation, are present long before cartilage degradation begins. The process of bone-cartilage crosstalk has been challenging to study due to its multi-tissue complexity. Thus, the use of explant model systems have been crucial in advancing our knowledge. Thus, we developed a novel patellar explant model, to study bone cartilage crosstalk, in particular related to subchondral bone damage, as an alternative to traditional femoral head explants or cylindrical core specimens. The commonly used osteochondral explant models are limited, for our application, since they involve bone damage during harvest. The specifics aim of this study was to validate this novel patellar explant model by using IL-1B to stimulate the inflammatory response and mechanical stimulation to determine the subsequent developments of PTOA. Materials and Methods. Lewis rats (n=48) were used to obtain patellar and femoral head explants which were harvested under an institutional ethical approval license. Explants were maintained in high glucose media (containing supplements), under sterile culture conditions. Initially, we characterised undamaged patellar explants and compared them with the commonly used femoral head. First, tissue viability was assessed using an assay of metabolic activity and cell damage. Second, we created chemical and mechanical damage in the form of IL-1B treatment, and mechanical stimulation, to replicate damage. Standard biochemical assays, histological assays and microstructural assays were used to evaluate responses. For chemical damage, explants were exposed to 10ng/ml of IL-1B for 24 hours at 0, 1, 3 and 7 days after harvesting. For mechanical damage, tissues were exposed to mechanical compression at 0.5 Hz, 10 % strain for 10 cycles, for 7 days. Contralateral patellae served as controls. In both groups, sGAG, ADAMTS4, and MMP-13 were measured as an assessment of representative cartilage responses while ALP, TRAP and CTSK were assessed as a representative of bone responses. In addition to this, histomorphometric, and immunohistochemical, evaluations of each explant system were also carried out. Results. Our results confirm that the patellar explant system is an excellent ex vivo model system to study bone-cartilage crosstalk, and one which does not induce any bone damage at the time of tissue harvest. We successfully established culture conditions to maintain viability in these explants for up to 28 days. Rat IL-1B treatment resulted in increased both proteoglycan content and bone metabolism markers after 7 days when compared with the controls. To confirm this finding, qualitative immunohistochemical staining showed chondrocytes increased expression of MMP13 after treatment with IL-1B. Furthermore, we observed that the levels of ADAMTS4 decreased in 48 hours after IL-1B exposure. Contrastingly IL-1B treatment had the opposite effect on CTSK markers when compared with the control. Mechanically compressed patellae showed a decrease in compressive moduli from day 3 to day 7, suggesting that tissue remodelling may have taken place as a compensatory mechanism in response to damage. In addition, MMP13 release decreased over 48 hours after mechanical compression, while TRAP levels were increased compared with the control. Conclusions. Thus, we successfully demonstrated that IL-1B and mechanical stimulation affects both bone and cartilage tissues independently in this system, which may have relevance in the understanding of bone-cartilage crosstalk after injury and how this is involved in PTOA development

Background: The treatment of post-traumatic elbow stiffness has seen many important changes over the years, particularly greater the development of arthroscopy. In this study mid-term clinical results of arthroscopy for post-traumatic elbow stiffness are evaluated in 15 sporting patients, with an average age of 32. Methods: 8 patients reported post-traumatic stiffness due to fracture of the radial head, 3 to fracture-dislocation, 1 to fracture of the radial diaphysis complicated by osteosynthesis, and the remaining 3 patients to stress syndromes with osteochondral detachment. Surgical treatment consists in debridment, arthroscopic capsular release, and removal of bone fragments by arthroscopy. Patients were followed-up from 4 up to 36 months, with a mean follow-up time of 18 months. Results: Results obtained have been good to excellent in 84% of cases with a average range in post-operative movement of 13–137° and reduction in pain symptomatology. Conclusion: In light of our mid-term clinical results on a small series of cases, arthroscopic surgical treatment would appear to be an acceptable option in management of the post-traumatic stiff elbow

Post-traumatic avascular necrosis of the femoral head usually occurs after hip dislocation and femoral neck fracture. Recently along the development of hip arthroscopy, early stage of avascular necrosis of the femoral head can be treated rthroscopically. We hereby present two cases of post-traumatic avascular necrosis patients treated with hip arthroscopy. Case 1. Twenty one year old female patient came to the hospital because of fall from height of 3 floors. Left acetabular fracture, both superior pubic rami fractures and severely displaced left femoral neck fracture were identified at the emergency department (Fig. 1-A). She underwent surgery at the injury day. After the repair of ruptured urinary bladder, internal fixation of the femoral neck was done. Four cannulated screws with washers were inserted for displaced femoral neck fracture, consistent with garden stage IV (Fig. 1-B). Skeletal traction of ipsilateral lower extremity was applied four weeks after the surgery for acetabular fracture. She visited us for painful limitation of motion on left hip at eight months postoperatively. Plain radiograph showed collapse of femoral head and osteophyte formation which were caused by post-traumatic avascular necrosis (Fig. 1-C,D). Femoral head was perforated by a screw. She was planned to remove the screw and resect the osteophyte arthroscopically. On arthroscopic examination, severe synovitis and folded, collapsed femoral cartilage were identified (Fig. 1-E). Screws were removed and osteophyte were also resected (Fig. 1-F). We filled the cavity caused by the screws with allogenic strut graft for structural support. After the surgery, pain was relieved and she came back to her active daily living and for six months, no other complication nor further collapse were identified postoperatively. Case 2. Fourty year old male patient was admitted to the hospital for fall from height about fifteen feet from the ground. Left femoral neck fracture was identified on the emergency department. Previously he had underwent intramedullary nailing for the femoral shaft fracture about five years ago. Urgent internal fixation with four cannulated screws was done on the day of injury. The fixation was unsatisfactory because previously inserted intramedullary nail hindered the proper trajectory of screws. Furthermore, direction of cephalad interlocking holes of the nail were not consistent with the anteversion of femoral neck, we could not place the screws through the nail. Four months after the index surgery, collapse of femoral head and loosening of screws have occurred. MRI showed the collapse of femoral head and posttraumatic avascular necrosis. Prominent bony beak of femoral neck were identified and he complained difficulty and pain on his hip during abduction. We left two screws for secure fixation and resected the bony beak using arthroscopic burr. After the surgery, he felt free from the pain on abduction of hip. Discussion. Even though collapse of the femoral head is identified, early intervention by the arthroscopy could minimize pain or delay the progression of arthritic change. Authors think that it might be helpful for the young adult patients in terms of pain relief and potential delay of the total hip arthroplasty

The results of surgical treatment of post-traumatic elbow contractures in adolescence have been conflicting in the literature. Some authors suggest that contracture release in this age group is less predictable and results less favorable than in adults. A retrospective review of the senior author’s patients produced 16 patients under the age of 21 that had post-traumatic elbow contracture releases. Three patients with arthroscopic releases and one patient lost to follow up were excluded from this study. Twelve adolescent patients (mean age 16.7 years, range 13–21) had open release of post-traumatic elbow contractures. All releases were initiated through a lateral approach with anterior capsular release and were supplemented by posterior release (in 4 patients) through the same incision. Medial-sided pathology was addressed through a separate medial incision in 3 patients. In three patients the radial head was excised. Muscle lengthening was used in only one patient. The mean follow-up was 18.9 months (range 10–42 months). Preoperative flexion was increased from 113 to 129deg (p< 0.01), extension from −51 to −15deg (p< 0.001) for a mean total gain of 54deg in the flexion-extension arc (p< 0.001). Pronation was improved from 58 to 77deg and supination from 56 to 62deg, but these improvements did not reach statistical significance. At the final follow-up the patients maintained 93% of the motion that was achieved intraoperatively. All patients achieved a functional ROM of at least 100deg in the flexion-extension arc. No patient lost motion. One patient had a superficial infection that was treated conservatively. Our experience with post-traumatic contracture release in adolescent patients has been rewarding; all patients reached a functional range of motion. The advantage of the lateral approach used in these patients is that it allows simple and safe access to the anterior capsule, which is often adequate to regain full extension. Through the same approach the posterior structures can also be addressed without violating the lateral collateral ligament. The medial approach is more demanding and was reserved only for patients with medial sided pathology. Fractional musculotendinous lengthening was rarely necessary in post-traumatic contractures. Open release in adolescent patients with congruent stiff elbows has yielded satisfactory results in our hands

Post-traumatic synostosis of the forearm are challenging situations after elbow trauma, injuries of the forearm or the wrist. According to Vince or Hastings classification, therapeutic options are still controversial, due to an unpredictive outcome with recurrence of the synostosis or progressive loss of mobility from post-op to definitive situations. A retrospective study of 13 cases, including 3 Vince Type 1, 6 Vince Type 2 and 4 Vince type 3 with a minimum follow-up of 3 years was analyzed as well as a review of 47 worldwide publications for defining the optimal therapeutic options. All data files were reviewed including extensive analysis of the CT-scans, and detailed surgical procedures. For Vince 1 synostosis, in post-traumatic situations, Sauve-Kapandji procedure give excellent or good results when no recurrence of the synostosis is seen. Instability of the proximal ulna after segmental resection is the major complication to be described. In Vince 2 synostosis, an extensive resection of the synostosis is mandatory to obtain a potential good result. Knowledge of the entire anatomy of the forearm is needed for accurate neurolysis of radial nerve and branches. The ulnar approach to the synostosis must be completed with an anterior approach to the radius for a complete resection. In Vince 3 synostosis, resection is easy but recurrence is frequent, due to the associated lesions of the elbow. Based on the litterature review, no additive treatment is necessary for better results Therapeutic options in post-traumatic synostosis of the forearm is a rare complications of elbow lesions (Vince 3), forearm comminutive or complex fractures (Vince 2), or wrist injuries (Vince 1). The latter give the more predictable results after complete resection. Elbow lesions associated with radio-ulnar synostosis are easy to treat but with important recurrence rate, whatever treatment was done. Vince 2 post-traumatic radio-ulnar synostosis are the most challenging situation as bone resection must be extensive meanwhile neurolysis of forearm nerves must be done in the same time. No adjuvant treatment is indicated in either situation according to Vince classification

We describe the natural history of a rabbit knee model of permanent post-traumatic joint contractures. Twenty-four skeletally mature female NZW rabbits had five-mm-squares of cortical bone removed from both femoral condyles. An extra-articular K-wire immobilized the knee joint in flexion. The K-wire was removed eight weeks later and the rabbits were divided into four groups depending on the remobilization time. The average extension loss for the experimental knees in the zero, eight, sixteen and thirty-two weeks remobilization groups was thirty-eight, thirty-two, twenty-one and twenty degrees, respectively. The motion loss stabilized in the later time intervals suggesting permanent contractures had developed. The contralateral unoperated knees average extension loss was nine degrees. The purpose of this study was to develop a rabbit knee model of post-traumatic contractures. A simulated intra-articular fracture plus eight weeks of immobilization leads to a permanent joint contracture even after thirty-two weeks of remobilization. This animal model of human post-traumatic joint contractures will allow further studies investigating mechanisms underlying the process. Twenty-four skeletally mature female NZW rabbits had 5 mm squares of cortical bone removed from both femoral condyles. An extra-articular Kirschner wire (K-wire) immobilized the knee in flexion. A second operation was performed eight weeks later to remove the K-wire. The rabbits were divided into four groups. Hind limbs were dissected, preserving the joint capsule. A device allowing six degrees-of-freedom coupled to a material testing system which applied a 0.2 Nm torque measured joint angles. Statistical analysis was performed using ANOVA with a posthoc Student-Newman-Keuls test. Data are presented as mean ± SD. The loss of extension for the experimental knees in the zero and eight weeks remobilization groups was significantly greater than the values of all contralateral unoperated knees. The loss of extension for the experimental knees in the sixteen and thirty-two weeks remobilization groups was also greater than the contralateral knees, although it was not statistically significant (p = 0.07). With this model, the severity of the contracture decreased with time of remobilization. However, the degree of contracture stabilized between sixteen and thirty-two weeks of remobilization, suggesting that the joints had developed a permanent contracture. This mimics the human scenario of permanent post-traumatic joint contractures. Funding: has not been received from a commercial party. This work was supported by The Alberta Heritage Foundation for Medical Research. Please contact author for tables and/or graphs

Aim:. To investigate the clinical outcomes of elbows with post-traumatic stiffness treated by open surgical release. Methods:. A retrospective review was completed on thirty-five consecutively managed patients who underwent an open elbow release for post-traumatic stiffness between 2007 and 2012. Pre-operative and post-operative range of motion (ROM), pain scores and functional outcomes were recorded. Results:. Mean follow-up was 31 months (6–84). The cohort consisted of 20 male and 15 female patients with an average age at time of surgery of 34 years (17–59). The interval from injury to time of release was 26 months (6–180). An improvement in mean ROM from 49° (0°–105°) to 102° (55°–150°) was obtained. The improvement in ROM in patients with pre-operative heterotopic bone was 61° compared to 45° in patients without heterotopic bone. The mean Mayo Elbow Performance Score improved from 44 pre-operatively to 82 at most recent follow-up. Mean VAS scores improved from 5.9 pre-operatively to 2.8 at most recent follow-up. Patients rated the affected elbow a mean of 73% as compared to the contralateral/normal side (50–100%). Apart from a 10% incidence of transient ulnar nerve neurapraxia in patients who had a medial or combined approach, complication rates and functional outcomes were comparable between medial, lateral and combined approaches. Conclusion:. Open release for post-traumatic elbow stiffness results in satisfactory functional outcomes in the majority of cases, with no significant differences between medial, lateral or combined approaches

Aim: To assess the functional and occupational outcome of open elbow arthrolysis for post-traumatic contractures. Materials and Methods: Prospective evaluation of 60 consecutive cases (86% male,14%female) of post-traumatic extrinsic elbow stiffness. Average age was 37 years (24–48). Moderate to high physical demand at work in 96% of cases. 56% of cases involved the right side. Open arthrolysis (column procedure) trough a lateral (72%) or posterior (28%) approach followed a minimum rehabilitation period of 6 months post original injury. In 8 cases, an anterior transposition of the ulnar nerve was required. Patients received postoperative analgesia with Bupivacaine 0,0125% trough an indwelling catheter. No chemical or radiotherapy ectopic calcification prophylaxis was used. Postoperative complications, range of motion, X-ray evaluation, time to return to work, activity level and workers’ compensation were evaluated at the end of follow-up (24 months, range 12–36). Results: Complications occurred in 14% of cases. Two patients required revision surgery for ectopic calcifications restricting prono-supination. The flexo-extension (FE) arc of motion improved from 49 ° to 115 ° and that of prono-supination (PS) from 100 ° to 158 ° The results were found to be statistically significant for FE (p= 0.054) and PS (p> 0,00001). In 20% of cases, patients returned to their previous job with some restrictions (33% disability) and 12% changed to a less physically demanding occupation. Conclusions: Open arthrolysis is an effective surgical procedure to improve mobility in post-traumatic stiff elbows. It is indicated when the joint interline is preserved. Good functional and occupational outcome in a high percentage of case in the working population was observed